1. A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to assistive personnel?
d. Providing
... [Show More] postmortem care to a client
2. A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statement by the client indicates an understanding of the use of the supplements?
C. I use ginger when I get car sick
3. A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
4. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take?
C. Allow room for two fingers to fit between the clients skin and the restraints
5. A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate?
A. Airborne
6. A nurse in a well-child clinic receives a telephone call from a parent who states that their child accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses should the nurse make?
A. Have your child drink one large glass of water.
7. A nurse is documenting a client's medical record. Which of the following entries should the nurse record.
B. Administered pain medication
8. A nurse provides oral care for a client who is unconscious. Which of the following actions should the nurse take?
A. Place the client in a side-lying position.
9. A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify which of the following situations is an example of negligence?
C. A nurse begins a blood transfusion without obtaining consent.
10. A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which of the following actions should the nurse take?
B. Offer the client oral hygiene after the collection
11. A nurse is assessing an older client. Which of the following findings should the nurse expect?
a. Decreased sense of balanced
12. A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)
a. "Cut the opening of the pouch 1⁄8 of an inch larger than the stoma " YES
b. "Place a piece a gauze over the stoma while changing the pouch" YES
c. "Use povidone-iodine to clean around the stoma" YES
d. "Empty the ostomy pouch when it becomes one-third full of contents" YES
13. A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
c. "Offer written information in the client's language"
14. A nurse is teaching a client about home care equipment. Which of the following information should the nurse include in the teaching? (select all that apply)
d. "Keep the oxygen delivery system 0.6 m (2 feet) from any heat source" Nope
e. "Lay the oxygen tank flat when storing" Nope
a. "Avoid using wool blankets when receiving oxygen"
b. check the O2 delivery rate at least once a day
c. align the middle of the ball in the flow meter with the line of the prescribed flow rate
15. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?
a. Provide a late supper.
16. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?
c. A client who has new onset of dyspnea 24hr after a total hip arthroplasty
17. A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization. The nurse should record the client's net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
DOSAGE CALCULATION 700 mL
18. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that if the following requires the completion of an incident report?
a. A client's prescribed laboratory testing was not obtained
19. A nurse is caring for a client who has a new prescription for negative-pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention.
d. The policy and procedure manual
20. A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?
d. Perform percussion over the lower back
21. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the following images indicates the correct number of mL the nurse should administer? (Round answer to the nearest whole number.)
DOSAGE CALCULATION: 8ml
22. A nurse is admitting a client who is malnourished. The client states, "My wedding ring is loose, and I'm worried I will lose it if it falls off." Which of the following is an appropriate response by the nurse?
d. I can put it in a locked storage unit for you
23. A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the following clinical situations should the nurse apply restraints?
d. When the client poses a threat to self
24. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
d. Client advocate
25. A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?
c. "Delirium has an abrupt onset." [Show Less]