1. A nurse in an acute care facility is preparing a discharge summary for a
client who is transferring to a long-term care facility. Which of the following
documentation should the nurse include?
A. Client flow sheet
B. Acuity ratings
C. Current medications
D. Incident reports: C. Current medications
The nurse should include the client's medications in the discharge summary to
ensure client safety and continuity of care.
2. A nurse is reviewing protocol in preparation for suctioning secretions from
a client who has a new tracheostomy. Which of the following actions should
the nurse plan to take?
A. Use a resuscitation bag with 80% oxygen prior to the procedure.
B. Select a suction catheter that is half the size of the lumen.
C. Place the end of the suction catheter in water-soluble lubricant.
D. Adjust the wall suction apparatus to a pressure of 170 mm Hg.: B. Select a
suction catheter that is half the size of the lumen.
,The nurse should select a suction catheter that is half the size of the lumen to prevent
hypoxemia and trauma to the mucosa.
3. A nurse is caring for a client who has decreased mobility. Which of the
following actions should the nurse take to decrease the client's risk of devel-
oping plantar flexion contractures?
A. Place a pillow under the client's knees.
B. Position a trochanter roll under each of the client's hips.
C. Advise the client to wear rubber-soled slippers.
D. Apply an ankle-foot orthotic device to the client's feet.: D. Apply an ankle-foot
orthotic device to the client's feet.
The nurse should use a device to maintain dorsiflexion, such as an ankle-foot
orthotic device or a foot board placed perpendicular to the mattress.
4. A nurse manager is overseeing the care activities on a unit. For which of the
following situations should the nurse manager intervene due to a violation of
HIPAA guidelines?
, A. A nurse who is caring for a client reviews the client's medical chart with a
nursing student who is working with the nurse.
B. A nurse asks a nurse from another unit to assist with documentation for a
client.
C. A nurse who is caring for a client returns a call to the person appointed in
the health care proxy to discuss the client's care.
D. A nurse discusses a client's status with the physical therapist who is
caring for the client.: B. A nurse asks a nurse from another unit to assist with
documentation for a client.
Only health care professionals directly caring for a client should have access to the
client's medical information; therefore, this is a violation of HIPAA guidelines.
5. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medica-
tion to a client. Which of the following actions should the nurse take?
A. Gently shake the container of medication prior to administration.
B. Transfer the medication to a medicine cup.
C. Place the client in a semi-Fowler's position prior to medication administra-
tion.
D. Verify the dosage by measuring the liquid before administering it.: A. Gently
shake the container of medication prior to administration.
The nurse should gently shake the liquid medication to ensure that the medication
is mixed.
6. A nurse on a medical unit is preparing to discharge a client to home. Which
of the following actions should the nurse take as part of the medication
reconciliation process?
A. Seal unused medications from the facility in a plastic bag.
B. Evaluate the client's ability to self-administer medications.
C. Report an identified discrepancy to The Joint Commission.
D. Compare prescriptions with medications the client received while at the
facility.: D. Compare prescriptions with medications the client received while at the
facility.
When performing medication reconciliation, the nurse should create a current,
accurate list of every medication the client is or should be taking. Part of the process
client who is transferring to a long-term care facility. Which of the following
documentation should the nurse include?
A. Client flow sheet
B. Acuity ratings
C. Current medications
D. Incident reports: C. Current medications
The nurse should include the client's medications in the discharge summary to
ensure client safety and continuity of care.
2. A nurse is reviewing protocol in preparation for suctioning secretions from
a client who has a new tracheostomy. Which of the following actions should
the nurse plan to take?
A. Use a resuscitation bag with 80% oxygen prior to the procedure.
B. Select a suction catheter that is half the size of the lumen.
C. Place the end of the suction catheter in water-soluble lubricant.
D. Adjust the wall suction apparatus to a pressure of 170 mm Hg.: B. Select a
suction catheter that is half the size of the lumen.
,The nurse should select a suction catheter that is half the size of the lumen to prevent
hypoxemia and trauma to the mucosa.
3. A nurse is caring for a client who has decreased mobility. Which of the
following actions should the nurse take to decrease the client's risk of devel-
oping plantar flexion contractures?
A. Place a pillow under the client's knees.
B. Position a trochanter roll under each of the client's hips.
C. Advise the client to wear rubber-soled slippers.
D. Apply an ankle-foot orthotic device to the client's feet.: D. Apply an ankle-foot
orthotic device to the client's feet.
The nurse should use a device to maintain dorsiflexion, such as an ankle-foot
orthotic device or a foot board placed perpendicular to the mattress.
4. A nurse manager is overseeing the care activities on a unit. For which of the
following situations should the nurse manager intervene due to a violation of
HIPAA guidelines?
, A. A nurse who is caring for a client reviews the client's medical chart with a
nursing student who is working with the nurse.
B. A nurse asks a nurse from another unit to assist with documentation for a
client.
C. A nurse who is caring for a client returns a call to the person appointed in
the health care proxy to discuss the client's care.
D. A nurse discusses a client's status with the physical therapist who is
caring for the client.: B. A nurse asks a nurse from another unit to assist with
documentation for a client.
Only health care professionals directly caring for a client should have access to the
client's medical information; therefore, this is a violation of HIPAA guidelines.
5. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medica-
tion to a client. Which of the following actions should the nurse take?
A. Gently shake the container of medication prior to administration.
B. Transfer the medication to a medicine cup.
C. Place the client in a semi-Fowler's position prior to medication administra-
tion.
D. Verify the dosage by measuring the liquid before administering it.: A. Gently
shake the container of medication prior to administration.
The nurse should gently shake the liquid medication to ensure that the medication
is mixed.
6. A nurse on a medical unit is preparing to discharge a client to home. Which
of the following actions should the nurse take as part of the medication
reconciliation process?
A. Seal unused medications from the facility in a plastic bag.
B. Evaluate the client's ability to self-administer medications.
C. Report an identified discrepancy to The Joint Commission.
D. Compare prescriptions with medications the client received while at the
facility.: D. Compare prescriptions with medications the client received while at the
facility.
When performing medication reconciliation, the nurse should create a current,
accurate list of every medication the client is or should be taking. Part of the process
