- A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized their concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system?
A. Identify nurses who accept the change to help influence other staff nurses
B. Provide a brief overview of the new scheduling system immediately before
it implementation
C. Introduce the new scheduling system by describing how it will save the institution money
D. Offer to reassign staff who do not support the change to another unit
B. Provide a brief overview of the new scheduling system immediately before
it implementation OR A. Identify nurses who accept the change to help influence other staff nurses
- A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway?
A. Antibiotic therapy was initiated 2hr after implementation of the care pathway
B. A blood culture was obtained after antibiotic therapy has been initiated
C. The route of antibiotic therapy on the care pathway was changed from IV to PO
D. An allergy to penicillin required an alternative antibiotic to be prescribed
A. Antibiotic therapy was initiated 2hr after implementation of the care pathway
- A nurse should recognize that an incident report is required when
A. A client refuses to attend physical therapy
B. A visitor pinches his finger in the client‟s bed frame
C. A client throws a box of tissues at a nurse
D. A nurse gives a med 30 min late
A. A client refuses to attend physical therapy
- Client satisfactory surveys from a med-surg unit indicate the pain is not being adequately relieved during the first 12 hr post-opt. The unit manager decides to identify post-opt pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery?
A. Prospective chart audit
B. Retrospective chart audit
C. Post-operative care policy
D. Pain assessment policy
D. Pain assessment policy - A nurse precepting a newly licenced nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask?
A. “Did you secure the restraints to the side rails of the bed?”
B. “Are you able to insert two fingers between the restraint and the client’s skin?”
C. “Did you tie the restraints using double knot?”
D. “Are you removing the client‟s restraints every 4 hr?”
B. “Are you able to insert two fingers between the restraint and the client’s skin?”
- A nurse is caring for an older adult client who has stage III pressure ulcer. The nurse request a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant?
A. Arrange the consultation for time when the nurse is caring for the client is able to be present for consultation
B. Provide the consultant with subjective opinions and beliefs about the client’s wound care.
C. Request the consultation after several wound care treatment tried
D. Arrange for the wound care nurse specialist to see the client daily to provide
the recommended treatment
A. Arrange the consultation for time when the nurse is caring for the client is able to be present for consultation
- A client is admitted with TB and placed in a negative pressure room. Which of the following actions is appropriate?
A. Notify the local health department of the admission
B. Place a sign on the client’s door with the diagnosis
C. Ensure that admitting staff undergo PPD skin tests
D. Determine who had contact with the client in the last 48 hr
D. Determine who had contact with the client in the last 48 hr
(maybe wrong)
POSSIBLY: A. Notify the local health department of the admission
- A nurse is caring for a client who is unconscious and whose partner is healthcare proxy. The partner has spoken with the provider and wishes to discontinue the client‟s feeding tube. The provider states the nurse, “I will not discontinue the client‟s treatment. His partner has no right to make decisions regarding the client‟s care. “Which of the following responses by the nurse is appropriate?
A. You should consider speaking with the facility’s ethics committee before making your decision
B. You have the right to make a decision, even if the partner is the client‟s health care proxy
C. The client has designated his partner as a health care proxy in his advance
directives.
D. We‟ll need to have the nursing supervisor review the client‟s advance directives
C. The client has designated his partner as a health care proxy in his advance
directives.
- A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following info is most important for the nurse to report at shift change?
A. Glasglow Coma scale score
B. Most recent blood glucose reading C. Lab test scheduled for next shift
D. Reddened area on the coccyx
A. Glasglow Coma scale score
- A nurse is assigned the following four clients for the current shift. Which of the following should the nurse assess first?
A. A client who has a hip fracture and is in Buck‟s traction
B. A client who has aspiration pneumonia and a respiratory rate of 28/min
C. A client who has diabetes mellitus stage 2 pressure ulcer on his foot
D. A client who has a C diff infection and needs a stool specimen
collected
D. A client who has a C diff infection and needs a stool specimen
collected
- A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take?
A. Notify the nursing supervisor about the issues
B. Contact the client’s physical therapist
C. Apply a warm compress to the hip
D. Reposition the client for comfort
A. Notify the nursing supervisor about the issues
- The mother of a client with breast cancer states, it’s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments. Which of the following actions is appropriate for client advocacy?
A. The nurse investigates potential resources to help the client purchase wig
B. The nurse explains to the mother that most clients with cancer lose their hair
C. The nurse informs the next shift nurse regarding the mother‟s concerns.
D. The nurse suggests counseling for the client‟s body image issues
A. The nurse investigates potential resources to help the client purchase wig
- Which of the following items must be discarded in a biohazard waste receptacle?
A. A urinary catheter drainage bag from a client who is post-opt
B. A bed sheet from a client with bacterial pneumonia
C. A perineal pad from a client who is 24-hr post-vaginal delivery
D. An empty IV bag removed from a client who has HIV
D. An empty IV bag removed from a client who has HIV
- A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don‟tget
better, I‟m going to quit. “Which of the following responses appropriate?
A. “So you are upset about all the changes on the Unit”
B. “I think you have a right to be upset, I am tired of the changes too”
C. “Just stick with it a little longer. Things will get better soon
D. ” You should file complaints with hospital administrator
A. “So you are upset about all the changes on the Unit”
- According to the HIPAA regulations, which of the following is a violation of client confidentiality?
A. Telephone the pharmacy with a prescription for the spouse to pick up
B. Providing a copy of the record to the transporting paramedic
C. Reporting a client‟s disposition to the referring provider
D. Informing housekeeping staff that the client is in dialysis unit
D. Informing housekeeping staff that the client is in dialysis unit
- A Nurse preceptor is evaluating a newly licensed nurse‟s competency in assisting with a sterile procedure. Which of the following actions indicates the nurse is maintaining sterile technique? (Select all that apply.)
A. Open the sterile pack by first unfolding the flap farthest from her body
B. Rests the cap of a solution container upside down on the sterile field
C. Removes the outside packaging of a sterile instrument before dropping into the sterile
field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within 1.25 cm (0.5 inch) border around the edge of the sterile field
A. Open the sterile pack by first unfolding the flap farthest from her body
C. Removes the outside packaging of a sterile instrument before dropping into the sterile
field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within 1.25 cm NOTE: OTHER SOURCES LIST ONLY A & C as the correct answers.
- A nurse is providing care for 4 post-opt clients. The nurse should first assess the client
A. Whose pulse has been steadily increasing during the past shift
B. Who is reporting a pain level of 8 on a scale of 0 to 10.
C. Whose urine output averaged 32 ml/hr for the past 24 hr
D. Who is reporting nausea after the prescribed antiemetic was administered
B. Who is reporting a pain level of 8 on a scale of 0 to 10. - A nurse is preparing to transcribe a client‟s med prescription in the medical record. Which of the following should the nurse recognize as containing the essential components of a medication order?
A. NPH insulin 10 Units before and at bedtime
B. Haloperidol (Hadol) 1mg per mouth
C. Multivit every morning by mouth
D. Aspirin 650 mg by mouth every 4hr
D. Aspirin 650 mg by mouth every 4hr
- A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?
A. Recommend that he takes time to plan at the beginning of shift
B. Advise him to complete less time-consuming tasks first
C. Ask other staff members to take over some of his staffs
D. Offer to provide care for his clients while he takes a break
A. Recommend that he takes time to plan at the beginning of shift
- 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. Irrigate the exposed area with water C. Report the incident to OSHA
D. Don personal protective equipment
B. Irrigate the exposed area with water
- A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
A. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
B. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min
C. A nurse explains to a client’s family that a DNR order includes withholding comfort measures
D. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better
C. A nurse explains to a client’s family that a DNR order includes withholding comfort measures
- A nurse is an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of tele health?
A. Assessing client needs
B. Providing med reconciliation
C. Establishing communication between providers
D. Developing client treatment protocols
- Which of the following put a hospital at the highest risk of infringement of client record confidentiality?
A. A nurse clusters documentation of care for multiple clients?
B. A provider and nurse access client info using one access code
C. Paper-based charts are stored at the nurse’s station
D. A nurse performs electronic documentation outside a client‟s room
C. Paper-based charts are stored at the nurse’s station
- Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques?
A. A nurse cleans up blood spill with a 1:10 bleach solution
B. A nurse uses googles to perform tracheostomy suctioning
C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen
D. A nurse places a mask on a client with TB before transport to the radiology department
- Which of the following should lead a nurse to suspect abuse that must be reported?
A. A school-age child has several bruises on her lower legs.
B. A toddler cries whenever his parents enters the hospitals room.
C. An Adolescent admitted to the emergency won‟t speak to his parents
D. A preschool child who was previously toilet trained now requires diapers in the hospital
B. A toddler cries whenever his parents enters the hospitals room. - A parish nurse is making referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parish nurse?
A. Liaison
B. Pastoral care provider
C. Health educator
D. Personal Health counselor
POSSIBLE ANSWER
A. Liaison
- A nurse performing triage during a mass casualty incident should recognize that which of the following clients should be transported to the hospital first?
A. A client who reports substernal chest pain radiating to the neck ?????
B. A client who has an open fracture of the femur
C. A client who has a 4-inch laceration on the forearm
D. A client who has a penetrating head injury and fixed dilated pupils
A. A client who reports substernal chest pain radiating to the neck ?????
- A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first?
A. Provide a staff in-service about client confidentiality
B. Report the incident to the nursing supervisor
C. Remind them that the client info is confidential
D. Fill out an incident report regarding the situation
C. Remind them that the client info is confidential
- A client has a substance use disorder is admitted to the mental health Unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states: “It‟s Ok. Soon everything will be just fine.” Which of the following is the nurse‟s primary first action?
A. Ask the client if he has considered hurting himself
B. Provide the client with info about Alcoholics Anonymous
C. Encourage the client to participate in physical activities
D. Reinforce the need to follow up with the discharge referral
A. Ask the client if he has considered hurting himself
- A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administer the injection. This illustrate which of the following?
A. False imprisonment
B. Battery
C. Assault
D. Libel
B. Battery
- A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager take first?
A. Report the situation to the director of nursing
B. Have a blood alcohol level drawn from the nurse C. Document a factual description of the situation
D. Remove the nurse from the unit
D. Remove the nurse from the unit
- A nurse observes a paper bag at the bedside of a client. This finding suggest that the client is receiving treatment for which of the respiratory disorders
A. Asthma
B. Hyperventilation
C. Stidor
D. Atelectasis
C. Hyperventilation
- A nurse is preparing the discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report?
A. Lab results within the expected reference range
B. List of regularly prescribed meds
C. Date of last bowel movement
D. Level of consciousness
D. Level of consciousness
- A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management?
A. Review the client‟s new lab values
B. Document assessment data
C. Complete required tasks
D. Determine client care goals
D. Determine client care goals
- A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed indicates understanding of isolation guidelines?
A. I will instruct visitors to wear a mask when visiting a client who is on contact precaution
B. I will place a client who has compromised immunity in a negative-pressure airflow room
C. I will wear N-95 respirator mask when caring for a client who is on droplet precaution
D. I will have a client who is on airborne precautions wear a mask when out of her
D. I will have a client who is on airborne precautions wear a mask when out of her
- A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse?
A. Changing the dressing on a postoperative wound
B. Referring a client to social services for assistance with transportation
C. Instructing a client who is obese about a low-fat diet
D. Providing the first oral feeding to a client following a stroke
A. Changing the dressing on a postoperative wound
- A case manager working in a rehabilitation unit is discharging to home a client who has a spinal cord injury level C-7. Which of the following is the priority action creating the discharge plan?
A. Select strategies for cost-effective home care
B. Identify the client‟s ability to perform activities of daily living
C.Provide educational handouts related to care requirements.
D.Recommend community resources available to assist with client care.
B. Identify the client’s ability to perform activities of daily living
- A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse plan to assess first?
A. A client who has a nasogastric tube to intermittent suction and reports nausea
B. A client who has an early morning blood glucose of 220 mg/dl
C. A client who had a bladder scan that indicated 250 ml of urine in the bladder
D. A client who is 3 days post-opt & whose dressing has serosanguinous drainage
D. A client who is 3 days post-opt & whose dressing has serosanguinous drainage
- A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse?
A. Plan break times for assistive personnel
B. Pick up the meal trays after lunch.
C. Administer a nasogastric tube feeding.
D. Determine adequacy of ventilator settings
C. Adminisnister a NG tube feeding
- An RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires
A. Recording of daily intake and output
B. Assistance with meals
C. A complete bed bath
D. Frequent dressing changes
D. Frequent dressing changes
- A nurse is caring for 4 clients. Which of the following tasks can be delegated to an assistive personnel?
A. Assessing a client who just returned from hemodialysis
B. Reviewing dietary instructions for a client with kidney stones
C. Obtaining a stool sample from a client with renal failure
D. Monitoring a client with a fluid restriction
C. Obtaining a stool sample from a client with renal failure - A charge nurse is making rounds and observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
A. Inform the unit manager of the incident
B. Remove the restraints from the client’s wrists
C. Speak with the AP about the incident
D. Review the chart for non-restraint alternatives for agitation.
B. Remove the restraints from the client’s wrists
- A client is brought to the emergency department (ED) following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse?
A. Document the client‟s refusal in the chart
B. Tell the client that a catheter will be inserted
C. Obtain a provider‟s prescription for a blood alcohol level.
D. Assess the client for urinary retention.
A. Document the client‟s refusal in the chart
- Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan?
A. Use clean gloves rather than sterile gloves for colostomy care.
B. Wait to dispose of sharps containers until they are completely full.
C. Return unused supplies from the bedside to the unit‟s supply stock.
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
A. Use clean gloves rather than sterile gloves for colostomy care.
- An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel?
A. Turning the client
B. Recording the client’s vital signs
C. Determining the client’s pain level
D. Checking the pulses of the client’s right foot.
B. Recording the client’s vital signs
- To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies in the nurse manager using?
A. Compromising
B. Collaborating
C. Cooperating
D. Competing
D. Competing
- A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a med-surg unit?
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
B. A primigravida client who is 1 day post-opt following a cesarean section and has a PCA
pump
C. A multigravida client who has preemclampsia and is receiving mistoprostol (Cytotec) for
induction of labor.
D. A client who is at 32 weeks of gestation and has premature rupture of membranes
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
- A nurse working on a med-surg unit is managing the care of 4 clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
A. A client who is at risk for pressure ulcers and has an albumin of 4.2 g/dl
B. A client who has type 1 DM and uses insulin pump
C. A client who has orthostatic hypotension and is receiving IV fluids.
D. A client who is receiving heparin and has an aPTT of 34 seconds
D. A client who is receiving heparin and has an aPTT of 34 seconds
- A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries. Which of the following statements by a nurse indicates an appropriate understanding of these safety procedures?
A. Prophylactic treatment should be initiated after a needlestick during preparation of an injection
B. I should stop the bleeding as soon as possible following a needlestick injury
C. An incident report should be completed if a client receives a stick from her own
used needle
D. The needle should be recapped to prevent injury during transport to the biohazard container.
A. Prophylactic treatment should be initiated after a needlestick during preparation of an injection
- A nurse on a medical surg Unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
A. Obtaining a urine specimen from an older adult client
B. Providing postmortem care for a client who has just died
C. Accompanying a client who just had a wound debridement to physical therapy
D. Reinforcing dietary teaching with a client who has heart disease
C. Accompanying a client who just had a wound debridement to physical therapy
- A nurse enters the room of a client who is unconscious and finds that the client‟s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first?
A. Recommend the son meet with the provider to get info about his mother‟s condition
B. Complete an incident report regarding the breach of the client’s confidentiality
C. Log out of the computer so that the client‟s son is unable to view his mother’s info
D. Report the possible violation of client confidentiality to the nurse manager
C. Log out of the computer so that the client’s son is unable to view his mother‟s info
- A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene?
A. The oxygen machine has a grounded plug
B. Accompanying a client who just had a wound debridement to physical
therapy
C. The family keeps a spare oxygen tank in the room
The window of the client’s room are open
D. The client is covered with a woolen blanket
D. The client is covered with a woolen blanket
- A nurse is teaching a client how to use a finger stick glucometer at home. Which of the following instruction should the nurse include?
A. Elevate the arm for 1 min before taking the blood sample
B. Cap the lancet prior to putting it in the trash
C. Obtainthebloodsamplefromthefingerpads.
D. Warm the hands prior to piercing the skin
D. Warm the hands prior to piercing the skin
- A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
A. Contact the client’s next of kin to obtain consent for treatment
B. Proceed with treatment without obtaining written consent
C. Have the client sign a consent for treatment.
D. Notify risk management before initiating treatment.
A. Contact the client’s next of kin to obtain consent for treatment
- A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include?
A. The client should avoid using the microwave oven to heat food
B. Regular programming evaluation can be conducted by telephones
C. The client should avoid using remote control devices to prevent dysrhythmias
D. Suctioning could cause the unit to have an electrical shock.
B. Regular programming evaluation can be conducted by telephones
- While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that 6 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 info on record to the nursing staff.
B. Ask the nurses who are caring for clients without this info 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 info during the admission process.
B. Ask the nurses who are caring for clients without this info in the medical record to obtain it.
- A client is admitted with COPD. Which of the following findings should the nurse report to the provider?
A. Oxygen saturation 89% on room air.
B. WBC’s count 9,000/mm
C. Report of dyspnea on exertion
D. Bilateral crackles on auscultation of lungs.
D. Bilateral crackles on auscultation of lungs
- A charge nurse notices 2 staff nurses are not taking meal breaks during 8-hr shifts. Which of the following actions should the nurse take first?
A. Provide coverage for the nurse’s breaks.
B. Determine the reasons the nurses are not taking scheduled breaks
C. Discuss the management strategies with the nurses.
D. Review facility policies for taking scheduled breaks.
B. Determine the reasons the nurses are not taking scheduled breaks
- A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (Select all that apply.)
A. Occupational therapist
B. Nutritional therapist
C. Physical therapist
D. Mental Health counselor
E. Case manager
B. Nutritional therapist
D. Mental Health counselor
E. Case manager
- A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective?
A. Guardian consent is required for an emancipated minor
B. Consent can be given by a durable power of attorney.
C. A family member can answer any questions the client has about the procedure.
D. The nurse can answer any questions the client has about the procedure
A. Guardian consent is required for an emancipated minor
(POSSIBLY INCORRECT)
PERSONAL CHOICE:
B. Consent can be given by a durable power of attorney.
- A nurse on a medical-surg unit is caring for 4 clients. This nurse should recognize that which of the following clients is the highest priority?
A. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy.
B. A client who has peripheral vascular disease and has absent pedal pulse in right foot.
C. A client who is post-opt following a laminectomy 12 hr ago and is unable to void.
D. A client who has methicillin-resistant Staphylococcus Aureus (MRSA) and has an axillary temp of 38 degree C ( 101 F)
B. A client who has peripheral vascular disease and has absent pedal pulse in right foot.
- A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. It’s not too late to cancel the surgery if you want to
B. This won’t take long and it will be over before you know it.
C. Why did you make the decision to have this procedure
D. You shouldn’t be worried because the procedure is very safe
A. It’s not too late to cancel the surgery if you want to
- A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A. A client who has a raised red skin rash on his arms, neck, and face
B. A client who reports right-sided flank pain and is diaphoretic
C. A client who reports shortness of breath and left neck and shoulder pain
D. A client who has active bleeding from a puncture wound in the left groin
C. A client who reports shortness of breath and left neck and shoulder pain
- A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first in the quality improvement process?
A. Review current literature regarding client falls.
B. Implement a fall prevention plan
C. Notify staff of the increased fall rates
D. Identify clients who are at risk for falls
D. Identify clients who are at risk for falls
- A nurse is evaluating a newly licensed nurse who is administering a vitamin K (Aquamephytoin) injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (Select all that apply.)
A. Selects the dorsogluteal site to administer the injection
B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
D. Aspirate the syringe for blood return after needle insertion
E. Inserts the needle at a 45 degree angle.
B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
- A nurse enters a client’s room and observes a fire in a trash can. Identify, the sequence of actions the nurse should take. (Move all the actions into the box on the right, placing them in the selected order performance.)
- Remove the client from the area
- Activate the fire alarm system
- Confine the fire by closing doors and windows
- Extinguish the fire if possible
Hint: Remember RACE mnemonic
- Which of the following actions taken by a nurse constitutes battery?
A. Failing to put up side rails on a confused client’s bed
B. Telling a client who refused his oral medication that he will be given an injection
C. Inserting a feeding tube against the wishes of a client who refuses to eat
D. Threatening to apply wrist restraints to control a client who is agitated
C. Inserting a feeding tube against the wishes of a client who refuses to eat