1. A nurse is planning to discharge a client who has terminal cancer and suggests that the family might benefit from respite services. When the client’s
... [Show More] partner asks how this service can help, which of the following responses by the nurse is appropriate?
a. “This service offers psychological interventions during and after your wife’s illness.”
b. “The clinicians help reduce the severity of your wife’s physical problems.”
c. “This service delivers meals and supplies to reduce your errands away from home.”
d. “It makes it possible for you to have some time away from caring for your wife.”
2. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include?
a. Warm the hands prior to piercing the skin.
b. Cap the lancet prior to putting it in the trash.- never recap
c. Elevate the arm for 1 min before taking the blood sample.- has to be down so gravity can assist to milk the blood out .
d. Obtain the blood sample from the finger pads.
3. A nurse is assessing a client who had a recent stroke. Which of the following findings should indicate the need for referral to an occupational therapist?
a. Receptive aphasia→ unable to understand language in its written or spoken form
b. Facial drooping→ speech therapist
c. Memory loss
d. Unilateral neglect –is one of the disabling features of stroke, and is defined as a failure to attend to the side opposite a brain lesion.
4. A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event?
a. A network for communication between staff members and families
b. A mental health specialist on the response team
c. A sufficient supply of personal protective equipment
d. A system for tracking client information
5. A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department?
a. Rotavirus
b. Pertussis
c. Respiratory syncytial virus
d. Group B streptococcal disease
6. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used for a client who has Clostridium difficile. Which of the following solutions should the nurse recommend to clean the equipment?
a. Chlorine bleach
b. Triclosan
c. Chlorhexidine
d. Isopropyl alcohol
7. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
a. Treat and discharge the client.
b. Ask the client’s son to go to the waiting area.
c. File an incident report.
d. Ask the client about his injuries with the son present
8. A nurse is completing discharge teaching with a client who is being treated for tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching?
a. “I need to take my prescribed medication for 3 months.”
b. “I should have a sputum culture done every 2 to 4 weeks.”
c. “I need to have a TB skin test done once per year.”
d. “I should wear a mask while around my family.”
9. An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel?
a. Checking the pulses of the client’s right foot
b. Recording the client’s vital signs
c. Turning the client
d. Determining the client’s pain level
10. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Which of the following is an appropriate task for the AP?
a. Inspect the skin of a newborn who is receiving phototherapy. – Assess
b. Answer the parents’ questions about newborn circumcision. - Teaching
c. Show a new mother how to change the newborn’s diaper. - Teaching
d. Obtain the weight of a newborn that is receiving formula
11. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
a. “A provider can write a prescription for restraints ‘as needed’.”
b. “I need to tie the restraint to the part of the bed frame that moves.”
c. “I should tie the restraints using a square knot.”
d. “I will remove a client’s restraints every 4 hours.”
12. An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions?
a. Mumps
b. Rubeola
c. Varicella
d. Rotavirus
13. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse?
a. Tell the client that a catheter will be inserted.
b. Document the client’s refusal in the chart.
c. Assess the client for urinary retention.
d. Obtain a provider’s prescription for a blood alcohol level.
14. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse?
a. Pick up the meal trays after lunch.
b. Administer a nasogastric tube feeding.
c. Plan break times for assistive personnel.
d. Determine adequacy of ventilator settings.
15. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure. Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA)
a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field
b. Opens the sterile pack by first unfolding the top flap away from her body
c. Prepares a container of sterile solution on the field after putting on sterile gloves
d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
e. Holds the sterile solution bottle with the label facing up
16. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first?
a. Auscultate the client’s lungs.
b. Notify the provider.
c. Place a faulty equipment tag on the pump.
d. Complete an incident report.
17. A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
a. Reinforcing teaching with a client who is learning to self-administer insulin
b. Ambulating a client who is scheduled for discharge later in the day
c. Administering morphine IV bolus to a client who is __ hr postoperative
d. Admitting a new client who has chronic back pain to the unit
18. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?
a. The nurse applies goggles.
b. The nurse turns her back to the sterile field.
c. The nurse holds her hands above her waist.
d. The nurse puts on a face mask.
19. A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel (AP). Which of the following actions should the nurse take to evaluate the delegated task?
a. Review vital sign trends at the end of the shift.
b. Recheck vital signs that are outside the expected reference range.
c. Ask the AP to write a summary of the delegated tasks during the shift.
d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift.
20. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?
a. Obtaining a stool sample from a client who has renal failure
b. Monitoring a client who has a fluid restriction
c. Assessing a client who just returned from hemodialysis
d. Reviewing dietary instructions for a client who has kidney stones
21. A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
a. A client who has a neck injury and is unable to breathe spontaneously
b. A client who has two open chest wounds with a left tracheal deviation
c. A client who has major burns over 75% of her body surface area
d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3)
22. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective?
a. “A family member can interpret to obtain informed consent from a client who is deaf.”
b. “Consent can be given by a durable power of attorney.”
c. “Guardian consent is required for an emancipated minor.”
d. “The nurse can answer any questions the client has about the procedure.”
23. A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?
a. A middle adult client who leaves the facility against medical advice
b. An older adult client who has advanced directives on file
c. A young adult client who is participating in a medical research study
d. An adolescent client whose parents refuse a blood transfusion for religious reasons
24. A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth?
a. Assessing client needs
b. Developing client treatment protocols
c. Providing medication reconciliation
d. Establishing communication between providers (Community Health pg. 75)
25. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes. The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions should the nurse take?
a. Refer the client to the social services department.
b. Provide the client with a week’s worth of supplies from the hospital (still needs help paying after)
c. Ask the provider about the possibility of less frequent monitoring (pt needs to monitor often)
d. Recommend the client reuse the testing lancets (breaks the safety & infection protocol)
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