Case Situation: Mrs.Sera Sommers, 63 y.o has a reoccurrence of psoriasis on her scalp, elbows and trunk.She is being seen by a practical nurse in her home. 1. Which one of the following observations regarding Mrs. Sommers skin is most important for practical nurse to report? 1. 2. 3. 4. red, cracked silvery, scaly pale itchy dry scaly 2. Which of the following actions by the practical nurse will best promote a safe therapeutic tub bath for Mrs. Sommers? 1. 2. 3. 4. Prepare the bath and assist Mrs Sommers in and out of the tub leave Mrs Sommers in the bathroom to ensure privacy Adk Mrs sommers to undress in the bathroom to observe the skin lesions Give Mrs sommers towels and tell her to dry well. 3. Which one of the following actions by the practical nurse is a priority for preventing Mrs sommers from developing a skin infection? 1. 2. 3. 4. Wash hands carefully before Mrs sommers care Encourage her to change her undergarments twice a day Instruct her to change her bed linen once a day Use sterile gloves when providing her care. 4. Mrs.sommers remains quietly in her chair and is refusing to attend her community social activities. She looks into her hand mirror frequently. Which one of the following approaches by the PN will best assist her to interact socially? 1. Tell mrs. Sommers that there is nothing wrong with her appearance 2. advice Mrs. Sommers how important it is to maintain her social activities 3. gain the support of mrs. Sommers family 4. encourage her to verbalize her feelings. 5. Case information: Sanddy smith is an 18 y.o client who is pregnant for the first time. Which one of the following instructions would be most appropriate for the PN to give sandy with regard to nutrition during pregnancy? 1. 2. 3. 4. it is important to have enough nutrients as you will be eating for two eat a balanced diet that includes foods rich in iron the goal of your diet is to minimize your weight gain you are probably already obtaining the nutrients you need. 6. Sandy has developed high blood pressure and is hospitalized. Which one of the following measures by the PN would be most effective to reduce sandy’s anxiety? 1. 2. 3. 4. initiate a discussion of her concerns post a no visitors sign on her door reassure her that everything will be allright encourage her friends to visit. 7. Sandys pregnancy progresses to term. She has a vaginal delivery of a health baby boy and is transferred to the postpartum unit. In addition to vital signs, which of the following data are most important for the PN to assess in Sandys immediate postpartum period? 1. fundus, lochia, perineum 2. breasts, hemorrhoids, voiding 3. breasts, fundus, voiding 4. perineum, hemorrhoids, lochia 8. During the delivery, Sandy had an episiotomy. Which of the follwing information is most appropriate for the PN to give Sandy in regard to taking a sitz bath? 1. 2. 3. 4. The sitz bath is used to cleanse and soothe the perineum the sitz bath should be taken before meals try to take your sitz bath once a day the sitz bath should be as hot as you can tolerate. 9. Sandy has decide to breastfeed her baby. Which one of the following actions by the PN would most effectively provide emotional support to sandy? 1. 2. 3. 4. assure sally that she made the right decision encourage sandy’s breastfeeding efforts by providing assistance inform sandy that the public health nurse will provide guidance at home provide sandy with written information on breastfeeding. 10. case information: Ralph white, 55 y.o., has COPD. Which one of the following manifestations is mr. White most like to experience? 1. 2. 3. 4. severe chest pain severe dyspnea on exertion pleural friction rub hemoptysis 11. Mr. White tells the PN that his wife died a year ago. Which one of the following responses by th PN would be most appropriate? 1. 2. 3. 4. I know how you feel. I lost my mother 3 years ago. That’s too bad. Can I get you a cup of tea? How have you been coping? Was this your first loss? 12. Mr white tells the nurse that he is having difficulty sleeping at night. Which one of the following suggestions by the Pn would be most appropriate? 1. 2. 3. 4. postpone bedtime until later in the evening have a cup of hot chocolate before retiring sleep with the bed flat sleep with the head of the bed raised. 13. According to Mr. Whites care plan, he is to increase his activity level gradulally. Which one of the following actions by the PN would best encourage his participation? 1. 2. 3. 4. plan mr white’s activity schedule with him take him for walks three times a shift inform him the physician wants him to walk more arrange for mr white to see the PT 14. Mr. White has discussed with the dietician ways to obtain adequate nutrition. Which one of the following would be a recommendation by the dietician that the PN should reinforce? 1. 2. 3. 4. eat 3 large meals a day eat small frequent meals avoid high-calorie liquid supplements avoid a high protein intake 15. Case information: John Adams is a 34 y.o client who experienced a compound fracture of his right humerus at work. He has just been transferred from the postoperative recovery room to the nursing unit following a closed reduction. The PN is admitting John. His colour is pale and he is drowsy. Which of the following nursing actions should be the first priority for the PN? 1. 2. 3. 4. Take his vital signs, obtain an oxygen set-up, and assess IV Report to the appropriate person, asses the operative site, and obtain an oxygen setup Have him deep breaths, take his vital signs and assess the operative site Report to the appropriate person for a directive, asses the operative site and have him take deep breaths. 16. A cast is applied to John’s arm and a sling is used for support. Which one of the following actions by the PN would best promote his level of comfort? 1. 2. 3. 4. Elevate the head of his bed 45 degrees Assist him into a supine position with his arm elevated Assist him into a lateral position on his non-operative site Teach him to splint his arm when he deep breathes 17. While caring for John, which one of the following manifestations should the PN report immediately? 1. 2. 3. 4. chest pain absence of bowel sounds edematous hand a capillary refill of less than 3 seconds 18. The PN has requested the assistance of a colleague to move John up in bed. Which of the following statements best describe the most efficient procedure? 1. 2. 3. 4. One person moves John’s upper body while the other person moves his lower body Each person one on each side, pulls the lifting or turning sheet while John pushes his heels Both staff face John, one person lifts one shoulder and the other person lifts the other shoulder The staff divide the lifting load evenly between their arms and use the large muscles of their legs. 19. As part of discharge instructions, the PN is teaching john to apply his own sling. Which one of the following instructions should the PN provide when explaining the position of the hand of the casted arm? 1. 2. 3. 4. The fingertips should touch the clavicle on the opposite shoulder the hand should be slightly higher than the elbow of the same arm The fingertips should be at level of the elbow of the unaffected arm the hand should be placed approximately at the level of the umbilicus. 20. Case information: Jannie,an 18 y.o. female client diagnosed with diabetes, is admitted to hospital ina diabetic coma. After being stabilized, she tells the nurse that she doesn’t always take her insulin. Jannie lives on the street, smokes heavily and has poor hygiene. Which one of the following ctions is most important for the practical nurse to take after Jannie’s diabetic coma? 1. 2. 3. 4. test urine for ketones prior to meals. explain that early manifestations of hyperglycemia are excessive thirst and urination assess feelings of weakness, diaphoresis and shakiness as manifestations of ketoacidosis Instruct Janie to report occurrences of “not feeling like herself” to the physician. 21. Jannies feet are dirty and have numerous calluses from walking barefoot. Which one of the following actions should the PN take when teaching Jannie about foot care? 1. Tell her she must wash her feet daily with lukewarm water and a mild soap 2. Suggest that she file her calluses and toenails regularly 3. Advise her that wearing shoes will prevent foot problems. 4. Explain that walking barefoot can cause injury and infection. 22. Which one of the following suggestions should the PN make when teaching to maintain adequate circulation? 1. 2. 3. 4. rub her feet with alcohol avoid tobacco use take baths with oil apply baby powder between her toes. 23. The PN observed that Jannie received her insulin but missed her breakfast. What should the pN do initially? 1. 2. 3. 4. Continue to observe her for a possible insulin reaction Ensure that Jannie receives a substitute meal document in nurses notes Jannies missed breakfast encourage her to eat a full meal at lunch time. 24. Jannie states, “I just can’t deal with this diabetes anymore.” Which one of the following statements would be most appropriate for the nurse to make? 1. Did you know that you can lead a normal life even though you have diabetes 2. Having diabetes is difficult for you, tell me more about that. 3. I understand how you are feeling because I have looked after many young people with diabetes. 4. It is very important that you accept your illness and learn to live with it. 25.Jannie asks the PN if she can leave the hospital to go out with her friends for a few hours. Which one of the following actions by the nurse is most appropriate? 1. 2. 3. 4. Grant Jannie’s request in order to respect her right to autonomy Refuse her request in order to be responsible for her safety verify the physician’s order for a hospital pass for Jannie Explain to Jannie that she cannot leave the hospital until her test result have been evaluated. 25. Case information: Joni, 9 years old, is admitted from the emergency following a severe asthma attack. She is sitting up in bed and has O2 running per nasal prongs. She is able to give necessary information during her initial assessment and she tells the nurse that when she eats eggs, dairy products and bread, she usually has an asthma attack. When assessing Joni’s respiratory status, which one of the following assessments would best indicate that she is in respiratory distress? 1. the use of accessory muscles for breathing 2. a respiratory rate of 26 breaths per minute 3. the ability to speak in sentences of 6-8 words 4. a frequent harsh cough 26. Joni says that she is getting really mad because she cannot eat the same foods as her friends eat without getting sick. Which one of the following responses should let Joni know that the nurse understands how she is feeling? 1. I know this makes youy mad now, but you will probably outgrow your asthma and then you can eat anything you want 2. Would you like me to give you a list of the foods you can eat safely? 3. I know you are mad now, but when you are feeling better, it will not bother you so much 4. It must be difficult not being able to eat the foods you like. 27. Joni is receiving oxygen. Which one of the following statements is coreect regarding oxygen administration? 1. 2. 3. 4. Oxygen flowrate should be verified with the physician’s order. Oxygen tubing should be changed once per shift Joni must be in semi-fowlers position when receiving oxygen oxygen should be gradually increased until the ordered level is reached. 28. When discussing food choices with Joni, which one of the following foods should th PN teach her to avoid? 1. 2. 3. 4. chicken with rice soup turkey sandwich green salad jello 29. Joni having difficulty getting to sleep at night. Which one of the following measures taken by the nurse would be most effective in helping her got o sleep? 1. 2. 3. 4. offer her a glass of milk allow her to stay up an hour later play her favorite music quietly suggest playing a board game with another child. 30. Case information: The PN is visiting Mrs Barton, a 64 y.o. home care client. Mrs Barton describes a heavy feeling in her abdomen and burning on voiding. She states that she has to go to the bathroom several times throughout the night. The practical nurse assesses her for a urinary tract infection. Which of the following signs must be reported immediately? 1. urinary frequency 2. types of fluids taken in the past 24 hours 3. hematuria 4. irritation of the perineum 31. Mrs. Barton is diagnosed with a UTI and is placed on medication BID. Which of the following statements should the nurse make to encourage Mrs. Barton to consistently take her medication? 1. 2. 3. 4. If you don’t take your medication twice a day, you will need to be hospitalized Your medication must be taken regularly to prevent further infections make sure you take the medication until you feel better try to take the medication first thing in the morning and at bedtime. 32. Mrs. Barton states that she feels she is not emptying her bladder. What approach should the PN take to promote her comfort when palpating her bladder? 1. Have her take slow deep breaths during the procedure 2. Place her ina dorsal recumbent position with knees flexed 3. place her npo prior to procedure 4. encourage her to drink cranberry juice prior to procedure. 33. Mrs. Barton states that she feels she is not emptying her bladder. What approach should the practical nurse take to promote her confort when palpating her bladder? 1. 2. 3. 4. Have Mrs Barton take slow deep breaths during the procedure Place her in a dorsal recumbent position with knees flexed Place her on npo prior to procedure encourage her to drink cranberry juice prior to procedure 34. What should the practical nurse do to maintain asepsis when palpating her bladder? 1. 2. 3. 4. wear disposable gloves wear sterile gloves perform pericare wash hands 35. Barton develops abdominal pain and is unable to void. Her BP begins to fall, her pulse is weak and rapid, and she has cold, clammy skin. What should the PN expect to find when assessing her respirations? 1. 2. 3. 4. bradynea tachypnea cheyne-stokes respirations kussmaul’s breathing 36. When should the pN update the home care coordinator regarding her decreasing BP, and weak and rapid pulse? 1. 2. 3. 4. at the end of the shift following the home visit at team report following morning immediately following the assessment 37. Case information: Mrs. Saunders, 42 y.o. finds a lump in her breast while performing a monthly breast assessment. A biopsy and possible mastectomy are recommended. She comes to the surgical unit on the morning of the surgery accompanied by her husband and 7-y.o. Which information is most important to report and record during her admission and assessment? 1. 2. 3. 4. family support religious affiliation occupation community resources 38. Her biopsy was positive and a left mastectomy was performed. What should the pN do while assisting her with her postoperative breathing exercises? 1. 2. 3. 4. ASK her to turn on her right side, and then breathe deeply. Assist her into the low-fowler’s position and then ask her to take short breaths Splint her left upper thoracic region, and then ask her to breathe deeply Support her entire thoracic region, and then ask her to take short breaths. 39. Mrs. Saunders is concerned about her present appearance and th type of clothing needed to camouflage the loss of her breast. Which one of the following responses should the PN give to Mrs. Saunders? 1. It si unlikely that anyone will notice a difference in your appearance, your grooming is impeccable. 2. You may want to try a temporary prosthesis that is worn under your clothing until you are healed. 3. If you are considering having reconstructive surgery, you do not need to make any changes in your clothing now. 4. You may want to change your hairstyle to draw attention away from the operative site. 40. She is receiving post-mastectomy chemotherapy and steroids. She has read that this treatment may cause weight gain. She does not want to gain weight and is not eating her meals. What should the PN do? 1. 2. 3. 4. Investigate her concerns further, report the finding and record the data related to food intake reassure her that not all clients gain weight, and encourage more food intake suggest to her that she consult a nutrition specialist and weigh herself daily encourage her to get more exercise and suggest a low-fat, low-salt, low-sugar diet. 41. Case information: Mrs. Johanson, 68 y.o. has pneumonia and is orthopneic. The PN is asked to collect a sputum specimen from mr. Johanson. What is the most appropriate collection time? 1. 2. 3. 4. after providing mouthcare immediately following A.M. care at bedtime before breakfast 42. The PN is asked to monitor his urinary output. What amount of urine output per hour should the PN report immediately? 1. 2. 3. 4. 15 45 60 70 ml ml ml ml 43. The physician has ordered him to ambulate to the bathroom. Which of the following findings should indicate to the PN that is not tolerating the increase in activity? 1. 2. 3. 4. he becomes flushed his heart rate is lower he becomes agitated his respiratory rate decreases 44. He tells the PN, “no one took the time to answer my call last night. “Which one of the following responses by the PN would be most appropriate? 1. 2. 3. 4. we were really short staffed last night. I’m sorry you felt alone. It sounds like you had a particularly difficult night last night? were you aware that the client next room was very sick last night? I’m sorry. I know how it feels when no one takes the time to respond. 45. Which one of the following is the primary reason why a PN should engage in continuouis learning? 1. 2. 3. 4. continuous learning activities contribute to the practical nurse’s overall mental health opportunities for career advancement for the PN will improve contact with other professionals will shape new ideas and opinions past learning is enhanced by knowledge of current trends and new technologies. 46. Pamela Flannigan and her newborn are to be discharged. She has started breastfeeding her baby and asks the PN whom she should contact if she has questions. Which one of the following responses would be most appropriate? 1. There are community services set up to address the needs of breastfeedig moms 2. your family doctor is your primary caregiver and will need to speak with you about breastfeeding 3. any health professionals can help you with breastfeeding. Breastfeeding is a very natural activity 4. clinics for breastfeeding moms are set up only when the mom runs into difficulty 47. Which of the following best defines informed consent? 1. 2. 3. 4. it it it it is the responsibility of the person performing the procedure may be verbal or written, except in an emergency prevents delays in completing diagnostic or surgical procedures is only required when clients are scheduled for surgery. 48. Which of the following chest assessment findings are characteristics of a healthy 82 y.o. male client? 1. 2. 3. 4. round-shaped chest, shortness of breath with activities of daily living barrel-chested respirations, respirations 20-30 breaths per minute retracted sternum, respirations deep and irregular symmetrical chest, respirations 12-22 breaths per minute 49. Mr.Smith, 67 y.o. has returned from the recovery room following a cholycystectomy. Which one of the following measures by the PN would best promote oxygenation in the first 12 hours? 1. 2. 3. 4. assist with early ambulation check the dressing every 4 hours give clear fluids in the first 8 hours encourage deep breathing 50. Which one of the following interventions should be the priority for the PN to implement when assessing a 70 y.o female client with a blood pressure of 200/115 mmHG? 1. provide her with the information on a low-cholesterol diet, and report her blood pressure to the nurse in charge 2. reinforce with her the importance of taking her medication and encourage her to reduce her sodium intake 3. encourage her to rest amd report her blood pressure to the appropriate person 4. ensure the side rails up and chart blood pressure on the graphic record. 51. Margo, 15 y.o. underwent surgery for a ruptured appendix 3 days ago. While changing the incisional dressing, the PN notices a thick, yellow drainage with an odor. What should the PN understand about this type of drainage? 1. 2. 3. 4. it it it it is normal following a ruptured appendix indicates wound dehiscence is a result of poor healing is evidence of wound infection 52. Jane, 80 y.o has chronic constipation. The physician has ordered a large volume enema that Jane asks to receive while on the toilet. Which one of the following responses is most appropriate for the practical nurse to make? 1. 2. 3. 4. It is against our rules to administer an enema in the bathroom when you are sitting on the toilet, the solution cannot flow to all parts of the colon the enema can be given more quickly if you are lying down I will ask the nurse in charge for permission 53. While performing a bed bath the PN notices a large callus on Mrs. Gradys right great toe. How should the nurse address this finding? 1. 2. 3. 4. help her file her callus ask her how she usually treats her calus soak her foot in warm water and apply dressing document and report the observation 54. Richard, 6 y.o. is receiving treatment for leukemia. He is placed in protective (reverse) isolation. What should the PN wear when giving richard morning care? 1. 2. 3. 4. gown and gloves gloves and mask sterile gloves, mask and gown gloves, mask and gown 55. Mrs. Lepage had abdominal surgery 2 days ago. The PN is at her bedside when she chokes on a piece of food. She is unable to speak or breathe. The PN rings the call bell for help. Which measure is most appropriate for dislodging the object? 1. 2. 3. 4. perform a mouth sweep give complete breaths perform thoracic thrusts perform abdominal thrusts 56. The PN is bathing Jannelle who was born 6 hours ago.What should the PN do? 1. 2. 3. 4. assess Janelle during her bath lightly soap her face assess her after her bath wash Janelle in the bathtub to remove the vernix caseosa 57. How should the PN promote wrist exercise for Micahel, 1 15- y.o. client who has just had a cast removed from his wrist? 1. 2. 3. 4. encourage Michael parents to supervise his exercise activities teach michael’s parents to exercise his wrist at home encourage Michael to perform range of motion exercises several times a day teach Michael to use his left hand to exercise the right wrist 58. John Brandt is a visually impaired client. What should the PN do to assist Mr. Brandt at meal times? 1.Roll the head of Mr. Brandt’s bed up to semi-Fowler’s positions 2. open all containers and arrange them on Mr. Brandt tray 3. describe the location of foods to Mr. Brandt as if they were on the face of a clock 4. give him a napkin to prevent him from soiling his clothing 59. Aaron Pinner, 32 y.o. has a drain following surgery for a ruptured appendix. After the initial dressing change, he reports a burning sensation at the drain site. What should the PN do first? 1. 2. 3. 4. notify the nurse-in-charge of mr. Pinner’s concerns of burning remove his dressing, and assess the skin underneath check mr.pinners chart for documentation of similar concerns tell him that this is a normal reaction to the drain. 60. When weighing a 1-day old infant, what should the PN do to ensure the infant’s safety? 1. 2. 3. 4. place a hand on the infant’s chest while weighing keep a hand poised slightly above the infant while weighing warm the scale and apply a protective pad prior to weighing weigh the infant with diaper and undershirt on. 61. Mrs. Jane White, 84 is markedly underweight. Which one of the following observations should the PN document as an accurate account of MRs. Whites intake following breakfast? 1. 2. 3. 4. appetite poor took 30 ml orange juice consumed very little appetite improving 62. Mary Brown, 64 y.o. is admitted to hospital. A urine specimen of 100 ml of cloudy yellow brown urine is obtained. Which one of the following actions should the PN take first regarding the urine specimen? 1. test the urine for sugar and acetone 2. encourage mary to report any voiding problems 3. have mary record her intake and output 4. report the observation immediately 63. Todd, 4 y.o. is brought to the pediatric unit by his mother. While caring for todd, the PN suspects child abuse. In addition to documenting the findings in todd’s chart, what must the PN do? 1. 2. 3. 4. notify the child’s family physician notify the nurse-in-charge discuss the situation with the police arrange an appointment with the social worker for todd and his mother 64. Tommy, 6, is 6 hours post-tonsillectomy. What should the PN do to decrease the risk of dehydration in Tommy? 1. 2. 3. 4. encourage him to eat crushed ice offer him a warm chicken broth keep a glass filled with orange juice at his bedside have him drink his milkshake with a straw 65. During shift report, what information related to the client’s IV infusion is most important for the PN to communicate initially to the oncoming staff? 1. 2. 3. 4. amount remaining to be absorbed urinary output flow rate volume infused 66. Bob steel, 50, was admitted for investigation of abdominal pain. ON his second day, he reports a marked increase in abdominal pain. What immediate assessments should the PN make? 1. 2. 3. 4. take his temperature and blood pressure inspect and palpate his abdomen determine the location and severity of the pain ask him when he last received his analgesic 67. What should the PN do on witnessing another nurse forcing a client to take medications? 1. 2. 3. 4. speak directly to the nurse involved about what was seen report the nurse’s actions to the team leader immediately write an anonymous note to the nurse involved tell the nurse that the PN is going to report the incident 68. Tim, 18 football player, is scheduled for arthroscopic surgery. What should the PN do just before sending him to the operating room? 1. 2. 3. 4. collect all his valuables, and put them in the bedside table perform a surgical scrub on the operative site ensure that the preoperative checklist is completed teach deep breathing and coughing exercises 69. Mrs. Carpenter, 79, lives alone and is having difficulty performing household activities due to recent exacerbation of rheumatoid arthritis. What should the nurse do? 1. 2. 3. 4. ask her if she would be interested in having home meal delivery ask her if she would be interested in having home support contact her family for assistance suggest that she consider moving to a supervised care facility 70. The registered nurse removes the clients drain and asks the PN to record the removal of the drain. What should the PN do? 1. 2. 3. 4. ask the registered nurse to clear instructions about what to document remind the RN that the person who removes the drain must document it ask the rn to check the documentation asap remind the RN to co-sign the documentation prior to the end of the shift 71. Mrs. Peters, 61, had a cholecystectomy 6 hours ago.which one of the following pulse assessments must the PN report immediately? 1. 2. 3. 4. a bounding pulse of 76 an irregular pulse of 90 a weak pulse of 68 a regular pulse of 60 72. Which one of the following measures should the PN take to ensure the passive exercises are done correctly? 1. 2. 3. 4. the the the the joints joints joints joints are are are are moved moved moved moved through range of motion exercises no less than four times a day just enough to contract muscles slightly beyond their free range of motions slowly to their point of resistance 73. In teaching a client about the importance of postpartum exercises, which one of the following points should the PN emphasize? 1. 2. 3. 4. postpartum exercises can begin on the third postpartum day the exercises are important in restoring muscle tone exercises are only recommended after a vaginal birth increase in lochia should not interfere with continuing the exercises 74. The PN is organizing recreational and play activities for a group of 5 year old children on the pediatric ward. Which of the following activities would be most appropriate for these children? 1. 2. 3. 4. simple puzzles and large throwing balls word games and comic books plastic scissors and coloured paper board games and building sets 75. Which one of the following forms is used by the PN to document routine vital signs? 1. 2. 3. 4. progress notes graphic record activity flow sheet nursing history form 76. The PN is assigned to care for a client who is depressed and somewhat withdrawn. Which one of the following interventions by the PN is most appropriate as a means of establishing a rpport with his client? 1. 2. 3. 4. introduce yourself and tell the client you will return shortly introduce a topic and change it if the client does not respond give a broad opening statement and allow the client time to respond be cheerful and optimistic to offset the clients depressed mood 77. Ruth Smith, 83 has an ulcer on her left leg. The PN is completing a dressing and observes that there is a small amount of purulent drainage. Which one of the following actions by the PN would be most appropriate? 1. 2. 3. 4. apply wet to dry dressing bid keep the ulcer open to air bid place the client’s leg under a heat lamp apply ointment as ordered 78. The PN is in a restaurant when a man at eh next table begins coughing. He is choking on a piece of food. What should the nurse do? 1. 2. 3. 4. perform a finger sweep allow him to cough ask someone to call an ambulance perform abdominal thrusts 79. During discharge planning, the PN becomes aware that Mr. Ploway lives alone and will require assistance with his activities of daily living when he returns home. What should the PN do? 1. 2. 3. 4. call the community nursing service to make an appointment for Mr. Ploway make arrangements for him to receive assistance with meals discuss his need for assistance at home with the health care team arrange for a family member to check on Mr. Poloway 80. Mr. Black, 60, is admitted to the unit following a prostatectomy. He has a CBI running. The colour of the CBI return is pink. Which one of the following actions by the PN is most appropriate? 1. 2. 3. 4. maintain the current rate of flow assess the client for signs of shock check the drainage tubing for patency immediately notify the nurse in charge 81. Greg Nesbitt, 32, is being admitted for elective surgery later in the day. Which one of the following actions by the PN would be most appropriate when orienting him to the unit? 1. 2. 3. 4. store his valuables in the bedside table explain in details his surgical procedure introduce him to all the staff on the unit demonstrate how to operate the nurse call system 82. Which one of the following actions by the PN would demonstrate the moste ffective method of practicing medical asepsis? 1. 2. 3. 4. wash hands vigorously in hot water before and after client contact prevent urinary drainage from lying directly on the floor use a disinfectant to clean a newly acquired skin tear wipe th client’s perineal area from back to front when giving a bed bath 83. In the morning, a client consumes a 180 ml glass of water; for lunch he consumes 90 ml stew, 180 ml soup, 20 ml jello and 90 ml coffee. Later, he feels ill, vomits 120 ml of undigested substance, and voids 200 ml. Which of the following data should the nurse record? 1. 2. 3. 4. intake intake intake intake of of of of 560 470 580 470 ml, ml, ml, ml, output output output output of of of of 200 200 320 320 ml ml ml ml 84. Mr. Samson, 68, is admitted for cellulites of his left leg. He asks the PN to explain why his temp is elevated. Which one of the following responses by the nurse would be most appropriate? 1. 2. 3. 4. elevated body temp prevents the spread of infection the control center of your brain has been affected by your condition elevated body temp helps to destroy bacteria body temp normally changes throughout the day 85. A client was in the bathtub when the nurse brought the morning medication. The medication was left with the breakfast tray, and the PN was asked to ensure that the client received it. Which one of the following responses by the PN would be most appropriate? 1. 2. 3. 4. I cannot take responsibility for the medication put the medication in the cereal, and I’ll feed it to the client I’ll take care of the medication for you, but please sign for it I’ll make sure he gets the medication when he gets out of the bath 86. Which one of the following chartin entries best describes respiratory status? 1. respirations 24 breaths per minute, laboured and irregular 2. respirations 16 bpm 3. breathing rapid and irregular 4. breathing slow, deep and irregular 87. Mr. Dahl is receiving a narcotic analgesic following his surgery. On his second postoperative day, an antihistamine is prescribed for his allergic rhinitis. Mr. Dahl currently reports dizziness and has poort coordination when he ambulates. Which one of the following rationales best explains his present manifestations? 1. 2. 3. 4. antihistamines negate the effect of narcotics medications may interact, potentiating their effects narcotics elevate blood pressure causing dizziness antihistamines cause inner ear swelling affecting balance 88. PETER Murphy has pneumonia. His physician has ordered medication to be given po, prn for its antipyretic effect. Which of the following data should the PN document on the clients chart when giving his medication? 1.site and intensity of the clients pain 2. reason the client requested the medication 3. clients temperature and physical manifestations 4. clients respiratory rate and chest assessment 89. The pN administered an antihypertensive medication. Which one of the following assessments by the practical nurse would indicate that this medication was effective? 1. 2. 3. 4. an increase in urination a decrease in blood pressure a decrease in pulse an increase in respirations 90. Mrs. Sheldon has a feeding tube in place and is to receive a liquid medication 300 mg, hs via this route. The medication is available in 125 mg/5 ml. How much medication should the PN give mRs. Sheldon? 1. 2. 3. 4. 8 ml 10 ml 12 ml 15 ml 91. Mary Norris, 23, has been diagnosed with genital herpes. She has lesions on the labia and in the perineal area. Her physician has ordered ointment to be applied to the lesions. What information is most important for the nurse to give Mary regarding the application of the ointment? 1. 2. 3. 4. apply apply apply apply the the the the ointment ointment ointment ointment following urination and defecation to the perianal area first and then to the labia wearing gloves only after it has warmed to room temperature 92. Lisa Latini is a 25 y.o. client. While in her room, the PN overhears her telling her roommate, “I find my decongestant nasal spray really helpful. Whenever I feel stuffed up, I just take a few sprays of it.” What information is most important for the PN to include when teaching her about the medication? 1. It is important to blow your nose gently before taking the nasal spray 2. Spray the medication toward the midline of the ethmoid bone to help prevent it from running down the Eustachian tube. 3. Nasal spray should be taken only as directed, or it may cause rebound congestion 4. lie on your back for 5 minutes after taking the nasal spray 93. Mr. Browning, 32, requires ear drops qid. Upon visual examination of his ear, a moderate amount of cerumen is observed. What should the PN do prior to instilling the ear drops? 1. 2. 3. 4. clean the ear canal with a cotton tipped applicator clean the outer ear with gauze and water straighten the ear canal by pulling down on the ear irrigate the ear canal with warm water 94. Mrs. Cox is an 84 year old client in a long term care facility. Which one of the following resources should the PN consult first when establishing Mrs. Cox’s nursing care priorities? 1. 2. 3. 4. Mrs. Cox the nursing team Mrs. Cox family the physicians order 95. How should the PN respond when asked by client to have sex? 1. 2. 3. 4. can you explain what you mean? Sorry, but I’m already involved in a relationship we can discuss this when I’m off duty No, that is an inappropriate request. 96. Mrs. Harper, a 65 year old male client weighing 100 kg, requests assistance to use the bathroom on the first day after his gallbladder surgery. Which one of the following methods would be most appropriate? 1. 2. 3. 4. mechanical lift one person transfer two person assist a walker 97. Which one of the following actions should the PN take when providing hair care for a 70 year old female client with Alzheimer’s disease? 1. 2. 3. 4. assess her ability to shampoo her hair shampoo her hair in bed using a trough and basin use a medicated shampoo shampoo her hair every other day 98. Carole 5 years old, was admitted through emergency with a fracture. Carole’s aunt, whoa ccompanied her, informed the staff that Carole has no allergies. Carol had recently been in hospital, and her old admission sheet indicates that she does have allergies. What should the PN do first? 1. 2. 3. 4. proceed with the assessment and request Carole’s medication as ordered ask carole if she is allergic to anything have carole’s parents contacted to verify her allergies ask the family physician about Carole’s allergies 99. Due to a hand injury, Mr. Bahn ask for assistance with the cleansing of his artificial eye. What should the PN do? 1. 2. 3. 4. stand m. bahn at the sink to cleanse the artificial eye cleanse the artificial eye using sterile technique ask Mr. Bahn how he usually cleanses his artificial eye cleanse the socket and artificial eye with antiseptic solution 100. Pat, a team member of the PN’s assigned area, has just left due to illness, and a replacement cannot be found. The PN is directed to take on the remainder of Pat’s clients. The pN should set priorities based on which one of the following factors? 1. 2. 3. 4. the clients medical diagnosis staff available to assist with care requests from clients the condition of the clients