Questions With Complete Answers
\.1. The nurse is caring for an older adult who was admitted with a Urinary tract infection and is
now exhibiting signs of Severe Inflammatory Response Syndrome (SIRS). Which collaborative
care goals should the nurse include in the plan of care? (Select all that apply) - Answer- BODY
TEMP with in normal limits.
REDUCE WBC count.
NEGATIVE URINE CULTURE
\.The nurse is caring for clients on an orthopedic unit. Which client has the greatest risk for
developing osteomyelitis? - Answer- OLDER ADULT W/OSTEOPOROSIS WHO IS BEDFAST
FOLLOWING COMPRESSION FRACTURE OF THE VERTABRAE
\.. A male college student is brought to an emergency clinic by his friends because they report
that he has been vomiting for the past 3 days as the result of food poisoning. Laboratory
findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to
a local hospital, Which intervention is most important for the nurse to include in this client's
plan of care? - Answer- Initiate cardiac monitoring for the clients.
\.The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving
palliative home care the day. Which intervention should the nurse ask the PN to ensure the
family is providing the client? - Answer- MUCOUS MEMBRANE MOIST
\.The nurse is caring for a group of five clients with the assistance of an experienced and
capable unlicensed assistive personnel (UAP). Which nursing actions can the nurse delegate to
the UP? (Select all that apply.) - Answer- POST OP VITAL SIGNS
, HYGIENE CARE FOLLOWING TRAUMATIC FOOT AMPUTATION
\.When triaging emergency room clients, which client should the nurse assess first? - Answer-
FEMALE WITH SEVERE RIGHT LOWER ABDOMINAL PAIN FEBRILE AND VOMITING *Confirm
\.While eating breakfast, a client admitted with syncope and a 2-month history of vertigo
complains of dizziness. Using the standard communication tool SBAR (Situation, Background,
Assessment, Recommendation), which statement is best for the nurse to provide the healthcare
provider about the client's background? - Answer- The client's significant history includes
atrial fibrillation and hypoglycemia.
\.Several nurses are elected by their peers to serve on a negotiating committee to recommend
new healthcare benefits - Answer- BE AVAILABLE TO ALL SHIFTS TO DISCUSS CHANGES IN
HEALTH BENEFITS
\.Several family members are visiting a client who had a myocardial infarction 4 days ago. The
unlicensed assistive one of the visitors is lying on the client's bed. Which action should the
nurse implement? - Answer- EXPLAIN THE CLIENT HAS THE RIGHT TO HAVE VISITOR LIE ON
THE BED
\.. The healthcare provider prescribes an oral medication to be given daily for 3 days. However,
the medication was also given on the fourth day. - Answer- REVIEW MEDICATION
TRANSCRIPTION WITH THE NURSE.
\.. The nurse initiates the procedure to remove a client's peripherally inserted central catheter
(PICC) when a code blue is called for another collapsed in the hallway while ambulating with the
unlicensed assistive personnel (UAP). Which action should the nurse take - Answer- Respond
to the code. OR Finish the procedure Not sure
\.Which client requires the most immediate intervention by the nurse? - Answer- CLIENT
WITH ACUTE KIDNEY INJURY who is somnolent and does respond to verbal commands.