Coordinated care
Client who has terminal illness decides to continue treatment. The appropriate response from the nurse is? A)"Why are you giving up?" B)"Tell me about your decision" C)"What does your family want?" D)"You have other available options"
B) "Tell me about your decision"
A nurse prepares to administer a beta blocker to a client. Which finding indicates the medication should be withheld? A)Confusion. B)Pedal edema. C)Pulse rate 52/min. D)Blood Pressure 102/70mm Hg
C) Pulse rate 52/min.
A nurse transfers a client who is partially weight-bearing from the bed to a chair using a transfer belt. Which action is appropriate? A)Place chair near foot of bed. B)Use side rails for support. C)Position the chair on the client's weaker side. D)Grasp under the belt along the client's sides.
D) Grasp under the belt along the client's sides.
A nurse discovers a client who is leaving against medical advice. Which action is appropriate? A)Notify the provider. B)Contact hospital security. C)Reinforce discharge instructions. D)Administer prescribed medications
A) Notify the provider.
A nurse provides care to a preschooler who is hospitalized. Which activity is age-appropriate? A)Shaking a colorful rattle. B)Putting a puzzle together. C)Arranging a coin collection. D)Building a model spaceship.
B)Putting a puzzle together.
A nurse recognize an increase in client falls in a long term care facility. Which step should the nurse use to begin quality improvement process? A)Collect data B)Identify causes C)Initiate corrective action D)Analyze possible solutions
A) Collect data
A nurse prepares to administer medication for a client. Which action does not follow safe practice guidelines? A)Verify any client allergies. B)Open medication package at bedside. C)Give within 2 hr of scheduled time. D)Provide information about purpose of the medication.
C) Give within 2 hr of scheduled time.
A nurse provides care to a client who has a Clostridium difficile infection. Which technique is appropriate for hand hygiene? A)Apply an alcohol based sanitizer. B)Use a chlorine bleach solution. C)Wash with an antibacterial soap. D)Cleanse with hydrogen peroxide.
C) Wash with an antibacterial soap.
A nurse provides care to a client who has a chest tube and observes fluctuations in the water sea chamber. What is the appropriate action? A)Locate air leak. B)Reinforce dressing. C)Continue to monitor D)Increase wall suction
C) Continue to monitor
A nurse reviews lab results for a client who is receiving heparin therapy. Which lab values should be reported to the RN? SATA. A)Hct 29%. B)Hgb 15g/dL. C)aPP 70 seconds. D)WBC 8,600/mm3. E)Platelet 115,000/mm3.
A)Hct 29%
E)Platelet 115,000/mm3.
A nurse reinforces teaching to a client about end of life decisions. Which information about advance directives is correct? A)informed consent should be verified B)A health care proxy can be designated C)specific dietary restrictions are identifies D)Legal counsel is needed to make changes
B) A health care proxy can be designated
A nurse provides care to a client who has chronic kidney disease. Which prescription should be questioned? A)Furosemide 20 mg PO, twice daily. B)Insulin detemir 8 units subcutaneous at bedtime. C)Lactated Ringer's 50 mL/hr by continuous IV infusion. D)Acetaminophen 650 mg rectal suppository every 6 hr PRN pain.
C) Lactated Ringer's 50 mL/hr by continuous IV infusion.
A nurse transports a newborn to the wrong mother. Upon identifying the error, which nursing action is your priority? A)Notify the provider. B)Inform risk management. C)Return the newborn to the nursery. D)Document the error in an incident report.
C) Return the newborn to the nursery.
A nurse performs wound care for a client who has a stage II pressure ulcer. What action is appropriate? A)Apply vacuum-assisted closure. B)Cover with hydrocolloid dressing. C)Debride with proteolytic enzymes. D)Clean using povidone-iodine solution.
B)Cover with hydrocolloid dressing.
A nurse reinforces teaching about fiberglass cast care to an adolescent who has fractured tibia. Which information should be included? SATA. A)Expect complete drying in 24hr. B)Pad the edges of the cast if irritation occurs. C)Use an ice pack on the cast to relieve itching. D)Stand with crutches 30-45 min each day. E)Report any changes in skin color below the cast
B)Pad the edges of the cast if irritation occurs.
C)Use an ice pack on the cast to relieve itching.
E)Report any changes in skin color below the cast
A nurse participates in the process of informed consent with a client who is considering a surgical procedure. which ethical principles is being demonstrated? A)Justice. B)Autonomy. C).Beneficence. D)Nonmaleficence
B) Autonomy
A client is prescribed a continuous infusion of dextrose 5% in water at 75 mL/hr. The IV tubing drop factor is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number) _______ gtt/min
19 gtt/min
A nurse reinforces teaching to a client about isometric exercises. Which activity should the nurse recommend? A)Walking. B)Swimming C)Aerobic Dance. D)Gluteal contractions
D) Gluteal contractions
A client reports leg pain when walking short distances. After noting hair loss on the lower left leg, which action should the nurse take? A)Check for edema in both legs. B)Compare bilateral posterior tibial pulses. C)Look for brown discoloration along the ankles. D)Monitor warmth & redness on lower extremities
B) Compare bilateral posterior tibial pulses.
A nurse reinforces teaching to a client who is postpartum and reports perineal discomfort. Which instruction should be included? A)Use a sitz bath. B)Massage the fundus. C)Ambulate with assistance. D)Cleanse the perineum with a squeeze bottle.
A)Use a sitz bath.
A LPN provides care to a group of clients. Which client should be reassigned to RN? A)A nasogastric tube & pH of the gastric aspirate is 3. B)Asthma & prescribed O2 via nonbreather mask. C)DM & a blood glucose level of 160 mg/dL. D)Stage 3 pressure ulcer & requires a sterile dressing change.
B) Asthma & prescribed O2 via nonbreather mask.
A nurse prepares to dispose of unused client medications. A witness is required for discarding which medications? SATA. A)Diazepam. B)Methadone. C)Benzocaine. D)Phenobarbital. E)Methylphenidate
A) Diazepam.
B) Methadone.
D) Phenobarbital.
E) Methylphenidate
A nurse reinforces teaching fir a client who has diverticulitis. Which foods are for a low-residue diet? SATA. A)White rice. B)Wheat toast. C)Canned fruit. D)Vegetable juice. E)Hard boiled egg
A) White rice.
C) Canned fruit.
D) Vegetable juice.
E) Hard boiled egg
A nurse reinforces teaching for a client who has an ileal conduit. Which information should be included? SATA. A)Self catheterization is necessary. B)Bowel movements will contain urine. C)Stoma should appear pink & moist. D)Low residue foods are recommended. E)Urine is collected in an external pouch
C) Stoma should appear pink & moist.
E) Urine is collected in an external pouch
A home health nurse reinforces availabiity of community resources for the caretaker of a client who is in hospice care. Which resources should the nurse include? SATA. A)Respite care. B)Meals on Wheels. C)Adult day care services. D)Anticipatory grief counseling. E)Alzheimer's Association.
A)Respite care.
D)Anticipatory grief counseling.