1. If a nurse observes a staff member placing a box of disposable face shields
outside the room of a client with chickenpox, what should the nurse do?
Intervene and explain that face shields should be used by staff
inside the room, not placed outside.
Ignore the action as it is acceptable.
Report the action as a violation of protocol.
Encourage the staff member to use the face shields for all patients.
2. Why is it appropriate for UAP to assist a client with atrial fibrillation in
showering, while other tasks are not?
UAP are allowed to perform any task assigned by a nurse without
restrictions.
UAP can only assist with clients who have stable conditions.
UAP are trained to handle all medical tasks, including assessments and
monitoring.
UAP can assist with activities of daily living like showering, but
cannot perform assessments or monitor critical conditions.
3. The nurse in the pediatric unit is preparing to admit a client with rubeola
(measles). The nurse should assign the client to a
private room with monitored negative air pressure
room with a client who has atopic dermatitis (eczema)
room with a client who has chickenpox
private room at the end of the hallway
,4. If a charge nurse has multiple clients in labor, how should they prioritize care
when one client has contractions every 30 seconds and another has a
temperature of 100.4° F (38° C)?
Assess both clients simultaneously.
Prioritize the client with a temperature of 100.4° F.
Prioritize the client with a history of complications.
Prioritize the client with contractions every 30 seconds.
5. Why is encouraging a patient with Alzheimer's disease to reminisce about
happy memories considered a beneficial intervention?
It helps to enhance the patient's mood and cognitive engagement.
It provides the patient with a sense of control over their care.
It serves as a distraction from the patient's condition.
It allows the nurse to avoid addressing difficult behaviors.
6. A patient arrives to the medical-surgical department following a surgical
repair of a femur fracture. The patient is complaining of pain and is restless.
Upon assessment the nurse notices petechial rash over the upper chest and
neck. What intervention should the nurse implement first?
Obtain an order for an arterial blood gas and a chest x-ray.
Notify the health care provider.
Instruct the certified personal assistant (CAP) to reposition the client
every two hours to relieve pain.
Prepare for for intubation and mechanical ventilation.
7. Identify three extrinsic risk factors for falling in older adults.
, Dim lighting, Hemiparesis, Uneven stairs
Throw rugs, Confusion, Hemiparesis
Uneven stairs, Throw rugs, Dim lighting
Hemiparesis, Confusion, Dim lighting
8. If the nurse assesses the client with the hot cast and finds that the cast is too
tight, what should be the nurse's immediate action?
Apply ice to the casted leg to reduce swelling.
Administer pain medication for the discomfort.
Loosen or remove the cast to relieve pressure.
Notify the physician and wait for further instructions.
9. If a nurse finds that a patient with bacterial pneumonia has worsening
bronchial breath sounds and a rising temperature, what should be the nurse's
priority action?
Perform a chest X-ray immediately.
Notify the healthcare provider for further evaluation.
Increase the patient's fluid intake.
Administer antipyretics as prescribed.
10. Adam has been videotaping his counseling session with clients without their
consent. This scenario is an example of ____ _.
Clinical competence
Self-protection
Common practice among therapists because it allows them to view
their behavior and interpersonal reactions during sessions
, Violation of client's privacy
11. Why is it important to refer a client with multiple sclerosis and ataxia to a
physical therapist?
A physical therapist can provide specialized exercises and
strategies to improve coordination and mobility.
A physical therapist can assist in communication techniques.
A physical therapist can manage medication for the client.
A physical therapist can help the client with dietary modifications.
12. In a scenario where a patient with Alzheimer's disease becomes agitated
during a group activity, which intervention should the nurse prioritize based
on best practices?
Redirect the patient to a calming activity that involves reminiscing.
Administer a sedative to manage the agitation.
Encourage the patient to participate in the activity despite their
agitation.
Confront the patient about their behavior to establish boundaries.
13. An 82-year-old woman is brought to the ED by her daughter for worsening
fatigue, dizziness, and light-headedness. The patient denies chest pain or
shortness of breath. She has not started any new medications. Her BP is
140/70 mm Hg, HR is 37 beats/minute, and RR is 15 breaths/minute. An IV is
started and blood is drawn. An ECG is seen in the figure. Which of the
following is the most appropriate next step in management?
Bed rest for the next 48 hours and follow-up with her primary-care
physician