Answers
In planning care for a 6 month-old infant, what must the nurse provide to
assist in the development of trust?
A) Food
B) Warmth
C) Security
D) Comfort
A nurse has just received a medication order which is not legible. Which
statement best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what
you mean." B) "Would you please clarify what you have written so I am
sure I am reading it correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if
you would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting
to read your writing."
A mother wants to switch her 9 month-old infant from an iron fortified
formula to whole milk because of the expense. Upon further assessment, the
nurse finds that the baby eats table foods well, but drinks less milk than
before. What is the best advice by the nurse?
A) Change the baby to whole milk
B) Add chocolate syrup to the bottle
,C) Continue with the present formula
D) Offer fruit juice frequently
, Privacy and confidentiality of all client information is legally protected.
In which of these situations would the nurse make an exception to this
practice?
A) When a family member offers information about their loved one
B) When the client threatens self-harm and harm to others
C) When the health care provider decides the family has a right to
know the client's diagnosis
D) When a visitor insists that the visitor has been given permission by the client
The nurse is caring for a client who is in the late stage of multiple
myeloma. Which of the following should be included in the plan of care?
A) Monitor for hyperkalemia
B) Place in protective isolation
C) Precautions with position changes
D) Administer diuretics as ordered
Which task could be safely delegated by the nurse to an unlicensed
assistive personnel (UAP)?
A) Be with a client who self-administers insulin
B) Cleanse and dress a small decubitus ulcer
C) Monitor a client's response to passive range of motion exercises
D) Apply and care for a client's rectal pouch
A client asks the nurse to call the police and states: “I need to report that I am
being abused by a nurse.” The nurse should first
A) Focus on reality orientation to place and person
B) Assist with the report of the client’s complaint to the police
, C) Obtain more details of the client’s claim of abuse
D) Document the statement on the client’s chart with a report to the manager
A nurse from the maternity unit is floated to the critical care unit because of
staff shortage on the evening shift. Which client would be appropriate to assign
to this nurse? A client with
A) A Dopamine drip IV with vital signs monitored every 5 minutes
B) A myocardial infarction that is free from pain and dysrhythmias
C) A tracheotomy of 24 hours in some respiratory distress
D) A pacemaker inserted this morning with intermittent capture
An unlicensed assistive personnel (UAP), who usually works on a surgical
unit is assigned to float to a pediatric unit. Which question by the charge nurse
would be most appropriate when making delegation decisions?
A) ”How long have you been a UAP and what units you have worked on?"
B) ”What type of care do you give on the surgical unit and what ages of clients?"
C) “What is your comfort level in caring for children and at what ages?"
D) ”Have you reviewed the list of expected skills you might need on this unit?"
A client frequently admitted to the locked psychiatric unit repeatedly
compliments and invites one of the nurses to go out on a date. The nurse’s
response should be to
A) Ask to not be assigned to this client or to work on another unit
B) Tell the client that such behavior is inappropriate
C) Inform the client that hospital policy prohibits staff to date clients
D) Discuss the boundaries of the therapeutic relationship with the client
In order to enhance a client's response to medication for chest pain from