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A nurse is conducting a disaster preparedness drill with a
group of nurses who are orienting to the facility. Which of the
following triage tag colors should the nurse instruct the group to
apply to a client who has full-thickness burns on 72% of his body?
a.Green
b. Yellow
c. Black
d.Red
A nurse is caring for a client who has early-stage
Alzheimer’s disease. In which of the following actions is
the nurse acting as a client advocate?
a.Performing an updated cognitive assessment on the client
b. Requesting a referral for the client to attend
reminiscent therapy sessions c. Providing assistance
for the client when ambulating down the hall
d. Reorienting the client several times throughout the day
A nurse is caring for a client who has a prescription for
transcutaneous electrical nerve stimulation (TENS). Which of
the following members of the interdisciplinary team should the
nurse contact for assistance?
a.Occupational therapist
b.Respiratory therapist
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c.Pharmacist
d. Physical therapist
A nurse is caring for a client who has a pressure ulcer on the
coccyx. Which of the following findings indicates the need for a
referral to a wound care specialist?
a.Minimal signs of induration at the wound edges
b.Presence of granulated tissue over the wound
c. Presence of slough in the wound bed
d.Epithelialization noted in areas of tissue loss
A nurse is planning discharge for a client who has a new
diagnosis of COPD and lives alone. Which of the following
actions is the nurse’s priority?
a.Suggest participating in a community support group
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b.Provide printed materials for new prescriptions
c.Set up appointments for in-home physical therapy
d. Request a referral for a home safety assessment
A charge nurse witnesses an assistive personnel (AP) giving
an oral medication to a client who has dysphagia. Upon
questioning, the AP states that a nurse poured the medication
into a cup and asked the AP to give it to the client. Which of the
following actions should the charge nurse take first?
a.Reinforce facility policy regarding medication
administration with the AP b. Discuss the
situation with the nurse who poured the
medication
c. Complete the appropriate documentation of the incident
d. Auscultate the client’s breath sounds
A nurse is observing assistive personnel (AP) administer a
0.9% sodium chloride enema to an adult client. For which of
the following actions by the AP should the nurse intervene?
a. Administers the solution at room temperature
b.Positions the client on her left side with knees flexed
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c.Inserts the tubing 8 cm (3.1 in) into the rectum
d.Points tubing in the direction of the umbilicus during insertion
A nurse is preparing to transfer a client to the radiology
department using a wheelchair. Which of the following
actions should the nurse take?
a.Leave a transfer belt in place until the client returns from
radiology
b.Keep the footplates lowered throughout the transfer process
c.Push the wheelchair into the elevator, large wheels last
d. Test the locks on both wheels of the chair prior to transfer
A nurse manager is preparing to institute a new system for
scheduling staff. Several nurses have verbalized concern over
the possible changes that will occur. Which of the following is an
appropriate method to facilitate the adoption of the new
scheduling system?
a.Introduce the new scheduling system by describing
how it will save the institution money
b.Offer to reassign staff who do not support the
change to another unit c. Identify nurses who accept the
change to help influence other staff nurses - check d.
Provide a brief overview of the new scheduling system
immediately before its implementation
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