1. A nurse is reviewing the techniques for transferring a client from a bed to a chair with a group of assistive personnel (AP). Which of the following
... [Show More] instructions should the nurse include?
ANS: Use lower-body strength
RATIONALE: The nurse should instruct the AP to use lower-body strength when lifting a client to reduce stress on the back
2. A nurse is participating in a quality improvement study about the effectiveness of client pain management in the unit. Which of the following strategies should the nurse use to collect data?
ANS: Review clients' charts for their rating of pain before pain medication was administered and 1 hr after administration
RATIONALE: The nurse should collect data from clients' charts about pain ratings before and after pain management interventions
3. A nurse is reinforcing teaching about confidentiality with a client who has a new diagnosis of HIV.
Which of the following information should the nurse include in the teaching?
ANS: "Your HIV status will be shared with members of your health care team."
RATIONALE: The diagnosis of HIV or AIDS is shared with every member of the healthcare team who provides direct care for the client, just like any other diagnoses
4. A nurse is planning care for a client who has a history of seizures. Which of the following pieces of equipment should the nurse place in the client's room?
ANS: Suction catheter
RATIONALE: The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a patent airway
5. A nurse in a provider's office is reviewing the medical record of a client who requests a prescription for an oral contraceptive. Which of the following findings should the nurse identify as a contraindication for oral contraceptive use?
ANS: Coronary artery disease
RATIONALE: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension\
6. A nurse is assisting with the care of a school-age child immediately following surgery. The child weighs 21.8 kg (48 lb) and has a chest tube applied to suction. Which of the following findings should the nurse report to the provider?
ANS: 250 mL of sanguineous drainage over the last 3 hr
RATIONALE: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately
7. A nurse is collecting data from a client who is at 30 weeks of gestation and has gestational diabetes.
Which of the following findings should the nurse report to the provider as an indication of hyperglycemia?
ANS: Polyuria
RATIONALE: The nurse should identify polyuria as an expected finding of hyperglycemia and report this finding to the provider
8. A nurse is discussing home safety with a group of clients who have type 1 diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?
ANS: "I will dispose of my needles in a plastic laundry detergent container."
RATIONALE: The nurse should instruct the client to dispose of needles in a puncture-proof container, such as a plastic laundry detergent container.
9. A nurse is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse take?
ANS: Encourage the client to reminisce about the past
RATIONALE: The client who has Alzheimer's disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remote memory remains in place for a longer period of time and can elicit feelings of happiness
10. A nurse is monitoring a client who is receiving telemetry. Which of the following ECG findings should the nurse report to the provider?
ANS: PR interval 0.24 seconds
RATIONALE: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval indicates a heart block; therefore, the nurse should report this finding provider
11. A nurse on a medical unit is reviewing a client's medical record. Which of the following procedures should the nurse identify requires the client to sign a separate informed consent form? ANS: Lumbar puncture
RATIONALE: The nurse should identify that a client needs to provide consent for general treatment, as well as a separate written, informed consent for any treatment that has an element of risk, such as a lumbar puncture
12. A licensed practical nurse (LPN) is reviewing client assignments for the upcoming shift. Which of the following clients should the LPN ask the charge nurse to reassign to a registered nurse (RN)?
ANS: A client who has a new colostomy and requires the development of a teaching plan
RATIONALE: Developing a client teaching plan is not within the scope of practice for an LPN. The nurse should contact the nursing supervisor to inform them of the client's need for a teaching plan regarding the new colostomy and request that this client is reassigned to an RN. The scope of practice of an LPN does allow the nurse to reinforce teaching once the plan has been established
13. A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using eating utensils. The nurse should identify the need for a referral to one of the following interprofessional team members?
ANS: Occupational therapist
RATIONALE: The nurse should identify the need for a referral to an occupational therapist to teach the client how to use special eating utensils
14. A nurse is preparing to perform blood glucose monitoring for a client who has type 1diabetes Mellitus. Which of the following actions should the nurse take first?
ANS: Hold the finger for testing in a dependent position
RATIONALE: Evidence-based practice indicates that the nurse should first position the testing site to enhance blood flow, which improves the ability to collect an adequate specimen
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