Question 1
A client has been admitted to the hospital with draining foot lesions. What should the nurse do?
Select all that apply.
Place the client in a room with negative air pressure.
Admit the client to a semi-private room.
Admit the client to a private room.
Post a "contact isolation" sign on the door.
Wear a protective gown when in the client's room.
Wear gloves when providing direct care.
Explanation:
Infection control policies must be followed to prevent the spread of infection. Until the
pathogens are identified, the client must be isolated in a private room. Utilizing contact isolation
and wearing a protective isolation gown and clean gloves, in addition to following isolation
protocol to exit the room, may aid in preventing the spread of infectious agents to others. A
draining foot lesion does not require a negative air pressure room, which is primarily reserved
for preventing the spread of tuberculosis.
Question 2
The nurse is changing a wet-to-dry dressing covering a surgical wound. Which is the appropriate
procedure for changing this type of dressing?
Correct response:
Cover the wet packing with a dry sterile dressing.
Explanation:
A wet-to-dry dressing should be able to dry out between dressing changes. Thus, the dressing
should be moist, not dry, when applied. As the moist dressing dries, the wound will be debrided
of necrotic tissue and exudate. Normal saline is most commonly used to moisten the sponge;
Burow's solution will irritate the wound. The sponge should not be packed into the wound
tightly because the circulation to the site could be impaired. The moist sponge should be placed
so that all surfaces of the wound are in contact with the dressing. Then the sponge is covered
and protected by a dry sterile dressing to prevent contamination from the external
environment.
,Question 3
The nurse works to reduce the number of children involved in automobile crashes who were not
wearing seat belts. Which strategy is the most effective?
Correct response:
Attend a school board meeting to advocate for classes teaching children seat belt safety.
Explanation:
The best strategy to affect child seat belt safety is to attend the school board meeting and
advocate for educational programming. The programming could be simple and done quickly.
This action also targets the best audience.
Question 4
A client who is showing signs of alcohol intoxication has just been brought to the emergency
department after a motor vehicle crash (MVC). Which action should the nurse prioritize as the
client is admitted to the unit?
Correct response:
Stabilize physical needs first, and observe for symptoms of withdrawal.
Explanation:
A client impaired with alcohol may have a serious traumatic injury with no report of pain. The
nurse should assume that the client who appears intoxicated and was brought in from the scene
of an MVC has sustained a traumatic injury until proven otherwise. The priority is to identify and
stabilize any physical needs first and monitor for symptoms of withdrawal to prevent
complications. The client's physical status is not fully known and is difficult to assess while the
client is still intoxicated, so transferring them to a detox unit is not safe. While the client may
need one-on-one observation at some point, there is nothing to suggest that observation is the
current priority intervention. A mental health assessment may be indicated later in the client's
care, but this is not the priority over the client's physical or withdrawal needs. The client may be
disoriented or confused while intoxicated or withdrawing from alcohol, but reorientation is not
the priority.
Question 5
,A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the
early introduction of stroke rehabilitation, the client has seen significant improvements in both
medical status and activities of daily living (ADLs). This morning, however, the nurse notes that
the client has been coughing since eating a minced and pureed breakfast. Auscultation of the
chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a
swallowing assessment?
Correct response:
speech therapist
Explanation:
The diagnosis and treatment of dysphagia (swallowing problems) is within the purview of
speech therapists. The health care provider should be made aware and respiratory therapy may
be involved with assessing and promoting the client’s oxygenation but swallowing assessment is
a task most often performed by a speech therapist.
Question 6
The nurse manager is preparing to meet with several registered nurses (RNs) in the department
to address practice issues. Which behavior by an RN will the nurse manager address as a
violation of the RN's "duty to care"?
Correct response:
declined assignment to care for a client with dementia who was incontinent of stool
Explanation:
The duty to care in nursing refers to the ethical obligation that nurses have to their clients.
Nurses can refuse to care for clients on several grounds such as moral conflict, feeling unsafe, or
lacking the skills needed to safely deliver care. The nurse cannot refuse care based on the
client's health concerns. Falsifying medical records is a breach of the ethical duty to be truthful
and accurate in communications. Sharing information on social media breaches the nurse's
ethical duty to protect client confidentiality. Making a medication error is a question of
competence related to this skill rather and is not related to the duty to care.
Question 7
, During the preoperative interview, the nurse obtains information about the client's medication
history. Which information is not necessary to record about the client?
Correct response:
use of all drugs taken in the last 18 months
Explanation:
The nurse does not need to ask about all drugs used in the last 18 months unless the client is
still taking them. The nurse does need to know all drugs the client is currently taking, including
herbs and vitamins, over-the-counter medications such as aspirin taken in the past 6 weeks, the
amount of alcohol consumed, and use of illegal drugs, because these can interfere with the
anesthetic and analgesic agents. Steroid use is of concern because it can suppress the adrenal
cortex for up to 1 year, and supplemental steroids may need to be administered in times of
stress such as surgery.
Question 8
A nurse is preparing for the admission of a client who is gravida 4 para 4 (G4 P4), speaks only
Spanish, and has an infant in the special care nursery (SCN) for respiratory distress. Which client
would be the most appropriate roommate?
Correct response:
G1 P1 who is a non–English-speaking client with an infant in the SCN for fetal distress
Explanation:
When assigning postpartum clients to shared rooms, both medical circumstances and emotional
support needs should be considered. Clients whose infants are in the special care nursery (SCN)
benefit from rooming together, as they share a similar experience of having a baby requiring
medical care. This can provide peer emotional support. Although the client who is G4 P4 and
who is 2 days postpartum with an infant and who speaks Spanish only involves shared language,
having a client with their baby in the room may unintentionally increase emotional distress for
the admitted client. The best match prioritizes both language and medical situation.
Question 9
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety,
the nurse should give hand-off reports at which time(s)? Select all that apply.
A client has been admitted to the hospital with draining foot lesions. What should the nurse do?
Select all that apply.
Place the client in a room with negative air pressure.
Admit the client to a semi-private room.
Admit the client to a private room.
Post a "contact isolation" sign on the door.
Wear a protective gown when in the client's room.
Wear gloves when providing direct care.
Explanation:
Infection control policies must be followed to prevent the spread of infection. Until the
pathogens are identified, the client must be isolated in a private room. Utilizing contact isolation
and wearing a protective isolation gown and clean gloves, in addition to following isolation
protocol to exit the room, may aid in preventing the spread of infectious agents to others. A
draining foot lesion does not require a negative air pressure room, which is primarily reserved
for preventing the spread of tuberculosis.
Question 2
The nurse is changing a wet-to-dry dressing covering a surgical wound. Which is the appropriate
procedure for changing this type of dressing?
Correct response:
Cover the wet packing with a dry sterile dressing.
Explanation:
A wet-to-dry dressing should be able to dry out between dressing changes. Thus, the dressing
should be moist, not dry, when applied. As the moist dressing dries, the wound will be debrided
of necrotic tissue and exudate. Normal saline is most commonly used to moisten the sponge;
Burow's solution will irritate the wound. The sponge should not be packed into the wound
tightly because the circulation to the site could be impaired. The moist sponge should be placed
so that all surfaces of the wound are in contact with the dressing. Then the sponge is covered
and protected by a dry sterile dressing to prevent contamination from the external
environment.
,Question 3
The nurse works to reduce the number of children involved in automobile crashes who were not
wearing seat belts. Which strategy is the most effective?
Correct response:
Attend a school board meeting to advocate for classes teaching children seat belt safety.
Explanation:
The best strategy to affect child seat belt safety is to attend the school board meeting and
advocate for educational programming. The programming could be simple and done quickly.
This action also targets the best audience.
Question 4
A client who is showing signs of alcohol intoxication has just been brought to the emergency
department after a motor vehicle crash (MVC). Which action should the nurse prioritize as the
client is admitted to the unit?
Correct response:
Stabilize physical needs first, and observe for symptoms of withdrawal.
Explanation:
A client impaired with alcohol may have a serious traumatic injury with no report of pain. The
nurse should assume that the client who appears intoxicated and was brought in from the scene
of an MVC has sustained a traumatic injury until proven otherwise. The priority is to identify and
stabilize any physical needs first and monitor for symptoms of withdrawal to prevent
complications. The client's physical status is not fully known and is difficult to assess while the
client is still intoxicated, so transferring them to a detox unit is not safe. While the client may
need one-on-one observation at some point, there is nothing to suggest that observation is the
current priority intervention. A mental health assessment may be indicated later in the client's
care, but this is not the priority over the client's physical or withdrawal needs. The client may be
disoriented or confused while intoxicated or withdrawing from alcohol, but reorientation is not
the priority.
Question 5
,A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the
early introduction of stroke rehabilitation, the client has seen significant improvements in both
medical status and activities of daily living (ADLs). This morning, however, the nurse notes that
the client has been coughing since eating a minced and pureed breakfast. Auscultation of the
chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a
swallowing assessment?
Correct response:
speech therapist
Explanation:
The diagnosis and treatment of dysphagia (swallowing problems) is within the purview of
speech therapists. The health care provider should be made aware and respiratory therapy may
be involved with assessing and promoting the client’s oxygenation but swallowing assessment is
a task most often performed by a speech therapist.
Question 6
The nurse manager is preparing to meet with several registered nurses (RNs) in the department
to address practice issues. Which behavior by an RN will the nurse manager address as a
violation of the RN's "duty to care"?
Correct response:
declined assignment to care for a client with dementia who was incontinent of stool
Explanation:
The duty to care in nursing refers to the ethical obligation that nurses have to their clients.
Nurses can refuse to care for clients on several grounds such as moral conflict, feeling unsafe, or
lacking the skills needed to safely deliver care. The nurse cannot refuse care based on the
client's health concerns. Falsifying medical records is a breach of the ethical duty to be truthful
and accurate in communications. Sharing information on social media breaches the nurse's
ethical duty to protect client confidentiality. Making a medication error is a question of
competence related to this skill rather and is not related to the duty to care.
Question 7
, During the preoperative interview, the nurse obtains information about the client's medication
history. Which information is not necessary to record about the client?
Correct response:
use of all drugs taken in the last 18 months
Explanation:
The nurse does not need to ask about all drugs used in the last 18 months unless the client is
still taking them. The nurse does need to know all drugs the client is currently taking, including
herbs and vitamins, over-the-counter medications such as aspirin taken in the past 6 weeks, the
amount of alcohol consumed, and use of illegal drugs, because these can interfere with the
anesthetic and analgesic agents. Steroid use is of concern because it can suppress the adrenal
cortex for up to 1 year, and supplemental steroids may need to be administered in times of
stress such as surgery.
Question 8
A nurse is preparing for the admission of a client who is gravida 4 para 4 (G4 P4), speaks only
Spanish, and has an infant in the special care nursery (SCN) for respiratory distress. Which client
would be the most appropriate roommate?
Correct response:
G1 P1 who is a non–English-speaking client with an infant in the SCN for fetal distress
Explanation:
When assigning postpartum clients to shared rooms, both medical circumstances and emotional
support needs should be considered. Clients whose infants are in the special care nursery (SCN)
benefit from rooming together, as they share a similar experience of having a baby requiring
medical care. This can provide peer emotional support. Although the client who is G4 P4 and
who is 2 days postpartum with an infant and who speaks Spanish only involves shared language,
having a client with their baby in the room may unintentionally increase emotional distress for
the admitted client. The best match prioritizes both language and medical situation.
Question 9
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety,
the nurse should give hand-off reports at which time(s)? Select all that apply.
