1-A client has returned from a hip arthroplasty. Which intervention…

1-A client has returned from a hip arthroplasty. Which intervention should be included in the plan of care?

 Ensuring that the client cannot lie on the operative side

 Maintaining in a hip-abducted position

 Documenting pedal pulse checks every 3 hours

 Slight elevation to the foot of the bed to decrease patient siding

 

2-A client with burns to the upper extremities has been taught to increase protein and calories in the diet. Which selection indicates to the nurse that teaching has been successful?

 Milkshakes as a between-meal snack

 Black beans as a side dish with lunch

 Fruit juices with two meals

 Cheese sandwich as a mid-morning snack

 

3-A client with diarrhea has excoriation over the buttocks. The plan of care for this client should include which nursing measure?

 Sprinkling talcum powder on the affected area with each diaper change.

 Exposing affected area to air.

 Applying cool compresses to the affected area four times a day.

 Rubbing a lanolin-based lotion on the affected area twice a day.

 

4-The physician prescribes the following treatments for a client admitted with complications of hemophilia. Which treatment should the nurse question?

 Intramuscular opioids.

 Intravenous fresh frozen plasma.

 Topical ice application.

 Oral steroids.

 

5-A nurse is caring for a newborn who is being bottle-fed. Which finding indicates that the newborn is receiving sufficient nourishment?

 Cannot be stimulated to suck between feedings.

 Regurgitates a small amount after each feeding.

 Has a stool after each feeding.

 Sleeps for 2 to 4 hours between feedings.

 

6-A client has consumed the following foods: 1/2 pint of milk; 3 ounces of tea; 8 ounces of chicken broth; and 4 tablespoons of gelatin. How many milliliters should the nurse record as intake?

510

430

630

710

 

7-Which factor in a client’s health history would be a significant risk factor for developing a transient ischemic attack (TIA)?

The client is being treated with a 15-year history of high blood pressure.

 The client is a retired bank executive.

The client’s father died of a pulmonary embolism

The client is 20 lb. (9.1 kg) overweight.

 

8-What is the main purpose of the urinary drainage catheter for a client following the repair of a cystocele?

 To assess bleeding from the operative site.

 To determine adequate fluid replacement.

 To allow for accurate measurement of urinary output.

 To keep the bladder empty.

 

9-A client with symptoms of myocardial infarction is to receive morphine sulfate 8 mg intravenously every 4 hours as needed. Two hours after receiving the morphine, the client reports chest pain. What is the most appropriate action for the nurse to take?

 Administer half of the prescribed dose of morphine to the client.

Reposition the client and reassess pain in an hour.

Consult with the healthcare provider about the client’s report of pain.

 Assure the client that he can receive morphine again in two hours.

 

10-What is the best action by the nurse who believes a client has not been adequately informed about surgery?

Contact the surgeon and request the client be seen for clarification

Continue with the surgery plans as scheduled

 Contact the client’s family and encourage them to request a consultation with the surgeon.

 Provide more detailed information to the client regarding the surgery.

 

11-A Nurse has several clients who require diagnostic testing. Which task should the nurse assign to the unlicensed assistive personnel (UAP)?

 Setting up the EKG machine in a client’s room

Taking a routine urine specimen to the laboratory

 Helping to move a critically ill client to radiology for a chest X-ray

 Giving water to drink to a post-cardiac catheterization client

 

12-A 7-year-old child is admitted for an open reduction and internal fixation of a fractured femur. A nurse should place the child in which room?

 7-year-old being treated for bacterial pneumonia

 8-year-old with an acute viral infection

 7-year-old, two days post-op, with a ruptured appendix 

 8-year-old, newly diagnosed with type 1 diabetes mellitus

 

13-Palliative care is prescribed for a client with metastatic lung cancer who is receiving opiates for pain, drinks less than a pint of fluids daily, has a productive cough, and is constipated. Which goal is the priority?

 Establishing a bowel routine

 Maintaining pain control

 Initiating intravenous fluids for hydration

 Clearing secretions from the airway

 

14-A client with limited English proficiency is admitted for surgery. Which is the best action to obtain surgical consent?

Request that the consent form be translated into the client’s language

Notify the charge nurse of the potential risk

Call for an interpreter to be present during the surgeon’s explanation

 Have a family member be the interpreter

 

15-The nurse is admitting a client with vaso-occlusive crisis. Which task can be delegated to the unlicensed assistive personnel (UAP)?

Obtaining a urine specimen

 Insert an indwelling urinary catheter

 Instruct about signs and symptoms of infection

 Assessing a pain score with a FACES chart

 

16-Which client, should the nurse assess first?

 Placement of a new tracheostomy

 Bilateral amputee with a pain score of 7

 Post-op hysterectomy reporting feeling hot

Post-op open heart surgery with chest tubes present

 

17A nurse performs central line care according to hospital policy. The client has developed an infection and is considering legal action. Which is the legal implication for the nurse?

Tort

 Malpractice

 Standard of care

 Vicarious liability

 

18-A client is admitted to a medical-surgical unit and diagnosed with a varicella-zoster virus (shingles) infection. Which nurse should be assigned to care for this client?

 Nurse who has been vaccinated for varicella.

 Nurse with a previous history of having chicken pox

 Nurse who is six months pregnant

 Nurse who has had shingles before

 

19-A nurse is present in a client’s room when the physician explains a procedure to the client and leaves an order for the consent form to be signed. Which response indicates the role of client advocate?

 The physician has asked that you sign the forms for the procedure.

 Keep in mind that you may not cancel the procedure once the consent is signed.

 Do you have any questions at all about the procedure you are about to have?

 Can you explain to me what type of procedure you are going to have?

 

20-Which post-procedure client should the nurse assess first?

Tonsillectomy 4 hours ago, and continually spitting blood

O Thyroidectomy 8 hours ago and 2+ deep tendon reflexes

O Retinal detachment repair 4 hours ago, and insists on lying on the operative side

O Cardiac catheterization via the femoral artery and bending legs

 

21-The nurse would initiate immediate intervention if seeing which staff members behavior?

Telling another staff member that a newly admitted client has an interesting tattoo on the upper thigh

 Relating to the hospital chaplain that a client has been told about a terminal diagnosis

Informing a client’s spouse that the patient is currently undergoing a diagnostic procedure.

Saying to the social worker that a client’s spouse is threatening to sue the hospital for malpractice

 

22-The nurse fails to recognize the deterioration of a client’s vital signs after surgery. The client requires a return to surgery. Which is the legal implication of the nurse’s failure to act?

 Common law

 Misdemeanor

Tort

 Statuary law

 

23-A client with chronic respiratory insufficiency is discharged home with oxygen therapy. The home health nurse would identify which home assessment as an issue to discuss?

 Candles on the mantel of the fireplace

 Grounded outlet with green dot on the plate

 Bottle of wine on the kitchen counter

 Pack of cigarettes on the living room table

 

24-Which would be the priority of care for a client diagnosed with ascites and has increasing abdominal girth?

 Respiratory complications

 Alteration of body image

 Skin integrity

 Nutritional needs

 

25-Using Maslow’s hierarchy of needs to set priorities, the nurse would assess which client first?

 Older adult client who lives alone since spouse died

 Adolescent client who fights with parents

 Young adult who reports a cough, weight loss, and night sweats

 Middle-aged client who is going through a divorce

 

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