1. Which actions are associated with a first-level need according to Maslows
hierarchy of needs? Select all that apply
1) eating a sandwich for lunch
2) inviting friends over for a party
3) taking a nap after working out at the gym
4) getting a haircut before the holiday season
5) locking the car door when alone in the car
6) Taking a bottle of water along when going for a walk Ans 1,3,6
2. A nurse identifies a 1 cm superficial break in the skin over the right trochanter of a
client during an admission assessment.What should the nurse do first?
1) initiate a turning schedule
2) complete a skin assessment form
3) inform the primary healthcare provider of the clients status
4) start wound care based on the agencys pressure ulcer protocol Ans 2
3. Which situations may lead to a legal action for assault? Select all that apply.
1) A nurse threatens a client with inserting a tube to feed the client if the client does not
eat all the food on their meal tray
2) A nurse administers a medication that the client has refused by telling the client
,that it is different from the refused medication
3) A nurse uses a restraint when a client attempts to leave the hospital before the
primary provider writes a discharge prescription
4) A nurse tells a client who has a prescription for bed rest that unless the client
stays in bed the 4 side rails on the bed will have to be raised
5) A nurse is heard by a client's relative telling another nurse on an elevator that the
client contracted hepatitis C from IV drug use when in fact, the client contracted the
disease via a blood transfusion Ans 1,4
4. A nurse caring for a newly admitted client reviews the information on the clients
admission history and performs a chart review. The nurse should as- sess the client
for which additional human response based on data collected?
1) Peripheral edema
2) burning on urination
3) suprapubic distension
4) decreased blood pressure Ans 3
5. A nurse assess four clients to determine their hygiene needs. The nurse should
anticipate that the client with which problem will have the greatest difficulty
having hygiene needs met by the nurse?
1) Pain
,2) Dementia
, 3) Impaired vision
4) Limited mobility Ans 2
6. A client with the diagnosis of stage 4 pancreatic cancer is consulting with a
discharge planner regarding the most appropriate level of care required after
palliative surgery. The client is able to provide self-care but will need pain
management. Which setting is most appropriate for this client?
1) Home hospice care
2) Rehab facility
3) Skilled nursing facility
4) Assistive living apartment Ans 1
7. A client comes to the emergency department reporting a sore throat and earaches.
The client has a hx of diverticulitis and emphysema with shortness of breath. Which
routes can the nurse use to obtain the clients temperature safely? Select all that apply
1) Oral
2) Skin
3) Rectal
4) Axillary
5) Temporal
6) Tympanic Ans 2,4,5