1. The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The nurse is aware that the most likely explanation for the elevated temperature is:
❍ A. There was damage to the hypothalamus.
❍ B. He has an infection from the abrasions to the head and face.
❍ C. He will require a cooling blanket to decrease the temperature.
❍ D. There was damage to the frontal lobe of the brain.
Answer A is correct. Damage to the hypothalamus can result in an elevated temperature because this portion of the brain helps to regulate body temperature. Answers B, C, and D are incorrect because there is no data to support the possibility of an infection, a cooling blanket might not be required, and the frontal lobe is not responsible for regulation of the body temperature.
2. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate:
❍ A. Pressure in the left ventricle
❍ B. The systolic, diastolic, and mean pressure of the pulmonary artery
❍ C. The pressure in the pulmonary veins
❍ D. The pressure in the right ventricle
Answer B is correct. The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect.
❍ B. Report this behavior to the charge nurse
❍ C. Monitor the situation and note whether any items are missing
❍ D. Ignore the situation until items are reported missing
Answer B is correct. The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response.
4. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:
❍ A. Administer the Lasix as ordered
❍ B. Administer half the dose
❍ C. Offer the patient a potassium-rich food
❍ D. Withhold the drug and call the doctor
Answer D is correct. The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor’s order, as stated in answer B, and answer C will not help with this situation.
5. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
❍ A. “You may be electrocuted if you use water with this unit.”
❍ B. “Please report skin irritation to the doctor.”
❍ C. “The unit may be used anywhere on the body without fear of adverse reactions.”
❍ D. “A cream should be applied to the skin before applying the unit.”
Answer B is correct. Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used
with the device.
6. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer?
❍ A. Warmth
❍ B. Odor
❍ C. Pain
❍ D. Ulcer with flat edges
Answer C is correct. Pain is a late sign of oral cancer. Answers A, B, and D are incorrect
because a feeling of warmth, odor, and a flat ulcer in the mouth are all early
occurrences of oral cancer.
7. The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?
❍ A. Contact organ retrieval to come talk to the wife
❍ B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs
upon the death of her husband
❍ C. Drop the subject until a later time
❍ D. Refrain from talking about the subject until after the death of her husband
Answer A is correct. Contacting organ retrieval to talk to the family member is the best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and
answer D is not good nursing etiquette and, therefore, is incorrect.
8. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
❍ A. Discard the solution and order a new bag
❍ B. Warm the solution
❍ C. Continue the infusion and document the finding
❍ D. Discontinue the medication
Answer A is correct. Crystals in the solution are not normal and should not be administered to the client. Discard the bad solution immediately. Answer B is incorrect because warming the solution will not help. Answer C is incorrect, and answer D requires a doctor’s order.
9. The home health nurse is planning for the day’s visits. Which client should be seen first?
❍ A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube
❍ B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
❍ C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
❍ D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally
placed venous catheter
Answer D is correct. The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. MRSA, in answer C, is methicillin-resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable.
10. Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy?
❍ A. High-fiber
❍ B. Low-residue
❍ C. Bland
❍ D. Clear-liquid
Answer D is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery.
❍ A. There was damage to the hypothalamus.
❍ B. He has an infection from the abrasions to the head and face.
❍ C. He will require a cooling blanket to decrease the temperature.
❍ D. There was damage to the frontal lobe of the brain.
Answer A is correct. Damage to the hypothalamus can result in an elevated temperature because this portion of the brain helps to regulate body temperature. Answers B, C, and D are incorrect because there is no data to support the possibility of an infection, a cooling blanket might not be required, and the frontal lobe is not responsible for regulation of the body temperature.
2. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate:
❍ A. Pressure in the left ventricle
❍ B. The systolic, diastolic, and mean pressure of the pulmonary artery
❍ C. The pressure in the pulmonary veins
❍ D. The pressure in the right ventricle
Answer B is correct. The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle. Therefore, answers A, C, and D are incorrect.
3. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
❍ A. Notify the police department as a robbery❍ B. Report this behavior to the charge nurse
❍ C. Monitor the situation and note whether any items are missing
❍ D. Ignore the situation until items are reported missing
Answer B is correct. The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response.
4. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:
❍ A. Administer the Lasix as ordered
❍ B. Administer half the dose
❍ C. Offer the patient a potassium-rich food
❍ D. Withhold the drug and call the doctor
Answer D is correct. The potassium level of 2.5meq/L is extremely low. The normal is 3.5–5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic, so answer A is incorrect. The nurse cannot alter the doctor’s order, as stated in answer B, and answer C will not help with this situation.
5. The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
❍ A. “You may be electrocuted if you use water with this unit.”
❍ B. “Please report skin irritation to the doctor.”
❍ C. “The unit may be used anywhere on the body without fear of adverse reactions.”
❍ D. “A cream should be applied to the skin before applying the unit.”
Answer B is correct. Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used
with the device.
6. The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer?
❍ A. Warmth
❍ B. Odor
❍ C. Pain
❍ D. Ulcer with flat edges
Answer C is correct. Pain is a late sign of oral cancer. Answers A, B, and D are incorrect
because a feeling of warmth, odor, and a flat ulcer in the mouth are all early
occurrences of oral cancer.
7. The nurse is caring for the client who has been in a coma for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?
❍ A. Contact organ retrieval to come talk to the wife
❍ B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs
upon the death of her husband
❍ C. Drop the subject until a later time
❍ D. Refrain from talking about the subject until after the death of her husband
Answer A is correct. Contacting organ retrieval to talk to the family member is the best choice because a trained specialist has the knowledge to assist the wife with making the decision to donate or not to donate the client’s organs. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect; answer C might be done, but there might not be time; and
answer D is not good nursing etiquette and, therefore, is incorrect.
8. An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
❍ A. Discard the solution and order a new bag
❍ B. Warm the solution
❍ C. Continue the infusion and document the finding
❍ D. Discontinue the medication
Answer A is correct. Crystals in the solution are not normal and should not be administered to the client. Discard the bad solution immediately. Answer B is incorrect because warming the solution will not help. Answer C is incorrect, and answer D requires a doctor’s order.
9. The home health nurse is planning for the day’s visits. Which client should be seen first?
❍ A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube
❍ B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
❍ C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
❍ D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally
placed venous catheter
Answer D is correct. The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. MRSA, in answer C, is methicillin-resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable.
10. Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy?
❍ A. High-fiber
❍ B. Low-residue
❍ C. Bland
❍ D. Clear-liquid
Answer D is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery.
I used tens unit and it really helped me out to get rid of my pains
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