A.
The nurse is preparing a self-care presentation for a group of adults in a smoking-cessation support group. The nurse is aware that which category is the most basic and most often needs to be met first when referring to Maslow's hierarchy of needs?
A. Love and belonging.
B. Physiological.
C. Safety and security.
D. Self-confidence.
B. Physiological.
A nurse cares for a patient her whole shift. The nurse wants to see what has been effective, as well as what did not work. This nurse is utilizing which of the steps of the nursing process?
A. Setting smart goals for planning.
B. Examining alternate diagnoses based on associated concepts.
C. Implementing nursing care.
D. Evaluating outcomes.
D. Evaluating outcomes
A nurse is reviewing the medication administration record of a client who has difficulty swallowing. Which of the following medications should the nurse identify as safe to crush before administering to the client?
A. Enteric-coated aspirin
B. Acetaminophen tablet.
C. Miconazole buccal tablet
D. Percocet opioid tablet
B. Acetaminophen tablet.
A nurse on a medical surgical unit is administering multiple medications to a client with dementia. Which of the following actions should the nurse take?
A. Delegating to an assistive personnel to apply the medicated cream.
B. Leaving the medications at the client's bedside so he can take some now and some later.
C. Checking the client's mouth to ensure that he has swallowed the medications.
D. Assisting the client to a low-Fowlers' position prior to administering medications.
C. Checking the client's mouth to ensure that he has swallowed the medications.
A client has an excoriated skin area with purulent drainage. Which diagnostic test does the nurse anticipate being ordered?
A) Skin biopsy
B) Culture
C) Urinalysis
D) Blood glucose
2) Answer: B
B) Culture
The student nurse is learning how to implement the nursing process into a plan of care for a client. The student nurse realizes that which aspect is part of the main purpose of the nursing process?
A. Deliver care to a client in an organized way.
B. Implement a plan that mirrors the medical model.
C. Identify client needs and deliver care to meet those needs.
D. Make sure that standardized care is available to clients.
C. Identify client needs and deliver care to meet those needs.
The charge nurse is talking to the newly licensed nurse about the general concept of the safety of nurses. The charge nurse would include which scenario as a safety concern related to body mechanics?
A. The nurse lifting or transferring from a twisted position.
B. Keeping equal weight on the feet when transferring clients
C. Whenever possible, pushing rather than pulling
D. Guide the client down slowly against a wall when the client is falling
A. The nurse lifting or transferring from a twisted position.
The nurse is evaluating a client with a pressure ulcer on the left hip to determine progress toward the healing goal. Which statement best describes progress toward healing?
A. Eschar covering entire wound.
B. Wet-to-moist dressings should be applied every four hours.
C. No additional breakdown areas are noted elsewhere on the body.
D. Granulation tissue is noted around the edges of the wound.
D. Granulation tissue is noted around the edges of the wound.
A nurse is determining a client's pressure ulcer using the Braden Scale, and calculates the score to be 23. What was one of the criteria the nurse has been assessing?
A. The client's ability to exercise.
B. If the client knows how to use his cane.
C. Usual food intake pattern.
D. If the client experiences pain while turning onto the side.
C. Usual food intake pattern.
Your patient's blood glucose level is 265 mg/dL. The patient is about to eat lunch. Per sliding scale, you administer 10 units of Insulin Lispro (Humalog) subcutaneously at 1200. As the nurse, you know the patient is most at risk for hypoglycemia at what time?
A. 1245
B. 1300
C. 1400
D. 1600
B. 1300
The nurse is caring for a client who was just informed of a cervical cancer diagnosis after not having a pap smear for years despite being Human Papilloma Virus positive. The nurse believes the client is experiencing severe stress when noting which assessment finding?
A. PERRLA 4mm size on exam.
B. Dilated peripheral blood vessels.
C. Hypoventilation.
D. Increased heart rate.
D. Increased heart rate.
A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that the surgery is necessary. The nurse considers the client's potential religious preferences in developing the plan of care with the client and ensuring that the provider has counseled with the client with a:
A. Medication reconciliation form signed by the religious leader.
B. Surgical informed consent signed by the client and the provider.
C. Blood product declination checklist, signed by the client and provider.
D. Complementary and alternative medication reconciliation form.
C. Blood product declination checklist, signed by the client and provider.
The nurse cares for a client with bacterial meningitis. When should the nurse remove the face mask when doffing PPE?
A. After removing the gown
B. After removing the gloves
C. Before removing the gown
D. Before removing the gloves
B. After removing the gown
The nurse notes that the hand of a client in wrist restraints is edematous. What action should the nurse take first?
A. Remove the restraint.
B. Massage the extremity.
C. Elevate the extremity on a pillow.
D. Use a different type of restraint.
A. Remove the restraint
Which goal would be most appropriate to include in the nursing care plan of a client with type 2 diabetes?
A. The client will learn to draw up cloudy before clear insulin.
B. The client will focus on monitoring dietary fats.
C. The client will monitor fasting glucose levels 3 days per week.
D. The client will inspect feet at least once daily.
D. The client will inspect feet at least once daily.
The nurse caring for the older adult is aware that the normal inflammatory response can be delayed, causing an atypical initial response to infection. What would the nurse expect to see as the first signs and symptoms of infection in an older adult client?
A. Fever, pain, and lethargy
B. Redness, swelling, and incontinence
C. Agitation, confusion, and general fatigue
D. Disorientation, bruising and rash
C. Agitation, confusion, and general fatigue
The nurse observes a post-op client use an incentive spirometer. Which action indicates that the client would benefit from additional instruction about the use of the device?
A. Tells the nurse that the incentive spirometer helps with lung expansion.
B. Holds the spirometer upright
C. Seals lips around the mouthpiece.
D. Takes a brisk low-volume breath
D. Takes a brisk low-volume breath
Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
A. Cleaning from the center outward in a circular motion.
B. Removing the drain before cleaning the skin.
C. Cleaning briskly around the site with alcohol.
D. Wearing sterile gloves and a mask.
A. Cleaning from the center outward in a circular motion.
A nurse is educating a patient, who is being treated for an inflammatory response, on how to prevent episodes of inflammation in the future. Which of the following should the nurse emphasize?
A. Avoid triggers
B. Take 81 milligrams of aspirin PO daily
C. Eat a high carbohydrate diet
D. Wear gloves to avoid infection
A. Avoid triggers
The nurse walks into the client room, and the client is confused and disoriented. Ten minutes prior, the client was oriented to person, place, and time and was not confused. Which nursing action is priority?
A. Position client in supine position.
B. Assess vital signs and pulse oxygenation
C. Initiate fall precautions
D. Obtain urine for urinalysis
B. Assess vital signs and pulse oxygenation
The nurse assesses a post-operative client with an abdominal wound and finds the client drowsy when speaking. The client's pain is ranked 2 on a scale of 0-10. Vital signs (VS) are within preoperative range, extremities are warm with good pulses but very dry skin. The client declines oral fluids due to nausea and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered high priority for a change in the current care plan?
A. Pain
B. Nausea
C. Constipation
D. Potential for wound infection
B. Nausea
The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:
A. Wash the gloves before removing them.
B. Gently pull on the fingers of the gloves when removing them.
C. Gently pull near the cuff on the outside of the glove and invert the gloves when removing them.
D. Remove the gloves and then turn them inside out.
C. Gently pull near the cuff on the outside of the glove and invert the gloves when removing them.
The experienced RN training a new graduate nurse on the unit is validating the nurse for proper understanding of HIPAA and the EHR. Which of the following observations supports this?
A. Sharing of her password with her preceptor.
B. Documentation of a nursing progress note.
C. Leaving the computer screen open with protected health information unattended
D. Informing the patient of their right to view their own health records electronically
D. Informing the patient of their right to view their own health records electronically
1) What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
B) Stage 2
The nurse is assessing an older adult client with a history of hypertension and dementia who is establishing care with the healthcare clinic. What type of assessment is she preforming?
A. Ongoing assessment
B. Initial assessment.
C. Emergency assessment
D. Focused assessment
B. Initial assessment.