A client is comatose upon arrival to the emergency department after falling a roof.
The client flexes with painful stimuli, and the nurse determines the client’s
Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to
implement to maintain the client’s airway?
A nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50 ml/hr. To
prepare enough of the solution for eight hours, how many ml of full strength
feeding will the nurse need?
Answer: 200
25 ml x 8hrs = 200
The alarm of a client’s pulse oximeter sounds and the nurse notes that the
oxygen saturation rate is indicated at 85%. What action should the nurse take
first?
Check the probe position
A client is known to have an irregular respiratory rate with periods of apnea
lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles in a
30-second interval followed by an apneic period. What intervention should the
nurse implement?
Reassess the respiratory rate, counting for one full minute
A retiree with depression complains of feeling “lonely and having no purpose” in
life.Based on Erikson’s developmental theory, which questions suggest that the
nurse understands the client’s most important emotional need?
“What about your life makes you proud?”
Following a precipitous labor, a client has a continuous trickling of bright red
blood from her vagina. Her uterus is firm and her vital signs are within normal
limits. The
nurse determines that the client’s symptoms may indicate which condition?
A cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to
assign to a practical nurse?
An elderly client with Alzheimer’s disease complicated by dysphagia
The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which
action has the highest priority when the nurse implements this prescription?
Set the flow meter
- A nurse who is new to the pediatric unit is positioning a 6-month-old for an
injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should
the nurse-manager who is supervising this nurse take first?
C. Instruct the nurse to select another injection site - After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis,
the nurse provides home care instructions to the mother. Which statement by the
child’s mother indicates that she understands home care treatment to promote
pulmonary function?
“Chest physiotherapy should be performed at least twice a day”
The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation?
Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child with
Type 1 diabetes mellitus. The parents correctly understands signs of
hypoglycemia if they include which symptom?
Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an
immobile client. What documentation of this finding is best for the nurse to enter
into the client’s record?
Stage 1 pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple bruises
on her back and upper arms. The child’s aunt tells the nurse that the child’s
parents abuse drugs and alcohol. What intervention is most essential for the
nurse to implement?
Report assessment findings to the proper legal authorities - A 14-year-old male client arrives at the emergency room in status epilepticus.
He was diagnosed with a seizure disorder in childhood. What is the most likely
cause of his present condition?
Acute withdrawal from anticonvulsant medication
A Chinese-American client who just delivered a baby states that she will not be
able to take the prescribed sitz baths to help heal her episiotomy incision
because this will cause an unhealthy balance of cold and hot forces. When
planning nursing care, what nursing diagnosis has the highest priority?
Impaired tissue integrity related to episiotomy - A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In
planning care for this child, which nursing diagnosis has the highest priority?
High risk for fluid volume deficit related to temperature elevation
During the first trimester of pregnancy, a client who was treated for genital
herpes with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is
experiencing an episode of genital herpes. Which nursing intervention has the
highest priority?
Determine if the client has taken acyclovir (Zovirax) for this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new prescription
for paroxetine (Paxil). The client reports current use of the MAO inhibitor
isocarboxazid
(Marplan). What intervention is most important for the nurse to implement?
Notify the healthcare provider that the client is currently taking Marplan
While performing a skin inspection on a newborn, the nurse finds a small dimple
and a dark tuft of hair in the lumbosacral area of the infant’s back. What is the
most likely indication of this finding?
External manifestation of a spinal abnormality
What action should the nurse implement first when delegating nursing activities
to an unlicensed assistive personnel (UAP)?
Evaluate the experience of the UAP
A female resident of a long-term care facility is being admitted to the medical
department. The client has a fractured hip and has methicillin-resistant
staphylococcus aureus (MRSA). Which room should the charge nurse assign this
client?
A semi-private room with a client who also has methicillin-resistant staphylococcus
aureus (MRSA)
The nurse is preparing a client for surgery. Which finding indicates that the client
is ready to proceed to the operating room (OR) for a scheduled surgical
procedure?
Hemoglobin 10.1 grams
The nurse is preparing to administer an intramuscular injection in the
ventrogluteal site of a client who weighs 80 kg. What size needle should the nurse
select?
21-gauge, 1.5-inch needle
A client at 38-weeks gestation is in active labor, and a vaginal birth after Cesarean
section (VBAC) is planned. Vaginal exam indicates that the client is 6 cm dilated,
90% effaced, and at station 0 with intact membranes. As the client’s contraction
become stronger, the fetal heart rate decelerates during the contractions but
returns to baseline. What action should the nurse take?
Continue to monitor the client’s labor progress
An elderly client with limited mobility reports frequent episodes of nocturia. To
reduce the risk for urinary incontinence, what action should the nurse
implement?
Keep the call bell within the client’s reach
Which diagnostic tests are most important for the nurse to monitor when
providing care for a client with a bowel obstruction?
Serum electrolytes - A 72-year-old male client reports that he has felt depressed since his wife died
six months ago. What question is most important for the nurse to ask this client?
“Have you ever felt like hurting yourself?”
After administering the first dose of newly prescribed to four clients within a
thirty minute time frame, the nurse evaluates each client for therapeutic
responses or any adverse reactions. Which medication should the nurse evaluate
first?
HYdromorphone (Dilaudid)
What is the most important symptom the nurse should monitor the client for
while assisting with the insertion of a subclavian central venous catheter?
Shortness of breath
The nurse is developing a plan of care for a client who has a prescription for the
calcium channel-blocker nifedipine (Procardia) to treat angina pectoris. What is
the purpose for administration of this