And Answers Verified 100% Correct
A nurse in an acute care unit is assessing a group of clients. Which of the following clients is the
nurse’s priority?
a. A client who has pneumonia and has an oxygen saturation of 95%
b. A client who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to 10
c. A client who has peripheral vascular disease and has +1 pedal pulses bilaterally
d. A client who has inflammatory bowel syndrome and reports two loose stools
;
c. A client who has peripheral vascular disease and has +1 pedal pulses bilaterally
=
A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation
of the left leg. The nurse has been unable to reach the provider despite several attempts over
the past 30 min. Which of the following actions should the nurse take?
a. Reposition the client for comfort.
b. Notify the nursing supervisor about the issue.
c. Contact the client’s physical therapist.
d. Apply a warm compress to the hip.
;
b. Notify the nursing supervisor about the issue.
=
Which of the following should lead a nurse to suspect abuse that must be reported?
a. A school-age child has several bruises on her lower legs.
b. A preschool child who was previously trained now requires diapers in the hospital.
c. A toddler cries whenever his parent enters the hospital room.
d. An adolescent admitted to the emergency department won’t speak to his parents.
;
c. A toddler cries whenever his parent enters the hospital room.
=
A home health nurse is assessing the home environment of a client who is on continuous oxygen
therapy. Which of the following findings requires the nurse to intervene?
a. The client is covered with a woolen blanket.
,b. The oxygen machine has a grounded plug.
c. The family keeps a spare oxygen tank in the room.
d. The windows of the client’s room are open.
;
a. The client is covered with a woolen blanket.
=
A nurse is caring for a client who has increased intracranial pressure and is receiving IV
corticosteroids. Which of the following information is most important for the nurse to report
at shift change?
a. Reddened area on the coccyx
b. Most recent blood glucose reading
c. Glasgow Coma Scale score
d. Laboratory tests scheduled for next shift
;
c. Glasgow Coma Scale score
=
A nurse in the emergency department is caring for a group of four clients. Which of the following
clients should the nurse recommend for transfer to the ICU?
a. A client who has chronic atrial fibrillation and a digoxin level of 0.3 ng/mL
b. A client who has bleeding esophageal varices and a blood pressure of 90/50 mm Hg
c. A client who has a head injury and Glasgow Coma Scale score of 10
d. A client who has chronic kidney disease and a creatinine level of 15 mg/dL
;
c. A client who has a head injury and Glasgow Coma Scale score of 10
=
A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get
better, I’m going to quit.” Which of the following responses by the unit manager is appropriate?
a. “Just stick with it a little longer. Things will get better soon.”
b. “So you are upset about all the changes on the unit?”
c. “You should file a written complaint with hospital administration.”
d. “I think you have a right to be upset. I am tired of the changes, too.”
;
b. “So you are upset about all the changes on the unit?”
=
An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize
that which of the following can be delegated to assistive personnel?
, a. Recording the client’s vital signs
b. Determining the client’s pain level
c. Checking the pulses of the client’s right foot
d. Turning the client
;
a. Recording the client’s vital signs
=
A nurse is caring for four clients. Which of the following tasks can be delegated to assistive
personnel?
a. Assessing a client who just returned from hemodialysis
b. Reviewing dietary instructions for a client with kidney stones
c. Monitoring a client with a fluid restriction
d. Obtaining a stool sample from a client with renal failure
;
d. Obtaining a stool sample from a client with renal failure
=
A nurse is providing teaching to a client who has a new diagnosis of diabetes mellitus. The client
expresses concern about the cost of blood glucose monitoring supplies. Which of the following
referrals should the nurse make to address the client’s concern?
a. Case manager
b. Dietitian
c. Chaplain
d. House supervisor
;
a. Case manager
=
A nurse manager is providing orientation to a group of newly licensed nurses. The nurse
manager should communicate that which of the following actions is the responsibility of the
nurse when responding to a disaster?
a. Assume leadership for directing the emergency plan.
b. Use the chain-of-command for communication.
c. Act as a spokesperson between the facility and the community.
d. Coordinate the activities of emergency medical services.
;
a. Assume leadership for directing the emergency plan.
=