1.

Question
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.
Incorrect
Correct Answer: A. Plan is developed for nursing care.

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. Question
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.
Incorrect
Correct Answer: C. Client-centered goals and expected outcomes are established.

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. Question
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
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: B. Highest possible level of wellness and independence in function.

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. Question
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.
Incorrect
Correct Answer: A. Alert and have some degree of independence.

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. Question
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.
Incorrect
Correct Answer: C. Client will report pain acuity less than 4 on a scale of 0-10.

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. Question
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.
Incorrect
Correct Answer: B. Be aware of and committed to accepted standards of practice from
nursing and other disciples.

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. Question
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.
Incorrect
Correct Answer: B. Knows the resources of the health care facility, family, and the
client.

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. Question
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.
Incorrect
Correct Answer: A. Knowledge, function, and specific 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. Question
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.
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: 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. Question
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
Incorrect
Correct Answer: B. Short-term goal

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. Question
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
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: A. A written guideline for implementation and evaluation.

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. Question
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.
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: B. Elevate the leg 5 inches above the heart.

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. Question
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.
Incorrect
Correct Answer: C. Elevate head of bed 30 degrees before meals.

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. Question
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.
Incorrect
Correct Answer: B. Calling the wound care 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. Question
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.
Incorrect
Correct Answer: A. Length of time the current treatment has been in place.

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. Question
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.
Incorrect
Correct Answer: 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. Question
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
Incorrect
The correct order is shown above.

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. Question
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.
Incorrect
Correct Answer: B. Canceling physical therapy sessions on the weekend.

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. Question
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.
Incorrect
Correct Answer: B. A client, who has a fever, is diaphoretic and restless.
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. Question
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.
Incorrect
Correct Answer: 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. Question
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
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: C. Feed the infant glucose water (10%)

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. Question
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?”
Incorrect
Correct Answer: A. “Have you noticed a change in the force of the urinary system?”
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. Question
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.
Incorrect
Correct Answer: A. Turn off the infusion

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. Question
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.
Incorrect
Correct Answer: B. Place medication in an empty nipple.

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. Question
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.
Incorrect
Correct Answer: C. Encourage stroking of the infant.

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. Question
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.
Incorrect
Correct Answer: A. Head circumference of 40 cm

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. Question
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.
Incorrect
Correct Answer: A. Tells her child that if he does not sit down and shut up she
will leave him there.

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. Question
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
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: B. Auscultate 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. Question
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.
Incorrect
Correct Answer: 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. Question
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
Incorrect
Correct Answer: A. Formula or breastmilk

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. Question
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?”
Incorrect
Correct Answer: C. “Is there a reason why you don’t want to take your medicine?”

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. Question
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”
Incorrect
Correct Answer: A. Hold a rattle

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. Question
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.
Incorrect
Correct Answer: B. Decreased size of the nose and ears.

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. Question
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.
Incorrect
Correct Answer: A. Increased oxidative enzyme levels.

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. Question
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
Incorrect
Correct Answer: A. Wide-spaced eyes, smooth philtrum, flattened nose

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. Question
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.”
Incorrect
Correct Answer: A. “Tell me where you hurt.”

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. Question
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.
Incorrect
Correct Answer: 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. Question
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
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: B. Epiphyseal fractures often interrupt a child’s normal growth
pattern.

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. Question
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.”
Incorrect
Correct Answer: 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. Question
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
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: A. increase her fluid intake to three liters/day.

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. Question
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.
Incorrect
Correct Answer: 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. Question
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
Incorrect
Correct Answer: B. Sociocultural

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. Question
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)
Incorrect
Correct Answer: A. Amitriptyline (Elavil)

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. Question
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
Incorrect
Correct Answer: C. A client with progressive pancreatic cancer

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. Question
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.
Incorrect
Correct Answer: 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. Question
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
Incorrect
Correct Answer: C. Faces pain-rating scale

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. Question
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.
Incorrect
Correct Answer: C. The client must be believed about perceptions of own pain.

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. Question
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
Incorrect
Correct Answer: C. Intravenous (IV)

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. Question
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.
Incorrect
Correct Answer: A. Administer smallest dose that provides relief with the fewest
side effects.

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. Question
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)
Incorrect
Correct Answer: B. Use of heat and cold applications

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. Question
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
Incorrect
The correct order is shown above.

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. Question
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.
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: A. Encourage expression of fears on past experiences.

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. Question
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
Incorrect
Correct Answer: C. Diaphoresis

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. Question
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.
Incorrect
Correct Answer: A. Assist the client with preparation of a sitz bath.

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. Question
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.
Incorrect
Correct Answer: 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. Question
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.
Incorrect
Correct Answer: B. Obtain baseline behavioral indicators from family members.

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. Question
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
Incorrect
Correct Answer: C. Oral

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. Question
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.
Incorrect
Correct Answer: 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. Question
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).
Incorrect
Correct Answer: C. Side-lying position with knees to chest and pillow against the
abdomen.

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. Question
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
Incorrect
Correct Answer: 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. Question
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
C. A client post-op toe amputation with diabetic
D. A client with terminal cancer and severe pain
Incorrect
Correct Answer: B & C.
checks and PRN hydrocodone.
neuropathic 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. Question
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
Incorrect
Correct Answer: C. PT 14 seconds

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. Question
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.
Incorrect
Correct Answer: B. A client second-day post-op who needs pain medication prior to
dressing changes

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. Question
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.”
Incorrect
Correct Answer: C. “Please tell him that I will be right there to check on him.”

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.