1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infa... [Show More] nt and her 4 year-old child?
lying in a crib. A 4 year-old could assist with the care of an infant with proper supervision. This enhances bonding with the infant and the developmental needs of the preschooler to "help" and not feel left out.
2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
correct sequence of care is to administer the epinephrine, then maintain airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normotensive, administering the epinephrine and then applying the oxygen, watching for hypotension and shock are later responses. The prevention of a severe crisis is maintained by using diphenhydramine.
4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?
10. A nurse observes a family member administer a rectal ember pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to
6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?
Review Information: The correct answer is B: clean the meatus, begin voiding, then catch urine stream
A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it''s best to just slip the container into the stream. Other responses are not correct technique.
13. The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?
Review Information: The correct answer is B: watermelon Watermelon is high in potassium and will replace any potassium lost by the diuretic. The other foods are not high in potassium.
14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?
An elderly client who had a myocardial infarction a week ago - UAP Review Information: The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure - PN
The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP.
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?
Review Information: The correct answer is B: Restlessness and increased mucus production
This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended.
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?
Review Information: The correct answer is C: Immediately wash the hands with vigor
The immediate action of vigorously washing will help remove possible contamination. Then the sequence would then be options 4, 1, 2.
15. 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 the medication without first aspirating. What should the nurse do?
Review Information: The correct answer is C: "Clothes are becoming tighter across her abdomen."
One of the most common signs of neuroblastoma is increased abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments.
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?
Review Information: The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream. Option 4 protects the client and is the most professional.
16. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
Review Information: The correct answer is D: Proceed with the triage process in the same manner as any adult client
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult.
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)?
Review Information: The correct answer is B: Glascow Coma Scale 8, respirations regular
The Glascow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise.
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? [Show Less]