Evolve – Comprehensive Nursing Competency
Assessment for NCLEX-RN Readiness|Graded A+!!!
The nurse is caring for a client with a cerebrovascular
accident (CVA) who is receiving enteral tube feedings.
Which task performed by the UAP requires immediate
intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
,D.Keeps head of bed elevated at 30 degrees - ANSWER-
B
Rationale:
Positioning the head of the bed flat when enteral feedings
are in progress puts the client at risk for aspiration (B). The
others are all acceptable tasks performed by the UAP (A,
C, and D).
When caring for a postsurgical client who has undergone
multiple blood transfusions, which serum laboratory finding
is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
,D.Calcium level, 10 mEq/L - ANSWER-B
Rationale:
Multiple blood transfusions are a risk factor for
hyperkalemia. A serum potassium level higher than 5.0
mEq/L indicates hyperkalemia (B). The others are normal
findings (A, C, and D).
Which vaccination should the nurse administer to a
newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - ANSWER-A
Rationale:
, The hepatitis B vaccination should be given to all
newborns before hospital discharge (A). HPV is not
recommended until adolescence (B). Varicella
immunization begins at 12 months (C). Meningococcal
vaccine is administered beginning at 2 years (D).
When caring for a client in labor, which finding is most
important to report to the primary health care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F - ANSWER-B
Rationale: