Reference no: EM132814143

Question 1. A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. which of the following responses should the nurse make?
a. it must be very difficult for you to receive this kind of news
b. i would get a second opinion if i were you
c. i think you would benefit from speaking with our chaplain
d. it might seem bad now, but things will get better

Question 2) A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should Identify that which of the following situations is an example of negligence?

A)An assistive personnel discusses client care in the cafeteria with visitors present.

B)A nurse administers medication without first identifying the client

C) An assistive personal prevents a client from leaving the facility

D) A nurse begins a blood transfusion without obtaining consent from a client

Question 3) 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 4) A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids which one of the following should the nurse offer the client as apart of full liquid diet?
A) applesauce
B) scrambled egg
C) plain yogurt
D) oatmeal

Question 5) A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child.Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?
A) I really don't know what I am supposed to do all day
B) 'it's nice having other people cook for me'
c) I am looking forward to being able to be independent again
D) I have never been the kind of person to ask other for help

Question 6)A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
A. I will remove my antiembolic stockings while I am in bed.
B. I will have my partner help me change positions every 4 hours.
C. I will perform ankle and knee exercises every hour.
D. I will hold my breath when rising from a sitting position.

Question 7) A nurse is assessing an older adult client. Which of the following finding should the nurse expect?
a) a nighttime urinary incontinence
b) decreased sense of balance
c) increased nighttime sleeping
d) heightened sense of pain

Question 8)a nurse is admitting a client who is at risk for falls to a medical- surgical unit. which of the following actions should the nurse take?

A) Elevate full- length side rails on both sides of the client's bed
B) Provide the client with a night light????
C) Place the bedside table 0.9m (3feet) away from the bed
d) Keep the client's room temperature at 19 c (64.4 )

Question 9) A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)
a. "Place a piece of gauze over the stoma while changing the pouch"
b. "Empty the ostomy pouch when it becomes one-third full of contents"
c. " Expect the stoma to turn a purple-blue color as it heals"
d. "Cut the opening of the pouch 1/8 of an inch larger than the stoma."
e. " Use povidone-iodine to clean around the stoma"

Question 10) A nurse is preparing to obtain a health history from a client which of the following action should the nurse take?
a) explain to the client the necessity of full disclosure of information
b) avoid document direct quotes from the client as a part of subjective data
c) use the client first name when initially meeting the client.
D) tell the client the purpose the collecting the information

Question 11) A nurse is preparing to obtain a health history from a client which of the following action should the nurse take?
A) Wearing clean gloves while cleaning the inner cannula
b) cut a 4 inch (10cm X 10cm) gauze pad to place under the flanges of the tracheostomy tube
c) secure the tracheostomy in place with a collar that has hook and loop faster
d) clean the skin around the stomy with full strength hydrogen peroxide

Question 12)a nurse is admitting client who is malnourished. The client states "my wedding ring is loose, and I'm worried I will lose it if it falls off" which of the following is an appropriate response by the nurse?
A) I can pin it to your hospital gown, so you won'tlose it
B) I will place it in your drawer, so it won't get lost
C) I will hold onto it unity a family member can take it home
D) I can put it a locker storage until for you

Question 13a nurse is caring for client who has pneumonia the nurse should recognize that which of the following should be discarded in a biohazard bag?
A) An emesis basin filled with blood from sever coughing
B) Bedpan containing diarrhea from a client who was receiving antibiotic
C) A calibrated toilet insert filled with urine
D) A disposable tissue containing expecting spectrum

Question 14) A nurse is planning discharge for a client who had a stroke and has difficulty holding utensils at mealtime. Which of the following referrals should the nurse anticipate?
a. Respiratory therapy
b. Dietary services
c. Occupational therapy
d. Pharmacy services

Question 15A nurse is assessing a client who receiving morphine for severe pain 30 min ago. which of following finding is the nurse priority?
a) Report pain of 8 on a scale from 0-10
b) Distended bladder
c) Respiration rate 7/min
d) Last bowel movement was 3 days ago

Question 16a nurse is caring for a client who scheduled for surgery. while the nurse is wetness the client signature. the client sate i trust the doctor but i did not understand what is meant by resecting my intestines which one of the following actions should the nurse take?
A) describe the surgery to the client
B) provide brochures about the procedure
C) notify the provider
D) complete an incident report

Question 17a nurse is documenting client which of the following abbreviation should the nurse use?

A) OJ for orange juice
B) Ss for sliding
C) BRB for bathroom privileges
D) SQ for subcutaneous

Question 18 nurse is preparing to administer several medication to a client which one of the following data should the nurse plan to use for the client identity ?
a) The client room number
b) The name of the client next kin
c) The client admitting diagnosis
d) The client telephone number

Question 19A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take?
A) hyperoxygenation the client manually for 30 to 60 seconds before suctioning
B) suction the client's airway for 20 seconds with each pass
C) decrease suction pressure to 150 mm hg if the oxygen saturation level drop during suctioning
D) apply intermittent suction during catheter insertion

Question 20A nurse manager overhears a nurse telling a client, "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?
a. defamation
b. Assault
c. Battery
d. Invasion of privacy

Question 21A nurse is caring for a client who has colostomy. Which of the following actions should the nurse take
A) Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma
B) Rub the peristomal skin dry after cleaning
C) Change the pouch once every 24 hr
D) Apply the pouch while the skin barrier is still damp

Question 22A nurse is providing teaching to a clientabout the need to increase iron in their diet. Which of the following food choices should the nurse include as the best source of iron?

A) 85 h (3 oz) canned tuna
B) 32 g (1/4 cup) lentils
C) 1 slice white bread
D) 1 medium eggs

Question 23a nurse administers an incorrect medication to a client and identifies the error. Which of the following actions should the nurse take first?
a. Report the error to the client's provider
b. Examine the client
c. Document the medication that was administered
d. Prepare an incident report

Question 24)A nurse is creating a plan of care for a client who has left sided hemiplegia Which of the following interventions should the nurse include?
A) instruct the ptremove forward to the left side when ambulating to avoid falls.
B) rest the client left arm over their chest.
C) apply an orthotic boot on the client left foot.
D) Place a thick pillow behind the client head to increase cervical flextion

Question 25a nurse is testing a client for conduction deafness by performing the weber test which one of the following should the nurse take when performing this test
A) Move a vibrating tuning fork in front of the client ear canal one after the other
B) Place the base of a vibrating tuning fork on the client mastoid process
C) Place the base of a vibrating tuning fork on the top of the client's head
D) Count how many second a client can hear a tuning fork after it has been struck.

Question 26 a nurse is receiving telephone prescription from a provider for a client who is experiencing pain which one of the following response should the nurse make?
A) "Late me clarify that you want the medication given qid. Correct? "
B) "I will sign my name now and leave a space for you to sign you name"
C) "Let me provide you with the client medical record number for identification "
D) "Will you please spell the name of the medication for me?"