1. A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission-based precautions should the nurse initiate?
• Airborne
• Rationale: Pulmonary tuberculosis is an infection that is t
...
1. A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission-based precautions should the nurse initiate?
• Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted by airborne droplets smaller than 5 microns in diameter. Therefore, this client requires airborne precautions to prevent communicating this infection to others
2. A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or older may be in a restraint for no more than 4 hr. Children who are 9 to 17 years old are limited to 2 hr and children who are younger than 9 years old are limited to 1 hr
3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following statements should the nurse make?
• Exercise in the morning after arising
• Rationale: Daily exercise has many benefits, including enhancing cardiovascular, psychological, and musculoskeletal health. The nurse should recommend that the client avoid exercising within 2 hr of bedtime to limit stimulation and enhance sleep
4. A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask?
• Remove the mask by securely holding the ties and moving it away from the face
• Rationale: The nurse should untie the bottom strings and then the top strings. Finally, while still holding the strings, the nurse should remove the mask from her face. This action prevents the nurse from touching the front of the mask, which is contaminated
5. A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to the parent?
• Inform the parent that anger is a natural response when dealing with loss
• Rationale: The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings
6. A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify that which of the following ethnic groups in the community is at greatest risk of developing hypertension?
• African Americans
• Rationale: Evidence-based practice indicates that individuals of African-American ethnicity have the highest prevalence of hypertension. Therefore, the nurse should identify community members of this ethnicity are at greatest risk of developing hypertension.
7. A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. Which of the following actions should the nurse plan to take first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a Healthy People 2020 initiative. Using the nursing process, the first action the nurse should take is to assess the needs of the community. By identifying disparities in community health, the nurse can develop interventions targeted at the community's specific needs.
8. A nurse is reviewing a client's new prescriptions that were just documented in the client's medical record by the provider. Which of the following abbreviations should the nurse clarify with the provider?
• Enoxaparin 40 mg SQ QD
• Rationale: The nurse should clarify this prescription with the provider. The abbreviations "SQ" and "QD" are considered error-prone and should not be used in documentation. The nurse should clarify that the provider intends the prescription to be administered subcutaneously once daily. "Subcutaneous" or "subcut" should be used instead of "SQ" and "daily" should be used instead of "QD."
9. A nurse is talking with a client who has major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following responses should the nurse take?
• It sounds as though you’re feeling hopeless
• Rationale: This statement by the nurse is an example of restating, which is a therapeutic response. This technique restates the main idea the client has expressed and allows the client to clarify any misunderstanding.
10. A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission National Patient Safety Goals regarding blood administration, which of the following actions should the nurse plan to take?
• Verify the client and blood component using a two-person process
• Rationale: The Joint Commission National Patient Safety Goals regarding blood transfusions includes improving the accuracy of client identification. The nurse should eliminate transfusion errors related to client misidentification by using a two-person verification process to identify the client and the blood component.
11. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflex urinary incontinence?
• A client who has a T12 spinal cord injury
• Rationale: The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of developing reflex urinary incontinence. With this type of incontinence, the client is unaware that the bladder is full and therefore lacks the urge to void, resulting in the involuntary loss of urine. The nurse should monitor for this form of incontinence and implement interventions such as intermittent catheterization.
12. A nurse is documenting an assessment in a client's electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take?
• Request that the AP use another computer to enter the data
• Rationale: The nurse should request that the AP to go to another computer that is not in use to enter the morning blood glucose from the client. This is time- sensitive data that needs to be entered in the computer as soon as possible.
13. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
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