Fundamentals of Nursing NCLEX Practice will play a vital role as nurses develop plans of care for

Exam: Part 5 these patient populations with multiple comorbidities and

embrace this challenging healthcare arena.
1. Once a nurse assesses a client’s condition and
identifies appropriate nursing diagnoses, a:
3. Priorities are established to help the nurse anticipate
A. Plan is developed for nursing care. and sequence nursing interventions when a client has
B. Physical assessment begins. multiple problems or alterations. Priorities are
C. List of priorities is determined. determined by the client’s:
D. Review of the assessment is conducted with other
team members. A. Physician
B. Non-Emergent, non-life-threatening needs
The planning stage is where goals and outcomes are C. Future well-being.
formulated that directly impact patient care based on D. Urgency of problems
EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome. Triage of patients involves looking for signs of serious
Nursing care plans are essential in this phase of goal illness or injury. These emergency signs are connected
setting. to the Airway – Breathing – Circulation/Consciousness –
Dehydration and are easily remembered as ABCD. If the
Option B: Assessment is the first step and involves client does not have any emergency signs, the health
critical thinking skills and data collection; subjective and worker proceeds to assess the client for priority
objective. Subjective data involves verbal statements conditions. This should not take more than a few
from the patient or caregiver. Objective data is seconds. Some of these signs will have been noticed
measurable, tangible data such as vital signs, intake and during the ABCD triage and others need to be
output, and height and weight. rechecked.
Option C: A nursing diagnosis encompasses Maslow’s
Hierarchy of Needs and helps to prioritize and plan care Option A: All clinical staff involved in the care of the sick
based on patient-centered outcomes. In 1943, Abraham should be prepared to carry out a rapid assessment to
Maslow developed a hierarchy based on basic identify the few clients who are severely ill and require
fundamental needs innate for all individuals. emergency treatment.
Option D: Data may come from the patient directly or Option B: Triage is the process of rapidly examining
from primary caregivers who may or may not be direct sick children when they first arrive in order to place them
relation family members. Friends can play a role in data in one of the following categories: those with
collection. Electronic health records may populate data EMERGENCY SIGNS who require immediate
and assist in assessment. 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-
2. Planning is a category of nursing behaviors in which:
URGENT cases. These clients can wait their turn in the
queue for assessment and treatment. The majority of
A. The nurse determines the health care needed for the
sick clients will be non-urgent and will not require
client.
emergency treatment.
B. The physician determines the plan of care for the
Option C: Ideally, all clients should be checked on their
client.
C. Client-centered goals and expected outcomes arrival by a person who is trained to assess how ill they
are established. are. This person decides whether the client will be seen
immediately and receive life-saving treatment, or will be
D. The client determines the care needed.
seen soon, or can safely wait for his or her turn to be
examined.
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. 4. A client-centered goal is a specific and measurable
behavior or response that reflects a client’s:
Option A: Nursing care plans are essential in this phase
of goal setting. Care plans provide a course of direction A. Desire for specific health care interventions.
for personalized care tailored to an individual’s unique B. Highest possible level of wellness and
needs. Overall condition and comorbid conditions play a independence in function.
role in the construction of a care plan. C. Physician’s goal for the specific client.
Option B: As explored by Salmond and Echevarria, D. Response when compared to another client with a
healthcare is changing, and the traditional roles of similar problem.
nurses are transforming to meet the demands of this
new healthcare environment. Nurses are in a position to Client-centered practices facilitate the development of
promote change and impact patient delivery care strong therapeutic relationships and enable care
models in the future. providers to understand how to maximize clients’
Option D: Care plans enhance communication, strengths and minimize challenges in achieving
documentation, reimbursement, and continuity of care treatment and recovery goals.
across the healthcare continuum. Critical thinking skills
Option A: Care providers negotiate between clients’ D. Client will take pain medication every 4 hours around
decisions and ongoing risk assessments. The care plan the clock.
reflects safe practices and promotes interventions that
minimize or reduce potential harms to the client. When developing goals for patients, the nurse needs to
Option C: Client-centred care empowers clients, look at several factors. Think back to the SMART goal
promoting autonomy, rights, voice, and self- criteria. In order to be specific, nurses focus on
determination in the treatment planning and recovery questions like ‘What is the problem? What is the
process and supports care plans that are developed in response desired?’ To make it measurable, ‘How will the
collaboration with clients, and allows clients to express client look or behave if the healthy response is
their self-identified needs and choices. achieved? What can I see, hear, measure, observe?’
Option D: Client-centred care is about treating clients
as they want to be treated, with knowledge about and Option A: One way to help nurses remember how to
respect for their values and personal priorities. Health write goals is to make sure they are SMART. SMART
care providers who take the time to get to know their goals are Specific, Measurable, Action-Oriented,
clients can provide care that better addresses the needs Realistic, and Timely. ‘Specific’ refers to who, what,
of clients and improves their quality of care. 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
5. For clients to participate in goal setting, they should are actions that can be taken to reach the goal.
be: ‘Realistic’ includes the ability to work on the goal, having
the resources, attitudes, abilities, and skills to reach this
A. Alert and have some degree of independence. goal, and how realistic it is to come to fruition. Finally,
B. Ambulatory and mobile. ‘Timely’ means that there is an end time frame or date at
C. Able to speak and write. which the goal is going to be evaluated.
D. Able to read and write. Option B: Goal setting occurs in the third phase of the
process, planning. Is the goal for nursing care to heal
Goal setting in nursing provides direction for planning patients? To help them get better? To help them get
nursing interventions and evaluating patient progress. well? While these are certainly at the forefront of nurses’
The purpose of goal setting in nursing is to enable the minds, how do you evaluate these statements? What if
patient and nurse to determine when the problem has the definition of wellness is different from one person to
been resolved and help motivate the patient and the another? This is why nursing goal statements that are
nurse by providing a sense of achievement. patient-centered and measurable are so important.
Option D: Considering action-oriented, ‘Are there steps
Option B: In light of the potential benefits of patient and nursing interventions needed to reach that goal? Is
participation in goal setting, a study by Baker, Rice, this a realistic outcome for the patient? Have we
Zimmerman, Marshak, et. al. believes the following are considered all of the factors involved, including the
needed: (1) patient and therapist education regarding client’s capabilities and limitations? Does the patient
the potential advantages of participation, (2) the have what he or she needs to reach that goal?’ And
enhancement of patient readiness to assume greater finally, ‘Is it timely? When do we expect the goal to be
responsibility in their care, and (3) the development of reached?’
models for use in achieving patient participation.
Option C: Patient and therapist education is needed
regarding methods for patient participation during initial 7. As goals, outcomes, and interventions are developed,
goal-setting activities. In a study by Baker, Rice, the nurse must:
Zimmerman, Marshak, et. al., the therapists stated that
they believed that it is important to include patients in A. Be in charge of all care and planning for the client.
goal-setting activities and that outcomes will be B. Be aware of and committed to accepted
improved if patients participate. Patients also indicated standards of practice from nursing and other
that participation is important to them. disciples.
Option D: Patient participation in goal setting is C. Not change the plan of care for the client.
emphasized in order to enhance patient management D. Be in control of all interventions for the client.
and the effectiveness of treatment. Participation should
improve outcomes and could be used to identify benefits Whenever a healthcare provider intervenes or
that may result from the treatment. These benefits implements care, they must reassess or evaluate to
include greater goal attainment, increased patient ensure the desired outcome has been met.
satisfaction, gains in function, better adherence to Reassessment may frequently be needed depending
treatment regimens, decreased depression in patients, upon overall patient condition. The plan of care may be
and reduced burnout rates among physical therapists. adapted based on new assessment data.

Option A: Patients’ participation in decision-making in

6. The nurse writes an expected outcome statement in health care and treatment is not a new area, but
measurable terms. An example is: currently it has become a political necessity in many
countries and health care systems around the world.
A. Client will have less pain. Emphasizing the importance of participation in the
B. Client will be pain-free. decision-making process motivates the service provider
C. Client will report pain acuity less than 4 on a and the health care team to promote participation of
scale of 0-10. patients in treatment decision-making.
Option C: A review of some literature reveals that the consequences of alternate actions; and determine
participation of patients in health care has been the right judgment and decisions. To provide safe and
associated with improved treatment outcomes. effective care to the clients, nurses must integrate
Moreover, this participation causes improved control of knowledge, skills, and attitudes to make sound judgment
diabetes, better physical functioning in rheumatic and decisions.
diseases, enhanced patients’ compliance with
secondary preventive actions, and improvement in Option B: Due to the increasing internal and external
health of patients with myocardial infarction. expectations of higher quality nursing, it is no longer
Option D: With enhanced patient participation, and acceptable for nurses to deliver nursing care only on
considering patients as equal partners in healthcare experience and textbook knowledge. Clinical nurses are
decision making patients are encouraged to actively expected to systematically gather the best research
participate in their own treatment process and follow evidence, draw from nursing experience, and consider
their treatment plan and thus a better health patient’s preferences when they are making professional
maintenance service would be provided. decisions
Option C: Some research findings showed that
changing the attitude and enhancing the knowledge of
8. When establishing realistic goals, the nurse: nurses are the first step in EBP. McCleary and Brown
conducted a study on 528 graduate nurses working in
A. Bases the goals on the nurse’s personal knowledge. educational pediatric hospitals of Canada and reported
B. Knows the resources of the health care facility, that the nurses’ knowledge of EBP and their positive
family, and the client. attitude towards it will contribute to its implementation in
C. Must have a client who is physically and emotionally the healthcare system.
stable. Option D: Melnyk et al. stated that acquiring knowledge
D. Must have the client’s cooperation. about research methods and having the skill to evaluate
research reports critically may enable overcoming the
The planning stage is where goals and outcomes are obstacles hindering the application of research findings
formulated that directly impact patient care based on and thus will lead to improvement of healthcare quality.
EDP guidelines. These patient-specific goals and the Hence, the EBP attitude, knowledge, and skills of nurses
attainment of such assist in ensuring a positive outcome. are so important.
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. 10. Collaborative interventions are therapies that
Electronic health records may populate data and assist require:
in assessment.
A. Physician and nurse interventions.
Option A: Nursing care plans are essential in this phase B. Nurse and client interventions.
of goal setting. Care plans provide a course of direction C. Client and Physician intervention.
for personalized care tailored to an individual’s unique D. Multiple health care professionals.
needs. Overall condition and comorbid conditions play a
role in the construction of a care plan. Collaborative interventions are actions that the nurse
Option C: The utilization of the nursing process to guide carries out in collaboration with other health team
care is clinically significant going forward in this members, such as physicians, social workers, dietitians,
dynamic, complex world of patient care. Aging and therapists. These actions are developed in
populations carry with them a multitude of health consultation with other health care professionals to gain
problems and inherent risks of missed opportunities to their professional viewpoint.
spot a life-altering condition.
Option D: As explored by Salmond and Echevarria, Option A: Dependent nursing interventions are activities
healthcare is changing, and the traditional roles of carried out under the physician’s orders or supervision.
nurses are transforming to meet the demands of this Includes orders to direct the nurse to provide
new healthcare environment. Nurses are in a position to medications, intravenous therapy, diagnostic tests,
promote change and impact patient delivery care treatments, diet, and activity or rest.
models in the future. Option B: Independent nursing interventions are
activities that nurses are licensed to initiate based on
their sound judgment and skills. Includes ongoing
9. To initiate an intervention the nurse must be assessment, emotional support, providing comfort,
competent in three areas, which include: teaching, physical care, and making referrals to other
health care professionals.
A. Knowledge, function, and specific skills. Option C: Nursing interventions are activities or actions
B. Experience, advanced education, and skills. that a nurse performs to achieve client goals.
C. Skills, finances, and leadership. Interventions chosen should focus on eliminating or
D. Leadership, autonomy, and skills. reducing the etiology of the nursing diagnosis. In this
step, nursing interventions are identified and written
Critical thinking and reflection are essential skills during the planning step of the nursing process;
because they can enhance nurses’ ability to solve however, they are actually performed during the
problems and make sound decisions. Critical thinking implementation step.
skills enable nurses to identify multiple possibilities in
clinical situations and alternatives to interventions; weigh
11. Well formulated, client-centered goals should:

A. Meet immediate client needs. 13. The following statements appear on a nursing care
B. Include preventative health care. plan for a client after a mastectomy: Incision site
C. Include rehabilitation needs. approximated; absence of drainage or prolonged
D. All of the above. erythema at the incision site; and the client remains
afebrile. These statements are examples of:
The process of client-centered goal planning
encourages members of the multi-professional team to A. Nursing interventions
work in partnership with the client, his or her family, and B. Short-term goals
each other, united by the aim of helping the client to C. Long-term goals
achieve his or her desired outcome. Goals enable D. Expected outcomes
clients, their carers or partners, and the multidisciplinary
team to focus on strengths rather than problems. They Goals or desired outcomes describe what the nurse
also enable the team to gauge where the client and hopes to achieve by implementing the nursing
family are in their ‘thinking’ (Davis and O’Connor, 1999). interventions and are derived from the client’s nursing
diagnoses. One overall goal is determined for each
Option A: Once set, goals provide a central focus for all nursing diagnosis. The terms goal, outcome, and
therapeutic activity, enabling clients to move away from expected outcome are oftentimes used interchangeably.
a period of dependency to a level of achievement and/or
adjustment to their situation. Option A: Nursing interventions are activities or actions
Option B: Goal planning is part of the overall care plan that a nurse performs to achieve client goals.
in which the client’s own values, beliefs, and aspirations Interventions chosen should focus on eliminating or
are recognized and valued, and form the central focus of reducing the etiology of the nursing diagnosis.
the rehabilitation process. Option B: Short-term goals can act as stepping stones
Option C: Goals for rehabilitation can be divided into to achieving longer-term targets. For example, a client
two groups: short-term and long-term. Short-term goals may have the long-term goal of being able to groom
can act as stepping stones to achieving longer-term herself, including cleaning her teeth, washing her face,
targets. A short-term goal for this client might be to be combing her hair, and applying her make-up on her own.
able to clean her teeth. 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
12. The following statement appears on the nursing care who have chronic health problems or who live at home,
plan for an immunosuppressed client: The client will in nursing homes, or extended-care facilities. Long-term
remain free from infection throughout hospitalization. goal indicates an objective to be completed over a
This statement is an example of a (an): longer period, usually over weeks or months.

A. Nursing diagnosis
B. Short-term goal 14. The planning step of the nursing process includes
C. Long-term goal which of the following activities?
D. Expected outcome
A. Assessing and diagnosing.
Short-term goals can act as stepping stones to B. Evaluating goal achievement.
achieving longer-term targets. For example, a client may C. Performing nursing actions and documenting them.
have the long-term goal of being able to groom herself, D. Setting goals and selecting interventions.
including cleaning her teeth, washing her face, combing
her hair, and applying her make-up on her own. A short- The planning stage is where goals and outcomes are
term goal for this client might be to be able to clean her formulated that directly impact patient care based on
teeth. EDP guidelines. These patient-specific goals and the
attainment of such assist in ensuring a positive outcome.
Option A: Actual or potential health problems that can Nursing care plans are essential in this phase of goal
be prevented or resolved by independent nursing setting. Care plans provide a course of direction for
intervention are termed nursing diagnoses. NANDA personalized care tailored to an individual’s unique
nursing diagnoses are a uniform way of identifying, needs.
focusing on, and dealing with specific client needs and
responses to actual and high-risk problems. Option A: Assessment is the first step and involves
Option C: Long-term goals are often used for clients critical thinking skills and data collection; subjective and
who have chronic health problems or who live at home, objective. Data may come from the patient directly or
in nursing homes, or extended-care facilities. Long-term from primary caregivers who may or may not be direct
goal indicates an objective to be completed over a relation family members. Friends can play a role in data
longer period, usually over weeks or months. collection. Electronic health records may populate data
Option D: Goals or desired outcomes describe what the in and assist in assessment. The formulation of a
nurse hopes to achieve by implementing the nursing nursing diagnosis by employing clinical judgment assists
interventions and are derived from the client’s nursing in the planning and implementation of patient care.
diagnoses. One overall goal is determined for each Option B: This final step of the nursing process is vital
nursing diagnosis. The terms goal, outcome, and to a positive patient outcome. Whenever a healthcare
expected outcome are oftentimes used interchangeably. provider intervenes or implements care, they must
reassess or evaluate to ensure the desired outcome has direction for planning interventions, serve as criteria for
been met. Reassessment may frequently be needed evaluating client progress, enable the client and nurse to
depending upon overall patient condition. The plan of determine which problems have been resolved, and help
care may be adapted based on new assessment data. motivate the client and nurse by providing a sense of
Option C: Implementation is the step that involves achievement.
action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase Option A: This is an example of nursing intervention.
requires nursing interventions such as applying a Nursing interventions are activities or actions that a
cardiac monitor or oxygen, direct or indirect care, nurse performs to achieve client goals. Interventions
medication administration, standard treatment protocols, chosen should focus on eliminating or reducing the
and EDP standards. etiology of the nursing diagnosis.
Option B: Evaluating is a planned, ongoing, purposeful
activity in which the client’s progress towards the
15. The nursing care plan is: achievement of goals or desired outcomes, and the
effectiveness of the nursing care plan (NCP).
A. A written guideline for implementation and Option C: This is an example of nursing intervention.
evaluation. Dependent nursing interventions are activities carried
B. A documentation of client care. out under the physician’s orders or supervision. Includes
C. A projection of potential alterations in client orders to direct the nurse to provide medications,
behaviors. intravenous therapy, diagnostic tests, treatments, diet,
D. A tool to set goals and project outcomes. and activity or rest.

Nursing care plans are essential in this phase of goal

setting. Care plans provide a course of direction for 17. When developing a nursing care plan for a client
personalized care tailored to an individual’s unique with a fractured right tibia, the nurse includes in the plan
needs. Overall condition and comorbid conditions play a of care independent nursing interventions, including:
role in the construction of a care plan. Care plans
enhance communication, documentation, A. Apply a cold pack to the tibia.
reimbursement, and continuity of care across the B. Elevate the leg 5 inches above the heart.
healthcare continuum. C. Perform a range of motion to right leg every 4 hours.
D. Administer aspirin 325 mg every 4 hours as needed.
Option B: Documentation is any written or electronically
generated information about a client that describes the This does not require a physician’s order. Independent
status, care or services provided to that client. Through nursing interventions are activities that nurses are
documentation, you communicate observations, licensed to initiate based on their sound judgment and
decisions, actions, and outcomes of these actions for skills. Includes ongoing assessment, emotional support,
clients, demonstrating the nursing process. providing comfort, teaching, physical care, and making
Option C: Behavioral tools are psychological referrals to other health care professionals.
instruments that are used for understanding and
interpreting human behavior. Such tools have found Option A: This intervention requires a doctor’s order.
many applications in corporate and educational sectors, Assessment and providing explanation while
considering their exploratory and insightful nature. administering medical orders are also part of the
Option D: A SMART goal is one that is specific, dependent nursing interventions.
measurable, attainable, relevant and time-bound. The Option C: C is not appropriate for a fractured tibia.
SMART criteria help to incorporate guidance and Isometrics contract muscles without bending joints or
realistic direction in goal setting, which increases moving limbs and help maintain muscle strength and
motivation and leads to better results in achieving lasting mass. Note: These exercises are contraindicated while
change. acute bleeding and edema are present.
Option D: Dependent nursing interventions are activities
carried out under the physician’s orders or supervision.
16. After determining a nursing diagnosis of acute pain, Includes orders to direct the nurse to provide
the nurse develops the following appropriate client- medications, intravenous therapy, diagnostic tests,
centered goal: treatments, diet, and activity or rest.

A. Encourage the client to implement guided imagery

when pain begins. 18. Which of the following nursing interventions are
B. Determine the effect of pain intensity on client written correctly?
function.
C. Administer analgesic 30 minutes before physical A. Apply continuous passive motion machines during
therapy treatment. the day.
D. Pain intensity reported as a 3 or less during B. Perform neurovascular checks.
hospital stay. C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
This is measurable and objective. Goals or desired
outcomes describe what the nurse hopes to achieve by It is specific in what to do and when. Nursing
implementing the nursing interventions and are derived interventions should be specific and clearly stated,
from the client’s nursing diagnoses. Goals provide beginning with an action verb indicating what the nurse
is expected to do. Action verb starts the intervention and
must be precise.
20. When calling the nurse consultant about a difficult
Option A: This intervention does not specify the location client-centered problem, the primary nurse is sure to
of the application. Nursing interventions are the actual report the following:
treatments and actions that are performed to help the
patient to reach the goals that are set for them. The A. Length of time the current treatment has been in
nurse uses his or her knowledge, experience, and place.
critical-thinking skills to decide which interventions will B. The spouse’s reaction to the client’s dressing
help the patient the most. change.
Option B: It was not stated in this intervention when the C. Client’s concern about the current treatment.
neurovascular check should be performed. Nurses must D. Physician’s reluctance to change the current
use their knowledge, experience, resources, research of treatment plan.
evidence-based practice, the counsel of others, and
critical-thinking skills to decide which nursing This gives the consulting nurse facts that will influence a
interventions would best benefit a specific patient. new plan. Other choices are subjective and emotional
Option D: Qualifiers of how, when, where, time, issues and conclusions about the current treatment plan
frequency, and amount provide the content of the may cause bias in the decision of a new treatment plan
planned activity. For example: “Educate parents on how by the nurse consultant. In general, it is important to
to take temperature and notify of any changes,” or create a supportive environment with open and honest
“Assess urine for color, amount, odor, and turbidity.” communication, focusing on the achievements and not
on negative aspects.

19. A client’s wound is not healing and appears to be Option B: Navigating the new system is very
worsening with the current treatment. The nurse first challenging and it is important for the clients to have a
considers: person to whom they could always turn with questions
and concerns. It could not necessarily be a formal
A. Notifying the physician. caseworker, but rather any clinician who had a trusting
B. Calling the wound care nurse. relationship and was helpful and willing to guide the
C. Changing the wound care treatment. client.
D. Consulting with another nurse. Option C: Education and information for both the patient
and the family were mentioned by all the participants in
Calling the wound care nurse as a consultant is a study as the main strategies to help them develop a
appropriate because he or she is a specialist in the area clear understanding of their condition and prognosis.
of wound management. Professional and competent Option D: Several successful strategies to improve
nurses recognize limitations and seek appropriate client-centered care have been introduced in different
consultation. As the largest health care workforce, hospitals: writing a family note (a summary that is given
nurses apply their knowledge, skills, and experience to to the family) at the family meeting, appointing a contact
care for the various and changing needs of patients. A person/therapy leader for each client, improving
large part of the demands of patient care is centered on continuity and coordination of care through
the work of nurses. interdisciplinary collaborations, having the same staff
working with the client, and providing written materials.
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 21. The primary nurse asked a clinical nurse specialist
care products. Interprofessional and interprofessional (CNS) to consult on a difficult nursing problem. The
collaboration, through multidisciplinary teams, is primary nurse is obligated to:
important in the right work environments. Skills for
teamwork are considered nontechnical and include A. Implement the specialist’s recommendations.
leadership, mutual performance monitoring, adaptability, B. Report the recommendations to the primary
and flexibility. physician.
Option C: Option C is possible unless the nurse is C. Clarify the suggestions with the client and family
knowledgeable in wound management, this could delay members.
wound healing. Also, the current wound management D. Discuss and review advised strategies with CNS.
plan could have been ordered by the physician.
Clinicians working in teams will make fewer errors when The primary nurse requested the consultation, it is
they work well together, use well-planned and important that they communicate and discuss
standardized processes, know team members and their recommendations. The primary nurse can then accept
own responsibilities, and constantly monitor team or reject the CNS recommendations. Effective clinical
members’ performance to prevent errors before they practice thus involves many instances where critical
could cause harm. information must be accurately communicated. Team
Option D: Another nurse most likely will not be collaboration is essential.
knowledgeable about wounds, and the primary nurse
would know the history of the wound management plan. Option A: Some of the recommendations may not be
Understanding the complexity of the work environment appropriate for this client. The primary nurse would
and engaging in strategies to improve its effects is know this information. A consultation requires review of
paramount to higher-quality, safer care. the recommendations, but not immediate
implementation. Collaboration in health care is defined 23. The nurse is reviewing the critical paths of the clients
as health care professionals assuming complementary on the nursing unit. In performing a variance analysis,
roles and cooperatively working together, sharing which of the following would indicate the need for further
responsibility for problem-solving, and making decisions action and analysis?
to formulate and carry out plans for patient care
Option B: This would be appropriate after first talking A. A client’s family attending a diabetic teaching
with the CNS about recommended changes in the plan session.
of care and the rationale. Then the primary nurse should B. Canceling physical therapy sessions on the
call the physician. Collaboration between physicians, weekend.
nurses, and other health care professionals increases C. Normal VS and absence of wound infection in a
team members’ awareness of each others’ type of post-op client.
knowledge and skills, leading to continued improvement D. A client demonstrating accurate medication
in decision making. administration following teaching.
Option C: The client and family do not have the
knowledge to determine whether new strategies are Variance analysis is the identification of patient or family
appropriate or not. Better to wait until the new plan of needs that are not anticipated and the actions related to
care is agreed upon by the primary nurse and physician these needs in a system of managed care. There are
before talking with the client and/or family. A study four kinds of origin for the variance: patient-family origin,
determined that improved teamwork and communication system-institutional origin; community origin, and
are described by health care workers as among the clinician origin.
most important factors in improving clinical effectiveness
and job satisfaction. 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
22. After assessing the client, the nurse formulates the also have a positive impact on outcomes, such as
following diagnoses. Place them in order of priority, with increased quality of care and patient satisfaction,
the most important (classified as high) listed first. improved continuity of information, and patient
education.
Ineffective airway clearance Option C: Clinical pathways are being increasingly used
Ineffective tissue perfusion for daily patient care. The pathways consist of a
Constipation sequence of critical treatment events matched to the
Anticipated grieving patient’s recovery. Variance analysis identifies
deviations from the pathway and can be used for quality
Nurses should apply the concept of ABCs to each improvement and clinical audit.
patient situation. Prioritization begins with determining Option D: Clinical pathways can be used as a means of
immediate threats to life as part of the initial assessment incorporating evidence-based medicine into clinical
and is based on the ABC pneumonic focusing on the practice. Variance analysis of the pathways can be
airway as priority, moving to breathing, and circulation utilized as a process of quality control and to improve
(Ignatavicius et al., 2018). patient outcomes.

Ineffective airway clearance can be an acute (e.g.,

postoperative recovery) or chronic (e.g., CVA or spinal 24. The RN has received her client assignment for the
cord injury) problem. High-risk for ineffective airway day shift. After making the initial rounds and assessing
clearance are the aged individuals who have an the clients, which client would the RN need to develop a
increased incidence of emphysema and a higher care plan first?
prevalence of chronic cough or sputum production.
Decreased tissue perfusion can be temporary, with few A. A client who is ambulatory.
or minimal consequences to the health of the patient, or B. A client, who has a fever, is diaphoretic and
it can be more acute or protracted, with potentially restless.
destructive effects on the patient. When diminished C. A client scheduled for OT at 1300.
tissue perfusion becomes chronic, it can result in tissue D. A client who just had an appendectomy and has just
or organ damage or death. received pain medication.
Constipation occurs when bowel movements become
less frequent than normal. It is accompanied by a This client’s needs are a priority. Clinical judgment and
difficult or incomplete passage of stool. Though prioritization of patient care is built on the nursing
common, constipation may also be a complex problem. process. Nurses learn the steps of the nursing process
Chronic constipation can result in the development of in their foundational nursing course and utilize it
hemorrhoids; diverticulosis; straining at stool, and throughout their academic and clinical careers to direct
perforation of the colon. patient care and determine priorities.
Grieving is an individual’s normal response to a loss that
may be perceived or actual. Assessment is necessary in Option A: An ambulatory client would not be a priority.
order to identify potential problems that may have led to However, a thorough assessment should still be done to
grief and also name any event that may happen during make sure that the client does not have any underlying
nursing care. 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, A. A cotton ball
2019). B. A penlight
Option C: The client does not have any emergent C. An ophthalmoscope
concerns based on the stem. Seasoned nurses are able D. A tongue depressor and flashlight
to pull from their depth of knowledge and experience
that allows them to act deductively and intuitively when Cranial nerves 9 and 10 are the glossopharyngeal and
prioritizing patient care. vagus nerves. The gag reflex would be evaluated. The
Option D: The client has already received pain 9th (glossopharyngeal) and 10th (vagus) cranial nerves
medication, therefore she is not a priority. For expert are usually evaluated together. Whether the palate
nurses, the ability to prioritize based on these processes elevates symmetrically when the patient says “ah” is
is predominately intuitive, and tasks are completed in a noted. If one side is paretic, the uvula is lifted away from
prioritized manner without much conscious thought. 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
25. Which of the following statements about the nursing absence of the gag reflex is common among healthy
process is most accurate? people and may not be significant.

A. The nursing process is a four-step procedure for Option A: For the 5th (trigeminal) nerve, the 3 sensory
identifying and resolving patient problems. divisions (ophthalmic, maxillary, mandibular) are
B. Beginning in Florence Nightingale’s days, nursing evaluated by using a pinprick to test facial sensation and
students learned and practiced the nursing process. by brushing a wisp of cotton against the lower or lateral
C. Use of the nursing process is optional for nurses cornea to evaluate the corneal reflex. If facial sensation
since there are many ways to accomplish the work of is lost, the angle of the jaw should be examined; sparing
nursing. of this area (innervated by spinal root C2) suggests a
D. The state board examinations for professional trigeminal deficit. A weak blink due to facial weakness
nursing practice now use the nursing process rather (eg, 7th cranial nerve paralysis) should be distinguished
than medical specialties as an organizing concept. from depressed or absent corneal sensation, which is
common in contact lens wearers. A patient with facial
The nursing process is a systematic decision-making weakness feels the cotton wisp normally on both sides,
method focusing on identifying and treating responses of even though blink is decreased.
individuals or groups to actual or potential alterations in Option B: A penlight provides a source of light and has
health it- is the essential core of nursing practice to become the most common used tool to assess pupil
deliver holistic, patient-focused care. Nursing process diameter. Asymmetry of pupil constriction in response to
provides an organizing framework for the practice of light means one pupil constricts and the other remains
nursing and the knowledge, judgments, and actions that dilated or constricts more slowly. It may indicate
nurses bring to patient care.” dynamic anisocoria or a Marcus Gunn pupil, a relative
afferent pupillary defect (RAPD), or temporal lobe
Option A: The nursing process is a five-step process. herniation in the brain.
The nursing process functions as a systematic guide to Option C: The eye can be examined with routine
client-centered care with 5 sequential steps. These are equipment, including a standard ophthalmoscope;
assessment, diagnosis, planning, implementation, and thorough examination requires special equipment and
evaluation. The utilization of the nursing process to evaluation by an ophthalmologist. Ophthalmoscopy
guide care is clinically significant going forward in this (examination of the posterior segment of the eye) can be
dynamic, complex world of patient care. done directly by using a handheld ophthalmoscope or
Option B: The term nursing process was first used by with a handheld lens in conjunction with the slit lamp
Hall in 1955. In 1958, Ida Jean Orlando started the biomicroscope.
nursing process that still guides nursing care today.
Defined as a systematic approach to care using the
fundamental principles of critical thinking, client-centered 27. Which technique would be best in caring for a client
approaches to treatment, goal-oriented tasks, evidence- following receiving a diagnosis of a stage IV tumor in the
based practice (EDP) recommendations, and nursing brain?
intuition.
Option C: Nursing process is not optional since A. Offering the client pamphlets on support groups for
standards demand the use of it. Holistic and scientific brain cancer.
postulates are integrated to provide the basis for B. Asking the client if there is anything he or his family
compassionate, quality-based care. As explored by needs.
Salmond and Echevarria, healthcare is changing, and C. Reminding the client that advances in technology are
the traditional roles of nurses are transforming to meet occurring every day.
the demands of this new healthcare environment. D. Providing accurate information about the disease
Nurses are in a position to promote change and impact and treatment options.
patient delivery care models in the future.
Providing information for the client is the best technique
for a new diagnosis. Every clinician at one time or
26. What equipment would be necessary to complete an another faces these important questions. In the
evaluation of cranial nerves 9 and 10 during a physical treatment of terminally ill patients, the health
assessment? 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 intervention for blood glucose <40 mg/dL in the first 4
to retain his or her dignity. hours of life and <45 mg/dL at 4 to 24 hours of life.
Option D: Placing the infant in a warmer does not
Option A: Cassem, in the Massachusetts General manage the hypoglycemia. In infants of diabetic
Hospital Handbook of General Hospital Psychiatry, mothers, lower glucose infusions rates of 3 to 5
recommends relaying negative information to patients mg/kg/minute may be used to minimize pancreatic
through a brief, rehearsed initial statement that stimulation and endogenous insulin secretion. Infants
succinctly communicates the news and clearly indicates requiring higher rates of intravenous dextrose (>12 to 16
that the treatment team is committed to the ongoing care mg/kg/minute) or for more than 5 days are more likely to
and support of the patient. have a persistent cause of hypoglycemia.
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 29. What question would be most important to ask a
versa. By observing the interactions of a patient with male client who is in for a digital rectal examination?
family, the consultant can become aware of long-
standing grudges or new difficulties in communication A. “Have you noticed a change in the force of the
that can make the process of coming to closure at the urinary system?”
end of a life more difficult. B. “Have you noticed a change in tolerance of certain
Option C: In most cases, patients who are told their foods in your diet?”
diagnosis in an up-front, clear manner have better C. “Do you notice polyuria in the AM?”
emotional adjustments to their situation than those who D. “Do you notice any burning with urination or any odor
are not told about their condition. By providing direct, to the urine?”
clear information in a compassionate manner, and by
making clear to the patient that everything possible will This change would be most indicative of a potential
be done to provide medical and emotional support, complication with (BPH) benign prostate hypertrophy.
physicians can elicit trust and reduce anxiety. 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
28. An 8.5 lb, 6 oz infant is delivered to a diabetic establish the etiologic role of BPH in these problems.
mother. Which nursing intervention would be
implemented when the neonate becomes jittery and Option B: Food intolerances are more common in those
lethargic? with digestive system disorders, such as irritable bowel
syndrome (IBS). According to the IBS network, most
A. Administer insulin. people with IBS have food intolerances. The symptoms
B. Administer oxygen. of food intolerances can also mimic the symptoms of
C. Feed the infant glucose water (10%). chronic digestive conditions, such as IBS. However,
D. Place the infant in a warmer. certain patterns in the symptoms can help a doctor
distinguish between the two.
After birth, the infant of a diabetic mother is often Option C: History can often distinguish polyuria from
hypoglycemic. Treatment will depend on the baby’s frequency, but rarely a 24-hour urine collection may be
gestational age and overall health. Treatment includes needed. Polyuria caused by solute diuresis is suggested
giving the baby a fast-acting source of glucose. This by a history of diabetes mellitus. Abrupt onset of polyuria
may be as simple as a glucose and water mixture or at a precise time suggests central diabetes insipidus, as
formula as an early feeding. Or the baby may need does preference for extremely cold or iced water.
glucose given through an IV. The baby’s blood glucose Option D: Dysuria is a symptom of pain and/or burning,
levels are checked after treatment to see if the stinging, or itching of the urethra or urethral meatus with
hypoglycemia occurs again. urination. It is one of the most common symptoms
experienced by most people at least once over their
Option A: Second-line therapies for the treatment of lifetimes. Primarily, causes of dysuria can be divided
persistent hypoglycemia include the use of broadly into two categories, infectious and non-
corticosteroids or glucagon, not insulin. Glucagon is a infectious.
hormone that stimulates endogenous glucose
production via glycogenolysis and gluconeogenesis;
thus its effectiveness depends on the infant having 30. The nurse assesses a prolonged late deceleration of
adequate glycogen stores. It is most useful in term the fetal heart rate while the client is receiving oxytocin
infants and infants of diabetic mothers. Glucagon dosing (Pitocin) IV to stimulate labor. The priority nursing
is as a 30 mcg/kg bolus or 300 mcg/kg per minute intervention would be to:
continuous infusion.
Option B: Oxygen is not administered to hypoglycemic A. Turn off the infusion.
neonates. Early initiation of breastfeeding is crucial for B. Turn the client to the left.
all infants. For asymptomatic infants at risk of neonatal C. Change the fluid to Ringer’s Lactate.
hypoglycemia, the AAP recommends initiating feeds D. Increase mainline IV rate.
within the first hour of life and performing initial glucose
screening 30 minutes after the first feed. The AAP Stopping the infusion will decrease contractions and
recommends goal blood glucose levels equal to or possibly remove uterine pressure on the fetus, which is
greater than 45 mg/dL prior to routine feedings, and 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 32. Which nursing intervention would be a priority during
mother on her left side and/or administering oxygen. If the care of a 2-month-old after surgery?
Oxytocin (Pitocin) is being administered, it should be
stopped. A. Minimize stimuli for the infant.
B. Restrain all extremities.
Option B: Variable decelerations are marked by a sharp C. Encourage stroking of the infant.
decrease (“V” shape) in FHR that does not correlate to D. Demonstrate to the mother how she can assist with
contractions. Umbilical cord compression is usually the her infant’s care.
cause of variable decelerations. Repositioning of the
mother can relieve this compression if it is minor. Tactile stimulation is imperative for an infant’s normal
Option C: Late decelerations are shown by the FHR emotional development. After the trauma of surgery,
gradually decreasing around the peak of the contraction sensory deprivation can cause failure to thrive. Most
and gradually increasing when the contraction is over. babies with FTT do not have a specific underlying
These decelerations will also have a “U” shape but will disease or medical condition to account for their growth
not mirror the contractions. The most common cause of failure. This is referred to as Non-organic FTT. Up to
late decelerations is uteroplacental insufficiency 80% of all children with FTT have Non-organic type FTT.
(insufficient oxygen exchange between the placenta and Non-organic FTT most commonly occurs when there is
the fetus). inadequate food intake or there is a lack of
Option D: Increasing the main IV line would not manage environmental stimuli.
the decelerations. While caring for a patient in labor, one
of the important nursing duties is monitoring the Option A: Provide sensory stimulation. Attempt to
variability of the fetal heart rate (FHR) and monitoring cuddle the child and talk to him or her in a warm,
the FHR response during contractions. Variability in the soothing tone and allow for play activities appropriate for
FHR during labor is a sign of fetal well-being or fetal the child’s age. Feed the child slowly and carefully in a
activity or both. The expected variability usually includes quiet environment; during feeding, the child might be
slight accelerations and decelerations. 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
31. Which nursing approach would be most appropriate frequently during and at the end of each feeding, and
to use while administering an oral medication to a 4- then place him or her on the side with the head slightly
month-old? elevated or held in a chest-to-chest position.
Option D: If a family caregiver is present, encourage
A. Place medication in 45cc of formula. him or her to become involved in the child’s feedings.
B. Place medication in an empty nipple. While caring for the child, point out to the caregiver the
C. Place medication in a full bottle of formula. child’s development and responsiveness, noting and
D. Place in supine position. Administer medication praising any positive parenting behaviors the caregiver
using a plastic syringe. displays.

This is a convenient method for administering

medications to an infant. Draw up the correct amount of 33. While performing a physical examination on a
medicine into an oral syringe (a syringe without a newborn, which assessment should be reported to the
needle) or an empty nipple. Let the infant suck the physician?
medicine out of the syringe or empty nipple. When
giving medicine to an infant, use his natural reflexes A. Head circumference of 40 cm.
(such as sucking) whenever possible. B. Chest circumference of 32 cm.
C. Acrocyanosis and edema of the scalp.
Option A: Avoid mixing medicine with foods the child D. Heart rate of 160 and respirations of 40.
must have. The child may begin to dislike the foods he
needs. Mix the medicine with a small amount (1 to 2 Average circumference of the head for a neonate ranges
teaspoons) of applesauce or pears and give it with a between 32 to 36 cm. An increase in size may indicate
spoon. This is a good way to give pills that have been hydrocephalus or increased intracranial pressure. A
crushed well. (To crush a pill, place it between two newborn’s head is usually about 2 cm larger than the
spoons and press the spoons together). chest size. Between 6 months and 2 years, both
Option C: Some medicines can be put in a small measurements are about equal. After 2 years, the chest
amount of juice or sugar water. Follow the instructions size becomes larger than the head.
from the doctor, nurse, or pharmacist. Do not put
medicine in a full bottle or cup in case the infant does Option B: The body of a normal newborn is essentially
not drink very much. cylindrical; head circumference slightly exceeds that of
Option D: Option D is partially correct however, the the chest. For a term baby, the average circumference
infant is never placed in a reclining position during a of the head is 33–35 cm (13–14 inches), and the
procedure due to a potential aspiration. Hold the infant average circumference of the chest is 30–33 cm (12–13
in a nearly upright position. If the infant struggles, gently inches).
hold one arm and place his other arm around the waist. Option C: Peripheral cyanosis (acrocyanosis) involves
Hold the baby close to the body. 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 A: While HPV infections are very common,
Option D: Heart rates normally fluctuate between 120 cancer caused by HPV is not. Most people infected with
and 160 beats per minute. In agitated states, a rate of HPV will not develop cancer-related to the infection.
200 beats per minute may occur transiently. The heart However, some people with long-lasting infections of
rate of premature infants is usually between 130 and high-risk types of HPV, are at risk of developing cancer.
170 beats per minute, and during occasional episodes of Option B: Hydroceles generally don’t pose any threat to
bradycardia, it may slow to 70 beats per minute or less. the testicles. They’re usually painless and disappear
Normal neonates breathe at rates that vary between 40 without treatment. However, if the patient has scrotal
and 60 respirations per minute. Rapid rates are likely to swelling, he should see his doctor rule out other causes
be present for the first few hours after birth. 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
34. Which action by the mother of a preschooler would measles virus recover fully. The risk of complications is
indicate a disturbed family interaction? higher in the following groups: children under 5 years
old. adults over 20 years old.
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. 36. While caring for a client, the nurse notes a pulsating
C. Tells her child that the injection can be given while mass in the client’s periumbilical area. Which of the
he’s in her lap. following assessments is appropriate for the nurse to
D. Reassures the child that it is acceptable to cry. perform?

Threatening a child with abandonment will destroy the A. Measure the length of the mass.
child’s trust in his family. Children growing up in such B. Auscultate the mass.
families are likely to develop low self-esteem and feel C. Percuss the mass.
that their needs are not important or perhaps should not D. Palpate the mass.
be taken seriously by others. As a result, they may form
unsatisfying relationships as adults. Auscultate the mass. Auscultation of the abdomen and
finding a bruit will confirm the presence of an abdominal
Option B: It can help to describe the need for injections aneurysm and will form the basis of information given to
and blood testing in kid terms. For example, the nurse the provider. Occasionally, an overlying mass (pancreas
might explain that the shots and blood tests help keep or stomach) may be mistaken for an AAA. An abdominal
the child feeling good throughout the day — and that not bruit is nonspecific for an unruptured aneurysm, but the
getting them could mean having to stay home from presence of an abdominal bruit or the lateral
school or miss fun activities because of health problems. propagation of the aortic pulse wave can offer subtle
Option C: Having both parents (or one parent plus clues and maybe more frequently found than a pulsatile
another caregiver) involved in the management process mass.
will help keep treatment consistent and also provide
support as the nurse deals with struggles over shots and Option A: In one study, 38% of AAA cases were
blood tests. detected on the basis of physical examination findings,
Option D: If the child argues or cries, the parents might whereas 62% were detected incidentally on radiologic
be tempted to skip an injection or test just this once. studies obtained for other reasons. Femoral/popliteal
Nurses shouldn’t negotiate blood tests or shots. They’re pulses and pedal (dorsalis pedis or posterior tibial)
necessary and not optional. The first time you’re talked pulses should be palpated to determine if an associated
out of one, you’ll set a precedent that that child won’t aneurysm (femoral/popliteal) or occlusive disease exists.
forget. Flank ecchymosis (Grey Turner sign) represents
retroperitoneal hemorrhage.
Option C: Do not percuss the abdominal mass. The
35. During the history, which information from a 21-year- presence of a pulsatile abdominal mass is virtually
old client would indicate a risk for development of diagnostic of an AAA but is found in fewer than 50% of
testicular cancer? cases. It is more likely to be noted with a ruptured
aneurysm.
A. Genital Herpes Option D: The mass should not be palpated because of
B. Hydrocele the risk of rupture. Most clinically significant AAAs are
C. Measles palpable upon routine physical examination; however,
D. Undescended testicle the sensitivity of palpation depends on the experience of
the examiner, the size of the aneurysm, and the size of
Undescended testicles make the client at high risk for the patient.
testicular cancer. Mumps, inguinal hernia in childhood,
orchitis, and testicular cancer in the contralateral testis
are other predisposing factors. The risk of testicular 37. When observing 4-year-old children playing in the
cancer might be a little higher for men whose testicles hospital playroom, what activity would the nurse expect
stayed in the abdomen as opposed to one that has to see the children participating in?
descended at least partway. If cancer does develop, it’s
usually in the undescended testicle, but about 1 out of 4 A. Competitive board games with older children.
cases occur in the normally descended testicle. B. Playing with their own toys alongside other children.
C. Playing alone with handheld computer games. them less interested in nursing. This could actually
D. Playing cooperatively with other preschoolers. contribute to weight loss and elevated bilirubin levels.

Playing cooperatively with other preschoolers.

Cooperative play is typical of the late preschool period. 39. While the nurse is administering medications to a
Cooperative play is the final stage of play and client, the client states “I do not want to take that
represents the child’s ability to collaborate and medicine today.” Which of the following responses by
cooperate with other children towards a common goal. the nurse would be best?
Children often reach the cooperative stage of play
between 4 and 5 years of age after they have moved A. “That’s OK, it's alright to skip your medication now
through the earlier five stages of play. and then.”
B. “I will have to call your doctor and report this.”
Option A: Competitive play is when children learn to C. “Is there a reason why you don’t want to take
play organized games with clear rules and clear your medicine?”
guidelines on winning and losing. Ludo, snake and D. “Do you understand the consequences of refusing
ladders, and football are all forms of competitive play. your prescribed treatment?”
Option B: After mastering onlooker play, a child will be
ready to move into parallel play. During parallel play, When a new problem is identified, it is important for the
children will play beside and in proximity to other nurse to collect accurate assessment data. This is
children without actually playing with them. Children crucial to ensure that client needs are adequately
often enjoy the buzz that comes with being around other identified in order to select the best nursing care
kids, but they don’t yet know how to step into others’ approaches. The nurse should try to discover the reason
games or ask other kids to step into their games. for the refusal which may be that the client has
Option C: Encourage the child to play with others and developed untoward side effects.
be active several times a week instead of spending time
in front of a screen. This can help to build healthy, active Option A: It is not alright to skip medication. Be very
bodies. (To be clear, learning can happen during screen matter-of-fact in communication style with the individual
time, too — just not this specific type of learning.) 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”.
38. The nurse is teaching the parents of a 3 month-old Option B: If they continue to refuse, document the
infant about nutrition. What is the main source of fluids missed dose and state the reason (individual refused),
for an infant until about 12 months of age? along with other relevant information if known (i.e. they
indicated nausea). In addition, contact the physician
A. Formula or breastmilk under circumstances as agreed when medication was
B. Dilute nonfat dry milk prescribed and/or implement any steps in the ISP for
C. Warmed fruit juice missed doses.
D. Fluoridated tap water Option D: Find out if they understand what the
medication is for. If they do not understand, remind them
Formula or breast milk are the perfect food and source of the purpose and ask them again to take it. Find out if
of nutrients and liquids up to 1 year of age. they understand the implications of not taking their
Breastfeeding with appropriate supplementation is the medication. If they do not understand, remind them of
preferred method for feeding infants 0-12 months old. the implications and ask them again to take it (In
Iron-fortified formulas are recommended if the child is addition to physical symptoms, implications may include
not breastfed or requires supplemental formula in the need to call the physician and report the missed
addition to breast milk. dose.)

Option B: The American Academy of Pediatrics

Committee on Nutrition updated their recommendations 40. The nurse is assessing a 4 month-old infant. Which
concerning infant feeding practices during the second motor skill would the nurse anticipate finding?
six months of life. The committee stated that
breastfeeding is the preferred method of feeding during A. Hold a rattle
the first year of life and that whole cow’s milk may be B. Bang two blocks
introduced after six months of age if adequate C. Drink from a cup
supplementary feedings are given. Reduced fat content D. Wave “bye-bye”
milk is not recommended during infancy.
Option C: When the infants are consuming one-third of The age at which a baby will develop the skill of
their calories from a balanced mixture of iron-fortified grasping a toy with help is 4 to 6 months. The baby is
cereals, vegetables, fruits, and other foods providing becoming more dexterous and doing more with their
adequate sources of both iron and Vitamin C it is hands. Their hands now work together to move a toy or
considered adequate supplementary feeding. shake a rattle. In fact, those hands will grab for just
Option D: The World Health Organization (WHO) notes about anything within reach, including a stuffed animal,
that babies that are breastfed don’t need additional the mother’s hair, and any colorful or shiny object
water, as breast milk is over 80 percent water and hanging nearby
provides the fluids your baby needs. Children who are
bottle-fed will stay hydrated with the help of their Option B: At 9 months, babies repeat different actions
formula. Water feedings tend to fill up your baby, making with objects. They mouth objects to explore the features.
They bang objects with their hand and bang two objects therapeutic effects of medication. Oxidative stress
together to create sounds and actions. They drop causes cells and entire organisms to age. If reactive
objects sometimes by chance and other times on oxygen species accumulate, this causes damage to the
purpose. DNA as well as changes in the protein molecules and
Option C: Babies are learning functional actions with a lipids in the cell. The cell ultimately loses its functionality
purpose in mind. They can put things in, such as put and dies. Over time, the tissue suffers, and the body
clothes in the dryer or a shape in a puzzle. From “put in” ages.
they learn a variety of functional actions. They can put a
sippy cup to their mouth to drink, a spoon in a bowl to Option B: Alcohol has a smaller water distribution level
scoop, and a spoon in their mouth to eat. in the elderly, resulting in higher blood alcohol levels.
Option D: Learning how to wave bye-bye is an Alcohol also interacts with various drugs to either
important milestone for an infant that usually occurs potentiate or interfere with their effects. The older one
between the age of 10 months and a year. A study in gets, the longer alcohol stays in the system. So it’s more
Pediatrics International found premature infants likely to be there when the client takes medicine. And
mastered the bye-bye gesture significantly later than full- alcohol can affect the way the meds work. It can also
term babies and used different hand and wrist motions. lead to serious side effects.
Option C: Magnesium is contained in a lot of
medications older clients routinely obtain over the
41. The nurse should recognize that all of the following counter. Magnesium toxicity is a real concern. Older
physical changes of the head and face are associated adults have lower dietary intakes of magnesium than
with the aging client except: younger adults. In addition, magnesium absorption from
the gut decreases, and renal magnesium excretion
A. Pronounced wrinkles on the face. increases with age. Older adults are also more likely to
B. Decreased size of the nose and ears. have chronic diseases or take medications that alter
C. Increased growth of facial hair. magnesium status, which can increase their risk of
D. Neck wrinkles. magnesium depletion
Option D: Albumin is the major drug-binding protein.
The nose and ears of the aging client actually become Decreased levels of serum albumin mean that higher
longer and broader. The chin line is also altered. Height levels of the drug remain free and that there are fewer
doesn’t change after puberty (well, if anything we get therapeutic effects and increased drug interactions.
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 43. When assessing a newborn whose mother
nose to break down and sag. This results in droopier, consumed alcohol during the pregnancy, the nurse
longer features. would assess for which of these clinical manifestations?

Option A: Wrinkles on the face become more A. Wide-spaced eyes, smooth philtrum, flattened
pronounced and tend to take on the general mood of the nose
client over the years. For example laugh or frown B. Strong tongue thrust, short palpebral fissures, simian
wrinkles above the eyebrows, lips, cheeks, and outer crease
edges of the eye orbit. C. Negative Babinski sign, hyperreflexia, deafness
Option C: The change in the androgen-estrogen ratio D. Shortened limbs, increased jitteriness, constant
causes an increase in growth of facial hair in most older sucking
adults. Women develop excessive body or facial hair
due to higher-than-normal levels of androgens, including The nurse should anticipate that the infant may have
testosterone. All females produce androgens, but the fetal alcohol syndrome and should assess for signs and
levels typically remain low. symptoms of it. These include the characteristics listed
Option D: The aging process shortens the platysma in choice A. Fetal alcohol syndrome is a condition in a
muscle, which contributes to neck wrinkles. Some child that results from alcohol exposure during the
amount of neck wrinkling is inevitable. The extent of the mother’s pregnancy. Fetal alcohol syndrome causes
necklines and other signs of aging skin are determined brain damage and growth problems. The problems
in part by genetics. Necklines and wrinkles are a normal caused by fetal alcohol syndrome vary from child to
part of aging. They’re caused in part by skin losing child, but defects caused by fetal alcohol syndrome are
elasticity and being exposed to UV light over time. not reversible.

Option B: A single palmar crease is a single line that

42. All of the following characteristics would indicate to runs across the palm of the hand. People most often
the nurse that an elder client might experience have 3 creases in their palms. A single palmar crease
undesirable effects of medicines except: appears in about 1 out of 30 people. Males are twice as
likely as females to have this condition. Some single
A. Increased oxidative enzyme levels. palmar creases may indicate problems with
B. Alcohol taken with medication. development and be linked with certain disorders.
C. Medications containing magnesium. Option C: Hyperreflexia is a sign of upper motor neuron
D. Decreased serum albumin. damage and is associated with spasticity and a positive
Babinski sign. In infants with at CST which is not fully
Oxidative enzyme levels decrease in the elderly, which myelinated the presence of a Babinski sign in the
affects the disposition of medication and can alter the
absence of other neurological deficits is considered situation and fosters the client’s sense of self-esteem
normal up to 24 months of age. and self-concept. Nurses need to allow patients the
Option D: Achondroplasia is the most common form of choice of what to do in relation to their dentures when
short-limb dwarfism. It is an autosomal dominant going to the theatre, although the anesthetist must make
disorder caused by a mutation in the gene that creates the final decision of whether or not to remove them
the cells (fibroblasts) which convert cartilage to bone. immediately before the anesthetic if they feel patient
This means, if the gene is passed on by one parent, the safety could be compromised.
child will have achondroplasia.
Option A: According to a study, “There are no set
national guidelines on how dentures should be managed
44. Which of these statements, when made by the during anesthesia, but it is known that leaving dentures
nurse, is most effective when communicating with a 4- in during bag-mask ventilation allows for a better seal
year-old? during induction [when the anesthetic is being infused],
and therefore many hospitals allow dentures to be
A. “Tell me where you hurt.” removed immediately before intubation [when a tube is
B. “Other children like having their blood pressure inserted into the airway to assist breathing]”.
taken.” Option B: The swallowing of dentures during general
C. “This will be like having a little stick in your arm.” anesthesia is a significant problem for anesthesiologists.
D. “Anything you tell me is confidential.” It is seen more often in patients with psychiatric
disorders, mental retardation, alcoholism, or poor-quality
Four-year-olds are egocentric and interested in having dentures. It has become an important issue for
the focus on themselves. As kids gain language skills, anesthesiologists preoperatively due to the increase in
they also develop their conversational abilities. Kids 4 to the proportion of dentures associated with the
5 years old can follow more complex directions and prolongation of life.
enthusiastically talk about things they do. They can Option C: The presence of any false teeth or dental
make up stories, listen attentively to stories, and retell plates should be clearly documented before and after
stories. any surgical procedure, with all members of the surgical
team made aware of what is to be done with them, they
Option B: They will not be interested in what it feels like add.
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 46. The nurse is assessing a client who states her last
speech to suit the circumstances. They may speak more menstrual period was March 17, and she has missed
formally in front of a teacher than they do with family and one period. She reports episodes of nausea and
friends. vomiting. Pregnancy is confirmed by a urine test. What
Option C: Preschoolers are concrete thinkers and will the nurse calculate as the estimated date of delivery
would literally interpret any analogies so they are not (EDD)?
helpful in explaining procedures. Concrete thinking is a
kind of reasoning that relies heavily on what we observe A. November 8
in the physical world around us. It’s sometimes called B. May 15
literal thinking. Young children think concretely, but as C. February 21
they mature, they usually develop the ability to think D. December 24
more abstractly.
Option D: Assurance of confidential communication is Naegele’s rule: add 7 days and subtract 3 months from
most appropriate for the adolescent. In addition, the first day of the last regular menstrual period to
confidentiality is not maintained if the child plans to harm calculate the estimated date of delivery. Naegele’s rule,
themselves, harm someone else, or discloses abuse. 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
45. A 64-year-old client scheduled for surgery with a menstrual history, including duration, flow, previous
general anesthetic refuses to remove a set of dentures menstrual periods, and hormonal contraceptives.
prior to leaving the unit for the operating room. What
would be the most appropriate intervention by the Option A: Determining gestational age is one of the
nurse? most critical aspects of providing quality prenatal care.
Knowing the gestational age allows the obstetrician to
A. Explain to the client that the dentures must come out provide care to the mother without compromising
as they may get lost or broken in the operating room. maternal or fetal status. It allows for the correct timing of
B. Ask the client if there are second thoughts about management, such as administering steroids for fetal
having the procedure. lung maturity, starting ASA therapy with a history of pre-
C. Notify the anesthesia department and the surgeon of eclampsia in previous pregnancies, starting
the client’s refusal. hydroxyprogesterone caproate (Makena) for previous
D. Ask the client if the preference would be to preterm deliveries.
remove the dentures in the operating room receiving Option B: An average pregnancy lasts 280 days from
area. the first day of the last menstrual period (LMP) or 266
days after conception. Historically, an accurate LMP is
Clients anticipating surgery may experience a variety of the best estimator to determine the due date.
fears. This choice allows the client control over the
Option C: An official EDD is established after As cognitive ability declines, the nurse provides a calm,
calculating the first-trimester sonogram EDD date and predictable environment for the client. This response
then using the LMP. If the LMP and first trimester EDD establishes time, location, and the caregiver’s name.
are within 7 days of each other, the LMP estimates the Orient the patient to surroundings, staff, necessary
due date. The margin of error is reduced depending on activities as needed. Present reality concisely and
when (i.e., how early) the sonogram occurred. briefly. Avoid challenging illogical thinking—defensive
reactions may result.

47. The family of a 6-year-old with a fractured femur Option A: Modulate sensory exposure. Provide a calm
asks the nurse if the child’s height will be affected by the environment; eliminate extraneous noise and stimuli.
injury. Which statement is true concerning long bone Increased levels of visual and auditory stimulation can
fractures in children? be misinterpreted by the confused patient.
Option B: Give simple directions. Allow sufficient time
A. Growth problems will occur if the fracture involves for the patient to respond, to communicate, to make
the periosteum. decisions. This communication method can reduce
B. Epiphyseal fractures often interrupt a child’s anxiety experienced in a strange environment.
normal growth pattern. Option C: Offer reassurance to the patient and use
C. Children usually heal very quickly, so growth therapeutic communication at frequent intervals. Patient
problems are rare. reassurance and communication are nursing skills that
D. Adequate blood supply to the bone prevents growth promote trust and orientation and reduce anxiety.
delay after fractures.

Epiphyseal fractures often interrupt a child’s normal 49. When a client wishes to improve the appearance of
growth pattern. Growth plate fractures are classified their eyes by removing excess skin from the face and
based on which parts of the bone are damaged, in neck, the nurse should provide teaching regarding which
addition to the growth plate. Areas of the bone of the following procedures?
immediately above and below the growth plate may
fracture. They are called the epiphysis (the tip of the A. Dermabrasion
bone) and metaphysis (the “neck” of the bone). B. Rhinoplasty
C. Blepharoplasty
Option A: The most serious complication is early D. Rhytidectomy
closure (complete or partial) of the growth plate.
Complete closure means the entire growth plate of the Rhytidectomy is the procedure for removing excess skin
affected bone has stopped expanding. This results in the from the face and neck. It is commonly called a facelift.
affected bone not growing as long as the opposite side. Rhytidectomy is a surgical procedure meant to
Option C: The severity of and need for treatment of counteract the effects of time on the aging face. In the
growth plate closures depend on the location of the rhytidectomy procedure (also known as a “face-lift”), the
fracture and the age of the patient. Other complications tissues under the skin are tightened and excess facial
of growth plate fractures include delayed healing of the and neck skin are excised. Rhytidectomy literally means
bone, nonhealing, infection, and loss of blood flow to the wrinkle (rhytid-) removal (-ectomy).
area, causing death of part of the bone.
Option D: Growth plate fractures are generally treated Option A: Dermabrasion involves the spraying of a
with splints or casts. Sometimes, the bone may need to chemical to cause light freezing of the skin, which is
be put back in place to allow it to heal in the correct then abraded with sandpaper or a revolving wire brush.
position. This may be done before or after the cast is It is used to remove facial scars, severe acne, and
placed and is called a closed reduction. The length of pigment from tattoos. Dermabrasion is an exfoliating
time the child needs to be in a cast or splint depends on technique that uses a rotating instrument to remove the
the location and severity of the fracture. The child’s age outer layers of skin, usually on the face. This treatment
also matters: younger patients heal faster than older is popular with people who wish to improve the
patients. appearance of their skin. Some of the conditions it can
treat include fine lines, sun damage, acne scars, and
uneven texture.
48. A client is admitted to the hospital with a history of Option B: Rhinoplasty is done to improve the
confusion. The client has difficulty remembering recent appearance of the nose and involves reshaping the
events and becomes disoriented when away from home. nasal skeleton and overlying skin. Rhinoplasty is surgery
Which statement would provide the best reality that changes the shape of the nose. The motivation for
orientation for this client? rhinoplasty may be to change the appearance of the
nose, improve breathing, or both. The upper portion of
A. “Good morning. Do you remember where you are?” the structure of the nose is bone, and the lower portion
B. “Hello. My name is Elaine Jones and I am your nurse is cartilage.
for today.” Option C: Blepharoplasty is the procedure that removes
C. “How are you today? Remember, you’re in the loose and protruding fat from the upper and lower
hospital.” eyelids. Eyelid surgery, or blepharoplasty, is a surgical
D. “Good morning. You’re in the hospital. I am your procedure to improve the appearance of the eyelids.
nurse Elaine Jones.”
50. A woman who is six months pregnant is seen in Option A: After gathering data from the nurses,
antepartal clinic. She states she is having trouble with additional information from the records and the client
constipation. To minimize this condition, the nurse can be obtained as necessary. Effective resolution and
should instruct her to management of a conflict require clear communication
and a level of understanding of the perceived areas of
A. Increase her fluid intake to three liters/day. disagreement. Conflict resolution is an essential element
B. Request a prescription for a laxative from her of a healthy work environment because a breakdown in
physician. communication and collaboration can lead to increased
C. Stop taking iron supplements. patient errors.
D. Take two tablespoons of mineral oil daily. Option B: The educator may be of assistance if
knowledge deficit or need for performance improvement
In pregnancy, constipation results from decreased is the problem. The American Association of Critical-
gastric motility and increased water reabsorption in the Care Nurses standards for healthy work environments
colon caused by increased levels of progesterone. recognizes the importance of proficiency in
Increasing fluid intake to three liters a day will help communication skills and The Joint Commission’s
prevent constipation. The client should increase fluid revised leadership standards place a mandate on
intake, increase roughage in the diet, and increase healthcare leadership to manage disruptive behavior
exercise as tolerated. that can impact patient safety.
Option C: Nursing leaders need to assess how nurses
Option B: Laxatives are not recommended because of deal with conflict in the healthcare environment in an
the possible development of laxative dependence or effort to develop and implement conflict management
abdominal cramping. The primary medical treatment for training and processes that can assist them in dealing
constipation in pregnancy is a medication called a with difficult situations.
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 52. Family members are encouraging your client to
because they can induce uterine contractions. “tough it out” rather than run the risk of becoming
Option C: Iron supplements are necessary during addicted to narcotics. The client is stoically abiding by
pregnancy, as ordered, and should not be discontinued. the family’s wishes. Priority nursing interventions for this
Daily oral iron and folic acid supplementation with 30 mg client should target which dimension of pain?
to 60 mg of elemental iron and 400 µg (0.4 mg) folic acid
is recommended for pregnant women to prevent A. Sensory
maternal anemia, puerperal sepsis, low birth weight, and B. Sociocultural
preterm birth. C. Behavioral
Option D: Mineral oil is especially bad to use as a D. Cognitive
laxative because it decreases the absorption of fat-
soluble vitamins (A, D, E, K) if taken near mealtimes. The family is part of the socio-cultural dimension of pain.
Mineral oil should always be prohibited during They are influencing the client and should be included in
pregnancy, as its use can cause hemorrhagic disease of the teaching sessions about the appropriate use of
the newborn due to impaired absorption of vitamin K. narcotics and about the adverse effects of pain on the
Similarly, castor oil is absolutely prohibited during healing process. The other dimensions should be
pregnancy. included to help the client/family understand the overall
treatment plan and pain mechanism.

51. A client with chronic pain reports to you, the charge Option A: The sensory dimension encompasses both
nurse, that the nurse has not been responding to the quality and severity of pain. It includes the patient’s
requests for pain medication. What is your initial action? report of the location, quality, and intensity of pain.
Assessing this dimension helps quantify the pain and
A. Check the MARs and nurses’ notes for the past clarify the extent of poorly localized or radiating pain.
several days. Option C: The behavioral dimension of pain refers to
B. Ask the nurse educator to give an in-service about the patient’s verbal or nonverbal behaviors exhibited in
pain management. response to pain. To assess it, rely on direct observation
C. Perform a complete pain assessment and history on and continued patient interaction. Watch for common
the client. behaviors associated with pain, such as guarding,
D. Have a conference with the nurses responsible splinting, tensing up, crying, moaning, and massaging a
for the care of this client. specific body part.
Option D: The cognitive dimension refers to thoughts,
As a charge nurse, you must assess the performance beliefs, attitudes, intentions, and motivations related to
and attitude of the staff in relation to this client. Handling pain and its management. Before assessing this
conflicts in an efficient and effective manner results in dimension, evaluate the patient’s cognitive capacity and
improved quality, patient safety, and staff morale, and functioning. Review the medical history for diseases or
limits work stress for the caregiver. The nurse manager conditions that may impair cognition; if any exists,
must approach this challenge thoughtfully because it assess its current level of progression. In some patients,
involves working relationships that are critical for the unit pain can temporarily worsen pre-existing cognitive
to function effectively. limitations.
53. A client with diabetic neuropathy reports a burning, Option B: Phantom limb pain usually subsides after
electrical type in the lower extremities that is not ambulation begins. Treatment, unfortunately, for PLP
responding to NSAIDs. You anticipate that the physician has not proven to be very effective. While treatment for
will order which adjuvant medication for this type of RLP tends to focus on an organic cause for the pain,
pain? PLP focuses on symptomatic control.
Option D: Trigeminal neuralgia is treated with anti-
A. Amitriptyline (Elavil) seizure medications such as carbamazepine (Tegretol).
B. Corticosteroids The first-line treatment for patients with classic TN and
C. Methylphenidate (Ritalin) idiopathic TN is pharmacologic therapy. The most
D. Lorazepam (Ativan) commonly used medication is the anticonvulsant drug,
carbamazepine. It is usually started at a low dose, and
Antidepressants such as amitriptyline can be given for the dose is gradually increased until it controls the pain.
diabetic neuropathy. The American Diabetes It controls pain for most people in the early stages of the
Association recommends amitriptyline, a tricyclic disease.
antidepressant, as the first choice; however, titration to
higher doses is limited by its anticholinergic adverse
effects. 55. As the charge nurse, you are reviewing the charts of
clients who were assigned to a newly graduated RN.
Option B: Corticosteroids are for pain associated with The RN has correctly chartered the dose and time of
inflammation. Corticosteroids produce their effect medication, but there is no documentation regarding
through multiple pathways. In general, they produce non-pharmaceutical measures. What action should you
anti-inflammatory and immunosuppressive effects, take first?
protein and carbohydrate metabolic effects, water and
electrolyte effects, central nervous system effects, and A. Make a note in the nurse’s file and continue to
blood cell effects. observe clinical performance.
Option C: Methylphenidate is given to counteract B. Refer the new nurse to the in-service education
sedation if the client is on opioids. Methylphenidate is department.
FDA-approved for the treatment of attention deficit C. Quiz the nurse about knowledge of pain
hyperactivity disorder (ADHD) in children and adults and management.
as a second-line treatment for narcolepsy in adults. D. Give praise for the correct dose and time and
Children with a diagnosis of ADHD should be at least six discuss the deficits in charting.
years of age or older before being started on this
medication. In supervising the new RN, good performance should be
Option D: Lorazepam is an anxiolytic. Lorazepam has reinforced first and then areas of improvement can be
common use as the sedative and anxiolytic of choice in addressed. Nursing activities are very important within
the inpatient setting owing to its fast (1 to 3 minute) the hospital and must solve the problems that the patient
onset of action when administered intravenously. needs. Every nursing activity should produce
Lorazepam is also one of the few sedative-hypnotics documentation with critical thinking. If nursing
with a relatively clean side effect profile. documents are not clear and accurate, inter-professional
communication and an evaluation of nursing care cannot
be optimal.
54. Which client is most likely to receive opioids for
extended periods of time? Option A: Making a note and watching do not help the
nurse to correct the immediate problem. Nursing activity
A. A client with fibromyalgia that has been completed or that will take place should
B. A client with phantom limb pain be properly documented. Accurate documentation and
C. A client with progressive pancreatic cancer reports play a pivotal role in health services. This
D. A client with trigeminal neuralgia documentation is necessary to identify nursing
interventions that have been provided to patients and to
Cancer pain generally worsens with disease progression show patient progress during hospitalization.
and the use of opioids is more generous. Opioids Option B: In-service might be considered if the problem
(narcotics) are used with or without non-opioids to treat persists. Nursing documentation also serves as an
moderate to severe pain. They are often a necessary effective tool of inter-professional communication
part of a pain relief plan for cancer patients. These between nurses and other health professionals for
medicines are much like natural substances (called delivering ongoing nursing care, evaluating patient
endorphins) made by the body to control pain. They progress and outcomes, and providing constant patient
were once made from the opium poppy, but today many protection. High-quality nursing documentation may
are man-made in a lab. improve the effectiveness of communication between
health professionals in first- and higher-level healthcare
Option A: Fibromyalgia is more likely to be treated with facilities.
non-opioid and adjuvant medications. It is recommended Option C: Asking the nurse about knowledge of pain
to continue nonpharmacologic measures along with the management is also an option; however, it would be a
use of medications for most patients with fibromyalgia. more indirect and time-consuming approach. It is also
Some patients may, however, respond adequately to an indicator of nurse performance and the nursing
nonpharmacologic measures alone. The medications service quality in a hospital. Documentation provides
that have been well studied and consistently effective details of patient condition, nursing interventions that
are certain antidepressants and anticonvulsants.
have been provided, and patient response to the
intervention(s). Option A: Use a person-centered perspective to
formulate collaborative intervention strategies consistent
with a physical therapy perspective. Understand the
56. In caring for a young child with pain, which need to involve family members and significant others
assessment tool is the most useful? including employers where appropriate.
Option B: Demonstrate an ability to integrate the patient
A. Simple descriptive pain intensity scale assessment into an appropriate management plan using
B. 0-10 numeric pain scale the concepts and strategies of clinical reasoning.
C. Faces pain-rating scale Option D: Understand the principles of an effective
D. McGill-Melzack pain questionnaire therapeutic patient/professional relationship to reduce
pain, promote optimal function and reduce disability
The Faces pain rating scale (depicting smiling, neutral, through the use of active and where appropriate,
frowning, crying, etc.) is appropriate for young children passive pain management approaches.
who may have difficulty describing pain or
understanding the correlation of pain to numerical or
verbal descriptors. The Faces Pain Scale-Revised (FPS- 58. Which route of administration is preferred if
R) is a self-report measure of pain intensity developed immediate analgesia and rapid titration are necessary?
for children. It was adapted from the Faces Pain Scale
to make it possible to score the sensation of pain on the A. Intraspinal
widely accepted 0-to-10 metric. The scale shows a close B. Patient-controlled analgesia (PCA)
linear relationship with visual analog pain scales across C. Intravenous (IV)
the age range of 4-16 years. It is easy to administer and D. Sublingual
requires no equipment except for the photocopied faces.
The other tools require abstract reasoning abilities to The IV route is preferred as the fastest and most
make analogies and use of advanced vocabulary. amenable to titration. Medications may be given as
repeated intermittent bolus doses or by continuous
Option A: The Simple Descriptive Scale exhibits infusion. Intravenous provides almost immediate
degrees of pain intensity (no pain, mild pain, moderate analgesia; subcutaneous may require up to 15 minutes
pain, and severe pain). Risk factors for the development for effect. Bolus IV dosing provides a shorter duration of
of chronic pain have been a major topic in pain research action than other routes.
in the past two decades. Now, it has been realized that
psychological and psychosocial factors may Option A: Intraspinal administration requires special
substantially influence pain perception in patients with catheter placement and there are more potential
chronic pain and thus may influence the surgical complications with this route. Intraspinal and
outcome. intraventricular administration are options if maximal
Option B: This pain scale is most commonly used. A doses of opioids and adjuvants administered through
person rates their pain on a scale of 0 to 10 or 0 to 5. other routes are ineffective or produce intolerable side
Zero means “no pain,” and 5 or 10 means “the worst effects {e.g., nausea/vomiting, excessive sedation,
possible pain.” These pain intensity levels may be confusion}. Opioids can be administered via indwelling
assessed upon initial treatment, or periodically after percutaneous or tunneled catheters into the epidural or
treatment. intrathecal space.
Option D: The McGill pain questionnaire, or MPQ, is Option B: A PCA bolus can be delivered; however, the
one of the most widely used multidimensional pain pump will limit the dosage that can be delivered unless
scales in the world. In the MPQ, the evaluation of pain is the parameters are changed. Patient-controlled
divided into three categories: sensory, affective, and analgesia (PCA) devices can be used to combine
evaluative. The questionnaire is self-reported and allows continuous infusion with intermittent bolus doses,
individuals to describe the quality and intensity of their allowing more flexible pain control. It is recommended
pain by using 78 adjectives in 20 different sections. 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,
57. In applying the principles of pain treatment, what is morphine 50 mgs/ml, hydromorphone 50 mgs/ml.
the first consideration? Option D: Sublingual is reasonably fast, but not a good
route for titration, medication variety in this form is
A. Treatment is based on client goals. limited. An alkaline pH microenvironment that favors the
B. A multidisciplinary approach is needed. unionized fraction of opioids increased sublingual drug
C. The client must believe in perceptions of own absorption. Although absorption was found to be
pain. independent of drug concentration, it was contact time
D. Drug side effects must be prevented and managed. dependent for methadone and fentanyl but not for
buprenorphine. These results indicate that although the
The client must be believed and his or her experience of sublingual absorption and apparent sublingual
pain must be acknowledged as valid. The data gathered bioavailability of morphine are poor, the sublingual
via client reports can then be applied to other options in absorption of methadone, fentanyl, and buprenorphine
developing the treatment plan. Assist patients to develop under controlled conditions is relatively high.
a daily routine to support achievement and, where
necessary, readjustment of habits and roles according to
individual capacity and life situation.
59. When titrating an analgesic to manage pain, what is Mindfulness meditation is a fairly loose term that applies
the priority goal? to many meditation practices, which have been found to
improve a wide spectrum of clinically relevant cognitive
A. Administer smallest dose that provides relief and health outcomes.
with the fewest side effects. Option D: Transcutaneous electrical stimulation is
B. Titrate upward until the client is pain-free. usually applied by a physical therapist. Transcutaneous
C. Titrate downwards to prevent toxicity. electrical nerve stimulation (TENS) is a therapy that
D. Ensure that the drug is adequate to meet the client’s uses low voltage electrical current to provide pain relief.
subjective needs. A TENS unit consists of a battery-powered device that
delivers electrical impulses through electrodes placed on
The goal is to control pain while minimizing side effects. the surface of your skin. The electrodes are placed at or
The World Health Organization cancer pain ladder near nerves where the pain is located or at trigger
provides a helpful starting point for achieving effective points.
pain management. Clinicians should begin with
nonopioid analgesics (e.g., acetaminophen, nonsteroidal
anti-inflammatory drugs [NSAIDs]), and gradually 61. Place the examples of drugs in the order of usage
progress to more potent analgesics until pain is relieved. according to the World Health Organization (WHO)
analgesic ladder.
Option B: For severe pain, the medication can be
titrated upward until pain is controlled. Many patients NSAIDs and corticosteroids
with terminal illnesses require immediate opioid therapy Codeine, oxycodone, and diphenhydramine
or have contraindications to common non-opioid Morphine, hydromorphone, acetaminophen, and
analgesics, such as NSAIDs. lorazepam
Option C: Downward titration occurs when the pain
begins to subside. Acetaminophen is useful as a primary The WHO analgesic ladder was a strategy proposed by
analgesic, or in combination with other drugs, for the World Health Organization (WHO), in 1986, to
treating mild to moderate pain. Dosages in healthy provide adequate pain relief for cancer patients. The
persons should be limited to no more than 4,000 mg analgesic ladder was part of a vast health program
every 24 hours to reduce the risk of hepatotoxicity. termed the WHO Cancer Pain and Palliative Care
Option D: Adequate dosing is important; however, the Program aimed at improving strategies for cancer pain
concept of controlled dosing applies more to potent management through educational campaigns, the
vasoactive drugs. The World Health Organization pain creation of shared strategies, and the development of a
ladder offers a stepwise guideline for approaching pain global network of support.
management. However, for many patients with terminal
illnesses, strong opioids are necessary for efficient and Step 1 includes non-opioids and adjuvant drugs. Mild
effective analgesia. pain: non-opioid analgesics such as nonsteroidal anti-
inflammatory drugs (NSAIDs) or acetaminophen with or
without adjuvants.
60. In educating clients about non-pharmaceutical Step 2 includes opioids for mild pain plus Step 1 drugs
alternatives, which topic could you delegate to an and adjuvant drugs as needed. Moderate pain: weak
experienced LPN/LVN, who will function under your opioids (hydrocodone, codeine, tramadol) with or without
continued support and supervision? non-opioid analgesics, and with or without adjuvants.
Step 3 includes opioids for severe pain (replacing Step 2
A. Therapeutic touch opioids) and continuing Step 1 drugs and adjuvant drugs
B. Use of heat and cold applications as needed. Severe and persistent pain: potent opioids
C. Meditation (morphine, methadone, fentanyl, oxycodone,
D. Transcutaneous electrical nerve stimulation (TENS) buprenorphine, tapentadol, hydromorphone,
oxymorphone) with or without non-opioid analgesics,
Use of heat and cold applications is a standard therapy and with or without adjuvants.
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 62. Which client is at greater risk for respiratory
with hot and cold can be extremely effective for a depression while receiving opioids for analgesia?
number of different conditions and injuries, and easily
affordable. The tricky part is knowing what situations call A. An elderly chronic pain client with a hip fracture.
for hot, and which calls for cold. Sometimes a single B. A client with heroin addiction and back pain.
treatment will even include both. C. A young female client with advanced multiple
myeloma.
Option A: Therapeutic touch requires additional training D. A child with an arm fracture and cystic fibrosis.
and practice. The National Center for Complementary
and Alternative Medicine places therapeutic touch (TT) At greatest risk are elderly clients, opiate naïve clients,
into the category of bio-field energy. In the TT method, and those with underlying pulmonary disease. The child
the therapist’s hand is used to increase comfort and has two of the three risk factors. Many complications
reduce pain using the body’s energy field correction can occur with multiple different opioids, such as non-
mechanism cardiogenic pulmonary edema, while many of the
Option C: Meditation is not acceptable to all clients and complications are unique to the opioid used as well as
an assessment of spiritual beliefs should be conducted. the route of administration.
 64. A client is being tapered off opioids and the nurse is
Option A: Pain in the elderly population is especially watchful for signs of withdrawal. What is one of the first
difficult given the myriad of physiological, signs of withdrawal?
pharmacological, and psychological aspects of caring for
geriatric patient. Opiates are the mainstay of pain A. Fever
treatment throughout all age groups but special attention B. Nausea
must be paid to the efficacy and side effects of these C. Diaphoresis
powerful drugs when prescribing to a population with D. Abdominal cramps
impaired metabolism, excretion, and physical reserve.
Option B: Prescription opioids and heroin are Diaphoresis is one of the early signs that occur between
chemically similar and can produce a similar high. In 6 and 12 hours. Fever, nausea, and abdominal cramps
some places, heroin is cheaper and easier to get than are late signs that occur between 48 and 72 hours.
prescription opioids, so some people switch to using According to Diagnostic and Statistical Manual of Mental
heroin instead. More recent data suggest that heroin is Disorders (DSM–5) criteria, signs, and symptoms of
frequently the first opioid people use. In a study of those opioid withdrawal include lacrimation or rhinorrhea,
entering treatment for opioid use disorder, approximately piloerection “goose flesh,” myalgia, diarrhea,
one-third reported heroin as the first opioid they used nausea/vomiting, pupillary dilation and photophobia,
regularly to get high. insomnia, autonomic hyperactivity (tachypnea,
Option C: Bone pain is one of the most common hyperreflexia, tachycardia, sweating, hypertension,
presentations of multiple myeloma and nearly all hyperthermia), and yawning.
patients have skeletal involvement in the course of the
disease. Consequently, many patients require narcotics Option A: A fever can be a withdrawal symptom among
for symptom management at the time of diagnosis but people who have been addicted to various substances,
the long-term impact of MM treatment on pain control or even after a period of intense substance use. Fever
remains uncertain. 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
63. A client appears upset and tearful, but denies pain be a component of a particularly dangerous type of
and refuses pain medication, because “my sibling is a alcohol withdrawal.
drug addict and has ruined our lives.” What is the priority Option B: Prolonged use of these drugs changes the
intervention for this client? way nerve receptors work in the brain, and these
receptors become dependent upon the drug to function.
A. Encourage expression of fears on past If the client becomes physically sick after he stops taking
experiences. an opioid medication, it may be an indication that he’s
B. Provide accurate information about the use of pain physically dependent on the substance.
medication. Option D: The symptoms the client is experiencing will
C. Explain that addiction is unlikely among acute care depend on the level of withdrawal he is experiencing.
clients. Also, multiple factors dictate how long a person will
D. Seek family assistance in resolving this problem. experience the symptoms of withdrawal. Because of
this, everyone experiences opioid withdrawal differently.
This client has strong beliefs and emotions related to the However, there’s typically a timeline for the progression
issue of sibling addiction. First, encourage expression. of symptoms.
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 65. In caring for clients with pain and discomfort, which
environment may help the client come to terms with task is most appropriate to delegate to the nursing
unresolved issues. assistant?

Option B: Giving facts and information is appropriate at A. Assist the client with preparation of a sitz bath.
the right time. Clients are often reluctant to share B. Monitor the client for signs of discomfort while
feelings for fear of ridicule and may have repeatedly ambulating.
been told to ignore feelings. Once the client begins to C. Coach the client to deep breathe during painful
acknowledge and talk about these fears, it becomes procedures.
apparent that the feelings are manageable. D. Evaluate relief after applying a cold application.
Option C: Encourage the client to explore underlying
feelings that may be contributing to irrational fears. Help The nursing assistant is able to assist the client with
the client to understand how facing these feelings, rather hygiene issues and knows the principles of safety and
than suppressing them, can result in more adaptive comfort for this procedure. Proper and appropriate
coping abilities. assignments facilitate quality care. Improper and
Option D: Family involvement is important, bearing in inappropriate assignments can lead to poor quality of
mind that their beliefs about drug addiction may be care, disappointing outcomes of care, the jeopardization
similar to those of the client. Present and discuss the of client safety, and even legal consequences.
reality of the situation with the client in order to Monitoring the client, teaching techniques, and
recognize aspects that can be changed and those that evaluating outcomes are nursing responsibilities.
cannot. The client must accept the reality of the situation
before the work of reducing the fear can progress. 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 67. For a cognitively impaired client who cannot
licensed practical nurse that are outside of the scope of accurately report pain, what is the first action that you
practice of the licensed practical nurse, the client is in should take?
potential physical and/or psychological jeopardy
because this delegated task, which is outside of the A. Closely assess for nonverbal signs such as
scope of practice for this licensed practical nurse, is grimacing or rocking.
something that this nurse was not prepared and B. Obtain baseline behavioral indicators from family
educated to perform. members.
Option C: Coaching the client to deep breathe during C. Look at the MAR and chart, to note the time of the
painful procedures is a nursing responsibility. The nurse last dose and response.
who delegates aspects of care to other members of the D. Give the maximum PRS dose within the minimum
nursing team must balance the needs of the client with time frame for relief.
the abilities of those to which the nurse is delegating
tasks and aspects of care, among other things such as Complete information from the family should be obtained
the scopes of practice and the policies and procedures during the initial comprehensive history and
within the particular healthcare facility. assessment. If this information is not obtained, the
Option D: Evaluation of relief after applying a cold nursing staff will have to rely on observation of
application is a nursing responsibility. The staff nonverbal behavior and careful documentation to
members’ levels of education, knowledge, past determine pain and relief patterns.
experiences, skills, abilities, and competencies are also
evaluated and matched with the needs of all of the Option A: Pain can be difficult to assess in cognitively
patients in the group of patients that will be cared for. impaired individuals because their self-reports of pain
can be inaccurate or difficult to obtain. Thus, behavioral
observation-based assessment is optimal in these
66. The physician has ordered a placebo for a chronic patients.
pain client. You are a newly hired nurse and you feel Option C: Assess potential causes of pain. The clinician
very uncomfortable administering the medication. What should consider pathological causes of pain and any
is the first action that you should take? procedure known to cause pain. Address any pain
history from family, significant others, and caregivers.
A. Prepare the medication and hand it to the physician. Option D: Use scheduled dosing when pain is chronic
B. Check the hospital policy regarding the use of the and/or when the patient is unable to ask for medication.
placebo. When administering the medication, it is best to start
C. Follow a personal code of ethics and refuse to give with a lower dose and gradually increase the dose to
it. alleviate the pain.
D. Contact the charge nurse for advice.

A charge nurse is a resource person who can help 68. Which route of administration is preferable for
locate and review the policy. If the physician is insistent, administration of daily analgesics (if all body systems
he or she could give the placebo personally, but are functional)?
delaying the administration does not endanger the
health or safety of the client. A. IV
B. IM or subcutaneous
Option A: In a treatment setting it is unethical to C. Oral
deliberately misinform the patient. However, placebo D. Transdermal
effects can be an important factor in a biopsychosocial E. PCA
context. Clinicians need to consider some ethical issues
relating to placebo effects. According to Pittrof and If the gastrointestinal system is functioning, the oral
Rubenstein, the ethical use of placebo effects should route is preferred for routine analgesics because of
always benefit the patient and involve disclosure. lower cost and ease of administration. Oral route is also
Option B: Placebo effects may thus be defined as less painful and less invasive than the IV, IM,
psychological and/or physiological responses that follow subcutaneous, or PCA routes. Although a few drugs
the administration of active and non-active substances taken orally are intended to be dissolved in the mouth,
when coupled with an affirmation of the treatment nearly all drugs taken orally are swallowed. Of these,
effects. The ethical use of placebo effects in a clinical most are taken for the systemic drug effects that result
setting should rely on realistic expectations and be after absorption from the various surfaces along the
based on best practice. The use of a placebo in clinical gastrointestinal tract.
settings might still be seen as controversial by some.
Option C: While following one’s own ethical code is Option A: IV therapy allows a higher concentration of
correct, you must ensure that the client is not nutrients or medication into the body — and that means
abandoned and that care continues. Placebo effects, the body gets what it needs faster and more effectively
when considered as supplements to pharmacologically without further damage to the GI system.
active substances, should aim to increase patients’ well- Option B: Rapid and uniform absorption of the drug
being. It is unethical to deliberately misinform patients. 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 The side-lying, knee-chest position opens
availability is limited compared to oral forms. retroperitoneal space and provides relief. The pillow
Transdermal delivery systems provide continuous provides a splinting action. Reduces abdominal pressure
administration of drugs through the skin, which and tension, providing some measure of comfort and
maintains constant plasma drug levels and avoids the pain relief. Note: Supine position often increases pain.
peaks and troughs that are seen with oral
administration. Option A: Diversional therapy is not the best choice for
Option E: Patient-controlled analgesia is used to treat acute pain, especially if the activity requires
acute, chronic, postoperative, and labor pain. A variety concentration. Keep the environment free of food odors.
of medications can be used for patient-controlled Sensory stimulation can activate pancreatic enzymes,
analgesia and are administered intravenously (IV), increasing pain.
through an epidural or peripheral nerve catheter, and Option B: The additional stimulation of massage may
transdermally. be distressing to the client. Provide alternative comfort
measures (back rub), encourage relaxation techniques
(guided imagery, visualization), quiet diversional
69. A first-day postoperative client on a PCA pump activities (TV, radio).
reports that the pain control is inadequate. What is the Option D: TENS is more appropriate for chronic
first action you should take? muscular pain. Maintain bed rest during an acute attack.
Provide a quiet, restful environment. Decreases
A. Deliver the bolus dose per standing order. metabolic rate and GI stimulation and secretions,
B. Contact the physician to increase the dose. thereby reducing pancreatic activity.
C. Try non-pharmacological comfort measures.
D. Assess the pain for location, quality, and
intensity. 71. What is the best way to schedule medication for a
client with constant pain?
Assess the pain for changes in location, quality, and
intensity, as well as changes in response to medication. A. PRN at the client’s request
This assessment will guide the next steps. Patient- B. Prior to painful procedures
controlled analgesia is used to treat acute, chronic, C. IV bolus after pain assessment
postoperative, and labor pain. A variety of medications D. Around-the-clock
can be used for patient-controlled analgesia and are
administered intravenously (IV), through an epidural or If the pain is constant, the best schedule is around-the-
peripheral nerve catheter, and transdermally. clock, to provide steady analgesia and pain control. The
other options may actually require higher doses to
Option A: The goal of PCA is to efficiently deliver pain achieve control. Pain medication prescribed around-the-
relief at a patient’s preferred dose and schedule by clock has the purpose of managing a patient’s baseline
allowing them to administer a predetermined bolus dose pain, which is the average pain intensity the patient
of medication on-demand at the press of a button. Each experiences. This is generally pain that is continuously
bolus can be administered alone or coupled with a experienced.
background infusion of medication.
Option B: The initial loading dose can be titrated by a Option A: The use of “as needed” or “pro re nata”
nurse to reach the minimum effective concentration (PRN) range opioid analgesic orders is a common
(MEC) of the desired medication. The bolus or demand clinical practice in the management of acute pain,
dose is the dose of medication delivered each time the designed to provide flexibility in dosing to meet an
patient presses the button. A lockout interval is the time individual’s unique needs. Range orders enable
after a demand dose in which a dose of medication will necessary adjustments in doses based on individual
not get administered even if the patient presses the response to treatment.
button; this is done to prevent overdosing. Option B: Of particular importance to nursing care,
Option C: The use of PCA has been proven to be more unrelieved pain reduces patient mobility, resulting in
effective at pain control than non-patient-controlled complications such as deep vein thrombosis, pulmonary
opioid injections and results in higher patient embolism, and pneumonia. Postsurgical complications
satisfaction. PCA has also been found to be preferred by related to inadequate pain management negatively
nurses because it allows for a reduction in their affect the patient’s welfare and the hospital performance
workload. PCA will enable patients to be in more control because of extended lengths of stay and readmissions,
over their pain and helps them shift toward a more both of which increase the cost of care.
internal locus of control over their 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
70. Which non-pharmacological measure is particularly lack of pain assessment was one of the most
useful for a client with acute pancreatitis? problematic barriers to achieving good pain control. The
most critical aspect of pain assessment is that it is done
A. Diversional therapy, such as playing cards or board on a regular basis (e.g., once a shift, every 2 hours)
games. using a standard format. The assessment parameters
B. Massage the back and neck with warmed lotion. should be explicitly directed by hospital or unit policies
C. Side-lying position with knees to chest and and procedures.
pillow against the abdomen.
D. Transcutaneous electrical nerve stimulation (TENS).
72. Which client(s) are appropriate to assign to the range 3.5-5.0 mEq/L). If bleeding signs are noted,
LPN/LVN, who will function under the supervision of the hematocrit should be monitored (normal range male
RN or team leader? Select all that apply. 42%-52%, female 37%-47%). An elevated BUN could
be seen if the client is having chronic gastrointestinal
A. A client who needs pre-op teaching for use of a PCA bleeding (normal range 10-20 mg/dL).
pump.
B. A client with a leg cast who needs neurologic Option A: Severity is categorized as mild when the
checks and PRN hydrocodone. serum potassium level is 3 to 3.4 mmol/L, moderate
C. A client post-op toe amputation with diabetic when the serum potassium level is 2.5 to 3 mmol/L, and
neuropathic pain. severe when the serum potassium level is less than 2.5
D. A client with terminal cancer and severe pain who is mmol/L. Values obtained from plasma and serum may
refusing medication. differ.
Option B: HCT calculation is by dividing the lengths of
The clients with the cast and the toe amputation are the packed RBC layer by the length of total cells and
stable clients and need ongoing assessment and pain plasma. As it is a ratio, it doesn’t have any unit.
management that are within the scope of practice for an Multiplying the ratio by 100 gives the accurate value,
LPN/LVN under the supervision of an RN. The RN which is the accepted reporting style for HCT. A normal
should take responsibility for preoperative teaching, and adult male shows an HCT of 40% to 54% and female
terminal cancer needs a comprehensive assessment to shows 36% to 48%.
determine the reason for refusal of medication. Option D: BUN and creatinine levels that are within the
ranges established by the laboratory performing the test
Option A: Preoperative teaching is a nursing suggest that the kidneys are functioning as they should.
responsibility. Proper and appropriate assignments Increased BUN and creatinine levels may mean that the
facilitate quality care. Improper and inappropriate kidneys are not working as they should. This healthcare
assignments can lead to poor quality of care, practitioner will consider other factors, such as the
disappointing outcomes of care, the jeopardization of medical history and physical exam, to determine what
client safety, and even legal consequences. condition, if any, may be affecting the kidneys.
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 74. Which client would be appropriate to assign to a
nurse’s responsibility for the performance of a task to newly graduated RN, who has recently completed
another nursing staff member while retaining orientation?.
accountability for the outcome. Responsibility can be
delegated. Accountability cannot be delegated. The A. An anxious, chronic pain client who frequently uses
delegating registered nurse remains accountable for all the call button.
client care despite the fact that some of these aspects of B. A client second-day post-op who needs pain
care can, and are, delegated to others. medication prior to dressing changes.
Option C: The client with the toe amputation is a stable C. A client with HIV who reports headache and
client and needs ongoing assessment and pain abdominal and pleuritic chest pain.
management that are within the scope of practice for an D. A client who is being discharged with a surgically
LPN/LVN under the supervision of an RN. The staff implanted catheter.
members’ levels of education, knowledge, past
experiences, skills, abilities, and competencies are also A second-day postoperative client who needs
evaluated and matched with the needs of all of the medication prior to dressing changes has predictable
patients in the group of patients that will be cared for. and routine care that a new nurse can manage. Some
Option D: A client with terminal cancer and severe pain staff members may possess greater expertise than
who is refusing medication is a nursing responsibility. others. Some, such as new graduates, may not possess
Based on these characteristics and the total client needs the same levels of knowledge, past experiences, skills,
for the group of clients that the registered nurse is abilities, and competencies that more experienced staff
responsible and accountable for, the registered nurse members possess.
determines and analyzes all of the health care needs for
a group of clients; the registered nurse delegates care Option A: Although clients with chronic pain can be
that matches the skills of the person that the nurse is relatively stable, the interaction with this client will be
delegating to. 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,
73. For a client who is taking aspirin, which laboratory and priority setting skills, therefore, are essential to the
value should be reported to the physician? complete and effective provision of care to an individual
client and to a group of clients.
A. Potassium 3.6 mEq/L Option C: The client with HIV has complex complaints
B. Hematocrit 41% that require expert assessment skills. Staff members
C. PT 14 seconds differ in terms of their knowledge, skills, abilities, and
D. BUN 20 mg/dL competencies. A staff member who has just graduated
as a certified nursing assistant and a newly graduated
When a client takes aspirin, monitor for increases in PT registered nurse cannot be expected to perform patient
(normal range 11.0-12.5 seconds in 85%-100%). Also, care tasks at the same level of proficiency, skill, and
monitor for possible decreases in potassium (normal competency as an experienced nursing assistant or
registered nurse. It takes time for new graduates to
refine the skills that they learned in school.
Option D: The client pending discharge will need
special and detailed instructions. Validated and
documented competencies must also be considered
prior to assignment of patient care. No aspect of care
can be assigned or delegated to another nursing staff
member unless this staff member has documented
evidence that they are deemed competent by a
registered nurse to do so.

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

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

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

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

Directly ask the client about the pain and do a complete

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

Option A: Poorly managing pain may put clinicians at

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