The practical nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the PN
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A. Ask another nurse to go back with the medication when the client's hung up the phone
B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
C. Return the medication to the client's drawer on the cart and document the client refused the dose
D. Leave the medication with the client, and let him take it when he finishes the conversation. - ANSWER-B
A client is admitted to the postoperative surgical unit with two test tubes after a left lobectomy. The ON observed that the chambers are set at the prescribed suction of 20 cm water pressure and tidying occurs with respirations and bubbling. What action should the PN implement?
A. Clamp the chest tube to see if the activity stops
B. Notify the registered nurse of the malfunction
C. Maintain system integrity to promote lung reexpansion
D. Apply a partially occlusive dressing toterm-10 chest - ANSWER-C
The mother of a 9-month-child who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child for the following day. Which response should the PN provide the mother?
A. Do not expose other children as the virus is very contagious even without direct contact
B. The child will no longer be contagious, no need to take any further precautions
C. The child can be around other children but should wear a mask
D. Make sure there are no children under the age of 5 months around the infected child. - ANSWER-A
The practical nurse is assisting the nurse with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the PN take?
A. Omit compelling this section of the assessment form
B. Ask her if she would like an interpreter to ask her the question
C. Reword the question in case the client did not understand
D. Watch the client's response when asked a different question - ANSWER-D
During immediate postoperative period following a total hip placement, which intervention is most important for the PN to implement?
A. Encourage client to use walker or cane when ambulating
B. Keep client's hip aligned with knees abducted
C. Teach client to sit on the side of the bed before standing
D. Monitor urinary flow via indwelling catheter - ANSWER-B
A client confides to the PN that the client has been substituting herbal supplements for high blood pressure instead of the prescribed medication. How should the PN respond first?
A. Ask the client's reason for choosing to take herbs instead of prescribed drugs
B. Reinforce that the healthcare provider prescribed the medication for a reason
C. Have client use own words to describe complications of high blood pressure
D. Point out the risks of not taking the herbal medications rather than prescribed - ANSWER-A
The PN is assigned to administer medications in a long term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the PN to take prior administering the medications this resident?
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A. Ask a regular staff member to confirm the resident's identity
B. Hold the medication until a family member again
C. Re-orient the resident to name, place, and situation
D. Confirm the room and bed numbers with those on the medication record. - ANSWER-D
An adult client who weighs 150 pounds has partial-thickness and full-thickness burns over 40% of the body from a house fire. After admission, which observation is most important for the practical nurse to report immediately?
A. Poor appetite and refusing to eat
B. Systolic blood pressure at 102
C. Painful moaning and crying
D. Urinary Output of 20ml/hr - ANSWER-D
A 12-year-old child is receiving a blood transfusion per infusion pump and begins to complain of "itchy" skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the practical nurse take first?
A. Apply lotion to the skin
B. Stop the transfusion
C. Inspect the infusion site
D. Obtain the vital signs - ANSWER-B
A PN is competing a focused assessment of an older adult's skin. The PN notes a crusted 0.7 cm lesion on the client's forehead. Which action should the PN take in response to this finding?
A. Report the finding to the healthcare provider
B. Place a clear occlusive dressing over the site
C. Apply a warm compress to remove the crusted area
D. Explain that this is a normal skin change with aging - ANSWER-C
While taking the vital signs of an older male client who takes psychotropic medications, the PN notes that he has uncontrollable hand movements and is excessively blinking his eyes. Which information in the client's medical record should the PN review?
A. Prescription for lorazepam
B. History of Parkinson's disease
C. Screening for tardive dyskinesia
D. Recent urine drug screen report - ANSWER-B
The PN is caring for an elderly female client who tells the PN, "When I sneeze, I wet my pants." After discussing the client's complaint with the charge nurse, the PN plans to reinforce teaching that the client has received about the importance of Kegel exercises.WHat muscles are involved in these exercises?
A. Pectoral muscles
B. Buttock muscles
C. Abdominal muscles
D. Pelvic floor muscles - ANSWER-D
While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?
A. Swab the oral cavity with a washcloth
B. Use oral swabs with normal saline
C. Provide a Yankauer tip for oral suction
D. Support the head with a small pillow - ANSWER-B
The practical nurse and unlicensed assistive personnel are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement?
A. Demonstrate to the UAP how to approach the client from the client's left side
B. Ask the UAP to leave the room and assess the client's body for bruising
C. Carefully observe the interaction between the client and family members.
D. Instruct the UAP to protect the client's left side when transferring to chair - ANSWER-A
After administering pantoprazole to a client with gastroesophogeal reflux disorder(GERD), which statement by the client indicates to the practical nurse that the medication is producing the desired effect?
A. After eating my meal, I did not experience any heartburn
B. I have a great appetite and am feeling really hungry
C. I should increase the amount of vitamin C in my diet
D. While eating, I had no difficulty swallowing any of the foods - ANSWER-A
During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed and refuses to participate in planned daytime activities. Which action should the practical nurse take?
A. Record the findings and report the symptoms to the charge nurse
B. Ask the family members to visit more often to stimulate the patient
C. Motivate the client by offering favorite foods as a prize
D. Withold any medications that may cause side effects - ANSWER-A
A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers question with one or two word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important to the PN to implement?
A. Persuade the client to lie down
B. Provide a drink high in electrolytes
C. Observe the client during the shift
D. Measure appropriate vital signs - ANSWER-D
At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?
A. Administer half of the missed dose immediately
B. Administer the missed dose as soon as possible
C. Give the missed dose with the next scheduled dose
D. Withhold the mossed dose unless seizure activity occurs - ANSWER-B
The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/her. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?
A. Daily weight
B. Gastric residual volumes
C. Bowel Sounds
D. Urinary and stool output - ANSWER-B
The practical nurse is caring for a client whose urine drug screen is positive for cocaine, Which behavior is this client likely to exhibit during cocaine withdrawal?
A. Elevated energy level
B. Euphoria
C. High self-esteem
D. Powerful craving for more - ANSWER-D
The PN administered darbepoetin alfa to a client with Chronic Kidney Disease(CKD). Which serum laboratory value should the PN monitor to gather the effectiveness of this drug?
A. Calcium
B. Phosphorous
C. Hemoglobin
D. White Blood Cell Count - ANSWER-B
The PN observes an UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?
A. Remain in the room to supervise the UAP
B. Determine if the UAP would like assistance
C. Assume care of the client immediately
D. Instruct the UAP to lower the bed for safety - ANSWER-D
Thirty minutes after receiving IV morphine, a postoperative client continues yes to rate pain as 7 on 10 point scale. Which action should the PN implement first?
A. Call HCP to request a different analgesic
B. Determine when morphine can be given again
C. Implement complimentary pain relief methods
D. Observe dressing to determine presence of bleeding - ANSWER-C
The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was 0 station. An hour later, the client tells the PN that she wants to go the bathroom. Which action is most important for the PN to implement?
A. Review the fetal heart rate and contraction pattern
B. Check the perineum for increase in bloody show
C. Request nurse to check client's cervical dilation
D. Palpate the client's bladder for distention - ANSWER-C
The PN identifies an electrolyte imbalance, exhibited changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?
A. Record usual eating patterns
B. Evaluate for muscle cramping
C. Document abdominal girth
D. Elevate both legs on pillows - ANSWER-B
The PN is caring for an older client who was informed about the diagnosis of terminal cancer two days ago. Which intervention wouldbe most helpful for the client's spouse at this time?
A. Consultation with the case manager and hospital chaplain
B. Visiting after procedures are done to avoid seeing the client in pain
C. Participating in the client's care within his/her capabilities and desires
D. Information about palliative and hospice care services - ANSWER-D
The PN is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? Select all that apply
A. Observe the progression of the seizure
B. Loosen clothing around the neck
C. Pad the side rails with pillows
D. Insert a tongue blade between the teeth
E. Hold the extremities close to the body - ANSWER-A,B,C
The HCP prescribes heparin 4,500 units subcutaneously once daily. The medication is available in a vial that contains heparin 10,000 units/mL. How many mL should the PN administer? - ANSWER-0.45
The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately?
A. Swollen and discolored menial shaft
B. Prepuce extends over head of penis
C. Leaking urine around the top of catheter
D. Moist and excavated perineal skin folds - ANSWER-A
A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement?
A. Stimulate the infant to cry
B. Give oxygen by positive pressure
C. Suction the oral and nasal passages
D. Turn the infant onto the right side - ANSWER-C
A client reports being able to swallow only small bites of solid food and liquids for the last 3 months. The PN should assess the client for what additional information?
A. Past traumatic injury to neck
B. Daily consumption of hot beverages
C. History of alcohol or tobacco use
D. Daily dietary intake of roughage - ANSWER-C
When caring for a child with sickle cell disease, the PN expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?
A. Decreased hemoglobin
B. Joint pain
C. Fatigue
D. Infection - ANSWER-C
At the first dressing change, the PN tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?
A. You will feel better when you see that the incision is not as bad as you may think.
B. It's OK if you don't want to look or talk about mastectomy. I will be available when you're ready
C. Part of recovery is accepting your new body image, and you will need to look at your incision
D. Would you like me to call another nurse to be here while I show you the wound? - ANSWER-C
A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coomb's test. Which is the implication of this finding?
A. The newborn is infected with an infectious blood-borne disease
B. The newborn needs phototherapy for physiologic jaundice
C. The mother's Rh antibodies are present in the neonatal serum
D. The mother no longer needs Rho immune globulin injections - ANSWER-C
During a clinic visit for a sore throat, a client's basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which intervention should the PN recommend to the client based on this finding?
A. Increase intake of dried peaches and apricots
B. Reduce intake of red meats
C. Encourage use of soft toothbrush
D. Force fluid intake to 1500 mL daily - ANSWER-A
The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the cloth used to anesthetize the eye if eye pain is experienced. What action should the PN implement?
A. Document in the chart that the client understands then action and the use of eye drops
B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common
C. Reteach the client about the action of the eye drops to decrease pressure in the eyes
D. Explain to the client that they eye drops do provide pain relief, but do not anesthetize the eyes. - ANSWER-D
The PN is reviewing care instructions with a client who has diabetic retinopathy and is experiencing glare around lights. What should the PN reinforce with the client?
A. Cover eyes with moist, cool compresses to reduce fasciculations
B. Make adjustments to personal schedule to avoid driving at night
C. Exert pressure on the inner cants whiners tearing occurs
D. Apply an eye shield at bedtime after installing eye drops - ANSWER-B
The PN is assigning care for a group of clients on the urology medical unit. Which client care interventions should the pN assign to the UAP? Select All That Apply
A. Empty bedside drainage unit for a client with indwelling urinary catheter
B. Teach the client with fluid restrictions how to measure urine output
C. Irrigate an indwelling urinary catheter for a client with bladder suspension
D. Transport a urine culture sample to the laboratory
E. Obtain a post-voided residual volume - ANSWER-A,E
A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?
A. Emphasize the importance of active foot flexion
B. Check the surgical dressing
C. Complete an incident report
D. Explain the use of incentive spirometer q2 hours - ANSWER-A
The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP?
A. Explain how to use a communication board
B. Document progress in use of communication board
C. Encourage voiding by assisting client to bedside commode
D. Establish bladder training schedule and training methods - ANSWER-C
When reinforcing diet teaching for a client who was diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply
A. Orange juice, oranges, bananas
B. Preserved meat, apple juice, seeds
C. Collard greens, kale, turnips
D. Soy Beans, lima beans, spinach
E. White grape juice, clear fat-free broth, consommé - ANSWER-A,C,D
When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?
A. Antiseptic cream
B. Petroleum jelly
C. Cornstarch
D. Stomadhesive - ANSWER-D
The PN observes an UAP prepare to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?
A. Confirm that the UAP completed hand hygiene correctly
B. Instruct the UAP to wash the hands for one minute
C. Ask the UAP why the hands were so obviously soiled
D. Advise the UAP to use the hand rub for 30 seconds - ANSWER-D
A male client with TB returns to the clinic for daily antibiotic injections for a urinary infection. The client has been taking anti tubercular medications for 10 weeks and states he has ringing in his ears. Which prescribed medication should the PN report to the HCP?
A. Pyrixodine with a B complex multivitamin
B. Gentamicin 160 mg IM daily
C. Rifampin 600 mg PO daily
D. Isoniazid 300 mg PO daily - ANSWER-B
An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?
A. Ask family members to remain with the client in the evenings from 5 to 8 pm
B. Administer a prescribed PRN benzodiazepine at the onset of a confused state
C. Ensure that the client is assigned to a room close to the nurses' station
D. Postpone administration of nighttime medications until after 11 pm. - ANSWER-C
Which action should the PN implement when using standard precautions to provide client care?
A. Apply sterile gloves to obtain a finger stick blood sample
B. Wear clean exam gloves to perform perineal catheter care
C. Replace the needle cap after giving an intramuscular injection
D. Wear a paper gown to prevent transmission of droplet pathogens. - ANSWER-B
When administering an analgesic to a client with low back pain, which intervention should the practical nurse implement to promote the effectiveness of the medication?
A. Massage the lower back and position the client in proper alignment
B. Encourage the client to ambulate frequently and take deep breaths
C. Assist client in performing passive and active range of motion exercises
D. Give medication with a full glass of water and offer high roughage foods - ANSWER-B
A young adult male tells the PN he has decided to change his hours at work so that he has more time to devote to his community. Which stage of Maslow's development is this young adult attempting to achieve?
A. Self-Actualization
B. Intimacy vs. Isolation
C. Altruism
D. Purposefullness - ANSWER-A
The PN assigns an UAP to bathe a client who is on contact precautions due to Clostridum Difficule maintain contact precautions, the PN should instruct the UAP to perform the following actions in which sequence?
A.Remove gloves and gown in room
B. Put on disposable gown
C. Perform standard hand washing
D. Repeat standard hand washing
E. Don a pair of procedure gloves - ANSWER-C,B,E,A,D
The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, "Why did this happen to my child? I just can't cope with this." How should the PN respond?
A. Ask her to share how the injury occurred to her child.
B. Recommend that she remain calm and positive for her child
C. Express that the present situation must be overwhelming
D. Determine if someone else can help her cope with this tragedy - ANSWER-C
While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness fo breath. Which action should the PN implement first?
A. Administer sublingual nitroglycerin
B. Assist the client back to the room
C. Have the client sit down in the hall
D. Obtain a 12 lead electrocardiogram - ANSWER-C
The PN is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body?
A. In front of the body to lean on while stepping forward
B. On the opposite side of the affected extremity
C. Approximately one foot way from the body to stabilize balance
D. On the same side as the affected extremity - ANSWER-D
A client is scheduled to receive hydroxyzine 75 mg IM postoperatively. The vial contains 50mg/mL. How many mL should the PN administer? - ANSWER-1.5
Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his progress?
A. I don't have any use for those who say disease is going to win
B. I've found support I need from my faith and family.
C. I think I've had this disease for a long time, but the doctor did not find it
D. I understand that this is a disease that occurs mostly in older men - ANSWER-B
In obtaining an orthostatic vital sign measurement, what action should the nurse take first?
A. Count the client's radial pulse
B. Apply a blood pressure cuff
C. Instruct the client to lie supine
D. Assist the client to stand upright - ANSWER-C
A female client tells the PN that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the PN to implement to complete a focused assessment?
A. Determine if the client uses any over-the-counter preparations for hemmorhoids
B. Place the client in a standing position, leaning over the exam bed for inspection.
C. Position client in left lateral position to inspect perineal area for fissures or sacs
D. Ask the client how long she has experienced discomfort related to hemorrhoids. - ANSWER-D
A client who is receiving chemotherapy has developed stomatitis. Which instruction should the PN provide the UAP who is assisting with the care of this client?
A. Keep the room environment free of unpleasant odors
B. Gather supplies for protective environmental precautions
C. Assist the client with feeding at meal times
D. Provide gentle and meticulous mouth care - ANSWER-B
The PN observes an UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?
A. Stop the procedure and tell the UAP to place the client in a fowler's position
B. Praise the UAP for doing the ora; hygiene but encourage family participation
C. Tell the UAP to continue because the unconscious client is positioned safely
D. Enroll the UAP in a hospital education class on conducting safe client care - ANSWER-C
When preparing for a bone marrow aspiration, the PN should place the client in which position to ensure access of the aspiration site?
A. Supine with a pillow under the lumbar area
B. Sitting up and leaning across the over-bed table
C. Side-lying with the posterior chest exposed
D. Prone with the posterior iliac crest draped - ANSWER-D
Which client information is most important for the PN to consider when providing instructions to the UAP to consider when providing instructions to the UAP about providing morning care to a postoperative client?
A. Oriented to person only
B. Oxygen saturation measurement of 95 to 96%
C. Urinary output of 50 mL/hr
D. Blood pressure of 144/84 - ANSWER-D
The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8 F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement?
A. Report the findings to the charge nurse
B. Monitor the client's temperature hourly
C. Offer the client fluids frequently
D. Provide care to moisten oral mucous - ANSWER-A [Show Less]