Transition Exam 1 Review questions
well answered passed
suicide precautions - ANS ✔A client is brought to the crisis response center by her family. During
evaluation, the client reports being depressed for the last month and that voices are telling her
to hurt herself. Which intervention is most important for the nurse to implement?
meeting daily to discuss manipulation and countertransference - ANS ✔What is the treatment
team's priority in planning the care of a client with an eating disorder?
implement chest physiotherapy - ANS ✔The nurse is caring for a client with atelectasis. What is
the nurse's most important intervention>
complete the revision in six weeks - ANS ✔A nurse manager is delegating the revision of the
unit's educational policies to staff nurses. What is the best instructional guidance the nurse
manager can offer?
taking a 5 pm tympanic temperature for the client in room 515 - ANS ✔Which task should the
RN delegate to the unlicensed assistive personnel (UAP)?
preventing atelectasis - ANS ✔When caring for a client with quadriplegia, which nursing
intervention is the priority?
promote independence and withdraw attention from the pseudoseizures - ANS ✔Which nursing
intervention is the most appropriate for a client diagnosed with functional neurologic symptom
disorder who has experienced pseudoseizures?
, elevating the head of the bed - ANS ✔A client comes to the emergency department with acute
shortness of breath and a cough that produces pink, frothy sputum. The client is restless and
extremely anxious. Admission assessment reveals crackles and wheezes, a blood pressure of
82/45 mmHg, a heart rate of 120 bpm, and a respiratory rate of 38 breaths/min. The client's
medical history includes hypertension, and heart failure. What is the nurse's priority
intervention?
notify the provider immediately - ANS ✔The nurse is monitoring a client, who is six hours post
embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to
detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared
for immediate surgery. The client refuses to consider additional surgery. What is the nurse's
initial intervention?
medicate the client for pain as ordered - ANS ✔An assessment of a client on the first day after a
thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure,
136/86 mmHg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client
is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority?
evaluate for depression - ANS ✔The nurse is planning care for a client with panic disorder. What
is the priority nursing intervention?
check patency of the chest tube - ANS ✔The nurse is assessing a client's chest tube and notes
that it is not working properly. What is the nurse's priority action?
auscultate the breath sounds - ANS ✔A 24-year-old client comes into the clinic reporting
sudden-onset, right-sided chest pain and shortness of breath. While assessing the client, the
nurse determines that the most important intervention is to:
maintain a patent airway - ANS ✔A client has received an infusion of antibiotics and is now
experiencing an anaphylactic reaction. What is the most important intervention by the nurse?
well answered passed
suicide precautions - ANS ✔A client is brought to the crisis response center by her family. During
evaluation, the client reports being depressed for the last month and that voices are telling her
to hurt herself. Which intervention is most important for the nurse to implement?
meeting daily to discuss manipulation and countertransference - ANS ✔What is the treatment
team's priority in planning the care of a client with an eating disorder?
implement chest physiotherapy - ANS ✔The nurse is caring for a client with atelectasis. What is
the nurse's most important intervention>
complete the revision in six weeks - ANS ✔A nurse manager is delegating the revision of the
unit's educational policies to staff nurses. What is the best instructional guidance the nurse
manager can offer?
taking a 5 pm tympanic temperature for the client in room 515 - ANS ✔Which task should the
RN delegate to the unlicensed assistive personnel (UAP)?
preventing atelectasis - ANS ✔When caring for a client with quadriplegia, which nursing
intervention is the priority?
promote independence and withdraw attention from the pseudoseizures - ANS ✔Which nursing
intervention is the most appropriate for a client diagnosed with functional neurologic symptom
disorder who has experienced pseudoseizures?
, elevating the head of the bed - ANS ✔A client comes to the emergency department with acute
shortness of breath and a cough that produces pink, frothy sputum. The client is restless and
extremely anxious. Admission assessment reveals crackles and wheezes, a blood pressure of
82/45 mmHg, a heart rate of 120 bpm, and a respiratory rate of 38 breaths/min. The client's
medical history includes hypertension, and heart failure. What is the nurse's priority
intervention?
notify the provider immediately - ANS ✔The nurse is monitoring a client, who is six hours post
embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to
detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared
for immediate surgery. The client refuses to consider additional surgery. What is the nurse's
initial intervention?
medicate the client for pain as ordered - ANS ✔An assessment of a client on the first day after a
thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure,
136/86 mmHg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client
is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority?
evaluate for depression - ANS ✔The nurse is planning care for a client with panic disorder. What
is the priority nursing intervention?
check patency of the chest tube - ANS ✔The nurse is assessing a client's chest tube and notes
that it is not working properly. What is the nurse's priority action?
auscultate the breath sounds - ANS ✔A 24-year-old client comes into the clinic reporting
sudden-onset, right-sided chest pain and shortness of breath. While assessing the client, the
nurse determines that the most important intervention is to:
maintain a patent airway - ANS ✔A client has received an infusion of antibiotics and is now
experiencing an anaphylactic reaction. What is the most important intervention by the nurse?
