- The nurse receives a phone call from the mother of a 10-year old child taking methylphenidate (Ritalin) daily. The mother reports the child has lost 2 pounds in the last 2 weeks. Which is the MOST appropriate response by the nurse? 1. "How much does your child exercise on a daily basis?" 2. "Stop giving the Ritalin for several days to see if the appetite improves." 3. "At what time do you give your child the Ritalin medication?" 4. "What is your child's bedtime and when does he usually awaken?"
- A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take FIRST? 1. Check the patency of the catheter. 2. Assess residual urine volume using bladder ultrasonography. 3. Assess the amount of drainage in the urinary drainage bag. 4. Decrease the tension on the catheter.
- The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST? 1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute, shallow respirations at 16/minute. 2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute. 3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute. 4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute.
- Which of the following describes the relationship between blood flow and resistance?
- Which of the following would cause increases resistance to blood flow?
- The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST? 1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test. 2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate. 4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement.
- During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation? 1. Administer the Ceclor as ordered; do not administer the naproxen. 2. Administer the naproxen as ordered; do not administer the Ceclor. 3. Administer both the Ceclor and naproxen as ordered; document the client's response. 4. Do not administer the Ceclor or naproxen; notify the healthcare provider.
- Which of the following causes arteriovenous anastomoses to dilate, allowing blood to bypass capillaries in the skin?
- A 7-year-old boy is brought to the emergency room by his mother following a fall from his bicycle. X-ray reveals healed fractures of the ribs. The child's mother states, "My son is such a careless child; he's always having accidents or fights with his brother." Which response by the nurse would be MOST appropriate? 1. "When I document information about these injuries, it will be on your son's hospital record forever." 2. "How would you describe your son's relationship with his brothers and sisters?" 3. "What I see suggests that someone has been abusing your son." 4. "I will need to talk to the nurse manager about this situation before you leave."
- An LPN/LVN informs the nurse that aspirin 325 mg was given to a client even though 80 mg aspirin had been ordered once daily. The LPN/LVN asks the nurse if it is necessary to complete a medication-error form since "no harm was done." Which statement, if made by the nurse, is BEST? 1. "What do you mean, "no harm was done"? 2. "A medication-error form must be completed whenever the wrong preparation of a medication is given." 3. "I will call the health care provider and ask what should be done to deal with this error." 4. "It is not necessary to complete an incident report with over-the-counter medications."
- The nurse cares for clients on an acute-care surgical area. Which client should the nurse see FIRST? 1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the chest drainage system. 2. The nursing assistive personnel reports that a client who had a thyroidectomy 24 hours ago refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden). 3. The family of a client who had a small bowel resection 48 hours ago reports the client is more confused than yesterday. 4. A client who had an ileostomy 3 days ago complains of "aching legs."
- The nurse cares for an 84-year-old man who appears disheveled, restless and confused. The nurse prepares to administer medication and observes that the client's armband is missing. Which is the MOST appropriate action for the nurse to take? 1. Ask the client's roommate to identify the client. 2. Ask the client to state his name. 3. Ask another nurse to identify the client. 4. Look in the chart at the picture of the client.
- The home health nurse is planning client visits for the day. Which of the following clients should the nurse see FIRST? 1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week. 2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft surgery (CABG). 3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours. 4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain medication.
- A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her husband is coaching her during labor. During the transitional phase of labor, the client begins to scream and grab the side rails with each contraction. Which action, if taken by the nurse, is MOST effective? 1. Offer the client pain medication before her next contraction. 2. Assist the client to a side-lying position with her knees flexed and a pillow between her legs. 3. Establish eye contact with the client and breathe with her. 4. Suggest to the client that she watch television between contractions.
- The nurse teaches the client how to perform a colostomy irrigation. During the teaching, the client states, "I can't do this." Which response, if made by the nurse, is BEST? 1. "Sure you can do this. You just need to have more practice." 2. "I'll do it for you this time, but you must perform the irrigation the next time." 3. "You seem to be frustrated. What are your specific concerns?" 4. "Most of the other clients learn this without any difficulty. Let's try it again."
- A nurse is performing triage in the emergency department. Which of the following clients should the nurse see FIRST? 1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C). 2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C). 3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C). 4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F (37.4° C).
- The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know everything I need to know about it." Which response by the nurse is BEST? 1. "After I explain the operation to you, both of us will sign the form for legal purposes and it will be placed in your chart." 2. "Tell me what the healthcare provider told you about the risks and benefits of this operation." 3. "Can I answer any questions that you have about the procedure?" 4. "You should read all these materials to be sure that you understand everything about this procedure."
- The parents of a newborn boy ask the nurse whether they should have their son circumcised. Which response by the nurse is MOST appropriate? 1. "The benefits of the procedure usually outweigh the risks of bleeding and infection." 2. "You should ask your obstetrician or pediatrician to advise you." 3. "It is not mandatory that your son have a circumcision. What are your concerns?" 4. "Some parents worry about the pain associated with circumcision, but there is actually very little discomfort."
- The client with with a 5-year history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. The client is agitated and verbally abusive. Admission orders include chlordiazepoxide (Librium) 50 mg IM or PO every 4-6 hours for agitation. Which action by the nurse is MOST appropriate? 1. Place the client in chest restraints. 2. Assist the client to the bathroom every 2 hours. 3. Assign a licensed practical nurse to stay with the client. 4. Administer disulfram (Antabuse) 500 mg every 12 hours.
- The school nurse teaches accident-prevention to the parents of school-aged children. Which statement, if made by a parent to the nurse, indicates teaching is effective? 1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his bike." 2. "I keep my guns and ammunition in a locked cabinet in the basement." 3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the monkey bars." 4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."