ANSWERS
• A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following
should occur during the orientation p
• A nurse in an acute mental health facility is caring for a newly admitted client. Which of the fola client
who has dehydration due to diarrhea. Which of the following findings should the nurse report to the pr
ovider? - ANSWER-Urine output 12 mL/hr
.• A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is to undergo a
contraction stress test. Which of the following statements by the client indicates an understanding of
the teaching? - ANSWER-I am having this test because my baby was not reactive during a nonstress test
.a charge nurse in a long-term care facility is developing a performance improvement plan for an
assistive personnel (AP). Which of the following actions should the nurse take when developing the
plans?
(Select all that apply) - ANSWER-Set a specific time frame for meeting performance goals
Ask the nurse supervisor to review the plan
Include the performance standard that the AP should meet
.A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall
precautions. Which of the following statements made by the nurse indicates an understanding of the
teaching? - ANSWER-"I will instruct the client to sit when putting on a pair of pants"
,.A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a
client's medical information. Which of the following individuals should the charge nurse identify as
appropriate with whom to share client information? - ANSWER-a social worker who is assigned to an
involuntary committed school age client
.A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a
tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse
intervene? - ANSWER-Suction for 30 seconds
.A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit.
Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching? - ANSWER-"I will document in the medical record the support nurse who assists with planning
care for my clients"
.A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following
actions by the newly licensed nurse should the supervising nurse intervene? - ANSWER-Tells a client he
will lose his phone privileges if he does not take his medication
.A charge nurse working in a long-term care facility overhears two AP's in the nurses stations discussing
a client who was just admitted. Which of the following actions should the charge nurse take? - ANSWER-
Tell the APs to stop the conversation
.A community health nurse is assisting in the development of a brochure about hypertension. Which of
the following actions should the nurse take? - ANSWER-Explain the medical terminology using basic one
syllable words
.A community health nurse is assisting with the development of a pamphlet regarding choking hazards
for toddlers. Which of the following foods should the nurse include? - ANSWER-grapes
.A home health nurse is caring for an older adult client who has rheumatoid arthritis. Which of the
following findings should the nurse identify as a safety risk? - ANSWER-The client's electrical wires are
run under carpeting
.A nurs is caring for a client wie suddenly develops chest pain and dyspea. Which of the following should
the nurse take first? - ANSWER-Elevate the head of the client's bed
, .A nurse begins to bath a newly admitted client who reports that she has not had anything to eat that
day.
The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an
example of which of the following? - ANSWER-Countertransference
.A nurse enters the room of a school age child and finds him on the food experiencing a tonic clonic
seizure. Which of the following actions should the nurse take? - ANSWER-Place a pillow under the child's
head
.A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of
vaginal fluids. Which of the following findings is evidence of an obstetric complication? - ANSWER-
Appears greenish-brown in color
.A nurse in a provider's office is collecting data from a client who has a history of hypertension during his
annual physical examination. Which of the following findings should the nurse report to the provider
immediately? - ANSWER-blurred vision
.A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following
statements made by the client should the nurse report to the provider ? - ANSWER-" I try not to look at
the scales on my body."
.A nurse in a providers office is reinforcing teaching about cigarette smoking. Which of the following
adverse effect should the nurse include in the teaching? - ANSWER-Somnolence
.A nurse in an acute care setting is preparing to administer medications to a client. Which of the
following actions should the nurse verify the client's identity? - ANSWER-Verify the client's identity using
a photograph
.A nurse in an inpatient psychiatric unit is caring for a client who was raised in an Asian culture. Which of
the following communication techniques by the nurse demonstrates cultural sensitivity? - ANSWER-
holding eye contact for brief instances