A nurse is caring for a group of clients, which of the following can be assigned to assistive personnel? -
a. Collecting a stool specimen to test for occult blood.
A nurse is working on a unit for clients with dementia. Which of the following client situations requires
the nurse to write an incident report? –
c. A client is found lying on the floor next to a chair.
A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes mellitus. The
client is independent and lives alone. Which of the following should be included in the discharge plan?
- c. Refer the client to a diabetic support group.
A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of 60 mg/dL. For
which of the following findings should the nurse monitor?
- a. Clammy Skin
A female client who is an abusive marriage has discusses with the nurse strategies to prevent this abuse.
which of the following client statements indicate an understanding of an appropriate strategy?
- a. "I need to recognize the signs that my husband is becoming abusive."
c. "I need to identify what triggers my husband's anger to prevent his abuse."
A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse
observes that the assistive personnel (AP) has no documented the client's blood glucose level. Which of
the following actions should the charge nurse take first?
- d. Determine if the AP has completed the assignment.
A client is scheduled for an outpatient colonoscopy. which of the following actions is a nursing
responsibility in the informed consent process?
- a. Verify that there is a signed and witnesses consent form in the client's chart.
A nurse smells alcohol on the breath of an assistive personnel (AP) during report. Which of the following
actions should the nurse take?
- c. Report the situation to the nurse manager.
A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an
appropriate assignment for the nurse to accept?
- b. A client who had a cesarean delivery 24hr ago.
A nurse in a provider's office is collecting data from a parent of an infant who is being screened for cystic
fibrosis. Which of the following supports a diagnosis of cystic fibrosis?
- a. Frothy stools.
,When caring for an assigned group of clients, the nurse should wear gloves when
- a. performing oral hygiene.
A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety
of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to
take?
- b. contact security personnel to place the money in the facility safe.
A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of
administration?
- d. Subcutaneously.
A nurse is reinforcing teaching about car seat safety to the parents of a newborn. The nurse should
instruct the parents to place the car seat in a?
- c. Rear-facing position in the back seat.
A nurse is caring for a client and recognizes the client's rights to confidentiality have been breached in
which of the following situations?
- a. A hospital risk manager includes information from a client's medical record in
A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring
peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following
actions should the nurse take?
- c. Notify the charge nurse of the finding.
A nurse is caring for a full-term newborn who was circumcised 6 hrs. ago. Which of the following
findings indicates that the newborn is experiencing pain?
- b. Furrowed Brow
A nurse is reinforcing teaching with a client about organ donation. Which of the following client
statements indicated a need for further teaching?
- c. "My doctor should decide if my organs will be donated."
A Client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't want to take
this medication because it makes me tired all the time." Which of the following is the appropriate
response?
- c. "Let's talk with your doctor about other options."
A nurse is preparing to administer an IM injection to a client. To reduce the risk of neddlestick injury, the
nurse should?
- b. dispose of the used needle immediately in a puncture-proof sharps container.
, A nurse is contributing to the discharge plan for a client following surgery. Which of the following
findings indicate the need for an interdisciplinary care conference?
- d. The client requires assistance to pay for dressing supplies.
A client who is 24 hours postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis, and
cough. Which of the following actions should the nurse take first?
- c. Elevate the head of the client's bed.
A nurse is caring for a 17-year old client who is admitted for an emergency appendectomy. Which of the
following is an appropriate action by the nurse in obtaining informed consent?
- a. Obtain verbal consent from the client while waiting for the parents to arrive.
b. Witness the signature of the client's parent when he arrives.
c. Have the client's older sibling give consent if a parent is not available.
d. Delay the procedure if the provider cannot contact the parents.
A nurse has delegated care to an assistive personnel. At the end of the shift, the AP asks the nurse to
enter data for her because the AP has forgotten her password and needs to leave. Which of the
following actions should the nurse take?
- a. Tell the AP to contact the IT department for charting assistance.
A nurse is reinforcing discharge teaching to a client following a gastrectomy. To prevent dumping
syndrome, which of the following foods should the nurse instruct the client to avoid?
- a. Ice Cream
A nurse is caring for a client admitted with shortness of breath who will be undergoing arterial blood gas
testing. Which of the following client statements indicated an understanding of the purpose of drawing
arterial blood gases?
- d. "This will indicate how much acid is building up in my blood."
A nurse manager is seeking ways to increase cost-effectiveness on the unit. In which of the following
client care situations should the nurse manager intervene? - a.
A nurse is collecting data from a client who reports recent weight loss and a Chronic cough that is now
producing blood-streaked sputum. For which of the following should the nurse expect the client to have
diagnostic testing?
- a. Lung Cancer D. Emphysema.
A nurse is caring for an older adult client with a decreased level of consciousness. Which of the following
is an appropriate intervention related to the client's mouth care?
- c. uses a sponge toothette to cleanse the inside of the mouth.