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1. a 35 year old female client with cancer refuses to allow A. evaluate the client's
the nurse to insert an IV for a scheduled chemotherapy mental status for compe-
treatment, and states that she is ready to go home and tence to refuse treatment
die. What intervention should the nurse initiate?
A. evaluate the client's mental status for competence
to refuse treatment
B. review the client's medical record for an advance
directive
C. determine if a DNR prescription has been obtained
D. document that the client is being discharged against
medical advice
2. A client with chronic renal disease is admitted to the D. serum albumin
hospital for evaluation prior to a surgical procedure.
Which laboratory test indicated the client's protein sta-
tus for the longest length of time.
A. Urine urea
B. transferrin
C. prealbumin
D. serum albumin
3. What client statement indicates to the nurse that the C. "I don't understand why
client requires assistance with bathing? I'm so weak and tired"
A. "I only bathe every other day"
B. "I left my eyeglasses at home"
C. "I don't understand why I'm so weak and tired"
D. "I wasn't able to pack a bag before I left for the
hospital"
4. How should a nurse handle linens that are soiled with D. place an isolation ham-
incontinent feces? per in the client's room
A. Place the soiled linens in a pillow case and deposit and discard the linens in it
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them in the dirty linen hamper
B. put the soiled linens in an isolation bag, then place
it in the dirty linen hamper
C. Ask the housekeeping staff to pick up the soiled
linen from the dirty utility room
D. place an isolation hamper in the client's room and
discard the linens in it
5. When caring for an immobile client, what nursing di- B. impaired gas exchange
agnosis has the highest priority?
A. altered tissue perfusion
B. impaired gas exchange
C. risk for fluid volume deficit
D. risk for impaired skin integrity
6. The nurse assess an immobile, elderly male client and C. turn the patient Q2
determines that his blood pressure is 138/60, his tem-
perature is 95.8F, and his output is 100 mL of concen-
trated urine during the last hour. He has wet-sound-
ing lung sounds, and increased respiratory secretions.
Based on these assessment findings, what nursing
action is the most important for the nurse to imple-
ment?
A. encourage additional additional fluid intake
B. provide the client with an additional blanket
C. turn the patient Q2
D. administer a PRN anti hypertensive prescription
7. The home health nurse visits an elderly female client D. the nurse notes that
who had a brain attack three months ago and is now there are numerous scat-
able to ambulate with the assistance of a quad cane. ter rubs throughout the
Which assessment finding has the greatest implica- house
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tions for this client's case?
A. The client's pulse rate is 10 beats higher than it was
at the last visit one week ago
B. the client tells the nurse that she does not have
much of an appetite today
C. the husband, who is the caregiver, begins to weep
when you ask how he is doing
D. the nurse notes that there are numerous scatter
rubs throughout the house
8. The nurse removes the dressing on a client's heel B. one-inch pressure sore
that is covering a pressure sore one-inch in diameter draining serous fluid
and finds that there is straw-colored drainage seep-
ing from the wound. What description of this finding
should the nurse include in the client's record?
A. stage 1 pressure sore draining sero-anguineous
drainage
B. one-inch pressure sore draining serous fluid
C. pressure sore draining serous fluid
D. pressure sore on heel with a small amount of puru-
lent drainage
9. A medication is prescribed to be given QID. What B. 0800, 1200, 1600, 2000
schedule should the nurse use to administer this pre-
scription?
A. 800
B. 0800, 1200, 1600, 2000
C. every other day at 0800
D. 0800, 1200, 1600, 2000, 0000, 0400
10. The nurse working in the emergency department is B. a 55-year-old woman
assessing four client's ability to tolerate pain. Which who has had moderate