Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks
the charge nurse to change her assignment. She is frustrated because she has had to
devote so much time and energy to helping a newly licensed nurse provide discharge
teaching for clients with diabetes mellitus. The charge nurse should:
Correct response:
• offer to assist with the discharge teaching needs.
Explanation:
Staff members need to know the charge nurse is a supportive leader who respects their
honesty and stands behind them. By offering to help with discharge teaching, the
charge nurse is actively engaging with her staff at a time of need. Changing all the
assignments on this extremely busy floor would be counterproductive. Insisting that the
staff member follow through with her assignment disrespects her request and genuine
need. Providing a float nurse could help, but there are no guarantees a float nurse is
available.
Remediation:
• Discharge
Question 2 See full question
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral
mucous membrane related to decreased nutrition and immunosuppression secondary to
the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to
decrease the pain of stomatitis
Correct response:
• Providing a solution of viscous lidocaine for use as a mouth rinse
Explanation:
To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen
viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared
mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.)
The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to
10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or
practical. Instead, the nurse should stay alert for this potential problem to ensure prompt
treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and
infection but wouldn't decrease pain in this highly susceptible client. Checking for signs
and symptoms of stomatitis also wouldn't decrease the pain.
Remediation:
• Impaired Oral Membrane
,Question 3 See full question
A nurse has been caring for an adolescent client in a residential facility. The child has
been through a series of foster placements since infancy with no success in any
placement until the age of 7 when placed with a middle-aged single woman. The client
thrived there until the woman was killed in a car accident. The client attempted suicide
after her foster mother died in response to the loss and the child was placed in the
residential facility. The nurse has become close to this client and wants to help her
address her issues and move on with her life. Which comment to the manager
demonstrates that the nurse understands the client’s issues and is able to respond
appropriately to the client’s needs?
You Selected:
• "It is difficult for her to love and trust again after her losses. In this facility, she
can learn to deal with her loss in a less emotionally charged environment than a
foster home."
Explanation:
The severe emotional trauma the girl has experienced will likely make it difficult for her
to be successful in an adoptive placement at the present time, whether that placement
is with someone she knows (the nurse) or another adoptive family. Additionally,
adoption by the nurse is inappropriate because it blurs the lines between her
professional and personal life and is likely to confuse the client. It is clear that the client
has many issues and that love alone is not likely to solve all her problems. Treatment at
the residential facility will allow her to work through emotional issues in a more
therapeutic environment. Though not currently ready for adoption, she may be ready for
adoption in the future after sufficient treatment.
Question 4 See full question
A client is about to undergo cardiac catheterization for which he signed an informed
consent. As the nurse enters the room to administer sedation for the procedure, the
client states, "I'm really worried about having this open heart surgery." Based on this
statement, how should the nurse proceed?
Correct response:
• Withhold the medication and notify the physician immediately.
Explanation:
The nurse should withhold the medication and notify the physician that the client does
not understand the procedure. The physician then has the obligation to explain the
procedure better to the client and determine whether or not the client understands. If the
client does not understand, he cannot give a true informed consent. If the medication is
administered before the physician explains the procedure, the sedation may interfere
with the client's ability to clearly understand the procedure. The nurse may not just
medicate the client and document the finding; the physician must be notified. The
,procedure does not need to be cancelled, only postponed until the client receives more
education and is able to give informed consent.
Remediation:
• Decisional Conflict
Question 5 See full question
Which action associated with restraint use on a confused client can be delegated to an
unlicensed healthcare worker/nursing assistant?
• Completion of range of motion on limbs restrained
Question 1 See full question
Four clients have been admitted to the cardiac intensive care unit after experiencing
acute myocardial infarctions. Each client has sustained a percentage of cardiac
damage. Which client is most in need of interventions to prevent the development of
cardiogenic shock?
Correct response:
• The client with 40% damage
Explanation:
At least 40% of the heart muscle must be involved for cardiogenic shock to develop. In
most circumstances, the heart can compensate for up to 25% damage. An infarction
involving 70% of the heart would have likely already caused cardiogenic shock.
Question 2 See full question
The nurse is providing postoperative care to a client with sickle cell anemia. What is the
most important intervention for the nurse to include in the plan of care?
Correct response:
• Increasing fluids
Explanation:
The main surgical risk of anesthesia is hypoxia. Emotional stress, demands of wound
healing, and the potential for infection can each increase the sickling phenomenon.
Increased fluids are encouraged because hydration promotes hemodilution, and
decreases sickling. Preparing the child psychologically to decrease fear will minimize
undue emotional stress, but is not a priority. Deep coughing is encouraged to promote
pulmonary hygiene and prevent respiratory tract infection. Analgesics are used to
control wound pain and to prevent abdominal splinting and decreased ventilation.
Remediation:
, A hospitalized client, with a productive cough, chills, and night sweats is suspected of
having active tuberculosis (TB). What is the nurse’s most important intervention?
You Selected:
• Maintain the client on respiratory isolation
Correct response:
• Maintain the client on respiratory isolation
Explanation:
This client is showing signs and symptoms of active TB and, because of the productive
cough, is highly contagious. He should be admitted to the hospital and placed in
respiratory isolation. Three sputum cultures should be obtained to confirm the
diagnosis.
Question 4 See full question
The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds
the client disoriented to time and place, diaphoretic, and complaining of palpitations.
What is the nurse’s priority intervention?
You Selected:
• Check blood glucose level
Correct response:
• Check blood glucose level
Explanation:
Check the blood glucose level first when symptoms arise, then proceed with treatment
according to the results. If the client is hypoglycemic, administration of a simple
carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given
orally. If consciousness is altered, subcutaneous or intramuscular glucagon is
appropriate. This client is showing symptoms of hypoglycemia, additional insulin would
further lower the blood glucose.
Remediation:
• Diabetes Mellitus (Type 1), Long-Term Care
Question 5 See full question
A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1°
F (39.5° C) rectally. What is the most appropriate initial nursing intervention?
You Selected:
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