ASSESSMENT 1 PRE PROCTORIO FUNDAMENTALS (NURS
100) ) WITH COMPLETE QUESTIONS WITH ANSWERS
LATEST UPDATED 100% VERIFIED & DETAILED
SOLUTIONS ( ALREADY GRADED A+)(2024-2025)
A nurse is caring for a client who is postoperative following a knee
arthroplasty and requires the use of thigh-length sequential
compression sleeves. Which of the following actions should the nurse
take?
Make sure two fingers can fit under the sleeves.
(The nurse should ensure that there is enough space for two fingers to
fit under the sleeve because any less space between the sleeves and
the legs can inhibit circulation when the sleeves inflate.)
A nurse is caring for a client who has pancreatitis.
-Exhibit 1
Nurses' Notes
1000:Client states, "I am unable to eat anything without vomiting."
Client reports pain in left upper quadrant of abdomen that radiates to
their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising
noted on client's abdomen. Client is pale and diaphoretic. Provider
prescribed blood work, abdominal CT, and NG tube insertion with low-
intermittent decompression. IV fluids started and infusing in left
peripheral IV site.
-Exhibit 2
Vital Signs
1000:
,BP 96/52 mm Hg
Heart rate 110/min
Respirations 22/min
Temperature 38.4° C (101.1° F)
Oxygen saturation 92% on room air
-Exhibit 3
Prescriptions
1100:
• CT of abdomen
• NG tube to low wall suction
• Serum amylase level
Select the 3 tasks the nurse should delegate to an assistive personnel
(AP).
-Document the client's vital
-Measure the client's intake and output
-Transfer the client from wheelchair to bed
(*Document the client's vital signs is correct. The nurse should identify
that documenting the client's vital signs is a task that is within the AP's
range of function.
*Measure the client's intake and output is correct. The nurse should
identify that measuring the client's intake and output is a task that is
within the AP's range of function.
*Transfer the client from wheelchair to bed is correct. The nurse should
identify that transferring the client from wheelchair to bed is a task that
is within the AP's range of function.)
A nurse is caring for a child who has a prescription for a blood
transfusion. The child's parents have refused the treatment due to their
religious beliefs. Which of the following actions should the nurse take?
, Examine personal values about the issue.
(Nurses should examine their values about the issue in question to
provide care that is without bias.)
A nurse is caring for a client who is postoperative and is exhibiting signs
of hemorrhagic shock. The nurse notifies the surgeon, who tells the
nurse to continue to measure the client's vital signs every 15 min and to
report back in 1 hr. Which of the following actions should the nurse
take next?
Notify the nursing manager.
(The greatest risk to the client is not receiving timely intervention for a
deterioration in physiological status; therefore, the next action the
nurse should take is to activate the chain of command to ensure that
the client receives the necessary care.)
A nurse on a medical-surgical unit is caring for a client who has a new
prescription for wrist restraints. Which of the following actions should
the nurse take?
Pad the client's wrist before applying the restraints.
(The use of restraints without padding can abrade the client's skin,
resulting in client injury.)
A nurse is caring for a client who has pharyngeal diphtheria. Which of
the following types of transmission precautions should the nurse
initiate?
Droplet
(Droplet precautions are a requirement for clients who have infections
that spread via droplet nuclei that are larger than 5 microns in
100) ) WITH COMPLETE QUESTIONS WITH ANSWERS
LATEST UPDATED 100% VERIFIED & DETAILED
SOLUTIONS ( ALREADY GRADED A+)(2024-2025)
A nurse is caring for a client who is postoperative following a knee
arthroplasty and requires the use of thigh-length sequential
compression sleeves. Which of the following actions should the nurse
take?
Make sure two fingers can fit under the sleeves.
(The nurse should ensure that there is enough space for two fingers to
fit under the sleeve because any less space between the sleeves and
the legs can inhibit circulation when the sleeves inflate.)
A nurse is caring for a client who has pancreatitis.
-Exhibit 1
Nurses' Notes
1000:Client states, "I am unable to eat anything without vomiting."
Client reports pain in left upper quadrant of abdomen that radiates to
their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising
noted on client's abdomen. Client is pale and diaphoretic. Provider
prescribed blood work, abdominal CT, and NG tube insertion with low-
intermittent decompression. IV fluids started and infusing in left
peripheral IV site.
-Exhibit 2
Vital Signs
1000:
,BP 96/52 mm Hg
Heart rate 110/min
Respirations 22/min
Temperature 38.4° C (101.1° F)
Oxygen saturation 92% on room air
-Exhibit 3
Prescriptions
1100:
• CT of abdomen
• NG tube to low wall suction
• Serum amylase level
Select the 3 tasks the nurse should delegate to an assistive personnel
(AP).
-Document the client's vital
-Measure the client's intake and output
-Transfer the client from wheelchair to bed
(*Document the client's vital signs is correct. The nurse should identify
that documenting the client's vital signs is a task that is within the AP's
range of function.
*Measure the client's intake and output is correct. The nurse should
identify that measuring the client's intake and output is a task that is
within the AP's range of function.
*Transfer the client from wheelchair to bed is correct. The nurse should
identify that transferring the client from wheelchair to bed is a task that
is within the AP's range of function.)
A nurse is caring for a child who has a prescription for a blood
transfusion. The child's parents have refused the treatment due to their
religious beliefs. Which of the following actions should the nurse take?
, Examine personal values about the issue.
(Nurses should examine their values about the issue in question to
provide care that is without bias.)
A nurse is caring for a client who is postoperative and is exhibiting signs
of hemorrhagic shock. The nurse notifies the surgeon, who tells the
nurse to continue to measure the client's vital signs every 15 min and to
report back in 1 hr. Which of the following actions should the nurse
take next?
Notify the nursing manager.
(The greatest risk to the client is not receiving timely intervention for a
deterioration in physiological status; therefore, the next action the
nurse should take is to activate the chain of command to ensure that
the client receives the necessary care.)
A nurse on a medical-surgical unit is caring for a client who has a new
prescription for wrist restraints. Which of the following actions should
the nurse take?
Pad the client's wrist before applying the restraints.
(The use of restraints without padding can abrade the client's skin,
resulting in client injury.)
A nurse is caring for a client who has pharyngeal diphtheria. Which of
the following types of transmission precautions should the nurse
initiate?
Droplet
(Droplet precautions are a requirement for clients who have infections
that spread via droplet nuclei that are larger than 5 microns in
