SET QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is caring for a client who signed an informed consent in preparation for a
procedure. The client tells the nurse, "I have decided not to have the procedure." Which
of the following actions should the nurse take?
1. Discuss alternative to the procedure
2. Explain why the procedure is necessary
3. Inform the provider that the client is withdrawing consent
4. Remind the client that he already signed the consent - ✔✔3. Inform the provider that
the client is withdrawing consent
✔✔A nurse is providing care to a client who has COPD and is receiving supplemental
oxygen. Which of the following findings should the nurse report to the RN immediately?
1. Speaks in short phrases
2. Use of accessory muscles to breathe
3. Increased sputum production
4. Pulse oximetry reading of 90% - ✔✔1. Speaks in short phrases
-indicates that the client is having a difficult time maintaining oxygen status
✔✔A staff nurse suspects that a newly licensed nurse is chemically impaired. Which of
the following actions should the staff nurse take?
1. Notify the charge nurse of the situation
, 2. Arrange transportation home for the newly licensed nurse
3. Confront the newly licensed nurse regarding her behavior
4. Examine unit narcotic records - ✔✔1. Notify the charge nurse of the situation
✔✔A nurse is planning care for a group of clients on a medical-surgical unit. Which of
the following actions should the nurse take first?
1. Taking a telephone prescription for a client who is to be transferred from PACU
2. Collecting data from a client who reports unilateral calf pain when ambulating
3. Reinforcing a client dressing on an above-the-knee amputation surgical site
4. Reassuring the partner for a client who sustained a closed head injury - ✔✔2.
Collecting data from a client who reports unilateral calf pain when ambulating
✔✔A nurse observes another nurse performing a procedure in the incorrect sequence.
The procedure does not harm the client. Which of the following actions should the nurse
take first?
1. Speak with the other nurse privately
2. Submit an incident report
3. Correct the mistake independently
4. Volunteer to perform the procedure next time - ✔✔1. Speak with the other nurse
privately
✔✔A nurse is caring for a client who states, "I have got to get out of this hospital! They
have found my address and are coming for my family!" What type of non-therapeutic
communication technique does this response represent?
1. Providing a passive statement
2. Showing disapproval
3. Offering false reassurance
4. Using a value statement - ✔✔3. Offering false reassurance
-discourages further communication and cannot be supported by fact
✔✔ A nurse is reviewing HIPPA with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates a need for further instruction?
1. "Information about a client can be disclosed to family members at any time"
2. "HIPPA establishes. regulations of health information in verbal, electronic or written
form"
3. "A clients address would be an example of personally identifiable information"
4. "HIPPA is a federal law not a state law" - ✔✔1. "Information about a client can be
disclosed to family members at any time"
✔✔A nurse is caring for an infant who has respiratory syncytial virus. Which of the
following actions should the nurse take?
1. Check that the infant's room has positive-pressure airflow
2. Wear a gown when changing the infants diaper
3. Instruct the parents to wear a surgical mask when holding the infant