Nursing Care Scenarios, Exams of Advanced Education

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( NCSBN) LPN QUESTIONS 2024

A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client? Face the client while asking questions as the interpreter translates the information The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)? Measure blood pressure, pulse and respirations The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept? An older adult client diagnosed with cystitis who has an indwelling urethral catheter A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate? "Have the client lift and move the walker out to arm's length, then walk into the walker." The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting? Improve the quality of care in a proactive manner During a discussion about a living will, the client's son states, "I do not understand the need for a living will." What is the best response by the nurse? "Health care decisions can be made based on the client's wishes." A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client's mental status and adjustment. What should the nurse do next to respond to this request? Verify that the client's medical record includes the client's written consent to release information. When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse? "Since I am late for lunch, would you perform my client's blood glucose test?" The nurse has been assigned to four clients. Which client should the nurse see first? The client with a history of coronary artery disease (CAD) reporting dyspnea, nausea and unusual discomfort in the upper back The client requests not to be interrupted before 10 am because it interferes with the client's time to meditate. What action shall the nurse take first? Meet with the client to formulate a mutually agreeable schedule. 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? Discuss with the client to find out about the preferred herbal preparation A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client? All clients have a right to be informed about their prescribed medications

The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? Close all doors in the area. 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? Explore for further identification about the nature of the problem 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? "When I emptied my urine catheter drainage bag it looked like rusty-colored water." 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)? Assist with transferring the client from the bed to the chair. A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan? Keep a time log for what was done during the hours worked 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?" "Have you discussed your wishes regarding resuscitation with your health care provider? "What does your family know about your condition and prognosis?" 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? The client's self-report of pain is the most important consideration The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)? Record and report the client's intake and output. 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? Occupational therapist 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? Hold the medication and contact the health care provider. A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? Complete and accurate documentation of assessments and interventions The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? The client with peptic ulcer disease who has been vomiting most of the night

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? Inform the charge nurse to offer information about advance directives The nurse is preparing to administer regular insulin subcutaneously to a client at 0800. What information from the client's electronic health record should the nurse review in order to safely administer the medication? (Select all that apply.) Name and date of birth. 0700 blood glucose. Medication administration record (MAR). 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? Encourage the UAP to directly confront the HCP about the unprofessional behavior. The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take? Report this request immediately to the nurse manager. 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? Achievement or status of progress related to prior goals 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? Case management is a collaborative process designed to meet complex client needs. The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include? Empty the child's mouth of any poisonous substance still present. The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first? Immediately wash hands vigorously with soap and warm water. The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is: To trace and screen recent contacts the client had A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints? (Select all that apply.) The client's status is documented every 15 minutes. The appropriate client advocate or relative has been notified. The radial and pedal pulses are palpable and strong.

The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child's parents? Wash hands thoroughly with soap and warm water after contact with the child. The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? (Select all that apply.) "Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." The nurse is reviewing the documentation of a client's care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take? (Select all that apply.) Mark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. The automated external defibrillator (AED) has been applied to a client receiving cardiopulmonary resuscitation (CPR). Indicate how the nurse will proceed by placing the following actions in the correct order. (Instructions: Drag and drop the steps into the correct order.)

1. Press the analyze button when the AED prompts the nurse to do so
2. Wait for the AED to analyze the clients heart rhythm
3. Call out "Stand Clear" when the AED Prompts the nurse to administer a shock
4. Press the shock button on the AED
5. Allow time for the AED to administer a shock
6. Immediately resume CPR The nurse enters the room while a student nurse is taking a manual blood pressure on a client sitting in the chair. For which of the following observations should the nurse reinforce teaching with the student nurse? (Select all that apply.) The client is talking on the telephone and laughing The client is crossing his legs The client is drinking a cup of black tea The air is released rapidly while auscultating for Korotkoff sounds An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce? Urine and saliva will be radioactive for 24 hours after ingestion.

The nurse understands that which situations require hand hygiene such as handwashing or hand sanitation? (Select all that apply.) Prior to and after eating After cleaning a wound After contact with objects in the immediate vicinity of the client Before having direct contact with a client The nurse is attending an in-service about health care-acquired infections (HAIs). Which factor is considered a common cause of HAIs for clients in the acute care hospital setting? Presence of an indwelling urinary catheter The nurse is caring for a client with bilateral wrist restraints. Which intervention(s) should the nurse include in the client's plan of care? (Select all that apply.) Routinely assess if the client is ready for restraint discontinuation. Remove restraints every two hours to allow for movement of involved extremity. Monitor the client's emotional response to the restraints. The parents of a toddler ask, "How long will our child have to sit in a car seat when riding in a car?" What would be the best response by the nurse? "Until the child outgrows the car seat." The nurse is preparing to ambulate a client who requires the use of a gait belt. Which of the following actions are appropriate for the nurse to take? (Select all that apply.) Secure the gait belt to fit around the client's waist. Use an underhand grasp at the center of the client's back to grasp the gait belt. While working a 12-hour night shift, the nurse has a "near miss" and catches an error before administering a new medication to the client. Which factors could have contributed to the near miss? (Select all that apply.) The nurse was interrupted when preparing the medication The nurse is assigned more clients than usual due to staffing issues The nurse works in the intensive care unit (ICU) The nurse has worked four 12-hour night shifts in a row A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client's dinner. What action should the nurse take next? Serve the dinner in the seclusion room, maintaining observation The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated? Complete an incident report

The nurse is caring for an 80-year-old client who requires wrist restraints. What client behaviors would support the need to continue to use restraints? (Select all that apply.) The client is confused and trying to pull out an IV catheter. The client is resisting care and attempting to hit the staff. The nurse observes an unlicensed assistive personnel (UAP) about to take a client's temperature with a tympanic thermometer. Which observation would require the nurse to intervene immediately? (Select all that apply.) The UAP cleans the thermometer by running it under hot water. The UAP applies lubricant to the thermometer probe. The UAP uses the client's room number and name to identify client. The parent of a 7-year-old child calls the clinic nurse because their child was sent home from school due to a rash. The child was diagnosed with fifth disease (erythema infectiosum) the day before and is otherwise in good health. What would be the appropriate action by the nurse? Explain that the rash is no longer contagious and does not require isolation. A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin- resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client? (Select all that apply.) Place the client in a private room. Keep all equipment in the client's room for their sole use. Perform hand hygiene after contact with the client and before leaving the room. Place personal protective equipment (PPE) at the door to the room. A child is admitted with a suspected diagnosis of meningococcal meningitis. Which admission order should the nurse implement first? Implement droplet precautions. The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client with a diagnosis of schizophrenia. Which of the following behaviors justify use of this chemical restraint? (Select all that apply.) The client is experiencing command hallucinations. The client is expressing paranoid delusions. The client is verbalizing a plan to harm another client. The nurse observes two unlicensed assistive personnel (UAPs) transferring a client using a mechanical lift. Which observations would require the nurse to intervene immediately? (Select all that apply.) The client is lowered as quickly as possible to the chair. No support is provided for the client's head. Which action shall the nurse take to preserve the client's right to autonomy?

Providing the client with requested information to make an informed decision. Four clients are admitted to an adult medical unit on the same shift. The nurse should implement airborne precautions for which client? The client with a productive cough who just returned from vacation in India The parent of a toddler who is being treated for suspected poisoning asks, "Why is activated charcoal used?" What is the best response by the nurse? "Activated charcoal binds with the poison to limit absorption in the digestive tract." The hospital is under a severe weather warning. The nurse is prioritizing clients for discharge to make beds available for possible emergency admissions. Which of the following adult clients would be most appropriate to discharge? (Select all that apply.) A client who can manage their self-care. A client who requires the administration of enoxaparin. A client who is ambulatory with the support of crutches. The nurse observes a nursing assistant using antiseptic hand sanitizer and rubbing their hands vigorously after leaving the room of a client diagnosed with Clostridium difficile (C-Diff). Which action by the nurse is appropriate? Instruct the nursing assistant to wash their hands again with soap and water. The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy? Accepting physical changes related to pregnancy. The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention? Smoking cessation The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure? Involve the client in making decisions. During a well-baby visit, the nurse is evaluating developmental milestones for the 7- month-old child. Which of these developmental activities should the child be able to perform? Sits without support During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next? Auscultate the area. A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? Confirm that the client's hearing is intact. Which of the following interventions should the nurse include in the plan of care for a client who recently experienced a fall at home? (Select all that apply.) Apply nonslip strips to the bottom surface of the shower. Monitor blood pressure when lying down, sitting and standing.

Ensure the room lighting is adequate and remove clutter in the room. The nurse in a primary care provider's office is collecting data on lifestyle choices and activities of daily living (ADLs) from an older adult client. Which of the following statements by the nurse would be appropriate? (Select all that apply.) "How do you spend your time on a typical day?" "How many glasses of alcohol do you drink per day or per week?" "Tell me what you eat on a typical day." A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.) Frequency and amount of naproxen used Color of bowel movements Bruising A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs? Identify the client's learning needs. A 20-year-old male client who has a profuse, purulent urethral discharge with painful urination is seen at a community health clinic. Which information will be most important for the nurse to obtain? Recent sexual contacts A client has a family history of coronary artery disease (CAD). Which of the following findings should be of concern to the nurse? Blood pressure of 154/ A newly pregnant woman asks the nurse what to expect in the early stages of pregnancy. Which developmental task will the client need to accomplish during this stage? Accepting the pregnancy and the physical changes involved. A client with a back injury asks the nurse how chiropractic manipulation works. What is the nurse's best response? Spinal column manipulation The nurse has given discharge instructions to a client who is diagnosed with alcohol use disorder. Which of the following statements indicate that the client correctly understands the nurse's instructions? (Select all that apply.) "I should avoid taking acetaminophen while drinking alcohol." "Alcoholism can lead to the development of cardiovascular disease." "Taking antihistamines while drinking alcohol can lead to sleepiness."

The nurse is caring for a client diagnosed with a chlamydial infection. Which of the following should the nurse plan to include in the client's education to prevent further transmission of the infection? (Select all that apply.) The client should not have sexual activity until at least seven days after completing the course of antibiotics. The client's sexual partners also need to receive antibiotic treatment for chlamydia. Retesting after treatment is necessary to confirm that reinfection has not occurred. The nurse, following hospital policy, reports an incident of suspected child abuse. The parent of the child becomes upset and demands to know the reason for the nurse's action. Which is the best response by the nurse? "As a nurse, I am required by law to report incidents of suspected child abuse." A client scheduled for a mammogram asks the nurse about the risks from radiation exposure. How should the nurse respond? "The radiation from today's mammograms is very low." The clinic nurse is evaluating an older male client who reports having trouble urinating. After the client uses the bathroom, which method should the nurse use to check for post-void residual (PVR)? Scan the bladder, using a portable ultrasound scanner. A newborn born prematurely is to be fed breast milk through a nasogastric tube. Why is breast milk preferred over formula for premature infants? Breast milk provides antibodies The nurse recognizes that which finding indicates a child has attained the developmental stage of concrete operations, according to Piaget? The child makes the moral judgment that "stealing is wrong." Which of the following actions performed by the nurse indicates that additional education on ergonomic principles is needed to reduce the risk of injury? Bend and twist at the waist when assisting a client in transferring to the chair. The nurse is administering pneumococcal vaccinations at a community health clinic. Which of these clients should not receive the vaccine? The client who had chemotherapy four days ago The nurse is teaching a class on health promotion to a group of college students living in a university dormitory. Which information should the nurse include? (Select all that apply.) Students should ensure their meningitis vaccines are current. Students should seek treatment for upper respiratory infections promptly. Students should maintain good hand hygiene practices. Students should obtain a flu vaccine annually. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) and a significant family history of coronary artery disease. Which of the following prescriptions by the health care provider would treat a major modifiable risk factor of coronary artery disease?

Atorvastatin The nurse is evaluating a pre-admission questionnaire completed by a sexually active female client. Which of the following indicate the client may be demonstrating high-risk behaviors for acquiring a sexually transmitted infection (STI)? (Select all that apply.) Uses oral contraceptives as the only birth control method Works as a sex worker several times per week Has recently had sexual intercourse without a condom The nurse is preparing to speak at a community center about strategies on how to prevent the transmission of human immunodeficiency virus (HIV). Which of the following statements would be appropriate for the nurse to include? (Select all that apply.) Condom use during all sexual activity significantly decreases the risk of contracting HIV. Testing for HIV is recommended for individuals with an increased risk. Antiviral medications started immediately after exposure can reduce the risk of developing HIV. Pre-exposure prophylaxis (PrEP) with antiviral drugs will significantly reduce the risk of contracting HIV. The nurse is caring for a 20-year-old male client who has not been previously vaccinated for human papilloma virus (HPV). The client states: "I thought the HPV vaccine is only given to women." What would be the best response by the nurse? "Vaccination for HPV is recommended for both males and females and helps prevent cancer." A 25-year-old client is scheduled for a gynecological exam and calls the office nurse for instructions prior to the appointment. It has been five years since her last exam. Which of the following instructions are appropriate for the nurse to provide? (Select all that apply.) "You should avoid sexual intercourse for 24 hours prior to your appointment." "You will need to have a Papanicolaou test (PAP test)." "Your exam should be scheduled between your menstrual periods." The nurse is evaluating a client's ability to perform basic activities of daily living (ADLs). Which of the following tasks should the nurse observe the client performing? (Select all that apply.) Using the bathroom Getting fully dressed Eating a meal independently An adolescent client is paralyzed from the waist down after being involved in a motor vehicle accident. Which client statement would indicate to the nurse that the client is using repression as an ego defense mechanism?

"I don't remember anything about what happened to me." After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased client prior to moving the body. What would be the most appropriate response by the nurse? "Is there anything you need from me to perform the bath?" The client diagnosed with paranoid-type schizophrenia is sitting alone, intently staring at and watching other clients and staff members. The client becomes hostile when approached with medication and claims that the medication controls the mind. What type of symptom(s) does the nurse recognize that this client is exhibiting? Positive symptoms The nurse is caring for a postpartum Latina client who keeps declining the hospital food because it is "cold." What action should the nurse take initially? Ask the client what foods are acceptable. A nurse is working to establish a therapeutic relationship with a client. Which action would support the nurse's goal? Establish trust and rapport with the client. The nurse is providing care for a client who has been diagnosed with terminal cancer. The nurse notes that the client's wife is not visiting very often. When she does visit the client, she only stays for a brief time, stands in the corner and does not approach the client during interactions. Which of the grieving processes is the client's wife most likely experiencing? Anticipatory grief A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse? "Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve hours after admission the client becomes diaphoretic, tremulous and irritable, and the client's pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here." What is the most likely cause for the client's symptoms and behavior? Early stage of alcohol withdrawal The nurse is working with a couple who is experiencing intense anxiety after their home was completely destroyed by a fire. The nurse should implement which initial intervention? Determine what community housing resources are available. The nurse is evaluating a client who is being physically abused by the client's domestic partner. The client states, "I need a little time away." Which is the most likely response from the partner for which the nurse should prepare the client? Fear of rejection, resulting in increased rage toward the client The nurse is caring for a client diagnosed with end-stage heart failure (HF). The family members are distressed about the client's impending death. Which action should the nurse take initially? Explore the family's past patterns for dealing with death.

A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." What is the best response by the nurse to the client's statement? "Have you thought about hurting yourself?" A nurse is collecting data on a client believed to be in an abusive relationship. Which client statement is most indicative that this individual is experiencing intimate partner abuse? "I must have done something to deserve this." The nurse in a long-term care facility is assigned to the dementia unit. What type of functions should the nurse expect to see impaired in these clients? Learning, creativity and judgment The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? ( Select all that apply. ) Breast cancer Coronary artery disease (CAD) Obstructive sleep apnea (OSA) Gallstones A client diagnosed with schizophrenia first speaks animatedly to another client, with exaggerated clarity of pronunciation. The nurse then observes the client turning abruptly away, mumbling to themselves and speaking to the wall. Which priority goal/outcome should the nurse select for the client's plan of care? Client will engage in meaningful and understandable verbal communication. The nurse on the mental health unit is assigned to a client diagnosed with post- traumatic stress disorder (PTSD). What priority interventions shall the nurse include in the client's plan of care? ( Select all that apply. ) Assign the same staff to the client as often as possible. Discuss the coping strategies the client is using in response to the trauma. Stay with the client during periods of flashbacks and nightmares. The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? ( Select all that apply. ) Insecurity in relationships Craving and inability to abstain from alcohol Prone to act impulsively The nurse is caring for a mother who has just delivered a stillborn infant. What would be the most therapeutic nursing intervention? Offering the mother the opportunity to hold, bathe and dress the infant.

The nurse is caring for a client who has an alcohol use disorder (AUD). The client states that the client's dysfunctional family caused the addiction. Which response by the nurse would best help the client accept responsibility for their own behavior? "The lab report showed a high blood alcohol level when you were admitted." A home health nurse is caring for a client diagnosed with late-stage, Lewy body dementia (LBD). The nurse is meeting with the client's family to discuss options for care of the client. What is the initial question the nurse should ask to assist the family with their decision-making process? "What type of assistance does your parent require?" The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder (OCD). Which behavior should the nurse expect to see with this diagnosis? The client is seen washing her hands every 15 minutes. While interviewing a client admitted to the behavioral health unit, the nurse notices that the client is shifting positions, moving and constantly twisting their hands, and avoiding eye contact. What initial action should the nurse take? Ask the client about their current feelings or thoughts. A client reports feeling upset after electroconvulsive therapy (ECT) because the client is experiencing memory loss and cannot remember important phone numbers for family and friends. What would be the most therapeutic response from the nurse? "I can understand that forgetfulness is upsetting to you." A couple that recently immigrated to the United States tells the nurse about their concern that hospital staff is giving their child the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family? Touch the child after or while looking at the child. The nurse is caring for a female client who underwent a left modified radical mastectomy. Which statement indicates the client needs additional support from the nurse? "I can't bear to look at myself in the mirror." The nurse is working in an inpatient psychiatric setting and understands that touching clients should be limited to a quick handshake for which reason? A handshake allows the use of therapeutic touch while maintaining boundaries. A nurse is caring for a client who is being treated for major depression. During which time period is the client most likely to be at the highest risk for attempting suicide? 1 to 2 weeks after initiating antidepressant medication. A client of Chinese descent is admitted with a diagnosis of generalized anxiety disorder (GAD). Based on traditional Chinese medicine (TCM), what should the nurse expect the client to believe about this illness? It is caused by an imbalance in yin/yang. The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)? Excitability, disorientation, tremors and tachycardia A client is on NPO status and has a nasogastric (NG) tube in place, connected to low- intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client? Provide oral care at least every 2 to 4 hours.

The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective? Urine output of 35 mL per hour The nurse is evaluating the plan of care for a client with osteoporosis. What type of activity should the nurse reinforce for this client? Walk for 30 minutes, 3 to 5 times a week. The nurse is caring for a client with a new sigmoid colostomy. Which statement(s) by the client will require additional teaching by the nurse? (Select all that apply.) "I'm sad that I cannot go swimming anymore." "I plan on going back to work right away." "The stool consistency should be liquid and green or yellow in color." "I should only change the pouch when it starts to fall off." The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? (Select all that apply.) "I will make sure that my foods do not have much fiber and are soft." "I will push as hard as I can to push out my stool." "I will make sure to insert my suppository just before bedtime." "l will drink no more than 1.5 liters each day." Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)? The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse is caring for a client with paraplegia due to a spinal cord injury at the T- level. Which nursing intervention should be a priority for this client? Obtain a pressure-reducing mattress for the client's bed. A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first? Take the client's vital signs. The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? A cup of yogurt A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client? Position the client in an upright position while they are eating. The nurse is reinforcing foot care instructions for a client with a history of arterial insufficiency in the legs. Which client statement should the nurse identify as incorrect? "I will use Epsom salt to remove any corns and calluses."

The nurse is evaluating a client who has been diagnosed with heart failure (HF) to gauge their understanding of the required diet modifications. Which menu items selected by the client indicate to the nurse that the client understood the teaching? Leftover turkey on a sandwich and fresh pineapple The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client's comfort? Keep conversations short. The nurse is administering medication to a client who does not speak English. Which of the following strategies should the nurse implement to ensure the client understands the purpose of the medication? (Select all that apply.) Use the translation phone line to interpret information between the client and nurse. Communicate through a facility-approved interpreter. Plan to take a longer amount of time than usual for medication administration. Maintain eye contact with the client, even when speaking to an interpreter. A client reports to the nurse the passage of hard dry stools at least twice a week. Which of these actions should the nurse suggest that the client take first to improve their bowel function? Increase daily fiber intake to at least 20 grams. A surgical client with acute pain refuses to participate in physical therapy. The client still has pain despite the administration of pain medication. Based on the information provided, which nonpharmacological intervention(s) would be appropriate for the nurse to add to the plan of care? (Select all that apply.) Ensure the client's room is kept at a comfortable temperature for physical therapy. Assist the client in meditating before going to physical therapy. Provide the client with a light back massage before physical therapy. An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? Very low-calorie diets are intended for short-term use only. A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents? Continue a regular diet and add electrolyte replacement drinks. The nurse is caring for a homeless client recently diagnosed with type 2 diabetes. Which actions demonstrate that the nurse is advocating for the patient? (Select all that apply.) Arrange for a follow-up appointment at a free clinic. Consult a social worker to help the client apply for Medicaid. Provide a list of area pharmacies that offer free or reduced-price medications.

During a 12-hour shift, a client who underwent a transurethral resection of the prostate (TURP) had an IV fluid intake of 1,200 mL, an oral intake of 400 mL, continuous bladder irrigation of 2,400 mL, two antibiotic piggybacks of 50 mL each and an indwelling urinary catheter output of 3,000 mL. What is the end-of-shift intake/output (I/O) balance? (Write the answer using a whole number.) 1100 mL The nurse has given discharge instructions to a client who underwent abdominal surgery. Which of the following statements indicates that the client correctly understands how to manage their pain at home? (Select all that apply.) "Listening to my favorite music might help control my pain." "A warm shower before bed might alleviate my pain and help me sleep." "Before I take an herbal supplement for pain, I should check with my provider." The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider? Serum creatinine level of 2.8 mg/dL The nurse in a health clinic is reviewing recommended nutritional therapy with a client who has a history of emphysema. Which action should the nurse emphasize to the client? Use oxygen during meals. The client is grimacing, crying and reports having pain. What is the first step the nurse should take when collecting data about the client's pain? Accept the client's report of pain. The nurse documents the following in the client's medical record: "Effective use of guided imagery to change report of pain from a level of 4 to 1 on the numeric pain scale." Which definition best describes this non-pharmacological technique? Focusing on pleasant mental pictures of a relaxing scene. The nurse is reviewing the history of a client with type 2 diabetes mellitus. The client's most recent hemoglobin A1C level was 9.5%. What information about nutritional therapy should the nurse reinforce with the client? (Select all that apply.) Choose foods low in fat content. Use carbohydrate counting. Limit alcohol intake. Use a diabetes exchange list. The nurse is planning the discharge of an 80-year-old female client. Which of the following indicates the client needs to be discharged to a skilled nursing facility instead of home? (Select all that apply.) The client needs intensive rehabilitation after hip replacement surgery. The client has a complex surgical dressing change.

The client is not able to manage her activities of daily living (ADL). An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action? A bladder ultrasound value of 900 mL The nurse observes a client using crutches. Which of the following actions by the client would require the nurse to intervene? (Select all that apply.) The client is resting their axillae or armpits on top of the crutches. While using a three-point gait, the client is bearing weight on both legs. The client is using crutches that have a broken rubber tip. The parent of a 5-year-old child is concerned about an outbreak of measles in the community. The nurse understands that additional education about immunizations is needed when the parent makes which of the following statements? (Select all that apply.) "My child should have passive immunity from the vaccine I had as a child." "If a child develops a rash, the risk of spreading measles is gone." An older adult client is to receive intravenous (IV) gentamicin for urosepsis. Before administering the medication, for which finding should the nurse notify the health care provider (HCP)? The client has a history of chronic kidney disease. A client has been taking alprazolam for three days. For which expected effect of the medication should the nurse evaluate the client? The client reports sleeping through the night. At 9 am, the nurse administers 10 units of insulin aspart subcutaneously to a client with a blood sugar of 322 mg/dL. At approximately what time should the nurse expect the insulin to peak? At noon A nurse notes an abrupt onset of confusion in an 85-year-old client. Which newly prescribed medication most likely caused this change in the client's mental status? Diphenhydramine The nurse receives an order to give a client iron by deep injection. What does the nurse understand about the reason for using this method of administration? Prevents the medication from tissue irritation The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse's instructions regarding the medication? "My doctor prescribed it for the pain in my legs." The nurse is caring for a client who is receiving regular insulin, supplied in a glass vial. Which step(s) should the nurse take to ensure the correct administration of the insulin? ( Select all that apply. ) The nurse should store opened vials of insulin at room temperature.

The nurse should discard the vial 28 days after it was opened The nurse should check the strength of the insulin before administering it. The nurse should only use an insulin syringe to administer insulin. A client with pneumonia is prescribed guaifenesin 1.2 grams orally, twice daily as needed for cough. The pharmacy delivers guaifenesin in 600 mg tablets. How many tablets should the nurse administer for each dose? 2 Tablets A client is admitted with deep vein thrombosis (DVT). The health care provider (HCP) orders the immediate administration of an intravenous bolus of heparin sodium 200 units/kg. The client weighs 187 lbs. How many mL should the nurse draw up from the supplied 10 mL vial that contains 5,000 units per mL? Do not round. 3.4 mL The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a new written order for a pain medication. The health care provider (HCP) wrote, “Give APAP every six hours as needed for pain.” Which parts of the medication order should the nurse clarify before administering the medication? ( Select all that apply. ) The dosage The route The drug name The nurse in a long-term care facility is preparing to administer medications. Which physiological changes does the nurse know will affect medication pharmacokinetics in older adults? Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exist. The nurse is reviewing medication safety with a client. Which statements by the client indicate a need for additional teaching? ( Select all that apply. ) "It will be safe to take vitamins and herbal supplements with the medication." "My diet will not affect the medication." "If I miss a dose, I can double up the next dose." "Alcohol is safe to drink with my medication." The health care provider (HCP) prescribes amoxicillin 120 mg PO every six hours for a client diagnosed with acute otitis media. The medication label reads amoxicillin 80 mg/ mL. How many mL should the nurse administer to the client with each dose? 7.5 mL The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administration? Use an oral syringe to administer the medication, alternating with a pacifier.

The nurse administers a medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? ( Select all that apply. ) Complete an incident report. Notify the health care provider (HCP). Monitor the client for adverse effects. Document the error in the medical record. Which of these activities can the nurse assign to an unlicensed assistive person (UAP)? Provide basic care to the client. Where can the nurse find the most reliable guidelines regarding the appropriate delegation of tasks to unlicensed assistive personnel (UAP)? That state's nurse practice act (NPA). The nurse observes another nurse walking away from their computer with a client's electronic medical record (EMR) still visible on the screen. What should the nurse do first? Walk over to the computer and close the client's medical record. The nurse is handing-off the care of a client admitted with pneumonia to the nurse for the next shift. What client information should the nurse include in the hand-off report, using the S.B.A.R. method? IV access, admitting diagnosis, allergies and antibiotics given A client is being prepped for a surgical procedure and the nurse is reviewing the consent form with the client. The client asks, "Is there any other way to take care of this without having surgery?" What should the nurse do next? Notify the surgeon that the client has additional questions about the surgery. A client's family member calls for an update on the client's condition. What should the nurse do first before providing information to the caller? Check with the client and obtain permission to provide the caller with the requested information The new graduate nurse understands that patient-centered care, according to QSEN should include which of the following nursing actions? ( Select all that apply. ) Communicating what care was provided and is needed at each transition in care. Recognizing the boundaries of therapeutic relationships. Respecting and encouraging individual expression of client values. A client with Parkinson's disease is prescribed benztropine (Cogentin). For which of the following should the nurse call the health care provider immediately? The client has a history of primary angle-closure glaucoma. The nurse recognizes that client identification in accordance with agency policy must occur immediately prior to which of the following actions? ( Select all that apply. ) Administration of oral acetaminophen Collection of a point of care blood glucose test

Discontinuation of an intravenous normal saline infusion Insertion of an indwelling urinary catheter The nurse is admitting a client who does not speak English. Which of the following interventions should the nurse include when caring for the client? ( Select all that apply. ) Pay attention to any effort by the client to communicate. Plan on taking twice as long as usual to complete nursing interventions. Use a trained medical interpreter provided through the facility's interpreter services. Make a note of the client's preferred language in their medical record. The nurse notices flames and smoke in the garbage can in a client's room. Which action should the nurse take first? Remove the client from the area. The nurse hears a scream coming from a client's room. When entering the room, the nurse finds the client lying on the floor beside the bed. Which of the following actions should the nurse take? ( Select all that apply ). Notify the client's provider about the incident. Observe the client for abnormal leg rotation. Take the client's vital signs. Determine the client's level of consciousness. The nurse is caring for a client with a chest tube. The client is confused and keeps attempting to pull out the chest tube. The nurse applies soft restraints on both of the client's wrists. Is the nurse acting appropriately? Yes, the nurse should apply a restraint to protect the client from self-injury, and then must contact the HCP. A client's wound has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions should the nurse implement for the client? Standard precaution and contact precautions A client has received a prescription for nitrofurantoin to treat a urinary tract infection. Which of the following statements made by the client indicates the need for additional teaching about the medication? "I will spend extra time in the sun to get plenty of vitamin D." Which of the following defines the Quality and Safety Education for Nurses (QSEN) competency of Patient-Centered Care? Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. The client has a nursing diagnosis of risk for impaired skin integrity. Which of the following interventions should the nurse include in the client's plan of care?

Use a mild soap and tepid water to clean the affected area. The nurse is preparing to enter a disaster scene to assist with triaging victims. What assessment priorities should the nurse adhere to? ( Select all that apply. ) The nurse will allocate resources to those victims with the strongest probability of survival. The nurse will assess clients by considering their airway, breathing, circulation and neurological function. The nurse and UAP are preparing to reposition a client in bed. Which of the following actions indicate that the UAP requires additional training on correct body mechanics? The UAP lifts the client, using their upper arm and shoulder strength. Michael, the nurse, worked the night shift and is giving a change of shift report to the oncoming nurse. Mr. Evans approaches the two nurses and asks, "What kind of place is this? My partner has had his call light on for 30 minutes and needs help to go to the bathroom - NOW!"Mr. Evans then says, "It's a good thing I got here when I did because who knows how long you would have made him wait! If he gets up without help and falls, you better believe that I'm suing this place!" How should Michael respond? "Mr. Evans, thank you for coming and letting me know the situation. I'm sorry your partner has waited so long for someone to help him. I can understand your frustration. The CNA or I will be right over." The nurse is reviewing the client's medical record and notes that the client has been taking an oral contraceptive for several years. For which potential complications should the nurse monitor the client? ( Select all that apply. ) Deep Vein Thrombosis (DVT) Depression Breast cancer Which of these are examples of primary prevention activities? ( Select all that apply. ) An exercise class Vaccination Car seat installation education The nurse is collecting baseline data on a 14-month-old child during a wellness visit in the primary care provider's office. Which of the following measurement methods are correct? ( Select all that apply. ) The nurse places the child on an infant platform scale in either a sitting or supine position. The nurse measures the child's chest circumference by placing the measurement tape around their chest at the nipple line. The nurse places the tape measure around the child's head at the widest part of the frontal and occipital bones.

A woman comes to a clinic to discuss contraceptive options. Which statement by the client indicates to the nurse a need for additional teaching? ( Select all that apply. ) "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential pregnancy." "I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection." "My diaphragm will work no matter how much weight I gain." The clinic nurse is meeting with a client who wants to talk about her and her partner's plan for a future pregnancy. What information is important for the nurse to give to the client? Folic acid should be started before the client has a confirmed pregnancy. The nurse is interviewing a client to verify pregnancy. What information from the client will provide presumptive findings? ( Select all that apply. ) Nausea Breast sensitivity Amenorrhea The nurse is caring for a patient who has just experienced a spontaneous abortion (miscarriage). What action should the nurse implement first? Monitor the client for bleeding and medicate for pain The nurse is providing education to a client in her first trimester of pregnancy. Which statement indicates the client needs further education? "I will schedule visits with my health care provider only as needed." A woman who is 15 weeks pregnant verbalizes concern to the nurse about weight gain during pregnancy. Which statement indicates a correct understanding of weight changes for a woman during the second trimester? "You should gain about one pound each week." The nurse is providing information to a pregnant client about the potential risks of an amniocentesis. Which risk factors shall the nurse include? ( Select all that apply. ) Premature rupture of membranes Preterm labor Spontaneous abortion A client who has just given birth asks the nurse what an Apgar score means. The correct response by the nurse should be: "The score is a general overview of how well your newborn is doing." A hospitalized, school-age child with a spica cast says to the nurse "I am bored." Which type of activity would be most appropriate for the nurse to implement for this child? Board games The nurse is caring for a client recently diagnosed with cancer. The client is quietly crying and states, "I am not sure if I should tell my daughter." Which statement by the nurse would be most appropriate? "You seem unsure about telling your daughter."

The nurse is providing care for an elderly client who was just admitted to the facility. During the admission process, the client's family reports that the client has been having increasing episodes of forgetting things and misplacing important items. Which of the following statements should the nurse include each time they check on the client? "Your call light is in your hand and I will check on you every hour." The nurse is caring for a client who has expressed some anxiety about their upcoming surgery. The most appropriate therapeutic response would be: "Tell me more about how you are feeling." The nurse is meeting a client for the first time. The client has told the nurse that he does not take his medication as prescribed. Which is the best response: "Tell me more about why you are not taking the medication as prescribed." The nurse is reviewing the chart of a client whose spouse died two years ago. What clinical manifestation(s) would indicate that the client is suffering from complicated grieving? (Select all that apply.) The client refuses to attend church services and social gatherings. The client is unable to talk about their spouse without crying uncontrollably. The client states that they have trouble sleeping and frequent nightmares. The nurse is caring for a client admitted to the hospital with a history of post-traumatic stress disorder (PTSD). Which of the following actions by the nurse would represent appropriate care of the client? Identify coping strategies used by the client when stressful situations arise. A client with a history of bipolar disorder is admitted to the hospital after a suicide attempt. Which of the following interventions should the nurse include in the client's plan of care? Develop a contract with the client that states they will not harm themselves. A client is admitted to the hospital after falling at home and is given an opioid analgesic for pain. Two days later, the client develops delirium. What clinical manifestation(s) should the nurse monitor the client for? (Select all that apply.) Disturbances in sleep-wake pattern Fluctuating emotions Rambling, incoherent speech The nurse is caring for a client newly diagnosed with generalized anxiety disorder (GAD) who has been prescribed alprazolam by the health care provider (HCP). Which of the following statements best describes this medication in the treatment of GAD? Alprazolam provides short-term treatment but is less effective than other drug therapy. Which of the following statements by a client taking lithium for bipolar disorder indicates the need for additional teaching? "I will need to have my blood drawn once a year to check the lithium level." The nurse is preparing interventions for a client with major depression who has been showing signs of impaired social interaction. Which of the following nursing interventions is initially appropriate for this client? Provide activities that require minimal concentration

The nurse is concerned that a client with a history of anorexia nervosa may be experiencing a recurrence of the condition. Which of the following findings would support the nurse's concern? (Select all that apply.) Constipation Weight loss Recent hair loss A client reports to the nurse that he must check to make sure that the iron is unplugged 10 times before leaving the house. The nurse understands that this is the client's attempt to: Reduce personal anxiety A nurse is caring for a client with a personality disorder. He comments to the nurse that she "doesn't know what she is doing because all the other nurses let him take his coffee into his room. Most of them will even bring me coffee in my room!" The nurse recognizes that this is what type of behavior? Manipulative behavior A newly diagnosed schizophrenic client reports to the nurse that he thinks that the employees at the fitness center are conspiring to have his membership revoked. Which of the following responses by the nurse is the most therapeutic? "Feeling this way must be frustrating and scary." A nurse is caring for a client who is experiencing alcohol withdrawal symptoms. Which nursing considerations are most appropriate? (Select all that apply.) Implement seizure precautions Orient the client frequently Monitor vital signs Administer prescribed medication The nurse is talking with a client who suddenly becomes tearful and stares out the window after seeing a rose on the lunch table. The client has a history of sexual abuse. Which intervention should the nurse include in the plan of care for this client? Determine if the client is having a flashback A client is placed on a high-protein diet and asks the nurse to describe the role of protein in the body. Which responses by the nurse describe the role of protein? (Select all that apply.) "Protein is necessary for the formation of body structures, including bone, muscle and red blood cells." "Protein plays a role in the body's immunity." "You can determine your protein needs according to your body weight." "Wound healing is poor with decreased levels of protein."

The nurse is caring for a client admitted with a phosphorus level of 1.5 mg/dL. Which statement by the client should alert the nurse to collect further data about possible causes for the phosphate imbalance? (Select all that apply.) "I do not eat any meat or dairy products." "I take a calcium supplement with every meal." A client is admitted for hypovolemia associated with multiple draining wounds. Which is the best method for the nurse to use to evaluate the client's fluid balance? Daily weight The nurse is reviewing a client's dietary history. The nurse understands that which factors will influence the clients' dietary intake? (Select all that apply.) Culture Personal feelings Education Religion The nurse explains a low cholesterol diet to a client diagnosed with heart disease. Which menu selection by the client demonstrates that the client understands the teaching? Turkey chili made with kidney beans The nurse is caring for a client who is receiving bolus enteral tube feedings. Which of the following actions by the nurse demonstrate safe practice for this client? (Select all that apply.) Verifying the initial placement of the tube by radiographic assessment Maintaining the head of the bed at 30 to 45° during feedings Aspirating and measuring the residual gastric contents before each feeding A nurse is caring for a client who is receiving enteral nutrition. Before starting the next bolus feeding, what action should the nurse take? Verify correct tube placement. The nurse is caring for a client who is recovering from a right total hip arthroplasty. The client reports a sudden onset of chest pain and difficulty breathing. What action should the nurse take first? Elevate the head of the bed. The nurse is monitoring a client who is caring for their prosthetic limb. Which action by the client demonstrates that the client correctly understands prosthetic limb care? The client dries the inside of the prosthetic socket after wiping it with soap and water. The nurse is monitoring a UAP as they provide perineal care to a client who suffers from urinary incontinence. What action by the UAP would require intervention by the nurse? The UAP cleanses the urinary meatus and then the labia majora and minora. The nurse is reviewing information with a client about their new ileostomy. Which statement by the client suggests that they understand the teaching? "It is normal for my stoma to remain red in color."