help 3

1. A client is brought to the emergency department 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 . Tell the client that a catheter will be inserted .

b . Document the client's refusal in the chart .

C. Assess the client for urinary retention .

d . Obtain a provider's prescription for a blood alcohol level .

b . Document the client's refusal in the chart

2 . A nurse is making shift assignments in a hospital . Which of the following tasks is appropriate to assign to a licensed practical nurse ?

a . Pick up the meal trays after lunch .

b . Administer a nasogastric tube feeding .

c . Plan break times for assistive personnel .

d . Determine adequacy of ventilator settings .

b . Administer a nasogastric tube feeding

states ) 3 . A nurse preceptor is evaluating a newly licensed nurse's competency in assisting with a sterile procedure . Which of the following actions indicates the newly licensed nurse is maintaining sterile technique ? ( SATA )

a . Places sterile items within a 1.25 cm ( 0.5 in ) border around the edges of the sterile field

b . Opens the sterile pack by first unfolding the top flap away from her body

C. Prepares a container of sterile solution on the field after putting on sterile gloves

d . Removes the outside packaging of a sterile instrument before dropping it onto the sterile field . Holds the sterile solution bottle with the label facing up

b . Opens the sterile pack by first unfolding the top flap away from her body

d . Removes the outside packaging of a sterile instrument before dropping it onto the sterile field the label

4. A nurse enters a client's room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly . Which of the following actions should the nurse take first ?

a . Auscultate the client's lungs .

b . Notify the provider .

C. Place a faulty equipment tag on the pump .

d . Complete an incident report .

a Auscultate the client's lungs .

5 . A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse ( LPN ) and an assistive personnel . Which of the following tasks should the nurse assign to the LPN ?

a . Reinforcing teaching with a client who is learning to self - administer insulin

b . Ambulating a client who is scheduled for discharge later in the day

C. Administering morphine IV bolus to a client who is hr postoperative

d . Admitting a new client who has chronic back pain to the unit

a . Reinforcing teaching with a client who is learning to self - administer insulin

6 . A nurse is supervising a newly licensed nurse who is performing surgical asepsis . After donning a sterile gown and gloves , which of the following actions by the newly licensed nurse demonstrates correct aseptic technique ?

a . The nurse applies goggles .

b . The nurse turns her back to the sterile field .

c . The nurse holds her hands above her waist .

d . The nurse puts on a face mask .

c . The nurse holds her hands above her waist .

7 . A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel ( AP ) . Which of the following actions should the nurse take to evaluate the delegated task ?

a . Review vital sign trends at the end of the shift .

b . Recheck vital signs that are outside the expected reference range .

C. Ask the AP to write a summary of the delegated tasks during the shift .

d . Compare the vital signs the AP obtained with those taken by another AP on a previous shift .

b . Recheck vital signs that are outside the expected reference range .

8 . A nurse is caring for four clients . Which of the following tasks can be delegated to an assistive personnel ?

a . Obtaining a stool sample from a client who has renal failure

b . Monitoring a client who has a fluid restriction

C. Assessing a client who just returned from hemodialysis

d . Reviewing dietary instructions for a client who has kidney stones

a . Obtaining a stool sample from a client who has renal failure

9. A nurse is triaging a group of clients following a disaster . Which of the following clients should the nurse recommend for treatment first ?

a . A client who has a neck injury and is unable to breathe spontaneously

b . A client who has two open chest wounds with a left tracheal deviation

C. A client who has major burns over 75 % of her body surface area

d . A client who has bipolar disorder and is exhibiting signs of hallucination ( Class 3 )

b . A client who has two open chest wounds with a left tracheal deviation

10. 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 " A family member can interpret to obtain informed consent from a client who is deaf . "

b . " Consent can be given by a durable power of attorney . "

C. " Guardian consent is required for an emancipated minor . "

d . " The nurse can answer any questions the client has about the procedure . "

b . " Consent can be given by a durable power of attorney

11 A nurse is caring for four clients . For which of the following clients should the nurse collaborate with the facility ethics committee ?

a . A middle adult client who leaves the facility against medical advice

b . An older adult client who has advanced directives on file

C. A young adult client who is participating in a medical research study

d . An adolescent client whose parents refuse a blood transfusion for religious reasons

d . An adolescent client whose parents refuse a blood transfusion for religious reasons

12. A nurse in an ambulatory care setting is orient 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 telehealth ?

a . Assessing client needs

b . Developing client treatment protocols

C. Providing medication reconciliation

d . Establishing communication between providers

d . Establishing communication between providers

13. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes . The client expresses concern about the cost of blood - glucose monitoring supplies . Which of the following actions should the nurse take ?

a . Refer the client to the social services department .

b . Provide the client with a week's worth of supplies from the hospital ( still needs help paying after )

C. Ask the provider about the possibility of less frequent monitoring ( pt needs to monitor often )

d . Recommend the client reuse the testing lancets ( breaks the safety & infection protocol )

a . Refer the client to the social services department

14. A charge nurse is receiving change - of - shift report . Which of the following situations should the charge nurse address first ?

a . A nurse on the previous shift wrote an incident report about a medication error .

b . Two staff members have called to say they will be absent .

c . Transport assistance is unavailable to take a client to occupational therapy .

d . The emergency department nurse is waiting to give report on a new admission .

d . The emergency department nurse is waiting to give report on a new admission

15. 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 . Complete required tasks .

b . Review the client's new laboratory values .

c . Determine client care goals

d . Document assessment data .

c . Determine client care goals ( set / plan goals )

16. A charge nurse is reviewing information about HIPAA with a group of staff nurses . Which of the following statements by a staff nurse indicates understanding ?

a . " Clients who participate in research studies forfeit their HIPAA right to privacy . "

b . " HIPAA allows facility - specific coding of client health care information to ensure privacy . "

c . " HIPAA prohibits the uploading of photographs of client's providers to social media sites . "

d . " HIPAA allows clients to request review of their own medical records . "

d . " HIPAA allows clients to request review of their own medical records . "

17. A nurse is caring for a client who has a tumor . The provider recommends surgery . The client refuses , but the client's partner wants the surgery performed . Which of the following is the deciding factor in determining if the surgery will be done ?

a . Whether the client understands the risk of refusing the procedure

b . Whether the facility ethics committee reached a consensus on the case

c . Whether the partner is the client's durable power of attorney for health care

d . Whether the client's refusal is based on religious belief

a . Whether the client understands the risk of refusing the procedure

18. A charge nurse is planning the care of four newborns . An assistive personnel and licensed practical nurse are available for staffing . Which of the following tasks should the nurse assign to a licensed practical nurse ?

a . Conduct the newborn hearing screening

b . Administer a hepatitis B vaccine .

C. Perform a New Ballard screening

d . Obtain vital signs . ( CNA )

b . Administer a hepatitis B vaccine

19. During a staff meeting a unit manager reviews the results for documenting client education and finds that they are below the benchmark . Which of the following strategies should the nurse manager implement first ?

a . Train LPNs to reinforce teaching with clients using a standardized teaching plan .

b . Determine factors that interfere with the documentation of client education

C. Include documentation of client education as part of unit nurses ' annual performance evaluation .

d . Offer incentives for the staff once the unit's results are back in adherence with the benchmark .

b . Determine factors that interfere with the documentation of client education

20. A nurse is explaining ethics and values to a newly licensed nurse . The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles ?

a . Utility

b . Autonomy

c . Nonmaleficence

d . Veracity

c Nonmaleficence

21. A nurse is caring for a group of clients . Which of the following clients should the nurse plan to assess first ?

a . A client who has congestive heart failure and has lost 0.9 kg ( 2 lb ) in the past 24 hr ( improvement )

b . A client who has diabetes mellitus and reports paresthesia in his fingers and toes )

c . A client who has a nasogastric tube and has crackles in the lungs )

d . A client who has a new diagnosis of Graves ' disease and a TSH level of 0.2 microunits / mL

c . A client who has a nasogastric tube and has crackles in the lungs

22. A charge nurse is planning to evacuate clients on the unit because there is a fire on another floor . Which of the following clients should the nurse evacuate first

a . A client who is in Buck's traction for a left hip fracture

b . A client who is 1 day postoperative following thoracic surgery and has a chest tube

c . A client who is confused and restrained for safety

d. A client who is receiving IV chemotherapy and is ambulatory

d A client who is receiving IV chemotherapy and is ambulatory

23. 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 information about his mother's condition .

b . Report the possible violation of client confidentiality to the nurse manager.

c . Complete an incident report regarding the breach of the client's confidentiality .

d . Log out the computer so that the client's son is unable to view his mother's . information .

d . Log out the computer so that the client's son is unable to view his mother's . information .

24. A nurse is preparing a client for cardiac catheterization . Just before the procedure , the client asks the nurse about the risks of the procedure . Which of the following actions should the nurse take ?

a . Explain the risks of the procedure to the client .

b . Convey the client's request to the nurse who witnessed the consent .

c . Check to see if the medial record indicates the provider explained the procedure to the client .

d . Notify the provider about the client's concerns .

d . Notify the provider about the client's concerns

25 . A nurse is prioritizing care after receiving change - of - shift report on four clients . Which of the following clients should the nurse assess first ?

a . A client who reports a headache with sensitivity to light

b . A client who reports an urge to void but has not urinated during the prior shift

c . A client who reports indigestion and pain in her jaw

d . A client who reports feeling lightheaded when he stands up from a lying position

c . A client who reports indigestion and pain in her jaw

26. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts . Which of the following actions should the nurse take first ?

a . Discuss time management strategies with the nurses .

b . Determine the reasons the nurses are not taking scheduled breaks .

C. Provide coverage for the nurses ' breaks .

d . Review facility policies for taking scheduled breaks .

. b . Determine the reasons the nurses are not taking scheduled breaks

27. A nurse s preparing to delegate bathing and turning of a newly admitted client who has end - stage bone cancer to an experienced assistive personnel ( AP ) . Which of the following assessments should the nurse make before delegating care ?

a . Has the AP checked the client's pain level prior to turning her ?

b. Is the client's family present so the AP can show them how to turn the client

C. Has data been collected about specific client needs related to turning ?

d . Does the AP have the time to change the client's central IV line dressing after turning her ?

C. Has data been collected about specific client needs related to turning ? ( Assessment of holistic care r / t pt needs and what the experienced AP can do )

28. A nurse is preparing to transfer a client from the emergency department to a medical surgical unit using the SBAR communication tool . Which of the following information should the nurse include in the background portion of the report ?

a . A prescribed consultation -under situation

b . The client's vital signs

C. The client's name -under situation

d . The client's code status -under situation

b . The client's vital signs

29. A nurse is planning discharge for a client who has rheumatoid arthritis . Which of the following statements by the client should the nurse identify as an indication that a referral to an occupation therapist is necessary ?

a . " I need some help planning my meals to maintain my weight . "

b . " I am tired of having pain in my joints all the time . "

C. " I'm having difficulty climbing the stairs at my house . "

d . " I will need assistance with bathing . "

d . " I will need assistance with bathing . "

30. A nurse in the emergency department is caring for a 16 - year - old client who reports abdominal pain and is accompanied by an adult neighbor . The provider diagnoses a ruptured appendix and states that the client requires an emergency appendectomy . Which of the following actions should the nurse ?

a . Ask the adult neighbor to sign the consent form .

b . Obtain consent from the hospital administrator .

C. Witness the client signing the consent form .

d . Attempt to notify the client's guardian to obtain consent .

d . Attempt to notify the client's guardian to obtain consent .

31. A nurse on a medical - surgical unit is caring for four clients . Which of the following findings is the highest priority ?

a . A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds - should be less than 2 or 3 seconds

b . A client who has COPD and has an oxygen saturation of 90 %

C. A client who had a cholecystectomy 6 hr ago and is requesting pain medication

d . A client whose TPN was discontinued 4 hr ago and is requesting clear liquids

a . A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds - should be less than 2 or 3 seconds - ABCS = GIVEN

32. A charge nurse suspects that a staff nurse is chemically impaired . Which of the following actions should the charge nurse take ?

a . Assign clients who are not prescribed narcotics to the staff nurse .

b . Collect data about the staff nurse to support further action .

c . Report the staff nurse to the facility ethics committee .

d . Counsel the staff nurse about substance use .

b . Collect data about the staff nurse to support further action

33. A nurse is assessing a client's comprehension of a pulmonary function test prior to the procedure . Which of the following client statements indicates to the nurse an understanding of the procedure ?

a . " I will be given contrast dye during this test . "

b . " I might have to wear a nose clip during this test . "

C. " I might have a tube inserted into my airway during the test . '

d . " I will run on a treadmill during this test . "

b . " I might have to wear a nose clip during this test .

34. A nurse in the emergency department is triaging four clients . Which of the following clients should the nurse recommend to be examined first ?

a . A toddler who has a 2 cm ( 0.79 in ) head laceration oozing dark red blood

b . An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10

c . An older adult client who has dyspnea and a respiratory rate of 26 / min ( ABC )

d . An adult client who has large ecchymoses on both legs

c . An older adult client who has dyspnea and a respiratory rate of 26 / min ( ABC )

35. A home health nurse finds piles of newspapers in the hallway of a Client home . The nurse explains the need to discard the newspapers for safety reasons . The client agrees to move the newspapers into the living room . Which of the following conflict resolution strategies has the nurse used ?

a . Collaborating

b . Smoothing

C. Accommodating

d . Compromising

a Collaborating

36. A nurse is planning to delegate client care assignments . Which of the following tasks should the nurse plan to delegate to an assistive personnel ?

a . Advising a client on self - administration of acetaminophen

b . Informing a family of a client's progress in physical therapy

c . Teaching a client to perform a finger - stick for testing blood glucose levels

d . Performing post mortem care prior to transferring the client to the morgue

d . Performing post mortem care prior to transferring the client to the morgue

37. A nurse is providing discharge teaching to a client following a total knee arthroplasty . Which of the following information should the nurse include ( SATA )

a . Advance directives information

b . Contact information for the physical therapist

c . Medication guidelines information

d . Insurance information

e . Information about follow - up care

b . Contact information for the physical therapist c . Medication guidelines information e . Information about follow - up care

38. A nurse is planning to discharge a client who has terminal cancer and suggests that the family might benefit from respite services . When the client's partner asks how this service can help , which of the following responses by the nurse is appropriate ?

a . " This service offers psychological interventions during and after your wife's illness . "

b . " The clinicians help reduce the severity of your wife's physical problems . "

c . " This service delivers meals and supplies to reduce your errands away from home . "

d . " It makes it possible for you to have some time away from caring for your wife . "

d . " It makes it possible for you to have some time away from caring for your wife . "

39. A nurse is teaching a client how to use a finger - stick glucometer at home . Which of the following instructions should the nurse include ?

a . Warm the hands prior to piercing the skin .

b . Cap the lancet prior to putting it in the trash.- never recap

c . Elevate the arm for 1 min before taking the blood sample.- has to be down so gravity can assist to milk the blood out .

d . Obtain the blood sample from the finger pads .

a . Warm the hands prior to piercing the skin

40. A nurse is assessing a client who had a recent stroke . Which of the following findings should indicate the need for referral to an occupational therapist ?

a . Receptive aphasia

b . Facial drooping

c . Memory loss

d . Unilateral neglect

d . Unilateral neglect -is one of the disabling features of stroke , and is defined as a failure to attend to the side opposite a brain lesion .

41. A nurse is participating in the development of a disaster management plan for a hospital . The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event ?

a . A network for communication between staff members and families

b . A mental health specialist on the response team

C. A sufficient supply of personal protective equipment

d . A system for tracking client information

C. A sufficient supply of personal protective equipment

42. A nurse in a clinic is reviewing laboratory reports for a group clients . Which of the following diseases should the nurse report to the state health department ?

a . Rotavirus

b . Pertussis

c . Respiratory syncytial virus

d . Group B streptococcal disease

b . Pertussis

43. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used for a client who has Clostridium difficile . Which of the following solutions should the nurse recommend to clean the equipment ?

a . Chlorine bleach

b . Triclosan

C. Chlorhexidine

d . Isopropyl alcohol

a Chlorine bleach

44. A nurse is assessing an older adult client who was brought to the emergency department by his adult son , who reports that the client fell at home . The nurse suspects elder abuse . Which of the following actions should the nurse take ?

a . Treat and discharge the client .

b . Ask the client's son to go to the waiting area .

c . File an incident report .

d . Ask the client about his injuries with the son present .

. b . Ask the client's son to go to the waiting area . c

45. A nurse is completing discharge teaching with a client who is being treated for tuberculosis ( TB ) . Which of the following statements by the client indicates an understanding of the teaching ?

a . " I need to take my prescribed medication for 3 months . "

b . " I should have a sputum culture done every 2 to 4 weeks . "

C. " I need to have a TB skin test done once per year . "

d . " I should wear a mask while around my family . "

b . " I should have a sputum culture done every 2 to 4 weeks . "

46. 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 . Checking the pulses of the client's right foot

b . Recording the client's vital signs C. Turning the client

d . Determining the client's pain level

b . Recording the client's vital signs

47. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel ( AP ) . Which of the following is an appropriate task for the AP ?

a. Inspect the skin of a newborn who is receiving phototherapy .

b . Answer the parents ' questions about newborn circumcision .

c . Show a new mother how to change the newborn's diaper .

d . Obtain the weight of a newborn that is receiving formula

d . Obtain the weight of a newborn that is receiving formula

48. A nurse is orienting a newly licensed nurse about the use of restraints . Which of the following statements by the newly licensed nurse indicates an understanding of the teaching ?

a . " A provider can write a prescription for restraints ' as needed " . "

b . " I need to tie the restraint to the part of the bed frame that moves . "

c . " I should tie the restraints using a square knot . "

d . " I will remove a client's restraints every 4 hours . "_

d . " I will remove a client's restraints every 4 hours . "

49. An infection control nurse is planning an education program for a group of newly licensed nurses . Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions ?

a . Mumps

b . Rubeola

c . Varicella-

d . Rotavirus

a . Mumps

50. A nurse is caring for a client who has cancer . The client and her partner are asking the nurse about hospice are . Which of the following statements by the nurse is appropriate ?

a " Hospice care will prolong the life expectancy of clients who are terminally ill . "

b . " Hospice care is a multidisciplinary program for clients who are terminally ill . "

c . " Hospice care is helpful for clients at various stages of chronic illness . "

d . " Hospital access is no longer available for clients who are in hospice care . "

b . " Hospice care is a multidisciplinary program for clients who are terminally ill .

51. A nurse is planning care for a client who has Addison's disease . Which of the following tasks should the nurse plan to delegate to an assistive personnel ?

a . Decide how often to measure vital signs .

b . Explain to the client about a 24 - hr urine specimen collection .

C. Determine the client's muscle strength prior to ambulation .

d . Remind the client to change positions slowly .

d . Remind the client to change positions slowly .

52. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors . Which of the following actions should the charge nurse take first ?

a . Notify the risk management department of the situation

b . Review with the nurse the principles of medication administration

c . Ask the nurse to describe medication administration procedure

d . Identify education opportunities for the nurse regarding safe medication administration

c . Ask the nurse to describe medication administration procedure

53. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV - positive due to multiple sexual partners . The nurse manager should identify that which of the following torts has occurred ?

a . Libel

b . Battery

c . Slander

d . Negligence

a . Libel

54. A nurse is preparing a client for an elective mastectomy . The client is wearing a plain gold wedding band . Which of the following is an appropriate procedure for taking care of this client's ring ?

a . Place the client's ring in the facility safe .

b . Tape the ring securely to the client's finger .

c . Place the ring in the bad with the client's clothing .

d . Agree to keep the ring for the client until after surgery .

a . Place the client's ring in the facility safe .

55. A nurse is prioritizing postpartum care for four clients . Which of the following actions should the nurse take first ?

a . Assist a client who requests help breastfeeding her 4 - hr - old newborn .

b . Administer RH immune globulin to a client who is Rh - negative and 6 hr postpartum . hours

C. Check uterine tone for a client who received methylergonovine .

d . Instruct a client who has an episiotomy about a sitz bath .

C. Check uterine tone for a client who received methylergonovine- if the uterine tone is not FIRM , then they can be risk for PP HEMORRHAGE - ABCS compromised

56. A hospice nurse is caring for a client who has a terminal illness and reports severe pain . After the nurse administers the prescribed opioid and benzodiazepine , the client becomes somnolent and difficult to arouse . Which of the following actions should the nurse take ?

a . Withhold the benzodiazepine but continue the opioid .

b . Contact the provider about replacing the opioid with an NSAID .

C. Administer the benzodiazepine but withhold the opioid .

d . Continue the medication dosages that relieve the client's pain .

d . Continue the medication dosages that relieve the client's pain .

57. A nurse is observing an assistive personnel ( AP ) administer 0.9 % sodium chloride enema to an adult client . For which of the following actions by the AP should the nurse intervene ?

a . Administers the solution at room temperature

b . Points tubing in the direction of the umbilicus during insertion

c . Position the client on her left side with knees flexed

d . Inserts the tubing 8 cm ( 3.1 in ) into the rectum

a . Administers the solution at room temperature

58. A nurse is providing information to a client about advance directives . The nurse should explain that advance directives include which of the following ? P. 38 ch 3

a . Instructions regarding treatments the client desires or does not desire

b . Information regarding the disposition of the client's body upon death

C. Information regarding organ donation

d . A form with directions for contacting next of kin

a . Instructions regarding treatments the client desires or does not desire

59. A nurse on a medical - surgical unit is caring for four clients . The nurse should recognize that which of the following clients is the highest priority ?

a . A client who has peripheral vascular disease ad has an absent pedal pulse in the right

b . A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy .

C. A client who has methicillin resistant Staphylococcus aureus ( MRSA ) and has an axillary temperature of 38C ( 101F )

d . A client who is postoperative following a laminectomy 12 hr ago and is unable to void

a . A client who has peripheral vascular disease ad has an absent pedal pulse in the right foot : ABCS - absent pulse means NO CIRCULATION = necrosis

60. A staff development nurse is giving an in - service presentation about advocacy in nursing . Which of the following statements by a nurse indicates an understanding of the role of a client advocate ?

a . " In the role of client advocate , I should take responsibility for coordinating each client's care . "

b . " As a client advocate , I will suggest the best course of action for clients who are indecisive . "

c . My role as a client advocate is to empower the clients to make informed healthcare decisions . ".

d . " As a client advocate , I will adhere to the provider's prescribed treatments . "

c . My role as a client advocate is to empower the clients to make informed healthcare decisions . " - keyword was informed ! If they are not informed , then nurses role in advocating is to make sure they are

61. A nurse manager observes an assistive personnel ( AP ) incorrectly transferring a client to the bedside commode . Which of the following actions should the nurse take first ?

a . Refer the AP to the facility procedure manual .

b . Instruct the AP to request assistance when unsure about a task .

C. Help the AP assist the client with the transfer-

d Demonstrate the proper client transfer technique for the AP.-

a . Refer the AP to the facility procedure manual

62. A nurse at the local health department is caring for four clients who have communicable diseases . Which of the following infections should the nurse report to the state health department ?

a . Chlamydia trachomatis

b . Pediculosis capitis

c . Impetigo contagiosa

d . Candida albicans .

a . Chlamydia trachomatis

63. charge nurse witnesses two nurses having a loud discussion at the nurses ' station about not wanting to care for a client who has drug - resistant tuberculosis . Which of the following actions should the charge nurse take ? P. 40 ch 3

a . Escort the nurses to the nurses ' lounge to continue the discussion.-

b . Recommend that both nurses be terminated.-

c . Make arrangements to take over the client's care.-

d . Contact the house supervisor to mediate the conflict.-

a . Escort the nurses to the nurses ' lounge to continue the discussion.- taking them out of being heard by other patients and families so HIPPA does not get violated .

64. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experiences to safely care for his assigned clients . Which of the following actions should the nurse take ? P. 8 ch 1

a . Accept the assignment with help from assistive personnel on the unit.-

b . Request that the charge nurse modify the assignment .

C. Document the concern in the nurse's notes .

d . Notify the risk manager.- you must follow chain of command , the first one to talk to is the charge nurse .

b . Request that the charge nurse modify the assignment.- bring attention to the charge nurse and negotiate ad new assignment , then take it up to chain of command , then file a assignment despite objection

65. A nurse is conducting an in - service about the nursing code of ethics with a group of newly licensed nurses . Which of the following information should the nurse include in the teaching as an example of advocacy ? P.36 ch 3

a . Recommending a referral for a client who requires physical therapy-

b . Suggesting a client's partner attend a support group for emotional support

C. Evaluating a client's home for safety hazards

d . Completing an incident report following a medication error

a . Recommending a referral for a client who requires physical therapy- assisting without controlling the situation .

66. A charge nurse in the emergency department is supervising a nurse who is floating from the medical - surgical unit . Which of the following assignments is appropriate for the float nurse ? .

a. Administer IV nitroglycerin to a client who is experiencing chest pain

b . Perform a urinary catheterization for a client who has experienced a cerebrovascular accident.-

C. Set up a trauma room for an incoming client who was in a motor - vehicle crash

d . Complete a SAD PERSONS assessment scale for a client who has attempted suicide

b . Perform a urinary catheterization for a client who has experienced a cerebrovascular accident.- only requires fundamental nursing skills , CVA patient is stable as well .

67. A home health nurse is assessing the home environment during an initial visit to a client who has history of falls . Which of the following findings should the nurse identify as increasing the client's risk for falls ? ( SATA )

a . A folding chair without arm rests

b . A wheeled office chair at the client's computer desk

C. A throw rug covering some cracked vinyl flooring in the kitchen

d . A two - wheeled walker used to assist the client with ambulation-

e . A raised vinyl seat on the toilet in the bathroom-

a . A folding chair without arm rests b . A wheeled office chair at the client's computer desk C. A throw rug covering some cracked vinyl flooring in the kitchen

68. A nurse in a long - term care facility should identify that which of the following will provide security for clients who have dementia ?

a . Turning off room lights at night-

b . Using a facility - wide paging system

c . Restricting space to reduce pacing

d . Setting alarms on exits

d . Setting alarms on exits

69. 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 . Have the client sign a consent for treatment.-

b . Notify risk management before initiating treatment.-

c . Proceed with treatment without obtaining written consent

d . Contact the client's next of kin to obtain consent for treatment

. c . Proceed with treatment without obtaining written consent .

70. A nurse is reviewing the medication administration record of a client and notices that an additional dose of medication has been administered . Which of the following actions should the nurse take first ?

a . Inform the nursing supervisor .

b . Notify the provider

C. Observe the client's condition .

d . Complete an incident report .

C. Observe the client's condition