c) assign one primary nurse to care for the client during the
hospital stay
d) place a linen bag outside of the client's room for discarding
linens after morning care
11. A nursing student is developing a plan of care for a client with
a chest tube that is attached to a Pleur-Evac drainage system.
The nurse intervenes if the student writes which incorrect
intervention in the plan?
a) position the client in semi-fowler's position
b) add water to the suction chamber as it evaporates
c) tape the connection sites between the chest tube and
the drainage system
d) instruct the client to avoid coughing and deep breathing
12. A nurse is caring for a client who has just had a plaster leg
cast applied. The nurse would plan to prevent the development
of compartment syndrome is instructing the licensed practical
nurseassigned to care for the client to:
a) elevate the limb and apply ice to the affected leg
b) elevate the limb and cover the limb with bath blankets
c) place the leg in a slightly dependent position and apply ice to
the affected leg
d) keep the leg horizontal and apply ice to the affected leg
13. A registered nurse (RN) is supervising a licensed practical
nurse (LPN) administering an intramuscular (IM) injection of iron
to an assigned client. The RN would intervene if the LPN is
observed to perform which of the following?
a) changing the needle after drawing up the dose and before
injection
b) preparing an air lock when drawing up the medication
c) using a Z-track method for injection
d) massaging the injection site after injection
14. A nursing student develops a plan of care for a client with
paraplegia who has a risk for injury related to spasticity of the leg
muscles. On reviewing the plan, the co-assigned nurse identifies
which of the following as an incorrect intervention.
a) use of padded restraints to immobilize the limb
b) performing range of motion to the affected limbs
c) removing potentially harmful objects near the spastic limbs
d) use of prescribed muscle relaxants as needed
15. A registered nurse (RN) is observing a licensed practical
nurse (LPN) preparing a client for treatment with a continuous
passive motion (CPM) machine. Which observation by the RN
would indicate that the LPN is performing an incorrect action?
a) places the client's knee in a slightly externally rotated position
b) keeps the client's knee at the hinged joint of the machine
c) assesses the client for pressure areas at the knee and the
groin
d) checks the degree of extension and flexion and the speed of
the CPM machine per the physician's orders
16. A client who is mouth breathing is receiving oxygen by face
mask. The nursing assistant asks the registered nurse (RN) why
b) situational
c) democratic
d) laissez-faire
38. A charge nurse knows that drug and alcohol use by nurses is
a reason for the increasing numbers ofdisciplinary cares by the
Board of Nursing. The charge nurse understands that when
dealing with a nurse with such an illness, it is most important to
assess the impaired nurse to determine:
d) ask the second nurse to refrain from eating and drinking in the
client area
46. A nurse is working in the emergency department of a small
local hospital when a client with multiple gunshot wounds arrives
by ambulance. Which of the following actions by the nurse is
contraindicated in the handling legal evidence?
a) initiate a chain of custody log
b) give clothing and wallet to the family
c) cut clothing along seams, avoiding bullet holes
c) keeps the child dry while on the cooling blanket to reduce the
risk of frostbite
b) places the cooling blanket on the bed and covers the blanket
with a sheet
d) checks the skin condition of the child before, during, and after
the use of the cooling blanket
52. A nursing instructor asks a nursing student to identify
situations that indicate a secondary level of prevention in health
care. Which situation, if identified by the student, would indicate
the need for further study of the levels of prevention?
a) teaching s stroke client how to use a walker
b) screening for hypertension in a community group
nurse reviews the plan of care with the student and will instruct
the student to remove which of hte following interventions?
a) a foot board
b) extra pillows
c) a bed trapeze
d) an electric bed
incorrect.
If you had difficulty with this
question, review critical paths.
7) C
- Tertiary prevention involves the reduction of
the amount and degree of disability, injury,
and damage following a crisis. Primary
prevention means keeping the crisis from
occurring, and secondary prevention focuses
on reducing the intensity and duration of a
crisis during the crisis itself. There is no known
aggregate care prevention level.
8) A
- The primary technique that can used to
handle resistance to change during the
change process is to introduce the change
gradually. Confrontation is an important
strategy used to meet resistance when it
occurs. Coercion is another strategy that can
be used to decrease resistance to change but
is not always a successful technique for
managing resistance. Manipulation usually
involves a covert action, such as leaving out
pieces
of
vital
information
that
the
participants might receive negatively. It is not
the best method of implementing a change.
9) B
- In the preicteric phase, the client has
nonspecific complaints of fatigue, anorexia,
nausea, cough, and joint pain. Options A, C,
and D are clinical manifestations that occur in
the icteric phase. In the posticteric phase,
jaundice decreases, the color of urine and
stool return to normal, and the clients
appetite improves.
10) A
- The client with an internal cervical radiation
implant should be placed in a private room at
the end of the hall because this location
provides less of a chance of exposure of
radiation to others. The clients room should
be marked with appropriate signs that indicate
the presence of radiation. Visitors should be
limited to 30-minute visits. Nurses assigned to
this client should be rotated so that one nurse
is not consistently caring for the client and
24) D
Mobility
of
the
client
with
hyperparathyroidism should be encouraged as
much as possible because of the calcium
imbalance that occurs in this disorder and the
predisposition to the formation of renal calculi.
Fluids should not be restricted. Options A and
C are not specifically associated with this
disorder.
25) A
Nurse-managed
clinics
focus
on
individualized disease prevention and health
promotion and maintenance. Therefore the
nurse must first assess the clients and their
needs in order to effectively plan the program.
Options B, C, and D do not address the clients'
needs.
26) C
- In this situation, the nurse has noted an
unusual occurrence, but before deciding what
action to take next, the nurse needs more
data than just suspicion. This can be obtained
by reviewing the client's record. State and
federal labor and opioid regulations, as well as
institutional policies and procedures, must be
followed. It is therefore most appropriate that
the nurse discuss the situation with the
nursing supervisor before taking further
action. The client does not need an increase in
opioids. To reassign the LPN to clients not
receiving opioids ignores the issue. A
confrontation is not the most advisable action
because it could result in an argumentative
situation.
27) A
- Myasthenia gravis can affect the client's
ability to swallow. The primary assessment is
to determine the client's ability to handle oral
medications or any oral substance. Options B
and C are not appropriate. Option B could
result in aspiration and option C has no useful
purpose. There is no specific reason for the
client to void before taking this medication.
28) D
29) D
33) C
Case
management
represents
an
interdisciplinary health care delivery system
to promote appropriate use of hospital
personnel and material resources to maximize
hospital revenues while providing for optimal
client care. It manages client care by
managing the client care environment.
30) C
- Variances are actual deviations or detours
from the critical paths. Variances can be either
positive or negative, or avoidable or
unavoidable and can be caused by a variety of
things. Positive variance occurs when the
client achieves maximum benefit and is
discharged earlier than anticipated. Negative
variance occurs when untoward events
prevent a timely discharge. Variance analysis
occurs continually in order to anticipate and
recognize negative variance early so that
appropriate action can be taken. Option B is
the only option that identifies the need for
further action.
34) C
Option C empowers the charge nurse to assist
the staff nurse while trying to identify and
reduce the behaviors that make it difficult for
the staff nurse to function. Options A, B, and D
are punitive actions, shift the burden to other
workers, and do not solve the problem.
31) D
35) D
32) A
36) A
- Variance analysis occurs continually as the
case manager and other caregivers monitor
client outcomes against critical paths. The
goal of critical paths is to anticipate and
recognize negative variance early so that
appropriate action can be taken. A negative
variance occurs when untoward events
preclude a timely discharge and the length of
stay is longer than planned for a client on a
37) A
41) C
38) D
- A nurse must be able to function at a level
that does not affect the ability to provide safe,
quality care. The highest priority is to
determine how the illness affects the nurse's
ability to practice. The other options will be
addressed if an investigation is carried out.
39) C
- When beginning the change process, the
nurse should identify and define the problem
that needs improvement or correction. This
important first step can prevent many future
problems, because, if the problem is not
correctly identified, a plan for change may be
aimed at the wrong problem. This is followed
by goal setting, prioritizing, and identifying
potential
solutions
and
strategies
to
implement the change.
40) B
- Tonic-clonic seizures cause tightening of all
body muscles followed by tremors. Obstructed
airway and increased oral secretions are the
major complications during and following a
seizure. Suction is helpful to prevent choking
and cyanosis. Options A and C are incorrect
because inserting an endotracheal tube or a
tracheostomy is not done. It is not necessary
42)D
- Chlamydia is a sexually transmitted disease.
Caregivers cannot acquire the disease during
administration
of
care,
and
standard
precautions are the only measure that needs
to be used.
43) C
- Proper care of an indwelling urinary catheter
is especially important to prevent prolonged
infection or reinfection in the client with
cystitis. The perineal area is cleansed
thoroughly using mild soap and water at least
twice a day and following a bowel movement.
The drainage bag is kept below the level of
the bladder to prevent urine from being
trapped in the bladder, and, for the same
reason, the drainage tubing is not placed or
looped under the client's leg. The tubing must
drain freely at all times.
44) D
- A client with acute glomerulonephritis
commonly experiences fluid volume excess
and fatigue. Interventions include fluid
restriction as well as monitoring weight and
intake and output. The client may be placed
on bed rest or at least encouraged to rest,
because a direct correlation exists between
proteinuria, hematuria, edema, and increased
activity levels. The diet is high in calories but
52) A
- Secondary prevention focuses on the early
diagnosis and prompt treatment of disease.
Tertiary prevention is represented by
rehabilitation services. Options B, C, and D
identify screening procedures. Option A
identifies a rehabilitative service.
53) B
- When the nurse asks a "why" question of the
client, the nurse is requesting an explanation
for feelings and behaviors when the client
may not know the reason. Requesting an
explanation is a nontherapeutic
communication technique. In option A, the
nurse is encouraging the verbalization of
emotions or feelings, which is a therapeutic
communication technique. In option C, the
nurse is using the therapeutic communication
technique of exploring, which involves asking
the client to describe something in more detail
or to discuss it more fully. In option D, the
nurse is using the therapeutic communication
technique of giving information. Identifying
the common fear of death among clients with
end-stage heart failure may encourage the
client to voice concerns.
54) D
- When communicating with a hearingimpaired client, the nurse should speak in a
normal tone to the client and should not
shout. The nurse should talk directly to the
client while facing the client, and he or she
should speak clearly. If the client does not
seem to understand what is being said, the
nurse should express the statement
differently. Moving closer to the client and
toward the better ear may facilitate
communication, but the nurse needs to avoid
talking directly into the impaired ear.
55) A
- After tonsillectomy, suction equipment
should be available, but suctioning is not
performed unless there is an airway
obstruction. Clear, cool liquids are
encouraged. Milk and milk products are
avoided initially because they coat the throat;
this causes the child to clear the throat,
thereby increasing the risk of bleeding. Option
C is an important intervention after any type
of surgery.
56) C
58) D
- The skin is cleansed with soap and water
(not Betadine), denatured with alcohol, and
allowed to air-dry before electrodes are
applied. The other three options are correct.
59) A
- A quiet, restful environment is provided as
part of seizure precautions. This includes
undisturbed times for sleep, while using a
nightlight for safety. The client should be
accompanied during activities such as bathing
and walking, so that assistance is readily
available and injury is minimized if a seizure
begins. The bed is maintained in low position
for safety.
60) B
- According to category-specific (respiratory)
isolation precautions, a client with TB requires
a private room. The room needs to be wellventilated and should have at least six
exchanges of fresh air per hour and should be
ventilated to the outside if possible. Therefore,
option 2 is the only correct option.