A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse?
1Write down potential solutions to the problems today by shift’s end
2Add this concern to the agenda of the next unit meeting
3Assure the staff nurse that the complaint will be investigated
4Explore for further identification about the nature of the problem
4 Explore for further identification about the nature of the problem
The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?
1″Ovulation, or midcycle is the best time to detect changes.”
2″Do the exam at the same time every month.”
3″Right after the period, when your breasts are less tender.”
4″The first of every month, because it will be easiest to remember.”
3
The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present?
1An open wound on the heel with minimal discomfort
2Occasional hiccups and sneezing
3Sustained insomnia and daytime fatigue
4Persistent dryness and itching of the perineal area
1An open wound on the heel with minimal discomfort-
A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman’s needs?
- 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear
- Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine
- 3 oz. chicken, one-half cup of corn, lettuce salad, small banana
- Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries
- Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries –
A nurse is taking a health history from parents of a child admitted with possible Reye’s syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye’s syndrome?
- Varicella
- Meningitis
- Hepatitis
- Rubeola
- Varicella –
A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: “I wonder if he has any idea how ridiculous he looks – he’s a grown man!” The nurse’s comment is an example of what type of attitude?
- Prejudice
- Ethnocentrism
- Discrimination
- Stereotyping
- Prejudice-
A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student’s question, what information should the nurse emphasize?
- Increased competition between health care insurers
- Increase in health care spending that’s growing faster than the economy
- Increase in the population who have health insurance
- Increase in spending for end-of-life treatment
2
A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child?
- Maintain hydration and encourage fluids
- Implement droplet precautions
- Monitor respiratory rate and oxygen saturation
- Anti- infective therapy
2
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse?
1Complaints for the feeling of pulling on the urinary catheter
2Light, pink to clear urine
3Occasional suprapubic cramping
4Minimal drainage into the urinary collection bag
4Minimal drainage into the urinary collection bag
A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time?
1Risk for fluid volume deficit
2Risk for excessive bleeding
3Risk for infection –
4Altered tissue perfusion
3
A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?
1Hypothermia
2Nausea and vomiting
3Hypoventilation
4Bradycardia
2
A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure?
1Place the hands or a folded blanket under the head of the child
2Provide privacy as much as possible to minimize frightening the other children
3Move any chairs or desks at least three feet away from the child
4Note the sequence of movements with the time lapse of the event
1Place the hands or a folded blanket under the head of the child –
A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client?
1Droplet
2Contact
3Standard
4Airborne
4
A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)?
1″I have active tuberculosis.”
2″I have been exposed to mycobacterium tuberculosis.”
3″I have never been infected with mycobacterium tuberculosis.”
4″I have never had tuberculosis.”
2
A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment?
1Wheezes
2Friction rubs
3Rhonchi
4Diminished sounds
3
A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, “I am a government official and spies are following me.” Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?
1Listen quietly without comment
2Ask for further information on the spies
3Confront the client about the delusions
4Contact security for potential safety concerns
1Listen quietly without comment –
Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?
1Less jaundice
2Increased appetite
3Decreased lethargy
4Less edema
3
The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications?
1Employer policy and procedures manuals
2Nursing faculty from a local nursing program
3The nurse practice act of the state in which the practice takes place
4American Nurses Association (ANA) professional standards
3
The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?
1Dry off infant with a warm blanket or towel
2Apply identification bracelets
3Assign the one-minute APGAR score
4Obtain vital signs
1Dry off infant with a warm blanket or towel –
The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed?
1″I will make an effort to talk with someone about my feelings if I start to feel overwhelmed.”
2″It’s common for women with postpartum depression to have delusions about the infant.”
3″Women with postpartum depression have feelings of guilt and worthlessness.”
4″I may experience postpartum depression up to a year after delivery.”
2
The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included?
1Diarrhea, dry mouth, weight loss, reduced libido
2Tachycardia, blurred vision, hypotension, anorexia
3Orthostatic hypotension, vertigo, reactions to tyramine, nausea
4Photosensitivity, seizures, edema, hyperglycemia
1Diarrhea, dry mouth, weight loss, reduced libido
A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin?
1Use the pulse reading from the electronic blood pressure device
2Take a radial pulse, counting for a full 60 seconds
3Check for a pulse deficit at least twice with another nurse
4Assess the apical pulse, counting for a full 60 seconds
4Assess the apical pulse, counting for a full 60 seconds –
A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client’s refusal of the medication?
1″You need to take your medicine. This is how you get better.”
2″What is it about the medicine that you don’t like?”
3″I can see that you are uncomfortable right now; let’s talk about it tomorrow.”
4″If you refuse your medicine, tell me how do you think you will get better?”
2
A parent expresses frustration and anger about the toddler constantly saying “no” and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need?
1Self-esteem
2Initiative
3Independence
4Trust
3
The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function?
1Squeeze the trapezius muscle firmly
2Lift the client’s arm and observe for pronation and drift
3Apply finger tip pressure for 10 seconds
4Rub the sternum with the knuckles
1Squeeze the trapezius muscle firmly –
A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?
1Discontinue breastfeeding during treatment
2Rotate the neonate to treat all of his/her skin
3Restrict holding the newborn during treatment
4Provide more frequent feedings
4Provide more frequent feedings-
A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, “You think you’re so perfect, pure and good.” How should the nurse respond?
1″You seem to be in a bad mood.”
2″Perfect? I don’t quite understand.”
3″You sound angry right now.”
4″That explains why you’ve been staring at me.”
3
The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day?
1It can cause severe headaches
2It may no longer work as well
3It will cause profound hypotensive effects
4it will irritate the skin
2
A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?
1Compare daily infant weights
2Monitor the infant’s urine output
3Ensure appropriate fluid intake
4Maintain accurate intake and output
2
A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point?
1They can expect the child will be mentally retarded
2Administration of a thyroid hormone will prevent problems
3This rare condition is hereditary
4Physical growth and development will be delayed
2
A child is admitted to the hospital for emergency surgery. The child’s parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about?
1Perfumed soap
2Shellfish
3Balloons
4Mold
3
A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action?
1Assist the woman to empty her bladder
2Monitor the pulse and blood pressure
3Call the registered nurse (RN) immediately
4Check lochia for color and amount
1Assist the woman to empty her bladder –
The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider?
1Diminish destructive behavior through peer pressure
2Plan strict schedules with defined expectations
3Punish inappropriate behavior as it occurs
4Achieve a client’s therapeutic goals
4Achieve a client’s therapeutic goals –
A client tells a nurse, “I have something very important to tell you if you promise not to tell anyone.” Which statement by the nurse would be the most appropriate response?
1″That depends on what you tell me.”
2″I must report everything to the treatment team.”
3″All right, I promise.”
4″I can’t make such a promise.”
4″I can’t make such a promise.” –
A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment?
1″I know I must avoid crowds.”
2″I will report any bruises or bleeding.”
3″I plan to use an electric razor for shaving.”
4″I will keep all laboratory appointments.”
1″I know I must avoid crowds.” –
The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene?
1Validate the client’s advance directive
2Participate with the compressions or breathing as requested by the first nurse
3Bring the code cart –
4Relieve the first nurse on the scene and continue single person CPR
3
The nurse and client are discussing the client’s progress toward understanding the client’s behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship?
1Termination
2Working –
3Orientation
4Pre-interaction
2
The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers?
1Ambulatory client who had three incontinent diarrhea stools in the past 24 hours
2Ambulatory older adult diagnosed with type 2 diabetes for the past 20 years
3Obese client who uses a wheelchair throughout the facility
4Malnourished older adult client who is on bed rest
4
A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client’s status?
1Glasgow Coma Scale 13, no ventilator required
2Glasgow Coma Scale 8, respirations regular –
3Appears to be sleeping, vital signs stable
4Comatose, breathing unlabored; is resting
2
A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time?
1Notify the health care provider of the client’s failure to follow the prescribed diet
2Make a referral to Meal-on-Wheels for delivery of one meal three times a week
3Discuss the diet with the client to learn the reasons for not following the diet –
4Recommend a release from home health care related to noncompliance
3
A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance?
1Trends in daily weights –
2Skin turgor over at least two areas of the body
3Changes in mucous membrane moistness
4Difference between intake and output
1Trends in daily weights –
The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse?
1Hematemesis –
2Pink-tinged saliva
3Serosanguinous drainage from the IV site
4Slight rust-colored urine
1Hematemesis –
The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse?
1Check the distal circulation of the casted extremity
2Obtain the pulse oximetry reading
3Measure the client’s blood pressure in the supine and Fowler’s positions
4Check the orientation to time, place and person
2
The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube?
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shift
1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate –
3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds in all four quadrants
2Measure the pH of stomach content aspirate –
3Auscultate the abdomen while instilling 10 mL of air into the G-tube
4Measure the length of tubing from the insertion site each shifto the G-tube
4Measure the length of tubing from the insertion site each shift
The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition?
1Pronounced wheezes
2Pain on deep inspiration
3Sudden back pain
4Sudden dyspnea
4
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure?
1The surgical repair of a diseased coronary artery
2An noninvasive radiographic examination of the heart
3A process to compress arterial plaque to improve blood flow
4The placement of an automatic internal cardiac defibrillator
3
A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child’s birth, which of these responses might the nurse expect from the grandparents?
1Anger
2Disbelief
3Depression
4Frustration
2
The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU?
1An ICU nurse and intensivist remotely monitor ICU clients around the clock
2An ICU nurse is on-call to answer questions when needed
3Clients can ask the intensivist for a second opinion
4Less staff is needed on site when a remote eICU is available
1
A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result?
1Provide a well-balanced nutritional intake
2Promote healing and strengthen the immune system
3Spare protein catabolism to meet metabolic and healing needs
4 stimulate increased peristalsis and nutrient absorption
3
A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse?
1″Use this medication at bedtime to promote rest.”
2″Notify the health care provider if your canister lasts only two weeks.”
3″Inhale this medication after other asthma sprays.”
4″Discontinue the inhaler if you are dizzy.”
2
An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client’s condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate?
1Notify the attending physician
2Consult the charge nurse and prepare to transfer the client to an intensive care unit
3Call the rapid response team
4Contact the family member indicated in the admission forms
1
The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care?
1Safety
2Elimination
3Rest
4Nutrition
1
A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance?
1Iron
2Calcium
3Vitamin E
4Vitamin K
4
The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase?
1The client revitalizes a relationship with the family to help in coping with a child’s death
2The client recognizes feelings and expresses them appropriately
3The client expresses a desire to be mothered and pampered
4The client recognizes regression as a part of a defense mechanism
2
During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately.
During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately.
An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client’s behalf
A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion?
1Proximity to emergency services
2Number of children in the home
3Knowledge level of the parents
4Age of children in the home
4
When reviewing the medication lithium with a client, the client asks, “How long will it take before I can feel the effects of the medication?” Which response by the nurse is the best?
1″About two weeks”
2″One month”
3″Immediately”
4″Several days”
1
A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy?
1Ambulate the client within four hours after procedure
2Change the dressing when it becomes saturated
3Monitor vital signs using post-op protocols
4Maintain client on NPO status for 24 hours
3
The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client’s T-tube to be?
1Dark brown
2Green
3Yellowish-brown
4Orange
3
A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.)
Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects.
The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time?
1Prior to going to sleep at night
2After each fecal elimination
3At the same time each day
4When it is one-third to one-half full
4
A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test?
1″Be sure to eat a fat-free diet until the test, and drink lots of water.”
2″Stay at the laboratory so that two blood samples can be drawn an hour apart.”
3″Do not eat or drink anything but water for 12 hours before the blood test.”
4″Have the blood drawn within two hours of eating breakfast.”
3
The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent?
1Restricted physical activity
2Separation from family
3Altered body image
4Unrelieved pain
3
In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect?
1Retained placenta
2Clotting disorder
3Vaginal lacerations
4Uterine atony
3
A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus?
1High-protein diet
2Fluid intake of at least 3000 mL/day
3Acetaminophen for inflammation
4Hot compresses to affected joints
2
A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client?
1Weigh the child twice per shift
2Relieve boredom through physical activity
3Institute seizure precautions
4Encourage the child to eat protein-rich foods
3
A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age?
1Riding a tricycle
2Tying shoelaces
3Jumping rope
4Playing hopscotch
1
The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect?
1Jaundice
2Peripheral edema
3Buffalo hump
4Increased muscle mass
3
A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach?
1Commenting “I believe you know better than to eat with your hands.”
2Removing the food and stating “You can’t have any more food until you use the spoon.”
3Jokingly stating “Well, I guess fingers sometimes work better than spoons.”
4Placing the spoon in the client’s hand and stating “Use the spoon to eat your food.”
4
The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication?
1Monitor serum electrolytes and creatinine
2Measure apical pulse prior to administration
3Maintain accurate intake and output ratios
4Monitor blood pressure every 4 hours
2
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse?
1Arrange to change client-care assignments
2Discuss with the parent the appropriate use of “time-out”
3Explain to the mother that the child needs extra attention
4Explain to the parent that this behavior is expected
4
The mother of a hospitalized 2 year-old child asks a nurse’s advice about the child’s screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach?
1Explain that this behavior will stop with in a few days
2Suggest that the mother “sneak out” of the child’s room when the child is asleep
3Request for the mother to remain with the child at all times
4Help the mother understand that this is a normal response to hospitalization
4
A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube?
1Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding
2Adequately flushing the tube with water before and after use
3Completely crushing all medications prior to administration
4Squeezing the tube to dislodge obstructions
2
A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display?
1Pull up to stand
2Use a spoon
3Say two words
4Sit without support
4
A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy?
1Heat intolerance
2Diarrhea
3Tachycardia
4Lethargy
4
The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse?
1Jaundice
2Anorexia
3Hematemesis
4Ascites
3
A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose?
1Foster independence with better communication
2Protect the ego and diminish anxiety
3Eliminate anxiety and apprehension
4Avoid conflict and unpleasant consequences
2
A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always “scratching his bottom” and is “extremely irritable.” Based on this information, which health issue would the nurse assess for initially?
1Pinworm
2Scabies
3Ringworm
4Allergies
1
The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse?
1Administer PRN pain medication as ordered
2Determine the origin of the pain
3Draw blood for for troponin/CK and CBC per standing orders
4Order ECG per standing orders
1
The client is diagnosed with Parkinson’s disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention?
1Allow the client the time needed to dress
2Encourage the client to dress more quickly
3Ask family members to dress the client
4Demonstrate methods on how to dress more quickly
1
A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse’s explanation should include which of these comments?
1″It tells us how far along your pregnancy is.”
2″It can help identify potential neurological defects.”
3″The results help determine if the baby is growing normally.”
4″The placental exchange of oxygen is measured.”
2
A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization?
1Protection from harm to self and others
2Return to independent functioning
3Elimination of negative findings
4Reorientation to reality
1
A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take?
1Drink small amounts of liquids frequently
2Eat the evening meal within two hours of going to sleep
3Sleep with head propped on several pillows
4Take a proton pump inhibitor either before or after eating
3
A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)?
1Lifts head from the prone position
2Rolls from abdomen to back
3Falls forward when sitting
4Responds to parents’ voices
3
A nurse is monitoring the client’s initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)?
1Paresthesia and muscle cramping
2Mild dysphagia and hoarseness
3Headache and nausea
4Irritability and insomnia
1
An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus?
1Muscle weakness
2Respiratory function
3Bladder control
4Peripheral sensation
2
There’s a new order to apply one-inch of nitroglycerin paste to the client’s chest every 12 hours, but the medication is not in the automatic medication dispensing system’s drawer for this client. What should the nurse do next?
1Use another client’s nitroglycerin paste until pharmacy sends a tube for this client
2Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart
3Call the pharmacy to send up a tube of nitroglycerin paste
4Call the prescriber and ask to substitute a different formulation of nitroglycerin
3
A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents?
1Report a persistent cough to the health care provider
2The child can return to school in four days
3Administer chewable medication for pain
4The child may gargle as necessary for discomfort
1
An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client’s medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider?
1Diltiazem (Cardizem)
2Digoxin (Lanoxin)
3Nitroglycerine ointment
4Metoprolol tartrate (Toprol XL)
2
A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse?
1″Smoking will decrease the circulation to my leg”
2″Coughing and deep breathing are important for a few weeks.”
3″I will put my right leg through a full range of motion.”
4″I might feel a throbbing pain in my right leg.”
3
The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority?
1The cast material should be dipped several times into warm water
2The cast should be uncovered until it dries
3The casted extremity should be placed on a supporting surface
4The wet cast should be handled with the palms of hands for 48 to 72 hours
4
The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first?
1Reposition the tube
2Increase the amount of suction
3Gently irrigate the tube with sterile normal saline
4Notify the surgeon
3
A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse?
1Reassure the child that the surgery will go fine with no problems
2Provide privacy with encouragement to work through feelings
3Distract the child with a choice of activities to do while waiting for surgery
4Make arrangements for friends to visit as soon as possible
2
A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use?
1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus
2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape
3Open the bottom of the pouch to allow the flatus to be expelled
4Assist the client to ambulate to reduce the flatus in the pouch
3
A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period?
1Manage postoperative pain
2Maintain fluid and electrolyte balance
3Control bladder spasms with PRN medication
4Ambulate the client within a few hours after surgery
1
The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, “This is not my baby, and I do not want it.” How should the nurse respond?
1″What a beautiful baby! The baby’s eyes are just like yours.”
2″This is a common occurrence after birth. Let’s talk about how to accept the baby.”
3″You seem upset, tell me about how you are feeling”?
4″Many women have postpartum blues and need some time to love the baby.”
The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse?
1″Do your eyes appear bloodshot and is there any itching?”
2″Tell me about your prescription for digoxin. Are you still taking the medication?”
3″Call back in a week and schedule an appointment if your symptoms don’t improve.”
4″Is there anyone else at home who has the same symptoms?”
2
A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics?
1Meticulous attention to hygiene, grooming
2Anxiety, hostility
3Psychomotor retardation, agitation
4Guilt, indecisiveness
3
A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate?
1Behavior consistent with hyperactivity
2Slow heart rate when sleeping
3Pale mucosa inside the mouth
4High hemoglobin level
3
The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective?
1Assist the client to analyze the meaning of behaviors
2Remind the client frequently to interact with other clients
3Offer the client frequent opportunities to interact with the nurse
4Initiate client interactions with one or two other clients
3
A female client admitted for a breast biopsy says tearfully to a nurse, “If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.” What would be the most appropriate response to this statement?
1″Are you questioning the depth of your relationship?”
2″Why are you concerned that you will be rejected?”
3″You sound worried that the surgery might change your relationship with your partner.”
4″I’m sure your companion will understand.”
3
The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis?
1Peak air flow volume
2Respiratory rate
3Pulse oximetry
4Skin color
1
The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.)
Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day.
A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care?
1Activity intolerance related to an imbalance of oxygen supply and demand
2Imbalanced nutrition related to poor appetite
3Risk for impaired skin integrity related to dependent edema
4Constipation related to reduced activity level
1
The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred?
1Performance on written tests
2Completion of a mailed survey
3Responses to verbal questions
4Reported behavioral changes
4
The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.)
may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If “skin glue” is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it’s best to stick to non-greasy, non-spicy foods for a few days.
The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis?
1Turn, cough and breathe deeply
2Ambulate client within 12 hours
3Maintain adequate hydration
4Splint incision when moving or coughing
1
A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care?
1Assist the parents to plan quiet play activities with the toddler at home
2Stress to the parents that they will need relief care givers
3Instruct the parents for them and the toddler to avoid contact with persons with infection
4Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class
4
A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client?
1Simple face mask
2Partial rebreather mask
3Venturi mask
4Non-rebreather mask
4
A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding?
1Cannot ride a bicycle
2Cannot catch a ball
3Cannot skip on alternate feet
4Cannot stand on one foot
4
A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client?
1″Hello. My name is Elaine Jones and I am your nurse for today.”
2″Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
3″How are you today? Remember, you’re in the hospital. I will be your nurse all day. My name is Elaine Jones.”
4″Good morning. I am Elaine Jones, your nurse. Do you remember where you are?”
2
A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client?
1Double glove when in contact with feces or emesis
2Wash hands thoroughly before and after any client contact
3Wear gloves when disposing of contaminated linens
4Use gloves when in contact with body secretions
2
A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents?
1Turn the baby every two hours using the abduction stabilizer bar
2Check frequently for swelling in the baby’s feet
3Gently rub the skin with a cotton swab to relieve itching
4Place favorite books and push-pull toys in the crib
2
A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization?
1Localized tenderness at the injection site
2Tympanic temperature of 104 F (40 C)
3Some irritability and fussiness
4Swelling at the injection site
2
A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.)
Correct Response
Assess vital signs and neurological function
Assess the airway
Prepare for CT imaging of the head
Assess the wound for presence of drainage or bruising on the head
A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, “Don’t waste good food on me. I’m dying from this disease I have.” Which response by the nurse would be the best?
1″None of the laboratory reports show that you have any physical disease.”
2″Try to eat a little bit. Breakfast is the most important meal of the day.”
3″I know you believe that you have an incurable disease.”
4″What has your primary health care provider told you?”
3
The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus?
1Achieve harmony
2Respect life in old age
3Maintain energy balance
4Restore yin and yang
4
The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet?
1A gluten-free diet, avoiding foods that contain wheat, rye and barley
2Balanced, high calorie diet with extra fat, salt, protein and calcium
3Foods low in sodium, potassium and phosphorus
4Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group
2
The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents?
1Progressive failure to adapt to peer pressure
2Reunion wish or a fantasy of some sort
3Feelings of anger or hostility toward others
4Feelings of alienation or isolation from peers
4
When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time?
1Ask the family members to call you when they notice the spot getting larger
2Record the findings in the nurse’s notes
3Outline the spot with a pen and note the time and date on the cast
4Report the finding to the registered nurse (RN) charge nurse
3
The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child’s ability to understand the information at this stage of development?
1Makes simple association of ideas
2Bases conclusions on abstract thinking
I3nterprets events from own perspective
4Thinks logically to organize facts
4
The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing?
1Open the airway and deliver two breaths followed by 30 compressions
2Provide continuous chest compressions until someone comes with the crash cart
3Provide a cycle of 30 compressions followed by two breaths
4Provide 15 compressions and then pause while someone delivers one “breath” using an ambu bag
3
A nurse is discussing with a group of parents when they can begin teaching their preschool children about injury prevention. Which approach should the nurse reinforce?
1Discuss the consequences of not wearing protective devices
2Protect their preschooler from outside influences
3Set good examples themselves through their actions
4Make sure their preschooler understands all the safety rules
3
The nurse is caring for a postmature infant in the newborn nursery. What factor should the nurse recognize as being the primary reason associated with complications of being post-term?
1Depletion of subcutaneous fat
2Progressive placental insufficiency
3Excessive fetal weight
4Low blood sugar levels
2
The registered nurse (RN) has initiated the administration of an intravenous vesicant chemotherapeutic agent to a client. Which finding during the care by a practical nurse (PN) would require the PN to immediately notify the RN?
1A rash on the client’s extremities
2Complaints of pain at the infusion site
3Stomatitis lesions in the mouth
4Severe nausea and vomiting
2
A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses his fears related to the prognosis. Which statement should be the initial response by a nurse?
1″Self-examination needs to be continued in order to prevent and detect recurrences.”
2″Chemotherapy is most likely to be started right away.”
3″Adoption may be a consideration if you want children.”
4″Testicular cancer has a very high cure rate with early diagnosis and treatment.”
4
A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate?
1Dry, nonproductive cough
2Poor appetite
3Frequent urinary infections
4Ribbon-like stools
1
The nurse is caring for a client who is diagnosed with chronic renal failure with hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client’s behavior?
1Low potassium level
2Elevated blood urea nitrogen (BUN)
3Low calcium level
4Metabolic alkalosis
2
The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.)
a false positive test and should be avoided for at least 3 days before the fecal occult blood test;
Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result.
A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse?
1Suggest to elevate the arm higher than heart level
2Ask if numbness is present in the fingers and if the client can move the fingers
3Have the client make an appointment with the surgeon for the next day
4Approve the application of a cool cloth to the fingers of the affected arm
2
The client is seen in the emergency one day after falling in his bathroom at home. The client reports having “a few drinks” prior to the fall. Which finding requires the nurse’s immediate attention?
1Bruise behind one ear
2Blurred vision
3Nausea and vomiting
4Headache
1
Diagnosed with heart failure, the client had an implantable cardioverter-defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort?
1Encouraging the client to sit upright in bed
2Confirming advanced directives and plans for resuscitation
3Deactivating the implantable cardioverter-defibrillator (ICD)
4Assisting the client to eat several small meals
3
The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce?
1Take on an empty stomach
2Take with milk, two hours after meals
3Take with calcium
4Take after meals
1
A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit?
1Plan another pregnancy as soon as possible
2Seek causes of the death for prevention purposes
3Focus on the other healthy children at home
4Discuss feelings with support persons and each other
4
A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information?
1″The therapy can be discontinued when the spots disappear.”
2″I will boil the nipples and pacifiers for 20 minutes.”
3″Expressed breast milk should be used immediately or frozen.”
4″Nystatin should be given four times a day after my baby eats.”
1
The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially?
1Place the bed in the low position
2Instruct the client to remain in bed
3Place the call bell within reach
4Have the client empty the bladder
4
The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes?
1Being a picky eater
2Weight gain
3Bedwetting
4Oily and acne-prone skin
3
An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first?
1Review the client’s pattern of weight gain over the past year
2Encourage her to talk about her self-image
3Give her several pamphlets on postpartum nutrition
4Ask the mother to record her diet for the next few weeks
2
A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire’s disease. Which finding would require the nurse’s immediate attention?
1Dry mouth with frequent requests for water
2Abdominal gas pains that are severe and disappear suddenly
3 Increased use of accessory muscles of breathing
4Difficulty sleeping due to leg cramps
3
Legionnaire’s disease is a type of acute bacterial pneumonia. Increased use of accessory breathing muscles and labored breathing are indicators of respiratory distress and should be reported immediately.
The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)?
1Record and report the client’s intake and output.
2Inspect and report peripheral IV site status.
3Palpate for edema in the lower extremities.
4Evaluate understanding of prescribed medications.
1
A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take?
1Discuss with the client to find out about the preferred herbal preparation
2Explain the importance of the medication to the client
3Contact the client’s health care provider about the refusal
4Report the behavior to the charge nurse
1
The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next?
1Close all doors in the area.
2Find the fire extinguisher.
3Remove oxygen devices.
4Begin evacuating the clients.
1
The licensed practical nurse (LPN) is caring for a client with an order that reads, “morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain.” There are no other licensed persons working that shift. Which action should the nurse take?
1Give the medication orally and follow-up with the health care provider.
2Hold the medication and contact the health care provider.
3Administer the prescribed dose as ordered.
4Check with the pharmacist to verify the order.
2
The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.)
“Have you thought about what you want done as your disease progresses?”
“What does your family know about your condition and prognosis?”
“Have you discussed your wishes regarding resuscitation with your health care provider?”
A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan?
1Set daily goals with the establishment of priorities
2Complete each task before beginning another activity
3Ask for additional assistance when necessary to complete tasks
4Keep a time log for what was done during the hours worked
4
A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client’s health care provider?
1″When I emptied my urine catheter drainage bag it looked like rusty-colored water.”
2″I just didn’t sleep well the last few nights. I keep having sad thoughts running through my mind.”
3″I really don’t want home-delivered meals any longer. I am just not hungry.”
4″My neighbors just don’t visit me anymore since I came home from the hospital.”
1
The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase?
1Selection of interventions that are measurable and achievable
2Achievement or status of progress related to prior goals
3Identification of any findings of physical and psychosocial stressors
4Establishment of goals to ensure continuity of care
2
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?
1Clinical specialty certification by an accredited organization
2Complete and accurate documentation of assessments and interventions
3Sworn statement that health care provider orders were followed
4Above-average performance reviews prepared by nurse manager
2
The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report?
1The client with asthma who is scheduled for a chest X-ray prior to discharge
2The client with peptic ulcer disease who has been vomiting most of the night
3The client with chronic kidney disease who completed peritoneal dialysis two hours ago
4The client with pancreatitis who reports pain at a level of eight out of 10
2
The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP’s complaints. What is the best action by the nurse?
1Notify the chief of the medical staff about the HCP’s breach of professional conduct.
2Encourage the UAP to directly confront the HCP about the unprofessional behavior.
3Complete an incident report describing the HCP’s unprofessional behavior.
4Walk up to the HCP and quietly state, “This unacceptable behavior has to stop.”
2
Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management?
1Case management strategies focus mainly on the client’s needs after discharge.
2Case management is a collaborative process designed to meet complex client needs.
3Physicians are responsible and accountable for client outcomes.
4The interdisciplinary team makes all the decisions for the client and family.
2
During the management of a client’s pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client’s pain?
1Cultural sensitivity is fundamental to client-centered pain management.
2Clients have the right to have their pain managed promptly.
3Nurses should not judge a client’s pain based on the nurse’s values.
4The client’s self-report of pain is the most important consideration.
4
A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)?
1Provide instruction to the client for ambulation with the orthotic.
2Monitor the client’s response to moving with the orthotic.
3Check the client’s skin for any redness or irritation from the orthotic.
4Assist with transferring the client from the bed to the chair.
4
Upon completing a review of a 27-year-old client’s admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take?
1Lecture the client on the importance of having advance directives.
2Inform the charge nurse to offer information about advance directives.
3Advance directives are not appropriate for this client due to the client’s age.
4Refer this issue to the client’s health care provider.
2
The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person?
1Physical therapist
2Pharmacist
3Physical therapist
4Occupational therapist
4
Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work.
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