Unlock document.
This document is partially blurred.
Unlock all pages and 1 million more documents.
Get Access
After completing an assessment the nurse analyzes all data collected. What is the
significance of the nurse performing this analysis?
1. Confirms observations
2. Identifies client outcomes
3. Establishes a foundation for the client's care
4. Prioritizes interventions according to client needs
A client is prescribed intravenous antibiotics however a culture and sensitivity has been
ordered. What should the nurse do prior to starting the intravenous antibiotics?
1. Assess vital signs.
2. Collect the ordered culture and sensitivity specimen.
3. Start intravenous antibiotics.
4. Obtain culture after two doses have been given.
The nurse identifies problems for a specific client. What action should the nurse
perform next when planning this client's care?
1. Identify outcomes for care
2. Determine resources needed for care
3. Translate the needs into nursing diagnoses
4. Select appropriate interventions to address the needs
The nurse receives a call from a client who reports a deep, long cut to the left hand
sustained while slicing a bagel and asks the nurse what to do. Which action should the
nurse direct the client to take?
1. Elevate the arm above the head and apply ice and pressure while en route to the
emergency department.
2. Apply heat and pressure en route to the emergency department.
3. Apply ice and elevate the arm.
4. Apply pressure and elevate the arm.
A client has a history of normal pressure hydrocephaly. What physiological function
most likely occurs to maintain this client's intracranial pressure within normal limits?
Select all that apply.
1. Displacing of brain tissue
2. Administer osmotic diuretics
3. Reducing the amount of cerebral oxygen
4. Compressing the cerebral venous system
5. Shunting of cerebrospinal fluid to the lumbar space
The nurse could safely delegate which task to the unlicensed assistive personnel
(UAP)?
1. Removal of antiemboli stockings to wash the feet and legs, then reapply the
stockings
2. Assessing the client's circulation to the feet every 4 hours while wearing
antiembolism stockings
3. Evaluating for presence of Homans' sign
4. Measuring and fitting the client for antiembolism stockings
The nurse manager is contacting the Board of Registered Nursing (BRN) to report a
staff member. Which action did the manager most likely observe the staff member
perform?
1> Changing a client's abdominal wound dressing
2> Instructed a client on self-administration of insulin
3> Assisting a client with ambulation to the bathroom
4> Informing a client to stop taking a prescribed medication
The nurse is caring for an older adult client with an ileostomy and hemiplegia
secondary to a stroke experienced a few years ago. When changing the client's
one-piece appliance, the nurse finds the skin under the skin barrier is ulcerated and
erythematous. The client does not empty the pouch until it is completely full because it
hurts so much to remove the skin barrier. Which action by the nurse is the priority?
1. Apply a two-piece ostomy appliance.
2. Treat the damaged skin and replace the one-piece pouch.
3. Keep the skin open to air to allow time for healing, and replace the ostomy appliance
in a few days.
4. Call the health care provider to report the damaged skin.
Immediately after a client dies, who is the nurse responsible for notifying?
1. Family
2. Primary care provider
3. Funeral home
4. Coroner, if indicated
The nurse observes the student administer heparin subcutaneously into the client's
abdomen. Which action indicates the need for further teaching?
1. The student determines the site by placing two fingers above the umbilicus and
injecting the medication above the fingers.
2. The student cleans the site, wiping in a circular motion with an antimicrobial wipe.
3. The student uses a 25 gauge needle.
4. The student inserts the needle at a 90 angle.
When delegating postmortem care to unlicensed assistive personnel (UAP), it is
essential that the nurse inform the UAP of which piece of information?
1. The tubes or other medical devices to be left in place
2. The disposition of the body after postmortem care is completed
3. The method to contact the family
4. The information to be documented in the medical record
Which health problems are classified as venous thromboembolisms?
Standard Text: Select all that apply.
1. Deep vein thrombosis
2. Pulmonary embolism
3. Coronary artery thrombosis
4. Myocardial infarction
5. Aortic aneurysm
The nurse is preparing to insert a urinary catheter. Place the steps for this procedure in
the proper order.
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Cleanse the meatus.
Response 2. Apply sterile gloves.
Response 3. Test the balloon of the indwelling catheter, if recommended by
manufacturer.
Response 4. Organize the supplies in the catheter kit.
Response 5. Place a sterile drape under the buttocks of the female or penis of the male
without contaminating the center of the drape.
A client has a urine output of 350 mL of urine over the last 24 hours. Which health
problem should the nurse consider as causing this low output? Select all that apply.
1. Pain
2. Trauma
3. Surgery
4. Hemorrhage
5. Elevated sodium
The nurse changes the client's IV dressing and removes the existing transparent wound
barrier. Prior to applying the new barrier, which action by the nurse is the most
appropriate?
1. Applying benzoin to make the dressing stick firmly
2. Placing a sterile piece of gauze over the insertion site before placing a new
transparent barrier over the wound
3. Cleansing the site with normal saline or a mild cleansing agent
4. Applying sterile gloves
A client says that a neighbor buys herbal preparations over the internet because they
cost less. What should the nurse explain about the selection of herbal preparations?
1. All herbal preparations are the same
2. Herbal preparations are not regulated
3. Preparations that cost less are less effective
4. Preparations from out of the country are the best
During a home visit the nurse wants to evaluate the success of discharge teaching
provided. What tool should the nurse use to evaluate the client's ability to measure pulse
before taking medications?
1. Measure the client's heart rate
2. Provide a paper and pencil test
3. Ask the client to complete a questionnaire
4. Observe the client count the pulse for 1 minute
Which statement indicates that unlicensed assistive personnel (UAP) understand
directions provided regarding client care?
Standard Text: Select all that apply.
1> "I will bathe the client in room 402."
2> "I am done with the assigned tasks for Mr. Wells."
3> "I can give the medication for you."
4> "I will note all orders."
5> "I understand my assignment is to take and document the vital signs."
