1. A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse
identify as a need for referral to
... [Show More] speech-language pathology?
a. Altered level of consciousness
b. Diminished hand-to-mouth coordination
c. Impaired voluntary cough
d. Unilateral ptosis
2. 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 raised vinyl seat on the toilet in the bathroom
b. A wheeled office chair at the client’s computer desk
c. A folding chair without arm rests
d. A two-wheeled walker used to assist the client with ambulation
e. A throw rug covering some cracked vinyl flooring in the kitchen
3. The family members of an older adult client are expressing conflict over whether the client should have surgery
that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the
client. The client is oriented to person, place, and time. Which of the following people has the legal authority to
make this healthcare decision?
a. The oldest adult child
b. The client
c. The partner
d. The provider
4. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is
disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
a. Contact the client’s next of kin to obtain consent for treatment.
b. Notify risk management before initiating treatment.
c. Proceed with treatment without obtaining written consent.
d. Have the client sign a consent for treatment.
5. The charge nurse is evaluating a newly licensed nurse’s understanding of infection control procedures. Which of
the following actions demonstrates that the nurse is following the appropriate protocol for a client to a
streptococcal pharyngitis?
a. Wearing a mask when was in 1 m (3.3 ft) of the client.
b. Placing the client in a positive-airflow room with 12 air exchanges per hour.
c. Explaining to the client that he can have visitors until his manifestations resolve.
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