Safety
A nurse is preparing to help a client with a skin infection to take a bath. In which way can the nurse ensure the clients safety?
a. check that the bathroom has nonskid floors
b. check that grab bars are shoulder level
a. check that the bathroom has nonskid floors
When assessing lung sounds the nurse applies the stethoscope chest piece to the client's upper back but avoids placing it over the scapula or the ribs. How does this intervention help in the assessment?
a. facilitates hearing sounds in the upper and lower lobes
b. listening for crackles in the posterior bases bilaterally
a. facilitates hearing sounds in the upper and lower lobes
Which ambulation aid would the nurse suggest to a client who has weakness on one side of his body?
a. Forearm crutches
b. Cane
b. Cane
The nurse is caring for a 70 Y/o client with a fractured wrist. Which is the best method to determine whether the client has retained the information taught?
a. Ask the client to recall the information after 15 min
b. Test client on information
a. Ask the client to recall the information after 15 min
A nurse who is taking the vital signs of a client with acute diarrhea, is ordered to attend to another client. What is the priority nursing action the nurse must preform before leaving the clients room?
a. Hand Hygeine
b. Removing PPE that is most contaminated first
a. Hand Hygiene
A nurse finds a fire has broken out in a clients room at the health care facility. Which intervention is the first priority?
a. contain the fire
b. evacuate client
b. evacuate client
A parent brings a newborn to a 3 month wellness visit when assessing the back the nurse observes a dark blue area on the lower back that resembles ecchymosis but does not elicit a pain response. What condition would you think about in this finding?
a. Ecchymosis
b. Mongolian spots
b. Mongolian spots
The nurse is assisting a client at a health care facility dangle his legs before he ambulates. The nurse places the client in fowler's position for a few minutes. What is the possible reason for this action?
a. Maintain safety should the client become dizzy or faint
b. To decrease the client's heart rate
a. Maintain safety should the client become dizzy or faint
A parent brings a newborn to a 3 month wellness visit when assessing the back the Post operative patient who had a knee replacement and is working with a physical therapist. The nurse is also working with the physical therapist. What is the nurse's role when working with other health care officials?
a. Collaborator
b. Delegator
a. Collaborator
A nurse is caring for a client who is unconscious following a traumatic brain injury following a motor vehicle accident. The nurse provides thorough oral care to the client on a regular basis. When providing this care, the nurse should take specific action to reduce the clients risk for what?
a. risk of aspiration
b. risk for infection
b. risk for infection
What is true about the incubation stage for influenza?
a. The person is experiencing vague nonspecific effects of influenza
b. The person is currently not experiencing symptoms of the flu
c. The person's symptoms are at their peak
a. The person is experiencing vague nonspecific effects of influenza
A nurse is assessing the neck injury of a client who has been wearing a cervical collar for over 2 weeks. What could occur if the client wears the collar for a prolonged period?
a. restricted movement and activity
b. difficulty swallowing
c. permanent neck stiffness
c. permanent neck stiffness
The nurse is caring for a client with a fractured wrist in a cylinder cast. Which action should the nurse perform to ID the neuromuscular function of the client?
a. Assess sensation in exposed fingers
b. Monitor mobility of the fingers
c. Observe the color of the client's nail beds.
b. Monitor mobility of the fingers
Select all that apply. During a nursing shift which events warrant a completion of an incident report?
a. A nurse reports that a client is crying and distraught over a Dx of cancer
b. An intravenous antibiotic was administered 2 hours late because the IV site infiltrated
c. A visitor slipped and fell in the hall way but was not injured
d. A client falls while being transferred from the bed to the chair
e. A nurse asks a UAP to feed the client
b. An intravenous antibiotic was administered 2 hours late because the IV site infiltrated
c. A visitor slipped and fell in the hall way but was not injured
d. A client falls while being transferred from the bed to the chair
A nurse is caring for an older adult client at a health care facility. What should the nurse consider to be a normal age related change?
a. Occasional falls
b. Decreased sensory perception
c. Decreased or unsteady mobility
c. Decreased or unsteady mobility
Select all that apply. The nurse is caring for a client with a latex allergy. Which nursing interventions are appropriate?
a. Flag the chart and room door
b. Apply an allergy alert ID bracelet on the client
c. Communicate to the interdisciplinary health care team to use non latex equipment
d. Remove blueberries from the clients dietary tray
e. Teach the client to wear a medic alert bracelet
a. Flag the chart and room door
b. Apply an allergy alert ID bracelet on the client
c. Communicate to the interdisciplinary health care team to use non latex equipment
The nurse is assessing the skin of a client who has been on a hiking trip. And developed a number of inflamed red patches on his hands and face as a result of an allergic reaction. How should the nurse document this finding?
a. flush
b. paller
c. xerosis
d. erythema
d. erythema
A nurse uses a commercial arm sling to support a clients arm. Which function does the sling perform?
a. Encloses the client's forearm
b. Provides elevation to the body parts
c. Reduces transmission of pathogens
b. Provides elevation to the body parts
A nurse in the intensive care unit has just reported for duty. A client is being transferred to the medical floor after the change of shift. Which action would the nurse take to ensure maximum efficiency of change of shift or transfer report?
a. Call the receiving nurse with a list of the client's medication.
b. Ask the health care provider to provide transfer report to the receiving nurse
c. Print the client's medical record to accompany the client during transfer.
d. Utilize electronic medical record while providing report to the receiving nurse
d. Utilize electronic medical record while providing report to the receiving nurse
A client is admitted to the mental health center after they attempted suicide. Which client concern is the priority for the nurse to manage?
a. Risk of self harm
b. Lack of support
c. Not accepting meals
a. Risk of self harm
Select all that apply. The nurse manager notices that a nurse is wearing fake nails. What is the appropriate action?
a. Remind the nurse that fake nails can spread fungal infections
b. Refer the nurse to the agency policy on fake nails
c. Provide the nurse with evidence that demonstrates the outcome of hand hygiene
d. Demand the nurse remove the fake nails immediately
e. Ask the nurse to use only polish instead of fake nails
a. Remind the nurse that fake nails can spread fungal infections
b. Refer the nurse to the agency policy on fake nails
c. Provide the nurse with evidence that demonstrates the outcome of hand hygiene
A nurse is assessing a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?
a. 1+ pitting edema
b. 2+pitting edema
c. 3+ pitting edema
d. 5+ brawny pitting edema
b. 2+ pitting edema
Nurse is caring for a post op client and plans to help the client ambulate but is aware that the client may feel threatened by physical closeness because the client is from a culture that tends to prefer more personal space when interacting with others. Using the principles of culturally competent care what would be the most appropriate nursing action?
a. Instruct family members to assist in ambulating client
b. Ambulate the client explaining it as an expected outcome of their treatment
c. Explain the purpose and need for assistance during ambulation
d. Let client ambulate slowly on his or her own when stable
c. Explain the purpose and need for assistance during ambulation
Select all that apply. A nurse needs to complete an assessment and vitals on a client who has alzhimers. How should the nurse approach the client to gain cooperation?
a. Approach the client from the front
b. Use the clients name
c. Focus on the nursing tasks
d. Speak loud and clearly
e. Smile and maintain eye contact
a. Approach the client from the front
b. Use the clients name
d. Speak loud and clearly
e. Smile and maintain eye contact
The nurse uses a cotton ball at various places on both sides of the body. What info does the nurse obtain during this assessment?
a. ability to identify temperature changes
b. ability to identify sharp and dull touch
c. ability to feel vibration
d. ability to ID fine touch
d. ability to ID fine touch