NURSING: PRIORITIZATION Questions and Answers with Explanation: Exam Practice and Review

Document Content and Description Below

NURSING: PRIORITIZATION Questions and Answers with Explanation: Exam Practice and Review Question 1 Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the c... harge nurse to change her assignment. She is frustrated because she has had to devote so much time and energy to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus. The charge nurse should: Question 2 During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis Question 3 A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client’s issues and is able to respond appropriately to the client’s needs? Question 4 A client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Question 5 Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? Question 1 Four clients have been admitted to the cardiac intensive care unit after experiencing acute myocardial infarctions. Each client has sustained a percentage of cardiac damage. Which client is most in need of interventions to prevent the development of cardiogenic shock? Question 2 The nurse is providing postoperative care to a client with sickle cell anemia. What is the most important intervention for the nurse to include in the plan of care? A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse’s most important intervention? Question 4 The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds the client disoriented to time and place, diaphoretic, and complaining of palpitations. What is the nurse’s priority intervention? Question 5 A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F (39.5° C) rectally. What is the most appropriate initial nursing intervention? Question 6 A 19-month-old child with croup is crying as a nurse tries to auscultate breath sounds. What is the nurse’s most appropriate intervention? Question 7 A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse’s most appropriate intervention? Question 8 Which nursing intervention is priority for an infant during the first 24 hours following surgery for cleft lip repair? Question 9 A nurse on a maternity unit witnesses a mother slapping the face of her crying neonate. What is the nurse’s priority action? Question 10 Two hours after starting total enteral nutrition (TEN) through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first? Question 1 Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? Question 2 A client with schizophrenia has been stable for some time. What action is most important for preventing relapse? Question 3 The nurse is caring for a client struggling with alcohol dependence. It is most important for the nurse to: Question 4 A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse? Question 5 The nurse is assessing a client 22 hours after a cesarean birth. Which assessment finding would require immediate action by the nurse? You Selected: • Heart rate of 132 beats/min and blood pressure of 84/60 mmHg Question 1 A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention? Question 2 A 22-year-old client with quadriplegia in supine position is apprehensive and flushed, with a blood pressure of 210/100 mmHg and heart rate of 50 bpm. Which nursing intervention should be done first? Question 3 A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck’s extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective? Question 4 The nurse is planning care for a child admitted to the pediatric unit with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first? Question 5 A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate? Question 6 Which nursing intervention is priority for a pregnant adolescent during her first trimester? Question 7 A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? Question 8 A nurse is teaching a group of parents about recurrent urinary tract infections (UTIs) in their children. What is the priority educational goal for this group of parents? Question 9 A client with a panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first? Question 10 A nurse finds a client crying after she was told by the health care provider that she is to start hemodialysis to treat her acute renal failure. What is the nurse’s most important intervention? : Question 1 In which circumstance may the nurse legally and ethically disclose confidential information about a client? Question 2 A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can she best handle the situation? Question 3 Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery? Question 4 A nurse feels that a 5-year-old boy in her care is showing signs and symptoms of diabetes mellitus. The nurse should: A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? Question 6 A nurse-manager for a community health organization is planning for the home health needs of an 8-year-old child who requires around-the-clock care by nursing assistants. The nurse-manager knows that when working with a nursing assistant, she must: Question 8 A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when she: Question 9 When creating a program to decrease the primary cause of disability and death in children, the nurse should: Question 10 During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I cannot get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. Question 11 An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that: Question 13 Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? Question 16 A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review? Question 17 A woman who delivered her last infant by caesarean section is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo “a trial labor.” The nurse explains to the client that: Question 18 A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse’s understanding of the case manager? Question 20 Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills? Question 1 A nurse is caring for a 14-month-old infant being treated for an upper respiratory infection. The physician would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent? Question 2 Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills? Question 3 A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task? Question 4 A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer? Question 5 A 17-year-old unmarried primigravida at 10 weeks’ gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do? Question 6 The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client’s respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client’s level of consciousness is declining. The nurse should first: Question 7 A nurse is caring for a client who is receiving hospice care at home. The client’s neighbors have been calling the nurse to inquire about the client’s condition. The nurse should tell the callers: Question 8 A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first? Question 9 A nurse is caring for a client who is well known in society. A person inquires about the medical details of the client, saying that he is a family member. The nurse reveals the requested information. Later, the nurse comes to know that the inquirer was not a family member. Which of the following ethical rules of professional–client relationships has the nurse violated? Question 10 A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client? Question 11 Professional regulations and laws that govern nursing practice are in place for which of the following reasons? Question 12 During a taped shift report, the evening nurse reports that a client has been “annoying all evening, and has been demanding and on the call bell constantly.” The nurse manager of the unit overhears this part of the report. Which of the following statements represents the best response by the nurse manager to the evening nurse? Question 13 A client on the palliative unit discusses treatment with the nurse. The client wants to refuse further chemotherapy and request pain management strategies only. What is the most appropriate action by the nurse in relation to the client’s requests? Question 14 The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child’s allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents? Question 15 The nurse manager is holding a meeting with the nursing team to discuss management’s decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening “to take this decision further.” To defuse this situation, which of the following would be the best step for the nurse manager to take? Question 16 The client and her husband are very distressed and state that they feel their nurse has been negligent in providing care during their labor. Which of the following is the nurse’s best defense against an accusation of negligence? Question 17 A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client’s scalp. Which referral should the nurse make first? Question 18 Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? Question 19 A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must: Question 20 A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client’s face. How will the nurse precede? Question 1 Question 2 A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? Question 3 A nurse is conducting a physical assessment on an adolescent who doesn't want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse can implement in this situation? Question 4 Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? Question 5 Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? Question 6 A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the health care surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make health care decisions for the fetus, who's responsible for making them? Question 7 A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to: Question 8 A group of nursing assistants hired for the medical-surgical floors are attending hospital orientation. Which topic should the educator cover when teaching the group about caring for clients with diabetes mellitus? Question 9 The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately? Question 10 A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching? Remediation: Question 11 Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. Question 12 The nurse assigns an unlicensed assistive personnel (UAP) to the care of a client who has just returned from surgery for repair of a fractured right wrist and application of an arm cast. The nurse should stress to the UAP the importance of reporting: Question 13 When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? Question 14 A physician's order for a client states the administration of a medication “b.i.d.” How many times should the nurse administer the medication to the client? Question 15 A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? Question 16 After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, the nurse prioritizes which nursing intervention? Question 17 A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, “This is turning me into an old woman before my time.” What is the best response by the nurse? Question 18 A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority? Question 19 An alert and oriented client states that he does not want chemotherapy. His family believes that he should receive it. Which is the nurse’s best response to the client? Question 20 A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. Question 1 When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be: Question 2 A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to: Remediation: Question 3 A nurse explains the guidelines for the unit's seclusion room to a client with an impulse control disorder. Which client statement indicates that the nurse has adequately communicated the client's rights? Question 4 The nurse refers the parents of a child with cystic fibrosis to an organization that helps families with children who have this disease. Such organizations are especially beneficial for parents by helping them: Question 5 An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? Question 6 A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take? Question 7 Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy? Question 8 The nurse uses which part of the SBAR acronym when stating, “I think the client is dry.” Question 9 A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Question 10 During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: Question 11 While the nurse is caring for a primiparous client on the first postpartum day, the client asks, “How is that woman doing who lost her baby from prematurity? We were in labor together.” Which response by the nurse would be most appropriate? Question 12 The nurse is serving on the Quality Improvement Committee for the maternity unit. Quality improvement projects for this unit impacting safety and quality of care include which projects? Select all that apply. Question 13 The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations? Question 14 When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following? Question 15 A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks the nursing assistant if she has been validated on obtaining fingerstick glucose readings. The nursing assistant says she did not have the skill validated, but she has seen it done many times and knows she can do it. What should the nurse do? Question 16 After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, the nurse prioritizes which nursing intervention? Question 17 A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best? Question 18 The recipient of a donated organ asks the nurse, “What did the donor die from?” Which response by the nurse is most appropriate? Question 19 A client with long-term body-focused repetitive behaviors including trichotillomania (hair pulling) finds support through an online website. The client begins to attend local meetings and realizes that a nurse from the clinic also attends. When approached outside of these meetings, how should the nurse respond? Question 20 Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client’s roommate tells the nurse that the client “went for a test.” What should the nurse do next? Question 1 There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply. Question 2 The family of a laboring client is distressed to discover that the on-call physician is a male. The client’s husband forbids the physician from providing care for his wife. What is the nurse’s best strategy in which to provide care in labor and birth when confronted with a cultural conflict? Question 3 A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data found in the accident victims would require immediate care? Question 4 A nurse has been caring for an 8-year-old girl with multiple chronic urinary tract infections. The mother states that the family lives in a house with an adult male boarder who occasionally babysits. The child’s mother appears protective, never leaving the daughter's side. Although the nurse helps the child's mother provide morning care, the child states, "It hurts down there." Her mother becomes visibly upset and tells her daughter not to discuss the matter. Which of the following is the nurse’s professional responsibility? Question 5 At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress notes above and begins planning client care based on which nursing diagnosis? Question 1 Which concept is most important for a nurse to communicate to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? Question 2 A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She does not have transportation. How can the nurse help this client be compliant with her care? Question 3 An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? Question 4 A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the health care surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make health care decisions for the fetus, who's responsible for making them? Question 5 Which measure included in the care plan for a client in the fourth stage of labor requires revision? Question 6 A nurse is assigned to a client who is using an insulin pump. She has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first? Question 7 Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? Question 8 The charge nurse on the pediatric floor has assigned a 6-year-old girl with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-private room. The 6-year-old’s mother is upset because the parent staying with the other child is male and believes the arrangement is violates her social norms. The nurse should: Question 9 A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi’s sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond? Question 10 A client who is positive for human immunodeficiency virus (HIV) tells the nurse that her significant other is the only family member who knows her health status. What should the nurse do to keep the client's health status confidential? Select all that apply. Question 11 The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding? Question 12 A client is being prepared for a bronchoscopy. The nurse can delegate which task to the unlicensed assistive personnel (UAP)? Question 13 The nurse is assisting with a bone marrow aspiration and biopsy. Place the tasks in the order in which the nurse should perform them, from highest priority to least priority. All options must be used. Question 14 A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: Question 15 A client has been admitted to the medical surgical unit following an emergency cholecystectomy. There is a Jackson Pratt drain with a portable suction unit attached. After 4 hours, the drainage unit is full. What should the nurse do? Question 16 A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? Question 17 The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of which of the following? Select all that apply. Question 18 A graduate nurse is asked to present a case study, during interdisciplinary rounds, on a client who has compartment syndrome from a leg injury. What would be the best approach by the graduate nurse to ensure a good comfort level with the topic? Select all that apply. Question 19 A client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Question 20 A client has accidentally received twice the normal dose of a medication that was administered on the previous shift. What should the nurse who discovers the error do first? Improve your mastery Question 1 Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client? Question 2 The client with recurrent depression and suicidal ideation tells the nurse, "I cannot afford this medicine anymore. I know I will be okay without it." The nurse should: Question 3 When making rounds on assigned clients, which client should the nurse assess first? Question 4 The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP: Question 5 A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is prescribed, but the mother will not sign the consent until the father arrives to give permission. What should the nurse do? Question 6 A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as: Question 7 A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client’s culture. By which of the following is the client’s right to self-determination best protected? Question 8 When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following? Question 9 A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's husband signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section? Question 10 Question 1 A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's: Question 2 A health care provider (HCP) prescribes a lengthy x-ray examination for a client with osteoarthritis. Which action by the nurse would demonstrate client advocacy? Question 3 A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks the nursing assistant if she has been validated on obtaining fingerstick glucose readings. The nursing assistant says she did not have the skill validated, but she has seen it done many times and knows she can do it. What should the nurse do? Question 4 The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. Which of the following should be the priority focus for the nurse when conducting discharge teaching? Question 5 A client with a history of pancreatic cancer is revived following cardiac arrest but is determined to have suffered brain death. The family tells the nurse they want to donate any usable body organs so their loved one can live on in others. Which action by the nurse is appropriate? Question 1 A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? Question 2 When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be: Question 3 When prioritizing a client's care plan based on 's hierarchy of needs, a nurse's first priority would be: Question 4 A nurse has received a shift report on four clients. Which client should she assess first? Question 5 A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client’s legs are numb all the way up to the hips. What should the nurse do next? Select all that apply. Question 6 A multigravid client at 34 weeks’ gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first? Question 7 The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations? Question 8 An anxious client asks the nurse for the results of recent blood work and wants to know what the results mean. Which of the following responses by the nurse is the most appropriate? Question 9 A client has been admitted to the hospital for treatment of kidney stones. The client is allowed a regular diet and is reviewing the menu. The client asks the nurse where the Atkins diet items are on the menu. What is the nurse’s understanding of the diagnosis and diet? High-protein, low-carbohydrate diets like the Atkins diet have been widely promoted as effective weight loss plans. The diet also allows for a high fat intake. The complications associated with this diet include high cholesterol, kidney problems, and osteoporosis. Remediation: Question 10 A nurse is providing care to a client with cancer. The client tells that nurse that the care provider is not giving enough information about the client's condition. Which behavior by the nurse demonstrates advocacy? Question 1 A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? Question 2 A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? Question 3 A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? Question 4 A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for: Question 5 The nurse is caring for a critically ill client with the client's mother and spouse in the room. The spouse begins to shout derogatory comments to the mother, blaming her for her spouse's critical state. What should the nurse do? Question 6 The nurse is caring for an adult client who had a gastric resection on November 4. At 1700 the following day, the client requests pain medication. The client’s health care provider has prescribed meperidine, 75 to 100 mg every 3 to 4 hours. The nurse reviews the client’s progress notes (view the chart). What should the nurse do next? • Administer the pain medication as requested. Question 7 A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client’s scalp. Which referral should the nurse make first? Question 8 The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client? Question 9 The nurse is caring for an eight-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? Question 10 A severely confused client presents over the weekend at the emergency department with acute abdominal pain. The client cannot identify their illness, but reports receiving multiple medicines at the local free clinic each week. The best action the nurse caring for this client can take is to: Question 1 A nurse writes a note in a client's chart that says: "The physician is incompetent because he ordered the incorrect drug dosage." This statement may lead to a charge of: Question 2 A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's: Question 3 A 9-year-old child presents to a school nurse with complaints of arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate? Question 4 A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's father states that he's going to have his son declared legally incompetent. Which response by the nurse is most therapeutic? Question 5 A client is scheduled for a right lower lobectomy for lung cancer. During the admission assessment, the client asks for information about a living will and advance directive. The nurse knows that the client understands teaching about the living will and advanced directive when he says: Question 6 When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort? Question 7 A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy? Question 8 A nurse is assigned to a client who is using an insulin pump. She has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first? Question 9 A multipara at 16 weeks’ gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should: Question 10 A multipara at 16 weeks’ gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should: Question 11 A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources? Question 12 The nurse is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which resource will provide the most helpful information? Question 13 The son of a dying patient is surprised at his mother’s adamant request to meet with the hospital chaplain and has taken the nurse aside and said, “I don’t think that’s what she really wants. She’s never been a religious person in the least.” What is the nurse’s best action in this situation? Question 14 A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind? Question 15 A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client? Question 16 A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. He requests that his evaluation and counseling records be e-mailed to his Human Resources representative. How should the nurse respond? Question 17 A nurse is caring for several clients on an oncology unit. Which client should the nurse see first? Question 18 Question 19 A male with an antisocial personality disorder is court-mandated to receive counseling after being detained by law enforcement officials. The chart entry reads: <handwriting> Progress notes 10/15/16 1130 The client came to the group therapy session and was verbally aggressive to other clients. The group leader set limits on his behavior, reinforced the group rules and guidelines. At two different times the client made excuses for his behavior, stating, “I really don’t have to be here,” and minimized the comments of other group members. Which priority action, by the nurse group leader, must be initiated? Question 20 During assessment, a client verbally rates the pain as 9 out of 10 on a 0 to 10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next? Question 1 A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to: Question 2 A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client’s legs are numb all the way up to the hips. What should the nurse do next? Select all that apply. Question 3 The nurse is caring for a client with end-stage cancer whose health status is declining. A prescription is written by the attending health care provider (HCP) to withhold all fluid, but the health care team cannot locate a family member or guardian. The nurse requests an ethics consultation. Which information is true of an ethics consultation? Select all that apply. Question 4 The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first? Question 5 While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: Question 6 A client is being prepared for a bronchoscopy. The nurse can delegate which task to the unlicensed assistive personnel (UAP)? Question 7 An elderly Cantonese-speaking client has been admitted to the emergency department after suffering a fall and suspected hip fracture in her home. Emergency medical services personnel have reported to the nurse that the client speaks no English. Who is the best person to perform translation services? Question 8 Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? Question 9 A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client’s family states that they want everything possible done for the client. Which of the following should happen in this case? Question 10 A nurse arriving for duty notes that a nursing assistant (or unregulated care provider [UCP]) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UCP? Question 1 When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be: Question 2 After working multiple shifts in the psychiatric intensive care unit, a nurse recognizes that she's becoming more distant and, at times, even irritable. The best action for the nurse to take would be to: Question 3 A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have Question 4 A pregnant woman does not have funds to purchase adequate, nutritious food. She works part time at a low-wage job and has two other children. The nurse can refer the client to which type of assistance? Question 1 A nurse has received a shift report on four clients. Which client should she assess first? Question 2 An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. Question 3 During her morning assessment, a nurse notes that a client is awake, alert, and has severe dyspnea; his respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3 L of oxygen. The nurse notes that the client's chart includes his living will. When considering best practice, the nurse should: Question 4 A multigravida in active labor is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next? Question 5 When a client wants to read the medical record, the nurse should: Question 6 A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? Question 7 A nurse is completing an admission interview of a client newly diagnosed with multiple myeloma. The client tells the nurse he is concerned that his insurance coverage and limited savings will not pay for all of his family's needs when he is not working. Based on this information, to whom would the nurse initiate a referral? Question 8 A client who is bound to a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to 5 days. During the past few weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair, he uses a cushion. During his appointment the nurse notes that he is not using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about his treatment regimen? Question 9 A nurse is caring for an elderly client who is being discharged to a skilled nursing facility. What should the nurse consider as a priority intervention in developing the discharge plan for this client? Question 10 A client in labor received an epidural for pain management. Before receiving the epidural, the client’s blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client’s blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), the nurse should: Question 1 In which circumstance may the nurse legally and ethically disclose confidential information about a client? Question 2 A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort? Question 3 When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse uses: Question 4 A nurse is making assignments for the infant unit. The shift's team members include a licensed practical nurse (LPN) with 10 years of experience, a registered nurse (RN) with 3 months of experience, and a client care assistant. Which assignment is most appropriate for the LPN? Question 5 An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's mother states that her daughter "has to bite the bullet, just like I did." What should the nurse do to make sure her client's request is honored? Question 6 Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first? Question 7 An elderly client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, “If my neighbor puts up a fence, I will blow him away with my shotgun. He has never respected my property line, and I have had it!” Which action should the nurse take? Question 8 The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Check all that apply. Question 9 Nurses who provide care in a large, long-term care facility use charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? Question 10 A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which of the following clients? Question 1 A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A man identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response be? Question 2 A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse’s best response to this situation? Question 3 A nurse is required to irrigate a client’s nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse? Question 4 A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? Question 5 Which client should the nurse assess first? Question 4 The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which of the following functions? Question 5 A client who is admitted to the adult unit of a mental health care facility with depression tells the nurse that he has pedophilia. The nurse should: Question 1 A nurse is developing a nursing diagnosis for a client. Which information should she include? Question 2 A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error? Question 3 The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? Select all that apply. Question 4 A charge nurse is making assignments for a team that includes two registered nurses (RNs) and one unlicensed assistive personnel (UAP). One client requires a nurse to perform several complex procedures. The charge nurse should: Question 5 What should be charted by the nurse when the client has an involuntary commitment or formal admission status? Question 1 When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, she realizes the client doesn't fully understand the surgery. She approaches the physician, who curtly says, "I've told him all about it. Just get the consent." The nurse should: Question 2 A client with terminal cancer tells the nurse that she is not afraid to die and she is thinking about how to plan her funeral. The most appropriate referral the nurse could suggest would be to the: Question 3 A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and his immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client? Question 4 When documenting information in a client's medical record, which of the following should the nurse do consistently for each entry? Question 5 The nurse is educating a woman with type 2 diabetes from France who speaks English as a second language. What behavior(s) alerts the nurse to a possible lack of communication of the educational material? Select all that apply. Question 1 The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first? Question 2 A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid–base balance? Question 3 The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches the back (see figure). The nurse should: Question 4 A client states, “If my heart stops beating, I do not want to be resuscitated.” Which action should the nurse take? Question 5 A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply. Question 1 During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? Question 2 Which reaction to learning about a diagnosis of being HIV positive would put the client at the greatest need of intervention by the nurse? Question 3 The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish-speaking only client with an infant who is in the special care nursery (SCN) for respiratory distress. The nurse should place the new client in a room with which client? Question 4 The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of which of the following? Select all that apply. Question 5 Which client is the best candidate for a vaginal birth after a caesarean (VBAC)? Question 1 A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Question 2 The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Question 3 A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score? Question 4 A charge nurse enters a client’s room and observes a physician instructing another nurse on how to insert a central line into the client’s neck. The nurse is holding the cannula and inserting the line. What would be the appropriate response by the charge nurse? Question 5 The nursing instructor is working with a student in a pre-operative unit. The student notices that the informed consent has not been signed. Which is the best action taken by the student nurse for obtaining informed consent? Question 1 A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS)/nursing care delivery model (NCDM) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS/NCDM? Question 2 When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be: Question 3 Thirty people are injured in a train derailment. Which client should be transported to the hospital first? Question 4 A nurse who fails to check a client's armband before administering medications is: Question 5 Which of the following theories of ethics most highly prioritizes the nurse’s relationship with clients and the nurse’s character in the practice of ethical nursing? Question 6 The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse? Question 7 Which client is the best candidate for a vaginal birth after a caesarean (VBAC)? Question 8 The nurse is assigned to care for 4 mothers and their term newborns. Which mother and newborn couplet requires the nurse’s attention first? Question 9 A registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are working together in the emergency department to care for a client who is hemorrhaging. Which actions would be delegated to the LPN/VN? Select all that apply. Question 10 The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The mother does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his mother, the nurse should consider that: • . [Show More]

Last updated: 1 year ago

Preview 1 out of 106 pages