NURS 420 SU Week 5 UPDATED ACTUAL Questions and
CORRECT Answers
A nurse is completing a follow-up family home visit and Dicuss with the family what changes have occured that have prevented them from
discovers that the care plan developed at the last visit was following plan of care
not followed. Which of the following actions should the
nurse take first?
A nurse in the ambulatory surgery center is providing Vaginal intercourse can be resumed after 2 weeks
discharge teaching to a client who had a dilation and
curettage (D&C) following a spontaneous miscarriage.
Which of the following should be included in the teaching?
A nurse is providing discharge instructions to a client who flexing her knees and feet frequnetly
developed deep-vein thrombus (DVT) postoperatively and
is prescribed anticoagulant therapy. Which of the following
instructions should the nurse include?
A nurse is providing discharge teaching to a client who has Urine and other secretions might turn orange
pulmmonary tuberculosis and a new prescription for
rifampin. Which of the following information should the
nurse provide?
Anurse is caring for a client who is recovering from a - Remove pillows prior to repositioning.
cerebrovascular accident (CVA). Which of the folowing
information should the nurse include when teaching family - Elevate the bed to waist height.
members about repositioning the client? SATA
- Stand with their feet wide apart.
- Face the direction of movement when repositioning the client.
A nurse in a clinic is assessing a client who has AIDS and a Candidiasis
significantly decreased CD4-T-cell count. The nurse should
recognize that the client is at risk for developing which of
the following infectious oral conditions?
A nurse is preparing a client's evening dose of risperidone Discard the tablet and obtain another dose of medication
when the tablet falls on the countertop. Which of the
following actions should the nurse take?
A nurse is reviewing the laboratory results of a client who is Increased band neutrophils & Elevated erythrocyte sedimentation rate
postoperative. Which of the following laboratory findings
should the nurse identify as an indication of postoperative
infection? SATA
, A nurse is caring for a client who is postoperative following Pain level
a laminectomy. select the 3 findings that require immediate
follow up. Lung sounds
Incision site
A nurse is caring for a client who has a C. Diff infection. nonantimicrobial soap
which of the following cleansing agents should the nurse
use for hand hygiene?
A nurse is caring for a client who is 2 days postoperative When prioritizing client needs, the nurse should first address the client's WBC count
following a small bowel resection? followed by notifying the provider of the client's incisional pain
A nurse is conducting a primary survey of a client who has 1. (A) Open the airway using a jaw-thrust maneuver
sustained life-threatening injuries due to a motor-vehicle 2. (B) Determine effectiveness of ventilator efforts
crash. Identify the sequence of actions the nurse should 3. (C) Establish IV access
take. 4. (D) Glasgow coma scale assessment
5. (E) Removing clothing for a thorough assessment
A nurse is assessing a client during a disaster triage. The Black
client is not breathing, has no carotid or radial pulse, and
does not respond to commands. Which of the following
color tags should be attached to this client?
A nurse in a clinic is caring for a client who has recently Cabbage
begun taking warfin. The nurse is reviewing potential drug
and food interactions risk and should instruct the client to
avoid which of the following?
A nurse reports an incident of suspected child abuse. One As a nurse, I am required by law to report suspected child abuse
of the parents of the child becomes upset and demands to
know the reason for the nurse's action. Which of the
following responses by the nurse is appropriate?
A home health nurse is assessing a patient who has heart Ensure the client has been taking their prescribed diuretic
failure and notes the patient has had a weight gain of 1.8kg
(4lb), as well as generalized edema, since the last visit 3
days ago. Which of the following actions should the nurse
take next?
A nurse is preparing to adminster a medication to a client Describe what the pill looks like
who states, "That looks different from the pill I usually take."
Which of the following response should the nurse make?
A team of nurse care manager is implementing a nurse lef, Nurse 3 and Nurse 4
community based pain management program for a
population of client who have chronic pain and are
underinsured. They are meeting today to discuss their
progress.
Which of the following nurses should the team in=dentify
as performing case management actions in the
implementation phase of the nursing process? SATA
CORRECT Answers
A nurse is completing a follow-up family home visit and Dicuss with the family what changes have occured that have prevented them from
discovers that the care plan developed at the last visit was following plan of care
not followed. Which of the following actions should the
nurse take first?
A nurse in the ambulatory surgery center is providing Vaginal intercourse can be resumed after 2 weeks
discharge teaching to a client who had a dilation and
curettage (D&C) following a spontaneous miscarriage.
Which of the following should be included in the teaching?
A nurse is providing discharge instructions to a client who flexing her knees and feet frequnetly
developed deep-vein thrombus (DVT) postoperatively and
is prescribed anticoagulant therapy. Which of the following
instructions should the nurse include?
A nurse is providing discharge teaching to a client who has Urine and other secretions might turn orange
pulmmonary tuberculosis and a new prescription for
rifampin. Which of the following information should the
nurse provide?
Anurse is caring for a client who is recovering from a - Remove pillows prior to repositioning.
cerebrovascular accident (CVA). Which of the folowing
information should the nurse include when teaching family - Elevate the bed to waist height.
members about repositioning the client? SATA
- Stand with their feet wide apart.
- Face the direction of movement when repositioning the client.
A nurse in a clinic is assessing a client who has AIDS and a Candidiasis
significantly decreased CD4-T-cell count. The nurse should
recognize that the client is at risk for developing which of
the following infectious oral conditions?
A nurse is preparing a client's evening dose of risperidone Discard the tablet and obtain another dose of medication
when the tablet falls on the countertop. Which of the
following actions should the nurse take?
A nurse is reviewing the laboratory results of a client who is Increased band neutrophils & Elevated erythrocyte sedimentation rate
postoperative. Which of the following laboratory findings
should the nurse identify as an indication of postoperative
infection? SATA
, A nurse is caring for a client who is postoperative following Pain level
a laminectomy. select the 3 findings that require immediate
follow up. Lung sounds
Incision site
A nurse is caring for a client who has a C. Diff infection. nonantimicrobial soap
which of the following cleansing agents should the nurse
use for hand hygiene?
A nurse is caring for a client who is 2 days postoperative When prioritizing client needs, the nurse should first address the client's WBC count
following a small bowel resection? followed by notifying the provider of the client's incisional pain
A nurse is conducting a primary survey of a client who has 1. (A) Open the airway using a jaw-thrust maneuver
sustained life-threatening injuries due to a motor-vehicle 2. (B) Determine effectiveness of ventilator efforts
crash. Identify the sequence of actions the nurse should 3. (C) Establish IV access
take. 4. (D) Glasgow coma scale assessment
5. (E) Removing clothing for a thorough assessment
A nurse is assessing a client during a disaster triage. The Black
client is not breathing, has no carotid or radial pulse, and
does not respond to commands. Which of the following
color tags should be attached to this client?
A nurse in a clinic is caring for a client who has recently Cabbage
begun taking warfin. The nurse is reviewing potential drug
and food interactions risk and should instruct the client to
avoid which of the following?
A nurse reports an incident of suspected child abuse. One As a nurse, I am required by law to report suspected child abuse
of the parents of the child becomes upset and demands to
know the reason for the nurse's action. Which of the
following responses by the nurse is appropriate?
A home health nurse is assessing a patient who has heart Ensure the client has been taking their prescribed diuretic
failure and notes the patient has had a weight gain of 1.8kg
(4lb), as well as generalized edema, since the last visit 3
days ago. Which of the following actions should the nurse
take next?
A nurse is preparing to adminster a medication to a client Describe what the pill looks like
who states, "That looks different from the pill I usually take."
Which of the following response should the nurse make?
A team of nurse care manager is implementing a nurse lef, Nurse 3 and Nurse 4
community based pain management program for a
population of client who have chronic pain and are
underinsured. They are meeting today to discuss their
progress.
Which of the following nurses should the team in=dentify
as performing case management actions in the
implementation phase of the nursing process? SATA
