Safety
Who is at greatest risk for falls?
A) An elderly man who recently had a humerus repair
B) A woman who is prone to episodes of low blood pressure
What is- a woman prone to episodes of low blood pressure.
You are changing the bed linens of a client admitted to a healthcare facility, which isolation precautions should you follow?
A) Standard Precautions
B) Isolation Precautions
What is- A) Standard precations
How will you know a client's crutches are fitted correctly?
A) The level of the handgrips are at the client's waist upon standing
B) The axillary bar is 3-4 inches below the axila upon standing
What is- A) The handgrips are at the client's waist upon standing
Which is an example of a subjective finding you might encounter while obtaining a review of systems?
A) Grip weakness in the right hand
B) Client reports shooting pain in left leg
What is- B) Client reports shooting pain in left leg
True or False
A normal heart rate is 70BPM
What is- True
A nurse needs to restrain a client who may be harmful to himself. What is the priority nursing action when applying restraints?
A) Obtain a physician's order for restraints
B) Reassess the client's condition every 2 hours
What is A) Obtain a physician's order for restraints
The nurse has worn a gown and gloves while caring for a client in contact isolation. How will the nurse appropriately remove this personal protective equipment (PPE)?
A remove gloves, remove gown, wash hands
B) remove gown, remove gloves, wash hands
What is B) remove gown, remove gloves, wash hands
How can you decrease risk for peripheral neurovascular dysfunction in a client with a leg cast?
A) Tell the client to avoid wiggling their toes
B) Elevate the extremity to a level above the client's heart
What is- B Elevate the extremity above the level of client's heart
A client is scheduled for discharge from the hospital and the client's PCP has prescribed injections of an anticoagulant. The nurse has to teach the client how to correctly self-administer the medication, client speaks very little English. How should the nurse meet this client's learning needs?
A) Demonstrate the correct technique for injecting the medication while relying on nonverbal communication.
B) Arrange for a professional interpreter to be present when the nurse performs client education.
What is B) Arrange for a professional interpreter to be present when the nurse performs client education.
In order to accurately assess apical heart rate where should the stethoscope be placed?
A) 4 inches below the left clavicle
B) Slightly below the left nipple
What is B- slightly below the left nipple
A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?
A) The blood pressure is elevated
B) The baseline pulse rate is needed
C) The radial pulse is difficult to obtain
What is C) The radial pulse is difficult to obtain
he nurse is caring for a client with diabetes who has thick toenails. What is the appropriate nursing intervention?
A) Clip the toenails with large clippers.
B) Use a handheld electric rotary file to reduce the length of the toenails.
C) Contact a podiatrist to care for toenails.
D) Clean under the toenails with a wooden orange stick.
What is C) Contact a podiatrist to care for toenails.
You are cleaning the pin sites of a client with an external fixation device, what sign requires you to perform a wound culture?
A) Pain
B) Temperature
C) Purulent drainage
What is C- Purulent drainage
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?
A) Once per day
B) According to medical orders
C) Immediately
D) Every four hours
What is C - Immediately
A client is found gasping for air, you reposition and provide oxygen. Your client is suffering from what condition?
A) Orthopnea
B) Bradypnea
C) Dyspnea
What is- C Dyspnea
A nurse is caring for a client with hypertension whose blood pressure has increased from 154/78 to 196/98 and heart rate of 110bpm. The nurse goes to lunch and the client experiences a cardiac arrest. What tort has the nurse likely committed?
A) Negligence
B) Battery
C) False imprisonment
What is -A) Negligence
A nurse is performing a physical assessment for a client using the palpation technique. What is one of the purposes of using this technique?
A) to assess the sounds from the heart, lungs, and abdomen
B) to determine the density of structures underlying the skin's surface
C) to check the skin temperature and moisture
D) to observe specific parts for normal or abnormal characteristics
What is B) to determine the density of structures underlying the skin's surface
An unconcious client is brought to the emergency room after ingesting too much prescribed medication, what is your priority intervention?
A) Establish IV access
B) Contact family members
C) Establish a patent airway
What is C- Establish a patent airway
The nurse is teaching a nursing student about caring for a client with dentures. Which education will the nurse provide?
A) "Use your ungloved hands to remove an unconscious client's dentures."
B) "Clean dentures with hot water to eliminate bacteria."
C) After brushing dentures, leave them out of the client's mouth overnight."
D) "Hold dentures over a plastic basin or towel when cleaning them."
What is D) "Hold dentures over a plastic basin or towel when cleaning them."
You note an increase in temperature from 102 degrees to 103.6 degrees, what is your next nursing action?
A) Cover the client's head with cap or towel
B) Offer the client fluids
C) Provide cooling measures
D) Consult physician to administer antipyretics
What is D) Consult physician to administer antipyretics
When assisting a client with ambulation by using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for?
A) pallor, weakness, or dizziness
B) Upper-arm strength
C) Walking gait
D) Tone and strength of muscles
What is C) Walking gait
A client has been swabbed for an antibiotic-resistant microorganism upon admission to the hospital, and the results reveal that she has been colonized. What are the implications of this assessment finding?
A) The client will be admitted and treated for sepsis.
B) The microorganism will multiply but is incapable of causing an infection.
C) The client will require a prophylactic course of antibiotics while in the hospital.
D) The microorganism is present on the client but is not making her sick.
What is- D) The microorganism is present on the client but is not making her sick.
A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening?
A) Calorie count
B) vital signs
C) Height and weight
D) Abdominal girth
What is C) Height and weight
A nurse is delegating some aspects of client hygiene to an unlicensed care provider and is ensuring the care provider has adequate knowledge to safely perform shaving. With which client would the use of a razor be contraindicated?
A) a man who had an unkempt beard and mustache upon admission
B) a man who has a history of type 1 diabetes and who takes insulin daily
C) a man who has a history of stroke and who takes oral anticoagulants
D) a man who is the early stages of Alzheimer's disease
What is C) a man who has a history of stroke and who takes oral anticoagulants
A nurse has assessed a client's blood pressure near the beginning of a shift and obtained a systolic blood pressure of 138 mmHg and a diastolic blood pressure of 71 mmHg. The systolic blood pressure:
A) represents the client's blood pressure between heartbeats.
B) Represents peak pressure in the client's arteries
C) Peaks when the client's heart is filling with blood
D) Corresponds directly to the heart rate
What is B) Represents peak pressure in the client's arteries