As the nurse observes the student nurse during the administration of
a narcotic
analgesic IM injection, the nurse notes that the student begins to give
... [Show More] the
medication
without first aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
C) Loudly state: “You forgot to aspirate.”
D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
The correct answer is D: Walk up and whisper in the student’s ear “Stop.
Aspirate. Then
inject.”
16. A client with Guillain Barre is in a non responsive state, yet vital signs
are stable and
breathing is independent. What should the nurse document to most
accurately describe
the client's condition?
A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required
The correct answer is B: Glascow Coma Scale 8, respirations regular
17. A client enters the emergency department unconscious via
ambulance from the
client’s work place. What document should be given priority to guide the
direction of care
for this client?
A) The statement of client rights and the client self determination act
B) Orders written by the health care provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency
department
The correct answer is C: A notarized original of advance directives
brought in by the
partner
18. The charge nurse has a health care team that consists of 1 PN, 1
unlicensed assistive
personnel (UAP) and 1 PN nursing student. Which assignment should be
questioned by
the nurse manager?
A) An admission at the change of shifts with atrial fibrillation and heart
failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running -
charge nurse
D) An elderly client who had a myocardial infarction a week ago - UAP
The correct answer is A: An admission at the change of shifts with atrial
fibrillation and
heart failure - PN
19. A mother brings her 3 month-old into the clinic, complaining that the
child seems to
be spitting up all the time and has a lot of gas. The nurse expects to find
which of the
following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
The correct answer is B: Restlessness and increased mucus production
20. As the nurse takes a history of a 3 year-old with neuroblastoma, what
comments by
the parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness."
The correct answer is C: "Clothes are becoming tighter across her
abdomen."
21. A 16 year-old enters the emergency department. The triage nurse
identifies that this
teenager is legally married and signs the consent form for treatment.
What would be the
appropriate action by the nurse?
A) Ask the teenager to wait until a parent or legal guardian can be
contacted
B) Withhold treatment until telephone consent can be obtained from the
partner
C) Refer the teenager to a community pediatric hospital emergency
department
D) Proceed with the triage process in the same manner as any adult client
The correct answer is D: Proceed with the triage process in the same
manner as any adult
client
22. A newly admitted elderly client is severely dehydrated. When planning
care for this
client, which task is appropriate to assign to an unlicensed assistive
personnel (UAP)?
A) Converse with the client to determine if the mucous membranes are
impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours
The correct answer is B: Report output of less than 30 ml/hr
23. The nurse has admitted a 4 year-old with the diagnosis of possible
rheumatic fever.
Which statement by the parent would cause the nurse to suspect an
association with this
disease?
A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care last month.
C) Both ears were infected over 3 months age.
D) Last week both feet had a fungal skin infection.
The correct answer is B: Strep throat went through all the children at the
day care last
month.
24. A nurse assigned to a manipulative client for 5 days becomes aware
of feelings for a
reluctance to interact with the client. The next action by the nurse should
be to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the
manipulative behavior
C) Confront the client about the negative effects of behaviors on other
clients and staff
D) Develop a behavior modification plan that will promote more functional
behavior
The correct answer is A: Discuss the feeling of reluctance with an
objective peer or
supervisor
25. A client is being treated for paranoid schizophrenia. When the client
became loud and
boisterous, the nurse immediately placed him in seclusion as a
precautionary measure.
The client willingly complied. The nurse’s action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client’s history of violence
D) Was necessary to maintain the therapeutic milieu of the unit
The correct answer is A: May result in charges of unlawful seclusion and
restraint
26. A client has been admitted to the Coronary Care Unit with a
myocardial infarction.
Which nursing diagnosis should have priority?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety related to pain
The correct answer is A: Pain related to ischemia
27. The provisions of the law for the Americans with Disabilities Act
require nurse
managers to
A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities
The correct answer is B: Provide reasonable accommodations for disabled
individuals
28. A 42 year-old male client refuses to take propranolol hydrochloride
(Inderal) as
prescribed. Which client statement s from the assessment data is likely to
explain his
noncompliance?
A) "I have problems with diarrhea."
B) "I have difficulty falling asleep."
C) "I have diminished sexual function."
D) "I often feel jittery."
The correct answer is C: "I have diminished sexual function."
29. A school-aged child has had a long leg (hip to ankle) synthetic cast
applied 4 hours
ago. Which statement from the mother indicates that teaching has been
inadequate?
A) ”I will keep the cast for the next day uncovered to prevent burning of
the skin."
B) ”I can apply an ice pack over the area to relieve itching inside the
cast."
C) ”The cast should be propped on at least 2 pillows when my child is
lying down."
D) ”I think I remember that standing cannot be done until after 72 hours."
The correct answer is D: "I think I remember that standing cannot be done
until after 72
hours." [Show Less]