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Q:
The nurse working in the emergency department is caring for a client who experienced deep-thickness burns over 40% of the body and is in shock. Which order should the nurse anticipate for this client?
1. Electrolyte solutions
2. Volume expanders
3. Nutrient solutions
4. Total parenteral nutrition
Q:
The nurse is caring for a client with a medical diagnosis of increased intracranial pressure. Which IV fluid order should the nurse accept without questioning?
1. Normal saline at 125 mL/hour.
2. Dextrose 5% and water at 80 mL/hour.
3. Dextrose 5% and 0.45% NaCl at 75 mL/hour.
4. Normal saline 0.45% at 200 mL/hour.
Q:
A client receiving an infusion of Dextrose 5% and water complains of a burning pain along the course of the vein. The site is red, warm, and is mildly edematous. Which term should the nurse use when documenting these findings?
1. Phlebitis at the IV insertion site
2. IV infiltrate
3. Extravasated vesicant drug
4. Extravasation
Q:
The nurse is initiating IV therapy for an adult client who requires IV fluid infusion for 2"3 days and might require blood administration. What should the nurse choose as the best option for IV catheterization?
1. Butterfly
2. Huber needle
3. Angiocatheter
4. Implantable venous access device
Q:
A client is recovering from hip arthroplasty using the anterolateral approach. What should the nurse ensure to maintain the integrity of the joint?
1. Place needed items on operative side
2. Keep needed items on the non-operative side
3. Instruct to avoid bending at the waist to put on shoes
4. Instruct to avoid crossing the operative leg past the body's midline
Q:
The nurse is assisting a client recovering from spinal fusion surgery with the application of a back brace. What action should be done prior to placing the brace on the client?
1. Apply lotion to the skin
2. Assist the client to put on a T-shirt
3. Measure the client's abdominal girth
4. Dust the skin with baby or corn powder
Q:
A client's x-ray report shows a fractured leg where one part of fractured bone is driven into another. How should the nurse document this client's fracture?
1. Impacted
2. Greenstick
3. Comminuted
4. Compression
Q:
A client comes into the emergency department with a soft tissue ankle sprain. In which order should the nurse instruct the client to treat this injury at home?
1. Apply ice
2. Rest the ankle
3. Elevate the foot
4. Apply an ace bandage
Q:
The nurse is caring for a client who is in skin traction. Which nursing actions are appropriate for this client?
Standard Text: Select all that apply.
1. Assess neurovascular status every 4 hours, once stable.
2. Place sheep skin under pressure areas.
3. Massage the skin with lotion or alcohol every 4 hours if redness is noted.
4. Remove the weight first when removing nonadhesive traction.
5. Use a fracture bedpan to minimize movement during elimination.
Q:
The nurse is providing care to a client who has a short arm cast. Which nerve areas should the nurse assess to determine if irritation is occurring?
Standard Text: Select all that apply.
1. Radial
2. Ulnar
3. Median
4. Peroneal
5. Tibial
Q:
The nurse caring for a client in traction inspects the apparatus and determines all is well when noting which finding?
1. The weight is sitting on the floor.
2. The rope is on the side of the pulley.
3. The knots are positioned 5 inches from the pulley.
4. All ropes are intact and connected with slipknots, and short ends are taped.
Q:
The nurse caring for a client with a plaster cast applied several days ago notes crumbs of plaster on the skin just under the edge of the cast. Which action by the nurse is the most appropriate?
1. Leaving the crumbs there to avoid injuring the skin
2. Using a surgical scrub brush to remove the crumbs
3. Using a dry cloth to remove the crumbs to avoid wetting the cast
4. Pull inner stockinette out and over the edge and secure with tape
Q:
The nurse working in the emergency department (ED) is assisting the health care provider with cast application. Which nursing action is the most appropriate after the health care provider completes application of the cast?
1. Holding the casted arm from the top of the cast to place it in a splint
2. Holding the casted arm from the top of the cast to place it on pillows
3. Using the palm of the hand to place the casted arm into a splint
4. Using the palm of the hand to place the casted arm on pillows
Q:
The nurse admits a client from the emergency department (ED) with a newly placed leg cast. Which actions should the nurse perform to prevent neurovascular impairment?
Standard Text: Select all that apply.
1. Assess the toes for nerve and circulatory impairment every hour for 8 hours.
2. Place the leg on pillows.
3. Apply ice to the site.
4. Elevate the foot of the bed.
5. Report excessive swelling or indications of neurovascular impairment.
Q:
Which task could be safely delegated by the nurse to the unlicensed assistive personnel (UAP)?
1. Caring of the client with the newly placed cast
2. Explaining to the client how to respond to itching under the cast
3. Caring of the insertion site for Crutchfield tongs
4. Caring of the client with a stable cast
Q:
An adolescent client newly placed in traction says, "Lying in this bed all the time is going to turn my body into mush. Is there any way I could exercise while I'm in traction?" Which response by the nurse is the most appropriate?
1. "Many people worry about muscle weakness when they are confined to bed. You could perform range of motion, isometric, and specific exercises."
2. "Don't worry about your muscles, because you can get them back after you get out of traction."
3. "You're young and in great shape. Your muscles won't weaken with a few weeks in bed."
4. "I'll put a referral in for physical therapy to come and work with you."
Q:
A client with a new case is complaining of itching under the cast. Which should the nurse instruct this client?
1. Use a back scratcher to scratch under the cast.
2. Use a wooden spoon to scratch inside the cast.
3. Blow air from a hair dryer set to cool under the cast, or apply ice.
4. Take an antihistamine to reduce itching.
Q:
The nurse working in the emergency department (ED) is providing discharge teaching for a client with a newly applied cast to the left arm. Which statement by the client indicates additional teaching is required?
1. "When I take a shower, I will put a plastic bag over my cast and keep it dry."
2. "When my fingers feel cold, I will cover them with a blanket."
3. "I will go home today and put ice on the cast over the fracture and prop it on pillows."
4. "If I lose sensation in my fingers, I will call my doctor."
Q:
For which client should the nurse anticipate a plaster cast would be used?
1. The client with a diagnosis of amyotrophic lateral sclerosis (ALS)
2. The client who had a compound fracture and multiple lacerations
3. The older adult client with muscle wasting secondary to cancer
4. The client with a fractured femur who plans to return to construction work before cast removal
Q:
The nurse observes the health care provider apply a cast made of strips of open-weave cotton saturated with powdered calcium sulfate crystals. When documenting this procedure, which term should the nurse use for this type of cast?
1. Plaster cast
2. Synthetic cast
3. Fiberglass cast
4. Thermoplastic cast
Q:
The nurse is caring for a client with a fracture of cervical vertebrae 4. Which piece of equipment connects the client to traction for this type of injury?
1. Pearson attachment
2. Buck's extension
3. Thomas splint
4. Crutchfield tongs
Q:
A client receiving an opiate for postoperative pain management is experiencing nausea and vomiting. What action would be the most beneficial for the client?
1. Provide an emesis basin
2. Maintain on NPO status
3. Keep Narcan at the bedside
4. Administer an antiemetic as prescribed
Q:
The nurse notes that a client is scheduled to receive conscious sedation for a surgical procedure. What should the nurse review prior to preparing the client for this type of anesthesia?
1. Adverse effects
2. Reversal agents
3. State nurse practice act
4. Assignment of a student nurse
Q:
The nurse is preparing preoperative medications for a client. Which medication will reduce the amount of respiratory secretions?
1. Opiate
2. Antibiotic
3. Antianxiolytic
4. Anticholinergic
Q:
Before beginning a surgical procedure the safety checklist is reviewed. Which information is necessary prior to starting this client's case?
1. Date of birth
2. Known allergies
3. Last urine output
4. Family members' names
Q:
The nurse is caring for a client who had surgery a day ago. Which observation indicates that the client was physically prepared for the procedure?
1. Does leg exercises 3 times a day
2. Rates pain as 5 on a scale from 0 to 10
3. Permits staff to reposition in bed every 2 to 4 hours
4. Deep breathes and coughs every 2 hours while awake
Q:
A client is highly anxious about an upcoming surgical procedure. What action should the nurse take to reduce this client's anxiety?
1. Answer the client's questions
2. Provide written teaching material
3. Instruct on range of motion exercises
4. Assign to review videotapes prior to teaching
Q:
A client scheduled for surgery is demonstrating mild levels of stress. How should this stress level affect the client's recovery? Select all that apply.
1. Increased alertness
2. Increased wound healing
3. Increased ability to learn
4. Increased ability to adjust to stressors
5. Increased adjustment to the environment
Q:
The nurse is caring for a client scheduled for surgery the next day. On what should the nurse focus to determine this client's level of stress? Select all that apply.
1. The surgical procedure
2. The client's religious beliefs
3. If the surgery is going to alter the client's life
4. Client's perception of the surgical experience
5. Number of stress-producing events in the client's recent past
Q:
The nurse is completing the preoperative checklist on the night shift in preparation for the client's surgery, scheduled for 0800. Which tasks could the nurse complete at this time?
1. Documenting the time of last voiding
2. Checking the medical record for the history, physical, and signed informed consent
3. Administering preoperative medication
4. Removing the prosthesis
Q:
The nurse performs preoperative teaching for a client requiring a surgical intervention. Which actions by the client indicate appropriate understanding of the information provided?
Standard Text: Select all that apply.
1. Demonstrating proper coughing and deep breathing
2. Asking questions about and voicing understanding of information provided
3. Having no anxiety about the impending surgery
4. Demonstrating proper performance of leg exercises
5. Demonstrating how to turn and get out of bed
Q:
A postoperative client displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure. Which complication should the nurse suspect is occurring?
1. Pneumonia
2. Atelectasis
3. Hypovolemia
4. Pulmonary embolism
Q:
In the ongoing postoperative period, the nurse independently determines, within the protocols of the hospital, the need for which provision of care?
1. Type of diet
2. Activity level
3. Assessment intervals
4. Intravenous solutions
Q:
Upon receiving the client from the postanesthesia care unit, which nursing action is the priority?
1. Apply clean linens to the bed.
2. Assemble required equipment, such as suction, IV pole, or oxygen equipment.
3. Assess the client.
4. Notify the family of the client's return to the room.
Q:
When providing preoperative teaching for the client who is scheduled for coronary artery bypass surgery in the morning, the nurse should include which dimensions?
Standard Text: Select all that apply.
1. Information
2. Psychosocial support
3. The role of the client and support people
4. Skills training
5. Coughing and deep breathing
Q:
The nurse administers the preoperative medication to the client 1 hour before elective surgery, and then discovers the preoperative consent is not signed. Which action by the nurse is the most appropriate?
1. Have the client sign the consent quickly, before the medication begins taking effect.
2. Have a family member or medical power of attorney sign the consent.
3. Send the client to the holding area without a signed consent.
4. Notify the health care provider that surgery will need to be canceled.
Q:
A client arrives at the surgeon's office 1 week after surgery to have the sutures removed. Which classification should the nurse use when documenting care for this client?
1. Preoperative
2. Postoperative
3. Perioperative
4. Intraoperative
Q:
A client is scheduled for surgery the new day. Which type of teaching should the nurse provide?
1. Postoperative
2. Preoperative
3. Perioperative
4. Intraoperative
Q:
A client has a deep wound with areas of exudate and eschar. Which would be the fastest way to debride this wound?
1. Surgical
2. Chemical
3. Autolytic
4. Mechanical
Q:
The nurse is preparing a care plan for a client with a stage IV pressure ulcer. What should be the goals of care for this client? Select all that apply.
1. Speed healing
2. Absorb drainage
3. Prevent infection
4. Prevent from injury
5. Remove necrotic tissue
Q:
The nurse is preparing to assist with the debridement of a client's wounds. In which order should the nurse complete surgical hand antisepsis?
1. Remove all jewelry
2. Wet hands with warm water.
3. Turn on water using foot pedal
4. Completely dry hands and forearms
5. Rub hands together for at least 20 sec
6. Apply 3"5 mL of antimicrobial soap to hands
7. Scrub hands and forearms up to 3 in. above elbows
8. Rinse hands and arms from finger tips to elbows
Q:
Prior to beginning a client's intravenous antibiotics the nurse needs to culture the wound. In which order should the nurse perform the steps to obtain this culture?
2. Use non"cotton-tipped swab
6. Place swab in culture medium
3. Rotate swab while obtaining specimen
1. Rinse wound thoroughly with sterile saline
5. Do not take specimen from exudate or eschar
4. Swab edges starting at top, crisscross wound to bottom
Q:
The nurse is preparing to assess a wound on a new admission on a medical"surgical unit. Which items should the nurse review in the medical record prior to assessing the client's wound?
Standard Text: Select all that apply.
1. The cause of the wound
2. The length of time the wound has been present
3. The previous treatments and client responses
4. The equipment used by other nurses
5. The current medication list
Q:
When the nurse documents a client's wound, which is the best means of describing the wound?
1. Measuring the wound and documenting size
2. Comparing the wound to a universally understood object, such as a quarter or cashew
3. Using terms such as small, medium, or large
4. Taking a picture and inserting it into the record
Q:
The nurse is performing a damp-to-damp dressing change, and is removing the old dressing. Part of the dressing is adhered to the tissue. Which action by the nurse is the most appropriate?
1. Removing that part of the dressing quickly, to reduce the pain
2. Wetting the dressing with alcohol to release the section adhered to the wound
3. Wetting the dressing with tap water to release the section adhered to the wound
4. Wetting the dressing with sterile saline to release the section adhered to the wound
Q:
The nurse is irrigating a wound with tracts and crevices. Which piece of equipment should be applied to the syringe in order to irrigate these areas?
1. A 22 gauge needle
2. A small gauge Robinson catheter
3. An IV catheter with the needle removed
4. An IV catheter with the needle in place
Q:
The nurse is applying a hydrocolloid dressing to a client's wound, which measures 2 inches by 3 inches. The nurse should cut the dressing to which dimensions?
1. 3.25 inches by 4.55 inches
2. 2 inches by 3 inches
3. 1 1/2 inches by 2 1/2 inches
4. 1 inch by 1 1/2 inches
Q:
The nurse changes the client's IV dressing and removes the existing transparent wound barrier. Prior to applying the new barrier, which action by the nurse is the most appropriate?
1. Applying benzoin to make the dressing stick firmly
2. Placing a sterile piece of gauze over the insertion site before placing a new transparent barrier over the wound
3. Cleansing the site with normal saline or a mild cleansing agent
4. Applying sterile gloves
Q:
The nurse is changing the client's dressing on a postoperative nondraining wound. Which personal protective equipment (PPE) should the nurse apply prior to the dressing change?
1. Sterile gown, mask, and sterile gloves
2. Sterile gown, mask, and goggles
3. Sterile gloves and mask
4. Sterile gloves
Q:
Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?
1. Changing the postoperative dressing on a clean wound
2. Irrigating the client's wound
3. Apply a dry dressing
4. Performing a damp-to-damp dressing change
Q:
The nurse is admitting a client with a pressure ulcer to the long-term care facility. When assessing the wound, the nurse finds partial-thickness skin loss free of eschar. In which stage is this client's ulcer?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
Q:
A client is assessed as: having no sensory deficits; skin is dry and not exposed to moisture; confined to bed; is completely immobile; requires moderate assistance in moving; and nutritional status is adequate. Which pressure ulcer risk score is the most appropriate based on the assessment data?
1. 14, indicating moderate risk
2. 15, indicating high risk
3. 12, indicating risk
4. 14, indicating high risk
Q:
For which client should the nurse consider applying a transparent film for wound care?
1. The client with a postoperative wound held together by sutures
2. A client with a stage I pressure ulcer
3. The client with a venous stasis ulcer
4. A client with a highly exudative wound
Q:
The client experiences a burn on the arm that is confined to the skin. How should the nurse describe this burn when documenting this client's care?
1. A clean wound
2. A dirty or infected wound
3. A partial-thickness wound
4. A full-thickness wound
Q:
The nurse notes black necrotic tissue on the client's wound. Which term should the nurse use when documenting this finding?
1. Debridement
2. Eschar
3. Alginate
4. Purulence
Q:
The nurse is caring for a client with induced hypothermia for major thoracic surgery. For which potential health problems should the nurse assess this client? Select all that apply.
1. Acidosis
2. Afterdrop
3. Hypotension
4. Hypertension
5. Rebound fever
Q:
The nurse is caring for a client with body temperature instability. What hypothalamic reactions should the nurse consider occurring to help control the client's temperature instability? Select all that apply.
1. Radiation
2. Convection
3. Conduction
4. Evaporation
5. Condensation
Q:
The nurse is instructing the unlicensed assistive personnel (UAP) to apply a warm compress to the client's knee. Which statement made by the UAP indicates that further instruction should be given?
1. "I can place the heating pad directly to the client's knee."
2. "I will maintain the proper temperature of the heating pad."
3. "I will inform you of any redness of the skin."
4. "I will report to you when the treatment is over."
Q:
The nurse is going to apply a cold compress to a client's lower forearm. What nursing intervention would be indicated?
1. Decrease the length of time the cold compress would normally be applied.
2. Increase the length of time that the compress would be applied.
3. Keep the length of time the same as it would be when applying to other areas of the body.
4. Leave the cold compress in place until it is no longer cool.
Q:
Many conditions can increase the risk for injury from heat applications. Which clients would be at the greatest risk for injury?
Standard Text: Select all that apply.
1. A client with a lot of body fat
2. A client being treated for anxiety
3. A client with peripheral vascular disease
4. A malnourished client
5. A client prescribed steroids
Q:
The nurse applies a warm moist compress to the client's left wrist. Which item should the nurse exclude from the documentation of the intervention for this client?
1. Assessment of site before and after the application
2. Client's response to the compress
3. Assessment of the site every 5"10 minutes
4. Vital signs before, during, and after the treatment
Q:
The nurse is applying a warm moist compress to the client's right calf. Prior to putting the compress in place, which action by the nurse is the most appropriate?
1. Turn the client onto the left side.
2. Position the client appropriately.
3. Turn the client onto the right side.
4. Elevate the head of the bed.
Q:
The nurse is preparing an ice bag to apply to the client's sprained left ankle. How should the nurse fill the bag?
1. One-third full of ice, and add water to make it more pliable
2. One-half to two-thirds full of crushed ice
3. Completely full to make it last longer
4. One-third to two-thirds full of ice cubes
Q:
Which is the most effective way for the nurse to apply an appliance such as a hot water bottle or disposable hot pack to a client?
1. Directly to the client's skin
2. Directly to the client's skin with a towel or blanket wrapped over the appliance to hold it to the leg
3. If possible, have the client lay on top of the appliance
4. Wrap the appliance in a towel and lay it on the site on the client
Q:
The nurse is applying an aquathermia pad to a client complaining of arthritic pain in the right knee. Which filler is appropriate for this unit?
1. Sterile water
2. Normal saline
3. Tap water
4. Distilled water
Q:
While applying a warm wet soak to the client's left leg, the unlicensed assistive personnel (UAP) notes a small burn on the inside of the calf. The UAP informs the RN. Which response by the nurse is the most appropriate?
1. "Please notify the health care provider."
2. "Describe the burn in detail, please."
3. "I'll go take a look at it."
4. "Make sure you document it and complete an incident form."
Q:
Which activity can the nurse safely delegate to unlicensed assistive personnel (UAP)?
1. Sterile warm soak to client's infected postoperative wound
2. Application of warm moist soak to client's left leg
3. Determine effectiveness of cold application to reduce client's pain
4. Responsibilities for the application of a warm pack to client's IV infiltrate
Q:
The nurse is providing care to several clients on a medical"surgical unit. Which clients would benefit from the application of heat?
Standard Text: Select all that apply.
1. Client with muscle spasms in the lower back
2. Client with traumatic injury and bleeding
3. Client with joint contracture
4. Client in pain
5. Client with inflammation
Q:
The nurse is caring for a client diagnosed with osteoarthritis. Which intervention should the nurse advise the client to do in order to reduce discomfort?
1. Apply ice to the painful joint.
2. Immerse the painful joint in cold water.
3. Apply heat pack once a day.
4. Apply heat to the painful joint several times a day.
Q:
The nurse receives a call from a client who reports a deep, long cut to the left hand sustained while slicing a bagel and asks the nurse what to do. Which action should the nurse direct the client to take?
1. Elevate the arm above the head and apply ice and pressure while en route to the emergency department.
2. Apply heat and pressure en route to the emergency department.
3. Apply ice and elevate the arm.
4. Apply pressure and elevate the arm.
Q:
The client calls the nurse into the room and says that the heat pack the nurse applied feels cold, and asks the nurse to turn the heat up on the aquathermia unit. Which response by the nurse is the most appropriate?
1. "I'll turn it up a little at a time and you let me know when it feels warm again."
2. "The doctor wants the aquathermia pad maintained at a specific temperature, so there's no need to change it."
3. "The aquathermia pad still feels warm to me."
4. "Your body has adjusted to the warmth, and is making it feel cooler, but it's actually the same temperature as when it was first applied."
Q:
The nurse applies an aquathermia heat pack to the client's right leg and removes it after no more than 45 minutes. What is the nurse trying to avoid by completing this action?
1. Vasodilation
2. Rebound phenomenon
3. Heat tolerance
4. Systemic effects
Q:
A client with a rectal tube begins to experience diarrhea. What should the nurse do?
1. Clamp the tube
2. Remove the tube
3. Reposition the client
4. Attach a collection bag
Q:
A client is considering the placement of a continent ileostomy. What should the nurse explain as an advantage of this type of surgery?
1. Gas may be expelled
2. An appliance is not needed
3. Additional surgery may be required
4. A drainage catheter needs to be inserted several times a day
Q:
The nurse notes that the skin around the stoma of a client with an ileostomy is partially denuded. What should the nurse do?
1. Keep the appliance off
2. Apply skin barrier paste
3. Apply Stomahesive powder
4. Increase the size of the stoma opening on the barrier
Q:
The nurse is providing ostomy care for a client with a colostomy. Which assessment findings should the nurse report to the health care provider if noted during the procedure?
Standard Text: Select all that apply.
1. No change in stoma size
2. A stoma that appears dry and grey in color
3. The presence of skin irritation
4. The amount of drainage
5. The odor of the drainage
Q:
The nurse is working with unlicensed assistive personnel (UAP) in a long-term care facility. Which tasks can the nurse delegate to the UAP?
Standard Text: Select all that apply.
1. Administering an enema to a stable client
2. Removing a fecal impaction for an unstable client
3. Assisting a client to perform ostomy care after hand surgery
4. Helping a client onto a bedpan
5. Assessing skin during an ostomy appliance change
Q:
The nurse educator is conducting an in-service to a group of new nurses regarding the use of ostomy appliances. When discussing the characteristics of ostomy appliances, which statements are appropriate for the educator to include in the presentation?
Standard Text: Select all that apply.
1. The ostomy appliance comes in a three-piece set.
2. The ostomy appliance should protect the skin near the stoma.
3. The ostomy appliance should collect both stool and urine.
4. The ostomy appliance controls odor.
5. All ostomy appliances can only be used once.
Q:
The nurse is caring for a client with a newly created ostomy. After changing the ostomy appliance, which items should the nurse include when documenting the procedure?
Standard Text: Select all that apply.
1. How the drainage was disposed
2. Quantity of drainage recorded on output record
3. Any client participation in the procedure
4. Assessment of stoma and skin around the stoma
5. The odor of the drainage
Q:
The nurse is changing the ostomy appliance for a client with a new loop colostomy. Which action by the nurse is the most appropriate?
1. Remove the plastic bridge in order to create a tight fit with the ostomy appliance.
2. Cut two holes in the skin barrier for each loop.
3. Cut an opening in the skin barrier for only the afferent or proximal end of the stoma.
4. Place a piece of tissue or gauze over the stoma, and use a guide to measure the size of the stoma.