ATI & NCLEX Final Exam Questions and Answers 2023

ATI & NCLEX Final Exam Questions and Answers 2023 A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply) - Home Health Care - Rehabilitation Facilities - Diagnostic Centers - Skilled Nursing Facilities - Oncology Centers *ANS* Home Health Care Rehabilitation Facilities Skilled Nursing Facilities These promote self-care and restorative health. A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring Evidence based practice for clients who have specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining if medications are safe for administration to clients *ANS* B. Ensuring that Health care providers comply with regulations. The nurse should identify that state licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations. A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary? (Select all that apply) - Intensive Care Unit - Oncology Treatment Centers - Burn Center - Cardiac Rehabilitation - Home Health Care *ANS* Intensive Care unit Oncology treatment Centers Burn Center Tertiary Care involves the provision of specialized and highly technical care. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply) - A client who is terminal cancer request hospice care in her home - A client ask about community resources available for older adults - A client who states that she wants her child baptized before surgery - A client request an electric wheelchair for use after discharge - A client states that he does not want to use a nebulizer *ANS* A client who has terminal cancer and request hospice care in her home A client who ask about community resources available for older adults A client who request an electric wheelchair for use after discharge A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical‑surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs *ANS* Bathing Ambulating Toileting Measuring Vital Signs A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence *ANS* Autonomy The client is exercising his right to make his own decisions A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence *ANS* Beneficence The action the promotes good for others, without any self interest. Taking positive action to help the client. A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principals? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence *ANS* C. Justice A fairness in care delivery and in use of resources. A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence *ANS* D. Nonmaleficence A commitment to do no harm. The nurse is being ethical by not wanting to cause more pain to the patient. A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill. D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form. *ANS* C. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill. There is not legal issue. It is an ethical dilemma because there is not easy way to resolve. The decision will be very life changing to client condition. A nurse observes an assistive personal (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is AP committing? A. Assault B. Battery C. False Imprisonment D. Invasion of Privacy *ANS* A. Assault Verbal Threatening is against the law. A nurse caring for a competent adult client who tells the nurse that the he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she prepares to administer a PRN sedative medication that the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False Imprisonment C. Negligence D. Breech of confidentiality *ANS* B. False Imprisonment. Medication was given with patients consent, it was used as a chemical restraint. A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." *ANS* C. "I plan to write that I don't want them to keep me on a breathing machine." A client has the right to chose what he/she wants in a life-threatening situation. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take? A. Alert the American Nurse Association B. Fill out an incident report C. Report the observation to the nurse manager on the unit D. Leave the nurse alone to sleep. *ANS* C. Report the observation the nurse manager on the unit. When entering client's room to change dressing, nurse notes client is coughing & sneezing. When preparing sterile field, it's important the nurse... A: keep sterile field at least 6 ft away from client's bedside B: instruct client to not cough/sneeze during dressing change C: place mask on client to limit spread of microorganisms into surgical wound D: keep box of Kleenex nearby for client to use during dressing change *ANS* C. Place mask on the client to limit spread of microorganisms into surgical wound Creates barrier, prevents spread. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body *ANS* D. Flap farthest from the body. Maintain sterility, and keep client safe from risk on infection. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand *ANS* The inner wrapping of an item on the sterile field An irrigation syringe on the sterile field One gloved hand with the other gloved hand. A nurse is reviewing hand hygiene techniques with a group of assistive personnel AP. Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) - Apply 3 to 5 mL of liquid soap to dry hands - Wash the hands with soap and water for atleast 15 seconds. - Rinse the hands with hot water - Use a clean paper towel to turn off faucets - Allow the hands to air dry *ANS* Apply 3 to 5mL of liquid soap to dry hands Wash hands with soap and water for at least 15 seconds Use a clean paper towel to turn off faucets A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field. *ANS* The nurse moistens a cotton ball with sterile normal saline and places. The produce is delayed 1hr because the provider receives an emergency call. The nurse turns to speak to someone who enters through the door behind the nurse. A nurse is caring for a client who fell at a nursing home the client is oriented person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) Place a belt restraint on the bedside commode. Keep the bed in its lowest position with all side rails up. Make sure that the clients call lights is within reach. Provide the client with nonskid footwear Complete fall risk assessment *ANS* Make sure that the client call lights is within reach Provide the client with nonskid footwear Complete fall risk assessment A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurses' station for assistance." C. "I will administer his medications." D. "I will prepare to insert airway." *ANS* B. "I will go to the nurses station for assistance. A nurse caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete fall risk assessment B. Educate the client and family about fall risks C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aids in his possession. *ANS* A. Complete fall risk assessment. A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closet to the nurses' station? A. A middle adult who is postoperative following laparoscopic cholecystectomy. B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is postoperative following an open reduction internal fixation of the ankle D. An older adult who is postoperative following a below the knee amputation. *ANS* D. An older adult who is postoperative following a below the knee amputation. A nurse caring for a 20 year old client who is sexually active and has come to college health clinic for a first time check up. Which of the following interventions should the nurse perform first to determine the clients need for health promotion and disease? A. Measure vital signs B. Encourage HIV screening. C. Determine risk factors D. Instruct client to use condom *ANS* C. Determine Risk Factors The first action of the nurse is the assessment. Talk with the client to first to determine what risk factors the client might have before initiating the appropriate health promotion and disease prevention. A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of her actions. B. Identify the client's support systems. C. Suggest and recommend community sources. D. Devise and set goals for the client E. Teach stress management strategies. *ANS* Help the client see the benefits of her actions Identify the client's support systems Suggest and recommend community sources Teach stress management strategies A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? A. Cholesterol Screening B. Nutrition Presentation C. Medication Therapy D. Cardiac Rehabilitation *ANS* B. Nutrition Presentation A key primary prevention strategy because it promotes health and wellness. A nurse in a providers office is talking about routine screenings with a 45 year old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates the client understands how to proceed? A. "So I don't need the colon cancer procedure for another 2 to 3 years." B. For now, I should continue to have a mammogram each year." C. "Because the doctor just did a pap smear, I'll come back next year for another one." D. "I had my blood glucose test last year, so I won't need it again till next year." *ANS* "For now i should continue to have a mammogram each year." Female clients aged between 40 and 50 should have a mammogram annually. A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psycho motor learning has taken place. A. The client is able to discuss the appropriate technique. B. The client is able to demonstrate the appropriate technique C. The client states that he understands D. The client is able to write the steps on a piece of paper. *ANS* B. The client is able to demonstrate the appropriate technique. Demonstrating technique shows that psychomotor learning is taking place. A nurse providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incisions." B. "Will you give me pain medicine after surgery?" C. " Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say." *ANS* C. "Can you tell me about how long the surgery will take?" A nurse preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? A. Encouraging the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. Identify goals the nurse and the client agree are reasonable D. Determine what the client knows about stress incontinence. *ANS* D. Determine what the client knows about stress incontinence. Always asses the client first to determine what information they already know and so the nurse then can collect material, educate appropriately and set goals for client. A nurse is evaluating how well a client learned information he presented in an instructional session about following a heart-healthy diet. The client states the she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select and prepare meals. C. Encourage the client to fill out an evaluation form D. Ask the client if she has resources for further instruction on this topic. *ANS* B. Ask the client to explain how to select and prepare meals. Asking the client to explain in their own words & how she will implement the material is a good way to evaluate what they have learned & if they fully understand it. A nurse is caring for a client who states. "I have to check with my wife and see if she thinks i am ready to go home." The nurse replies, "How do you feel about going home today." Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating. *ANS* D. Reflecting. Reflecting directs the focus of the conversation back to the client so he can further explore his own feelings. Which of the following actions should the nurse take when using communication technique of active listening. (Select all that apply,) A. Use an open posture B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Respond positively when giving feedback. *ANS* Use open posture Establish and maintain eye contact Respond positively when giving feedback A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used to it!" B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about your support system you'll have after you leave the hospital." E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming." *ANS* "Your daily routines will be different when you get home." "Tell me about your support system you'll have after you leave the hospital." "Let me tell you about a friend of mine with a colostomy who also enjoys swimming." Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and the client. B. Encourage the client to communicate his thoughts and feelings. C. Give the nurse-client communication no time time limits D. Allow communication to occur spontaneously throughout the nurse-client relationship. *ANS* B. Encourage the client to communicate his thoughts and feelings. A nurse is caring for a school-age child who it sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child. C. Stand facing the child D. Stand with a relaxed posture. *ANS* B. Sit at eye level with the child. A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room. B. Ask the family one question at a time. C. Look at the interpreter with asking the family a question. D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk. *ANS* Ask the family one question at a time. Use lay terms if possible Do not interrupt the interpreter and the family as they talk. A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? A. Contact the hospitals spiritual services. B. Ask him what is making him cry. C. Provide quite times for these moments. D. Turn on the television for a distraction. *ANS* C. Provide quite times for these moments. A nurse caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make? A."I believe in this case you should really make an exception and accept the blood transfusion." B. "I know your family would approve of your decision to have a blood transfusion." C. " Why does your religion mandate that you cannot receive any blood transfusions." D."Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution." *ANS* D. "Lets discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution." What trends in in nursing are expected to influence nursing in the 21st century? Select all that apply. A. Higher client acuity in hospital and long-term settings B. Traditional nursing education programs C. Shift to community-based care D. Advanced technology E. Greater life expectancy *ANS* Higher client acuity in hospital and long-term settings. Shift to community-based care Advanced Technology Greater life expectancy A client has been involved in a motor vehicle crash and has multiple injuries. What guiding principle of Florence Nightingale would assist this client's recuperation and health maintenance? Select all that apply. A. Clean air and water B. Cleanliness C. Blood administration D. Light E. Efficient drainage *ANS* Clean air and water Cleanliness Light Efficient Drainage The nurse caring for a client must be attentive to the client's emotions, lifestyle, physical changes, spiritual needs, and individual challenges. When the nurse attends to these needs, what type of care is the nurse providing? A. Behavioral Healthcare B. Specialized Healthcare C. Caring Healthcare D. Holistic Healthcare *ANS* D. Holistic Healthcare. A high school student interested in becoming a nurse asks the nursing instructor what the role of the LPN/LVN is. What is the BEST response by the instructor? A. The LPN/LVN provides bedside car. B. The LPN/LVN develops the plan of care for clients. C. The LPN/LVN performs wound care. D. The LPN/LVN supervises registered nurses (RNs). E. The LPN/LVN administration prescribed medications to clients. *ANS* A. The LPN/LVN provides bedside care. The LPN/LVN is supervising a nursing assistant working in a long-term care facility. What task may be assigned to the nursing assistant by the LPN/LVN? A. Administer prescribed medication to a client. B. Change a sterile Dressing C. Assist with feeding a client D. Insert a nasogastric tube in a client *ANS* C. Assist with feeding a client A client no longer requires care in the coronary intensive care unit after coronary artery bypass graft surgery. Where should the nure prepare to transfer the client? A. Sub-acute or Step-down unit B. Skilled care unit C. Medical Floor D. Long-Term care *ANS* A. Sub-acute or Step-down unit The nurse is caring for a terminally ill client that is to be discharged. What referral should the nurse make with the client's family's approval? A. Extended Care B. Telehealth C. Respite Care D. Hospice *ANS* D. Hospice A client that is home bound requires long-term intravenous antibiotic therapy. The insurance company refuses to keep the client in the hospital during this treatment regimen. What services would best meet the needs of the client? A. Hospice B. Respite Care C. Home healthcare D. Telehealth *ANS* C. home healthcare The RN is developing the plan of care for a client with pneumonia. Who should the nurse include in the development of the care plan? A. Unit Secretary B. Dietary C. The client D. Administration. *ANS* C. The Client The nurse is concerned about a newly developed policy regarding scheduling on the unit. Who is the appropriate person for the nurse to discuss the concerns with? A. The nurse manager B. The nurse's peers C. The chief of nursing. D. The board of directors. *ANS* A. The nurse manager A student nurse approaches the instructor and states, "The staff nurse told me to witness this surgical consent after the surgeon signs it." What is the best response by the instructor? A. "Students are not to serve as a witness to legal papers. Let's explain this to the staff nurse so they may have it witnessed." B. " You will need another student to go with you and co-sign the consent" C. "That is fine. Do you want me to come with you?" D." This type of consent doesn't need to be witnessed." *ANS* A. "Students are not to serve as a witness to legal papers. Let's explain this to the staff nurse so they may have it witnessed." A nurse is caring for a client that has been confused and climbing out of the bed. What action should the nurse take if the nurse must take care of another client and leave the room? A. Place all four side rails up and come back and check on the client when finished with the other task. B. Place the client in soft wrist restraints so the client will not get out of the bed. C. Inform the client not to get out of bed. D. Don't leave the client alone and request that another nurse sit one-on-one with the client. *ANS* C. Do not leave the client alone and request that another nurse sit one-on-one with the client. A nurse discovers that a neighbor is a client on the unit in which the nurse works although the nurse is not assigned to care for that client. The nurse accesses the electronic medical record (EMR) to find out what the client's diagnosis is. What action may clients take if they are aware of this type of incident? A. Report the incident as a HIPPA violation B. Sue the nurse for libel C. Sue the nurse for negligence D. Report the nurse for defamation. *ANS* A. Report the incident as a HIPPA violation A staff nurse comes to work and accepts the assignment of clients. After a verbal altercation with the nurse manager about the assignments, the nurse states, "I quit!" and leaves the facility. What action may the nurse manager take? A. Call to ask the nurse to come back. B. Report the for abandonment of care C. Have the police arrest the nurse. D. Let the nurse cool off and come back when ready. *ANS* B. Report the nurse for abandonment of care. The nurse is caring for a client who is recovering from a recent stroke and is unable to move the left side of the body. Based on Maslow's hierarchy of needs, what nursing action will take priority in the care of this client? A.Ensuring the client is eating and drinking. B. Instituting fall precautions C. Assisting with education regarding sexual activity D. Providing care with hygiene. *ANS* A. Ensuring the client is eating and drinking. The nurse is observing a client to determine belonging needs. What questions will the nurse ask? A. "What type of medications are you taking" B. "Are you having difficulty breathing?" C. "Do you have a history of falling?" D. "Are you feeling isolated or upset?" *ANS* D. "Are you feeling isolated or upset?" The nurse is assisting a client who is recovering from a hip replacement in the home setting. The nurse offers suggestions to safety adaptions. What suggestions by the nurse would be most helpful in addressing the client's safety needs? Select all that apply. A. Encourage ambulation and exercise B. Adjust the temperature in the home for comfort C. Remove scatter rugs D. Use a night light E. Have a shower chair when bathing. *ANS* Encourage ambulation and exercise Remove scatter rugs Use a night light Have a shower chair when bathing A client is going to have a surgical procedure. What intervention provided by the nurse can help the client feel safe and aid in postoperative recovery? A. Explain the procedure before surgery B. Inform the client that they will be alright C. Call a family member prior to the client entering the surgical suite D. Make sure all insurance information has been obtained. *ANS* A. Explain the procedure before surgery A client with diabetes asks the nurse, "If i can't do heavy exercise, what's the point in exercising?" What response by the nurse can encourage the client to perform moderate exercise? Select all that apply. A. It will prevent the use of insulin. B. It will prevent cancer. C. It will enhance energy levels. D. It will reduce stress. E. It will provide relaxation. *ANS* It will enhance energy levels It will reduce stress It will provide relaxation A parent brings a toddler in to the clinic with a strong odor of cigarette smoke on the toddler's clothing. What information should the nurse discuss with the parent? A. Second hand smoke may cause numerous health-related problems. B. If the parent continues to smoke around the child, the parent will be reported for child abuse. C. Continuing to smoke around the child can create childhood nicotine addiction. D. Seeing a parent smoke will lead to a child smoking. *ANS* A. Second hand smoke may cause numerous health-related problems. The nurse is gathering data from a client in the home setting for care of a pressure wound. The nurse observes multiple areas of ecchymosis in various stages of healing. The client states, "They do the best care for but get frustrated when i wet the bed." What is the priority nursing action? A. Ask the family why they are abusing the client B. Place the client in the car and take the client to the nearest ER. C. Ensure the clients safety and notify adult protective services D. Call the police department and file a complaint. *ANS* C. Ensure the clients safety and notify adult protective services. A client is admitted to the acute care facility with a suspected case of malaria. What question is priority? A. Have you had unprotected sex? B. Have you recently traveled out of the country? C. What medications are you taking? D. Do you take any street drugs? *ANS* B. Have you recently traveled outside of the country The nurse is caring for a group of clients. What Fundamentals procedure of healthcare should the nurse include in the care? A. Sterile Techniques B. Having assistance from another healthcare worker C. Determining financial status D. The use of standard precautions *ANS* D. The use of standard precautions. The nurse is visiting an older adult client in the home for a dressing change. When the nurse arrives she finds the client on the floor, unresponsive. What is the priority action by the nurse? A. Notify the clients family members B. Obtain clients glucose levels C. Est. patent airway D. Take the clients BP *ANS* Establish Client Airways The nurse is assigned to care for a group of four clients. Which client should be seen first? A. A client, short of breath with chest pain. B. A client that is incontinent of stool. C. A client requiring a flu vaccine D. A client requesting a bath *ANS* A. A client, short of breath with chest pain. The nurse is caring for a client with acute blood loss from a duodenal ulcer. The client is a Jehovah's Witness and refuses consent for blood administration ordered by the physician. What action by the nurse is appropriate? A. Sedate the client and assist with the blood administration. B. Inform the client that death is probable without the blood C. Respect the client's wishes and continue to monitor the client's condition D. Have the clients sign out of the hospital against medical advice. *ANS* C. Respect the client's wishes and continue to monitor the client's condition. The nurse is attempting to obtain data from a client who only speaks Spanish. What is the best action by the nurse? A. Obtain a professional interpreter B. Ask a family member to interpret C. Ask a bilingual nurse to assist D. Use a translation application on a smartphone *ANS* A. Obtain a professional interpreter. A muslim-arab female client is in the clinic for a gynecologic procedure. The client does not directly look at the nurse or physician in the eye when speaking. What does the nurse interpret this behavior to mean? A. The client does not trust the caregivers B. The client is demonstrating modesty C. The client believes she has a sexually transmitted infection D. The client has been sexually abused. *ANS* B. The client is demonstrating modesty. The nurse is preparing to irrigate a draining wound. What protective personal equipment should be donned because of a risk splashing? Select all that apply. A. Shoe protectors B. Particulate filter mask C. Face shield D. Gloves E. Mask *ANS* Face Shield Gloves Mask What observations made by the charge nurse requires that the LPN/LVN receive further education? A. The LPN/LVN recaps a needle after injecting a client. B. The LPN/LVN places the safety lock on the needle after injecting a client C. The LPN/LVN washes her hand injecting a client with medication. D. The LPN/LVN places a syringe and needle in the sharp container. *ANS* A. The LPN recaps a needle after injecting a client. The nurse is visiting an older adult client in the home for a dressing change. When the nurse arrives she finds the client on the floor, unresponsive. What is the priority action by the nurse? *ANS* Establish Client Airways The nurse is providing care to a group of clients. What priority action by the nurse can help decrease the spread of infection to this client group? A. Have the client wear a mask whenever care is delivered B. Administer prophylactic antibiotics to all clients. C. Wash hands when entering and leaving client rooms. D. Wear gloves whenever delivering client care. *ANS* C. Wash hands when entering and leaving client rooms. Which of these clients need to be placed in protective isolation? Select all that apply. A. A client with sever burns over 50% of the body B. A client taking antibiotics for an infection C. A client receiving large doses of corticosteroids. D. A client with bronchitis E. A client receiving a bone marrow transplant *ANS* A client with severe burns over 50% of the body A client taking antibiotics for an infection A client with Bronchitis A client receiving a bone marrow transplant A client is suspected to be infected with methicillin-resistant Staphylococcus aureus (MRSA) in a sacral wound. What precautions should the nurse be sure are followed during wound care? A. Droplet B. Contact C. Airborne D. Standard *ANS* B. Contact Which client requires a negative pressure room? A. A client with pneumonia B. A client with pharyngitis C. A client with a draining leg wound D. A client with pulmonary tuberculosis *ANS* A. A client with pulmonary tuberculosis The nurse is interviewing a client during admission to the hospital and the client gives information that is unclear to the nurse. That statement made by the nurse best demonstrates "seeking clarification?" A. I don't know what you are talking about B. What did you say? C. We can move on to something else D. Would you please explain what you meant? *ANS* D. Would you please explain what you meant A client has been diagnosed with a terminal illness and is crying. What statement made by the nurse is a barrier for further communication? A. Everything will be okay. It out of your hands. B. I am here if you would like to talk C. Is there anything that i can do for you or questions that I can answer. D.This must be difficult for you *ANS* A. Everything will be okay. Its out of your hands. A client is having abdominal pain. What open-ended statement can the nurse use to find out more about the clients condition? A. Tell me more about how you feel B. Rate your pain on a scale of 1 to 10 C. Point with one finger where your pain is located D. What medication are you taking? *ANS* A. Tell me more about how you feel? The nurse provided discharge instructions to a client. What statement made by the nurse can best help determine if the client understood the instructions? A. Reread the instructions that I gave you. B. Did you understand the instruction? C. Please repeat back in your own words the instructions I gave you. D. I am going to give you questions regarding the the instructions and I want you to answer them *ANS* C. Please repeat back in your own words the instructions I gave you.