Nursing Practice Scenarios: Appropriate Responses to Various Situations, Exams of Nursing

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Comprehensive Practice A **A client is postoperative following a lumbar discectomy and is having difficulty voiding. The nurse should recognize that which of the following medications place the client at risk for urinary retention? Ketorolac Hydromorphone (Dilaudid) Bethanechol (Urecholine) Tobramycin (Nebcin) **A nurse is caring for an older adult client in a long-term care facility who is disoriented and continues to get out of bed without assistance. Which of the following images indicates the nurse is using an appropriate intervention to minimize the risk of injury due to a fall? D **A practical nurse (PN) on medical-surgical unit is beginning her shift and is working with a registered nurse (RN) and an assistive personnel (AP). The PN should expect to be assigned which of the following tasks? Teach a client who has a new diagnosis of diabetes mellitus how to self-administer insulin. Create a plan of care for a newly admitted client. Obtain a stool specimen from a client who has ulcerative colitis---- Administer an NG tube feeding to a client who had a stroke **A nurse on an acute mental health unit observes a client who begins to speak loudly in the common room, saying that he can’t hear the TV. Which of the following is an appropriate response by the nurse?

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You will need to go to your room until you can calm down okay The TV is loud enough for everyone to hear it You are being inconsiderate. Please stop talking so loudly Let’s go to another room to talk about what is upsetting you **A client tells a nurse that he would like to observe kosher dietary laws. The nurse should recognize which of the following?

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A vegetarian diet is the preferred diet Dairy products are served separately from meat Fasting during daylight is required during a month-long holiday Fish with scales and fins should not be eaten **A nursing unit receives new glucose monitoring equipment from staff development with the promise that in-service education will be given soon. Which of the following instructions should the nurse give to the assistive personnel (AP) who is preforming glucose monitoring on the unit? Contact the staff development department for instruction Continue using the current glucose monitors Check for accuracy and proper functioning of the new monitor Read the instruction manual before attempting to use the new monitor **Which of the following should the nurse document as an indication of the IV infiltration in a client’s forearm? Redness along vein Tissue sloughing at the site Forearm that is warm to the touch Pallor surrounding the infusion site **A client requests information about advanced directives. Which of the following is the appropriate response by the nurse? Advanced directives are written instructions regarding end of life care Advanced directives provide education on palliative care issues

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Advanced directives require the provider’s approval before changes can be implemented Advanced directives help determine legal competency **A nurse is caring for a client who is on telemetry. Which of the following ECG findings should the nurse report to the charge nurse? One P wave prior to each QRS complex

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PR interval 0.24 seconds QRS duration 0.06 seconds Ventricular rate 75/min **A nurse is checking the reflexes of a newborn. Which of the following techniques should the nurse use to elicit the Babinski reflex? Startle the infant by clapping hands Stroke the sole of the infant’s foot upward and toward the great toe Hold the infant upright and allow one foot to touch the table’s surface Place an object in the palm of the infant’s hand **A charge nurse in a long-term care facility notices an assistive personnel’s (AP) repeated failure to provide oral care for clients. Which of the following actions should the nurse take? Provide oral care for clients after the AP has completed other care Develop an educational session about the importance of oral care for all Aps Discuss the unacceptable behavior with the AP while reinforcing expectations Suspend the AP for 3 days pending disciplinary action **A nurse is caring for a client who has terminal cancer. Which of the following statements by the client’s family should indicate the nurse that they are coping with their situation? Dad I remember the time we all went to the lake fishing Dad I truly believe that it’s not your time to leave us I feel like I don’t know what to do anymore I think we need to concentrate on whose house we plan to meet at for our holiday get-together

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**A nurse is performing a dressing change for a client who had abdominal surgery 5 days ago. The nurse notes organs protruding from the incision. Which of the following actions should the nurse take? Apply an abdominal binder Have the client lie flat in bed.

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Cover the exposed area with sterile, saline-soaked dressing Place gentle pressure on the exposed organ with sterile gauze **A nurse in a skilled nursing facility is caring for a client who is receiving warfarin (Coumadin) therapy following a total hip replacement. An assistive personnel reports a positive guaiac. Which of the following laboratory values should the nurse report to the provider? Hematocrit 40% International normalized ratio of 4. Hemoglobin 15 g/dL-- Prothrombin time 18 seconds ** A nurse is reinforcing teaching with a client who has hypertension and is beginning medication therapy with captopril (Capoten). Which of the following over-the-counter medications should the nurse instruct the client to avoid? Acetaminophen (Tylenol) Diphenhydramine Ibuprofen (Advil) Guaifenesin (Robitussin) **A nurse is reinforcing teaching for a client who is in her first trimester of pregnancy. Which of the following physiological changes should the nurse instruct the client to expect during the first trimester? Leukorrhea Shortness of breath Pedal edema Perineal pressure

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** A nurse is collecting data from a client who has a peptic ulcer disease. Which of the following should the nurse identify as the priority finding? Gnawing epigastric pain Heartburn

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Regurgitation Hematemesis **A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD). Which of the following behavioral indications should the nurse expect? Dependence Euphoria Memory Loss Hypervigilance **A nurse is collecting data from a client who has schizophrenia. Which of the following statements by the client should the nurse identify as a delusion? My doctor’s glasses have lasers that will burn holes in my brain if I look at him The movie had an explosion. I once drove a green truck. Where is the ketchup The voice keeps telling me to go kick the table over. Why won’t it stop I can’t sit here because the purple monkey on the ceiling will jump on me **A nurse is caring for a client who sustained a broken leg while assisting other from a structural fire. The client states I am glad those people were saved but I sure wish I was not hurt. Which of the following is an appropriate response by the nurse? You are a real hero. I am sure that makes your injuries worthwhile It is difficult to experience personal injuries for whatever reason Things will get better before long Let’s talk about this later when we have more time

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**A nurse is reinforcing teaching for a client who has a new prescription for lithium carbonate (Lithobid). Which of the following instructions should the nurse include? Eliminate all foods containing tyramine Drink 2 to 3 liter of fluid each day Take lithium carbonate on an empty stomach

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Reduce your daily sodium intake to 1,000 mg **A nurse in a provider’s office is reinforcing teaching with a client who is receiving peritoneal dialysis via a newly inserted catheter. For which of the following should the nurse instruct the client to contact the provider? Bloody peritoneal fluid Clear peritoneal fluid Cloudy peritoneal fluid Straw-colored peritoneal fluid **A child is brought to the clinic by his parents with injuries inconsistent with the reported cause. A nurse suspects physical abuse. Which of the following actions should the nurse take? Interview the child with the parents in the room Ask the provider to talk to the child and parents Make a note in the chart to check the child during the next visit Report the suspected abuse to the appropriate agency **A nurse is reviewing discharge instructions with a client who has undergone a lumbar laminectomy. Which of the following should the nurse include? Use a soft mattress for sleeping Practice bending from the waist several times daily Sit in a straight backed chair Wear shoes with a slightly raised heel to promote body alignment

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**A nurse is reinforcing teaching with a client about cancer prevention, the nurse should instruct that frequent consumption of which of the following foods increases the risk of cancer? Tuna Lamb Chicken Turkey

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** A nurse is reinforcing teaching to a client who is scheduled for a lumbar puncture. Which of the following should the nurse include in the teaching? Nausea is common adverse effect after this procedure You should increase your fluid intake after this procedure You will be instructed to remain in an upright position for the first 4 hours after the procedure The provider will apply a pressure bandage to the puncture site **A newborn is scheduled to have a heel stick for blood glucose testing every 4hr. The newborn’s blood glucose on admission was less than 40 mg/dL. Which of to the following additional clinical manifestations should the nurse observe for in this newborn? Jitteriness Bradycardia Inconsolability Insomnia **A nurse is contributing to the plan of care for a client who has a prescription for range of motion exercise of the shoulder. To promote shoulder hyperextension, which of the following exercises should the nurse recommend? Move his arm behind his body with his elbow straight Move his arm in a full circle Raise his arm out to the side and reach it above his head with his palm facing away from his head Raise his arm from his side straight forward and then up above his head. **A nurse is receiving change-of-shit report for four clients. Which of the following clients should the nurse attend to first?

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A client who requests to be moved to a room closer to the nurse’s station A client who is postoperative and had received morphine twice during the last 8hrs A client whose urinary output was 100 mL for the past 12hr A client who insists on speaking with the provider prior to discharge

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**A nurse is reinforcing teaching regarding home safety to a client who has diabetes mellitus and is being discharged after an admission for hepatitis B. Which of the following client statements indicates an understanding of the teaching? I will recap my used syringes and throw them away in a plastic bag I will take Tylenol for aches and pains I will use my own eating utensils and dishes at home Houseguest will need to wear masks when they come to visit me **A nurse in a long-term care facility is transcribing new prescriptions for four clients. Which of the following prescription is accurately transcribed by the nurse? Alprazolam (Xanax) 0.5 mg PO QHS for sleep Regular insulin (Humulin R) 10 U SC at 0800 Docusate sodium (Colace) 250 mg PO QOD Potassium chloride (Micro-K) 20mEq PO every morning **A nurse is caring for a client who has altered mental status and has become increasing belligerent. Which of the following medications prescriptions, if written for this client, should the nurse question? Haloperidol (Haldol) Lorazepam (Ativan) Zolpidem (Ambien) Alprazolam (Xanax) **A nurse is caring for a client who is experiencing acute kidney failure. The nurse should monitor the client for which of the following acid-base imbalances?

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Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis

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**A nurse in an urgent care clinic is collecting data from four clients. Which of the following clients should the nurse recommend for treatment first? A client who has a fever and abdominal pain in the upper aspect of the right lower quadrant A client who has shortness of breath after taking a dose of amoxicillin (Amoxil) A client who has hemoptysis and has taken medication for tuberculosis (TB) for 2 months A client who has a purple stoma following an open colon resection with a colostomy 2 weeks ago. **A nurse on a medical unit is preforming an audit on his client assisgnment. For which of the following should the client have a separate signed informed consent form. Chest radiography Echocardiogram Indwelling urinary catheter Lumbar puncture ** A nurse in an acute care hospital is planning to discharge an adult client who is immunocompromised. Which of the following immunizations should the nurse plan to administer before discharge. Measles, mumps, and rubella (MMR) immunization Pneumococcal polysaccharide (PPSV) immunization Varicella immunization Herpes zoster immunization ** A nurse is reinforcing teaching to a client regarding care of her newborn. The nurse determines that the teaching is effective when the client points to which part of the newborn’s head and states it will take 12 to 18 months for the soft stop to close.

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(top of the head near face) **A parent of a 3yr old child tells the nurse that he cannot get his child to sit at the table to eat a full meal. Which of the following responses by the nurse is appropriate? Provide the child with foods of the same texture rather than a variety of unfamiliar foods

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Engage the child in conversation during meals to encourage him to eat like the rest of the family Encourage active play prior to meals to increase the child’s appetite Offer the child heathful snacks frequently, rather than expecting him to fully eat at mealtimes **A nurse in a providers office is caring for four clients. Which of the following should the nurse see first. A client who is at 38 weeks gestation and reports urgency and frequency of urination A client who is at 37 weeks gestation and reports edema of the ankles A client who is at 36 weeks gestation and reports painless vaginal bleeding A client who is at 34 weeks gestation and reports abundant amounts of odorless vaginal mucus **A nurse and an assistive personnel (AP) are caring for four clients in a long-term-care facility. For which of the following situations is it necessary to complete an incident report? A client throws an object across the dinning room A client refuses his morning medications A client who is prescribed full liquid diet receives a clear liquid diet A client who is confused walks into another client’s room ** A nurse working in the clinic receives a phone call from a mother whose child has just ingested the contents of a bottle of acetaminophen (Tylenol). Which of the following is an appropriate response by the nures?

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Adminster syrup of ipecac to the child to induce vomiting Take the child to the emergency department Give the child a glass of milk to drink Monitor the child’s level of consciousness **A client is scheduled for colon cancer surgery in the morning. The night nurse learns that the client has decided not to have the surgery, even through he has already signed the informed consent form. Which of the following actions should the nurse take?

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Inform the client that a signed consent form is legally in effect for 24hr Report the situation to the surgeon who obtained the informed consent Reinforce client teaching about the purpose of the procedure Notify the client’s family about the refusal of treatment **A nurse is caring for a newborn who is 1hr old. The mother received fentanyle (Sublimaze) 30 min before delivery. For which of the following should the nurse monitor for in the newborn? Hyperbillrubinemia Hypoglycemia Respiratory depression Increased heart rate **A nurse is reinforcing discharge teaching with the parent of a school-age child who had a tonsillectomy. Which of the following statements by the parent indicates an understandin of the instructions? I will encourage my child to drink 4 ounces of orange juice twice a day I will allow my child to chew gum to prevent throat pain I will ensure my child uses a straw to drink fluids I will give my child chocolate ice cream ** A nurse is reviewing the laboratory results for an infant receiving gentamicin intermittent IV bolus twice daily and notes the serum creatinine is 0.9 mg/dL. The nurse is aware that this result can indicate an adverse effect on which of the following systems? Hepatic Renal

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Gastrointestinal Endocrine **A is reinforcing teaching with an adolescent client about a scheduled blood draw of HbA1c. The nurse knows that the client understands the purpose for this test when the client states that this test will measure his average blood glucose level over the past

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2 to 3 days 6 weeks 2 to 3 months 6 months **A nurse is caring for a client in Buck’s traction. Which of the following interventions should the nurse perform while the client is in this traction? Allow the weights to hang freely Inspect the skin every 24hr Remove the weights every 24hr Let the client use the bedside commode **A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the nurse should obtain which of the following? Motor response Vital signs Short-term memory Gait **A nurse is reinforcing teaching to a client who has a new prescription for atorvastatin (Lipitor). For which of the following shold the nurse tell the client to monitor and report to the provider? Anorexia Muscle tenderness Facial flushing Insomnia

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**A nurse working in a clinic is collecting data on a toddler. Which of the following findings should the nurse identify as suggestive of physical neglect? The toddler is inadequately dressed for the weather The toddler has irriation to the external genitalla

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The toddler has symmetrical burns to both legs The toddler does not react when the nurse adminsters an injection **A parent of a 2month old infant asks the nurse how she will know if her baby is growing appropriately. Which of the following is an appropriate response by the nurse? Your baby should weigh 2.5 time his height by 6 months Your baby should gain 1 pound per month during the first 6 months Your baby’s weight should be double his birth weight by 4 to 6 months Your baby should grow half an inch per month during the first 6 months **A nurse is contributine to a teaching plan for a group of male adolescents regarding use of anabolic steroids. Which of the following should the nurse include in the teaching as risk of using anabolic steroids? Decreased appetite Reduced height potential Increased dental caries Impaired vision **A client who is 1 day postoperative is unable to ambulate. The nurse should recognize that which of the following will promote venous return? Encouraging the client to cough and deep breathe Maintaining a sequential compression device Elevating the head of the bed Massaging the clients legs