Reference no: EM133954816
Questions
1. Which action should a nurse take prior to assisting an elderly client to shave his face?
Soften the clients skin by applying lotion on it
Cleanse the client's face with a bactericidal solution.
Have the client sign a consent form
Determine what medication the client takes
2. Which of these questions, if asked by a nurse, would indicate that the nurse is evaluating the client's response to pain intervention?
Where is the pain?
What else was happening?
Was pain relived by the measures?
What was the cause?
3. A client who is tree days postoperative after abdominal surgery has an order for the diet to progress to full liquids. Which of these food should a nurse add to the patient's diet?
Mashed potatoes
Pureed carrots
Orange-flavored gelatin
Vanilla ice cream
4. A client is plaster hip spica cast and is returned to the assigned room. The cast is still slightly wet. Which action by the nurse would be appropriated?
Maintain increased humidity in the client room.
Monitor the capillary refill time in the toes on both feet
Use only the tips of the fingers when handling the cast
Keep the cast covered with a light-weight blanket
5. A 15 year old client with hemophilia is admitted with hemarthrosis which nursing action should be implemented?
Elevating the head of the bed 45degrees
Immobilizing the affected joint
Providing passive range-of-motion exercises to all extremities
Maintaining supplemental oxygen
6. During the postoperative assessment of a client who has had spinal fusion and rod placement, which body system should be the primary focus for a nurse?
Neurological
Genitourinary
Integumentary
Gastrointestinal
7. While assessing a newborn, a nurse notes these findings at one moment of life: a loud cry, cries when back is rubbed, well-flexed extremities, heart rate 160beats per minute, and a pink body with blue hands and feet. Based on these findings, what is this client's 1-minute Apgar score?
10
9
8
7
8. During the postpartal admission assessment, the nurse notes that a client's perineum appears edematous and ecchymontic. Based on this finding, which action should the nurse take?
Assess the client's vaginal tone
Apply petrolatum to the client's perineum
Massage the client's perineum
Observe the client for vaginal discharge of bright red blood
9. Which client statement supports a nursing diagnosis of stress urinary incontinence?
I have trouble making it to the bathroom in time
I wet my pants every time I cough
I have to go to the bathroom every two hours
Urine leaks out when I have a bladder spam
10. Which technique is essential to confirm correct placement of a nasogastric tube prior to initiating tube feedings?
Aspirate contents and measure the pH
Observe the bubbles after placing the end of the tube in a cup of what
Inject air and listen for gargling sounds
X-ray to identify location
11. A nurse has received a report on these assigned clients. Which client should the nurse follow-up first?
A client who is receiving cancer chemotherapy and who has a white blood cell count of 500mm today
A client admitted with hepatitis, who has jaundice and t-colored urine
A client admitted with acute diverticulitis, who has a with blood cell count (WDC) OF 10,000mm
A client admitted with acute pancreatitis who has a fasting serum glucose of 130mg-Dl today, and had a reading of 160mg-Dl yesterday.
12. Each of these clients has impaired mobility related to knee surgery. Which client should a nurse assess first?
A 37year old who has limited mobility
A 20year old who has a sport-related injury
A 59year old who has a history of hypertension
A 70year old who has bilateral cataracts
13. Which nursing diagnosis is a priority for a client who is 1hour postoperative after extensive abdominal surgery?
Risk of infection
Risk of deficient fluid volume
Risk for ineffective airway clearance
Risk for impaired physical mobility
14. The nurse charts on all assigned client's at 2.00 P.M. The nurse then remembers something that happened to a client at 9am that was not charted. Which action would the nurse take?
Enter the scenario after the original 2pm charting and mark it as a "late entry."
Put the information in the margin and indicate the accurate time placement by drawing the arrow
Include the 9am scenario in the shift report
Draw a line through he previous charting with "error" and re-record everything including the new information
15. Which statement by the client would the nurse recognized as a suggestive of hypothyroidism?
"my head aces every evening."
"My hands shake whenever I reach for anything."
"I sweat whenever I walk more than one block."
"I feel cold and tired all the time."
16. Which action would the nurse include to enhance the effectiveness of client teaching sessions?
Initially demonstrate and explain the procedure t the client
Include all content in one session
Include all clients on the unit in the sessions
Avoid repetition of content
17. Which task is appropriated for the nurse to delegate to a nursing assistant in an acute care unit?
Suctioning the tracheostomy that was performed on a client yesterday
Ambulating a client that was admitted with a myocardial infarction yesterday
Measuring the blood pressure of a client that was admitted with an asthmas attack yesterday
Feeding a client that was admitted with a stroke yesterday
18. Which task should the licensed practical nurse(LPN) delegated to the nursing assistant?
Ambulating a client that had hip replacement surgery 3days ago
Changing the dressing for a client that had wound debridement last week
Checking the 11am blood sugar for a client that has ketoacidosis
Measuring the pulse oximetry level for a client that has status asthmaticus
19. When making decisions regarding withholding and withdrawing treatment, which of these conditions would be most significant
Whether the client has sufficient representation
Whether the client has a power of attorney
Whether the family members are in agreement
Whenever a client is legally competent
20. The nurse asks the client that is ready for discharge from an alcohol detoxification program if the client is concerned about starting to drink again. The client looks away and does not respond. Which of these responses by the nurse would best assist the client to verbalize their feelings?
"You will have to talk about it sometime; it might as well be now."
"If you do not discuss these feelings with me now, you may relapse when you are home."
"Clients often feel scared just before they go home. Is this how you feel?
"You seem unsure about going home. Do you want me to speak with your doctor to cancel your discharge?"
21. Which of these measures would the nurse manger use to evaluate the effectiveness of the nursing care that is provided on the unit?
Developing specific nursing protocol to be use by all staff on the unit.
Ensuring that all documentation includes the time of each intervention on the client' record
Using clinical pathways to compare client responses with established standards
Randomly reviewing clients' care plans on a regular basis.
22. Which of these nursing actions is an example of malpractice?
Neglecting to report a decrease in blood pressure in a client who then develops shock
Incorrectly informing a family member that they need to wear a mask when visiting a client
Yelling at a client who has been ringing the call bell constantly for two hours
Injuring a back muscle while lifting a client up in the bed
23. Which of these employees demonstrates the competency of commitment to work ethic as expected by employers?
An employee who volunteers to work overtime frequently
An employee who applies theory into clinical practice
An employee who documents relevant data observations of client
An employee who arrives on time and takes only the allowed breaks
24. Which of the following actions would the nurse recognize as a potential risk for causing a medication errors?
Questioning the doctor about a dosage that is greater than usual
Checking with the pharmacist when multiple tablets are needed for a single dose
Removing the unit dose wrapper from the medication at the medication room
Administering the medication, and looking up information about the medication afterward
25. When assessing a client's abdomen, the nurse should perform which of these techniques first?
Auscultation
Percussion
Palpation
Inspection