Practice Qs

Question 1

The adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse’s first response?
A. “It is important that you continue your medication while learning to meditate”

B. “Spiritual meditation requires a time commitment of 15 to 20 minutes daily.”

C. Obtain your HCP permission before starting meditation.

D. Complementary therapy and western medicine can be effective for you.

Answer 1

A.
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued.

Question 2

A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the practical nurse implement to maximize the client’s oxygenation?

A. Encourage deep breathing prior to suctioning.
B. Increase the oxygen flow rate during suctioning attempts.
C. Provide oxygen during rest periods between suctioning.
D. Limit suctioning attempts to five second intervals.

Answer 2

C. Provide oxygen during rest periods between suctioning.

When a client is unable to effectively clear respiratory tract secretions with coughing, suctioning with oxygen during rest periods of 10 to 15 seconds between suction attempts should be provided to ensure maximal oxygenation.

Question 3

A young woman, who is the primary caregiver for her mother who has Alzheimer’s disease, tells the practical nurse (PN), “Sometimes I hate my mother for living this long and my Dad for dying and not caring for her.” What response should the PN offer?

A. What you do to cope with these feelings?
B. Have you told your family how you feel?
C. It’s normal feel these emotions when you are stressed.
D. Don’t worry, at least you can talk about your angry

Answer 3

A. What you do to cope with these feelings?

A response that invites the client to share feelings and perceptions is the most therapeutic communication.

Question 4

Which action should the practical nurse (PN) follow when applying an elasticized bandage to a client’s leg?

A. Secure the end with metal clips.
B. Overlap turns of the bandage equally.
C. Adjust the tension as needed.
D. Wrap from the proximal to distal end.

Answer 4

B. Overlap turns of the bandage equally.

Question 5

The practical nurse (PN) obtains an elevated blood pressure reading for an older male client who is alert. When the PN offers the client his morning blood pressure medication, he refuses to take it. What action should the PN take?

A. Mixed the crushed medication in his breakfast oatmeal.
B. Explain the importance of routine use of antihypertensives.
C. Tell the client that he should not refuse his prescriptions.
D. Document that the client refused to take the medication.

Answer 5

B. Explain the importance of routine use of antihypertensives.

A client has the right to refuse any medication but should be informed of the therapeutic value of routine compliance with taking antihypertensive medications.

Question 6

The practical nurse (PN) hears breath sounds that are short, popping, and discontinuous on inspiration when auscultating a client’s lungs. Which description should the PN document in the client’s record?

A. Wheezes present.
B. Crackles auscultated.
C. Pleural friction rub noted.
D. Bronchovesicular sounds heard.

Answer 6

B. Crackles are short, popping, discontinuous sounds heard on inspiration.

Question 7

The practical nurse (PN) is obtaining information for a male client’s psychosocial assessment. Which action should the PN implement first?

A. Determine the value the client places on his health
B. Establish a therapeutic relationship
C. Determine is he has abnormal behaviors
D. Ask the client to share info about his past

Answer 7

B. Establish a therapeutic relationship

Question 8

A client is prescribed a medication that is labeled as a sustained released (SR). What action should the practical nurse (PN) implement when administering this drug form?

A. Instruct the client to chew the medication.
B. Do not crush or dissolve the tablet or capsule contents.
C. Obtain a different drug form for administration.
D. Delay giving the medication until the stomach is empty.

Answer 8

B. Sustained-release tablets or capsules are drug forms that are coated and delay dissolution over a period of time and should not be crushed or dissolved for administration

Question 9

The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates that the teaching has been effective?
A. “If i exercise at least two times weekly for one hour, I will lower my cholesterol.”

B. “I need to avoid eating proteins, including red meat.”

C. “I will limit my intake of beef to 4 oz per week.”

D. “My blood level of low density lipoproteins.”

Answer 9

C.

Limiting saturated fat from animal food sources to no more than 4 oz per week is important diet modification for lower cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4-6 times per week.

Question 10

What nutritional assessment data should the nurse collect to best reflect total muscle mass in the adolescent?

A. Height in Inches or centimeters.
B. Weight in kilograms or pounds.
C. Triceps skin fold thickness
D. Upper arm circumference

Answer 10

D.
Upper arm circumference is an indirect measure of muscle mass. A and B do not distinguish between fat and muscularity. C is a measure of body fat.

Question 11

The client who is in the hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic Q4H as needed. Which action should the nurse implement?

A. Give an around the clock schedule for administration of analgesics.

B. Administer analgesic medication as needed when the pain is severe.

C. Provide medication to keep the client sedated and unaware of stimuli.

D. Offer a medication-free period so that the client can do daily activities

Answer 11

A.
The most effective management of pain is achieved using an around the clock schedule that provides analgesic medication on a regular basis and in a timely manner.

Question 12

An unlicensed assistive personnel (UAP) places a client in the left lateral position prior to administration a soap suds enema. Which instruction should the nurse provide the UAP?

A. Position the client on the right side of the bed in reverse Trendelenburg.

B. Fill the enema container with 1000 ml of warm water and 5 ml of Castile soap.

C. Reposition in a Sims position with the clients weight on the anterior ilium

D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Answer 12

C.
The left sided sims position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results.

Question 13

A client who is 5’5 tall and wieghs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse t0 include during the preoperative assessment?

A. What is your daily caloric consumption?

B. What vitamin and mineral supplements do you take?

C. Do you feel that you are overweight?

D. Will a clear liquid diet be okay after surgery?

Answer 13

B.

Vitamin and mineral supplements may impact medications used during the operative period.

Question 14

What action should the nurse implement when accessing the implanted infusion port for a client who receives long term IV medications?

A. Cleanse the site with iodine solution

B. Insert a Huber-point needle into the port

C. Flush the tubing with 5 ml of NS

D. Place a sterile dressing over the port

Answer 14

B.
An implanted infusion port needs to be accessed using a huber-point needle to prevent damage to the self sealing septum of the port

Question 15

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline with potassium chloride 20 meq at 83 ml/hr. The clients eight hour urine output is 400 ml, BUN is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl and the serum potassium is 3.7 meq/L. Which action is most important for the nurse to implement?

A. Notify the HCP and request to change the IV infusion to hypertonic D10W

B. Decrease the infusion rate of the current IV and report to the HCP

C. Document in the medical record that these normal findings are expected outcomes

D. Obtain potassium chloride 20 meq in anticipation of a prescription to add to present IV

Answer 15

C.

The results are all within normal range

Question 16

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

A. Loosen the right wrist restraint

B. Apply a pulse oximeter to the right hand

C. Compare hand color bilaterally

D. Palpate the right radial pulse

Answer 16

A.
The priority nursing action is to restore circulation by loosening the restraint, because blue fingers indicates decreased circulation.

Question 17

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
A. Infuse normal saline at a keep vein open rate.
B. Discontinue the IV and flush the port with heparin.
C. Infuse 10 percent dextrose and water at 54 ml/hr.
D. Obtain a stat blood glucose level and notify the healthcare provider.

Answer 17

TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation.
Correct Answer: C

Question 18

Which action is most important for the nurse to implement when donning sterile gloves?
A. Maintain a thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above elbows.
D. Put the glove on the dominant hand first.

Answer 18

C
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).

Question 19

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.

Answer 19

A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.
Correct Answer: B

Question 20

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?
A. Reaffirm the client’s desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client’s impending death.
D. Notify the healthcare provider of the family’s request.

Answer 20

The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented.
Correct Answer: D

Question 21

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
A. Adequate venous blood flow to the lower extremities.
B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client’s knee joint.
D. Change in the circumference of the joint in centimeters.

Answer 21

The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).
Correct Answer: C

Question 22

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
A. Complimentary healing practices interfere with the efficacy of the medical model of treatment.
B. Conventional medications are likely to interact with folk remedies and cause adverse effects.
C. Many complimentary healing practices can be used in conjuntion with conventional practices.
D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

Answer 22

C
Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).

Question 23

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Answer 23

Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.
Correct Answer: C

Question 24

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?
A. Generalized dry skin
B. Localized dry skin on lower extremities
C. Red flush over entire skin surface
D. Rashes in the axillary, groin and skin fold regions.

Answer 24

D
Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown and teh development of pressure ulcers (A, B, and C) do not address the concepts of inflammation and tissue integrity.

Question 25

While instructing a male client’s wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion.

Answer 25

The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement.
Correct Answer: A

Question 26

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels warm.
D. The body’s receptors adapt over time as they are exposed to heat.

Answer 26

(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client.
Correct Answer: D

Question 27

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use.

Answer 27

The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client’s nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D).
Correct Answer: B

Question 28

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client’s risk of infection?
A.Administration of plasma expanders

B.Use of careful handwashing technique

C.Application of a topical antibacterial cream

D.Limiting visitors to the client with burn

Answer 28

B.
The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client’s risk of infection?Rationale:
Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

Question 29

The health care provider has changed a client’s prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?
A.The client will experience increased tolerance to the drug’s effects and may need a higher dose.

B.The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.

C.The medication will be more highly protein-bound, increasing the duration of action.

D.The therapeutic index will be increased, placing the client at greater risk for toxicity

Answer 29

B.
Rationale:
Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug’s therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

Question 30

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
A.”At home I take my pills at 8:00 am.”

B.”It costs a lot of money to buy all of these pills.”

C.”I get so tired of taking pills every day.”

D.”This is a new pill I have never taken before.”

Answer 30

D.
Rationale:
The client’s recognition of a “new” pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client’s feelings C should be acknowledged, but observation of the five rights of medication administration is most essential.

Question 31

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, “I want to go outside now and smoke. It takes forever to get anything done here!” Which intervention is best for the nurse to implement?
A.Encourage the client to use a nicotine patch.

B.Reassure the client that it is almost time for another break.

C.Have the client leave the unit with another staff member.

D.Review the schedule of outdoor breaks with the client.

Answer 31

D.
Rationale:
The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules.

Question 32

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
A.Consult with the pharmacist about the need to continue the medication.

B.Administer the antihypertensive medication as prescribed preoperatively.

C.Withhold the medication until the client is fully alert and vital signs are stable.

D.Contact the health care provider to renew the prescription for the medication.

Answer 32

D.
Rationale:
Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

Question 33

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?
A.Instruct in the use of the incentive spirometer.

B.Elevate the head of the bed during all meals.

C.Use aseptic technique to change the dressing.

D.Encourage frequent ambulation in the hallway.

Answer 33

D.
Rationale:
Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.

Question 34

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.)
A. Place the client in a high Fowler position.

B. Help the client assume a left side-lying position.

C. Measure the tube from the tip of the nose to the umbilicus.

D. Instruct the client to swallow after the tube has passed the pharynx.

E. Assist the client in extending the neck back so the tube may enter the larynx.

Answer 34

Rationale:
(A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

Question 35

The nurse selects the best site for insertion of an IV catheter in the client’s right arm. Which documentation should the nurse use to identify placement of the IV access?
A. Left brachial vein

B. Right cephalic vein

C. Dorsal side of the right wrist

D.Right upper extremity

Answer 35

B.
Rationale:
The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

Question 36

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.

B. Confirm placement of the tube.

C. Use a syringe to instill the medications.

D. Turn off the intermittent suction device.

Answer 36

D.
Rationale:
The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction.

Question 37

In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
A. Check the bath water temperature.

B. Shut the bathroom door.

C. Ensure that the client has voided.

D. Provide extra towels.

Answer 37

A.
Rationale:
To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety.

Question 38

Which client is most likely to be at risk for spiritual distress?
A. Roman Catholic woman considering an abortion

B. Jewish man considering hospice care for his wife

C. Seventh-Day Adventist who needs a blood transfusion

D. Muslim man who needs a total knee replacement

Answer 38

A.
Rationale:
In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah’s Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

Question 39

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?
A. “Fill your lungs with air through your mouth and then compress the inhaler.”

B. “Compress the inhaler while slowly breathing in through your mouth.”

C. “Compress the inhaler while inhaling quickly through your nose.”

D. “Exhale completely after compressing the inhaler and then inhale.”

Answer 39

B.
Rationale:
The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

Question 40

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement?
A. Stay with the client while the client is standing.

B. Record the findings on the graphic sheet in the chart.

C. Keep the blood pressure cuff on the same arm.

D.Record changes in the client’s pulse rate.

Answer 40

A.
Rationale:
Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

Question 41

The nurse is using a standard framework and professional norms when preparing a change-of-shift report. What are some other ethical strategies the nurse needs to employ when preparing this report? Select all that apply
1. Respect assumptions.

2. Monitor language and tone.
3. Adopt a “need-to-know” policy.
4. Be alert to the presence of gossip.
5. Try to limit the use of obscene language.
6. Hold yourself and one another accountable.

Answer 41

2, 3, 4, 6

Some ethical strategies to use when preparing a change-of-shift report include the following: monitoring language and tone, adopting a “need-to-know” policy, being alert to the presence of gossip, and holding oneself and one another accountable. Respecting assumptions and limiting the use of obscene language are not appropriate strategies. Change-of-shift report is given from one caregiver to another caregiver who is taking on responsibility for the client’s care to ensure continuity of care.