Assessment 1 with Actual Solutions
A nurse is preparing a client for transfer to another unit? which finding does the nurse include in
the transfer report? ✔️✔️response to pain medication
review of ongoing discharge plan
recent physical changes
A nurse is preparing to administer 250mg of an antibiotic IM. available is 3g/5mL. how many
mL would the nurse administer per dose? ✔️✔️0.4
A nurse is preparing to administer TPN, what indicates a need to obtain a new bag? ✔️✔️the
TPN solution has an oily appearance and a layer of fat on top of the solution
("cracking")
A nurse is preparing to perform a routine abdominal assessment for a client, which action should
the nurse take? ✔️✔️perform palpation after auscultation
A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound.
which of the following actions should the nurse take to prevent contamination during the
dressing change? ✔️✔️restart the procedure if the sterile solution splashes onto the sterile field
when pouring the solution into the dressing tray
,(if liquid comes in contact with the sterile field at any point it is considered contaminated and
unsterile)
A nurse is preparing to transfer a client from a chair to the bed. the client can bear partial weight
and has upper body strength. which of the following devices should the nurse use to transfer the
pt? ✔️✔️a stand-assist lift
(for pt with upper body strength and able to bear partial bodyweight)
A nurse is providing dietary education to a client with cholecystitis who has been prescribed a
low-fat diet. which of the following meal selections by the client indicates an understanding of
education? ✔️✔️roast turkey, rice pilaf, green beans
A nurse is providing discharge teaching to a client who has a prescription for home O2, which
info should the nurse teach? ✔️✔️wear cotton socks when the O2 is in use
(other fabrics cause static)
A nurse is providing teaching about the Mediterranean diet to a client newly who has a new
diagnosis of hypertension. what statement indicates need for further teaching? ✔️✔️i will limit
my intake of red meat to 2x weekly
, (should be limited to 2x monthly)
A nurse is reviewing info about advance directives with a newly admitted client. which of the
following statements by the client indicates an understanding of the teaching? ✔️✔️i have a
living will that outlines my wishes when i am unable to make a decision
A nurse is reviewing psychosocial stages of development for a school-age child, what would be
an expected behavioral finding for this child? ✔️✔️develop sense of industry through
advances in learning, strive to develop healthy self-respect by finding out in what areas they
excel
peer groups plays important role in social development
A nurse is reviewing the health history of an OA who has a hip fracture
the nurse should identify what is a risk of developing pressure injuries? ✔️✔️urinary
incontinence
(r/f skin breakdown--> pressure injury, poor nutrition, infection, poor tissue perfusion, friction
and shear, immobility, alterations in sensory perception)
A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3d,
what lab results indicates the client is experiencing FVD? ✔️✔️increased hematocrit
(increased USG and BUN)