. A nurse is caring for a client who has compartment syndrome following the application of a
tast to the leg. Which of the following.. nurse take?
Check the client's pedal pulses
Administer a dose of antlemetic medica
...
. A nurse is caring for a client who has compartment syndrome following the application of a
tast to the leg. Which of the following.. nurse take?
Check the client's pedal pulses
Administer a dose of antlemetic medication
Position the client's leg above the level of the heart
.Apply ice to the extremity
2. A nurse is preparing to administer levothyroxine 50 micrograms to a client .Aavailable
levothyroxine 0.025 mg/tablet .How many table to the nurse administer per dose?
3. A nurse is providing teaching about home safety to the adult child of an older adult client
who is postoperative following knee replacement surgery.Which of the following instructions
should the nurse include
Place a throw rug over electrical cords
Encourag the client to avoid wearing shoes at home
Mark the edges of the doorway to the house with tape
Ensure that area rugs have rubber backs
4. A nurse manager is reviewing the steps of the progressive discipline process prior to
counseling a staff member who exhibits unprofessional behavior. Identify the sequence of
steps the nurse manager should plan to take in response to the staff member's conduct.
(Move the steps into the box on the right, placing them in order of performance. Use all the
steps.)
2- Give the staff member a written earning about the behavior.
1- Verbally remind the staff member of the expected behavior changes.
4- Suspend the staff member from employment at the facility
5- Dismiss the staff member from employment at the facility.
3- Set up a meeting to speak with the staff member about the behavior.
5. A nurse is providing teaching to a client who has a multiple sclerosis . Which of the
following statement should the nurse include
Limit your daily intake of high fiber foods
Establish a voiding schedule by urinating exercises every 4 hours
Avoid exercises that increase your body temperatureWear an eye patch over one eye for an entire day before switching
6. A nurse in an emergency department is caring for a toddler who has burns following a
house fire. Which of the following actions should the nurse take first?
Calculate the fluid replacement based on vital signs and urinary output
Determine the location and depth of burns
Administer antibiotics to prevent sepsis.
Check the mouth for smooth and smoky breath
7. A nurse is caring for a client who has a pressure injury on the coccyx .Which of the
following should indicateto the nurse that… a stage III pressure injury ?
Bone is exposed within the wound
Shough and eschar is present
Subcutaneous fat is visible
The skin is reddened and intact
8. (OJO) A newly licensed nurse is unsure if an assigned task is within their scope of practice.
which of the following resources should the nurse consult?
Written prescription from the provider
Institutional policies and procedures
Verbal direction from the nurse manager
State Nurse Practice Act
9. A nurse is caring for a client who has a prescription for 1 unit of packed RBCS. Flve minutes
after beginning the transfusion… with chills. After stopping the transfusion, which of the
following actions should the nurse taket?
Infuse 500 mL lactated Ringer's Iv.
Adininister epinephrine subcutaneously.
Document the reaction in the medical record.
Place the blood bag in a biohazard bag before discarding
10. A Nurse is teaching participants at a community center about advance directives. Which of
the following information should the nurse include in the teaching?
Assigning a health care surrogate requires legal consultationA client must create a do not resuscitate order when completing advances directives.
Advance directives cannot be changed once implemented.
A health care surrogate makes health care decisions when the client is no longer able.
11. A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of
the following Information should the nurse
Limit Intake of nuts and legumes.
Choose foods high in vitamin B12
Choose high-fat cheese as a meal substitute.
Limit Intake of foods high in vitamin C
12. OJO A nurse in an emergency department is assesing a client with major depressive
disorder. Which of t nurse take first? Exhibit
Obtain the clients weight
Administer ondansetron to the client for ma
Obtain a blood glucose level
Implement seizure precaution for the client
13. A nurse is assessing the grief response of a client whose child died 6 mONTHS age Which of
the following client statement should.. the provider as an Indication of major depressive
disorder?
I am unable to feel any joy since my child died.
I feel guilty because my child died
I now that will be reunited with my child someday
I am angry that my child died.
14. A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity a nurse should engage in to assist in disaster preparedness?
Participate in community drills and mock events.
Vaccinate susceptible children and adults against smallpox
Assess types, levels and scopes of disasters.
Make quarantine preparations for those exposed to anthrax
Rationale: Assess First
15. A nurse is caring for a client who is experiencing acute mania. Which of the following
foods should the nurse provide for this client?
Peanut butter sandwich
Oatmeal with butter
Chicken noodle soup
Celery sticks
16. A nurse is admitting a client who has dementia to a long-term care facility. The client tells
the nurse that she lived in this facility years ago and took care of all the residents byherself. The nurse should document this as which of the following findings?
Agnosia
Projection
Perseveration
Confabulation
17. A nurse is providing dietary teaching to a client who had an exacerbation of COPD. which of
the following information should the nurse including in the teaching?
You should eat hot foods to reduce your sense of fulness during a meal.
While eating, you should drink liquids frequently.
Lunch should be your largest meal of the day
During meals, you should eat foods with a high-calorie content first
18. A nurse is caring for four clients on a medical-surgical unit For which of the following clients
should the nurse complete a medication conciciliation ?
A client who has a prescription for a gallbladder sonogram
A client who transfers from a private room Into a semi-private room
A client who received twice the prescribed dose of a medication
A client who returns to the unit from the PACU following surgery
19. A nurse is Initiating bladder retraining for a client who has urge urinary incontinence. Which
of the following instruction should the nurse…the client ?
Take your diuretic medication with your evening meal
Decrease your intake of cranberry juice
Pan to urinate every 3 hours while you are awake
Limit your fluid Intake to 500 milliters per day. "
20. A nurse realizes that the wrong medication has been administered to a client. Which of
the following actions should the nurse take first?
A. Notify the provider.
B. Report the incident to the nurse manager.
C. Measure the client vital signs.
D. Fill out an incident report.
21. A nurse is teaching a client who had a left below-the-knee amputation 3 days ago. The
nurse should identity that which of the following statement by the client Indicates an
understanding of the teaching?
I will change the wrapping on my left leg once a day at home
I Should avoid moving the joints in my left leg
I might still experience the feeling of numbness and brigling in my leftI can elevate my left leg on a pillow while lying in bed.
22. A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of
the Following clients should the nurse report to the nurse ?
A client who has a prescription for compression stockings and did not receive them
A client who consumes all the food from their meal tray
A client who requests assistance to use the bedside commode
A client who requests to sit in the bedside chair while watching TV
23. A nurse is preparing to obtain a client signature on an informed consent form. Which of the
following actions should the nurse…
Notify the provider if the client has questions about the procedure
Ask the client to explain his understanding of the procedure.
Inform the client of his right to change his mind
witness the client signing the informed consent form
24. A nurse is updating the plan of care for a client who has an exacerbation of psoriasis. Which
of the following intervention should the nurse include in the plan ?
Cover lesions with an occlusive dressing after applying a corticosteroid
Discontinue ultraviolet light therapy If lesions itchy
Scrub external lesions with a pumice stone
Instruct the client to add rubbing alcohol to bath water.
25. A nurse is caring for a client who received a large amount of heparin IV in error. Which of the
following laboratory should the nurse
aPTT
INR
Ferritin level
Albumin level
26. (OJO) A nurse in an emergency department is caring for a client following a motor vehicle
crash . The client Glasgow coma scale,, following findings should the nurse expects?
The client opens eyes to sound
The client withdraws from pain.
The client Is oriented times three
The client is unable to obey commands27. A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result
of the client’s biopsy report while on the elevator. Which of the following actions
should the nurse take?
Report the information to the charge nurse
review confidentiality policies with laboratory employees- would be the job of the
Facility manager or someone who audits or teaches HIPAA stuff
contact the laboratory manager regarding the situation - you are not high enough up the
chain to do that
Notify the facilities legal department - no need to go that far
28. (OJO)A nurse is assessing a client who has a prescription for hydrocodone PRN . Which of
the following adverse effects should the nurse identify priority for withholding this
medication and notifying the provider ?
Constipation
Hypotension
Urinary retention
Nausea
29. A nurse is performing initial assessment of a newborn. Which of the following actions should
the nurse take to prevent any heat lost thro.. production?
Place the newborns crib away from of on air went to perform the assessment
Evaluate respirations by observing the newborn's uncovered chest for 1 min
Perform the assessment inmediately after bith before removing amniotic fluid
Cover the scale with a warmed blanket before weighing the baby.
30. A nurse is completing an incident report after a client fall. Which of the
following competencies of Quality and Safety Education for Nurse is the use
demonstrating?
A. Quality improvement.
B. Patient centered care
C. Evidence based practice.D. Informatics
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