QUESTIONS AND ANSWERS
1A nurse is caring for a client who has a Penrose drain. To ensure proper placement an d
functioning ofIthe drain, which ofIthe following should the nurse expect to observe?
ANS: The safety pin is present at the distal end ofIthe drain.
A community health nurse is helping to reinforce teaching about hepatitis A with a gro up
ofIemployees at a childcare facility. Which ofIthe following characteristics should t he nurse
identify as an external factor that can impede learning for the participants? ANS: Poor
lighting in the learning setting
A nurse is observing newly licensed nurse who is providing tracheostomy care for a cli ent. The
nurse identifies proper performance ofIthe procedure when the newly licensed nurse selects
which ofIthe following solutions to clean the inner cannula?
ANS: Hydrogen peroxide
. A nurse is caring for a client who has right sided heart failure. The client's partner exp resses
concern the the client will die. Which ofIthe following responses should the nur se make?
ANS: "It is difollowingicult to see someone so sick. What have you been told ab out
your partner's prognosis?"
A nurse is reinforcing discharge instructions with the parent ofIan infant who has rotav irus.
which ofIthe following statements by the parent indicates an understanding ofIthe
teaching?
ANS: "I will apply diaper cream to my baby's skin during each diaper change."
, A nurse is caring for a client who is scheduled for surgery in the morning. The nurse l earns
that the client has decided not to have surgery even though he has already signed the
informed consent form. Which ofIthe following actions should the nurse take? ANS:
Report the situation to the provider who obtained the informed consent.
A nurse has to administer medications to a group ofIclients. For which ofIthe followin g
client situations should the nurse complete and incident report?
ANS: The nurse administered insulin lispro to a client who has diabetes mellitus and
is NPO.
a nurse is collecting data from a client who is experiencing a situational crisis followin g the loss
of a job. The client states, I don't think I can go through this again. Which o fIthe following
actions is the nurse's priority?
ANS: Determine ifIthe client is experiencing psychotic thinking.
A nurse is reinforcing discharge teaching with a client who is 48 hr post op from a ma
stectomy. Which ofIthe following statements by the client indicates an understanding o
fIthe teaching?
ANS: "I will wear rubber gloves whenever I wash dishes or do yard work."
a Nurse is reinforcing teaching about home care for conjunctivitis with the parent ofIa
school age child. which of the following information should the nurse include?
ANS: Separate the child's used washcloth from those ofIothers.
a Nurse prescribes levothyroxine 0.3 PO daily for a client. Available is levothyroxine 1
50mcg/tablet. How many tablets should the nurse administer?
ANS: 2
, . a nurse is collecting data from an older adult client during a routine physical exam. W hich
ofIthe following client statements should the nurse identify as a possible indicatio n
ofIabuse?