Reference no: EM132814248

Question 1: A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take?

• Remove the restraints every 4 hr.
• Apply the restraints to allow as little movement as possible.
• Attach the restraints securely to the side rails of the client's bed.
• Allow room for two ?ingers to fit between the client's skin and the restraints.

Question 2: A nurse is documenting in a client's medical record. Which of the following entries should the nurse record?

• "Drank adequate amounts of fluid with meals."
• "Administered pain medication."
• "incision without redness or drainage."
• "Oral temperature slightly elevated at 0800."

Question 3: A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

• "Delirium has an abrupt onset."
• "Delirium has a slow progression."
• "Delirium does not affect a client's perception of her environment."
• "Delirium does not affect a client's sleep cycle.

Question 4: A nurse is teaching a client who has diabetes mellitus about mixing regular insulin and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?

• "I should draw up the NPH insulin before the regular insulin."
• "I should wait 3 minutes alter mixing the insulin to inject it."
• "I should roll the vial of NPH insulin between my hands before drawing it up."
• "I should inject air into the vial of regular insulin first."

Question 5 A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• "I will tell the client's visitors to wear a mask when they are within 3 feet of the client."
• "I will wear an N95 respirator mask when caring for the client."
• "I will place the client in a private room."
• "I will remove my gown before my gloves after providing client care."

Question 6: A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

• Allow the client to select the temperature of the bath water.
• Complete the bath even if the client is in distress. Give detailed instructions for the client to follow.
• Use distractions when bathing the client.

Question 7: A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take?

• Have the client apply a mask when children are visiting.
• Place the client in a seriprivate room.
• Use sterile gloves to provide perineal care.
• Cleanse hands with an alcohol-based hand rub before client contact.

Question 8: A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy?

• The cephalic vein in the left distal forearm
• The cephalic veing on the back of the right hand
• The radial vein on the left wrist
• The basilic vein in the right antecubital fossa

Question 9: 63 A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team?

• Primary care provider
• Social worker
• Occupational therapist
• Registered dietician

Question: 10: A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

• Describe the surgery to the client.
• Notify the provider
• Provide brochures about the procedure.

Question 11: Complete an incident report.27A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate?
A. Droplet
B. Airbornes
C. C. Protective environment
D. D. Contact

Question 12: A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements?
A. "I use garlic for my menopausal symptoms"
B. "I take echinacea to control my cholesterol."
C. "I use ginger when I get car sick."
D. "I take ginkgo biloba for a headache."

Question 13: A nurse on a medical- surgical unit is providing care for four clients.
The nurse should identify which of the following situations as an ethical dilemma?

a. A client who has Crohn's disease report that this prescription drug plan will not pay for his medication
b. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she doesn't like him
c. A surgeon who removed the wrong kidney during surgical procedure refuses to take responsibility for her actions
d. The family of a client who has terminal illness asks that the provider not tell the client the diagnosis

Question 14: A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take?
A) Allow room for two fingers to fit between the client's skin and the restraints
B) attach the restrain securely to the side rails of the client's bed
C) apply the restraint to allow as little movements as possible
D) remove the restraints

Question 15: a nurse is caring for a client who was recently diagnosed with a terminal illness. The clients the nurse I am looking forwards to grandchildren grow up and the nurse should identify that the client is experience which of the following stage of grief.
A) denial
B) bargaining
C) anger
D) acceptance

Question 16: A nurse is teaching a client about home care of oxygen equipment.
Which of following information should the nurse include in the teaching? (Select all that apply)

a. Align the middle of the ball in the flow meter with the line of the prescribed flow rate
b. Lay the oxygen tank flat when storing
c. Keep the oxygen delivery system 0.6 m (2 feet) from any heat source
d. Check the oxygen delivery rate at least once per day
e. Avoid using wool blankets when receiving oxygen

Question 17: A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis which of the following actions should the nurse take
a.Cover the area of percussion with a towel
b.perform percussion over the lower back
c.schedule postural drainage after meal
d.instruct the client to exhale quickly during vibration

Question 18: to ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
A. Case manager
B. Client care provider
C. Client advocate
D. Client educator

Question 19: a nurse is planning care for a client who reports having a latex allergy.
which of the following interventions should then nurse include in the plan?
a. apply adhesive tape when securing an IV insertion site
b. use plastics syringes for medication administration.
c. wear powdered glove when providing care to the client
d. cover the blood pressure cuff with a stockinette
Question 20: A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
A) I should make circular motions with my fingertips under my arms.
B) I should use the palm of my hand to apply pressure to each breast
C) I should perform my self exam the week that period starts.
D) I should make different patterns on each breast when I do self-exam

Question 21: A nurse is obtaining informed consent from a client who is schedule for surgery. the client states "I don't want to go through with the procedure" which of the following action should the Nurse take?
A. Discuss Alternative Treatment with the Client
B. Express Approval of the Client decision to not have the procedure
C. Document the client decision in the medical record
D. Explain to the Client the risk Involved with not having the procedure
A nurse is assessment the body temperature of an adult clients using a temporal artery thermometer which of the

Question 22: A nurse is assessing the body temperature of an adult client using
a temporal artery thermometer. Which of the following actions should the nurse take? (Select all that apply).
A. Slide the probe across the client's forehead
B. Document the client's temperature with "AX" next to the value
C. Hold the client's hair aside while performing the procedure
D. Move the probe in a circular motion to obtain the reading
E. Pull the client's pinna up and back

Question 23: A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify that which of the following medication can interact adversely with this Supplement?
A: levothyroxine
B: Atorvastatin
C: Warfarin
D: Albuterol
a nurse is performing a skin assessment on an older adult

Question 24: client. which of the following finding should the nurse expect?
a. increased production of oils
b. thickened outer layer
c. reduced sweat production
d. increased skin elasticity

Question 25: A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?
a. rinse the client's mouth with alcohol-based mouthwash
b. apply mineral oil in the client's lips
c. brush the client's teeth daily
d. place the clients in a side lying position.