AND VERIFIED ANSWERS | GRADED A+| PASS ON FIRST ATTEMPT |
A nurse in a community health clinic is caring for four clients who each have a communicable
disease. Which of the following is considered a nationally notifiable infectious disease?
A) Respiratory Syncytial Virus (RSV)
B) Methicillin-resistant Staphylococcus aureus (MRSA)
C) Clostridium Difficile
D) Chlamydia trachomatis - ANSWER D) Chlamydia trachomatis
A nurse is caring for a group of clients on a unit. Which of the following assessments should
the nurse recognize as the priority to report to the charge nurse?
A) a client with heart failure and 2+ edema of lower extremities
B) a client who is 2 days postoperative with a urine output of 20 ml/hr
C) a client who started taking verapamil with a HR of 75/min
D) a client who is taking morphine and reports nausea - ANSWER B) a client who is 2 days
postoperative with a urine output of 20 ml/hr
Rationale:
output is below expected range and can indicate hypovolemia or renal complications. A & C
are expected findings for patient scenario. Verapamil affects blood pressure do not take if
low BP or heart rate less than 60
A charge nurse is evaluating a plan of care that a newly licensed nurse developed for a client
who is to receive a continuous NG tube feeding. Which of the following interventions should
the charge nurse ensure is part of the plan of care?
A) flush the tube every 8 hrs with 0.9% sodium chloride irrigation
B) use an acidic juice to unclog a blocked tube
1
,C) Add dissolvable medications to the tube feeding
D) use a 60 ml syringe to flush out a clogged tube - ANSWER D) use a 60 ml syringe to
flush out a clogged tube
Rationale:
A larger syringe is used to unclogged tubing due to smaller syringes causing higher amounts
of pressure. The tubing should be flushed every 4 hours with 30-50 ml of water. Dissolvable
medications should be added to 30 ml of water, enteral feeding should be stopped, with
tubing flushed prior to admin.
A charge nurse is observing a newly licensed nurse care for a client who has a prescription
for application of an aquathermia pad to the right lower leg. Which of the following actions
should indicate to the charge nurse that the nurses know how to use the device? SELECT ALL
THAT APPLY!!
A) ask client to report of aquathermia pad gets too warm
B) check the client's leg 30 mins after applying the aquathermia pad
C) show the client how to adjust the temperature
D) ensure the client's call light is within reach
E) decrease the temperature by 2.8 C (5 F) if the client's skin becomes reddened -
ANSWER A) ask client to report of aquathermia pad gets too warm
D) ensure the client's call light is within reach
Rationale:
Want to check on client 15-20 mins after applying for complications. Adjusting the
temperature can affect pain and circulation and should not be done. If patient's skin is
reddened it should be discontinued and provider is notified.
A nurse is caring for a client who is experiencing adverse effects after receiving a new
medication. Which of the following communication tools should the nurse use for
management of this complication?
A) critical pathway
2
, B) incident reporting
C) SBAR framework
D) root cause analysis - ANSWER C) SBAR framework
Rationale:
root cause analysis helps to identify why a standard is not being met, incident reporting is
when an error or incident occurs between clients and nursing staff, and critical pathway is
for determining best care for certain medical conditions or procedures. SBAR is used to
communicate patient information and for finding the best solution.
A nurse is teaching a client about the Patient Protection and Affordable Care Act and their
rights regarding insurance coverage. Which of the following statements by the client
indicates an understanding of the teaching?
A) "My insurance coverage no longer has lifetime coverage limits."
B) "I can provide health insurance coverage for my children on my policy until they turn 21
years old."
C) "My insurance will not provide coverage for preexisting conditions."
D) "I can lose my insurance coverage since I have been sick so much this year." - ANSWER
A) "My insurance coverage no longer has lifetime coverage limits."
Rationale:
Children can stay on their parents plan until they turn 26 years old; the act cannot deny
those with preexisting conditions; and the act prevents cancellation of insurance due to
illness
A charge nurse is managing a conflict with a staff nurse who does not agree with the client
care assignment. Which of the following statements is an example of using the conflict
resolution strategy known as smoothing?
A) "Would you accept the assignment if we reassign your client who has total care needs and
assign another client who can provide more self-care?"
B) "Tell me what changes we need to make so that you'll feel comfortable with the
assignment."
3
A nurse in a community health clinic is caring for four clients who each have a communicable
disease. Which of the following is considered a nationally notifiable infectious disease?
A) Respiratory Syncytial Virus (RSV)
B) Methicillin-resistant Staphylococcus aureus (MRSA)
C) Clostridium Difficile
D) Chlamydia trachomatis - ANSWER D) Chlamydia trachomatis
A nurse is caring for a group of clients on a unit. Which of the following assessments should
the nurse recognize as the priority to report to the charge nurse?
A) a client with heart failure and 2+ edema of lower extremities
B) a client who is 2 days postoperative with a urine output of 20 ml/hr
C) a client who started taking verapamil with a HR of 75/min
D) a client who is taking morphine and reports nausea - ANSWER B) a client who is 2 days
postoperative with a urine output of 20 ml/hr
Rationale:
output is below expected range and can indicate hypovolemia or renal complications. A & C
are expected findings for patient scenario. Verapamil affects blood pressure do not take if
low BP or heart rate less than 60
A charge nurse is evaluating a plan of care that a newly licensed nurse developed for a client
who is to receive a continuous NG tube feeding. Which of the following interventions should
the charge nurse ensure is part of the plan of care?
A) flush the tube every 8 hrs with 0.9% sodium chloride irrigation
B) use an acidic juice to unclog a blocked tube
1
,C) Add dissolvable medications to the tube feeding
D) use a 60 ml syringe to flush out a clogged tube - ANSWER D) use a 60 ml syringe to
flush out a clogged tube
Rationale:
A larger syringe is used to unclogged tubing due to smaller syringes causing higher amounts
of pressure. The tubing should be flushed every 4 hours with 30-50 ml of water. Dissolvable
medications should be added to 30 ml of water, enteral feeding should be stopped, with
tubing flushed prior to admin.
A charge nurse is observing a newly licensed nurse care for a client who has a prescription
for application of an aquathermia pad to the right lower leg. Which of the following actions
should indicate to the charge nurse that the nurses know how to use the device? SELECT ALL
THAT APPLY!!
A) ask client to report of aquathermia pad gets too warm
B) check the client's leg 30 mins after applying the aquathermia pad
C) show the client how to adjust the temperature
D) ensure the client's call light is within reach
E) decrease the temperature by 2.8 C (5 F) if the client's skin becomes reddened -
ANSWER A) ask client to report of aquathermia pad gets too warm
D) ensure the client's call light is within reach
Rationale:
Want to check on client 15-20 mins after applying for complications. Adjusting the
temperature can affect pain and circulation and should not be done. If patient's skin is
reddened it should be discontinued and provider is notified.
A nurse is caring for a client who is experiencing adverse effects after receiving a new
medication. Which of the following communication tools should the nurse use for
management of this complication?
A) critical pathway
2
, B) incident reporting
C) SBAR framework
D) root cause analysis - ANSWER C) SBAR framework
Rationale:
root cause analysis helps to identify why a standard is not being met, incident reporting is
when an error or incident occurs between clients and nursing staff, and critical pathway is
for determining best care for certain medical conditions or procedures. SBAR is used to
communicate patient information and for finding the best solution.
A nurse is teaching a client about the Patient Protection and Affordable Care Act and their
rights regarding insurance coverage. Which of the following statements by the client
indicates an understanding of the teaching?
A) "My insurance coverage no longer has lifetime coverage limits."
B) "I can provide health insurance coverage for my children on my policy until they turn 21
years old."
C) "My insurance will not provide coverage for preexisting conditions."
D) "I can lose my insurance coverage since I have been sick so much this year." - ANSWER
A) "My insurance coverage no longer has lifetime coverage limits."
Rationale:
Children can stay on their parents plan until they turn 26 years old; the act cannot deny
those with preexisting conditions; and the act prevents cancellation of insurance due to
illness
A charge nurse is managing a conflict with a staff nurse who does not agree with the client
care assignment. Which of the following statements is an example of using the conflict
resolution strategy known as smoothing?
A) "Would you accept the assignment if we reassign your client who has total care needs and
assign another client who can provide more self-care?"
B) "Tell me what changes we need to make so that you'll feel comfortable with the
assignment."
3
