A nurse is providing education to a client with a fractured femur who will need to use crutches for the
next 6 weeks. Identify if the following directions provided by the nurse for walking upstairs using
crutches are true or false.
TRUE
1. Hold to rail with one hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the 'unaffected' leg.
3. If not allowed to place weight on the 'affected' leg, hop up with the 'unaffected' leg.
4. Bring the 'affected' leg and the crutches up beside the 'unaffected' leg.
5. Remember, the 'unaffected' leg goes up first and the crutches move with the 'affected' leg.
A client is prescribed antibiotic "A" 50 mg IV. The mixed IV solution contains 100 mL. The nurse is to
administer the medication over ½ hour. The drip factor of the available IV tubing is 15gtt/mL. What is the
drip rate in drops per minute?
50 gtt per minute
...
Match the development tasks with the correct age group.
Develop sense of personal identity that family expectations influence. Peer relationships develop as
support system. Concerned with body images that media portray.
Adolescents 12-20 years
Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally,
do not exhibit stranger anxiety. Understand behavior in terms of what is socially acceptable.
Pre-schoolers 3-6 years
Develop sense of industry through advances in learning. Strive to develop healthy self- respect by finding
out in what areas they excel. Peer groups play important role in social development.
School-age children 6-12 years
Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close
relationships. Have influences that help with formation of healthy self-concept, such family and friends.
Young adults 20-35 years
,Match the following isolation precautions to the correct disease process.
Airborne precautions:
A private room.
-Masks or respiratory protection devices for caregivers and visitors.
-An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to
have tuberculosis.
-Negative pressure airflow exchange in the room of at least six exchanges per hour.
Measles
Contact precautions:
-A private room or a room with other clients with the same infection.
-Gloves and gowns worn by the caregivers and visitors.
Vancomycin resistant enterococcus (VRE)
Droplet precautions:
A private room or a room with other clients with the same infectious disease.
Masks for providers and visitors.
Pertussis
Match the description to the correct stage of pressure ulcer.
Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down
to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of
adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
Stage 3
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting
structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black
scab-like material), or slough (tan, yellow, or green scab-like material).
Stage 4
Intact skin with an area of persistent, no blanchable redness, typically over a bony prominence, that may
feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible
discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
, Stage 1
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and
may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected,
possibly with pain and scant drainage.
Stage 2
What is the name of a legal document that instructs health care providers and family members about
what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to
make decisions?
Select one:
a. Living will
b. Informed consent
c. Durable power of attorney for health care
d. Do Not Resuscitate
-A living will is a legal document that specifically outlines a client’s wishes regarding life-sustaining
treatment.
A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been
prescribed a high calorie, low protein diet. Which of the following meal selections is appropriate for this
client?
a. Grilled cheese sandwich, potato chips, chocolate pudding.
b. Chicken breast, mashed potatoes, spinach.
c. Scrambled eggs, bacon and pancakes.
d. Steak, French fries, corn.
-This option meets the prescribed diet. It is high in calories and while chicken does provide protein it is a
low-fat source and can be eaten in moderation on a low-protein diet. Spinach will provide additional
vitamin K for this client at risk for bleeding due to liver failure.
A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce
the client's risk for falls?
a. Hourly rounding by the nurse.
b. Place bedside table in close proximity.
next 6 weeks. Identify if the following directions provided by the nurse for walking upstairs using
crutches are true or false.
TRUE
1. Hold to rail with one hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the 'unaffected' leg.
3. If not allowed to place weight on the 'affected' leg, hop up with the 'unaffected' leg.
4. Bring the 'affected' leg and the crutches up beside the 'unaffected' leg.
5. Remember, the 'unaffected' leg goes up first and the crutches move with the 'affected' leg.
A client is prescribed antibiotic "A" 50 mg IV. The mixed IV solution contains 100 mL. The nurse is to
administer the medication over ½ hour. The drip factor of the available IV tubing is 15gtt/mL. What is the
drip rate in drops per minute?
50 gtt per minute
...
Match the development tasks with the correct age group.
Develop sense of personal identity that family expectations influence. Peer relationships develop as
support system. Concerned with body images that media portray.
Adolescents 12-20 years
Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally,
do not exhibit stranger anxiety. Understand behavior in terms of what is socially acceptable.
Pre-schoolers 3-6 years
Develop sense of industry through advances in learning. Strive to develop healthy self- respect by finding
out in what areas they excel. Peer groups play important role in social development.
School-age children 6-12 years
Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close
relationships. Have influences that help with formation of healthy self-concept, such family and friends.
Young adults 20-35 years
,Match the following isolation precautions to the correct disease process.
Airborne precautions:
A private room.
-Masks or respiratory protection devices for caregivers and visitors.
-An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to
have tuberculosis.
-Negative pressure airflow exchange in the room of at least six exchanges per hour.
Measles
Contact precautions:
-A private room or a room with other clients with the same infection.
-Gloves and gowns worn by the caregivers and visitors.
Vancomycin resistant enterococcus (VRE)
Droplet precautions:
A private room or a room with other clients with the same infectious disease.
Masks for providers and visitors.
Pertussis
Match the description to the correct stage of pressure ulcer.
Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down
to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of
adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
Stage 3
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting
structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black
scab-like material), or slough (tan, yellow, or green scab-like material).
Stage 4
Intact skin with an area of persistent, no blanchable redness, typically over a bony prominence, that may
feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible
discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
, Stage 1
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and
may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected,
possibly with pain and scant drainage.
Stage 2
What is the name of a legal document that instructs health care providers and family members about
what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to
make decisions?
Select one:
a. Living will
b. Informed consent
c. Durable power of attorney for health care
d. Do Not Resuscitate
-A living will is a legal document that specifically outlines a client’s wishes regarding life-sustaining
treatment.
A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been
prescribed a high calorie, low protein diet. Which of the following meal selections is appropriate for this
client?
a. Grilled cheese sandwich, potato chips, chocolate pudding.
b. Chicken breast, mashed potatoes, spinach.
c. Scrambled eggs, bacon and pancakes.
d. Steak, French fries, corn.
-This option meets the prescribed diet. It is high in calories and while chicken does provide protein it is a
low-fat source and can be eaten in moderation on a low-protein diet. Spinach will provide additional
vitamin K for this client at risk for bleeding due to liver failure.
A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce
the client's risk for falls?
a. Hourly rounding by the nurse.
b. Place bedside table in close proximity.
