1. A nurse is assessing pressure ulcers on four clientsto evaluate the effectiveness of a change
in wound care procedure. Which of the following findings
... [Show More] indicate wound healing?
a. Erythema on the skin surrounding a client’s wound
b. Inflammation noted on the tissue edges of a client’s wound
c. Increase in serosanguinous exudate from a client’s wound
d. Deep red color on the center of a client’s wound
2. A nurse received change-of-shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
a. Administer pain medication to a client who has rheumatoid arthritis and received the
last dose at 0400
b. Obtain a breakfast tray for a client who received a morning dose of insulin aspart
c. Replace a client’s enteral nutrition feeding solution that has been hanging for 24 hr
d. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following
clients should the nurse assign to the newly licensed nurse?
a. A client who sustained a concussion and is being monitored for complications
b. A client who has a brain tumor and is admitted for chemotherapy
c. A client who has Gullain-Barre syndrome and a tracheostomy
d. A client who has multiple sclerosis and ataxia
4. A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client indicates an understanding of the teaching?
a. My durable power of attorney for health care is part of my advance directives
b. My doctor will need to provide approval for the decisions outlined in my living will
c. Once I sign my living will, a family member must co-sign it
d. I will wait until I have a serious health problem to sign my advance directives
5. A nurse is chairing a committee about preventing infant abduction in a new birth care center.
Which of the following quality control tasks should the nurse assign to be completed first?
a. Establishmeasurement criteria for infantsafety systems
b. Evaluate the selected infantsafety system
c. Choose an infantsafety system
d. Identify the industry standards for infantsafety
6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently
during meals. The nurse plans to perform dysphagia screening to determine the client’s need
for a referral to which of the following providers?
a. Respiratory therapist
b. Physical therapist
c. Occupational therapist
d. Speech therapist
7. A home health nurse is assessing the home environment during an initial visit to a client who
has a history of falls. Which of the following findings should the nurse identify as increasing the
client’s risk for falls? (Select all that apply.)
a. A wheeled office chair at the client’s computer desk
b. A two-wheeled walker used to assist the client with ambulation
c. A throw rug covering some cracked vinyl flooring in the kitchen
d. A folding chair without arm rests
e. A raised vinyl seat on the toilet in the bathroom
8. A nurse manager is planning to assign care for four clients on a medical-surgical unit. Which
of the following clients should the nurse assign to a licensed practical nurse?
a. An adolescent client who is newly diagnosed with diabetes and requires teaching
regarding insulin administration
b. A middle adult client who had a below-the-knee amputation and requires a dressing
change
c. An older adult client who has lung cancer and has periodic episodes ofsevere dyspnea
d. A young adult client who is postoperative, receiving morphine via epidural, and reports
pruritus
9. While auditing the medical records of clients currently on an oncology unit, the nurse
manager findsthat six of the 15 records lack documentation regarding advance directives.
Which of the following is the priority action for the nurse to take?
a. Reinforce the potential consequences of not having thisinformation on record to the
nursing staff
b. Ask nurses who are caring for clients without this information in the medical record to
obtain it
c. Meet with nursing staff to review the policy regarding advance directives
d. Remind nursesto obtain this information during the admission process
10. A nurse is caring for a group of clients. Which of the following clients should the nurse see
first?
a. A client who is postoperative and has a fever
b. A client whose pressure ulcer has serosanguinous drainage on the dressing
c. A client who has diabetes mellitus and is diaphoretic
d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0 to 10
11. A nurse isreceiving change-of-shift report for four clients. Which of the following clients
should the nurse care for first?
a. A client who has pneumonia and requires a tracheostomy dressing change
b. A client who has a new colostomy and requires discharge teaching
c. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
d. A client who is 4 hr postoperative following a hernia repair and has pitting edema of
the right leg - check
12. A nurse manager discovers there is a conflict between nurses working the day shift and
nurses working the night shift. Which of the following actions should the nurse manager take
first?
a. Encourage the nursesto resolve the conflict autonomously
b. Meet with a committee of nurses from each shift to discuss issues related to the conflict
c. Gather information regarding the situation
d. Acknowledge the conflict and encourage the nurses to focus on working as a team
13. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid
chemical in an industrial setting. Which of the following actionsshould the nurse take first?
a. Remove the client’s clothing
b. Don personal protective equipment - check
c. Report the incident to OSHA
d. Irrigate the exposed area with water
14. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong
client. Which of the following actions should the nurse perform first?
a. Measure the client’s vitalsigns
b. Call the provider
c. Inform the nurse manager
d. Complete an incident report
15. A nurse is assessing a client who has meningitis. Which of the following findings should the
nurse report to the provider immediately?
a. Increased temperature
b. Generalized rash overtrunk
c. Report of photophobia
d. Decreased level of consciousness
16. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance
with the care pathway, antibiotic therapy is prescribed. Which of the following situations
requires the nurse to complete a variance report with regard to the care pathway?
a. The route of antibiotic therapy on the care pathway was changed from IV to PO
b. An allergy to penicillin required an alternative antibiotic to be prescribed
c. A blood culture was obtained after antibiotic therapy had been initiated
d. Antibiotic therapy was initiated 2 hr after implementation of the care pathway
17. A nurse manager is making staffing assignments for the maternal newborn unit. Which of
the following clients should the nurse manager assign to a float nurse from the medical-surgical
unit?
a. A client who is post-term and is receiving oxytocin for labor induction
b. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion
c. A client who gave birth to herfirst child and requiresinstruction on breastfeeding
techniques
d. A client who is 2 days postoperative following a caesarean birth and is having difficulty
ambulating
18. A nurse is coordinating an inter-professional team to review proposed standardsto reduce
the transmission of MRSA. Which of the following members of the inter-professional team
should the nurse consult?
a. Risk management coordinator
b. Nursing supervisor
c. Infection control nurse
d. Clinical pharmacist
19. A nurse is caring for a client who has uterine prolapse. The provider has recommended a
total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option.
Which of the following is an appropriate action for the nurse to take?
a. Initiate a mental health consult to determine the client’sreasons for refusing surgery
b. Inform the client of the consequences of uterine prolapse and the need for intervention
c. Provide the client with information on treatment options and outcomes - check
d. Discuss with the client her concerns regarding the procedure
20. A nurse in the emergency department is assessing a client who is unconscious following a
motor-vehicle crash. The client requires immediate surgery. Which of the following actions
should the nurse take?
a. Obtain telephone consent from the facility administrator before the surgery
b. Transport the client to the operating room without verifying informed consent
c. Delay the surgery until the nurse can obtain informed consent
d. Ask the anesthesiologist to sign the consent
21. A nurse is planning to delegate client care assignments. Which of the following tasks should
the nurse plan to delegate to assistive personnel?
a. Informing a family of a client’s progress in physical therapy
b. Advising a client on self-administration of acetaminophen
c. Teaching a client to perform a finger-stick for testing blood glucose levels
d. Performing postmortem care prior to transferring the client to the morgue
22. A nurse is working on a quality improvement team that is assessing an increase in client falls
at the facility. After problem identification, which of the following actions should the nurse plan
to take first as part of the quality improvement process?
a. Notify staff of the increased fall rate
b. Identify clients who are at risk for falls
c. Review current literature regarding client falls
d. Implement a fall prevention plan
23. A nurse is completing a performance evaluation for assistive personnel (AP). Which of the
following actions by the AP requires intervention by the nurse?
a. The AP uses alcohol hand antiseptic after caring for a client who has C. dif
b. The AP removes cut flowers from the room of a client who is in a protective environment
c. The AP wears a mask when caring for a client who has varicella
d. The AP closes the door of a client who is on airborne precautions
24. A charge nurse noticesthat staff nurses are having difficulty using new IV infusion pumps for
medication administration. Which of the following is the priority action by the charge nurse?
a. Demonstrate use of the pump during medication administration
b. Assess the staff nurses’ knowledge deficit
c. Pair an inexperienced nurse with an experienced nurse
d. Plan an in-service education program on the unit
25. A nurse is preparing a shift assignment for assistive personnel (AP) on the unit. Which of the
following tasks should the nurse assign to the AP?
a. Administer the initial bolus feeding to a client who has an NG tube
b. Instruct a client to splint an abdominal incision
c. Check a client’s pain level 30 min after receiving acetaminophen
d. Collect a urine specimen from a newly admitted client
26. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a
client. Which of the following actions should the nurse take?
a. Provide treatment for minor injuries
b. Provide treatment for life-threatening injuries
c. Allow the client to die without further intervention
d. Treat the client’s injuries within 30 min
27. A home health nurse is performing a safety assessment of a client’s home. Which of the
following findings should the nurse identify as a safety hazard?
a. The client’s electrical cord is taped to the floor
b. The client has used tacks to secure the carpet on the stairs
c. The client’s bedside lamp is plugged in using an extension cord with two prongs
d. The client stores cleaning supplies in a locked cabinet above his head
28. A charge nurse is observing a newly licensed nurse provide care for a client who has a C. dif
infection. Which of the following actions by the newly licensed nurse indicates an understanding
of proper infection control procedures?
a. Removesfresh flowers from the client’s room
b. Wears a gown when caring for the client
c. Washes her hands with an alcohol-based hand rub after caring for the client
d. Applies a mask before entering the client’s room
29. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following supplies to manage
the tracheostomy at home? (Select all that apply.)
a. Petroleum jelly
b. Cotton balls
c. Obturator
d. Oxygen tank
e. Pipe cleaners
30. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
a. An adolescent client who is legally emancipated
b. An older adult client who has questions about the procedure
c. An adult client who ha.....................................................................................CONTINUED...............................................................DOWNLOAD FOR BEST SCORES [Show Less]