1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicate wound healing?
a. Erythema on the skin surrounding a
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1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicate wound healing?
a. Erythema on the skin surrounding a client’s wound
b. Inflammation noted on the tissue edges of a client’s wound
c. Increase in serosanguinous exudate from a client’s wound
d. Deep red color on the center of a client’s wound
2. A nurse received change-of-shift report at 0700 for four clients. Which of the following actions should the nurse perform first?
a. Administer pain medication to a client who has rheumatoid arthritis and received the last dose at 0400
b. Obtain a breakfast tray for a client who received a morning dose of insulin aspart
c. Replace a client’s enteral nutrition feeding solution that has been hanging for 24 hr
d. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse?
a. A client who sustained a concussion and is being monitored for complications
b. A client who has a brain tumor and is admitted for chemotherapy
c. A client who has Gullain-Barre syndrome and a tracheostomy
d. A client who has multiple sclerosis and ataxia
4. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?
a. My durable power of attorney for health care is part of my advance directives
b. My doctor will need to provide approval for the decisions outlined in my living will
c. Once I sign my living will, a family member must co-sign it
d. I will wait until I have a serious health problem to sign my advance directives
5. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first?
a. Establish measurement criteria for infant safety systems
b. Evaluate the selected infant safety system
c. Choose an infant safety system
d. Identify the industry standards for infant safety
6. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client’s need for a referral to which of the following providers?
a. Respiratory therapist
b. Physical therapist
c. Occupational therapist
d. Speech therapist
7. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client’s risk for falls? (Select all that apply.)
a. A wheeled office chair at the client’s computer desk
b. A two-wheeled walker used to assist the client with ambulation
c. A throw rug covering some cracked vinyl flooring in the kitchen
d. A folding chair without arm rests
e. A raised vinyl seat on the toilet in the bathroom
8. A nurse manager is planning to assign care for four clients on a medical-surgical unit. Which of the following clients should the nurse assign to a licensed practical nurse?
a. An adolescent client who is newly diagnosed with diabetes and requires teaching regarding insulin administration
b. A middle adult client who had a below-the-knee amputation and requires a dressing change
c. An older adult client who has lung cancer and has periodic episodes of severe dyspnea
d. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus
9. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?
a. Reinforce the potential consequences of not having this information on record to the nursing staff
b. Ask nurses who are caring for clients without this information in the medical record to obtain it
c. Meet with nursing staff to review the policy regarding advance directives
d. Remind nurses to obtain this information during the admission process
10. A nurse is caring for a group of clients. Which of the following clients should the nurse see first?
a. A client who is postoperative and has a fever
b. A client whose pressure ulcer has serosanguinous drainage on the dressing
c. A client who has diabetes mellitus and is diaphoretic
d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0 to 10
11. A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first?
a. A client who has pneumonia and requires a tracheostomy dressing change
b. A client who has a new colostomy and requires discharge teaching
c. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
d. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg - check
12. A nurse manager discovers there is a conflict between nurses working the day shift and nurses working the night shift. Which of the following actions should the nurse manager take first?
a. Encourage the nurses to resolve the conflict autonomously
b. Meet with a committee of nurses from each shift to discuss issues related to the conflict
c. Gather information regarding the situation
d. Acknowledge the conflict and encourage the nurses to focus on working as a team
13. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first?
a. Remove the client’s clothing
b. Don personal protective equipment - check
c. Report the incident to OSHA
d. Irrigate the exposed area with water
14. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first?
a. Measure the client’s vital signs
b. Call the provider
c. Inform the nurse manager
d. Complete an incident report
15. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
a. Increased temperature
b. Generalized rash over trunk
c. Report of photophobia
d. Decreased level of consciousness
CONTINUED........... DOWNLOAD FOR BEST SCORES
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