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1. A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in the patient teaching about cancer? (Select all that apply.)


a. Alcohol used
b. Physical activity
c. Body weight
d. Colorectal screening
e. Tobacco used
f. Mammography
g. Pap testing
h. Sunscreen use


2. The nurse is performing an admission assessment for a non-English speaking patient who is from China. Which actions could the nurse take to enhance communication (select all that apply)?


a. Use an electronic translation application.
b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Ask the patient's teenage daughter to interpret.
e. Use exaggerated gestures to convey information.


3. Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)?


a. Institutional policies
b. Stability of the patient
c. State nurse practice act
d. LPN/LVN teaching abilities
e. Experience of the LPN/LVN


4. The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)?

a. Throws away a medication that is not labeled
b. Uses a hand sanitizer before preparing a medication
c. Identifies the patient by the room number on the door
d. Checks lab test results before administering a diuretic
e. Gives the patient a list of current medications upon discharge


5. The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a health care provider. In which order should the nurse make the following statements?


a. "The patient needs to be evaluated immediately and may need intubation and mechanical ventilation."
b. "The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low."
c. "The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable."
d. "This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour."


6. In what order will the nurse perform these actions when doing a physical assessment for a patient admitted with abdominal pain?


a. Percuss the abdomen to locate any areas of dullness.
b. Palpate the abdomen to check for tenderness or masses.
c. Inspect the abdomen for distention or other abnormalities.
d. Auscultate the abdomen for the presence of bowel sounds.


7. The nurse plans to provide instructions about diabetes to a patient who has a low literacy level. Which teaching strategies should the nurse use (select all that apply)?


a. Discourage use of the Internet as a source of health information.
b. Avoid asking the patient about reading abilities and level of education.
c. Provide illustrations and photographs showing various types of insulin.
d. Schedule one-to-one teaching sessions to practice insulin administration.
e. Obtain CDs and DVDs that illustrate how to perform blood glucose testing.


8. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient (select all that apply)?

a. Observe for depression.
b. Review laboratory results.
c. Assess teeth and oral mucosa.
d. Ask about transportation needs.
e. Determine food likes and dislikes.


9. The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply.


a. Hopelessness
b. Powerlessness
c. Interrupted sleep pattern
d. Disturbed self esteem
e. Self care deficit


10. The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply.


a. Collect and organize client information
b. Analyze data
c. Identify problems, risk, and client strengths
d. Develop nursing diagnoses
e. Develop client goals


11. The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply.


a. Client and Family
b. Other nursing staff on the unit
c. Security department
d. Hospital administration
e. This is not a collaborative intervention so no collaboration will be needed prior to implementation


12. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares to implement which priority interventions? Select all that apply.


a. Administering oxygen
b. Inserting a Foley catheter
c. Administering furosemide (Lasix)
d. Administering morphine sulfate intravenously
e. Transporting the client to the coronary care unit
f. Placing the client in a low Fowler's side-lying position


13. The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse effects. Which findings are characteristic of digoxin toxicity. Select all that apply.

a. Tremors
b. Diarrhea
c. Irritability

d. Blurred vision
e. Nausea and vomiting



14: What are the later signs and symptoms associated with the progression of lung cancer? (Select all that apply.)


a. White sputum
b. Chest pain or tightness
c. Shortness of breath
d. Wheezing
e. Weight gain
f. Recurrent attacks of asthma
g. Purulent sputum


15. Which clients are at highest risk to develop silicosis based on their occupation? (Select all that apply.)


a. Miners
b. Dentists
c. Potters
d. Bricklayers
e. Optometrists
f. Painters




16. What are the signs and symptoms of pneumothorax? (Select all that apply.)


a. Decreased respiration
b. Decreased breath sounds on affected side
c. Shortness of breath
d. Blue tinge to mucous membranes
e. Tracheal deviation
f. Decreased oxygen saturation


17. The client has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.)


d. Sudden onset of shortness of
c. Oxygen saturation greater than 95%
b. Tracheal deviation
a. Production of pink sputum

e. Drainage greater than 70 ml/hr

f. Pain at insertion site


18. The nurse is teaching a client to cough productively. Put the actions in proper sequence. 


a. Encourage client to take several deep breaths.
b. Assist client to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed.
c. Instruct the client to inhale deeply several times, to exhale slowly, and to cough at the end of exhalation.
d. Instruct client to follow coughing with several maximum inhalation breaths.
e. Encourage client to take a deep breath, hold it for 2 seconds, and cough two or three times in succession.


19. Which interventions would help prevent aspiration during eating for a client with a temporary tracheostomy? (Select all that apply.)

a. Avoid having the client eat a meal when he or she is fatigued.
b. Add water or broth to foods to make them thinner and easier to swallow rapidly.
c. Inflate the cuff of the tracheostomy tube to maximum pressure before initiating a feeding to mechanically block aspirated food from moving further down the airway.
d. When feeding the client, allow the client to indicate when he or she is ready for the next bite.
e. Encourage the client to tuck his or her chin down and forward while swallowing.
f. Urge the client to swallow three or four bites or mouthfuls in a row to reduce the time when he or she is at risk for aspiration.
g. Place the client in a lithotomy position for 30 minutes immediately following a meal.


20. A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in the patient teaching about cancer? (Select all that apply.)


21. The nurse explains to the patient newly diagnosed with HIV that prophylactic measures that should be taken as early as possible during the course of the infection include which the following (Select all that apply.)?
a. Hepatitis A vaccine
b. Hepatitis B vaccine
c. Pneumococcal vaccine
d. Influenza virus vaccine

e. Trimethoprim-sulfamethoxazole
f. Varicella zoster immune globulin


22. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order will the nurse perform the following actions?


a. Administer acetaminophen (Tylenol).
b. Perform wet-to-dry dressing change.
c. Administer intravenous antibiotics.
d. Sponge patient with cool water.



23. "The client diagnosed with appendicitis has undergone an appendectomy. At two hours postoperative, the nurse takes the vital signs and notes T 102.6 F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority.

a. Increase the IV rate.
b. Notify the health care provider.
c. Elevate the foot of the bed.
d. Check the abdominal dressing.
e. Determine if the IV antibiotics have been administered.





24. A nurse is caring for a child who had a laparoscopic appendectomy. What interventions should the nurse document on the child's clinical record? Select all that apply. 

a. Intake and Output

b. Measurement of Pain

c. Tolerance to low-residue diet  

d. Frequency of dressing changes

e. Auscultation of bowel sounds






25. When assessing a patient's sleep-rest pattern related to respiratory health, the nurse would ask if the patient: (Select all that apply.) 

a. Has trouble falling asleep 
b. Awakens abruptly during the night 
c. Sleeps more than 8 hours per night 
d. Has to sleep with the head elevated



1. D, F, G, H
Rationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.












2. A, B, C
Electronic translation applications, telephone-based interpreters, and agency interpreters are all appropriate to use to communicate with non-English-speaking patients. When no interpreter is available, family members may be considered, but some information that will be needed in an admission assessment may be misunderstood or not shared if a child is used as the interpreter. Gestures are appropriate to use, but an exaggeration of the gestures is not needed.


3. A, B, C, E
The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, LPN/LVN scope of practice includes caring for patients who are stable, while registered nurses should provide most of the care for unstable patients. Since LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process.




4. A, B, D, E
National Patient Safety Goals have been established to promote safe delivery of care. The nurse should use at least two reliable ways to identify the patient such as asking the patient's full name and date of birth before medication administration. Other actions that improve patient safety include performing hand hygiene, disposing of unlabeled medications, completing appropriate assessments before administering medications, and giving a list of the current medicines to the patient and caregiver before discharge.

5. D, B, C, A
The order of the nurse's statements follows the SBAR format.
















6. C, D, A, B
When assessing the abdomen, the initial action is to inspect the abdomen. Auscultation is done next because percussion and palpation can alter bowel sounds and produce misleading findings.





7. C, D, E
For patients with low literacy, visual and hands-on learning techniques are most appropriate. The nurse will need to obtain as much information as possible about the patient's reading level in order to provide appropriate learning materials. The nurse should guide the patient to Internet sites established by reputable heath care organizations such as the American Diabetes Association.








8. A, B, C, D
The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients' ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.


9. A, B

A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).





10. B, C, D

The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.




11. A, B

Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.





12. A, B, C, D

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.


13. B, D, E

Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache, visual disturbances such as diplopia, blurred vision, yellow-green halos, photophobia, drowsiness, fatigue, and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL.

14: B, C, D, G
Chest pain or tightness, shortness of breath, wheezing, and purulent sputum are all symptoms associated with lung cancer. White sputum, weight gain, and recurrent attacks of asthma are not known to be associated with lung cancer.







15. A, C, D
People working in mines, those making pottery, and those working with a brick would be at highest risk to develop silicosis because of the dust generated in these occupations.







16. B, C, E, F
Symptoms of pneumothorax include rapid respiration, reduced breath sounds on the affected side, dyspnea, decreased oxygen saturation, tracheal deviation, and prominence of one side of the chest.








17. B, D, E
Immediate intervention is warranted if the client has tracheal deviation because this could indicate a pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 ml/hr because this could indicate hemorrhage. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.



18. B, A, E, C, D
When the client can tolerate it, the best position for effective coughing and secretion removal is sitting with the shoulders turned inward and the head bent slightly down while hugging a pillow.










19. A, D, E
Aspiration is less likely to occur if the client is well rested. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order. Aspiration may become more likely if the client is urged to swallow faster. Placing the client in a lithotomy position after the meal will not prevent aspiration.









20. D, F, G, H
Rationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.



21. A, B, C, D
Rationale: Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4 count has dropped or when an infection has occurred.





22. C, A, D, B
Rationale: The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.


23. A, C, D, E, B
A. The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained.
C. The foot of the bed should be elevated to help treat shock, the symptoms of which include elevated pulse and decreased BP. Those signs and an elevated temperature indicate an infection may be present and the client could be developing septicemia.
D. The dressing should be assessed to determine if bleeding is occurring.
E. The nurse should administer any IV antibiotics ordered after addressing hypovolemia. The nurse will need this information when reporting to the HCP.
B. The HCP should be notified when the nurse has the needed information.


24. A, B, E
A. Assessment and documentation of fluid balance are critical aspects of all postoperative care.

B. Laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it is absorbed. The amount of pain should be measured and documented with either a 1-10 scale or the Wong's FACES for younger children.

C. A special diet is not indicated after this surgery.

D. After a laparoscopic appendectomy, there is little drainage and no dressings.

E. Auscultating for bowel sounds and documenting their presence or absence evaluate the child's adaptation to the intestinal trauma caused by the surgery.


25. A,B,D

The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night is not indicative of impaired respiratory health.

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