NUR 2755 FORM A, B & C TEST EXAM/ MDC4 EXAM
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A charge nurse witnesses an assistive personnel (AP) giving an oral medication toa client
who has dysphagia. Upon questioning, the AP states that a nurse poured themedication into a
cup and asked the AP to give it to the client. Which of the following actions should the charge
nurse take first?
a. Reinforce facility policy regarding medication administration withthe
AP b. Discuss the situation with the nurse who poured the medication
c. Complete the appropriate documentation of the incident
d. Auscultate the client’s breath sounds
A nurse is observing assistive personnel (AP) administer a 0.9% sodium chlorideenema
to an adult client. For which of the following actions by the AP should the nurse intervene?
a. Administers the solution at room temperature
b. Positions the client on her left side with knees flexed
c. Inserts the tubing 8 cm (3.1 in) into the rectum
d. Points tubing in the direction of the umbilicus during insertion
A nurse is preparing to transfer a client to the radiology department using a
wheelchair. Which of the following actions should the nurse take?
a. Leave a transfer belt in place until the client returns from radiology
b. Keep the footplates lowered throughout the transfer process
c. Push the wheelchair into the elevator, large wheels last
d. Test the locks on both wheels of the chair prior to transfer
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A nurse manager is preparing to institute a new system for scheduling staff.Several nurses
have verbalized concern over the possible changes that will occur. Which of the following is an
appropriate method to facilitate the adoption of the new scheduling system?
a. Introduce the new scheduling system by describing how it will save the
institution money
b. Offer to reassign staff who do not support the change to another unit c.
Identify nurses who accept the change to help influence other staff nurses -
check d. Provide a brief overview of the new scheduling systemimmediately
before its implementation
A nurse is planning discharge for a client following a hip arthroplasty. The clienttells the
nurse that she lives alone. Which of the following actions should the nursetake first?
a. Report the information to the provider
b. Contact the case manager for a consultation
c. Determine the specific needs of the client
d. Document the client’s living situation in the medical record
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A charge nurse is making assignments for a medical-surgical unit. Which of the
following clients is appropriate to assign to a licensed practical nurse?
a. A client who has emphysema and has an oxygen saturation level of
92% b. A client who is scheduled to start oral nutrition 2 daysafter stroke
c. A client who is scheduled to receive 2 units of RBCs following a hip replacement d.
A client who has dehydration and is being admitted from theemergency department
A nurse enters a client’s room and identifies that the client is receiving too much IVfluid
because the IV pump is not working properly. Which of the following actions should the nurse
take first?
a. Place a faulty equipment tag on the pump
b. Auscultate the client’s lungs
c. Complete an incident report
d. Notify the provider
A nurse is discussing advance directives with a client. Which of the following
statements by the client indicates an understanding of advance directives?
a. I know I have the right to determine if I remain on a breathing machine b.I
know I’ll need a lawyer to change them later, so I want to get them right c. I trust my
doctor, so I’m going to leave it to him to do what’s best for me d. By naming a health
care proxy, I give up the right to make my own medical decisions
A nurse manager is receiving report and is faced with the following situations thatrequire
intervention. Which of the following should the nurse manager address first?
a. Two nurses had a heated disagreement about a scheduling issue
b. No transport assistance is available to take a client to physical
therapy c. Three staff members have called to say they will beabsent
d. A client is refusing care from assistive personnel of the opposite gender
A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting
to the facility. Which of the following triage tag colors should the nurse instructthe group to
apply to a client who has full-thickness burns on 72% of his body?
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a. Green
b. Yellow
c. Black
d. Red
A nurse is caring for a client who has early-stage Alzheimer’s disease. Inwhich
of the following actions is the nurse acting as a client advocate?
a. Performing an updated cognitive assessment on the client
b. Requesting a referral for the client to attend reminiscent therapy
sessions c. Providing assistance for the client when ambulating down the hall
d. Reorienting the client several times throughout the day
A nurse is caring for a client who has a prescription for transcutaneous electricalnerve
stimulation (TENS). Which of the following members of the interdisciplinary team should
the nurse contact for assistance?
a. Occupational therapist
b. Respiratory therapist
c. Pharmacist
d. Physical therapist
A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the
following findings indicates the need for a referral to a wound care specialist?
a. Minimal signs of induration at the wound edges
b. Presence of granulated tissue over the wound
c. Presence of slough in the wound bed
d. Epithelialization noted in areas of tissue loss
A nurse is planning discharge for a client who has a new diagnosis of COPD andlives
alone. Which of the following actions is the nurse’s priority?
a. Suggest participating in a community support group
a. Provide printed materials for new prescriptions
b. Set up appointments for in-home physical therapy
c. Request a referral for a home safety assessment