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,{{Correct Ans- Enoxaparin 40 mg sq qd
A nurse is talking with a client who has major depressive disorder the client states nobody cares if I'm
around or not which of the following responses should the nurse night
{{Correct Ans- It sounds as though you're feeling hopeless
A nurse is preparing to administer a unit of packed red blood cells to a client in adherence with the joint
commission national patient safety goals regarding blood administration which of the following actions
should the nurse plan to take
{{Correct Ans- Verify the client and blood component using a two person process
A nurse is caring for a client who is morbidly obese and is 3 days postoperative following bariatric
surgery. What dietary recommendations should the nurse take?
Restrict fluid intake to no more than 1,000 mL (34 oz) each day.
Eat foods that are high in protein.
Avoid drinking fluids that contain sodium.
Begin adding soft foods one to two times a day. {{Correct Ans- Eat foods that are high in protein.
Rationale: The nurse should recommend that the client increase protein intake to promote healing from
surgery. A client who is 3 days postoperative following bariatric surgery should limit foods to clear and
full liquids. The nurse should recommend food items such as Greek yogurt. This full-liquid food also
meets the dietary requirement for protein-rich foods.
A nurse is planning a community health program about substance use disorders. What information
should the nurse include when discussing the guidelines for safe limits of alcohol consumption?
A healthy man under the age of 65 years should consume no more than five drinks each day.
A healthy woman of any age should consume no more than four drinks each day.
A healthy man over the age of 65 years should consume no more than 14 drinks in a week.
A healthy woman of any age should consume no more than seven drinks in a week. {{Correct Ans- A
healthy woman of any age should consume no more than seven drinks in a week.
,Rationale:
Recommendations for safe limits of alcohol consumption for a healthy woman include
consuming no more than seven drinks in a week.
A nurse in a community health clinic is screening a 10-yr old girl for scoliosis. What instructions should
the nurse give the child for this examination.
"Walk across the room with the heel of one foot against the toes of your other foot."
"Lie on your back on the examination table."
"Bend forward at the waist and let your arms hang down."
"Close your eyes and stand with your heels together." {{Correct Ans- Bend forward at the waist and let
your arms hand down
Rationale: During a scoliosis screening, the nurse should have the child bend forward at the waist,
keeping her back parallel with the floor and having her arms dangle freely. In this position, the nurse can
observe asymmetry of the ribs and flanks.
A nurse is asked by a provider to perform an invasive procedure for which he has not received training.
What action should the nurse take to ensure that it is within his legal scope of practice to perform this
procedure?
Ask the provider for instructions on how to perform the procedure.
Check the state's nurse practice act before performing the procedure.
Request that the charge nurse assist him to perform the procedure.
Obtain informed consent from the client before performing the procedure. {{Correct Ans- Check the
state's nurse practice act before performing the procedure.
Rationale: The nurse should check the state's nurse practice act to verify that performance of the
procedure is within his scope of practice. This will ensure that the nurse follows legal guidelines for his
scope of practice. If the nurse works in more than one state, he should check the nurse practice act for
each state, because guidelines for this procedure might differ from state to state. If the procedure is
, Rationale:
within the nurse's scope of practice, he should take necessary steps to gain competence in the
procedure before performing it on a client.
A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the
same language as the nurse. What action should the nurse plan to take?
Direct the interview questions to the interpreter.
Ensure the client and the interpreter are compatible.
Ask the client's partner to act as the interpreter.
Ask the interpreter to translate questions word for word. {{Correct Ans- Ensure the client and the
interpreter are compatible.
Rationale: The nurse should ensure that the client is comfortable with the interpreter. The nurse should
consider the client's age, gender, and culture when using an interpreter.
A charge nurse is observing a newly licensed nurse prepare medications for a client. What actions by the
newly licensed nurse adheres to safe medication administration practices?
The nurse breaks a non-scored caplet in half to administer a prescribed dose.
The nurse uses the client's room number as an identifier for medication administration.
The nurse compares the medication label with the client's medication administration record.
The nurse prepares to administer an antibiotic 1 hr prior to the scheduled time. {{Correct Ans- The nurse
compares the medication label with the client's medication administration record.
When preparing medications for administration, safe practice includes comparing the medication label
with the client's medication administration record a minimum of three times: prior to removing the
medication from the drawer, when removing medication from the drawer, and at the client's bedside
prior to administering the medication.
A nurse is documenting an assessment in a client's electronic health record who an assistive personnel
(AP) asks to enter the morning blood glucose for the client. What actions should the nurse take?
Allow the AP to use the computer while the nurse is still logged in.
,{{Correct Ans- Enoxaparin 40 mg sq qd
A nurse is talking with a client who has major depressive disorder the client states nobody cares if I'm
around or not which of the following responses should the nurse night
{{Correct Ans- It sounds as though you're feeling hopeless
A nurse is preparing to administer a unit of packed red blood cells to a client in adherence with the joint
commission national patient safety goals regarding blood administration which of the following actions
should the nurse plan to take
{{Correct Ans- Verify the client and blood component using a two person process
A nurse is caring for a client who is morbidly obese and is 3 days postoperative following bariatric
surgery. What dietary recommendations should the nurse take?
Restrict fluid intake to no more than 1,000 mL (34 oz) each day.
Eat foods that are high in protein.
Avoid drinking fluids that contain sodium.
Begin adding soft foods one to two times a day. {{Correct Ans- Eat foods that are high in protein.
Rationale: The nurse should recommend that the client increase protein intake to promote healing from
surgery. A client who is 3 days postoperative following bariatric surgery should limit foods to clear and
full liquids. The nurse should recommend food items such as Greek yogurt. This full-liquid food also
meets the dietary requirement for protein-rich foods.
A nurse is planning a community health program about substance use disorders. What information
should the nurse include when discussing the guidelines for safe limits of alcohol consumption?
A healthy man under the age of 65 years should consume no more than five drinks each day.
A healthy woman of any age should consume no more than four drinks each day.
A healthy man over the age of 65 years should consume no more than 14 drinks in a week.
A healthy woman of any age should consume no more than seven drinks in a week. {{Correct Ans- A
healthy woman of any age should consume no more than seven drinks in a week.
,Rationale:
Recommendations for safe limits of alcohol consumption for a healthy woman include
consuming no more than seven drinks in a week.
A nurse in a community health clinic is screening a 10-yr old girl for scoliosis. What instructions should
the nurse give the child for this examination.
"Walk across the room with the heel of one foot against the toes of your other foot."
"Lie on your back on the examination table."
"Bend forward at the waist and let your arms hang down."
"Close your eyes and stand with your heels together." {{Correct Ans- Bend forward at the waist and let
your arms hand down
Rationale: During a scoliosis screening, the nurse should have the child bend forward at the waist,
keeping her back parallel with the floor and having her arms dangle freely. In this position, the nurse can
observe asymmetry of the ribs and flanks.
A nurse is asked by a provider to perform an invasive procedure for which he has not received training.
What action should the nurse take to ensure that it is within his legal scope of practice to perform this
procedure?
Ask the provider for instructions on how to perform the procedure.
Check the state's nurse practice act before performing the procedure.
Request that the charge nurse assist him to perform the procedure.
Obtain informed consent from the client before performing the procedure. {{Correct Ans- Check the
state's nurse practice act before performing the procedure.
Rationale: The nurse should check the state's nurse practice act to verify that performance of the
procedure is within his scope of practice. This will ensure that the nurse follows legal guidelines for his
scope of practice. If the nurse works in more than one state, he should check the nurse practice act for
each state, because guidelines for this procedure might differ from state to state. If the procedure is
, Rationale:
within the nurse's scope of practice, he should take necessary steps to gain competence in the
procedure before performing it on a client.
A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the
same language as the nurse. What action should the nurse plan to take?
Direct the interview questions to the interpreter.
Ensure the client and the interpreter are compatible.
Ask the client's partner to act as the interpreter.
Ask the interpreter to translate questions word for word. {{Correct Ans- Ensure the client and the
interpreter are compatible.
Rationale: The nurse should ensure that the client is comfortable with the interpreter. The nurse should
consider the client's age, gender, and culture when using an interpreter.
A charge nurse is observing a newly licensed nurse prepare medications for a client. What actions by the
newly licensed nurse adheres to safe medication administration practices?
The nurse breaks a non-scored caplet in half to administer a prescribed dose.
The nurse uses the client's room number as an identifier for medication administration.
The nurse compares the medication label with the client's medication administration record.
The nurse prepares to administer an antibiotic 1 hr prior to the scheduled time. {{Correct Ans- The nurse
compares the medication label with the client's medication administration record.
When preparing medications for administration, safe practice includes comparing the medication label
with the client's medication administration record a minimum of three times: prior to removing the
medication from the drawer, when removing medication from the drawer, and at the client's bedside
prior to administering the medication.
A nurse is documenting an assessment in a client's electronic health record who an assistive personnel
(AP) asks to enter the morning blood glucose for the client. What actions should the nurse take?
Allow the AP to use the computer while the nurse is still logged in.
