1.The unlicensed assistive personnel (UAP) calls the nurse to the room of q client who ws admitted to the psychiatric unit yesterday for sever panic attacks. The UAP says, “Look the client is curled up like a ball, trembling, shaking, and breathing fast. I can’t take the vital signs. The nurse helps to calm the client.

a. Have the UAP take the client’s vital signs and assist the client into bed

b. Hold the client in a close embrace while the UAP takes the vital signs

c. Determine what the client was thinking just before the panic attack started

d. Say to the client, “You worked yourself up needlessly. There’s nothing to be anxious about. “

2. Two nurses have come to the nurse manage to report that they suspect the charge urse of diverting narcotics with supporting information. They are very distraught to report this as the charge nurse has been on the unit for many years and gets along well with everyone. However, ethically, they feel it is the right thing to do.

a. Schedule a meeting with the charge nurse and the two nurses together to discuss the allegations.

b. Send an email to the Charge nurse demanding to know why narcotics are being stolen

c. Ask the nurses to provide the proof needed to confront the charge nurse about the allegations.

d. Meet with the charge nurse to discuss the issue but do not divulge the source of the information.

3. The nurse preparing to undergo an elective cholecystectomy. In  hich order should the following preoperative steps be performed?

Items to be ordered.

1. client signs consent form

2. Healthcare provider explains procedure to client

3. Consent form is placed in chart

4. preoperative medication is administered

5. Witness Signs consent form

4. A client with diabetes presents to the clinic. Their glycosylated hemoglobin (HbA1C) is 9.4 %. The client has difficulty adhering to the prescribed diet and asks for suggestions.

Which dietary choices should the most appropriate for the nurse to recommend? Select all that apply

a. Spaghetti with meatballs and parmesan cheese ,steamed broccoli ,raw carrots ,and a glass of water

b. Hamburger with roll and a slice of cheese, curly French fries, an orange, and a glass of milk

c. one fish fillet, rice pilaf, cream corn ,one slice of watermelon, and a glass of soda

d. Baked ravioli, sausage, and mixed green salad, a piece of cherry pie, and a saucer water

e. Ham sandwich with a slice of cheese, a banana, and iced tea with low calorie sweetener

5. The nurse assesses a client diagnosed with bipolar disorder managed with lithium based on the clients assessment the provider requests laboratory evaluation. What assessment finding by the nurse supports the finding of the providers request?

a. Describe a headache two days ago for which pain medication helped

b. Reports having two loose stools in the past four days

c. Report sleeplessness and tremors to both hands that started yesterday

d. Expresses no episodes of manic behavior in the past six months

6. A student in the local high school attempted suicide because of being bullied by other students in the school; the student is now in a coma. the community health nurse plans a presentation about bullying to students and teachers at the school what is most important for the nurse to include in the presentation? Select all that apply

a. When students have low self-esteem, they are more apt to react negatively to bullying.

b. Students who bully other students usually lack empathy and are aggressive.

c. Bullying helps students grow into strong adults who can manage tough situations.

d. Bullies are often observing violent or abusive behavior at home.

e. Victims of bullying frequently experience social isolation.

7. A 46-year-old client presents to the emergency Department following a motor vehicle accident. Complete the following sentences by choosing from the list of options the nurses expects the client is experiencing

1. Alcohol withdrawal, an anxiety attack, excruciating pain, compartment syndrome

2. A benzodiazepine, additional pain, medication emergency surgery, and anti hypertensive

8. The nurse receives change of shift report of four clients on a maternity unit. Click to identify the client the nurse should assist first.

Room 302 -client with cervical radium implant in place who has been crying in her room

Room 303-client who presents with 5/10 pain after abdominal hysterectomy

Room 305 -client with a possible ectopic pregnancy who reports intense shoulder pain
Room 306-client in the 15th registration who has uterine cramping and spotting

9. The nursing supervisor calls a nurse who is off shift at home and states we are asking all available staff to come into work immediately we really need you are you able to come in what hospital plan is the most likely reason for the supervisors call to the nurse?

a. Infection control plan

b. Disaster plan

c. Client elopement plan

d. Unit staffing plan

10. A nurse works in a mobile clinic providing human immunodeficiency virus(HIV) screening to residents to various neighborhoods . Today,  a client has tested positive for HIV and says to the nurse, “ I kind of knew I was positive, but I just wanted to be sure. I know who I got it from too! Women are so deceiving. Anyway, I already took my revenge as I already slept with several women deliberately.  What question is most important for the nurse to ask the client?

a. Did you use condoms when you had sexual intercourse with these women?

b. Do you know that it is a crime to knowingly infect women with HIV?

c. Can you locate all the women with whom you have sex while infected?

d. Do you know you are just as deceiving as the woman who infected you?

11. The nurse receives a prescription to administer 100 mL of IV fluids at 125 mL/hr . the bag is hung at 0900. at what time should the nurse hang on your back answer in military time without a colon. _______

12. A hospitalized client develops watery incontinent diarrhea. a stool culture confirms a diagnosis of Chloridoids difficile which action should the nurse take? Which actions should the nurse take? Select all that apply

a. Place the client on contact precautions in a private room

b. Clean all equipment that has been in the room with bleach wipes

c. Question the health care providers orders which do not include antibiotics

d. Wash hands with soap and water after touching anything in the room

e. performs hand hygiene with a waterless hand product when leaving room

13. A pediatric client sustains an injury and is prescribed pain medication. the nurse administers morphine sulfate as prescribed. when checking on the client 10 minutes after the opioid, the client’s respiratory rate is 6 breaths per minute. the rapid response team is called to the unit and naloxone is prescribed at 0.1 mg/kg. the client weighs 66 pounds. the medication is available in 400 micrograms/mL. how many milliliters (mL) of naloxone should the nurse administer? round to the nearest hundredth.

________

14. A pregnant client presents in active labor at 29 weeks gestation. the labor is controlled with tocolytic medications. the client asks when they will be able to go home. which response by the nurse is most accurate?

a. Your length of a stay depends on our ability to stop your labor until full term

b. After the baby is born you will be charged to go home with the baby

c. Whenever the healthcare provider says that you are ready to go home

d. when we can stabilize your preterm labor and arrange home health visits

15.  A client presents to the emergency department (ED) reporting vomiting, diarrhea, fatigue, and abdominal pain. the client is diagnosed with hyponatremia, dehydration, and gastroenteritis of another origin. in addition to normal saline intravenous fluids which diet should the nurse anticipate?

a. High-fat diet

b. high-fiber diet

c. low-sodium diet

d. non-diary diet

16. The nurse provides teaching to the parents of a 7-year-old child who just had a cast applied for a fractured arm with the wrist and elbow immobilized.  Which instruction to the nurse include in the teaching?

a. Evaluate the casted arm daily when resting and when sitting up

 b.  Swelling of the fingers is to be expected for the next 48 hours

c. Allow the affected limit to hang down for one hour each day

d. immobilized the shoulder to decrease pain and arm

17. 68 year old client with history of DM type 2 ,HTN, CAD, previous alcohol abuse, current 2 PPD smoker admitted for glucose control and infected left foot wound requiring IV antibiotics. being discharged to home where he lives with his adult son education provided to client and his son on glucose monitoring insulin administration oral medication low sodium diabetic diet and wound care follow up appointment at diabetes and nutrition care clinic in one week to assess wound healing and review clients home glucose monitoring log client already has glucometer and glucose monitoring supplies at home wheelchair and Walker have been delivered to the home prescription ready for pickup in outpatient pharmacy.

Education Note:  return demonstration of home glucose monitoring

Observe client performing steps as follows:

1. Wash hands with soap and water

2. Dried hands with a clean towel

3. Pricked the pad of the left middle finger with a Lancet

4. Touched the edge of the test strip to the drop of blood

5. insert the test strip into the glucometer

6. Waiting for reading

The following says questions are part of an unfolding case study.

The home health nurse cares for a client after discharge from an acute care facility the nurse observes that the client returned demonstration of home glucose monitoring records the steps in the order completed in the electronic health record and reviews the procedure with the client.

For each potential response by the client the nurse clicks to specify if the response is indicated or not indicated.

Nursing Response   

-have you run out of hand sanitizer and alcohol wipes

– your hand hygiene was performed just like I showed you

-lets review the best way to use the Lancet to draw blood

-it is better for your hands to dry by gently waving them

-the blood needs to drip to the strip to avoid contamination

-the test strip needs to be inserted before the finger stick

18. The nurse speaks with the client on the telephone on 3/8 to provide the safest and most effective care to the client how should the nurse respond?

a.  the social worker will secure a taxi voucher for you to come to the appointment

b. Do you have Internet access we can complete your visit on your telehealth platform

c. When is a good time for the home health nurse to schedule a visit with you

d. We have some openings next week if you will have transportation then

19.

68 year old client with history of DM type 2 ,HTN, CAD, previous alcohol abuse, current 2 PPD smoker admitted for glucose control and infected left foot wound requiring IV antibiotics. being discharged to home where he lives with his adult son education provided to client and his son on glucose monitoring insulin administration oral medication low sodium diabetic diet and wound care follow up appointment at diabetes and nutrition care clinic in one week to assess wound healing and review clients home glucose monitoring log client already has glucometer and glucose monitoring supplies at home wheelchair and Walker have been delivered to the home prescription ready for pickup in outpatient pharmacy.

The home health nurse visits the client and the client’s home on 3/10 complete the following sentences by choosing the list of options. the nurse expects the client is experiencing and prioritizes the assessment of the client.

1.

2. -blood glucose

-wound

-vital signs

-HbA1C

20. The home health nurse visits the client and the client’s home on 3/10 and recognize that the client is experiencing multiple complications of diabetes mellitus complete the following sentence by choosing the list of options the client and our symptoms of diabetic ketoacidosis that contribute to a self care deficit.

1.-vision impairment

-urinary frequency

-fruity breath

-increasing pain

2.-poor diet

-confusion

-noxious order

-polypharmacy

the findings that is of most importance immediate concern to the nurse.  Select your answer by clicking the desired location on the image below to move a pin click another location on the image to remove a pin click it once.

3/10- glucometer in the cupboard OK easy

Point of care glucose my French range 70-100mg/dL

 result 392

22. The home health nurse plans the client’s care for the remainder of the home visit on 3/10.

Select three actions the nurse should prioritize today.

1. Reinforce education on insulin self-administration.
2. Coordinate admission to an assisted living facility.
3. Stabilize the client’s blood glucose levels.
4. Contact the health care provider to reduce polypharmacy.
5. Address the client’s increased heart rate and blood pressure.
6. Perform wound care and administer antibiotics.
7. Contact the son to discuss his neglects of the client.
8. Reinforce education on a low-sodium diabetic diet.
9. Obtain functional glucose monitoring supplies.
10. Call adult protective services to report neglect.

23. A client diagnosed with post-traumatic stress disorder is being admitted to the inpatient psychiatric unit due to suicidal thoughts. As the nurse completes the admission, the client reports an inability to sleep due to recurrent nightmares of the traumatic event.

When the nurse asks the client about the event, what situation is the client likely to describe?

1. Smoking marijuana as a teenager
2. Speaking in public for the first time
3. Fatal shooting of family members
4. The wedding of the client’s first child

A woman in labor has just received an epidural block.

What is the most appropriate initial nursing action?

1. Monitor the maternal pulse for possible bradycardia.
2. Limit parenteral fluids and maintain client’s NPO status.
3. Monitor the maternal blood pressure for possible hypotension.
4. Monitor the fetal heart rate for possible tachycardia.

25. a nurse monitors a client experiencing a sudden onset of acute abdominal pain and frank vaginal bleeding.

Which additional assessment finding is most concerning to the nurse?

1. Late decelerations
2. Moderate variability
3. Accelerations with fetal movement
4. Average FHR of 126 beast/min                                                                              

26.The nurse assesses a client 12 hours post vaginal birth and finds a boggy uterus that is displaced above and to the right of the umbilicus Which immediate nursing action is most appropriate?

A Evaluate and document the lochia.

B Assess the blood pressure and pulse.

C Assist the client in emptying her bladder.

D Notify the health care provider of potential hemorrhage.

27Nursing Notes

Laboratory Results

MAR

Lab

Reference

Range 8/8, Glucose 70-100

Regular Insulin subcutaneous AC

and HS

Blood glucose < 70, initiate

hypoglycemia protocol

Blood glucose 70-130, give 0 units

Blood glucose 131-180, give 4 units

Blood glucose 181-240, give 8 units

Blood glucose 241-300, give 10 units

Blood glucose 301-350, give 12 units

Blood glucose 351-400, give 16 units

Blood glucose > 400, give 20 units

and call provider

30

31

1705

4 units

Given

0610

8 units

Given

Client asking when they will receive their breakfast tray. Trays have not arrived

from the kitchen. Call placed to kitchen and tray carts should arrive “soon.

A client’s roommate calls the nurse to request assistance for the client at 0715 When the nurse enters the room and assesses the client, which client cues is the nurse most likely to find? Select all that apply.

A client’s roommate calls the nurse to request assistance for the client at 0715

27.When the nurse enters the room and assesses the client, which client cues is the

nurse most likely to find? Select all that apply.

A Excessive thirst

B Bradycardia

C Slurred speech

D Diaphoresis

Confusion

F pallor

28.The nurse cares for an infant whose cleft lip was recently repaired What are important aspects of this infant’s postoperative care?

A Supine and side-lying positions, postural drainage, and arm restraints

B Arm restraints, postural drainage, and mouth irrigations

C Mouth irrigations, prone position, and cleansing of suture line

D Cleansing of suture line, supine and side-lying positions, and arm

29 A client admitted with exacerbation of emphysema is now ready for discharge. The client is dressed and sitting comfortably in a chair reading the newspaper while waiting for their ride. The nurse takes a set of vital signs: blood pressure 132/82 heart rate 79, respiratory rate 20, and Sp02 86% on room air Which initial action by the nurse is most appropriate?

A Remove the pulse oximeter probe and place it on the client’s toe

B Reposition the pulse oximeter probe and recheck saturation level.

C Place nasal cannula on client and turn flow meter to 2 liters/minute.

D Call the physician and report the client’s oxygen saturation level.

• 30 client is admitted O the medical unit from home and is found to have a Stage 3

pressure injury Which image best represents this pressure injury? (Injury photos)

31. The health care provider prescribes hydromorphone 1 mg to be administered

intravenously every 3 hours for pain. In the medication system is hydromorphone 4

mg/mL. How many milliliters (mL) should the nurse administer when the client requests a

dose? Do not round

          32.A client was admitted yesterday following an all-terrain vehicle accident. The client sustained a distal tibia fracture which required surgery. The client is postoperative

day one following an open reduction and internal fixation of the right tibia fracture. Postoperative orders are documented in the electronic health record. The client requests pain medication one hour after the last dose, stating, “It hurts really bad, way more than yesterday.” The nurse checks the client’s toes for movement. The client cannot move his toes, which appear dusky and are cool to the touch Which intervention should the nurse implement first?

A Call the health care provider immediately.

B Elevate the leg on pillows above heart level.

C Apply a new bag of ice to the affected area.

D Administer the prescribed pain medication

33. The nurse cares for a young Chinese client who is determined brain dead after a

tragic accident. The health care team plans to speak with the parents about donation of the client’s organs. The nurse tells the team that this is not a good plan What is the reason for the nurse ‘disagreement with the plan?

A The client’s parents do not speak English and may not understand the request.

B Keeping the deceased body intact is a fundamental belief of this family’s culture

C The nurse is not a strong supporter of removing clients’ organs after death.

D The timing is not right as the parents are grieving the inevitable loss

34.The nurse provides discharge teaching to an older adult client. The client appears distracted and at times there is a confused look on the client’s face. The client says,”| don’t understand a word you’re saying.” The nurse self-assesses and determines that a different communication approach is needed. C How should the nurse change the communication approach to ensure the client understands the teaching? Select all that apply

A Use correct gestures because the nurse used gestures at the wrong

time and in an inappropriate way.

B Use proper pacing because the nurse spoke rapidly and didn’t always

speak the words clearly.

C Change time of teaching because the client was watching television

during the education session

D Use correct gestures because the nurse used gestures at the wrong time and in an inappropriate way.

E Use proper pacing because the nurse spoke rapidly and didn’t always

B speak the words clearly.

Change time of teaching because the client was watching television during the education session

Use clarity and brevity because the nurse spoke in long sentences and used several filler words

E Change the facial expression because the nurse’s words did not always match the facial expression

35. New prescription: Enalapril 5 mg PO daily, Fill. 30 tabs

Refill prescription: Bupropion XL 150 mg PO daily, Fill: 30 tabs

A 61-year-old client self-monitors their blood pressure and brings a log to their follow-up appointment. How should the nurse interpret the client’s data? Select all that apply.

A The client will likely continue taking this medication at the current dose.

B The client no longer requires blood pressure medication

C The medication is not providing appropriate blood pressure control.

D The client may require the medication less frequently

E The client may require a smaller dose of the medication

The medication is providing excellent blood pressure control.

F The provider may discontinue this medication and try a different one

H The client is experiencing a medication interaction

36.Based on the client’s statement, which nursing actions are priority? Select all that apply.

A Inquire if the client has a plan for ending his life

B Tell the client that suicide is very selfish and cowardly.

C Remove all items from the meal tray that can cause harm.

D Remind the client that his kids will grow up without a father.

E Ensure the client is placed on suicide watch. 

37. A transgender client who was assigned female at birth receives hormones as part of their gender-affirming care. The hormones have not sufficiently reduced breast tissue size and the client is scheduled for a breast reduction Which statement by the client indicates an accurate understanding of the reason for this surgery?

A This single surgery will complete my transition from female to male

B “Removing my breasts will ensure that my other genitals can grow.”

“In order to have a successful transition, I need to have flat breasts

“I need to have my breasts removed since the medications were not

38.Nursing Notes

MAR

0850

45-year-old client 2-days post-op bowel repair, Midline abdominal incision

closed with staples. NG to left naris to continuous wall suction. Strict NPO

TPN infusing to right arm PICC line.

0900 Abdominal dressing due. to be changed per wound care orders

0940 LPN into client room, repeat focused assessment completed. Client

complains of pain at incision rated 5/10 and mild nausea. Abdominal dressing

changed as ordered. Incision assessment remains unchanged. Abdominal

binder reapplied. NG depth verified by measurement at naris, tape secure,

remains connected to continuous suction, Client educated on incentive

spirometer use with return demonstration by client. BMP results analyzed to

confirm TPN formula. Medications administered per MAR. Plan of care

discussed with client.

A 45-year-old client is two days postoperative. For each action performed by the licensed practical/vocational nurse (LPN/LVN), click to specify if the action is within or outside the LPN/LVN scope of practice.

LPN Completed Task

Within Scope

Outside Scope

Verify NG measurement depth

Morphine administration

Apply abdominal binder

Incentive spirometer education

Evaluation of BMP lab results Abdominal dressing change

Plan of care education

38. nurse on the oncology unit who was known to be uninvolved in any aspect of the

unite governance and not seen as a leader is noted to be energized and empowered

lately. The nurse. just shared an article in the staff meeting on a new evidence-based practice for clients undergoing a surgical procedure.

What specific occurrence is the most likely contributor to the nurse’s increased leadership stance?

A The nurse decided to be in control on the unit to avoid the talk about poor leadership.

B Wants a transfer to another unit and believes that being active on this unit will achieve that goal.

C The manager’s annual evaluation of the nurse gave the nurse only a 1% raise in salary.

D Was asked to work on the shared governance council and is actively participating  .practice for clients undergoing a surgical procedure.

What specific occurrence is the most likely contributor to the nurse’s increased? leadership stance

39

40.The nurse prepares to initiate continuous enteral tube feedings for a client.

Which client is properly positioned for continuous enteral tube feedings? (Refer to pics)

41client with a cardiac valve disorder presents to the Emergency Department

reporting chest pain beneath the left clavicle. The client is suspected of experiencing pericarditis Which assessment data should the nurse expect?

A An annoying nonproductive cough lasting a week

B An elevated C-reactive protein laboratory value

A friction rub heard at the lower left sternal border

D An oral temperature of 101.2 °F (38.4 °C)

---

42.5/4

1815

Client reports 7/10 pain to surgical site, Administered IV pain medication an assisted client with positioning and ice application. Client reports some nausea and would like to eat dinner tray a little later.

After receiving report for the 1900 shift, the nurse assesses a client complaining of pain and requesting pain medication

Medication

5/4

0550 Given

1025 Given

1400 Given

Morphine 4 mg IV every 4 hours PRN pain

Ketorolac 15 mg IV every 6 hours PRN pain

0800 Given

1610 Given

For each nursing action, click to specify if the action is appropriate or inappropriate.

Nursing Actions

Nursing action	appropriate	inappropriate
ask the client what medication they last received
administer morphine as prescribed
call the previous nurse to verify then documents administration for them
discuss the situation we did nurse manager

45. The nurse cares for a 2-year-old who has cystic fibrosis. The client is small for their age.

What dietary suggestions can the nurse recommend to the child’s parent to enhance?

their growth?

A High-protein, high-calorie meal with skim-milk milkshakes between meals.

B Low-fat, low residue, and high-potassium diet with juices often.

C Low-carbohydrate, soft diet with no extra sugar products

D High-fiber, high-fat diet with extra water between meals.

46. The nurse assesses a client who lost significant blood and requires blood transfusion.

Which cue in the client’s history leads the nurse to believe that another means of treatment might need to be established?

The client reacted to a previous blood transfusion.

B The client’s blood type is O-positive

C The client is of the Jehovah’s Witnesses faith.

D The client attends and is active in a Baptist church

47.A client comes to the outpatient endoscopy center for a screening colonoscopy to

be done using conscious sedation. The client asks, “What is conscious sedation?”  The nurse’s response is based on which information?

A The client will be awake and able to talk during the entire procedure

B The client will maintain spontaneous respirations during the procedure.

C Clients are completely unconscious during the entire procedure.

D Most clients require intubation for a short time during the procedure

48. client has a blood pressure reading of 168/90 mmHg and a radial pulse of 82 bpm What is this client’s pulse pressure? Round to the nearest whole number .mmHg

49. The nurse knows that working with informatics and technology every day provides

effective health care to clients.

What are the advantages of using informatics in health care delivery? Select all that apply.

A Increased client anonymity and confidentiality.

B Reduced need for nurses in acute and urgent care units

C The ability to achieve and maintain high standards of care.

D Access to standardized plans of care for many health problems.

Improved communication among the client’s health care team.

50.Every morning, a client performs a spiritual ritual of burning candles, placing a shawl over the head and praying. The nurse determines that the safety of the client and the roommate are not at risk What assessment of the environment lets the nurse know that the client is practicing the ritual in a safe manner

A Lights one candle at a time instead of all at the same time.

B Uses flameless candles instead of lighting real ones

C Lights the candles and burns them for only five minutes.

D Burns the candles in the bathroom to avoid bothering the roommate

51.When examining a client who gave birth 5 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes.

Which nursing action is the priority?

Answers: A – D

A Begin intravenous fluid infusion.

B Assess the client’s vital signs.

C Call the health care provider.

D Massage the client’s fundus.

52.Nursing Notes.          Health History

2/9

Client in OBGYN clinic with reports of breast changes. Client states she felt a small firm area in the upper area of her right breast about 8 months ago.

Client states in the past 2 months the firm area has become larger, a bit red, and the skin near the firm area is dimpling. Client denies any pain in her breast or axillary area:

The following six questions are part of an unfolding case study.

A 62-year-old client presents to the care clinic with acute symptoms.

Complete the following sentences by choosing from the lists of options.

The nurse anticipates the provider will first recommend a(n) 1) to further evaluate the client’s complaints. If malignancy is suspected. the nurse anticipates the provider will then recommend to confirm the diagnosis.

Nursing Notes.          Health History

Medical History

Obesity

Metabolic Syndrome

Osteoporosis

Surgical History

• Laparoscopic cholecystectomy-age 36

Obstetric History

Nulligravid

Menopause-age 51

Social History

• Smoking 1 ppd x 38 years

Medications

Alendronate 10 mg PO daily

Multivitamin PO daily

Ibuprofen PO PRN

Answers 1 – 2

1. Select answer choice

mammogram

MRI imaging

core biopsy.

genetic testing

2. Select answer choice

needle-aspiration biopsy

hormone receptor testing

lymph node biopsy

BRCA1 evaluation

53.Nursing Notes.      Health History.       Diagnostic Results

Health History

2/9

Client in OBGYN clinic with reports of breast changes. Client states she felt a small firm area in the upper area of her right breast about 8 months ago.

Client states in the past 2 months the firm area has become larget, a bit red, and the skin near the firm area is dimpling. Client denies any pain in her breast or axillary area.

2/11

Client to OBGYN clinic for needle biopsy results. Client provided update on results from provider. Tumor staging Il based on high potential for lymph node involvement. Client and provider discussed treatment options for surgical removal of tumor and potential for chemotherapy and radiation. Client tearful and asks for time to make a treatment decision.

Nursing Notes.        Health History.       Diagnostic Results

Date	Diagnostic Study	Result/Impression
2/10	Diagnostic Mammogram	BI-RADS-4-highly suggestive of malignancy, recommend biopsy
2/11	Needle Biopsy	Moderately differentiated invasive carcinoma

Nurse Statement	Therapeutic	Non-therapeutic
“There are many support groups for women with breast cancer. I can provide you with contact information.”
“Let’s identify your family and friends who will be your support system through your treatment.”
“Now you can participate in those breast cancer walks and wear beautiful pink ribbons!”
“At least we caught the cancer before it spread to other organs. That would be more difficult to treat.”
“Tell me what’s worrying you right now regarding your recent diagnosis.”
“Don’t worry, treatment options have come so far, and the cure rates get higher every year.”
“Let me explain exactly what is involved in the recovery after surgery so you are well prepared.”

54. Client states in the past 2 months the firm area has become larger, a bit red, and the skin near the firm area is dimpling. Client denies any pain in her breast or axillary area.

2/11

Client to OBGYN clinic for needle biopsy results. Client provided update on results from provider. Tumor staging Il based on high potential for lymph node involvement. Client and provider discussed treatment options for surgical removal of tumor and potential for chemotherapy and radiation. Client tearful and asks for time to make a treatment decision.

2/20

Client admitted for preoperative preparation for lumpectomy surgery today to right breast with balloon catheter insertion followed by 4 days high dose brachytherapy inpatient. Provider explained both procedures to client, informed consent witnessed by RN. Client asks the nurse “Can you go over those procedures again? Details are calming to me when I feel anxious.”

The nurse cares for the client in the acute oncology department.

For each education topic, click to specify if the nurse should include or not include the information.

Client Education	Include	Do Not Include
“The external radiation will take up to four weeks to complete. You may experience uncomfortable changes to your skin exposed to the radiation.”
“The surgeon will biopsy sentinel lymph nodes during your surgery to assess for metastasis of the cancer.”
“Your right breast will be removed. Once you are healed, you can plan reconstructive surgery.”
“You will need to clean the catheter insertion sites with soapy water daily and monitor for signs of infection.”
“The surgeon will attempt to remove the tumor and surrounding healthy tissue to eliminate all malignant cells in your breast.”
“We will insert radioactive seeds through the catheters surgically placed in your breast to deliver high-dose radiation to the target area.”

55. Diagnostic Results.      Vital Signs.       Nursing Notes.     Health History

2/9

Client in OBGYN clinic with reports of breast changes. Client states she felt a small firm area in the upper area of her right breast about 8 months ago.

Client states in the past 2 months the firm area has become larger, a bit red, and the skin near the firm area is dimpling. Client denies any pain in her breast or axillary area.

2/11

Client to OBGYN clinic for needle biopsy results. Client provided update on results from provider. Tumor staging ll based on high potential for lymph node involvement. Client and provider discussed treatment options for surgical removal of tumor and potential for chemotherapy and radiation. Client tearful and asks for time to make a treatment decision.

2/20

Client admitted for preoperative preparation for lumpectomy surgery today to right breast with balloon catheter insertion followed by 4 days high dose brachytherapy inpatient. Provider explained both procedures to client, informed consent witnessed by RN. Client asks the nurse “Can you go over those procedures again? Details are calming to me when I feel anxious.”

2/26

Client post lumpectomy and brachytherapy. Chemotherapy plan initiated due to evidence of metastasis to lymph nodes. Combination high-dose chemotherapy will be administered intravenously in cyclic treatments over 4-month period. First chemotherapy administered today. Client provided education by RN.

Date	Diagnostic Study	Result/Impression
2/10	Diagnostic Mammogram	BI-RADS-4-highly suggestive of malignancy, recommend biopsy
2/11	Needle Biopsy	Moderately differentiated invasive carcinoma
2/21	Tumor margin	Negative margins do not contain malignant cells
2/22	Lymph node biopsy	Positive-malignant cells detected in sample

Medical History

Obesity

Metabolic Syndrome

Osteoporosis|

Surgical History

• Laprascopic cholecystectomy-age 36

Obstetric History

Nulligravid

Menopause age 51

Social History

• Smoking 1 ppd x 38 years

Medications

Alendronate 10 mg PO dail

Multivitamin PO daily

Ibuprofen PO PRN

Date.     Pressure Blood.    Heart Rate.      Respiratory Rate.   Temperature

2/20.      112/75.                  66.                            18.                     98.6* F

0700                                                                                                37*C

The nurse cares for the client in the outpatient cancer clinic on 2/26.

Which potential complications of treatment should the nurse discuss with the client? Select all that apply.

Answers: A – H

A.Extravasation at IV site

B.Alopecia

C.Anemia

D.Myelosuppression

E.Neutropenia

F Stomatitis

G Thrombocytopenia

H Weight loss

56. Client post lumpectomy and brachytherapy. Chemotherapy plan initiated due to evidence of metastasis to lymph nodes. Combination high-dose chemotherapy will be administered intravenously in cyclic treatments over 4-month period. First chemotherapy administered today. Client provided education by RN.

3/11

Client admitted to oncology unit with sore throat, fever, and productive cough.

Client received first chemotherapy round 10 days ago and is currently within nadir. Client sore throat began 2 days ago and fever began this AM. Client admitted for evaluation and treatment.

The nurse cares for the client in the acute oncology department on 3/11.

Click to identify the provider order the nurse should question.

Select your answer by clicking the desired location on the image below. To move a pin, click another location on the image. To remove a pin, click it once.

Admit to oncology unit.

Blood culture and sensitivity

Sputum culture and sensitivity

Labs: CBC with differential, CMP

Maintenance IV fluids D5 0.9% normal saline at 75 mL/hr

Cefazolin 1 g IVPB BID, start if positive culture.

Ondansetron 8mg IVP every 6 hours PRN
nausea/vomiting

Filgrastim 340 mcg SQ daily

58. A child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. The client has not voided in several hours, is lethargic, and skin turgor is poor.

Which action by the nurse is the priority?

Answers: A – D

A Administration of antidiarrheal medication

B An IV bolus of normal saline solution

C Clear oral liquids, 1 to 2 ounces at a time

D Oral rehydration solution as tolerated

59. The nurse cares for a client on the oncology unit who had a bilateral mastectomy 2 days ago. Today, when the nurse enters the client’s room to administer medications, the client is crying and says to the nurse, “This is so unfair.”

Which response by the nurse is most appropriate?

Answers: A – D

A The client didn’t ask a question so the nurse should remain silent.

B “Why do you think having breast cancer is unfair?”

C “You should count your blessings; at least you are alive.”

D.”I see you’re upset. Would you like to talk about what’s upsetting you?

60.  A client who takes inhaled corticosteroids reports experiencing throat irritation.

What assessment questions should the nurse ask the client to determine if the client is taking the appropriate measures to prevent the side effects of the corticosteroid inhaler? Select all that apply.

Answers: A – E

A.”Are you rinsing your mouth with water and gargling each time you use the inhaler?”

B.”Are you spraying your throat with a numbing spray before each inhaled dose?”

C. “Are you ensuring that you inhale the medication as slowly as possible?”

D “Have you been drinking any hot beverages after inhaling the drug?”

swallowing the water?”

E. When you rinse and gargle after using the inhaler, are you swallowing the water?

61. A team of nurses is on a humanitarian aid trip working in a resource-limited rural community. They have been there for a few days and have helped many residents.

They are now down to their last resources and as they walk through the area, they see the 3 client situations in the images.

Knowing that they are only able to assist one case with the remaining resources, which client situation would benefit the greatest from the remaining resources?

There is an image for the answers, please refer to the original question

62. A client is admitted to the hospital for complications of chronic renal failure. The nurse preceptor reviews the client’s health history with a novice nurse.

Which medical conditions in the client’s health history would the novice nurse correctly identify as predisposing the client to chronic renal failure?

Answers: A – D

A Diabetes, increased age, and hypertension
B Increased age, obesity, and hypotension
C Cardiovascular disease, diabetes, and emphysema
Hypertension, diabetes, and osteoporosis

63. Two nurses are traveling home from work and arrive on the scene of a serious 4-car accident on an icy rural road. They can see that there are many victims. The nurses have called for emergency medical assistance and have started to help by triaging the victims to make it easier for emergency response personnel to treat the victims when they arrive. After being triaged, in what order should the clients be addressed for treatment?

Place the clients in order from highest priority to lowest.

Items to be Ordered

1.Driver found with the steering wheel crushing his chest; the driver is deceased.

2. Girl who has a small cut to the face, is scared and calling for her parent

3. Woman bleeding severely from a crushed right leg and begging the nurses not to let her die.

4. Boy with an obvious broken arm who walks to the nurse and says, “Is my mom okay?”

5. Man thrown from a car, has many obvious external injuries, is unresponsive and bleeding profusely.

64. Nursing Notes

12/2

0853

32-year-old client with obsessive compulsive disorder. Plans for discharge home tomorrow. Upon assessment the nurse hears the client state, “I can’t get it out of my head that all teenagers are out to kill me, but I’ll get them before they get me.” Medication administered without incident.

The night shift nurse plans discharge teaching for a client with obsessive-compulsive disorder.

After reading the previous shift’s nursing notes, which action by the nurse is most appropriate?

Answers: A – D

A.Ignore the statement and continue with the discharge plan. The client is well known by staff and never acts on his threats.

B.Call the day shift nurse tonight to verify if the client was joking when the statement was made.

C.Assess the client in the morning to see if he is up for discharge and still feels the same way he felt the night before.

D.Hold discharge teaching in the morning and notify the health care provider of the findings.

65. The client with pneumonia is treated with levofloxacin and takes antacids daily for heartburn. After five days of administering the antibiotic to the client, the nurse asks the health care provider to hold the client’s antacid until the antibiotic is finished.

What assessment finding prompted the nurse’s decision?

Answers: A – D

A The client states the antibiotic causes the antacid to “taste funny.”

B The client is no longer experiencing heartburn.

C The client has developed another infection.

D The client’s pneumonia does not seem to be resolving.

66. A client on the psychiatric unit with paranoid personality disorder refused to eat breakfast the past two mornings because they are convinced that the day shift nurse is poisoning the food. The health care provider has changed the client’s treatment regimen.

What assessment finding indicates that the new treatment regimen is effective?

Answers: A – D

A The client ate 40% of their breakfast today.
The client no longer says the nurse is poisoning the food.
C The client is following the new treatment regimen.
The client sits in the dining room during breakfast.

67. Nursing Notes.          Vital Signs

10/2

0830

Client presents to clinic requesting the influenza vaccine. Client states, “My husband has the flu and I don’t want to get it. My throat feels a little itchy, but other than that, I feel fine.” Live attenuated influenza vaccine administered intranasally and tolerated well. Client education provided.

A client with a history of Guillain-Barré syndrome, pneumonia, and hypertension presents to the clinic.

What assessment information was overlooked that should have prevented the client from getting the vaccine?

Nursing Notes

Vital Signs

Date	Blood Pressure	Heart Rate	Respiratory Rate	Temperature
10/2 0830	138/88	98	20	101.9 F 38.8 °C

A client with a history of Guillain-Barré syndrome, pneumonia, and hypertension presents to the clinic.

What assessment information was overlooked that should have prevented the client from getting the vaccine?

Answers: A – D

A Blood pressure and heart rate

B Temperature and health history

C Husband’s illness and oxygen saturation

D Client’s subjective report

68.A client was admitted to the medical unit 5 days ago with symptoms of fatigue, confusion, nausea, and abdominal pain. The client has a 20-year history of alcohol abuse and was diagnosed with pancreatitis and liver failure. Lungs are clear to auscultation. Liver is palpable in the left upper abdominal quadrant. Since admission, the client has been NPO. The diet is to be advanced starting today.

Which dietary choice is most appropriate?

Answers: A – D

A.Low potassium

B Low carbohydrate

C.Low sodium

D. Low calorie

69.A nurse cares for a client on the postpartum unit.

Which finding 12 hours after birth requires further assessment by the nurse?

Answers: A – D

A Fundus two fingerbreadths below the umbilicus
B Fundus two fingerbreadths above the umbilicus
C Fundus at the level of the umbilicus
Fundus one fingerbreadth below the umbilicus

70. Nursing Notes.           Laboratory Results

Client with history of atrial fibrillation admitted from skilled nursing facility for worsening signs of congestive heart failure. Bilateral lower extremities swollen, client is short of breath with wheezing noted in bilateral lung fields, heart rate rapid and irregular, SNF staff report client gained 2 pounds since yesterday.

1/9

Client receiving diuretics as prescribed, swelling and wheezing improving.

Client attempted to get out of bed and remove the IV during the night, appeared agitated and somewhat confused. Update given to client’s daughter on the phone who says this is typical nighttime behavior. She requests to stay with the client at night for reassurance and reorientation.

Lab	Reference Range	1/8
MRSA Screening	Negative	Positive

The nurse cares for an 86-year-old client in the acute care setting.

For each response by the nurse, click to specify if the response is appropriate or inappropriate.

Nurses’ Response	Appropriate	Inappropriate
“Be sure to wash your hands when entering and leaving the room.”
“I’m sorry. With your mother’s condition, that is not possible.”
“You will need to wear a gown and gloves while in the room.”	•
“You don’t need to stay; the nursing staff will care for your mother.”
“You can stay if you wear a mask while in the room.”

71. Nursing notes

11/1

0600

Client admitted to the medical unit with diagnosis of pneumonia. Client is nonverbal and spouse is the historian on the client’s admission to the unit. The spouse tells the nurse that the client is of the Muslim faith and even though nonverbal, the client will need to maintain the ritual of praying 3 times daily.

Nursing assessment conducted. Client is alert and oriented but unable to speak. Paper pad and marker given to client to communicate with staff.

0830

Morning medications administered. Client only had coffee from the breakfast tray. Client did not eat the bacon and eggs on the whole wheat bread.

1230

Client ate 100% of the turkey sandwich served at lunch. Resting quietly in bed.

No reports of pain or discomfort.

1545

Client refused dinner tray served with pork chops, mashed potatoes, and vegetables.

1700

Client asked nurse to place a call to spouse and ask him to bring her dinner.

A 48-year-old client is admitted with pneumonia. Based on the information in the client’s chart, what assessment information should have been identified by the staff as the reason for the client’s poor oral intake of meals today?

Based on the information in the client’s electronic health record, what assessment information should be identified by the staff as the reason for the client’s poor oral intake of meals today?

Answers: A – D

A.The client has pneumonia.

B The client prays 3 times daily.

C The client is of the Muslim faith.

D The client is non-verbal.

72. The nurse presents a teaching session to the community. Screenings completed indicate many individuals are at risk for heart disease.

What information should the nurse ensure is included in the teaching? Select all that apply.

Answers: A- E

A Engage in a smoking cessation program.

B Start exercising for at least 30 minutes daily.

C Eliminate meats like beef and pork from diet.

D Check cholesterol to ensure HDL is low and LDL high.

E Take blood pressure medications as prescribed.

73. Which instructions by the nurse contribute to infant safety and security and should be included in client education? Select all that apply.

Answers: A – E
	The parent should check the photo ID of any person who comes to the room.
	Because of infant security systems, the baby can be left unattended in the client’s room.
	The baby should be carried in the parent’s arms from the room to the nursery.
D	Parents should use caution when posting photos of their infant on the internet.
E	The parent should request that a second staff member verify the identity of any questionable person.

74. The nurse monitors a client’s heart rhythm via central telemetry.

Which rhythm requires immediate nursing action?

Please refer to the original question where there is EKG image.

75. An older female client presents for an annual physical. The nurse notices the client’s height is 1.5 inches less than the previous year.

Which diagnostic test should the nurse anticipate?

Answers: A – D

A CT (computed tomography) scan

B MRI (magnetic resonance imaging) scan

C DEXA (Dual-energy X-ray absorption) scan

D Routine X-ray studies

76. The charge nurse delegates care of clients on the unit. In what order should the assigned nurse plan to see these clients?

Place the clients in the order they should be seen by the nurse , from first to last.

 Items to be Ordered

1. Has a nasogastric feeding tube and is experiencing new onset shortness of breath
2.  Client combative and the unlicensed assistive personnel is waiting for help to bathe the client .
3. Admitted with a hip fracture , ended physical therapy session today and going home tomorrow.
4. Arrived back to the floor 5 hours ago and has been medicated twice for nausea and vomiting
5. Just admitted to the floor from the emergency department (ED ) with COPD exacerbation

77. The home health unlicensed assistive personnel ( UAP ) cares for a 48-year – old client who was recently discharged from the hospital after a myocardial infarction , helping with bathing . From statements made by the client , the UAP suspects that the nurse assigned to the client is engaged in an unethical relationship with the client . What is the most appropriate action for the UAP to take ?

1. Warn the client that the relationship with the nurse is unethical .
2.  Confront the nurse to confirm the suspicion .
3. No action should be taken as the UAP has no evidence .
4.  Call the clinical manager and report the suspicion . VERSION 42

78. A school – age child sustained a traumatic brain injury after being thrown from a horse . The child’s level of consciousness ranges from unconscious to semi- conscious . The parents think their child is in pain due to periodic crying and restlessness and ask about pain medication.

 What is the most appropriate nursing action? 

1. Explain that analgesia is unnecessary when the child is not fully awake and alert .
2. Discuss with parents the child’s previous experiences with pain and check the level .
3. Explain that analgesia is contraindicated with a head injury and should be avoided .
4. Discuss with the health care provider what analgesia can be safely administered

79. Following a traumatic brain injury sustained in an automobile accident, a client is closely monitored in the intensive care unit .

When planning the client’s care, which action should the nurse identify as most critical for this client?

1. Assess pupil size and accommodation every six hours .
2. Administer acetaminophen 325 mg orally for headache .
3. Accurately document Glasgow Coma Scale every hour .
4. Administer ondansetron 4 mg IV push after client vomits .

80. After suffering a sprained ankle from a fall during a baseball game , a client seeks medical attention at an urgent care center . What instructions should the nurse include when discharging this client ? Select all that apply .

1. Apply ice to affected ankle for 2 to 3 days .
2. Administer opioid analgesia as prescribed .
3. Maintain cold application on and off every 20 minutes.
4. Wrap cold application in a towel before using .
5. Apply heat to affected ankle for 2 to 3 days .

81. The nurse prepares to administer routine immunizations to a 4-month-old infant. The infant is currently up to date on all previously recommended immunizations . Which immunizations will the nurse prepare to administer ? Select all that apply .

1. Measles , mumps , and rubella (MMR )
2. Diphtheria ,tetanus ,and acellular pertussis (DTaP )
3. Rotavirus ( RV )
4. Haemophilus influenzae type B (HIB )
5. Inactivated poliovirus (IPV )

82. A client with Alzheimer’s disease was admitted to the unit yesterday for pneumonia . Yesterday , the spouse , who is the client’s caregiver at home , said to the nurse , am so tired . I am up several times every night caring for my spouse .” Today , the nurse enters the room to administer the client’s morning medications and finds the spouse as shown in the image . A woman in a chair

 What nursing action is most appropriate ?

1. Tell the spouse to sleep in the empty bed in the client’s room, instead of the uncomfortable chair .
2. Offer the spouse to speak with the social worker about resources to assist with the client’s care . C
3. Remind the spouse that she took a vow when they got married that said , “for better or worse
4. ” Ask maintenance about the possibility of bringing a recliner chair to the room for the spouse.

83. The parent of a 3 -year -old child calls the nurse at the pediatrician’s office in a panic . The parent fears that the child who has a fever was given too much over the counter acetaminophen .

After determining that the child is alert , oriented , and not in any distress , what question should the nurse ask the parent to gather more useful information on the issue being reported ?

1. What color was the acetaminophen liquid that you gave your child ? “
2. “Did your child drink all of the acetaminophen that you gave them ? “
3. “What device did you use to measure the acetaminophen ? “
4. “Would you measure the child’s temperature now and tell me what it is?”

84. A client with HIV presents to the clinic reporting not feeling well . The client states , ” haven’t been taking my medication like I should this month . ” Which assessment data indicates possible infection ?

1. Creamy white patches on tongue
2. Oral temperature of 99.2 ° F (37.3 C )
3. Cough producing clear sputum
4. White blood cell count 10, 000 cells / mm 3

85. A client is placed in wrist restraints , and the nurse prepares to maintain client safety while the client is restrained .

 Place the steps the nurse should follow in the correct order from first to last .

 Items to be Ordered

1. Release restraint one at a time if restraints are on both limbs .
2. Document client’s restraint assessment on facility’s restraint documentation record .
3. Observe client and assess circulation , physical status , and emotional wellbeing .
4. Reapply restraint and ensure call bell is within client’s reach
5. Offer toileting , nutrition , fluids, and hygiene and assess for any immobility issues .

86. Nursing Notes Vital Signs 4/6 1430

Handoff Report : This is a 34-year – old client with sickle cell anemia who is a frequent flier here for an acute pain episode . The client also has a history of asthma , but currently lung sounds are clear, and they are not experiencing dyspnea Client currently rates their pain 9/10 primarily in the back and legs and prefers Dilaudid for pain control Between care, they’re usually chatting on the phone with someone or laughing at a show they’re watching , so it’s likely the pain rating is inaccurate . The client is a hard stick , but they showed me where they usually get IVs in, so there is a 22 gauge in the left wrist and the client is currently receiving a 1 -liter bolus of normal saline . Vital signs are stable with 02 saturation of 96% on room air , and the client is afebrile . I’d expect a higher BP and pulse with 9/10 pain so be aware of drug -seeking tendencies

Date:4/6 1415

 Blood:116/74

Heart Rate:85

 Respiratory Date:16

 Temperature :98.8*F (37.1*C)

 The following six questions are part of an unfolding case study.

The medical -surgical nurse receives handoff report before admitting a client from the emergency department (ED ). Which statements made by the ED nurse are inappropriate and suggest the nurse may not be promoting justice for the client? Select all that apply .

1. Drug – seeking “
2. “Laughing at a show”
3. “Client is a hard stick “
4. “Chatting on the phone “
5. ” Acute pain episode “
6. ” Pain rating is inaccurate “
7. Prefers ‘Dilaudid
8. “Frequent flier “
9. “I’d expect a higher BP”

87. The nurse shares their concerns about the handoff report with the nursing manager, who recognizes this is not an isolated incident . The unit cares for many clients with sickle cell disease , so the manager addresses the issues of ethical care and avoiding bias at the staff meeting .

For each statement made by a nurse, click to specify if the statement indicates effective or ineffective teaching.

Nursing Statements    Effective.        Ineffective

• “The words and tone we use can actually affect the care a client receives.”
• For report and documentation, only include opinions relevant to client care.”
• The incidence of opioid addiction in clients with sickle cell disease is quite low.
• The client’s subjective report is the most reliable indicator of pain severity”
• “It’s important to give report where clients or visitors cannot overhear you .

88. Complete the following sentences by choosing from the lists of options. The nurse responds to the client’s question and says, “I understand you are experiencing severe pain. 1 will administer the hydromorphone over (1). |will also (2)”

1. Select answer choice

• 4 minutes
• 10 seconds
• 30 seconds
• 1 minutes

2. Select answer choice

• request a prescription for patient -controlled analgesia
• report the ED nurse to the manager
• bring your capsules for pain control
• remind you of your risk for opioid addiction

89. The nurse reviews the MAR and prepares to administer the client’s scheduled morning medication . What should the nurse gather to complete this task ? Select all that apply .

1. Emesis basin
2. Medicine cup
3. Gown
4. Pill crusher
5. Cup of water
6. Eye shield
7. Mask
8. Applesauce
9. Pill cutter
10. Gloves

90. Click to identify the client information that is most concerning to the nurse on 4/8 . Select your answer by clicking the desired location on the image below . To move a pin , click another location on the image . To remove a pin, click it once .

4/8 0830

Client admitted 2 days ago for vaso- occlusive pain episode. Pain well-controlled on hydromorphone PCA, client reports 3 – 4/10 pain to back and lower extremities . Client now reports pain at the peripheral IV site. Flushes easily but no blood return present . No warmth or erythema to insertion site, but client reports constant dull pain that increases with flushing . Client often requires multiple attempts for successful IV insertion and says, “ Can you just let me put the new one in myself ? They let me do that last time because the nurses always poke me so many times. I know exactly where to do it.” Blood pressure 128/80 , heart rate 90, respirations 20, 95% RATemperature 100.1 F (37.8 °C)

91. The radiology tech arrives to perform the client’s STAT portable chest x- ray, and the nurse finds the client’s significant other beside them in the bed .

 For each response by the nurse , click to specify if the response is appropriate or inappropriate .

• You shouldn’t be on the client’s bed. Security will be called if we find you there again .
• We need you to step out of the room until the x- ray is completed .
• Do you plan to stay overnight ? I will check if there is a cot or recliner available.
• Let’s ask the client if they want you here for this procedure or prefer privacy.
• You will need to move into the bedside chair during this procedure .

92. A new mother expresses concerns that because of the emergency cesarean birth under general anesthesia , she did not have the opportunity to hold and bond with her infant immediately after birth .

The nurse’s response is based on which information ?

1. The mother should focus on parenting her healthy baby and not worry about bonding .
2. The time immediately after birth is a critical period for most people , but it is possible to adapt as needed .
3. Attachment , or bonding , is a process that occurs over time and does not always require early contact .
4. Early contact is essential for optimum parent – infant relationships , especially after a surgical delivery .

93. An infant is seen in the emergency department with a fractured tibia and fibula .

The nurse assesses the client with the knowledge that when infants are seen for fractures , which nursing intervention is a priority ?

1. Assess for genetic factors and variants that increase the risk of fractures
2. No intervention is necessary ; it is not uncommon for infants to fracture bones .
3. Assess for child abuse ; fractures in infants are often non -accidental .
4. Assess the family’s safety practices ; fractures in infants usually result from falls .

94. A client presents to the Emergency Department reporting a painful and swollen ankle after falling while playing soccer and is diagnosed with a sprained ankle . In addition to applying a compression bandage and a splint , which intervention should the nurse perform next ?

1. Document neurovascular status .
2. Place the ankle on two pillows .
3. Administer narcotic medication .
4. Apply heat to the ankle .

95. Orders Laboratory Results 8/3

• Lactulose 300 mg PO BID
• Furosemide 40 mg daily
• Metoprolol 100 mg PO BID

 An older adult client is brought to the emergency department ( ED) by an adult child who states the client has become much more confused in the last day or so with hallucinations . The client will not eat . Upon assessment the nurse finds the client has dry mucous membranes and tenting skin turgor .

Based on the assessment findings , which condition should the nurse anticipate focusing management strategies on to relieve the client’s confusion and hallucinations ?

Lab.                              Reference Range

Total bilirubin               <1.2 mg/dL

  Serum ammonia.      15-45|1/dl

 Aspartate transaminase ( AST)  10 – 40U / L

1. Counseling and medications to treat depression .
2. Intravenous therapy to alleviate hypokalemia . Medications to relieve glaucoma .
3. Fluid resuscitation to manage dehydration

96. A client comes to the clinic for an annual visit and reports ongoing sleep difficulties .

Which measures are appropriate for the nurse to suggest to improve the client’s sleep ? Select all that apply .

1. Keep a sleep log of times asleep .
2. Minimize light when going to sleep .
3. Nap as often as wanted during the day .
4. Exercise before bed to become tired .
5. Watch television when falling asleep .

97. A client presents to the emergency department with reports of lightheadedness . The client reports , “I became dizzy while walking from the bedroom to the bathroom and had to sit down . I thought I was going to fall .” Current vital signs are blood pressure 90/52 , heart rate 114 , temperature 98.6 °F (37 C ), respiratory rate 18 , and SpO2 98 % on room air . The nurse learns that the client takes nitroglycerin for angina and that earlier today the client took one sildenafil tablet that was given to him by a friend before having sexual intercourse .

What does the nurse believe is the likely cause of the client’s condition for which discharge teaching will need to be performed?

1. Dose of the sildenafil was probably too high
2. Because hypotensive from the sexual intercourse
3. May have taken too many nitroglycerin tables
4. Interaction between sildenafil and nitroglycerin

98. A client is admitted to the emergency department following a motor vehicle accident . The client sustained an open femur fracture and multiple lacerations . Estimated blood loss was 1000 mL . The client is on telemetry , and the nurse explains the cardiac rhythm to the client .

Which is the correct statement by the nurse?

1. Your heart is beating in a rhythm that needs to be treated with medications . “
2. Your heart has an irregular rhythm due to the injuries you sustained .”
3. Your heart is beating quickly because of your blood loss and pain .
4. “Your injuries are severe , and your heart Is not reacting well .”

99. The unlicensed assistive personnel (UAP ) working in the nursing home has just arrived for the shift and has taken report from the nurse .

 How should the nurse instruct the UAP in planning care of and communicating with a bedbound client who is deemed grumpy , difficult to care for , and defiant regarding morning care?

1. Greet the client in a cordial manner and start morning care regardless of what the client says .
2. Ask the client , Are you grumpy today ?” If the client says yes , then do not provide morning care .
3. Make the client aware that morning care must be accepted at the time when it is offered .
4. Communicate with client in a pleasant yet firm manner. Agree on a mutual time to provide care

100. The nurse obtains information on a client from a health screening form .

 Which information alerts the nurse and health care provider that the client is at risk for stroke ? Select all that apply .

1. The client has gained about 25 pounds in the last 5 years .
2. The client exercises at his local gym at least 3 times a week .
3. The client drinks 3-4 vodka martini drinks each day .
4. The client takes 5 mg oral glipizide daily for his diabetes .
5. The client’s blood pressure reading runs about 170/96