1. A nurse in a long-term care facility is assisting with an inservice for newly hired assistive personnel about legal issues
within the facility.
... [Show More] WhichofIthe following should the nurse
include as an example ofIassault?
ANS: Informing a client the nurse is going to administer an
injection even though the client refuses
.
2. A nurse is collecting data from who is severe pain. Which ofIthe
following questions should the nurse ask first?
ANS: "Where is your pain located?"
3. A nurse is reviewing the laboratory results for a client who is at
29 weeks gestation. For which of the following results should
the nurse notify the provider?
ANS: Platelet count 95,000 mm3
4. A nurse is performing a dressing change for a client who had
abdominal surgery 5 day s ago. The nurse notes organs protruding
from the incision. Which of the following act ions should the
nurse take?
ANS: Cover the exposed area with sterile, saline-soaked
dressings.
5. A nurse is speaking with the adult daughter ofIa client who has
Alzheimer's disease. T he daughter states, "I love my dad, but
caring for him is wearing me out." Which of th e following
response should the nurse make?
ANS: "Let's discuss how caring for your father is
afollowingecting your health.
6. A nurse is contributing to the plan ofIcare for a care for a client
who has chest tube co nnected to a closed drainage system. Which
ofIthe following actions should the nurse i nclude in the plan of
care?
ANS: Maintain the drainage system below the level ofIthe
client's chest.
7. A nurse in an acute mental health facility is caring for a client
who has borderline personality disorder and reports. "I am going
to kill my girlfriend when I get out ofIhere." Which ofIthe
following actions should the nurse take?
ANS: Notify the client's care team of the threats against the
partner
8. A nurse is admitting a client who is at high risk for suicide.
Which ofIthe following actions is the nurse's priority?
ANS: Search the client's personal belongings
9. A nurse is caring for a client who is 1 day postoperative and is
unable to ambulate. W hich ofIthe following actions should the
nurse take to promote the client's venous return?
ANS: Maintain the sequential compression device.
10. A nurse on an acute care unity is collecting data from a school-
age Child who has cystic fibrosis. Which ofIthe following
findings is the priority for the nurse?
ANS: Reports lack ofIappetite
11. a nurse working in a provider's ofollowingice receives a phone
call from the parent ofIa schoolage child who has varicella. The parent asked the nurse when the
child can return to school. Which ofIthe following responses
should the nurse make?
ANS: "When the lesions have scabbed over."
12. A nurse in a pediatric clinic is collecting the data from a schoolage child whose injuries are inconsistent with the parent's stated
cause. Which ofIthe following actions should the nurse take?
ANS: Report the suspected abuse to a appropriate agency.
13. A nurse is collecting data from a middle adult female client
who is taking melatonin.Which ofIthe following responses to
the med should the nurse expect?
ANS: Improved sleep
14. A nurse on a pediatric unit is collecting data from four newly
admitted clients. Which ofIthe following clients should the nurse
identify as being at risk for urinary retention?ANS: A schoolage child who has allergic rhinitis and is taking
diphenhydramine.
15. A nurse is preparing to administer purified protein derivative
(PPD) to a client who ha s suspected TB. Which ofIthe following
actions should the nurse plan to take?
ANS: Ensure the injection produces a wheal on the skin
16. A client who is diagnosed with Parkinson's disease verbalizes
frustration due to increas e difollowingiculty with ambulation.
Which ofIthe following responses should the nurs e take?
ANS: Perform active ROM with your arms and legs two
times a day.
17. a Nurse is collecting data from a client who has multiple
fractures following a motor-vehicle crash. For which ofIthe
following client statements
ANS: "I am so frustrated. I cannot even open my milk carton
for breakfast." [Show Less]