Complete Questions with Correct
Answers,.
There has been a community disaster and stable clients must be discharged from a
facility to prepare for the influx of new casualties. A nurse should identify that which of
the following clients is safe to discharge? - Correct answera client who has
multiple sclerosis and reports ataxia
This client is safe to discharge because multiple sclerosis is a chronic disorder and
ataxia is an expected finding.
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize
that which of the following clients is the priority? - Correct answerA client who
has peripheral vascular disease and has an absent pulse in the right foot
When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority finding is an absent pulse, which indicates no blood flow to
the extremity.
A nurse finds that a new IV pump has infused 400 mL of solution over 2 hr when the
rate was set at 100 mL/hr. After notifying the provider and verifying that the pump was
properly programmed, which of the following is the nurse's priority? - Correct
answerTag the pump for maintenance and acquire a new pump for the client
The greatest risk is the potential for injury to a client if a nurse uses the pump again
before repair; therefore, the priority for the nurse is to tag the pump for maintenance and
acquire a new pump for the client.
A charge nurse is planning care for a group of clients. Which of the following tasks
should be delegated to an assistive personnel (AP)? select all that apply - Correct
answerambulating a client who uses a walker, adding thickener to thin liquids on a
client's food tray
Flushing a client's saline lock is incorrect. This is not within the AP's scope of practice.
Ambulating a client who uses a walker is correct. This is within the AP's scope of
practice.
, Adding thickener to thin liquids on a client's food tray is correct. This is within the AP's
scope of practice.
Teaching a client how to use an incentive spirometer is incorrect. This is not within the
AP's scope of practice.
Evaluating a client's gag reflex before mealtime is incorrect. This is not within the AP's
scope of practice.
A nurse is caring for a client. Which of the following tasks should the nurse delegate to
an assistive personnel (AP)? select all that apply - Correct answerPlace an
absorbent pad on the client's bed, report the client's blood pressure to the nurse, apply
barrier cream to the client's buttocks, document the client's vital signs
A charge nurse on a maternal newborn unit is receiving change of shift charge nurse
report for a group of newborns. Which of the following 3 newborns should the charge
nurse identify as requiring priority care? Select 3 newborns the charge nurse should
identify as priority. - Correct answerNewborn 5, Newborn 3, Newborn 1
When prioritizing hypotheses using the urgent vs. non-urgent approach to newborn
care, the charge nurse should identify newborn 1, newborn 3, and newborn 5 as
requiring priority care based on acuity. Newborn 1 has manifestations of respiratory
distress including tachypnea, grunting, nasal flaring, and retractions. The charge nurse
should further determine if newborn 1 requires prompt interventions. Newborn 3
presents with manifestations of hypoglycemia including blood glucose below the
expected range, hypothermia, and maternal history of gestational diabetes insulin
dependent. Newborn 5 is 23 hours of age and has not had a successful feeding. The
newborn additionally has not voided or passed their first meconium stool. Newborns are
expected to have at least one void during the first 24 hours of life, and one meconium
stool with in the first 24 to 48 hours of life. While newborns are sleepier during the first
48 hours after birth, the newborn should be awoken for feedings at least every 3 hours.
These finding indicate that further intervention by the nurse is needed.
A nurse manager is assessing incident reports for the unit. Which of the following
client's medical records indicate professional negligence? Select 2 clients that the nurse
manager should recognize have charts that indicate professional negligence. -
Correct answerClient 4, Client 5
When recognizing cues, the nurse should identify client 4 and client 5 have medical
records that indicate instances of professional negligence. Professional negligence
occurs when an individual with professional training fails to practice at the level
expected of their profession and harm is caused to a client. For professional negligence
to occur there must be a correlation between the nurse's actions and the harm that
came to the client. In client 4's medical record, the nurse failed to administer the client's
prescribed antiseizure medication within the indicated time frame and the client
experienced a seizure. In client scenario 5's medical record, the nurse administered the