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 fountainc) Client was having auditory hallucinations is
becomingagitated
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. Dry the newborn
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 to10
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 oflabor?
a. The client
reports the urge
to pushb) The
cervix is dilated
2cm
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 cerebrovascularaccident.
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 movementc)
paresthesia of the
distalextremity
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
oral
rehydrationsolutions.
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
hirddegre
e AVblock
c)
Atrial
fibrill
ation
d) Ventricular fibrillation
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 aftereating.
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
sd)
Lym
edise
ase
13. The nurse is assessing an adolescent client for sickle cell anemia. Which of the
following is a priority finding by the nurse?
a. A pain score 7
on a scale of 0 to
10b) Shortness
ofbreath
c) New onset of a new enuresis
d) Priapism
14. Nurses caring for a client whose 1 day postop following a
Hypophysectomyfor the removal of the pituitary tumor. Which of thefollowing findings requires further assessment by nurse?
a. Glascow scale score a 15
b. Blood drainage on initial dressing measuring 3 cm
c. Report of dry mouth
d. ) Urinary output greater than fluidintake [Show Less]