Module 3

Question 1

An 87 year old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. What intervention is most important to protect him from injury

Answer 1

provide a bedside commode

Question 2

A mother and her 3 year old live at home built in 1932. What NANDA RN Dx is the most applicable for the child?

Answer 2

Risk for poisoning

Question 3

A 75 year old client, hospitalized with a CVA becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?

Answer 3

Use a bed exit safety monitoring device

Question 4

What RN intervention is the highest in priority for a client at risk for falls in a hospital setting?

Answer 4

Place the bed in the lowest position

Question 5

When planning to teach healthcare topics to a group of male adolescents, what topic is the highest priority

Answer 5

Guns are the most frequently used weapon for adolescent suicide

Question 6

A client tells the nurse “This pill is a different color than the one that I usually take at home.” What is the best response by the nurse?

Answer 6

I will recheck your medication orders

Question 7

What is missing from this order:

Codeine q4-6 hours, PO. PRN for pain

Answer 7

dosage is missing

Question 8

PCP ordered 5 mL of a med to be given IM to a 40 year old female who weighs 135 and is 5’7” tall. What is an appropriate method of administration

Answer 8

Two 3mL syringes, #20-#23 gauge, 1 1/2 inch needle

Question 9

An older client with renal insufficiency is to receive a cardiac med. What is the nurse most likely to administer

Answer 9

decreased dosage

Question 10

Proper administration of an otic med to a 2 year old client includes

Answer 10

pull the ear down and back

Question 11

what client is at greater risk for experiencing sensory overload

Answer 11

An 80 year old client admitted for emergency surgery

Question 12

An alert 80 year old client is transferred to a LTC facility. On the 2nd night he becomes confused and agitated. What are 2 RN Dx?

Answer 12

Acute confusion

Disturbed sensory perception

Question 13

The RN Dx risk Risk for Impaired Skin Integrity R/T sensory-perception disturbance would best fit a client who…

Answer 13

uses a W/C due to paraplegia

Question 14

What does this statement indicate about a client’s needs:

“I can’t hear the doorbell.”

Answer 14

client needs a sensory aid

Question 15

A hospitalized client is disoriented and believes she is in a train station. What response from the nurse is most appropriate?

Answer 15

“It may seem like a train station sometimes but, this is Valley Hospital.”

Question 16

A PCP writes a prescription for 0.15 mg of digoxin IV every day. The med is available in a concentration of 400 mcg/mL. How many mL will the RN administer?

Answer 16

~0.38 mL

Question 17

A RN student is preparing to administer insulin to a client with diabetes. What’s the correct order for the administration of this drug? (8)

Answer 17

1. Mix the insulins
2. Assess the skin for the injection
3. Cleanse the site with alcohol
4. Pinch the skin lightly
5. Insert the needle quickly into the SubQ tissue
6. Inject the medication
7. Count to 5
8. Remove the syringe

Question 18

A client with impaired vision is admitted to the hospital. What interventions are most appropriate to meet the clients needs? (3)

Answer 18

1. Identify yourself by name
2. Stay in the clients field of vision
3. Explain the sounds in the environment

Question 19

Medication errors can place the client at significant risk. What practices will help decrease the possibility of errors

Answer 19

Establish a reporting system for “near misses
Communicate effectively
Create a culture of trust

Question 20

The RN, at shift change, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, trying to get out of bed, and pulled out the IV line which was subsequently reinserted. What actions by the RN is appropriate?

Answer 20

Document the behaviors that require continued use of the restraints
Provide ROM when restraints are removed
Orient the client
Assess the tightness of the restraints

Question 21

The RN is to administer 0.75 mL of meds SQ in the upper arm to a 300 lb pt. the RN can grasp approx 2 inches of the clients tissue. What needle is most appropriate?

Answer 21

2 mL syringe, #25 gauge, 5/8 needle

Question 22

The RN is to administer a TB test to a client who is 6 ft tall and weighs 180 lbs. what is the most appropriate needle for the RN to use?

Answer 22

TB syringe, #25-27 gauge, 1 1/2 inch needle

Question 23

A client is exhibiting S/S of acute confusion/delirium. What strategy should the nurse implement to promote a therapeutic environment?

Answer 23

Keep the room organized and clean

Question 24

A client is at risk for sensory deprivation. What 3 clinical signs would the RN observe?

Answer 24

Deceased attention span
Excessive sleeping
Crying, depression

Question 25

The RN is assessing for sensory function. What assessment tool matches the specific sense it will be testing?

1. Visual
2. Hearing
3. Tactile
4. Olfactory
5. Gustatory

Answer 25

1. Snellen chart
2. Tuning fork
3. Stereognosis
4. Identifying aromas
5. Identifying taste

Question 26

An 85 year old client has impaired hearing. When creating the care plan, which intervention should have the highest priority?

Answer 26

Obtaining an amplified telephone

Question 27

3 types of griefs that are considered normal or “healthy”?

Answer 27

Abbreviated
Anticipatory
Disenfranchised

Question 28

A clients family tells the RN that their culture does not permit a dead person to be left alone before burial. Hospital policy states that after 1800 when mortuaries close, bodies are to be stored in the hospital morgue fridge until the next day. How would the nurse best manage this situation

Answer 28

Inquire of the nursing supervisor how an exception to the policy could be made

Question 29

The shift changed while the RN staff was waiting for the adult children of a deceased client to arrive. The oncoming RN has never met the family. What initial greeting is most appropriate?

Answer 29

I’m very sorry for your loss

Question 30

At what age does a child begin to accept that he or she will someday die?

Answer 30

9-12 years old

Question 31

An 82 year old man has been told by his PCP that is no longer safe for him to drive a car. What statement by the client would indicate beginning positive adaptation to this loss?

Answer 31

Well at least I have friends and family who can take me places

Question 32

When asked to sign the permission form for the surgical removal of a large but noncancerous lesion on her face, the client begins to cry. What response by the RN is most appropriate?

Answer 32

Tell me what it means to you to have this surgery

Question 33

A nursing care plan includes the desired outcome of “quality of life” for a client with a chronic degenerative illness who is likely to live for many more years. What is an example that would indicate the outcome has been met?

Answer 33

The client verbalized satisfaction with current relationships with other people

Question 34

The RN is caring for a family in a shelter 2 days after the loss of their home due to a fire. The fire caused minor burns to several members of the family but no life threatening conditions. What is the most important assessment data for the RN to gather at this time?

Answer 34

Family members fried responses and coping behaviors

Question 35

The client has been close to death for some time and the family asks how the RN will now when the client has actually died. What is the most accurate response from the RN?

Answer 35

When there is no apical pulse

Question 36

In working with a dying client, the RN demonstrates assisting the client to die with dignity when performing which action?

Answer 36

Allows the client to make as many decisions about care as possible