FULL QUESTIONS ACCURATE RESPONSES
CONFIRMED
◉ A nurse on a surgical unit is caring for a group of clients. Which of
the following is the priority action of the nurse?
Taking a telephone prescription about a client who is to be
transferred from PACU
Assessing a client who experiences unilateral calf pain when
ambulating
Reinforcing a client's dressing for the surgical site of an above-the-
knee amputation
Reassuring the partner of a client who sustained a closed head
injury. Answer: Assessing a client who experiences unilateral calf
pain when ambulating;
When using the urgent vs nonurgent approach to client care, the
nurse should determine that the priority action is assessing a client
who has manifestations of a deep vein thrombosis, which can lead to
pulmonary embolus. The nurse should assess this client and report
the findings immediately to the provider.
,◉ A nurse is planning a staff education session regarding biological
weapons of mass destruction. Which of the following should he plan
to include in the session? (Select all that apply).
Sarin
Smallpox
Anthrax
Hydrogen cyanide
Botulism. Answer: Smallpox
Anthrax
Botulism;
Sarin is incorrect. Sarin is a chemical - rather than a biological -
agent of mass destruction.Smallpox is correct. Smallpox is a
biological weapon of mass destruction.Anthrax is correct. Anthrax is
a biological weapon of mass destruction.Hydrogen cyanide is
incorrect. Hydrogen cyanide is a chemical - rather than a biological -
agent of mass destruction.Botulism is correct. Botulism is a
biological weapon of mass destruction.
◉ An assistive personnel (AP) reports to the nurse that a client who
is 3 days postoperative following an abdominal hysterectomy has a
dressing that is saturated with blood. Which of the following tasks
should the nurse delegate to the AP?
, Change the abdominal dressing.
Obtain vital signs.
Palpate for possible bladder distention.
Observe the incision site.. Answer: Obtain vital signs;
Obtaining vital signs is a skill within the scope of practice for an AP;
therefore, the nurse can delegate this task to the AP.
◉ A nurse is caring for a client whose family member requests to
view the client's medical record. Which of the following responses
should the nurse make?
"I will ask the nursing supervisor to obtain the medical records for
you."
"The health care provider will share this information with you."
"The ethics committee will need to approve this request for you."
"The client must provide permission to share the records with you.".
Answer: "The client must provide permission to share the records
with you.";
Client information is shared only with individuals involved directly
in the client's care. The client must provide permission for the family
to access protected health information.