Fundamentals of Nursing NCLEX Practice
Exam: Part 5
1. Once a nurse assesses a client’s condition and
identifies appropriate nursing diagnoses, a:
A. Plan is developed for nursing care.
B. Physical assessment begins.
C. List of priorities is determined.
D. Review of the assessment is conducted with other
team members.
The planning stage is where goals and outcomes are
formulated that directly impact patient care based on
EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome.
Nursing care plans are essential in this phase of goal
setting.
Option B: Assessment is the first step and involves
critical thinking skills and data collection; subjective and
objective. Subjective data involves verbal statements
from the patient or caregiver. Objective data is
measurable, tangible data such as vital signs, intake and
output, and height and weight.
Option C: A nursing diagnosis encompasses Maslow’s
Hierarchy of Needs and helps to prioritize and plan care
based on patient-centered outcomes. In 1943, Abraham
Maslow developed a hierarchy based on basic
fundamental needs innate for all individuals.
Option D: Data may come from the patient directly or
from primary caregivers who may or may not be direct
relation family members. Friends can play a role in data
collection. Electronic health records may populate data
and assist in assessment.
2. Planning is a category of nursing behaviors in which:
A. The nurse determines the health care needed for the
client.
B. The physician determines the plan of care for the
client.
C. Client-centered goals and expected outcomes
are established.
D. The client determines the care needed.
The planning stage is where goals and outcomes are
formulated that directly impact patient care based on
EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome.
Option A: Nursing care plans are essential in this phase
of goal setting. Care plans provide a course of direction
for personalized care tailored to an individual’s unique
needs. Overall condition and comorbid conditions play a
role in the construction of a care plan.
Option B: As explored by Salmond and Echevarria,
healthcare is changing, and the traditional roles of
nurses are transforming to meet the demands of this
new healthcare environment. Nurses are in a position to
promote change and impact patient delivery care
models in the future.
Option D: Care plans enhance communication,
documentation, reimbursement, and continuity of care
across the healthcare continuum. Critical thinking skills
will play a vital role as nurses develop plans of care for
these patient populations with multiple comorbidities and
embrace this challenging healthcare arena.
3. Priorities are established to help the nurse anticipate
and sequence nursing interventions when a client has
multiple problems or alterations. Priorities are
determined by the client’s:
A. Physician
B. Non-Emergent, non-life-threatening needs
C. Future well-being.
D. Urgency of problems
Triage of patients involves looking for signs of serious
illness or injury. These emergency signs are connected
to the Airway – Breathing – Circulation/Consciousness –
Dehydration and are easily remembered as ABCD. If the
client does not have any emergency signs, the health
worker proceeds to assess the client for priority
conditions. This should not take more than a few
seconds. Some of these signs will have been noticed
during the ABCD triage and others need to be
rechecked.
Option A: All clinical staff involved in the care of the sick
should be prepared to carry out a rapid assessment to
identify the few clients who are severely ill and require
emergency treatment.
Option B: Triage is the process of rapidly examining
sick children when they first arrive in order to place them
in one of the following categories: those with
EMERGENCY SIGNS who require immediate
emergency treatment; those with PRIORITY SIGNS who
should be given priority in the queue so they can be
rapidly assessed and treated without delay; and those
who have no emergency or priority signs and are NON-
URGENT cases. These clients can wait their turn in the
queue for assessment and treatment. The majority of
sick clients will be non-urgent and will not require
emergency treatment.
Option C: Ideally, all clients should be checked on their
arrival by a person who is trained to assess how ill they
are. This person decides whether the client will be seen
immediately and receive life-saving treatment, or will be
seen soon, or can safely wait for his or her turn to be
examined.
4. A client-centered goal is a specific and measurable
behavior or response that reflects a client’s:
A. Desire for specific health care interventions.
B. Highest possible level of wellness and
independence in function.
C. Physician’s goal for the specific client.
D. Response when compared to another client with a
similar problem.
Client-centered practices facilitate the development of
strong therapeutic relationships and enable care
providers to understand how to maximize clients’
strengths and minimize challenges in achieving
treatment and recovery goals.
Option A: Care providers negotiate between clients’
decisions and ongoing risk assessments. The care plan
reflects safe practices and promotes interventions that
minimize or reduce potential harms to the client.
Option C: Client-centred care empowers clients,
promoting autonomy, rights, voice, and self-
determination in the treatment planning and recovery
process and supports care plans that are developed in
collaboration with clients, and allows clients to express
their self-identified needs and choices.
Option D: Client-centred care is about treating clients
as they want to be treated, with knowledge about and
respect for their values and personal priorities. Health
care providers who take the time to get to know their
clients can provide care that better addresses the needs
of clients and improves their quality of care.
5. For clients to participate in goal setting, they should
be:
A. Alert and have some degree of independence.
B. Ambulatory and mobile.
C. Able to speak and write.
D. Able to read and write.
Goal setting in nursing provides direction for planning
nursing interventions and evaluating patient progress.
The purpose of goal setting in nursing is to enable the
patient and nurse to determine when the problem has
been resolved and help motivate the patient and the
nurse by providing a sense of achievement.
Option B: In light of the potential benefits of patient
participation in goal setting, a study by Baker, Rice,
Zimmerman, Marshak, et. al. believes the following are
needed: (1) patient and therapist education regarding
the potential advantages of participation, (2) the
enhancement of patient readiness to assume greater
responsibility in their care, and (3) the development of
models for use in achieving patient participation.
Option C: Patient and therapist education is needed
regarding methods for patient participation during initial
goal-setting activities. In a study by Baker, Rice,
Zimmerman, Marshak, et. al., the therapists stated that
they believed that it is important to include patients in
goal-setting activities and that outcomes will be
improved if patients participate. Patients also indicated
that participation is important to them.
Option D: Patient participation in goal setting is
emphasized in order to enhance patient management
and the effectiveness of treatment. Participation should
improve outcomes and could be used to identify benefits
that may result from the treatment. These benefits
include greater goal attainment, increased patient
satisfaction, gains in function, better adherence to
treatment regimens, decreased depression in patients,
and reduced burnout rates among physical therapists.
6. The nurse writes an expected outcome statement in
measurable terms. An example is:
A. Client will have less pain.
B. Client will be pain-free.
C. Client will report pain acuity less than 4 on a
scale of 0-10.
D. Client will take pain medication every 4 hours around
the clock.
When developing goals for patients, the nurse needs to
look at several factors. Think back to the SMART goal
criteria. In order to be specific, nurses focus on
questions like ‘What is the problem? What is the
response desired?’ To make it measurable, ‘How will the
client look or behave if the healthy response is
achieved? What can I see, hear, measure, observe?’
Option A: One way to help nurses remember how to
write goals is to make sure they are SMART. SMART
goals are Specific, Measurable, Action-Oriented,
Realistic, and Timely. ‘Specific’ refers to who, what,
when, where, and why. ‘Measurable’ means that you
can actually measure and evaluate the progress of that
goal in a concrete way. ‘Action-oriented’ means there
are actions that can be taken to reach the goal.
‘Realistic’ includes the ability to work on the goal, having
the resources, attitudes, abilities, and skills to reach this
goal, and how realistic it is to come to fruition. Finally,
‘Timely’ means that there is an end time frame or date at
which the goal is going to be evaluated.
Option B: Goal setting occurs in the third phase of the
process, planning. Is the goal for nursing care to heal
patients? To help them get better? To help them get
well? While these are certainly at the forefront of nurses’
minds, how do you evaluate these statements? What if
the definition of wellness is different from one person to
another? This is why nursing goal statements that are
patient-centered and measurable are so important.
Option D: Considering action-oriented, ‘Are there steps
and nursing interventions needed to reach that goal? Is
this a realistic outcome for the patient? Have we
considered all of the factors involved, including the
client’s capabilities and limitations? Does the patient
have what he or she needs to reach that goal?’ And
finally, ‘Is it timely? When do we expect the goal to be
reached?’
7. As goals, outcomes, and interventions are developed,
the nurse must:
A. Be in charge of all care and planning for the client.
B. Be aware of and committed to accepted
standards of practice from nursing and other
disciples.
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client.
Whenever a healthcare provider intervenes or
implements care, they must reassess or evaluate to
ensure the desired outcome has been met.
Reassessment may frequently be needed depending
upon overall patient condition. The plan of care may be
adapted based on new assessment data.
Option A: Patients’ participation in decision-making in
health care and treatment is not a new area, but
currently it has become a political necessity in many
countries and health care systems around the world.
Emphasizing the importance of participation in the
decision-making process motivates the service provider
and the health care team to promote participation of
patients in treatment decision-making.
Option C: A review of some literature reveals that
participation of patients in health care has been
associated with improved treatment outcomes.
Moreover, this participation causes improved control of
diabetes, better physical functioning in rheumatic
diseases, enhanced patients’ compliance with
secondary preventive actions, and improvement in
health of patients with myocardial infarction.
Option D: With enhanced patient participation, and
considering patients as equal partners in healthcare
decision making patients are encouraged to actively
participate in their own treatment process and follow
their treatment plan and thus a better health
maintenance service would be provided.
8. When establishing realistic goals, the nurse:
A. Bases the goals on the nurse’s personal knowledge.
B. Knows the resources of the health care facility,
family, and the client.
C. Must have a client who is physically and emotionally
stable.
D. Must have the client’s cooperation.
The planning stage is where goals and outcomes are
formulated that directly impact patient care based on
EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome.
Data may come from the patient directly or from primary
caregivers who may or may not be direct relation family
members. Friends can play a role in data collection.
Electronic health records may populate data and assist
in assessment.
Option A: Nursing care plans are essential in this phase
of goal setting. Care plans provide a course of direction
for personalized care tailored to an individual’s unique
needs. Overall condition and comorbid conditions play a
role in the construction of a care plan.
Option C: The utilization of the nursing process to guide
care is clinically significant going forward in this
dynamic, complex world of patient care. Aging
populations carry with them a multitude of health
problems and inherent risks of missed opportunities to
spot a life-altering condition.
Option D: As explored by Salmond and Echevarria,
healthcare is changing, and the traditional roles of
nurses are transforming to meet the demands of this
new healthcare environment. Nurses are in a position to
promote change and impact patient delivery care
models in the future.
9. To initiate an intervention the nurse must be
competent in three areas, which include:
A. Knowledge, function, and specific skills.
B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.
Critical thinking and reflection are essential skills
because they can enhance nurses’ ability to solve
problems and make sound decisions. Critical thinking
skills enable nurses to identify multiple possibilities in
clinical situations and alternatives to interventions; weigh
the consequences of alternate actions; and determine
the right judgment and decisions. To provide safe and
effective care to the clients, nurses must integrate
knowledge, skills, and attitudes to make sound judgment
and decisions.
Option B: Due to the increasing internal and external
expectations of higher quality nursing, it is no longer
acceptable for nurses to deliver nursing care only on
experience and textbook knowledge. Clinical nurses are
expected to systematically gather the best research
evidence, draw from nursing experience, and consider
patient’s preferences when they are making professional
decisions
Option C: Some research findings showed that
changing the attitude and enhancing the knowledge of
nurses are the first step in EBP. McCleary and Brown
conducted a study on 528 graduate nurses working in
educational pediatric hospitals of Canada and reported
that the nurses’ knowledge of EBP and their positive
attitude towards it will contribute to its implementation in
the healthcare system.
Option D: Melnyk et al. stated that acquiring knowledge
about research methods and having the skill to evaluate
research reports critically may enable overcoming the
obstacles hindering the application of research findings
and thus will lead to improvement of healthcare quality.
Hence, the EBP attitude, knowledge, and skills of nurses
are so important.
10. Collaborative interventions are therapies that
require:
A. Physician and nurse interventions.
B. Nurse and client interventions.
C. Client and Physician intervention.
D. Multiple health care professionals.
Collaborative interventions are actions that the nurse
carries out in collaboration with other health team
members, such as physicians, social workers, dietitians,
and therapists. These actions are developed in
consultation with other health care professionals to gain
their professional viewpoint.
Option A: Dependent nursing interventions are activities
carried out under the physician’s orders or supervision.
Includes orders to direct the nurse to provide
medications, intravenous therapy, diagnostic tests,
treatments, diet, and activity or rest.
Option B: Independent nursing interventions are
activities that nurses are licensed to initiate based on
their sound judgment and skills. Includes ongoing
assessment, emotional support, providing comfort,
teaching, physical care, and making referrals to other
health care professionals.
Option C: Nursing interventions are activities or actions
that a nurse performs to achieve client goals.
Interventions chosen should focus on eliminating or
reducing the etiology of the nursing diagnosis. In this
step, nursing interventions are identified and written
during the planning step of the nursing process;
however, they are actually performed during the
implementation step.
11. Well formulated, client-centered goals should:
A. Meet immediate client needs.
B. Include preventative health care.
C. Include rehabilitation needs.
D. All of the above.
The process of client-centered goal planning
encourages members of the multi-professional team to
work in partnership with the client, his or her family, and
each other, united by the aim of helping the client to
achieve his or her desired outcome. Goals enable
clients, their carers or partners, and the multidisciplinary
team to focus on strengths rather than problems. They
also enable the team to gauge where the client and
family are in their ‘thinking’ (Davis and O’Connor, 1999).
Option A: Once set, goals provide a central focus for all
therapeutic activity, enabling clients to move away from
a period of dependency to a level of achievement and/or
adjustment to their situation.
Option B: Goal planning is part of the overall care plan
in which the client’s own values, beliefs, and aspirations
are recognized and valued, and form the central focus of
the rehabilitation process.
Option C: Goals for rehabilitation can be divided into
two groups: short-term and long-term. Short-term goals
can act as stepping stones to achieving longer-term
targets. A short-term goal for this client might be to be
able to clean her teeth.
12. The following statement appears on the nursing care
plan for an immunosuppressed client: The client will
remain free from infection throughout hospitalization.
This statement is an example of a (an):
A. Nursing diagnosis
B. Short-term goal
C. Long-term goal
D. Expected outcome
Short-term goals can act as stepping stones to
achieving longer-term targets. For example, a client may
have the long-term goal of being able to groom herself,
including cleaning her teeth, washing her face, combing
her hair, and applying her make-up on her own. A short-
term goal for this client might be to be able to clean her
teeth.
Option A: Actual or potential health problems that can
be prevented or resolved by independent nursing
intervention are termed nursing diagnoses. NANDA
nursing diagnoses are a uniform way of identifying,
focusing on, and dealing with specific client needs and
responses to actual and high-risk problems.
Option C: Long-term goals are often used for clients
who have chronic health problems or who live at home,
in nursing homes, or extended-care facilities. Long-term
goal indicates an objective to be completed over a
longer period, usually over weeks or months.
Option D: Goals or desired outcomes describe what the
nurse hopes to achieve by implementing the nursing
interventions and are derived from the client’s nursing
diagnoses. One overall goal is determined for each
nursing diagnosis. The terms goal, outcome, and
expected outcome are oftentimes used interchangeably.
13. The following statements appear on a nursing care
plan for a client after a mastectomy: Incision site
approximated; absence of drainage or prolonged
erythema at the incision site; and the client remains
afebrile. These statements are examples of:
A. Nursing interventions
B. Short-term goals
C. Long-term goals
D. Expected outcomes
Goals or desired outcomes describe what the nurse
hopes to achieve by implementing the nursing
interventions and are derived from the client’s nursing
diagnoses. One overall goal is determined for each
nursing diagnosis. The terms goal, outcome, and
expected outcome are oftentimes used interchangeably.
Option A: Nursing interventions are activities or actions
that a nurse performs to achieve client goals.
Interventions chosen should focus on eliminating or
reducing the etiology of the nursing diagnosis.
Option B: Short-term goals can act as stepping stones
to achieving longer-term targets. For example, a client
may have the long-term goal of being able to groom
herself, including cleaning her teeth, washing her face,
combing her hair, and applying her make-up on her own.
A short-term goal for this client might be to be able to
clean her teeth.
Option C: Long-term goals are often used for clients
who have chronic health problems or who live at home,
in nursing homes, or extended-care facilities. Long-term
goal indicates an objective to be completed over a
longer period, usually over weeks or months.
14. The planning step of the nursing process includes
which of the following activities?
A. Assessing and diagnosing.
B. Evaluating goal achievement.
C. Performing nursing actions and documenting them.
D. Setting goals and selecting interventions.
The planning stage is where goals and outcomes are
formulated that directly impact patient care based on
EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome.
Nursing care plans are essential in this phase of goal
setting. Care plans provide a course of direction for
personalized care tailored to an individual’s unique
needs.
Option A: Assessment is the first step and involves
critical thinking skills and data collection; subjective and
objective. Data may come from the patient directly or
from primary caregivers who may or may not be direct
relation family members. Friends can play a role in data
collection. Electronic health records may populate data
in and assist in assessment. The formulation of a
nursing diagnosis by employing clinical judgment assists
in the planning and implementation of patient care.
Option B: This final step of the nursing process is vital
to a positive patient outcome. Whenever a healthcare
provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has
been met. Reassessment may frequently be needed
depending upon overall patient condition. The plan of
care may be adapted based on new assessment data.
Option C: Implementation is the step that involves
action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase
requires nursing interventions such as applying a
cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment protocols,
and EDP standards.
15. The nursing care plan is:
A. A written guideline for implementation and
evaluation.
B. A documentation of client care.
C. A projection of potential alterations in client
behaviors.
D. A tool to set goals and project outcomes.
Nursing care plans are essential in this phase of goal
setting. Care plans provide a course of direction for
personalized care tailored to an individual’s unique
needs. Overall condition and comorbid conditions play a
role in the construction of a care plan. Care plans
enhance communication, documentation,
reimbursement, and continuity of care across the
healthcare continuum.
Option B: Documentation is any written or electronically
generated information about a client that describes the
status, care or services provided to that client. Through
documentation, you communicate observations,
decisions, actions, and outcomes of these actions for
clients, demonstrating the nursing process.
Option C: Behavioral tools are psychological
instruments that are used for understanding and
interpreting human behavior. Such tools have found
many applications in corporate and educational sectors,
considering their exploratory and insightful nature.
Option D: A SMART goal is one that is specific,
measurable, attainable, relevant and time-bound. The
SMART criteria help to incorporate guidance and
realistic direction in goal setting, which increases
motivation and leads to better results in achieving lasting
change.
16. After determining a nursing diagnosis of acute pain,
the nurse develops the following appropriate client-
centered goal:
A. Encourage the client to implement guided imagery
when pain begins.
B. Determine the effect of pain intensity on client
function.
C. Administer analgesic 30 minutes before physical
therapy treatment.
D. Pain intensity reported as a 3 or less during
hospital stay.
This is measurable and objective. Goals or desired
outcomes describe what the nurse hopes to achieve by
implementing the nursing interventions and are derived
from the client’s nursing diagnoses. Goals provide
direction for planning interventions, serve as criteria for
evaluating client progress, enable the client and nurse to
determine which problems have been resolved, and help
motivate the client and nurse by providing a sense of
achievement.
Option A: This is an example of nursing intervention.
Nursing interventions are activities or actions that a
nurse performs to achieve client goals. Interventions
chosen should focus on eliminating or reducing the
etiology of the nursing diagnosis.
Option B: Evaluating is a planned, ongoing, purposeful
activity in which the client’s progress towards the
achievement of goals or desired outcomes, and the
effectiveness of the nursing care plan (NCP).
Option C: This is an example of nursing intervention.
Dependent nursing interventions are activities carried
out under the physician’s orders or supervision. Includes
orders to direct the nurse to provide medications,
intravenous therapy, diagnostic tests, treatments, diet,
and activity or rest.
17. When developing a nursing care plan for a client
with a fractured right tibia, the nurse includes in the plan
of care independent nursing interventions, including:
A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
C. Perform a range of motion to right leg every 4 hours.
D. Administer aspirin 325 mg every 4 hours as needed.
This does not require a physician’s order. Independent
nursing interventions are activities that nurses are
licensed to initiate based on their sound judgment and
skills. Includes ongoing assessment, emotional support,
providing comfort, teaching, physical care, and making
referrals to other health care professionals.
Option A: This intervention requires a doctor’s order.
Assessment and providing explanation while
administering medical orders are also part of the
dependent nursing interventions.
Option C: C is not appropriate for a fractured tibia.
Isometrics contract muscles without bending joints or
moving limbs and help maintain muscle strength and
mass. Note: These exercises are contraindicated while
acute bleeding and edema are present.
Option D: Dependent nursing interventions are activities
carried out under the physician’s orders or supervision.
Includes orders to direct the nurse to provide
medications, intravenous therapy, diagnostic tests,
treatments, diet, and activity or rest.
18. Which of the following nursing interventions are
written correctly?
A. Apply continuous passive motion machines during
the day.
B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
It is specific in what to do and when. Nursing
interventions should be specific and clearly stated,
beginning with an action verb indicating what the nurse
is expected to do. Action verb starts the intervention and
must be precise.
Option A: This intervention does not specify the location
of the application. Nursing interventions are the actual
treatments and actions that are performed to help the
patient to reach the goals that are set for them. The
nurse uses his or her knowledge, experience, and
critical-thinking skills to decide which interventions will
help the patient the most.
Option B: It was not stated in this intervention when the
neurovascular check should be performed. Nurses must
use their knowledge, experience, resources, research of
evidence-based practice, the counsel of others, and
critical-thinking skills to decide which nursing
interventions would best benefit a specific patient.
Option D: Qualifiers of how, when, where, time,
frequency, and amount provide the content of the
planned activity. For example: “Educate parents on how
to take temperature and notify of any changes,” or
“Assess urine for color, amount, odor, and turbidity.”
19. A client’s wound is not healing and appears to be
worsening with the current treatment. The nurse first
considers:
A. Notifying the physician.
B. Calling the wound care nurse.
C. Changing the wound care treatment.
D. Consulting with another nurse.
Calling the wound care nurse as a consultant is
appropriate because he or she is a specialist in the area
of wound management. Professional and competent
nurses recognize limitations and seek appropriate
consultation. As the largest health care workforce,
nurses apply their knowledge, skills, and experience to
care for the various and changing needs of patients. A
large part of the demands of patient care is centered on
the work of nurses.
Option A: Option A may be appropriate after deciding
on a plan of action with the wound care nurse specialist.
The nurse may need to obtain orders for special wound
care products. Interprofessional and interprofessional
collaboration, through multidisciplinary teams, is
important in the right work environments. Skills for
teamwork are considered nontechnical and include
leadership, mutual performance monitoring, adaptability,
and flexibility.
Option C: Option C is possible unless the nurse is
knowledgeable in wound management, this could delay
wound healing. Also, the current wound management
plan could have been ordered by the physician.
Clinicians working in teams will make fewer errors when
they work well together, use well-planned and
standardized processes, know team members and their
own responsibilities, and constantly monitor team
members’ performance to prevent errors before they
could cause harm.
Option D: Another nurse most likely will not be
knowledgeable about wounds, and the primary nurse
would know the history of the wound management plan.
Understanding the complexity of the work environment
and engaging in strategies to improve its effects is
paramount to higher-quality, safer care.
20. When calling the nurse consultant about a difficult
client-centered problem, the primary nurse is sure to
report the following:
A. Length of time the current treatment has been in
place.
B. The spouse’s reaction to the client’s dressing
change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current
treatment plan.
This gives the consulting nurse facts that will influence a
new plan. Other choices are subjective and emotional
issues and conclusions about the current treatment plan
may cause bias in the decision of a new treatment plan
by the nurse consultant. In general, it is important to
create a supportive environment with open and honest
communication, focusing on the achievements and not
on negative aspects.
Option B: Navigating the new system is very
challenging and it is important for the clients to have a
person to whom they could always turn with questions
and concerns. It could not necessarily be a formal
caseworker, but rather any clinician who had a trusting
relationship and was helpful and willing to guide the
client.
Option C: Education and information for both the patient
and the family were mentioned by all the participants in
a study as the main strategies to help them develop a
clear understanding of their condition and prognosis.
Option D: Several successful strategies to improve
client-centered care have been introduced in different
hospitals: writing a family note (a summary that is given
to the family) at the family meeting, appointing a contact
person/therapy leader for each client, improving
continuity and coordination of care through
interdisciplinary collaborations, having the same staff
working with the client, and providing written materials.
21. The primary nurse asked a clinical nurse specialist
(CNS) to consult on a difficult nursing problem. The
primary nurse is obligated to:
A. Implement the specialist’s recommendations.
B. Report the recommendations to the primary
physician.
C. Clarify the suggestions with the client and family
members.
D. Discuss and review advised strategies with CNS.
The primary nurse requested the consultation, it is
important that they communicate and discuss
recommendations. The primary nurse can then accept
or reject the CNS recommendations. Effective clinical
practice thus involves many instances where critical
information must be accurately communicated. Team
collaboration is essential.
Option A: Some of the recommendations may not be
appropriate for this client. The primary nurse would
know this information. A consultation requires review of
the recommendations, but not immediate
implementation. Collaboration in health care is defined
as health care professionals assuming complementary
roles and cooperatively working together, sharing
responsibility for problem-solving, and making decisions
to formulate and carry out plans for patient care
Option B: This would be appropriate after first talking
with the CNS about recommended changes in the plan
of care and the rationale. Then the primary nurse should
call the physician. Collaboration between physicians,
nurses, and other health care professionals increases
team members’ awareness of each others’ type of
knowledge and skills, leading to continued improvement
in decision making.
Option C: The client and family do not have the
knowledge to determine whether new strategies are
appropriate or not. Better to wait until the new plan of
care is agreed upon by the primary nurse and physician
before talking with the client and/or family. A study
determined that improved teamwork and communication
are described by health care workers as among the
most important factors in improving clinical effectiveness
and job satisfaction.
22. After assessing the client, the nurse formulates the
following diagnoses. Place them in order of priority, with
the most important (classified as high) listed first.
Ineffective airway clearance
Ineffective tissue perfusion
Constipation
Anticipated grieving
Nurses should apply the concept of ABCs to each
patient situation. Prioritization begins with determining
immediate threats to life as part of the initial assessment
and is based on the ABC pneumonic focusing on the
airway as priority, moving to breathing, and circulation
(Ignatavicius et al., 2018).
Ineffective airway clearance can be an acute (e.g.,
postoperative recovery) or chronic (e.g., CVA or spinal
cord injury) problem. High-risk for ineffective airway
clearance are the aged individuals who have an
increased incidence of emphysema and a higher
prevalence of chronic cough or sputum production.
Decreased tissue perfusion can be temporary, with few
or minimal consequences to the health of the patient, or
it can be more acute or protracted, with potentially
destructive effects on the patient. When diminished
tissue perfusion becomes chronic, it can result in tissue
or organ damage or death.
Constipation occurs when bowel movements become
less frequent than normal. It is accompanied by a
difficult or incomplete passage of stool. Though
common, constipation may also be a complex problem.
Chronic constipation can result in the development of
hemorrhoids; diverticulosis; straining at stool, and
perforation of the colon.
Grieving is an individual’s normal response to a loss that
may be perceived or actual. Assessment is necessary in
order to identify potential problems that may have led to
grief and also name any event that may happen during
nursing care.
23. The nurse is reviewing the critical paths of the clients
on the nursing unit. In performing a variance analysis,
which of the following would indicate the need for further
action and analysis?
A. A client’s family attending a diabetic teaching
session.
B. Canceling physical therapy sessions on the
weekend.
C. Normal VS and absence of wound infection in a
post-op client.
D. A client demonstrating accurate medication
administration following teaching.
Variance analysis is the identification of patient or family
needs that are not anticipated and the actions related to
these needs in a system of managed care. There are
four kinds of origin for the variance: patient-family origin,
system-institutional origin; community origin, and
clinician origin.
Option A: Critical pathways are care plans that detail
the essential steps inpatient care with a view to
describing the expected progress of the patient. They
also have a positive impact on outcomes, such as
increased quality of care and patient satisfaction,
improved continuity of information, and patient
education.
Option C: Clinical pathways are being increasingly used
for daily patient care. The pathways consist of a
sequence of critical treatment events matched to the
patient’s recovery. Variance analysis identifies
deviations from the pathway and can be used for quality
improvement and clinical audit.
Option D: Clinical pathways can be used as a means of
incorporating evidence-based medicine into clinical
practice. Variance analysis of the pathways can be
utilized as a process of quality control and to improve
patient outcomes.
24. The RN has received her client assignment for the
day shift. After making the initial rounds and assessing
the clients, which client would the RN need to develop a
care plan first?
A. A client who is ambulatory.
B. A client, who has a fever, is diaphoretic and
restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has just
received pain medication.
This client’s needs are a priority. Clinical judgment and
prioritization of patient care is built on the nursing
process. Nurses learn the steps of the nursing process
in their foundational nursing course and utilize it
throughout their academic and clinical careers to direct
patient care and determine priorities.
Option A: An ambulatory client would not be a priority.
However, a thorough assessment should still be done to
make sure that the client does not have any underlying
diseases. In unfamiliar situations, patient prioritization
should be approached as a structured process,
highlighting risk factors that may contribute to a decline
in the patient’s condition and potential interventions that
can reduce the risk of adverse outcomes (Jessee,
2019).
Option C: The client does not have any emergent
concerns based on the stem. Seasoned nurses are able
to pull from their depth of knowledge and experience
that allows them to act deductively and intuitively when
prioritizing patient care.
Option D: The client has already received pain
medication, therefore she is not a priority. For expert
nurses, the ability to prioritize based on these processes
is predominately intuitive, and tasks are completed in a
prioritized manner without much conscious thought.
25. Which of the following statements about the nursing
process is most accurate?
A. The nursing process is a four-step procedure for
identifying and resolving patient problems.
B. Beginning in Florence Nightingale’s days, nursing
students learned and practiced the nursing process.
C. Use of the nursing process is optional for nurses
since there are many ways to accomplish the work of
nursing.
D. The state board examinations for professional
nursing practice now use the nursing process rather
than medical specialties as an organizing concept.
The nursing process is a systematic decision-making
method focusing on identifying and treating responses of
individuals or groups to actual or potential alterations in
health it- is the essential core of nursing practice to
deliver holistic, patient-focused care. Nursing process
provides an organizing framework for the practice of
nursing and the knowledge, judgments, and actions that
nurses bring to patient care.”
Option A: The nursing process is a five-step process.
The nursing process functions as a systematic guide to
client-centered care with 5 sequential steps. These are
assessment, diagnosis, planning, implementation, and
evaluation. The utilization of the nursing process to
guide care is clinically significant going forward in this
dynamic, complex world of patient care.
Option B: The term nursing process was first used by
Hall in 1955. In 1958, Ida Jean Orlando started the
nursing process that still guides nursing care today.
Defined as a systematic approach to care using the
fundamental principles of critical thinking, client-centered
approaches to treatment, goal-oriented tasks, evidence-
based practice (EDP) recommendations, and nursing
intuition.
Option C: Nursing process is not optional since
standards demand the use of it. Holistic and scientific
postulates are integrated to provide the basis for
compassionate, quality-based care. As explored by
Salmond and Echevarria, healthcare is changing, and
the traditional roles of nurses are transforming to meet
the demands of this new healthcare environment.
Nurses are in a position to promote change and impact
patient delivery care models in the future.
26. What equipment would be necessary to complete an
evaluation of cranial nerves 9 and 10 during a physical
assessment?
A. A cotton ball
B. A penlight
C. An ophthalmoscope
D. A tongue depressor and flashlight
Cranial nerves 9 and 10 are the glossopharyngeal and
vagus nerves. The gag reflex would be evaluated. The
9th (glossopharyngeal) and 10th (vagus) cranial nerves
are usually evaluated together. Whether the palate
elevates symmetrically when the patient says “ah” is
noted. If one side is paretic, the uvula is lifted away from
the paretic side. A tongue blade can be used to touch
one side of the posterior pharynx, then the other, and
symmetry of the gag reflex is observed; bilateral
absence of the gag reflex is common among healthy
people and may not be significant.
Option A: For the 5th (trigeminal) nerve, the 3 sensory
divisions (ophthalmic, maxillary, mandibular) are
evaluated by using a pinprick to test facial sensation and
by brushing a wisp of cotton against the lower or lateral
cornea to evaluate the corneal reflex. If facial sensation
is lost, the angle of the jaw should be examined; sparing
of this area (innervated by spinal root C2) suggests a
trigeminal deficit. A weak blink due to facial weakness
(eg, 7th cranial nerve paralysis) should be distinguished
from depressed or absent corneal sensation, which is
common in contact lens wearers. A patient with facial
weakness feels the cotton wisp normally on both sides,
even though blink is decreased.
Option B: A penlight provides a source of light and has
become the most common used tool to assess pupil
diameter. Asymmetry of pupil constriction in response to
light means one pupil constricts and the other remains
dilated or constricts more slowly. It may indicate
dynamic anisocoria or a Marcus Gunn pupil, a relative
afferent pupillary defect (RAPD), or temporal lobe
herniation in the brain.
Option C: The eye can be examined with routine
equipment, including a standard ophthalmoscope;
thorough examination requires special equipment and
evaluation by an ophthalmologist. Ophthalmoscopy
(examination of the posterior segment of the eye) can be
done directly by using a handheld ophthalmoscope or
with a handheld lens in conjunction with the slit lamp
biomicroscope.
27. Which technique would be best in caring for a client
following receiving a diagnosis of a stage IV tumor in the
brain?
A. Offering the client pamphlets on support groups for
brain cancer.
B. Asking the client if there is anything he or his family
needs.
C. Reminding the client that advances in technology are
occurring every day.
D. Providing accurate information about the disease
and treatment options.
Providing information for the client is the best technique
for a new diagnosis. Every clinician at one time or
another faces these important questions. In the
treatment of terminally ill patients, the health
professional needs many skills: the ability to deliver bad
news, the knowledge to provide appropriate optimal
end-of-life care, and the compassion to allow a person
to retain his or her dignity.
Option A: Cassem, in the Massachusetts General
Hospital Handbook of General Hospital Psychiatry,
recommends relaying negative information to patients
through a brief, rehearsed initial statement that
succinctly communicates the news and clearly indicates
that the treatment team is committed to the ongoing care
and support of the patient.
Option B: In considering the emotional state of a person
with terminal illness, it is often helpful to consider the
effects of the family members on the patient and vice
versa. By observing the interactions of a patient with
family, the consultant can become aware of long-
standing grudges or new difficulties in communication
that can make the process of coming to closure at the
end of a life more difficult.
Option C: In most cases, patients who are told their
diagnosis in an up-front, clear manner have better
emotional adjustments to their situation than those who
are not told about their condition. By providing direct,
clear information in a compassionate manner, and by
making clear to the patient that everything possible will
be done to provide medical and emotional support,
physicians can elicit trust and reduce anxiety.
28. An 8.5 lb, 6 oz infant is delivered to a diabetic
mother. Which nursing intervention would be
implemented when the neonate becomes jittery and
lethargic?
A. Administer insulin.
B. Administer oxygen.
C. Feed the infant glucose water (10%).
D. Place the infant in a warmer.
After birth, the infant of a diabetic mother is often
hypoglycemic. Treatment will depend on the baby’s
gestational age and overall health. Treatment includes
giving the baby a fast-acting source of glucose. This
may be as simple as a glucose and water mixture or
formula as an early feeding. Or the baby may need
glucose given through an IV. The baby’s blood glucose
levels are checked after treatment to see if the
hypoglycemia occurs again.
Option A: Second-line therapies for the treatment of
persistent hypoglycemia include the use of
corticosteroids or glucagon, not insulin. Glucagon is a
hormone that stimulates endogenous glucose
production via glycogenolysis and gluconeogenesis;
thus its effectiveness depends on the infant having
adequate glycogen stores. It is most useful in term
infants and infants of diabetic mothers. Glucagon dosing
is as a 30 mcg/kg bolus or 300 mcg/kg per minute
continuous infusion.
Option B: Oxygen is not administered to hypoglycemic
neonates. Early initiation of breastfeeding is crucial for
all infants. For asymptomatic infants at risk of neonatal
hypoglycemia, the AAP recommends initiating feeds
within the first hour of life and performing initial glucose
screening 30 minutes after the first feed. The AAP
recommends goal blood glucose levels equal to or
greater than 45 mg/dL prior to routine feedings, and
intervention for blood glucose <40 mg/dL in the first 4
hours of life and <45 mg/dL at 4 to 24 hours of life.
Option D: Placing the infant in a warmer does not
manage the hypoglycemia. In infants of diabetic
mothers, lower glucose infusions rates of 3 to 5
mg/kg/minute may be used to minimize pancreatic
stimulation and endogenous insulin secretion. Infants
requiring higher rates of intravenous dextrose (>12 to 16
mg/kg/minute) or for more than 5 days are more likely to
have a persistent cause of hypoglycemia.
29. What question would be most important to ask a
male client who is in for a digital rectal examination?
A. “Have you noticed a change in the force of the
urinary system?”
B. “Have you noticed a change in tolerance of certain
foods in your diet?”
C. “Do you notice polyuria in the AM?”
D. “Do you notice any burning with urination or any odor
to the urine?”
This change would be most indicative of a potential
complication with (BPH) benign prostate hypertrophy.
The goals of the evaluation of such men are to identify
the patient’s voiding or, more appropriately, urinary tract
problems, both symptomatic and physiologic; to
establish the etiologic role of BPH in these problems.
Option B: Food intolerances are more common in those
with digestive system disorders, such as irritable bowel
syndrome (IBS). According to the IBS network, most
people with IBS have food intolerances. The symptoms
of food intolerances can also mimic the symptoms of
chronic digestive conditions, such as IBS. However,
certain patterns in the symptoms can help a doctor
distinguish between the two.
Option C: History can often distinguish polyuria from
frequency, but rarely a 24-hour urine collection may be
needed. Polyuria caused by solute diuresis is suggested
by a history of diabetes mellitus. Abrupt onset of polyuria
at a precise time suggests central diabetes insipidus, as
does preference for extremely cold or iced water.
Option D: Dysuria is a symptom of pain and/or burning,
stinging, or itching of the urethra or urethral meatus with
urination. It is one of the most common symptoms
experienced by most people at least once over their
lifetimes. Primarily, causes of dysuria can be divided
broadly into two categories, infectious and non-
infectious.
30. The nurse assesses a prolonged late deceleration of
the fetal heart rate while the client is receiving oxytocin
(Pitocin) IV to stimulate labor. The priority nursing
intervention would be to:
A. Turn off the infusion.
B. Turn the client to the left.
C. Change the fluid to Ringer’s Lactate.
D. Increase mainline IV rate.
Stopping the infusion will decrease contractions and
possibly remove uterine pressure on the fetus, which is
a possible cause of the deceleration. When late
decelerations are observed, the nurse should attempt to
increase the oxygen delivery to the fetus by turning the
mother on her left side and/or administering oxygen. If
Oxytocin (Pitocin) is being administered, it should be
stopped.
Option B: Variable decelerations are marked by a sharp
decrease (“V” shape) in FHR that does not correlate to
contractions. Umbilical cord compression is usually the
cause of variable decelerations. Repositioning of the
mother can relieve this compression if it is minor.
Option C: Late decelerations are shown by the FHR
gradually decreasing around the peak of the contraction
and gradually increasing when the contraction is over.
These decelerations will also have a “U” shape but will
not mirror the contractions. The most common cause of
late decelerations is uteroplacental insufficiency
(insufficient oxygen exchange between the placenta and
the fetus).
Option D: Increasing the main IV line would not manage
the decelerations. While caring for a patient in labor, one
of the important nursing duties is monitoring the
variability of the fetal heart rate (FHR) and monitoring
the FHR response during contractions. Variability in the
FHR during labor is a sign of fetal well-being or fetal
activity or both. The expected variability usually includes
slight accelerations and decelerations.
31. Which nursing approach would be most appropriate
to use while administering an oral medication to a 4-
month-old?
A. Place medication in 45cc of formula.
B. Place medication in an empty nipple.
C. Place medication in a full bottle of formula.
D. Place in supine position. Administer medication
using a plastic syringe.
This is a convenient method for administering
medications to an infant. Draw up the correct amount of
medicine into an oral syringe (a syringe without a
needle) or an empty nipple. Let the infant suck the
medicine out of the syringe or empty nipple. When
giving medicine to an infant, use his natural reflexes
(such as sucking) whenever possible.
Option A: Avoid mixing medicine with foods the child
must have. The child may begin to dislike the foods he
needs. Mix the medicine with a small amount (1 to 2
teaspoons) of applesauce or pears and give it with a
spoon. This is a good way to give pills that have been
crushed well. (To crush a pill, place it between two
spoons and press the spoons together).
Option C: Some medicines can be put in a small
amount of juice or sugar water. Follow the instructions
from the doctor, nurse, or pharmacist. Do not put
medicine in a full bottle or cup in case the infant does
not drink very much.
Option D: Option D is partially correct however, the
infant is never placed in a reclining position during a
procedure due to a potential aspiration. Hold the infant
in a nearly upright position. If the infant struggles, gently
hold one arm and place his other arm around the waist.
Hold the baby close to the body.
32. Which nursing intervention would be a priority during
the care of a 2-month-old after surgery?
A. Minimize stimuli for the infant.
B. Restrain all extremities.
C. Encourage stroking of the infant.
D. Demonstrate to the mother how she can assist with
her infant’s care.
Tactile stimulation is imperative for an infant’s normal
emotional development. After the trauma of surgery,
sensory deprivation can cause failure to thrive. Most
babies with FTT do not have a specific underlying
disease or medical condition to account for their growth
failure. This is referred to as Non-organic FTT. Up to
80% of all children with FTT have Non-organic type FTT.
Non-organic FTT most commonly occurs when there is
inadequate food intake or there is a lack of
environmental stimuli.
Option A: Provide sensory stimulation. Attempt to
cuddle the child and talk to him or her in a warm,
soothing tone and allow for play activities appropriate for
the child’s age. Feed the child slowly and carefully in a
quiet environment; during feeding, the child might be
closely snuggled and gently rocked; it may be necessary
to feed the child every 2 to 3 hours initially.
Option B: Do not restrain the child. Burp the child
frequently during and at the end of each feeding, and
then place him or her on the side with the head slightly
elevated or held in a chest-to-chest position.
Option D: If a family caregiver is present, encourage
him or her to become involved in the child’s feedings.
While caring for the child, point out to the caregiver the
child’s development and responsiveness, noting and
praising any positive parenting behaviors the caregiver
displays.
33. While performing a physical examination on a
newborn, which assessment should be reported to the
physician?
A. Head circumference of 40 cm.
B. Chest circumference of 32 cm.
C. Acrocyanosis and edema of the scalp.
D. Heart rate of 160 and respirations of 40.
Average circumference of the head for a neonate ranges
between 32 to 36 cm. An increase in size may indicate
hydrocephalus or increased intracranial pressure. A
newborn’s head is usually about 2 cm larger than the
chest size. Between 6 months and 2 years, both
measurements are about equal. After 2 years, the chest
size becomes larger than the head.
Option B: The body of a normal newborn is essentially
cylindrical; head circumference slightly exceeds that of
the chest. For a term baby, the average circumference
of the head is 33–35 cm (13–14 inches), and the
average circumference of the chest is 30–33 cm (12–13
inches).
Option C: Peripheral cyanosis (acrocyanosis) involves
the hands, feet, and circumoral area. It is evident in
most infants at birth and for a short time thereafter. If
limited to the extremities in an otherwise normal infant, it
is due to venous stasis and is innocuous. Localized
cyanosis may occur in presenting parts, particularly in
association with abnormal presentations.
Option D: Heart rates normally fluctuate between 120
and 160 beats per minute. In agitated states, a rate of
200 beats per minute may occur transiently. The heart
rate of premature infants is usually between 130 and
170 beats per minute, and during occasional episodes of
bradycardia, it may slow to 70 beats per minute or less.
Normal neonates breathe at rates that vary between 40
and 60 respirations per minute. Rapid rates are likely to
be present for the first few hours after birth.
34. Which action by the mother of a preschooler would
indicate a disturbed family interaction?
A. Tells her child that if he does not sit down and
shut up she will leave him there.
B. Explains that the injection will burn like a bee sting.
C. Tells her child that the injection can be given while
he’s in her lap.
D. Reassures the child that it is acceptable to cry.
Threatening a child with abandonment will destroy the
child’s trust in his family. Children growing up in such
families are likely to develop low self-esteem and feel
that their needs are not important or perhaps should not
be taken seriously by others. As a result, they may form
unsatisfying relationships as adults.
Option B: It can help to describe the need for injections
and blood testing in kid terms. For example, the nurse
might explain that the shots and blood tests help keep
the child feeling good throughout the day — and that not
getting them could mean having to stay home from
school or miss fun activities because of health problems.
Option C: Having both parents (or one parent plus
another caregiver) involved in the management process
will help keep treatment consistent and also provide
support as the nurse deals with struggles over shots and
blood tests.
Option D: If the child argues or cries, the parents might
be tempted to skip an injection or test just this once.
Nurses shouldn’t negotiate blood tests or shots. They’re
necessary and not optional. The first time you’re talked
out of one, you’ll set a precedent that that child won’t
forget.
35. During the history, which information from a 21-year-
old client would indicate a risk for development of
testicular cancer?
A. Genital Herpes
B. Hydrocele
C. Measles
D. Undescended testicle
Undescended testicles make the client at high risk for
testicular cancer. Mumps, inguinal hernia in childhood,
orchitis, and testicular cancer in the contralateral testis
are other predisposing factors. The risk of testicular
cancer might be a little higher for men whose testicles
stayed in the abdomen as opposed to one that has
descended at least partway. If cancer does develop, it’s
usually in the undescended testicle, but about 1 out of 4
cases occur in the normally descended testicle.
Option A: While HPV infections are very common,
cancer caused by HPV is not. Most people infected with
HPV will not develop cancer-related to the infection.
However, some people with long-lasting infections of
high-risk types of HPV, are at risk of developing cancer.
Option B: Hydroceles generally don’t pose any threat to
the testicles. They’re usually painless and disappear
without treatment. However, if the patient has scrotal
swelling, he should see his doctor rule out other causes
that are more harmful such as testicular cancer.
Option C: Measles has a low death rate in healthy
children and adults, and most people who contract the
measles virus recover fully. The risk of complications is
higher in the following groups: children under 5 years
old. adults over 20 years old.
36. While caring for a client, the nurse notes a pulsating
mass in the client’s periumbilical area. Which of the
following assessments is appropriate for the nurse to
perform?
A. Measure the length of the mass.
B. Auscultate the mass.
C. Percuss the mass.
D. Palpate the mass.
Auscultate the mass. Auscultation of the abdomen and
finding a bruit will confirm the presence of an abdominal
aneurysm and will form the basis of information given to
the provider. Occasionally, an overlying mass (pancreas
or stomach) may be mistaken for an AAA. An abdominal
bruit is nonspecific for an unruptured aneurysm, but the
presence of an abdominal bruit or the lateral
propagation of the aortic pulse wave can offer subtle
clues and maybe more frequently found than a pulsatile
mass.
Option A: In one study, 38% of AAA cases were
detected on the basis of physical examination findings,
whereas 62% were detected incidentally on radiologic
studies obtained for other reasons. Femoral/popliteal
pulses and pedal (dorsalis pedis or posterior tibial)
pulses should be palpated to determine if an associated
aneurysm (femoral/popliteal) or occlusive disease exists.
Flank ecchymosis (Grey Turner sign) represents
retroperitoneal hemorrhage.
Option C: Do not percuss the abdominal mass. The
presence of a pulsatile abdominal mass is virtually
diagnostic of an AAA but is found in fewer than 50% of
cases. It is more likely to be noted with a ruptured
aneurysm.
Option D: The mass should not be palpated because of
the risk of rupture. Most clinically significant AAAs are
palpable upon routine physical examination; however,
the sensitivity of palpation depends on the experience of
the examiner, the size of the aneurysm, and the size of
the patient.
37. When observing 4-year-old children playing in the
hospital playroom, what activity would the nurse expect
to see the children participating in?
A. Competitive board games with older children.
B. Playing with their own toys alongside other children.
C. Playing alone with handheld computer games.
D. Playing cooperatively with other preschoolers.
Playing cooperatively with other preschoolers.
Cooperative play is typical of the late preschool period.
Cooperative play is the final stage of play and
represents the child’s ability to collaborate and
cooperate with other children towards a common goal.
Children often reach the cooperative stage of play
between 4 and 5 years of age after they have moved
through the earlier five stages of play.
Option A: Competitive play is when children learn to
play organized games with clear rules and clear
guidelines on winning and losing. Ludo, snake and
ladders, and football are all forms of competitive play.
Option B: After mastering onlooker play, a child will be
ready to move into parallel play. During parallel play,
children will play beside and in proximity to other
children without actually playing with them. Children
often enjoy the buzz that comes with being around other
kids, but they don’t yet know how to step into others’
games or ask other kids to step into their games.
Option C: Encourage the child to play with others and
be active several times a week instead of spending time
in front of a screen. This can help to build healthy, active
bodies. (To be clear, learning can happen during screen
time, too — just not this specific type of learning.)
38. The nurse is teaching the parents of a 3 month-old
infant about nutrition. What is the main source of fluids
for an infant until about 12 months of age?
A. Formula or breastmilk
B. Dilute nonfat dry milk
C. Warmed fruit juice
D. Fluoridated tap water
Formula or breast milk are the perfect food and source
of nutrients and liquids up to 1 year of age.
Breastfeeding with appropriate supplementation is the
preferred method for feeding infants 0-12 months old.
Iron-fortified formulas are recommended if the child is
not breastfed or requires supplemental formula in
addition to breast milk.
Option B: The American Academy of Pediatrics
Committee on Nutrition updated their recommendations
concerning infant feeding practices during the second
six months of life. The committee stated that
breastfeeding is the preferred method of feeding during
the first year of life and that whole cow’s milk may be
introduced after six months of age if adequate
supplementary feedings are given. Reduced fat content
milk is not recommended during infancy.
Option C: When the infants are consuming one-third of
their calories from a balanced mixture of iron-fortified
cereals, vegetables, fruits, and other foods providing
adequate sources of both iron and Vitamin C it is
considered adequate supplementary feeding.
Option D: The World Health Organization (WHO) notes
that babies that are breastfed don’t need additional
water, as breast milk is over 80 percent water and
provides the fluids your baby needs. Children who are
bottle-fed will stay hydrated with the help of their
formula. Water feedings tend to fill up your baby, making
them less interested in nursing. This could actually
contribute to weight loss and elevated bilirubin levels.
39. While the nurse is administering medications to a
client, the client states “I do not want to take that
medicine today.” Which of the following responses by
the nurse would be best?
A. “That’s OK, it's alright to skip your medication now
and then.”
B. “I will have to call your doctor and report this.”
C. “Is there a reason why you don’t want to take
your medicine?”
D. “Do you understand the consequences of refusing
your prescribed treatment?”
When a new problem is identified, it is important for the
nurse to collect accurate assessment data. This is
crucial to ensure that client needs are adequately
identified in order to select the best nursing care
approaches. The nurse should try to discover the reason
for the refusal which may be that the client has
developed untoward side effects.
Option A: It is not alright to skip medication. Be very
matter-of-fact in communication style with the individual
taking the medication. Do not beg, threaten, bribe, or
force the individual. Do not say “I’ll get in trouble “ or
“You’ll get in trouble”.
Option B: If they continue to refuse, document the
missed dose and state the reason (individual refused),
along with other relevant information if known (i.e. they
indicated nausea). In addition, contact the physician
under circumstances as agreed when medication was
prescribed and/or implement any steps in the ISP for
missed doses.
Option D: Find out if they understand what the
medication is for. If they do not understand, remind them
of the purpose and ask them again to take it. Find out if
they understand the implications of not taking their
medication. If they do not understand, remind them of
the implications and ask them again to take it (In
addition to physical symptoms, implications may include
the need to call the physician and report the missed
dose.)
40. The nurse is assessing a 4 month-old infant. Which
motor skill would the nurse anticipate finding?
A. Hold a rattle
B. Bang two blocks
C. Drink from a cup
D. Wave “bye-bye”
The age at which a baby will develop the skill of
grasping a toy with help is 4 to 6 months. The baby is
becoming more dexterous and doing more with their
hands. Their hands now work together to move a toy or
shake a rattle. In fact, those hands will grab for just
about anything within reach, including a stuffed animal,
the mother’s hair, and any colorful or shiny object
hanging nearby
Option B: At 9 months, babies repeat different actions
with objects. They mouth objects to explore the features.
They bang objects with their hand and bang two objects
together to create sounds and actions. They drop
objects sometimes by chance and other times on
purpose.
Option C: Babies are learning functional actions with a
purpose in mind. They can put things in, such as put
clothes in the dryer or a shape in a puzzle. From “put in”
they learn a variety of functional actions. They can put a
sippy cup to their mouth to drink, a spoon in a bowl to
scoop, and a spoon in their mouth to eat.
Option D: Learning how to wave bye-bye is an
important milestone for an infant that usually occurs
between the age of 10 months and a year. A study in
Pediatrics International found premature infants
mastered the bye-bye gesture significantly later than full-
term babies and used different hand and wrist motions.
41. The nurse should recognize that all of the following
physical changes of the head and face are associated
with the aging client except:
A. Pronounced wrinkles on the face.
B. Decreased size of the nose and ears.
C. Increased growth of facial hair.
D. Neck wrinkles.
The nose and ears of the aging client actually become
longer and broader. The chin line is also altered. Height
doesn’t change after puberty (well, if anything we get
shorter as we age) but ears and noses are always
lengthening. That’s due to gravity, not actual growth. As
people age, gravity causes the cartilage in the ears and
nose to break down and sag. This results in droopier,
longer features.
Option A: Wrinkles on the face become more
pronounced and tend to take on the general mood of the
client over the years. For example laugh or frown
wrinkles above the eyebrows, lips, cheeks, and outer
edges of the eye orbit.
Option C: The change in the androgen-estrogen ratio
causes an increase in growth of facial hair in most older
adults. Women develop excessive body or facial hair
due to higher-than-normal levels of androgens, including
testosterone. All females produce androgens, but the
levels typically remain low.
Option D: The aging process shortens the platysma
muscle, which contributes to neck wrinkles. Some
amount of neck wrinkling is inevitable. The extent of the
necklines and other signs of aging skin are determined
in part by genetics. Necklines and wrinkles are a normal
part of aging. They’re caused in part by skin losing
elasticity and being exposed to UV light over time.
42. All of the following characteristics would indicate to
the nurse that an elder client might experience
undesirable effects of medicines except:
A. Increased oxidative enzyme levels.
B. Alcohol taken with medication.
C. Medications containing magnesium.
D. Decreased serum albumin.
Oxidative enzyme levels decrease in the elderly, which
affects the disposition of medication and can alter the
therapeutic effects of medication. Oxidative stress
causes cells and entire organisms to age. If reactive
oxygen species accumulate, this causes damage to the
DNA as well as changes in the protein molecules and
lipids in the cell. The cell ultimately loses its functionality
and dies. Over time, the tissue suffers, and the body
ages.
Option B: Alcohol has a smaller water distribution level
in the elderly, resulting in higher blood alcohol levels.
Alcohol also interacts with various drugs to either
potentiate or interfere with their effects. The older one
gets, the longer alcohol stays in the system. So it’s more
likely to be there when the client takes medicine. And
alcohol can affect the way the meds work. It can also
lead to serious side effects.
Option C: Magnesium is contained in a lot of
medications older clients routinely obtain over the
counter. Magnesium toxicity is a real concern. Older
adults have lower dietary intakes of magnesium than
younger adults. In addition, magnesium absorption from
the gut decreases, and renal magnesium excretion
increases with age. Older adults are also more likely to
have chronic diseases or take medications that alter
magnesium status, which can increase their risk of
magnesium depletion
Option D: Albumin is the major drug-binding protein.
Decreased levels of serum albumin mean that higher
levels of the drug remain free and that there are fewer
therapeutic effects and increased drug interactions.
43. When assessing a newborn whose mother
consumed alcohol during the pregnancy, the nurse
would assess for which of these clinical manifestations?
A. Wide-spaced eyes, smooth philtrum, flattened
nose
B. Strong tongue thrust, short palpebral fissures, simian
crease
C. Negative Babinski sign, hyperreflexia, deafness
D. Shortened limbs, increased jitteriness, constant
sucking
The nurse should anticipate that the infant may have
fetal alcohol syndrome and should assess for signs and
symptoms of it. These include the characteristics listed
in choice A. Fetal alcohol syndrome is a condition in a
child that results from alcohol exposure during the
mother’s pregnancy. Fetal alcohol syndrome causes
brain damage and growth problems. The problems
caused by fetal alcohol syndrome vary from child to
child, but defects caused by fetal alcohol syndrome are
not reversible.
Option B: A single palmar crease is a single line that
runs across the palm of the hand. People most often
have 3 creases in their palms. A single palmar crease
appears in about 1 out of 30 people. Males are twice as
likely as females to have this condition. Some single
palmar creases may indicate problems with
development and be linked with certain disorders.
Option C: Hyperreflexia is a sign of upper motor neuron
damage and is associated with spasticity and a positive
Babinski sign. In infants with at CST which is not fully
myelinated the presence of a Babinski sign in the
absence of other neurological deficits is considered
normal up to 24 months of age.
Option D: Achondroplasia is the most common form of
short-limb dwarfism. It is an autosomal dominant
disorder caused by a mutation in the gene that creates
the cells (fibroblasts) which convert cartilage to bone.
This means, if the gene is passed on by one parent, the
child will have achondroplasia.
44. Which of these statements, when made by the
nurse, is most effective when communicating with a 4-
year-old?
A. “Tell me where you hurt.”
B. “Other children like having their blood pressure
taken.”
C. “This will be like having a little stick in your arm.”
D. “Anything you tell me is confidential.”
Four-year-olds are egocentric and interested in having
the focus on themselves. As kids gain language skills,
they also develop their conversational abilities. Kids 4 to
5 years old can follow more complex directions and
enthusiastically talk about things they do. They can
make up stories, listen attentively to stories, and retell
stories.
Option B: They will not be interested in what it feels like
to other children. By the time your child is in their later
years of primary school, their language and ability to
convey ideas has improved a lot. They even alter their
speech to suit the circumstances. They may speak more
formally in front of a teacher than they do with family and
friends.
Option C: Preschoolers are concrete thinkers and
would literally interpret any analogies so they are not
helpful in explaining procedures. Concrete thinking is a
kind of reasoning that relies heavily on what we observe
in the physical world around us. It’s sometimes called
literal thinking. Young children think concretely, but as
they mature, they usually develop the ability to think
more abstractly.
Option D: Assurance of confidential communication is
most appropriate for the adolescent. In addition,
confidentiality is not maintained if the child plans to harm
themselves, harm someone else, or discloses abuse.
45. A 64-year-old client scheduled for surgery with a
general anesthetic refuses to remove a set of dentures
prior to leaving the unit for the operating room. What
would be the most appropriate intervention by the
nurse?
A. Explain to the client that the dentures must come out
as they may get lost or broken in the operating room.
B. Ask the client if there are second thoughts about
having the procedure.
C. Notify the anesthesia department and the surgeon of
the client’s refusal.
D. Ask the client if the preference would be to
remove the dentures in the operating room receiving
area.
Clients anticipating surgery may experience a variety of
fears. This choice allows the client control over the
situation and fosters the client’s sense of self-esteem
and self-concept. Nurses need to allow patients the
choice of what to do in relation to their dentures when
going to the theatre, although the anesthetist must make
the final decision of whether or not to remove them
immediately before the anesthetic if they feel patient
safety could be compromised.
Option A: According to a study, “There are no set
national guidelines on how dentures should be managed
during anesthesia, but it is known that leaving dentures
in during bag-mask ventilation allows for a better seal
during induction [when the anesthetic is being infused],
and therefore many hospitals allow dentures to be
removed immediately before intubation [when a tube is
inserted into the airway to assist breathing]”.
Option B: The swallowing of dentures during general
anesthesia is a significant problem for anesthesiologists.
It is seen more often in patients with psychiatric
disorders, mental retardation, alcoholism, or poor-quality
dentures. It has become an important issue for
anesthesiologists preoperatively due to the increase in
the proportion of dentures associated with the
prolongation of life.
Option C: The presence of any false teeth or dental
plates should be clearly documented before and after
any surgical procedure, with all members of the surgical
team made aware of what is to be done with them, they
add.
46. The nurse is assessing a client who states her last
menstrual period was March 17, and she has missed
one period. She reports episodes of nausea and
vomiting. Pregnancy is confirmed by a urine test. What
will the nurse calculate as the estimated date of delivery
(EDD)?
A. November 8
B. May 15
C. February 21
D. December 24
Naegele’s rule: add 7 days and subtract 3 months from
the first day of the last regular menstrual period to
calculate the estimated date of delivery. Naegele’s rule,
derived from a German obstetrician, subtracts 3 months
and adds 7 days to calculate the estimated due date
(EDD). It is prudent for the obstetrician to get a detailed
menstrual history, including duration, flow, previous
menstrual periods, and hormonal contraceptives.
Option A: Determining gestational age is one of the
most critical aspects of providing quality prenatal care.
Knowing the gestational age allows the obstetrician to
provide care to the mother without compromising
maternal or fetal status. It allows for the correct timing of
management, such as administering steroids for fetal
lung maturity, starting ASA therapy with a history of pre-
eclampsia in previous pregnancies, starting
hydroxyprogesterone caproate (Makena) for previous
preterm deliveries.
Option B: An average pregnancy lasts 280 days from
the first day of the last menstrual period (LMP) or 266
days after conception. Historically, an accurate LMP is
the best estimator to determine the due date.
Option C: An official EDD is established after
calculating the first-trimester sonogram EDD date and
then using the LMP. If the LMP and first trimester EDD
are within 7 days of each other, the LMP estimates the
due date. The margin of error is reduced depending on
when (i.e., how early) the sonogram occurred.
47. The family of a 6-year-old with a fractured femur
asks the nurse if the child’s height will be affected by the
injury. Which statement is true concerning long bone
fractures in children?
A. Growth problems will occur if the fracture involves
the periosteum.
B. Epiphyseal fractures often interrupt a child’s
normal growth pattern.
C. Children usually heal very quickly, so growth
problems are rare.
D. Adequate blood supply to the bone prevents growth
delay after fractures.
Epiphyseal fractures often interrupt a child’s normal
growth pattern. Growth plate fractures are classified
based on which parts of the bone are damaged, in
addition to the growth plate. Areas of the bone
immediately above and below the growth plate may
fracture. They are called the epiphysis (the tip of the
bone) and metaphysis (the “neck” of the bone).
Option A: The most serious complication is early
closure (complete or partial) of the growth plate.
Complete closure means the entire growth plate of the
affected bone has stopped expanding. This results in the
affected bone not growing as long as the opposite side.
Option C: The severity of and need for treatment of
growth plate closures depend on the location of the
fracture and the age of the patient. Other complications
of growth plate fractures include delayed healing of the
bone, nonhealing, infection, and loss of blood flow to the
area, causing death of part of the bone.
Option D: Growth plate fractures are generally treated
with splints or casts. Sometimes, the bone may need to
be put back in place to allow it to heal in the correct
position. This may be done before or after the cast is
placed and is called a closed reduction. The length of
time the child needs to be in a cast or splint depends on
the location and severity of the fracture. The child’s age
also matters: younger patients heal faster than older
patients.
48. A client is admitted to the hospital with a history of
confusion. The client has difficulty remembering recent
events and becomes disoriented when away from home.
Which statement would provide the best reality
orientation for this client?
A. “Good morning. Do you remember where you are?”
B. “Hello. My name is Elaine Jones and I am your nurse
for today.”
C. “How are you today? Remember, you’re in the
hospital.”
D. “Good morning. You’re in the hospital. I am your
nurse Elaine Jones.”
As cognitive ability declines, the nurse provides a calm,
predictable environment for the client. This response
establishes time, location, and the caregiver’s name.
Orient the patient to surroundings, staff, necessary
activities as needed. Present reality concisely and
briefly. Avoid challenging illogical thinking—defensive
reactions may result.
Option A: Modulate sensory exposure. Provide a calm
environment; eliminate extraneous noise and stimuli.
Increased levels of visual and auditory stimulation can
be misinterpreted by the confused patient.
Option B: Give simple directions. Allow sufficient time
for the patient to respond, to communicate, to make
decisions. This communication method can reduce
anxiety experienced in a strange environment.
Option C: Offer reassurance to the patient and use
therapeutic communication at frequent intervals. Patient
reassurance and communication are nursing skills that
promote trust and orientation and reduce anxiety.
49. When a client wishes to improve the appearance of
their eyes by removing excess skin from the face and
neck, the nurse should provide teaching regarding which
of the following procedures?
A. Dermabrasion
B. Rhinoplasty
C. Blepharoplasty
D. Rhytidectomy
Rhytidectomy is the procedure for removing excess skin
from the face and neck. It is commonly called a facelift.
Rhytidectomy is a surgical procedure meant to
counteract the effects of time on the aging face. In the
rhytidectomy procedure (also known as a “face-lift”), the
tissues under the skin are tightened and excess facial
and neck skin are excised. Rhytidectomy literally means
wrinkle (rhytid-) removal (-ectomy).
Option A: Dermabrasion involves the spraying of a
chemical to cause light freezing of the skin, which is
then abraded with sandpaper or a revolving wire brush.
It is used to remove facial scars, severe acne, and
pigment from tattoos. Dermabrasion is an exfoliating
technique that uses a rotating instrument to remove the
outer layers of skin, usually on the face. This treatment
is popular with people who wish to improve the
appearance of their skin. Some of the conditions it can
treat include fine lines, sun damage, acne scars, and
uneven texture.
Option B: Rhinoplasty is done to improve the
appearance of the nose and involves reshaping the
nasal skeleton and overlying skin. Rhinoplasty is surgery
that changes the shape of the nose. The motivation for
rhinoplasty may be to change the appearance of the
nose, improve breathing, or both. The upper portion of
the structure of the nose is bone, and the lower portion
is cartilage.
Option C: Blepharoplasty is the procedure that removes
loose and protruding fat from the upper and lower
eyelids. Eyelid surgery, or blepharoplasty, is a surgical
procedure to improve the appearance of the eyelids.
50. A woman who is six months pregnant is seen in
antepartal clinic. She states she is having trouble with
constipation. To minimize this condition, the nurse
should instruct her to
A. Increase her fluid intake to three liters/day.
B. Request a prescription for a laxative from her
physician.
C. Stop taking iron supplements.
D. Take two tablespoons of mineral oil daily.
In pregnancy, constipation results from decreased
gastric motility and increased water reabsorption in the
colon caused by increased levels of progesterone.
Increasing fluid intake to three liters a day will help
prevent constipation. The client should increase fluid
intake, increase roughage in the diet, and increase
exercise as tolerated.
Option B: Laxatives are not recommended because of
the possible development of laxative dependence or
abdominal cramping. The primary medical treatment for
constipation in pregnancy is a medication called a
laxative, which makes it easier and more comfortable to
go to the bathroom. It is generally safe to use gentle
laxatives, but it is best to avoid stimulant laxatives
because they can induce uterine contractions.
Option C: Iron supplements are necessary during
pregnancy, as ordered, and should not be discontinued.
Daily oral iron and folic acid supplementation with 30 mg
to 60 mg of elemental iron and 400 µg (0.4 mg) folic acid
is recommended for pregnant women to prevent
maternal anemia, puerperal sepsis, low birth weight, and
preterm birth.
Option D: Mineral oil is especially bad to use as a
laxative because it decreases the absorption of fat-
soluble vitamins (A, D, E, K) if taken near mealtimes.
Mineral oil should always be prohibited during
pregnancy, as its use can cause hemorrhagic disease of
the newborn due to impaired absorption of vitamin K.
Similarly, castor oil is absolutely prohibited during
pregnancy.
51. A client with chronic pain reports to you, the charge
nurse, that the nurse has not been responding to
requests for pain medication. What is your initial action?
A. Check the MARs and nurses’ notes for the past
several days.
B. Ask the nurse educator to give an in-service about
pain management.
C. Perform a complete pain assessment and history on
the client.
D. Have a conference with the nurses responsible
for the care of this client.
As a charge nurse, you must assess the performance
and attitude of the staff in relation to this client. Handling
conflicts in an efficient and effective manner results in
improved quality, patient safety, and staff morale, and
limits work stress for the caregiver. The nurse manager
must approach this challenge thoughtfully because it
involves working relationships that are critical for the unit
to function effectively.
Option A: After gathering data from the nurses,
additional information from the records and the client
can be obtained as necessary. Effective resolution and
management of a conflict require clear communication
and a level of understanding of the perceived areas of
disagreement. Conflict resolution is an essential element
of a healthy work environment because a breakdown in
communication and collaboration can lead to increased
patient errors.
Option B: The educator may be of assistance if
knowledge deficit or need for performance improvement
is the problem. The American Association of Critical-
Care Nurses standards for healthy work environments
recognizes the importance of proficiency in
communication skills and The Joint Commission’s
revised leadership standards place a mandate on
healthcare leadership to manage disruptive behavior
that can impact patient safety.
Option C: Nursing leaders need to assess how nurses
deal with conflict in the healthcare environment in an
effort to develop and implement conflict management
training and processes that can assist them in dealing
with difficult situations.
52. Family members are encouraging your client to
“tough it out” rather than run the risk of becoming
addicted to narcotics. The client is stoically abiding by
the family’s wishes. Priority nursing interventions for this
client should target which dimension of pain?
A. Sensory
B. Sociocultural
C. Behavioral
D. Cognitive
The family is part of the socio-cultural dimension of pain.
They are influencing the client and should be included in
the teaching sessions about the appropriate use of
narcotics and about the adverse effects of pain on the
healing process. The other dimensions should be
included to help the client/family understand the overall
treatment plan and pain mechanism.
Option A: The sensory dimension encompasses both
the quality and severity of pain. It includes the patient’s
report of the location, quality, and intensity of pain.
Assessing this dimension helps quantify the pain and
clarify the extent of poorly localized or radiating pain.
Option C: The behavioral dimension of pain refers to
the patient’s verbal or nonverbal behaviors exhibited in
response to pain. To assess it, rely on direct observation
and continued patient interaction. Watch for common
behaviors associated with pain, such as guarding,
splinting, tensing up, crying, moaning, and massaging a
specific body part.
Option D: The cognitive dimension refers to thoughts,
beliefs, attitudes, intentions, and motivations related to
pain and its management. Before assessing this
dimension, evaluate the patient’s cognitive capacity and
functioning. Review the medical history for diseases or
conditions that may impair cognition; if any exists,
assess its current level of progression. In some patients,
pain can temporarily worsen pre-existing cognitive
limitations.
53. A client with diabetic neuropathy reports a burning,
electrical type in the lower extremities that is not
responding to NSAIDs. You anticipate that the physician
will order which adjuvant medication for this type of
pain?
A. Amitriptyline (Elavil)
B. Corticosteroids
C. Methylphenidate (Ritalin)
D. Lorazepam (Ativan)
Antidepressants such as amitriptyline can be given for
diabetic neuropathy. The American Diabetes
Association recommends amitriptyline, a tricyclic
antidepressant, as the first choice; however, titration to
higher doses is limited by its anticholinergic adverse
effects.
Option B: Corticosteroids are for pain associated with
inflammation. Corticosteroids produce their effect
through multiple pathways. In general, they produce
anti-inflammatory and immunosuppressive effects,
protein and carbohydrate metabolic effects, water and
electrolyte effects, central nervous system effects, and
blood cell effects.
Option C: Methylphenidate is given to counteract
sedation if the client is on opioids. Methylphenidate is
FDA-approved for the treatment of attention deficit
hyperactivity disorder (ADHD) in children and adults and
as a second-line treatment for narcolepsy in adults.
Children with a diagnosis of ADHD should be at least six
years of age or older before being started on this
medication.
Option D: Lorazepam is an anxiolytic. Lorazepam has
common use as the sedative and anxiolytic of choice in
the inpatient setting owing to its fast (1 to 3 minute)
onset of action when administered intravenously.
Lorazepam is also one of the few sedative-hypnotics
with a relatively clean side effect profile.
54. Which client is most likely to receive opioids for
extended periods of time?
A. A client with fibromyalgia
B. A client with phantom limb pain
C. A client with progressive pancreatic cancer
D. A client with trigeminal neuralgia
Cancer pain generally worsens with disease progression
and the use of opioids is more generous. Opioids
(narcotics) are used with or without non-opioids to treat
moderate to severe pain. They are often a necessary
part of a pain relief plan for cancer patients. These
medicines are much like natural substances (called
endorphins) made by the body to control pain. They
were once made from the opium poppy, but today many
are man-made in a lab.
Option A: Fibromyalgia is more likely to be treated with
non-opioid and adjuvant medications. It is recommended
to continue nonpharmacologic measures along with the
use of medications for most patients with fibromyalgia.
Some patients may, however, respond adequately to
nonpharmacologic measures alone. The medications
that have been well studied and consistently effective
are certain antidepressants and anticonvulsants.
Option B: Phantom limb pain usually subsides after
ambulation begins. Treatment, unfortunately, for PLP
has not proven to be very effective. While treatment for
RLP tends to focus on an organic cause for the pain,
PLP focuses on symptomatic control.
Option D: Trigeminal neuralgia is treated with anti-
seizure medications such as carbamazepine (Tegretol).
The first-line treatment for patients with classic TN and
idiopathic TN is pharmacologic therapy. The most
commonly used medication is the anticonvulsant drug,
carbamazepine. It is usually started at a low dose, and
the dose is gradually increased until it controls the pain.
It controls pain for most people in the early stages of the
disease.
55. As the charge nurse, you are reviewing the charts of
clients who were assigned to a newly graduated RN.
The RN has correctly chartered the dose and time of
medication, but there is no documentation regarding
non-pharmaceutical measures. What action should you
take first?
A. Make a note in the nurse’s file and continue to
observe clinical performance.
B. Refer the new nurse to the in-service education
department.
C. Quiz the nurse about knowledge of pain
management.
D. Give praise for the correct dose and time and
discuss the deficits in charting.
In supervising the new RN, good performance should be
reinforced first and then areas of improvement can be
addressed. Nursing activities are very important within
the hospital and must solve the problems that the patient
needs. Every nursing activity should produce
documentation with critical thinking. If nursing
documents are not clear and accurate, inter-professional
communication and an evaluation of nursing care cannot
be optimal.
Option A: Making a note and watching do not help the
nurse to correct the immediate problem. Nursing activity
that has been completed or that will take place should
be properly documented. Accurate documentation and
reports play a pivotal role in health services. This
documentation is necessary to identify nursing
interventions that have been provided to patients and to
show patient progress during hospitalization.
Option B: In-service might be considered if the problem
persists. Nursing documentation also serves as an
effective tool of inter-professional communication
between nurses and other health professionals for
delivering ongoing nursing care, evaluating patient
progress and outcomes, and providing constant patient
protection. High-quality nursing documentation may
improve the effectiveness of communication between
health professionals in first- and higher-level healthcare
facilities.
Option C: Asking the nurse about knowledge of pain
management is also an option; however, it would be a
more indirect and time-consuming approach. It is also
an indicator of nurse performance and the nursing
service quality in a hospital. Documentation provides
details of patient condition, nursing interventions that
have been provided, and patient response to the
intervention(s).
56. In caring for a young child with pain, which
assessment tool is the most useful?
A. Simple descriptive pain intensity scale
B. 0-10 numeric pain scale
C. Faces pain-rating scale
D. McGill-Melzack pain questionnaire
The Faces pain rating scale (depicting smiling, neutral,
frowning, crying, etc.) is appropriate for young children
who may have difficulty describing pain or
understanding the correlation of pain to numerical or
verbal descriptors. The Faces Pain Scale-Revised (FPS-
R) is a self-report measure of pain intensity developed
for children. It was adapted from the Faces Pain Scale
to make it possible to score the sensation of pain on the
widely accepted 0-to-10 metric. The scale shows a close
linear relationship with visual analog pain scales across
the age range of 4-16 years. It is easy to administer and
requires no equipment except for the photocopied faces.
The other tools require abstract reasoning abilities to
make analogies and use of advanced vocabulary.
Option A: The Simple Descriptive Scale exhibits
degrees of pain intensity (no pain, mild pain, moderate
pain, and severe pain). Risk factors for the development
of chronic pain have been a major topic in pain research
in the past two decades. Now, it has been realized that
psychological and psychosocial factors may
substantially influence pain perception in patients with
chronic pain and thus may influence the surgical
outcome.
Option B: This pain scale is most commonly used. A
person rates their pain on a scale of 0 to 10 or 0 to 5.
Zero means “no pain,” and 5 or 10 means “the worst
possible pain.” These pain intensity levels may be
assessed upon initial treatment, or periodically after
treatment.
Option D: The McGill pain questionnaire, or MPQ, is
one of the most widely used multidimensional pain
scales in the world. In the MPQ, the evaluation of pain is
divided into three categories: sensory, affective, and
evaluative. The questionnaire is self-reported and allows
individuals to describe the quality and intensity of their
pain by using 78 adjectives in 20 different sections.
57. In applying the principles of pain treatment, what is
the first consideration?
A. Treatment is based on client goals.
B. A multidisciplinary approach is needed.
C. The client must believe in perceptions of own
pain.
D. Drug side effects must be prevented and managed.
The client must be believed and his or her experience of
pain must be acknowledged as valid. The data gathered
via client reports can then be applied to other options in
developing the treatment plan. Assist patients to develop
a daily routine to support achievement and, where
necessary, readjustment of habits and roles according to
individual capacity and life situation.
Option A: Use a person-centered perspective to
formulate collaborative intervention strategies consistent
with a physical therapy perspective. Understand the
need to involve family members and significant others
including employers where appropriate.
Option B: Demonstrate an ability to integrate the patient
assessment into an appropriate management plan using
the concepts and strategies of clinical reasoning.
Option D: Understand the principles of an effective
therapeutic patient/professional relationship to reduce
pain, promote optimal function and reduce disability
through the use of active and where appropriate,
passive pain management approaches.
58. Which route of administration is preferred if
immediate analgesia and rapid titration are necessary?
A. Intraspinal
B. Patient-controlled analgesia (PCA)
C. Intravenous (IV)
D. Sublingual
The IV route is preferred as the fastest and most
amenable to titration. Medications may be given as
repeated intermittent bolus doses or by continuous
infusion. Intravenous provides almost immediate
analgesia; subcutaneous may require up to 15 minutes
for effect. Bolus IV dosing provides a shorter duration of
action than other routes.
Option A: Intraspinal administration requires special
catheter placement and there are more potential
complications with this route. Intraspinal and
intraventricular administration are options if maximal
doses of opioids and adjuvants administered through
other routes are ineffective or produce intolerable side
effects {e.g., nausea/vomiting, excessive sedation,
confusion}. Opioids can be administered via indwelling
percutaneous or tunneled catheters into the epidural or
intrathecal space.
Option B: A PCA bolus can be delivered; however, the
pump will limit the dosage that can be delivered unless
the parameters are changed. Patient-controlled
analgesia (PCA) devices can be used to combine
continuous infusion with intermittent bolus doses,
allowing more flexible pain control. It is recommended
that the hourly SQ volume limit not exceed 5 cc.
Medications can be concentrated to maintain SQ volume
limits; maximal concentrations: fentanyl 50 ug/ml,
morphine 50 mgs/ml, hydromorphone 50 mgs/ml.
Option D: Sublingual is reasonably fast, but not a good
route for titration, medication variety in this form is
limited. An alkaline pH microenvironment that favors the
unionized fraction of opioids increased sublingual drug
absorption. Although absorption was found to be
independent of drug concentration, it was contact time
dependent for methadone and fentanyl but not for
buprenorphine. These results indicate that although the
sublingual absorption and apparent sublingual
bioavailability of morphine are poor, the sublingual
absorption of methadone, fentanyl, and buprenorphine
under controlled conditions is relatively high.
59. When titrating an analgesic to manage pain, what is
the priority goal?
A. Administer smallest dose that provides relief
with the fewest side effects.
B. Titrate upward until the client is pain-free.
C. Titrate downwards to prevent toxicity.
D. Ensure that the drug is adequate to meet the client’s
subjective needs.
The goal is to control pain while minimizing side effects.
The World Health Organization cancer pain ladder
provides a helpful starting point for achieving effective
pain management. Clinicians should begin with
nonopioid analgesics (e.g., acetaminophen, nonsteroidal
anti-inflammatory drugs [NSAIDs]), and gradually
progress to more potent analgesics until pain is relieved.
Option B: For severe pain, the medication can be
titrated upward until pain is controlled. Many patients
with terminal illnesses require immediate opioid therapy
or have contraindications to common non-opioid
analgesics, such as NSAIDs.
Option C: Downward titration occurs when the pain
begins to subside. Acetaminophen is useful as a primary
analgesic, or in combination with other drugs, for
treating mild to moderate pain. Dosages in healthy
persons should be limited to no more than 4,000 mg
every 24 hours to reduce the risk of hepatotoxicity.
Option D: Adequate dosing is important; however, the
concept of controlled dosing applies more to potent
vasoactive drugs. The World Health Organization pain
ladder offers a stepwise guideline for approaching pain
management. However, for many patients with terminal
illnesses, strong opioids are necessary for efficient and
effective analgesia.
60. In educating clients about non-pharmaceutical
alternatives, which topic could you delegate to an
experienced LPN/LVN, who will function under your
continued support and supervision?
A. Therapeutic touch
B. Use of heat and cold applications
C. Meditation
D. Transcutaneous electrical nerve stimulation (TENS)
Use of heat and cold applications is a standard therapy
with guidelines for safe use and predictable outcomes,
and an LPN/LVN will be implementing this therapy in the
hospital, under the supervision of an RN. Treating pain
with hot and cold can be extremely effective for a
number of different conditions and injuries, and easily
affordable. The tricky part is knowing what situations call
for hot, and which calls for cold. Sometimes a single
treatment will even include both.
Option A: Therapeutic touch requires additional training
and practice. The National Center for Complementary
and Alternative Medicine places therapeutic touch (TT)
into the category of bio-field energy. In the TT method,
the therapist’s hand is used to increase comfort and
reduce pain using the body’s energy field correction
mechanism
Option C: Meditation is not acceptable to all clients and
an assessment of spiritual beliefs should be conducted.
Mindfulness meditation is a fairly loose term that applies
to many meditation practices, which have been found to
improve a wide spectrum of clinically relevant cognitive
and health outcomes.
Option D: Transcutaneous electrical stimulation is
usually applied by a physical therapist. Transcutaneous
electrical nerve stimulation (TENS) is a therapy that
uses low voltage electrical current to provide pain relief.
A TENS unit consists of a battery-powered device that
delivers electrical impulses through electrodes placed on
the surface of your skin. The electrodes are placed at or
near nerves where the pain is located or at trigger
points.
61. Place the examples of drugs in the order of usage
according to the World Health Organization (WHO)
analgesic ladder.
NSAIDs and corticosteroids
Codeine, oxycodone, and diphenhydramine
Morphine, hydromorphone, acetaminophen, and
lorazepam
The WHO analgesic ladder was a strategy proposed by
the World Health Organization (WHO), in 1986, to
provide adequate pain relief for cancer patients. The
analgesic ladder was part of a vast health program
termed the WHO Cancer Pain and Palliative Care
Program aimed at improving strategies for cancer pain
management through educational campaigns, the
creation of shared strategies, and the development of a
global network of support.
Step 1 includes non-opioids and adjuvant drugs. Mild
pain: non-opioid analgesics such as nonsteroidal anti-
inflammatory drugs (NSAIDs) or acetaminophen with or
without adjuvants.
Step 2 includes opioids for mild pain plus Step 1 drugs
and adjuvant drugs as needed. Moderate pain: weak
opioids (hydrocodone, codeine, tramadol) with or without
non-opioid analgesics, and with or without adjuvants.
Step 3 includes opioids for severe pain (replacing Step 2
opioids) and continuing Step 1 drugs and adjuvant drugs
as needed. Severe and persistent pain: potent opioids
(morphine, methadone, fentanyl, oxycodone,
buprenorphine, tapentadol, hydromorphone,
oxymorphone) with or without non-opioid analgesics,
and with or without adjuvants.
62. Which client is at greater risk for respiratory
depression while receiving opioids for analgesia?
A. An elderly chronic pain client with a hip fracture.
B. A client with heroin addiction and back pain.
C. A young female client with advanced multiple
myeloma.
D. A child with an arm fracture and cystic fibrosis.
At greatest risk are elderly clients, opiate naïve clients,
and those with underlying pulmonary disease. The child
has two of the three risk factors. Many complications
can occur with multiple different opioids, such as non-
cardiogenic pulmonary edema, while many of the
complications are unique to the opioid used as well as
the route of administration.

Option A: Pain in the elderly population is especially
difficult given the myriad of physiological,
pharmacological, and psychological aspects of caring for
geriatric patient. Opiates are the mainstay of pain
treatment throughout all age groups but special attention
must be paid to the efficacy and side effects of these
powerful drugs when prescribing to a population with
impaired metabolism, excretion, and physical reserve.
Option B: Prescription opioids and heroin are
chemically similar and can produce a similar high. In
some places, heroin is cheaper and easier to get than
prescription opioids, so some people switch to using
heroin instead. More recent data suggest that heroin is
frequently the first opioid people use. In a study of those
entering treatment for opioid use disorder, approximately
one-third reported heroin as the first opioid they used
regularly to get high.
Option C: Bone pain is one of the most common
presentations of multiple myeloma and nearly all
patients have skeletal involvement in the course of the
disease. Consequently, many patients require narcotics
for symptom management at the time of diagnosis but
the long-term impact of MM treatment on pain control
remains uncertain.
63. A client appears upset and tearful, but denies pain
and refuses pain medication, because “my sibling is a
drug addict and has ruined our lives.” What is the priority
intervention for this client?
A. Encourage expression of fears on past
experiences.
B. Provide accurate information about the use of pain
medication.
C. Explain that addiction is unlikely among acute care
clients.
D. Seek family assistance in resolving this problem.
This client has strong beliefs and emotions related to the
issue of sibling addiction. First, encourage expression.
This indicated to the client that the feelings are real and
valid. It is also an opportunity to assess beliefs and
fears. Verbalization of feelings in a nonthreatening
environment may help the client come to terms with
unresolved issues.
Option B: Giving facts and information is appropriate at
the right time. Clients are often reluctant to share
feelings for fear of ridicule and may have repeatedly
been told to ignore feelings. Once the client begins to
acknowledge and talk about these fears, it becomes
apparent that the feelings are manageable.
Option C: Encourage the client to explore underlying
feelings that may be contributing to irrational fears. Help
the client to understand how facing these feelings, rather
than suppressing them, can result in more adaptive
coping abilities.
Option D: Family involvement is important, bearing in
mind that their beliefs about drug addiction may be
similar to those of the client. Present and discuss the
reality of the situation with the client in order to
recognize aspects that can be changed and those that
cannot. The client must accept the reality of the situation
before the work of reducing the fear can progress.
64. A client is being tapered off opioids and the nurse is
watchful for signs of withdrawal. What is one of the first
signs of withdrawal?
A. Fever
B. Nausea
C. Diaphoresis
D. Abdominal cramps
Diaphoresis is one of the early signs that occur between
6 and 12 hours. Fever, nausea, and abdominal cramps
are late signs that occur between 48 and 72 hours.
According to Diagnostic and Statistical Manual of Mental
Disorders (DSM–5) criteria, signs, and symptoms of
opioid withdrawal include lacrimation or rhinorrhea,
piloerection “goose flesh,” myalgia, diarrhea,
nausea/vomiting, pupillary dilation and photophobia,
insomnia, autonomic hyperactivity (tachypnea,
hyperreflexia, tachycardia, sweating, hypertension,
hyperthermia), and yawning.
Option A: A fever can be a withdrawal symptom among
people who have been addicted to various substances,
or even after a period of intense substance use. Fever
symptoms may range from mild to severe. Although mild
fevers can accompany a variety of substance withdrawal
syndromes and are usually self-limiting, fever can also
be a component of a particularly dangerous type of
alcohol withdrawal.
Option B: Prolonged use of these drugs changes the
way nerve receptors work in the brain, and these
receptors become dependent upon the drug to function.
If the client becomes physically sick after he stops taking
an opioid medication, it may be an indication that he’s
physically dependent on the substance.
Option D: The symptoms the client is experiencing will
depend on the level of withdrawal he is experiencing.
Also, multiple factors dictate how long a person will
experience the symptoms of withdrawal. Because of
this, everyone experiences opioid withdrawal differently.
However, there’s typically a timeline for the progression
of symptoms.
65. In caring for clients with pain and discomfort, which
task is most appropriate to delegate to the nursing
assistant?
A. Assist the client with preparation of a sitz bath.
B. Monitor the client for signs of discomfort while
ambulating.
C. Coach the client to deep breathe during painful
procedures.
D. Evaluate relief after applying a cold application.
The nursing assistant is able to assist the client with
hygiene issues and knows the principles of safety and
comfort for this procedure. Proper and appropriate
assignments facilitate quality care. Improper and
inappropriate assignments can lead to poor quality of
care, disappointing outcomes of care, the jeopardization
of client safety, and even legal consequences.
Monitoring the client, teaching techniques, and
evaluating outcomes are nursing responsibilities.
Option B: Monitoring the client for signs of discomfort
while ambulating is a nursing responsibility. When a
registered nurse delegates aspects of patient care to a
licensed practical nurse that are outside of the scope of
practice of the licensed practical nurse, the client is in
potential physical and/or psychological jeopardy
because this delegated task, which is outside of the
scope of practice for this licensed practical nurse, is
something that this nurse was not prepared and
educated to perform.
Option C: Coaching the client to deep breathe during
painful procedures is a nursing responsibility. The nurse
who delegates aspects of care to other members of the
nursing team must balance the needs of the client with
the abilities of those to which the nurse is delegating
tasks and aspects of care, among other things such as
the scopes of practice and the policies and procedures
within the particular healthcare facility.
Option D: Evaluation of relief after applying a cold
application is a nursing responsibility. The staff
members’ levels of education, knowledge, past
experiences, skills, abilities, and competencies are also
evaluated and matched with the needs of all of the
patients in the group of patients that will be cared for.
66. The physician has ordered a placebo for a chronic
pain client. You are a newly hired nurse and you feel
very uncomfortable administering the medication. What
is the first action that you should take?
A. Prepare the medication and hand it to the physician.
B. Check the hospital policy regarding the use of the
placebo.
C. Follow a personal code of ethics and refuse to give
it.
D. Contact the charge nurse for advice.
A charge nurse is a resource person who can help
locate and review the policy. If the physician is insistent,
he or she could give the placebo personally, but
delaying the administration does not endanger the
health or safety of the client.
Option A: In a treatment setting it is unethical to
deliberately misinform the patient. However, placebo
effects can be an important factor in a biopsychosocial
context. Clinicians need to consider some ethical issues
relating to placebo effects. According to Pittrof and
Rubenstein, the ethical use of placebo effects should
always benefit the patient and involve disclosure.
Option B: Placebo effects may thus be defined as
psychological and/or physiological responses that follow
the administration of active and non-active substances
when coupled with an affirmation of the treatment
effects. The ethical use of placebo effects in a clinical
setting should rely on realistic expectations and be
based on best practice. The use of a placebo in clinical
settings might still be seen as controversial by some.
Option C: While following one’s own ethical code is
correct, you must ensure that the client is not
abandoned and that care continues. Placebo effects,
when considered as supplements to pharmacologically
active substances, should aim to increase patients’ well-
being. It is unethical to deliberately misinform patients.
67. For a cognitively impaired client who cannot
accurately report pain, what is the first action that you
should take?
A. Closely assess for nonverbal signs such as
grimacing or rocking.
B. Obtain baseline behavioral indicators from family
members.
C. Look at the MAR and chart, to note the time of the
last dose and response.
D. Give the maximum PRS dose within the minimum
time frame for relief.
Complete information from the family should be obtained
during the initial comprehensive history and
assessment. If this information is not obtained, the
nursing staff will have to rely on observation of
nonverbal behavior and careful documentation to
determine pain and relief patterns.
Option A: Pain can be difficult to assess in cognitively
impaired individuals because their self-reports of pain
can be inaccurate or difficult to obtain. Thus, behavioral
observation-based assessment is optimal in these
patients.
Option C: Assess potential causes of pain. The clinician
should consider pathological causes of pain and any
procedure known to cause pain. Address any pain
history from family, significant others, and caregivers.
Option D: Use scheduled dosing when pain is chronic
and/or when the patient is unable to ask for medication.
When administering the medication, it is best to start
with a lower dose and gradually increase the dose to
alleviate the pain.
68. Which route of administration is preferable for
administration of daily analgesics (if all body systems
are functional)?
A. IV
B. IM or subcutaneous
C. Oral
D. Transdermal
E. PCA
If the gastrointestinal system is functioning, the oral
route is preferred for routine analgesics because of
lower cost and ease of administration. Oral route is also
less painful and less invasive than the IV, IM,
subcutaneous, or PCA routes. Although a few drugs
taken orally are intended to be dissolved in the mouth,
nearly all drugs taken orally are swallowed. Of these,
most are taken for the systemic drug effects that result
after absorption from the various surfaces along the
gastrointestinal tract.
Option A: IV therapy allows a higher concentration of
nutrients or medication into the body — and that means
the body gets what it needs faster and more effectively
without further damage to the GI system.
Option B: Rapid and uniform absorption of the drug
especially those of the aqueous solutions. Rapid onset
of the action compared to that of the oral and the
subcutaneous routes. IM injection bypasses the first-
pass metabolism. It also avoids the gastric factors
governing drug absorption.
Option D: Transdermal route is slower and medication
availability is limited compared to oral forms.
Transdermal delivery systems provide continuous
administration of drugs through the skin, which
maintains constant plasma drug levels and avoids the
peaks and troughs that are seen with oral
administration.
Option E: Patient-controlled analgesia is used to treat
acute, chronic, postoperative, and labor pain. A variety
of medications can be used for patient-controlled
analgesia and are administered intravenously (IV),
through an epidural or peripheral nerve catheter, and
transdermally.
69. A first-day postoperative client on a PCA pump
reports that the pain control is inadequate. What is the
first action you should take?
A. Deliver the bolus dose per standing order.
B. Contact the physician to increase the dose.
C. Try non-pharmacological comfort measures.
D. Assess the pain for location, quality, and
intensity.
Assess the pain for changes in location, quality, and
intensity, as well as changes in response to medication.
This assessment will guide the next steps. Patient-
controlled analgesia is used to treat acute, chronic,
postoperative, and labor pain. A variety of medications
can be used for patient-controlled analgesia and are
administered intravenously (IV), through an epidural or
peripheral nerve catheter, and transdermally.
Option A: The goal of PCA is to efficiently deliver pain
relief at a patient’s preferred dose and schedule by
allowing them to administer a predetermined bolus dose
of medication on-demand at the press of a button. Each
bolus can be administered alone or coupled with a
background infusion of medication.
Option B: The initial loading dose can be titrated by a
nurse to reach the minimum effective concentration
(MEC) of the desired medication. The bolus or demand
dose is the dose of medication delivered each time the
patient presses the button. A lockout interval is the time
after a demand dose in which a dose of medication will
not get administered even if the patient presses the
button; this is done to prevent overdosing.
Option C: The use of PCA has been proven to be more
effective at pain control than non-patient-controlled
opioid injections and results in higher patient
satisfaction. PCA has also been found to be preferred by
nurses because it allows for a reduction in their
workload. PCA will enable patients to be in more control
over their pain and helps them shift toward a more
internal locus of control over their care.
70. Which non-pharmacological measure is particularly
useful for a client with acute pancreatitis?
A. Diversional therapy, such as playing cards or board
games.
B. Massage the back and neck with warmed lotion.
C. Side-lying position with knees to chest and
pillow against the abdomen.
D. Transcutaneous electrical nerve stimulation (TENS).
The side-lying, knee-chest position opens
retroperitoneal space and provides relief. The pillow
provides a splinting action. Reduces abdominal pressure
and tension, providing some measure of comfort and
pain relief. Note: Supine position often increases pain.
Option A: Diversional therapy is not the best choice for
acute pain, especially if the activity requires
concentration. Keep the environment free of food odors.
Sensory stimulation can activate pancreatic enzymes,
increasing pain.
Option B: The additional stimulation of massage may
be distressing to the client. Provide alternative comfort
measures (back rub), encourage relaxation techniques
(guided imagery, visualization), quiet diversional
activities (TV, radio).
Option D: TENS is more appropriate for chronic
muscular pain. Maintain bed rest during an acute attack.
Provide a quiet, restful environment. Decreases
metabolic rate and GI stimulation and secretions,
thereby reducing pancreatic activity.
71. What is the best way to schedule medication for a
client with constant pain?
A. PRN at the client’s request
B. Prior to painful procedures
C. IV bolus after pain assessment
D. Around-the-clock
If the pain is constant, the best schedule is around-the-
clock, to provide steady analgesia and pain control. The
other options may actually require higher doses to
achieve control. Pain medication prescribed around-the-
clock has the purpose of managing a patient’s baseline
pain, which is the average pain intensity the patient
experiences. This is generally pain that is continuously
experienced.
Option A: The use of “as needed” or “pro re nata”
(PRN) range opioid analgesic orders is a common
clinical practice in the management of acute pain,
designed to provide flexibility in dosing to meet an
individual’s unique needs. Range orders enable
necessary adjustments in doses based on individual
response to treatment.
Option B: Of particular importance to nursing care,
unrelieved pain reduces patient mobility, resulting in
complications such as deep vein thrombosis, pulmonary
embolism, and pneumonia. Postsurgical complications
related to inadequate pain management negatively
affect the patient’s welfare and the hospital performance
because of extended lengths of stay and readmissions,
both of which increase the cost of care.
Option C: Assessment of pain is a critical step to
providing good pain management. In a sample of
physicians and nurses, Anderson and colleagues found
lack of pain assessment was one of the most
problematic barriers to achieving good pain control. The
most critical aspect of pain assessment is that it is done
on a regular basis (e.g., once a shift, every 2 hours)
using a standard format. The assessment parameters
should be explicitly directed by hospital or unit policies
and procedures.
72. Which client(s) are appropriate to assign to the
LPN/LVN, who will function under the supervision of the
RN or team leader? Select all that apply.
A. A client who needs pre-op teaching for use of a PCA
pump.
B. A client with a leg cast who needs neurologic
checks and PRN hydrocodone.
C. A client post-op toe amputation with diabetic
neuropathic pain.
D. A client with terminal cancer and severe pain who is
refusing medication.
The clients with the cast and the toe amputation are
stable clients and need ongoing assessment and pain
management that are within the scope of practice for an
LPN/LVN under the supervision of an RN. The RN
should take responsibility for preoperative teaching, and
terminal cancer needs a comprehensive assessment to
determine the reason for refusal of medication.
Option A: Preoperative teaching is a nursing
responsibility. Proper and appropriate assignments
facilitate quality care. Improper and inappropriate
assignments can lead to poor quality of care,
disappointing outcomes of care, the jeopardization of
client safety, and even legal consequences.
Option B: The clients with the cast are within the scope
of practice for an LPN/LVN under the supervision of an
RN. Delegation, simply defined, is the transfer of the
nurse’s responsibility for the performance of a task to
another nursing staff member while retaining
accountability for the outcome. Responsibility can be
delegated. Accountability cannot be delegated. The
delegating registered nurse remains accountable for all
client care despite the fact that some of these aspects of
care can, and are, delegated to others.
Option C: The client with the toe amputation is a stable
client and needs ongoing assessment and pain
management that are within the scope of practice for an
LPN/LVN under the supervision of an RN. The staff
members’ levels of education, knowledge, past
experiences, skills, abilities, and competencies are also
evaluated and matched with the needs of all of the
patients in the group of patients that will be cared for.
Option D: A client with terminal cancer and severe pain
who is refusing medication is a nursing responsibility.
Based on these characteristics and the total client needs
for the group of clients that the registered nurse is
responsible and accountable for, the registered nurse
determines and analyzes all of the health care needs for
a group of clients; the registered nurse delegates care
that matches the skills of the person that the nurse is
delegating to.
73. For a client who is taking aspirin, which laboratory
value should be reported to the physician?
A. Potassium 3.6 mEq/L
B. Hematocrit 41%
C. PT 14 seconds
D. BUN 20 mg/dL
When a client takes aspirin, monitor for increases in PT
(normal range 11.0-12.5 seconds in 85%-100%). Also,
monitor for possible decreases in potassium (normal
range 3.5-5.0 mEq/L). If bleeding signs are noted,
hematocrit should be monitored (normal range male
42%-52%, female 37%-47%). An elevated BUN could
be seen if the client is having chronic gastrointestinal
bleeding (normal range 10-20 mg/dL).
Option A: Severity is categorized as mild when the
serum potassium level is 3 to 3.4 mmol/L, moderate
when the serum potassium level is 2.5 to 3 mmol/L, and
severe when the serum potassium level is less than 2.5
mmol/L. Values obtained from plasma and serum may
differ.
Option B: HCT calculation is by dividing the lengths of
the packed RBC layer by the length of total cells and
plasma. As it is a ratio, it doesn’t have any unit.
Multiplying the ratio by 100 gives the accurate value,
which is the accepted reporting style for HCT. A normal
adult male shows an HCT of 40% to 54% and female
shows 36% to 48%.
Option D: BUN and creatinine levels that are within the
ranges established by the laboratory performing the test
suggest that the kidneys are functioning as they should.
Increased BUN and creatinine levels may mean that the
kidneys are not working as they should. This healthcare
practitioner will consider other factors, such as the
medical history and physical exam, to determine what
condition, if any, may be affecting the kidneys.
74. Which client would be appropriate to assign to a
newly graduated RN, who has recently completed
orientation?.
A. An anxious, chronic pain client who frequently uses
the call button.
B. A client second-day post-op who needs pain
medication prior to dressing changes.
C. A client with HIV who reports headache and
abdominal and pleuritic chest pain.
D. A client who is being discharged with a surgically
implanted catheter.
A second-day postoperative client who needs
medication prior to dressing changes has predictable
and routine care that a new nurse can manage. Some
staff members may possess greater expertise than
others. Some, such as new graduates, may not possess
the same levels of knowledge, past experiences, skills,
abilities, and competencies that more experienced staff
members possess.
Option A: Although clients with chronic pain can be
relatively stable, the interaction with this client will be
time-consuming and may cause the new nurse to fall
behind. Time is finite and often the needs of the client
are virtually infinite. Time management, organization,
and priority setting skills, therefore, are essential to the
complete and effective provision of care to an individual
client and to a group of clients.
Option C: The client with HIV has complex complaints
that require expert assessment skills. Staff members
differ in terms of their knowledge, skills, abilities, and
competencies. A staff member who has just graduated
as a certified nursing assistant and a newly graduated
registered nurse cannot be expected to perform patient
care tasks at the same level of proficiency, skill, and
competency as an experienced nursing assistant or
registered nurse. It takes time for new graduates to
refine the skills that they learned in school.
Option D: The client pending discharge will need
special and detailed instructions. Validated and
documented competencies must also be considered
prior to assignment of patient care. No aspect of care
can be assigned or delegated to another nursing staff
member unless this staff member has documented
evidence that they are deemed competent by a
registered nurse to do so.

75. A family member asks you, “Why can’t you give

more medicine? He is still having a lot of pain.” What is
your best response?

A. “The doctor ordered the medicine to be given every 4

hours.”
B. “If the medication is given too frequently he could
suffer ill effects.”
C. “Please tell him that I will be right there to check
on him.”
D. “Let’s wait about 30-40 minutes. If there is no relief
I’ll call the doctor.”

Directly ask the client about the pain and do a complete

pain assessment. This information will determine which
action to take next. Pain assessment is critical to optimal
pain management interventions. While pain is a highly
subjective experience, its management necessitates
objective standards of care.

Option A: Poorly managing pain may put clinicians at

risk for legal action. Current standards for pain
management, such as the national standards outlined by
the Joint Commission (formerly known as the Joint
Commission on Accreditation of Healthcare
Organizations, JCAHO), require that pain is promptly
addressed and managed.
Option B: Continuous, unrelieved pain also affects the
psychological state of the patient and family members.
Common psychological responses to pain include
anxiety and depression. The inability to escape from
pain may create a sense of helplessness and even
hopelessness, which may predispose the patient to
more chronic depression.
Option D: Inadequately managed pain can lead to
adverse physical and psychological patient outcomes for
individual patients and their families. Continuous,
unrelieved pain activates the pituitary-adrenal axis,
which can suppress the immune system and result in
postsurgical infection and poor wound healing.