With Answers
Awchargewnursewonwpedwunitwiswmakingwassignmentswforwawnursewwhowhaswfloatedwfromwla
borwandwdeliverywunit.wWhichwofwthewfollowingwclientswiswappropriatewforwchargewnursewtowa
ssign.
A.wAwpreschoolerwwithwawhipwspicawcastwwhowiswbeingwdischargedwtoday
B.wanwinfantwscheduledwforwawsurgicalwrepairwofwventricularwseptalwdefectwtomorrow
C.wawtoddlerwwithwawfracturedwfemurwwhowhaswbeenwinwBryantswforw5wdays
Dwanwadolescentwwhowisw2wdayswpostwopwfollowingwanwappendectomy.w-
wCORRECTwwANSWER-
Anwadolescentwwhowisw2wdayswpostwopwfollowingwanwappendectomy
rationale:wThewcarewrequirewfundamentalwnursingwskillswandwknowledge
Awclientwiswscheduledwforwawlumbarwpuncturewtowrulewoutwbacterialwmeningitis.wShewtellswthe
wnursewthatwshewiswfearfulwofwbecomingwparalyzedwfromwthewneedlewbeingwplacedwintowherws
pinalwcolumn.wWhichwresponsewshouldwnursewmake?
A.wletswnotwfocuswonwthewnegative.wletswfocuswonwgettingwbetter
Bwwhywarewyouwfeelingwsowanxiouswaboutwthiswprocedure
Cwthewneedlewiswinsertedwbelowwthewthirdwlumbarwvertebrae,wwellwbelowwthewpointwatwwhich
wyourwspinalwcordwends.
D.wYourwdoctorwiswverywskilledwinwthiswprocedure.wEverythingwwillwbewallwright.w-
wCORRECTwwANSWER-
"Thewneedlewiswinsertedwbelowwthewthirdwlumbarwvertebrae,wwellwbelowwthewpointwatwwhichwt
hewspinalwcordwends."
rationale:wThiswiswawtherapeuticwresponsewthatwprovideswinformationwthatwspecificallywaddr
esseswthewclient'swconcernswandwhelpswtowdecreasewanxietywandwfears.
Awnursewatwawlongwtermwcarewfacilitywiswparticipatingwinwqualitywimprovementwprojectwtowred
ucewoccurrencewofwpressurewulcers.wWhichwofwthewfollowingwauditswshouldwbewconductedwt
owdeterminewthewimpactwofwawnewwskincarewregimenwonwthewincidencewofwpressurewulcersw
amongwclientswwhowarewimmobile?
a.wprospectivewaudit
b.woutcomewaudit
c.wprocesswaudit
d.wstructurewauditw-wCORRECTwwANSWER-outcomewaudit
,rationale:wAnwoutcomewauditwiswconductedwtowdeterminewthewactualwresultwawspecificwnursin
gwinterventionwhaswhadwonwclientwoutcomes.wThiswtypewofwauditwiswappropriatewtowusewwhen
wdeterminingwthewimpactwofwawnewwskincarewregimenwonwthewincidencewofwpressurewulcersw
amongwclientswwhowarewimmobile.
Awnursewhaswassignedwfourwtaskswtowanwassistivewpersonnel.wWhichwofwthewfollowingwshoul
dwthewnursewinstructwthewAPwtowperformwfirst?
A.wtakewanwABGwspecimenwtowthewlab.
B.wTransportwawclientwtowthewradiologywdepartmentwforwanwxray.
Cwobtainwawcleanwcatchwurinewsamplewforwawnewlywadmittedwclient
Dwpasswfreshwwaterwtowclientsw-wCORRECTwwANSWER-TakewanwABGwspecimenwtowthewlab
rationale:wABGwsampleswarewkeptwonwicewandwshouldwbewtransportedwimmediatelywtowthewl
abworwthewspecimenwwillwdeteriorate.
Awnursewhaswbeenwassignedwtowcarewforwfourwclientswonwawmedwsurgwfloor.wWhichwofwthewfoll
owingwclientswshouldwthewnursewevaluatewfirst?
A.wAwclientw48whourswfollowingwabdominalwsurgerywwithwrednesswandwswellingwatwthewedge
swofwthewincision.
B.wAwclientwfollowingwkneewreplacementwsurgerywcomplainingwofwpainwandwwarmthwinwthewc
alf.
C.wAwclientwadmittedwwithwcholecystitiswwhowreportswfrequentwnauseawandwvomiting
D.wAwclientwadmittedwwithwawGIwbleedwreceivingwpackedwRBCswforwhemoglobinwofw7.8wgm/d
Lw-wCORRECTwwANSWER-
Awclientwfollowingwkneewreplacementwsurgerywcomplainingwofwpainwandwwarmthwinwthewcalfw
Rationale:wThromboembolismwiswawpotentiallywseriouswcomplicationwafterwjointwsurgerieswa
ndwpain,wwarmthwandwrednesswarewclinicalwmanifestationswofwthromboembolismwwhichwcan
wleadwtowawpulmonarywembolism.
Awnursewinwawlong-
termwfacilitywiswassistingwwithwanweducationalwprogramwregardingwcommonwsiteswofwhealthw
carewassociatedwinfectionswforwawgroupwofwnewlywhiredwassistivewpersonnel.wWhichwofwthewf
ollowingwsiteswshouldwbewincludedwinwthewteachingw(selectwallwthatwapply)w
A.wurinarywtract
b.wsurgicalwwound
cwmusculoskeletalwsystem
d.wrespiratorywtract
e.wbloodwstreamw-wCORRECTwwANSWER-Urinary
surgicalwwound
respiratory
bloodwstream
awnursewinwawpedwofficewiswconductingwawtelephonewtriagewandwreceiveswawcallwfromwawclient
wregardingwherw4-day-
, oldwnewbornwwhowwaswcircumcisedw2wdayswago.wthewmotherwstateswherwsonwhaswawyelloww
dischargewaroundwhiswpeniswandwaskswthewnursewwhatwshewshouldwdo.wwhatwiswanwappropri
atewresponsewfromwthewnursew-wCORRECTwwANSWER-
"downotwattemptwtowremovewit"thewyellowwexudatewcoverswthewpenisw24whrwafterwthewcircum
cisionwandwwillwpersistwforw2-
3wdays.wthiswiswanwexpectedwfindingwandwshouldwnotwbewremoved
Awnursewinwawprovider'swofficewiswcollectingwdatawonwawgroupwofwclientswwhowarewpregnant.w
Whichwofwthewfollowingwclientswshouldwbewthewnurse'swprioritywconcern?
A.wAwclientwwhowisw26wweekswofwgestationwandwreportingwleukorrhea.
B.wAwclientwwhowisw10wweekswofwgestationwandwreportingwurinarywfrequency.
C.wAwclientwwhowisw37wweekswofwgestationwandwreportingwperinealwdiscomfort.
D.wAwclientwwhowisw34wweekswofwgestationwandwreportingwabdominalwtendernessw-
wCORRECTwwANSWER-
Awclientwwhowisw34wweekswofwgestationwandwreportingwabdominalwtenderness
Rationale:wAbdominalworwuterinewtendernesswiswanwearlywclinicalwfindingwassociatedwwithwa
bruptionwplacenta,wwhichwcouldwleadwtowanwunstablewstatus.
Awnursewinwawrehabwcenterwiswcaringwforwawclientwwhowjustwhadwawcerebrovascularwaccident.
wBasedwonwawreviewwofwthewclient'swmedicalwrecord,wwhichwofwthewfollowingwfindingswshould
wbewimmediatelywreportedwtowthewprovider?
A.wTemperaturew37.6wCw(99.8wF)
B.wBloodwglucosewlevelw144wmg/dL
C.wdrywmouth
D.wheadachew-wCORRECTwwANSWER-Temperaturew37.6wCw(99.8wF)
rationale:wsorewthroat,wmalaise,wmouthwsores,wandwfeverwarewclinicalwfindingswassociatedw
withwagranulocytosis,wawpotentiallywdangerouswbloodwdyscrasiawthatwiswanwadverseweffectw
ofwclozapine.
Awnursewiswassessingwawclientwwhowiswpostopwfollowingwawgastricwbypass.wwhichwofwthewfind
ingswindicateswthewclientwcouldwbewexperiencingwanwanastomoticwleak?
A.wLethargy
B.wNeuralgia.
C.wBradycardia
D.wOliguriaw-wCORRECTwwANSWER-Oliguria
Rationale:wWhenwawgastricwbypasswiswperformed,wthewstomach,wduodenum,wandwpartwofwjej
unumwarewbypassedwbywsurgicallywconnectingwthewsmallwintestinewtowawnewlywcreatedwsto
machwpouch.wThewleakagewofwgastricworwintestinalwfluidswatwthiswconnectionwiswanwanastom
oticwleakwandwcanwresultwinwperitonitisworwdeath.wOliguriawiswawfindingwconsistentwwithwperito
nitiswandwcanwindicatewclientwiswexperiencingwanastomoticwleak.