Question: A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a 0 to 10 pain scale. After placing a call to the healthcare provider, which action should the nurse implement?
Answer Options:
A) Instruct the client to use guided imagery and slow rhythmic breathing. B) Tune to a television show or easy listening music to provide distraction. C) Provide at least 20 minutes of back massage and gentle effleurage. D) Place a hot water circulation device, such as an Aqua K pad, to the operative site.
Answer: A) Instruct the client to use guided imagery and slow rhythmic breathing.
Question: The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCl) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?
Answer Options:
A) Check a serum potassium level postinfusion. B) Maintain continuous cardiac monitoring. C) Monitor urinary output. D) Obtain vital signs every 2 hours.
Answer: B) Maintain continuous cardiac monitoring.
Question: The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe?
Answer Options:
A) Around the nostrils.
B) Across the forehead.
C) Over the cheeks.
D) Bridge of the nose.
E) Tops of the ears.
Answer: A) Around the nostrils.
C) Over the cheeks.
E) Tops of the ears.
Question: The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?
Answer Options:
A) Send email to facility administrators reporting the action. B) Comment about the action on a staff discussion board. C) Remind the colleague of information security principles. D) Ask the colleague why the action is being performed.
Answer: C) Remind the colleague of information security principles.
Question: An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious but unable to get up by themselves. The client is unable to recall what happened. Which action should the nurse take first?
Answer Options:
A) Encourage the adult child to report the incident to other siblings. B) Gather a history from the adult child about the circumstances of previous falls. C) Ask the adult child to remain with the client during the examination. D) Inform the adult child that fall prevention is a priority for older adults.
Answer: B) Gather a history from the adult child about the circumstances of previous falls.
Question: When identifying the goals to be included in a client’s plan of care, the nurse should take which action?
Answer Options:
A) Ensure that all treatments prescribed by the healthcare provider have been initiated. B) Compare the client’s manifestations with the defining criteria of related problems. C) Review the priority nursing problems included in the plan of care. D) List the nursing actions that need to be implemented most immediately.
Answer: C) Review the priority nursing problems included in the plan of care.
Question: A client who is terminally ill has an advance directive that stipulates no resuscitative measures are to be taken. The client’s death is imminent and the family is in the client’s room. The client is currently exhibiting Cheyne-Stokes respirations and has a blood pressure of 60/30 mm Hg. Which is the priority nursing action?
Answer Options:
A) Teach the client’s family how to use an oral suction device to clear the airway. B) Apply an automatic blood pressure cuff and take readings every 15 minutes. C) Elevate the head of the client’s bed and apply oxygen using a face mask. D) Allow privacy for the family and client to express their feelings to one another.
Answer: D) Allow privacy for the family and client to express their feelings to one another.
Question: A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a 0 to 10 pain scale. After placing a call to the healthcare provider, which action should the nurse implement?
Answer Options:
A) Instruct the client to use guided imagery and slow rhythmic breathing. B) Tune to a television show or easy listening music to provide distraction. C) Provide at least 20 minutes of back massage and gentle effleurage. D) Place a hot water circulation device, such as an Aqua K pad, to the operative site.
Answer: A) Instruct the client to use guided imagery and slow rhythmic breathing.
Question: The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCl) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?
Answer Options:
A) Check a serum potassium level postinfusion. B) Maintain continuous cardiac monitoring. C) Monitor urinary output. D) Obtain vital signs every 2 hours.
Answer: B) Maintain continuous cardiac monitoring.
Question: The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe?
Answer Options:
A) Around the nostrils. B) Across the forehead. C) Over the cheeks. D) Bridge of the nose. E) Tops of the ears.
Answer: A) Around the nostrils.
C) Over the cheeks.
E) Tops of the ears.
Question: The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?
Answer Options:
A) Send email to facility administrators reporting the action. B) Comment about the action on a staff discussion board. C) Remind the colleague of information security principles. D) Ask the colleague why the action is being performed.
Answer: D) Ask the colleague why the action is being performed.
Question: An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious but unable to get up by themselves. The client is unable to recall what happened. Which action should the nurse take first?
Answer Options:
A) Encourage the adult child to report the incident to other siblings. B) Gather a history from the adult child about the circumstances of previous falls. C) Ask the adult child to remain with the client during the examination. D) Inform the adult child that fall prevention is a priority for older adults.
Answer: B) Gather a history from the adult child about the circumstances of previous falls.
Question: When identifying the goals to be included in a client’s plan of care, the nurse should take which action?
Answer Options:
A) Ensure that all treatments prescribed by the healthcare provider have been initiated. B) Compare the client’s manifestations with the defining criteria of related problems. C) Review the priority nursing problems included in the plan of care. D) List the nursing actions that need to be implemented most immediately.
Answer: C) Review the priority nursing problems included in the plan of care.