1. A nurse working in a long-term care facility is caring for an older adult client has dementia. The clients often agitated and frequently wanders the
... [Show More] halls. Which of the following intervention should the nurse include in the plan of care?
a) Give the client several choices when scheduling activities.
b) Confront the client regarding unacceptable behavior
c) Maintain Nutritional requirements by offering finger foods
d) Stimulate the client by leaving the television on throughout the day
2. A nurse on a mental health unit receives report on four clients. Which of the following client should the nurse attend to first?
a. A client who has begun to demonstrate catatonic behavior
b. The client was compulsive behavior and is frequently drinking from the water fountain c) Client was having auditory hallucinations is becoming agitated
d) A client was making sexual comments to clients of the opposite sex
3. A nurse is caring for the full term newborn immediately following birth. Which of the following actions should the nurse take first?
a. Instill erythromycin ophthalmic ointment and the newborn’s eyes.
b. Place identification bracelets on the newborn.
c. Weigh the newborn.
d. D ry the newborn
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4. A nurse receives report on a group of clients. Which of the following client should the nurse attend to first?
a. A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L per minute via nasal cannula
b. ) A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10
c. The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL
d. A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid
5. A client at 38 weeks of gestation enters the emergency department. The nurse should recognize that which of the following indicates that the client is in the latent phase of labor?
a. The client reports the urge to push b) The cervix is dilated 2 cm
c) Contractions are 2 to 3 minutes apart
d) The client reports nausea and vomiting
6. The charge nurse for medical surgical units discovers client care assignments that should be reassigned. Which of the following delegated tasks should be reassigned?
a. An AP is to calculate intake and output every two hours for client in acute renal failure.
b. An AP is to collect vital signs every 30 minutes for client who had a cholecystectomy
c. A licensed practical nurse is to check nasogastric tube placement for client list had a bowel resection. d) A licensed practical nurses to provide initial feeding for client who had a cerebrovascular accident.
7. A nurse caring for the client who has a cast due to a compound fracture to the right ankle. Which of the following findings requires immediate intervention?
a. pruiritus under the cast
b. Localized stabbing pain upon movement c) paresthesia of the distal extremity
d) Edema present when leg is in the dependent position
8. The nurses providing care for preschoolers with acute gastroenteritis. Basing information below which of the following is an appropriate nursing action? Click on the links of this below for additional client information
a. Offer the child a cup of chicken broth.
b. Encourage the child’s intake of gelatin. c) Administer
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oral rehydration solutions.
d) Institute a banana, Rice, applesauce, and toast diet.
9. A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable. Which of the following dysrhythmias should the nurse plan for cardioversion?
a. Ventricular asystole
b. T hird- degre e AV block c) Atrial fibrill ation
d) Ventricular fibrillation
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10. A nurse assesses an older adult client with the decrease caloric intake and weight loss. Which of the following findings should the nurse report to the provider immediately?
a. ) The clinic experiences coughing and wheezing after eating.
b. The client reports abdominal pain at a five on a scale of 0 to 10.
c. The client experience is a drop in oxygen saturation to 91% while eating.
d. The client reports a burning sensation in epigastric area.
11. A nurse and an assistive personnel are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate an AP?
a. Applying condom catheter for client for spinal cord injury
b. Administrative oral fluids to client was dysphasia
c. Documenting the report of pain from client who is postoperative
d. Reviewing active range of motion exercises with a client who is had a stroke
12. A nurse from the state health department this is instructing a group nurses regarding reportable infections. Which of the following infections should the nurse report to the CDC?
a. Candida albicans
b. Herpes simplex virus 2
c. st aphy lococ cus aureu s d) Lym e
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