- ACTUAL EXAM WITH A STUDY GUIDE AND PRACTICE EXAM |
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A nurse in a long - term care facility enters the day room and finds the
window curtains on fire . Clients are panicking and the room is filling
with smoke . Indicate the emergency actions the nurse must take . (
Move the steps into the box on the right , placing them in the selected
order of performance . Use all the steps . - CORRECT ANSWER RACE
to prioritize the actions to take : R - Rescue and remove the clients , A-
Activate the alarm , C- Confine the E- Extinguish the fire .
A nurse is assigned care of a client who has HIV . Which of the
following infection control precautions should the nurse plan to use
while caring for this client ? - CORRECT ANSWER Standard
Precautions
What precautions are used for MTV, Herpes Zoster - CORRECT
ANSWER Airborne
What precautions are used for pertussis and CDiff - CORRECT
ANSWER Contact precautions
When are droplet precautions used - CORRECT ANSWER Measles,
Influenza, Mumps, Respiratory illnesses
A nurse working on a medical - surgical unit suspects that several
clients have Clostridium difficile when they all develop watery diarrhea
. Which of the following actions should the nurse plan to take while
waiting for the client's lab results - CORRECT ANSWER Place all
clients who have manifestations on contact precautions .
A nurse is planning to perform passive range of motion for a client who
is immobilized . Which of the following actions should the nurse plan to
take ? - CORRECT ANSWER Support extremities above and below
joints .
,A nurse is participating in an interdisciplinary treatment meeting for a
client who is to go home within a week . Which of the following health
care providers should the nurse identify will assist the client with
activities of daily living ? - CORRECT ANSWER Occupational
therapist
Who assist the client with obtaining resources to assist with issues
such as finances , nutrition , transportation , and in - home care . -
CORRECT ANSWER social worker
Assist with strength training improve movement - CORRECT ANSWER
Physical Therapist
A nurse is implementing a bladder - training program for a client . For
which of the following actions by the assistive personnel ( AP ) who is
helping with the client's care should the nurse intervene ? - CORRECT
ANSWER Instructs the client to urinate whenever the urge occurs
A nurse is collecting data from a client who has venous insufficiency .
Which of the following findings should the nurse expect ? - CORRECT
ANSWER Pitting edema
A nurse is caring for a client who has a stage - 3 pressure ulcer that
now has some granulating tissue . Which of the following interventions
should the nurse recommend for inclusion in the plan of care ? -
CORRECT ANSWER Cleanse with 0.9 % sodium chloride irrigation
A nurse is reviewing a provider's prescriptions for a group of clients .
Which of the following client prescriptions should the licensed
practical nurse clarify with the provider ? (LPN) - CORRECT ANSWER
Administer 1 g of vancomycin intrathecally .
A nurse is caring for a client who reports an area of redness , warmth ,
tenderness and pain in the right calf . Which of the following actions
should the nurse anticipate when notifying the provider of this finding
? - CORRECT ANSWER Arrange for a venous duplex ultrasound .
,A nurse is caring for a client who is 2 days postoperative following
abdominal surgery and is progressing from a clear liquid diet to a full
liquid diet . The nurse should remind the client that which of the
following items is included in a full liquid diet ? - CORRECT ANSWER
Chocolate pudding
A nurse is talking with a client who has a new diagnosis of acute
bursitis in her right shoulder . Which of the following self - care
strategies should the nurse recommend ? - CORRECT ANSWER
Intermittent ice and heat
A nurse is assisting with the preparation of a presentation at a
community center about complementary and alternative therapies .
Which of the following therapies should the nurse describe as the use
of an electronic monitoring device to help clients learn to control
physical responses ? - CORRECT ANSWER Biofeedback
Flexion is an action that decreases the angle between two connecting
bones . Flexion of the fingers would be making a fist with the hand -
CORRECT ANSWER Flexion
An action that increases the angle between two connecting bones
Extension of the fingers would be to straighten the fingers of the hand
- CORRECT ANSWER Extension
A nurse is caring for a client who is Hindu and adheres strictly to the
traditional dietary laws of this religion . The client has no other dietary
restrictions . Which of the following foods should the nurse select as a
component of the client's meals ? - CORRECT ANSWER Steamed
Vegetables
A nurse is caring for a group of clients on a medical - surgical unit .
Which of the following actions jeopardize client confidentiality ? (
Select all that apply . ) - CORRECT ANSWER Sharing a personal
password with a coworker, Discussing clients at the table in the
cafeteria ,Disposing of written report sheet into the facility trash
receptacle
, A nurse is reinforcing teaching with a family member about how to
position a client when administering enteral feedings at home . Which
of the following statements from the family member should the nurse
identify as an indication that he understands the instructions ? -
CORRECT ANSWER I will position the head of the bed 45 degrees
during the feeding
A nursing is caring for a client who presents to an urgent care with a
laceration on his forearm . Which of the following activities is an
example of primary prevention ? - CORRECT ANSWER Administering
a tetanus immunization
A nurse on an inpatient mental health unit is caring for a group of
clients . Which of the following actions by the nurse demonstrates the
ethical concept of autonomy ? - CORRECT ANSWER Supporting a
client's wishes to refuse prescribed treatments
A nurse is collecting data from a client who has hypokalemia as a
result of nausea , vomiting , and diarrhea . Which of the following
findings should the nurse expect ? - CORRECT ANSWER
Weak,irregular pulse
A nurse is assisting with a presentation about caring for clients who
are receiving diuretic therapy . The nurse should explain that which of
the following medications can put clients at risk for hyperkalemia ? -
CORRECT ANSWER Spironolactone
A nurse is contributing to the plan of care for a client who has a
pressure ulcer on his heel . Which of the following information should
the nurse include in the plan ? - CORRECT ANSWER Provide the
client a diet high in vitamin C
A nurse is caring for an older adult client who has constipation . Which
of the following actions should the nurse take ? - CORRECT ANSWER
Add fluid and fiber to the diet
A nurse is reinforcing home safety information with an older adult
client . Which of the following statements should the nurse identify as