CORRECT ANSWERS
A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the
following clients should the nurse assign to the room
closest to the nurses' station?
A. A middle adult who is postoperative following a laparoscopic cholecystectomy
B. A middle adult who requires telemetry for a possible myocardial infarction
C. A young adult who is postoperative following an open reduction internal fixation of the ankle
D. An older adult who is postoperative following a below-the-knee amputation
- ANSWERS-D
A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which
of the following examples should the charge nurse should include as a developmental task for a young
adult?
A. Becoming actively involved in providing guidance to the next generation
B. Adjusting to major changes in roles and relationships due to losses
C. Devoting a great deal of time to establishing an occupation
D. Finding oneself "sandwiched" between and being responsible for two generations
- ANSWERS-C
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following
data should the charge nurse identify as objective data? (Select all that apply.)
A. Respiratory rate is 22/min with even, unlabored respirations.
B. The client's partner states, "He said he hurts after walking about 10 minutes."
C. Pain rating is 3 on a scale of 0 to 10
D. Skin is pink, warm, and dry.
E. The assistive personnel reports the client walked with a limp.
- ANSWERS-A, D, E
,A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not
require a provider's prescription. Which of the following interventions should the charge nurse include?
(Select all that apply.)
A. Writing a prescription for morphine sulfate as needed for pain.
B. Inserting a nasogastric (NG) tube to relieve gastric distention.
C. Showing a client how to use progressive muscle relaxation.
D. Performing a daily bath after the evening meal.
E. Repositioning a client every 2 hr to reduce pressure ulcer risk.
- ANSWERS-C, D, E
A client who has an indwelling
catheter reports a need to
urinate. Which of the following
actions should the nurse take?
A. Check to see whether
the catheter is patent.
B. Reassure the client that it is
not possible for her to urinate.
C. Recatheterize the bladder
with a larger-gauge catheter.
D. Collect a urine specimen
for analysis.
- ANSWERS-A
A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty
swallowing). The nurse caring for the client should initiate a referral with which of the following members of
the interprofessional care team?
A. Social worker
,B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist
- ANSWERS-D
A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the
medication he is receiving for pain management. Which of the following members of the interprofessional
care team can assist the client in understanding the medication's effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist
- ANSWERS-A, C, D
A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive
devices. The nurse caring for the client should initiate a referral to which of the following members of the
interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist
- ANSWERS-D
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the
following information should the nurse include in her counseling?
A. Carbon monoxide has a distinct odor.
B. Water heaters should be inspected every 5 years.
C. The lungs are damaged from carbon monoxide inhalation.
, D. Carbon monoxide binds with hemoglobin in the body.
- ANSWERS-D
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following
information should the nurse including in her counseling? (Select all that apply.)
A. Most food poisoning is caused by a virus.
B. Immunocompromised individuals are at risk for complications from food poisoning
C. Clients who are at high risk should eat or drink only
pasteurized dairy products.
D. Healthy individuals usually recover from the illness in a few weeks.
E. Handling raw and fresh food separately can prevent food poisoning.
- ANSWERS-B, C, E
A mother tells the nurse that her 2-year-old toddler has temper tantrums and says "no" every time the
mother tries to help her get dressed. The nurse should recognize, the toddler is manifesting which of the
following stages of development?
A. Trying to increase her independence
B. Developing a sense of trust
C. Establishing a new identity
D. Attempting to master a skill
- ANSWERS-A
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The
client said his leg pain was back, so I checked his medical record, and he last received his pain medication
6 hours ago. The prescription reads every 4 hours PRN for
pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I
checked with
the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly
licensed nurse that she left out which of the following steps of the nursing process?
A. Assessment