1. A nurse is teaching a client about crutch walking using the four-point gait. Which of the following statements by the nurse should be included in the
... [Show More] teaching?
● “Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot”
● “look down at your foot before moving the crutches”
● “Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches”
● “support your body weight on the underarm crutch path”
2. A nurse has completed an informed consent form with a client. The client then states, “I have changed my mind and do not want to have the procedure done”. Which of the following actions should the nurse take?
● Proceed with preparation of the patient for the surgical procedure
● Remind the client that a signed informed consent form is a legally binding document
● Inform the surgical team to cancel the client’s surgery
● Notify the surgeon that the client wishes to withdraw informed consent for the procedure
3. A client is admitted to the emergency room with a respiratory rate of 7 breaths/min. Arterial blood gas (ABG) reveal the following xxx
Ph 1.22
Pco2 63 mm kg Kco3 26 mkg/t
Which of the following is the correct analysis of the ABG results?
● Respiratoryalkalosis
● Metabolic alkalosis
● Metabolicacidosis
● Respiratory acidosis
4. A nurse is caring for a client with sustained blood loss. Which of the following is a manifestation of hypovolemia?
● Dyspnea
● Increased blood pressure
● Decreased heart rate
● Weak pulse
5. A nurse is caring for client who has cancer and is receiving palliative care. Which of the following statement by the client indicates they understand this type of treatment?
● “This treatment should help me live a little”
• I am thinking of getting a second opinion”.
● “This is not working, and I plan to stop treatment”
● I am hoping this will lesson or reduce my discomfort
6. A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
● Complete an incident report
● Call the client’s provider
● Assess the client
● Notify the nurse manager
7. A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to unlicensed assistive personnel (UAP) for which of the following clients?
● A client that is 2 hr. postoperative following an abdominal hysterectomy
● A client that is 1 hr. postoperative following a thyroidectomy
● A client that is 2 days postoperative following a craniotomy
● A client that is 2 days postoperative following gastric bypass surgery
8. A nurse in a long-term care facility is caring for an older adult client that had a stroke 4 weeks ago and who is unable to move independently. Which of the following findings indicates a complication of immobility?
● A reddened area over the sacrum
● Pale yellow urine
● Pain sensation intact
● Decreased fatigue
9. A nurse is caring for a client who has the following artificial blood gas results: HCO3 18 mEq, PCO2 38 mmHg and pH7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?
• Metabolic alkalosis
• Respiratory alkalosis
• Respiratory acidosis
● Metabolic acidosis
10. A nurse is assessing a client who is 48 hrs. postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
● Straw-colored urine from an including catheter
● Yellow green drainage on the surgical incision
● Respiratory rate 20 breaths/min
● Blood pressure 102/66 mmHg
11. A nurse is giving a presentation about client confidentially to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?
● Discussing a client’s surgical procedure with the nurse manager
● Identifying the client by name when making a referral for home health services
● Notifying the provider of physical examination findings
● Reporting laboratory findings to a member of the client’s family
12. A nurse is completing a client’s history and physical examinations. Which of the following information should the nurse consider subjective data?
● Blood pressure
● Petechiae
● Cyanosis
● Nausea
13. A nurse is caring for a client with a hip fracture that requires surgical repair. Which of the following heath care professionals is responsible for obtaining informed consent from the client for the procedure?
● Nurse
● Unit secretary
● Hospital client’s representative
● Surgeon
14. A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretion?
● Encourage coughing and deep breathing
● Encourage the client to increase fluid intake
● Encourage the client to ambulate frequently
● Encourage regular use of the incentive spirometer
15. A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse’s action. Which of the following responses by the nurse is appropriate?
● “The supervisor will be coming to explain the situation”
● “As a nurse, I am requested by law to report suspected child abuse”
● “I am unable to discuss this, but I can contact my supervisor to speak with you”
● “I reported the incident to my supervisor who decided to contact the authorities” [Show Less]