help 5

1 ) 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 as part of the quality improvement process ?

a . Notify staff of the increased fall rate

b . Review current literature regarding client falls

c . Implement a fall prevention plan

d . Identify clients who are at risk for falls

d . Identify clients who are at risk for falls

2 ) 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 2 hr after implementation of the care pathway .

b . A blood culture was obtained after antibiotic therapy had 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 .

b . A blood culture was obtained after antibiotic therapy had been initiated .

3 ) A nurse is caring for a client who has cancer . The client and her partner are asking the nurse about hospice care . 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 . "

4 ) A nurse manager discovers there is a conflict between nurses working the day shift and nurses working on the night shift . Which of the following actions should the nurse manager take first ?

a . Acknowledge the conflict and encourage the nurses to focus on working as a team .

b . Gather information regarding the situation

c . Encourage the nurses to resolve the conflict autonomously

d . Meet with a committee from each shift to discuss issues related to the conflict

. b . Gather information regarding the situation

5 ) A nurse in the emergency room is assessing several clients . Which of the following is the highest priority ?

a . A client who report right sided flank pain and is diaphoretic

b . A client who has a raised red skin rash on his arms , neck and face

c . A client who has active bleeding from a puncture wound of the left groin area

d . A client who reports SOB and left neck and shoulder pain .

d . A client who reports SOB and left neck and shoulder pain .

6 ) A nurse is providing change - of - shift report for an oncoming nurse . Which of the following information should the nurse include in the report ?

a . " The client's partner came to visit him 2 hours ago and smelled of alcohol . "

b . " The client is currently in the radiology department for a chest x - ray . "

c . " The client will need vital signs every 4 hours . "

d . " The client is the president of a local bank . "

b . " The client is currently in the radiology department for a chest x - ray . "

7 ) A nurse is planning discharge for a client who has lung resection . The nurse initiates a referral for a social worker . Which of the following assessment data supports this referral ?

a . The client needs to have someone bring O₂ tanks and equipment to her home .

b . The client needs to have range - of - motion exercises to assist with ambulation

c . The client needs to arrange financial resources to purchase equipment .

d . The client needs to have someone come in to help her bathe at home .

c . The client needs to arrange financial resources to purchase equipment

8 ) A nurse is caring for a dient who requests information about the prevalence of tay sachs disease . Which of the following resources should the nurse use to obtain this information ?

a . The facility's case manager

b . The client's health provider

c . A collaborative , user - edited website

d . An evidence - based nursing journal

d . An evidence based nursing journal

9 ) A nurse is orienting a newly licensed nurse about client confidentiality . Which of the following statements by the newly licensed nurse indicates an understanding of the teaching ?

a . " I should encrypt personal health information when sending emails .

b . " I can post the client's vital signs in the client's room . "

c . " I can use another nurse's password as long as I log off after using the computer "

d . " I should discard personal health information documents in the trash before leaving the unit "

a . " I should encrypt personal health information when sending emails .

10 ) A nurse is discussing critical pathway use during a staff meeting . Which of the following information should the nurse manager include as an outcome of critical pathway use ?

a . Decreased cost - effectiveness

b . Increased length of stay

c . Decreased care delays

d . Increased variation in clinical interventions

c . Decreased care delays

11 ) A nurse is providing instructions about chemotherapy for a client who has a new diagnosis of breast CA. The client has decided to try an alternative treatment rather than starting chemotherapy . Which of the following actions should the nurse take ?

a . Notify spiritual services to speak with the client about their decision .

b . Inform the client about the risks of not starting chemotherapy immediately .

c . Respect the dient's decision about not receiving chemotherapy .

d . Tell the client they can't change their mind once consent is given

c . Respect the dient's decision about not receiving chemotherapy .

12 ) 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 .

13 ) A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube . The nurse should assess the client's need for which of the following supplies to manage tracheostomy at home ? ( SATA )

a . Pipe cleaners

b . 02 Tank

c . Cotton balls

d . Petroleum Jelly

e . Obturator

a . Pipe cleaners b . 02 Tank e . Obturator

14 ) 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 .

15 ) A nurse is planning to develop a standard for removal of indwelling urinary catheters from dients following a colon resection . Which of the following resources should the nurse use ?

a . Maslow's hierarchy of needs

b . Critical pathway

c . Surgical record

d . Providers prescription

b . Critical pathway

16 ) 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

17 ) A nurse is admitting a client who is scheduled for cholecystectomy . The client does not speak English and is accompanied by her adult daughter . Which of the following actions should the nurse take ?

a . Access a language line to interpret what is being said

b . Ask the client's daughter to interpret the conversation

c . Talk loudly while facing the client

d . Request the assistance of an assistive personnel who speaks the client's language

a . Access a language line to interpret what is being said

18 ) A charge nurse is making room for new admissions following a community caster . which of the following clients should the nurse recommend for discharge ?

a . A client who has a DVT and INR of 2.0

b . A client who has a new onset of left - sided weakness

c . A client who has angina and a troponin level of 3ng / mL

d . A client who is receiving chemotherapy and has tumor lysis syndrome

a . A client who has a DVT and INR of 2.0

19 ) 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 . "

20 ) A home health nurse is performing a safety assessment of a client's home . Which of the following findings should the nurse identify as a safety hazard ?

a . The client's bedside lamp is plugged in using an extension cord with two prongs .

b . The client's electrical cord is taped to the floor .

c . The client stores cleaning supplies in a locked cabinet above his head .

d . The client has used tacks to secure carpet on the stairs .

a . The client's bedside lamp is plugged in using an extension cord with two prongs .

21 ) A nurse from the labor and delivery unit is assigned to float to a medical - surgical unit . Which of the following actions should the nurse take first ?

a . Clarify competencies with the medical - surgical charge nurse

b . Refer to the assigned resource nurse regarding client assignments

c . Inform the nursing supervisor of the lack of experience on the medical - surgical unit

d . Request orientation to the medical - surgical unit

d . Request orientation to the medical - surgical unit

22 ) A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit . Which of the following responses by the nurse is appropriate ?

a . " I'm not taking care of your relative today , so I don't have the latest information . "

b . " I will have your relative's nurse come and talk with you about her care . "

c . " Let me check your relative's medical record to see how she's doing . "

d . " Please ask your relative about this , because I cannot share information about her . "

d . " Please ask your relative about this , because I cannot share information about her . "

23 ) A nurse is supervising an assistive personnel ( AP ) who is feeding a client who has dysphagia . Which of the following actions by the AP should the nurse identify as correct technique ?

a . Instructing the client to place her chin toward her chest when swallowing

b . Providing a 10 min rest period prior to meals

c . Withholding fluids until the end of the meal

d . Elevating the head of the client's bed to 30 degrees during mealtime

a . Instructing the client to place her chin toward her chest when swallowing

24 ) A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client . Which of the following actions should the nurse perform first ?

a . Complete an incident report

b . Measure the client's vital signs

c . Inform the nurse manager

d . Call the provider

b . Measure the client's vital

25 ) A nurse manager is reviewing isolation guideline with a newly licensed nurse . Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines ?

a . " I will instruct visitor to wear a mask when visiting a client who is on contact precautions . "

b . " I will place a client who has compromised immunity in a negative - pressure airflow room . "

c . " I will wear N95 respirator mask when caring for a client who is a droplet precaution . "

d . " I will have a client who is on airborne precaution wear a mask when out of her room . "

d . " I will have a client who is on airborne precaution wear a mask when out of her room . "

26 ) A nurse is receiving a verbal prescription from the provider for a client who is having increased pain . The nurse should transcribe which of the following prescriptions in the client's medical record ?

a . Morphine sulfate 10.0 mg every 4 hours IV prn for pain

b . Morphine sulfate 10mg q 4h IV prn for pain

c . MS 10mg IV every 4h for pain

d . MS04 10mg IVP Q4h pm for pain

b . Morphine sulfate 10mg q 4h IV prn for pain

27 ) A nurse on a medical surgical unit is caring for a group of clients with assistance of a licensed practical nurse ( LPN ) and assistive personnel . Which of the following tasks should the nurse assign to the LPN ?

a . Reinforcing dietary teaching with a client who has heart disease

b . Obtaining a urine specimen from an older adult client

c . Providing postpartum care for a client who has just died

d . Accompanying a client who just had a wound debridement to physical therapy

a . Reinforcing dietary teaching with a client who has heart disease

28 ) A nurse is planning for four clients who were classified using a disaster triage tag system following a mass casualty event . Which of the following clients should the nurse identify as the priority ?

a . A client who has a red tag

b . A client who has a green tag

c . A client who has a black tag

d . A client who has a Yellow tag

a . A client who has a red tag

29 ) A nurse enters a client's room and observes a fire in the trashcan . Identify the sequence of actions the nurse should take .

a . Active the fire alarm system .

b . Confine the fire by closing doors and windows .

c . Extinguish the fire if possible .

d . Remove the client from the area .

d . Remove the client from the area .

30 ) A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure . Which of the following findings indicate wound healing ?

a . Erythema on the skin surrounding a client's wound

B. Deep red color on the center of the clients wound

C. Inflammation noted on the tissue edges of a client's wound

d . Increase in serosanguineous exudate from the clients wound

B. Deep red color on the center of the clients wound

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

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

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

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

32 ) A nurse is providing information to a client about advance directive . The nurse should explain that advance directives include which of the following ?

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

33 ) A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance . Which of the following actions should the nurse take ? ( SATA )

a . File an anonymous report of the incident to the nurse manager .

b . Request that the coworker complete an incident report .

C. Submit an incident report to the risk manager

d . Document a factual account of the incident .

e . Identify all witnesses to the incident .

C. Submit an incident report to the risk manager

d . Document a factual account of the incident .

e . Identify all witnesses to the incident .

34 ) 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

35 ) 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 is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy .

b . A client who has peripheral vascular disease and has an absent pedal pulse in the right foot .

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

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

. b . A client who has peripheral vascular disease and has an absent pedal pulse in the right foot .

36 ) A nurse is caring for a group of clients who are receiving physical therapy , which of the following information regarding a client should the nurse report to the physical therapist ?

a . A client has a prescription for a clean - catch urine test .

b . A client has a hemoglobin of 5g / dL

c . A client has opioid - induced constipation

d . A client has new a diagnosis of colorectal cancer

d . A client has new a diagnosis of colorectal cancer

37 ) A nurse is evaluating the implementation of infection control measures by unit nurses when caring for clients who have Clostridium Difficile . The charge nurse should intervene for which of the following actions by a unit nurse ?

a . Places the client in contact precautions

b . Wears goggles when emptying the bedpan of liquid stool

c . Cleans contaminated equipment w / bleach - based solution

d . Uses alcohol - based hand sanitizer after removing gloves

d . Uses alcohol - based hand sanitizer after removing gloves

38 ) A charge nurse is completing client assignments . Which of the following assignments is appropriate for a licensed practical nurse ?

a . A client who receiving IV chemotherapy .

b . A client who is 1 - day postoperative and has a continuous bladder irrigation .

c . A client who requires discharge instructions for type 1 diabetes mellitus .

d . A client who requires a blood transfusion to be administered .

b . A client who is 1 - day postoperative and has a continuous bladder irrigation .

39 ) 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 medical - surgical unit ?

a . A client who has gestational diabetes and is receiving biweekly nonstress tests .

b . A primigravida client who is 1 - day postoperative following a Cesarean section and has a PCA pump .

c . A multigravida client who has preeclampsia and is receiving misoprostol ( Cytotec ) for induction of labor .

d . A client who is at 32 weeks of gestation and has premature rupture of membranes .

b . A primigravida client who is 1 - day postoperative following a Cesarean section and has a PCA pump .

40 ) A charge nurse overhears a provider and a nurse talking about a client's diagnosis in the cafeteria . Which of the following actions should the nurse take first ?

a . Remind them that client information is confidential .

b . Complete an incident report about the situation .

c . Report the incident to the nursing supervisor .

d . Discuss the need for client confidentiality at the next staff meeting . .

a . Remind them that client information is confidential.

41 ) A nurse is delegating tasks to an assistive personnel ( AP ) . Which of the following tasks should the nurse assign to the AP ?

a . Check on a client whose telemetry monitor is continuously beeping .

b . Instruct a client about the use of an incentive spirometer .

c . Tag a malfunctioning piece of equipment as broken .

d . Determine whether an oxygen flow meter is accurately set at 2 L / min via nasal cannula

c . Tag a malfunctioning piece of equipment as broken

42 ) 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 .

43 ) A nurse is caring for a client who has a new diagnosis of chlamydia . Which of the following actions should the nurse take ?

a . Initiate contact precautions

b . Report the infection to the local health department

c . Apply an antiviral cream to lesions

d . Instruct the client to use condoms until the treatment is completed

b . Report the infection to the local health department

44 ) A nurse is teaching a newly licensed nurse about hazardous and infectious materials , which of the following situations should the nurse include as a safe handling technique ?

a . A nurse removes her gown after leaving the client's room

b . A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen

c . A nurse cleans up a blood spill with hydrogen peroxide

d . A nurse places a mask on a client with tuberculosis before transport to the radiology department

d . A nurse places a mask on a client with tuberculosis before transport to the radiology department

45 ) A client who is unconscious and has extensive internal injuries arrives via ambulance to the emergency room . The staff cannot reach the client's family . Which of the following permits the staff to proceed with emergency surgery ?

a . Nonmaleficene

b . Implied consent

C. Living will

d . Good Samaritan Act

b . Implied consent

46 ) A nurse is teaching a newly licensed nurse about the purpose of interdisciplinary conferences , the nurse should identify that which of the following client's needs an interdisciplinary conference ?

a . A client whose partner requests that the client be moved to a private room

b . A client who has a recent stroke and is showing manifestations of depression

c . A client whose provider is unhappy with the nursing care

d . A client whose MRI results have not been made available after 2 days

b . A client who has a recent stroke and is showing manifestations of depression

47 ) A nurse is caring for a dient who is scheduled for a hysterectomy and has signed the informed consent form . The client tells the nurse that she is unsure about having the procedure . Which of the following responses should the nurse make ?

a . I will contact the provider and request medication to help you relax

b . You should not have signed the consent form if you have reservations about the surgery

c . If you have any concerns about the procedure , the surgery can be canceled

d . Let me provide you with resources you can read about the surgery

c . If you have any concerns about the procedure , the surgery can be canceled

48 ) 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 .

49 ) A nurse on a medical - surgical unit is delegating client care . Which of the following tasks should the nurse delegate to assistive personnel ?

a . Suctioning a client's long - term tracheostomy

b . Performing a dressing change on a client's peripherally inserted central

c . Using a pain rating scale to monitor a client's pain level

d . Instructing a client on self - administration of a tap water enema

c . Using a pain rating scale to monitor a client's pain level

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

a . Transport assistance is unavailable to take a client to OT

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

c . The ER department nurse is waiting to give report on a new admission

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

c . The ER department nurse is waiting to give report on a new admission

51 ) A nurse manager is reviewing the nursing code of ethics with the staff nurse . Which of the following statements by nurse indicate understanding of the teaching ? ( SATA )

a . I have the assistive personnel double - check packed RBCs when other nurses are busy .

b . I can delegate the removal of an IV catheter to an LPN on the unit .

c . I administer pain medication to my clients even if they have a history of narcotic addiction .

d . The family of a newly admitted client recently treated me to lunch in the hospital cafeteria .

e . I will attend continuing education classes for professional growth .

b . I can delegate the removal of an IV catheter to an LPN on the unit .

c . I administer pain medication to my clients even if they have a history of narcotic addiction .

e . I will attend continuing education classes for professional growth .

52 ) A nurse is 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 ?

53 ) A nurse is planning care for a client who is disoriented and has a history of wandering . Which of the following actions should the nurse include in the plan ?

a . Raise all four side r rails on the client's bed

b . Remove the clock and calendar from the client's room

c . Obtain a prescription for a sedative for the client,

d . Provide distractions for the client during the day

d . Provide distractions for the client during the day

54 ) A nurse working on a medical - surgical unit is managing the care of four 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 level of 4.2 g / dL .

b . A client who has Type 1 diabetes and uses in 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 .

55 ) A nurse is caring for a dient who is scheduled for coronary artery bypass surgery and does not wish to have any blood transfusions . The nurse should recognize that administering blood to the client is a violation of which of the following ethical principles ?

a . Autonomy

b . Fidelity

c . Justice

d . Veracity

a . Autonomy

56 ) A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility . Which of the following information should the nurse include in the change - of - shift report ?

a . The steps to follow when providing wound care

b . The client's preferred time for bathing

c . The belief that the client has a difficult relationship with his son

d . The time the client received his last dose of pain medication

d . The time the client received his last dose of pain medication

57 ) A nurse is assessing a client who had a stroke 2 days ago . Which of the following findings should the nurse identify as a need for referral to speech - language pathology ?

a . Altered level of consciousness

b . Diminished hand - to - mouth coordination

c . Impaired voluntary cough

d . Unilateral ptosis

c . Impaired voluntary cough

58 ) A nurse in the ER department is assessing a preschool - age child who has bruises on both arms and a spiral fracture of the left ulna . The child's parents tell the nurse that the child tripped over some toys and fell down . Which of the following actions should the nurse take ?

a . Report the child's injuries to CPS

b . Complete an incident report concerning the child's injuries

c . Take pictures of the child's injuries once the parent leaves the room

d . Have a facility security officer interview the parent

. Report the child's injuries to CPS

59 ) A charge nurse observes a client fall during ambulation and notes that his gait belt was not in place . In reviewing the incident report , the nurse finds no mention of a gait belt . Which of the following ethical principles should guide the nurse's subsequent actions ?

a . Veracity

b . Beneficence

c . Nonmaleficene

d . Fidelity

a . Veracity

60 ) A charge nurse is teaching a group of nurses about the purpose of a living will . Which of the following information about living wills should the charge nurse include in the teaching ?

a . Provides protection against malpractice

b . Addresses resuscitation measures

c . Documents that the client gave informed consent

d . Designates a health care surrogate to make health care decisions

b . Addresses resuscitation measures

61 ) A nurse is caring for a client who has CA. The client's adult child asks the nurse for info about the client's treatment plan , which of the following responses should the nurse make ?

a . You will have to speak directly to your mother about her treatment

b . What would you like to know about your mother's treatment ?

c . I cannot provide this information to you without your mother's consent

d . I will ask your mothers primary care provider to speak with you

c . I cannot provide this information to you without your mother's consent

62 ) 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 .

63 ) A nurse is participating in an interdisciplinary conference for a client who has heart failure , reports limited resources and lives alone . Which of the following actions is the nurse's priority ?

a . Order durable medical equipment for the client's home

b . Help the client obtain financial assistance

c . Coordinate the team and the plan of care

d . Perform a dietary assessment

c . Coordinate the team and the plan of care

64 ) A nurse is caring for a dient who has increased intracranial pressure and is receiving IV corticosteroids . Which of the following information is most important for the nurse to report at shift change ?

a . Glasgow Coma Scale score

b . Reddened area on the coccyx

c . Laboratory tests scheduled for the next shift

d . Most recent blood glucose reading

Glasgow Coma Scale score

65 ) 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

b . The client's vital signs

c . The client's name

d . The client's code status

b . The client's vital signs

66 ) A case manager is preparing a discharge plan for a dient following coronary artery bypass grafting surgery . Which of the following client issues should the nurse address first ?

a . Low pain tolerance

b . Decreased self - esteem

c . Inadequate food supply

d . Limited social support

d . Limited social support

67 ) A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma . The parent states she is unable to afford the nebulizer prescribed for the child . Which of the following referrals should the nurse recommend ?

a . Child protective services

b . Social worker

c . Respiratory therapist

d . Pharmacist

b . Social worker

68 ) A charge nurse is supervising the actions taken by a staff nurse following a client fall . The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure ?

a . Documents in the client's record that an incident report was filed

b . Sends the incident report to the ethics committee

c . Lists names of witnesses to the fall in the nurses note

d . Includes the client's account of the fall in the incident report

d . Includes the client's account of the fall in the incident report

69 ) A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes mellitus . The client tells the nurse that she has decided to go home . Which of the following actions should the nurse take ?

a . Inform the client that she cannot leave without a discharge prescription from the provider

b . Ask the client if she would like a sedative to help her relax

c . Assign a security officer to the client's room until the provider can speak with the client

d . Have the client sign the Against Medical Advice Form

d . Have the client sign the Against Medical Advice Form

70 ) 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 dient'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 .