NUR 329: Exam 1 Qs with 100% accurate solutions + rationales 2026 - Chamberlain

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?

1. Apical pulse rate of 110 and 4+ pitting edema of feet.

2. Thick white sputum and crackles that clear with cough.

3. The client sleeping with no pillow and eupnea.

4. Radial pulse rate of 90 and capillary refill time

1. Apical pulse rate of 110 and 4+ pitting edema of feet.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will:

1. Be able to ambulate in the hall by date of discharge.

2. Have an audible S1 and S2 with no S3 heard by end of shift.

3. Turn, cough, and deep breathe every two (2) hours.

4. Have a pulse oximeter reading of 98% by day two (2) of care.

2. Have an audible S1 and S2 with no S3 heard by end of shift.

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.

1. Notify health-care provider of a weight gain of more than one (1) pound in a week.

2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.

3. Instruct client to remove the saltshaker from the dinner table.

4. Encourage client to monitor urine output for change in color to become dark.

5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.

3. Instruct client to remove the saltshaker from the dinner table.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?

1. Sponge the client's forehead.

2. Obtain a pulse oximetry reading.

3. Take the client's vital signs.

4. Assist the client to a sitting position.

4. Assist the client to a sitting position.

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?

1. The client's peripheral pitting edema has gone from 3+ to 4+.

2. The client is able to take the radial pulse accurately.

3. The client is able to perform ADLs without dyspnea.

4. The client has minimal jugular vein distention.

3. The client is able to perform ADLs without dyspnea.

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?

1. An elevated B-type natriuretic peptide (BNP).

2. An elevated creatine kinase (CK-MB).

3. A positive D-dimer.

4. A positive ventilation/perfusion (V/Q) scan.

1. An elevated B-type natriuretic peptide (BNP).

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?

1. Instruct the client to take a cough suppressant if a cough develops.

2. Teach the client how to prevent orthostatic hypotension.

3. Encourage the client to eat bananas to increase potassium level.

4. Explain the importance of taking the medication with food.

2. Teach the client how to prevent orthostatic hypotension.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?

1. The client diagnosed with myocardial infarction who has an audible S3 heart

sound.

2. The client diagnosed with congestive heart failure who has 4+ sacral pitting

edema.

3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.

4. The client with chronic renal failure who has an elevated creatinine level.

1. The client diagnosed with myocardial infarction who has an audible S3 heart sound.

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

1. Assist the client to go down to the smoking area for a cigarette.

2. Transport the client to the intensive care unit via a stretcher.

3. Provide the client going home discharge-teaching instructions.

4. Help position the client who is having a portable x-ray done.

4. Help position the client who is having a portable x-ray done.

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?

1. The client diagnosed with congestive heart failure who is being discharged in the morning.

2. The client who is having frequent incontinent liquid bowel movements and

vomiting.

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood

pressure of 94/62.

4. The client who is complaining of chest pain with inspiration and a nonproductive

cough.

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?

1. Check the client for peripheral edema and make sure the client takes a diuretic

early in the day.

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.

3. Determine if the client has gained weight and instruct the client to keep the legs elevated.

4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?

1. Measure intake and output.

2. Provide two (2)-g sodium diet.

3. Weigh client daily.

4. Plan for frequent rest periods.

4. Plan for frequent rest periods.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction?

1. Creatine kinase (CK-MB).

2. Lactate dehydrogenase (LDH).

3. Troponin.

4. White blood cells (WBCs).

3. Troponin.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?

1. Midepigastric pain and pyrosis.

2. Diaphoresis and cool clammy skin.

3. Intermittent claudication and pallor.

4. Jugular vein distention and dependent edema.

2. Diaphoresis and cool clammy skin.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

1. Administer sublingual nitroglycerin.

2. Obtain a STAT electrocardiogram.

3. Have the client sit down immediately.

4. Assess the client's vital signs.

3. Have the client sit down immediately.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.

1. Administer morphine intramuscularly.

2. Administer an aspirin orally.

3. Apply oxygen via a nasal cannula.

4. Place the client in a supine position.

5. Administer nitroglycerin subcutaneously.

2. Administer an aspirin orally.

3. Apply oxygen via a nasal cannula.

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?

1. Social worker.

2. Physical therapy.

3. Cardiac rehabilitation.

4. Occupational therapy.

3. Cardiac rehabilitation.

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?

1. Medicate the client with intravenous morphine.

2. Assess the client's chest dressing and vital signs.

3. Encourage the client to turn from side to side.

4. Check the client's telemetry monitor.

2. Assess the client's chest dressing and vital signs.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?

1. The client is keeping the affected extremity straight.

2. The pressure dressing to the right femoral area is intact.

3. The client is complaining of numbness in the right foot.

4. The client's right pedal pulse is 3+ and bounding.

3. The client is complaining of numbness in the right foot.

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

1. Notify the health-care provider immediately.

2. Elevate the head of the client's bed.

3. Document this as a normal and expected finding.

4. Administer morphine intravenously.

1. Notify the health-care provider immediately.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication?

1. The client's apical pulse is 64.

2. The client's calcium level is elevated.

3. The client's telemetry shows occasional PVCs.

4. The client's blood pressure is 90/62.

4. The client's blood pressure is 90/62.

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?

1. Instruct the UAP to stop encouraging the leg movements.

2. Report this behavior to the charge nurse as soon as possible.

3. Praise the UAP for encouraging the client to move legs.

4. Take no action concerning the UAP's behavior.

3. Praise the UAP for encouraging the client to move legs.

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response?

1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal."

2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias."

3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed."

4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal."

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?

1. The client's BP is 110/70 and pulse is 90.

2. The client's groin dressing is dry and intact.

3. The client refuses to keep the leg straight.

4. The client denies any numbness and tingling.

3. The client refuses to keep the leg straight.

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching?

1. "I should keep the tablets in the dark-colored bottle they came in."

2. "If the tablets do not burn under my tongue, they are not effective."

3. "I should keep the bottle with me in my pocket at all times."

4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. "If my chest pain is not gone with one tablet, I will go to the ER."

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse?

1. "Chest pain is caused by decreased oxygen to the heart muscle."

2. "There is ischemia to the myocardium as a result of hypoxemia."

3. "The heart muscle is unable to pump effectively to perfuse the body."

4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1. "Chest pain is caused by decreased oxygen to the heart muscle."

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?

1. Perform passive range-of-motion exercises.

2. Assess the client's neurovascular status.

3. Keep the client in high Fowler's position.

4. Assess the gag reflex prior to feeding the client.

2. Assess the client's neurovascular status.

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?

1. The client has a BP of 110/70.

2. The client has an apical pulse of 56.

3. The client is complaining of a headache.

4. The client's potassium level is 4.5 mEq/L.

2. The client has an apical pulse of 56.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?

1. Assess the client's radial pulse.

2. Assess the client's serum potassium level.

3. Assess the client's glucometer reading.

4. Assess the client's pulse oximeter reading.

2. Assess the client's serum potassium level.

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.

1. Encourage a low-fat, low-cholesterol diet.

2. Instruct client to walk 30 minutes a day.

3. Decrease the salt intake to two (2) g a day.

4. Refer to counselor for stress reduction techniques.

5. Teach the client to increase fiber in the diet.

1. Encourage a low-fat, low-cholesterol diet.

2. Instruct client to walk 30 minutes a day.

4. Refer to counselor for stress reduction techniques.

5. Teach the client to increase fiber in the diet.

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?

1. "Do you have a daily bowel movement?"

2. "Do you get yearly chest x-rays?"

3. "Are you sexually active?"

4. "Have you had any weight change?"

3. "Are you sexually active?"

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?

1. Perform isometric exercises daily.

2. Walk for 15 minutes three (3) times a week.

3. Do not walk outside if it is less than 40 ̊F.

4. Wear open-toed shoes when ambulating.

3. Do not walk outside if it is less than 40 ̊F.

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?

1. Put a nitroglycerin tablet under the tongue.

2. Stop the activity immediately and rest.

3. Document when and what activity caused angina.

4. Notify the health-care provider immediately.

2. Stop the activity immediately and rest.

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?

1. Instruct client to keep a diary of activity, especially when having chest pain.

2. Discuss the need to remove the Holter monitor during a.m. care and showering.

3. Explain that all medications should be withheld while wearing a Holter monitor.

4. Teach the client the importance of decreasing activity while wearing the monitor.

1. Instruct client to keep a diary of activity, especially when having chest pain.

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet?

1. "I will not eat more than six (6) eggs a week."

2. "I should bake or grill any meats I eat."

3. "I will drink eight (8) ounces of whole milk a day."

4. "I should not eat any type of pork products."

2. "I should bake or grill any meats I eat."

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?

1. The 44-year-old client diagnosed with a myocardial infarction.

2. The 65-year-old client admitted with unstable angina.

3. The 75-year-old client scheduled for a cardiac catheterization.

4. The 50-year-old client complaining of chest pain.

3. The 75-year-old client scheduled for a cardiac catheterization.

The client tells the nurse, "Every time I come in the hospital you hand me one of these advance directives (AD). Why should I fill one of these out?" Which statement by the nurse is most appropriate?

1. "You must fill out this form because Medicare laws require it."

2. "An AD lets you participate in decisions about your health care."

3. "This paper will ensure no one can override your decisions."

4. "It is part of the hospital admission packet and I have to give it to you."

2. "An AD lets you participate in decisions about your health care."

The nurse is presenting an in-service discussing do not resuscitate (DNR) orders and advance directives. Which statement should the nurse discuss with the class?

1. Advance directives must be notarized by a notary public.

2. The client must use an attorney to complete the advanced directive.

3. Once the DNR is written, it can be used for every hospital admission.

4. The health-care provider must write the DNR order in the client's chart

4. The health-care provider must write the DNR order in the client's chart

In which client situation would the AD be consulted and used in decision making?

1. The client diagnosed with Guillain-Barré who is on a ventilator.

2. The client with a C6 spinal cord injury in the rehabilitation unit.

3. The client in end-stage renal disease who is in a comatose state.

4. The client diagnosed with cancer who has Down syndrome.

3. The client in end-stage renal disease who is in a comatose state.

The nurse is moving to another state which is part of the multistate licensure compact. Which information regarding ADs should the nurse be aware of when practicing nursing in other states?

1. The laws regarding ADs are the same in all the states.

2. Advance directives can be transferred from state to state.

3. A significant other can sign a loved one's advance directive.

4. Advance directives are state regulated, not federally regulated.

4. Advance directives are state regulated, not federally regulated.

Which client would be most likely to complete an advance directive?

1. A 55-year-old Caucasian person who is a bank president.

2. A 34-year-old Asian licensed practical nurse.

3. A 22-year-old Hispanic lawn care worker.

4. A 65-year-old African American retired cook.

1. A 55-year-old Caucasian person who is a bank president.

The client with an AD tells the nurse, "I have changed my mind about my AD. I really want everything possible done if I am near death since I have a grandchild." Which action should the nurse implement?

1. Notify the health information systems department to talk to the client.

2. Remove the AD from the client's chart and shred the document.

3. Inform the client he or she has the right to revoke the AD at any time.

4. Explain this document cannot be changed once it is signed.

3. Inform the client he or she has the right to revoke the AD at any time.

The client has just signed an AD at the bedside. Which intervention should the nurse implement first?

1. Notify the client's health-care provider about the AD.

2. Instruct the client to discuss the AD with significant others.

3. Place a copy of the advance directive in the client's chart.

4. Give the original advance directive to the client.

2. Instruct the client to discuss the AD with significant others.

The HCP has notified the family of a client in a persistent vegetative state on a ventilator of the need to "pull the plug." The client does not have an AD or a durable power of attorney for health care, and the family does not want their loved one removed from the ventilator. Which action should the nurse implement?

1. Refer the case to the hospital ethics committee.

2. Tell the family they must do what the HCP orders.

3. Follow the HCP's order and "pull the plug."

4. Determine why the client did not complete an AD.

1. Refer the case to the hospital ethics committee.

The client asks the nurse, "When will the durable power of attorney for health care take effect?" On which scientific rationale would the nurse base the response?

1. It goes into effect when the client needs someone to make financial decisions.

2. It will be effective when the client is under general anesthesia during surgery.

3. The client must say it is all right for it to become effective and enforced.

4. It becomes valid only when the clients cannot make their own decisions.

4. It becomes valid only when the clients cannot make their own decisions.

The male client requested a DNR per the AD, and the HCP wrote the order. The client's death is imminent and the client's wife tells the nurse, "Help him please. Do something. I am not ready to let him go." Which action should the nurse take?

1. Ask the wife if she would like to revoke her husband's AD.

2. Leave the wife at the bedside and notify the hospital chaplain.

3. Sit with the wife at the bedside and encourage her to say good-bye.

4. Request the client to tell the wife he is ready to die, and don't do anything.

3. Sit with the wife at the bedside and encourage her to say good-bye.

Which situation would cause the nurse to question the validity of an AD when caring for the elderly client?

1. The client's child insists the client make his or her own decisions.

2. The nurse observes the wife making the husband sign the AD.

3. A nurse encouraged the client to think about end-of-life decisions.

4. A friend witnesses the client's signature on the AD form.

2. The nurse observes the wife making the husband sign the AD

The nurse is aware the Patient Self-Determination Act of 1991 requires the health-care facility to implement which action?

1. Make available an AD on admission to the facility.

2. Assist the client with legally completing a will.

3. Provide ethically and morally competent care to the client.

4. Discuss the importance of understanding consent forms.

1. Make available an AD on admission to the facility.

The spouse of a client dying from lung cancer states, "I don't understand this death rattle. She has not had anything to drink in days. Where is the fluid coming from?" Which is the hospice care nurse's best response?

1. "The body produces about two (2) teaspoons of fluid every minute on its own."

2. "Are you sure someone is not putting ice chips in her mouth?"

3. "There is no reason for this, but it does happen from time to time."

4. "I can administer a patch to her skin to dry up the secretions if you wish."

1. "The body produces about two (2) teaspoons of fluid every minute on its own."

The nurse is discussing placing the client diagnosed with chronic obstructive pulmonary disease (COPD) in hospice care. Which prognosis must be determined to place the client in hospice care?

1. The client is doing well but could benefit from the added care by hospice.

2. The client has a life expectancy of six (6) months or less.

3. The client will live for about one (1) to two (2) more years.

4. The client has about eight (8) weeks to live and needs pain control.

2. The client has a life expectancy of six (6) months or less.

The client diagnosed with end-stage congestive heart failure and type 2 diabetes is receiving hospice care. Which action by the nurse demonstrates an understanding of the client's condition?

1. The nurse monitors the blood glucose four (4) times a day.

2. The nurse keeps the client on a strict fluid restriction.

3. The nurse limits the visitors the client can receive.

4. The nurse brings the client a small piece of cake.

4. The nurse brings the client a small piece of cake.

The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention?

1. The client will ask all of his or her spiritual questions and get answers.

2. The nurse is able to explain to the client how death will affect the spirit.

3. Spirituality provides a sense of meaning and purpose for many clients.

4. The nurse is the expert when assisting the client with spiritual matters.

3. Spirituality provides a sense of meaning and purpose for many clients.

The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the female nurse implement at the time of death?

1. Allow the wife to stay in the room during postmortem care.

2. Call the client's iman to perform last rites when the client dies.

3. Place incense around the bed, but do not allow anyone to light it.

4. .Do not touch the body, and have the male family members perform care.

4. .Do not touch the body, and have the male family members perform care.

The nurse writes a client problem of "spiritual distress" for the client who is dying. Which statement is an appropriate goal?

1. The client will reconcile self and the higher power of his or her beliefs.

2. The client will be able to express anger at the terminal diagnosis.

3. The client will reconcile self to estranged members of the family.

4. The client will have a dignified and pain-free death.

1. The client will reconcile self and the higher power of his or her beliefs.

The hospice care nurse is planning the care of an elderly client diagnosed with end-stage renal disease. Which interventions should be included in the plan of care? Select all that apply.

1. Discuss financial concerns.

2. Assess any comorbid conditions.

3. Monitor increased visual or auditory abilities.

4. Note any spiritual distress.

5. Encourage euphoria at the time of death.

1. Discuss financial concerns.

2. Assess any comorbid conditions.

4. Note any spiritual distress.

The nurse is orienting to a hospice organization. Which statement does not indicate a right of the terminal client? The right to:

1. Be treated with respect and dignity.

2. Have particulars of the death withheld.

3. Receive optimal and effective pain management.

4. Receive holistic and compassionate care.

2. Have particulars of the death withheld.

The client is on the ventilator and has been declared brain dead. The spouse refuses to allow the ventilator to be discontinued. Which collaborative action by the nurse is most appropriate?

1. Discuss referral of the case to the ethics committee.

2. Pull the plug when the spouse is not in the room.

3. Ask the HCP to discuss the futile situation with the spouse.

4. Inform the spouse what is happening is cruel.

1. Discuss referral of the case to the ethics committee.

The client has been in a persistent vegetative state for several years. The family, who have decided to withhold tube feedings because there is no hope of recovery, asks the nurse, "Will the death be painful?" Which intervention should the nurse implement?

1. Tell the family the death will be painful but the HCP can order medications.

2. Inform the family dehydration provides a type of natural euphoria.

3. Relate other cases where the clients have died in excruciating pain.

4. Ask the family why they are concerned because they want the client to die anyway.

2. Inform the family dehydration provides a type of natural euphoria.

The family is dealing with the imminent death of the client. Which information is most important for the nurse to discuss when planning interventions for the grieving process?

1. How angry are the family members about the death?

2. Which family member will be making decisions?

3. What previous coping skills have been used?

4. What type of funeral service has been planned?

3. What previous coping skills have been used?

The client who is terminally ill called the significant others to the room and said good-bye, then dismissed them and now lies quietly and refuses to eat. The nurse understands the client is in what stage of the grieving process?

1. Denial.

2. Anger.

3. Bargaining.

4. Acceptance.

4. Acceptance.

The nurse is assessing a client diagnosed with chronic pain. Which characteristics would the nurse observe?

1. The client's blood pressure is elevated.

2. The client has rapid shallow respirations.

3. The client has facial grimacing.

4. The client is lying quietly in bed.

4. The client is lying quietly in bed.

The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement?

1. Have the client see a psychologist because the pain is not real.

2. Tell the client the pain is the cancer coming back.

3. Refer the client to a physical therapist to prevent a frozen shoulder.

4. Discuss changing the client to a more potent narcotic medication.

3. Refer the client to a physical therapist to prevent a frozen shoulder.

The male client diagnosed with chronic pain since a construction accident which broke several vertebrae tells the nurse he has been referred to a pain clinic and asks, "What good will it do? I will never be free of this pain." Which statement is the nurse's best response?

1. "Are you afraid of the pain never going away?"

2. "The pain clinic will give you medication to cure the pain."

3. "Pain clinics work to help you achieve relief from pain."

4. "I am not sure. You should discuss this with your HCP."

3. "Pain clinics work to help you achieve relief from pain.

The client diagnosed with cancer is experiencing severe pain. Which regimen would the nurse teach the client about to control the pain?

1. Nonsteroidal anti-inflammatory drugs (NSAIDs) around the clock with narcotics used for severe pain.

2. Morphine sustained release, a narcotic, routinely with a liquid morphine

preparation for breakthrough pain.

3. Extra-Strength Tylenol, a nonnarcotic analgesic, plus therapy to learn alternative methods of pain control.

4. Demerol, an opioid narcotic, every six (6) hours orally with a suppository when

the pain is not controlled.

2. Morphine sustained release, a narcotic, routinely with a liquid morphine preparation for breakthrough pain.

The client is being discharged from the hospital for intractable pain secondary to cancer and is prescribed morphine, a narcotic. Which statement indicates the client understands the discharge instructions?

1. "I will be sure to have my prescriptions filled before any holiday."

2. "There should not be a problem having the prescriptions filled anytime."

3. "If I run out of medications, I can call the HCP to phone in a prescription."

4. "There are no side effects to morphine I should be concerned about."

1. "I will be sure to have my prescriptions filled before any holiday."

The male client who has made himself a do not resuscitate (DNR) order is in pain. The client's vital signs are P 88, R 8, and BP 108/70. Which intervention should be the nurse's priority action?

1. Refuse to give the medication because it could kill the client.

2. Administer the medication as ordered and assess for relief from pain.

3. Wait until the client' respirations improve and then administer the medication.

4. Notify the HCP the client is unstable and pain medication is being held.

2. Administer the medication as ordered and assess for relief from pain.

The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse?

1. The client diagnosed with leukemia who has a hemoglobin of 6.0 g/dL.

2. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.

3. The client diagnosed with colon cancer who needs the colostomy irrigated.

4. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.

2. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.

The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients in a pain clinic. Which intervention would be inappropriate to delegate to the UAP?

1. Assist the client diagnosed with intractable pain to the bathroom.

2. Elevate the head of the bed for a client diagnosed with back pain.

3. Perform passive range of motion for a client who is bedfast.

4. Monitor the potassium levels on a client about to receive medication.

4. Monitor the potassium levels on a client about to receive medication.

The client diagnosed with chronic back pain is being placed on a transcutaneous electrical nerve stimulation (TENS) unit. Which information should the nurse teach?

1. The TENS unit will deaden the nerve endings, and the client will not feel pain.

2. The TENS unit could cause paralysis if the client gets the unit wet.

3. The TENS unit stimulates the nerves in the area, blocking the pain sensation.

4. The TENS unit should be left on for an hour, and then taken off for an hour.

3. The TENS unit stimulates the nerves in the area, blocking the pain sensation.

The nurse is caring for clients on a medical floor. Which client should the nurse assess first after the shift report?

1. The client with arterial blood gases of pH 7.36, PaCO2 40, HCO3 26, PaO2 90.

2. The client with vital signs of T 99 ̊F, P 101, R 28, and BP 120/80.

3. The client complaining of pain at a "10" on a 1-to-10 scale who can't localize it.

4. The client who is postappendectomy with pain at a "3" on a 1-to-10 scale.

3. The client complaining of pain at a "10" on a 1-to-10 scale who can't localize it.

The female client in the oncology clinic tells the nurse she has a great deal of pain but does not like to take pain medication. Which action should the nurse implement first?

1. Tell the client it is important for her to take her medication.

2. Find out how the client has been dealing with the pain.

3. Have the HCP tell the client to take the pain medications.

4. Instruct the client not to worry—the pain will resolve itself.

2. Find out how the client has been dealing with the pain.

The nurse is teaching an in-service on legal issues in nursing. Which situation is an example of battery, an intentional tort?

1. The nurse threatens the client who is refusing to take a hypnotic medication.

2. The nurse forcibly inserts a Foley catheter in a client who refused it.

3. The nurse tells the client a nasogastric tube insertion is not painful.

4. The nurse gives confidential information over the telephone.

2. The nurse forcibly inserts a Foley catheter in a client who refused it.

Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care?

1. The Health Insurance Portability and Accountability Act.

2. The State Nurse Practice Act.

3. The Emergency Rendering Aid Act.

4. The Good Samaritan Act.

4. The Good Samaritan Act.

The family has requested a client with terminal cancer not be told of the diagnosis. The client tells the nurse, "I think something is really wrong with me, but the doctor says everything is all right. Do you know if there is something wrong with me?" Which response by the nurse would support the ethical principle of veracity?

1. "I think you should talk to your doctor about your concerns."

2. "What makes you think something is really wrong?"

3. "Your family has requested you not be told your diagnosis."

4. "The doctor would never tell you incorrect information."

3. "Your family has requested you not be told your diagnosis."

The nurse is obtaining the client's signature on a surgical permit form. The nurse determines the client does not understand the surgical procedure and possible risks. Which action should the nurse take first?

1. Notify the client's surgeon.

2. Document the information in the chart.

3. Contact the operating room staff.

4. Explain the procedure to the client.

1. Notify the client's surgeon.

The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?

1. The nurse tells the client civilian clothes can be worn on the unit.

2. The nurse allows the client to have family visits during visiting hours.

3. The nurse delivers unopened mail and packages to the client.

4. The nurse listens to the client talking on the telephone to a friend.

4. The nurse listens to the client talking on the telephone to a friend.

The client receiving dialysis for end-stage renal disease wants to quit dialysis and die. Which ethical principle supports the client's right to die?

1. Autonomy.

2. Self-determination.

3. Beneficence.

4. Justice.

1. Autonomy.

Which document is the best professional source to provide direction for a nurse when addressing ethical issues and behavior?

1. The Hippocratic Oath.

2. The Nuremberg Code.

3. Home Health Care Bill of Rights.

4. ANA Code of Ethics.

4. ANA Code of Ethics.

Which element is not necessary to prove nursing malpractice?

1. Breach of duty.

2. Identify the ethical issues.

3. Injury to the client.

4. Proximate cause.

2. Identify the ethical issues.

The nurse is caring for a client who is confused and fell trying to get out of bed. There is no family at the client's bedside. Which action should the nurse implement first?

1. Contact a family member to come and stay with the client.

2. Administer a sedative medication to the client.

3. Place the client in a chair with a sheet tied around him or her.

4. Notify the health-care provider to obtain a restraint order.

4. Notify the health-care provider to obtain a restraint order.

Which entity mandates the registered nurse's behavior when practicing professional nursing?

1. The state's Nurse Practice Act.

2. Client's Bill of Rights.

3. The United States legislature.

4. American Nurses Association.

1. The state's Nurse Practice Act.

The nurse must be knowledgeable of ethical principles. Which is an example of the ethical principle of justice?

1. The nurse administers a placebo, and the client asks if it will help the pain.

2. The nurse accepts a work assignment in an area in which he or she is not

experienced.

3. The nurse refuses to tell a family member the client has a positive HIV test.

4. The nurse provides an indigent client with safe and appropriate nursing care.

4. The nurse provides an indigent client with safe and appropriate nursing care.

The nurse is discussing malpractice issues in an in-service class. Which situation is an example of malpractice?

1. The nurse fails to report a neighbor who is abusing his two children.

2. The nurse does not intervene in a client who has a BP of 80/50 and AP of 122.

3. The nurse is suspected of taking narcotics prescribed for a client.

4. The nurse falsifies vital signs in the client's medical records.

2. The nurse does not intervene in a client who has a BP of 80/50 and AP of 122.