TRANSITION EXAM 1 questions n
answers rated A+
The nurse hung the wrong intravenous antibiotic for the postoperative client. Which
intervention should the nurse implement first?
a. Assess the client for any adverse reactions
b. Complete the incident or adverse occurrence report
c. Administer the correct intravenous antibiotic medication
d. Notify the client's healthcare provider - correct answer ✔✔ A
The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are
caring for clients in a critical care unit. Which task would be most appropriate for the nurse to
assign/delegate?
a. Instruct the UAP to obtain the client's serum glucose level.
b. Request the LPN to change the central line dressing.
c. Ask the LPN to bathe the client and change the bed linens.
d. Tell the UAP to obtain urine output for the 12 hour shift. - correct answer ✔✔ D
The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to
the unlicensed assistive personnel (UAP)?
a. Instruct the UAP to apply sequential compression devices to the client on strict bed rest
b. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray
c. Request the UAP to prepare the client for a wound debridement at the bedside
,d. Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit - correct
answer ✔✔ C
The charge nurse is making assignments on a pediatric unit. Which client should be assigned to
the licensed practical nurse (LPN)?
a. The 6-year-old client diagnosed with sickle cell crisis
b. The 8-year-old client diagnosed with biliary atresia
c. The 10-year-old client diagnosed with anaphylaxis
d. The 11-year-old client diagnosed with pneumonia - correct answer ✔✔ D
The nurse is caring for the following clients on a medical unit. Which client should the nurse
assess first?
a. The client with disseminated intravascular coagulation (DIC) who has blood oozing from the
intravenous site.
b. The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling
and inability to empty bladder.
c. The client with renal calculi who is complaining of severe flank pain and has hematuria.
d. The client with Addison's disease who has bronze skin pigmentation and hypoglycemia. -
correct answer ✔✔ C
The charge nurse of a critical care unit is making assignments for the night shift. Which client
should be assigned to the graduate nurse who has just completed an internship?
a. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose
Glasgow Coma Scale score is 13.
b. The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has
a serum K+ level of 3.2 mEq/L.
,c. The client diagnosed with Addison's disease who is lethargic and has a BP 80/45, P 124, and R
28.
d. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a
positive Trousseau's sign. - correct answer ✔✔ A
The older adult client becomes confused and wanders in the hallways. Which fall precaution
intervention should the nurse implement first?
a. Place a Posey vest restraint on the client
b. Move the client to a room near the nurse's station
c. Ask the HCP for an antipsychotic medication
d. Raise all four side rails on the client's bed - correct answer ✔✔ B
The home health agency director of nursing is making assignments for the nurses. Which client
should be assigned to the nurse new to home health nursing?
a. The client diagnosed with AIDS who is dyspneic and confused
b. The client who does not have the money to get prescriptions filled
c. The client with full-thickness burns on the arm who needs a dressing change
d. The client complaining of pain who is diagnosed with diabetic neuropathy - correct answer
✔✔ D
The charge nurse has received laboratory data for clients in the medical department. Which
client would require intervention by the charge nurse?
a. The client diagnosed with a myocardial infarction who has an elevated troponin level
b. The client receiving heparin who has a partial thromboplastin time (PTT) of 68 seconds
c. The client diagnosed with end-stage liver failure who has an elevated ammonia level
, d. The client receiving phenytoin who has levels of 24 mg/dL - correct answer ✔✔ D
The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a
pediatric unit. Which nursing task should be assigned to the LPN?
a. Administer PO medications to a client diagnosed with gastroenteritis
b. Take the routine vital signs for all the clients on the pediatric unit
c. Transcribe the HCP's orders into the computer
d. Assess the urinary output of a client diagnosed with nephrotic syndrome - correct answer
✔✔ A
Which client warrants immediate intervention from the nurse on the medical unit?
a. The client diagnosed with an abdominal aortic aneurysm who has an audible bruit
b. The client with adult respiratory distress syndrome (ARDS) who has bilateral crackles
c. The client diagnosed with bacterial meningitis who has nucal rigidity and neck pain
d. The client with Crohn's disease who has right lower abdominal pain and has diarrhea -
correct answer ✔✔ D
Which assessment data warrants immediate intervention by the nurse for the client diagnosed
with chronic kidney disease (CKD) who is on peritoneal dialysis?
a. The client's serum creatinine level is 2.4 mg/dL
b. The client's abdomen is soft to touch and nontender
c. The dialysate being removed from the abdomen is cloudy
d. The dialysate instilled was 1500 mL and removed was 2100 mL - correct answer ✔✔ C
answers rated A+
The nurse hung the wrong intravenous antibiotic for the postoperative client. Which
intervention should the nurse implement first?
a. Assess the client for any adverse reactions
b. Complete the incident or adverse occurrence report
c. Administer the correct intravenous antibiotic medication
d. Notify the client's healthcare provider - correct answer ✔✔ A
The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are
caring for clients in a critical care unit. Which task would be most appropriate for the nurse to
assign/delegate?
a. Instruct the UAP to obtain the client's serum glucose level.
b. Request the LPN to change the central line dressing.
c. Ask the LPN to bathe the client and change the bed linens.
d. Tell the UAP to obtain urine output for the 12 hour shift. - correct answer ✔✔ D
The nurse is caring for clients on a skilled nursing unit. Which task should not be delegated to
the unlicensed assistive personnel (UAP)?
a. Instruct the UAP to apply sequential compression devices to the client on strict bed rest
b. Ask the UAP to assist the radiology tech to perform a STAT portable chest x-ray
c. Request the UAP to prepare the client for a wound debridement at the bedside
,d. Tell the UAP to obtain the intakes and outputs (I&Os) for all the clients on the unit - correct
answer ✔✔ C
The charge nurse is making assignments on a pediatric unit. Which client should be assigned to
the licensed practical nurse (LPN)?
a. The 6-year-old client diagnosed with sickle cell crisis
b. The 8-year-old client diagnosed with biliary atresia
c. The 10-year-old client diagnosed with anaphylaxis
d. The 11-year-old client diagnosed with pneumonia - correct answer ✔✔ D
The nurse is caring for the following clients on a medical unit. Which client should the nurse
assess first?
a. The client with disseminated intravascular coagulation (DIC) who has blood oozing from the
intravenous site.
b. The client with benign prostatic hypertrophy (BPH) who is complaining of terminal dribbling
and inability to empty bladder.
c. The client with renal calculi who is complaining of severe flank pain and has hematuria.
d. The client with Addison's disease who has bronze skin pigmentation and hypoglycemia. -
correct answer ✔✔ C
The charge nurse of a critical care unit is making assignments for the night shift. Which client
should be assigned to the graduate nurse who has just completed an internship?
a. The client diagnosed with a head injury resulting from a motor vehicle accident (MVA) whose
Glasgow Coma Scale score is 13.
b. The client diagnosed with inflammatory bowel disease (IBD) who has severe diarrhea and has
a serum K+ level of 3.2 mEq/L.
,c. The client diagnosed with Addison's disease who is lethargic and has a BP 80/45, P 124, and R
28.
d. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy and has a
positive Trousseau's sign. - correct answer ✔✔ A
The older adult client becomes confused and wanders in the hallways. Which fall precaution
intervention should the nurse implement first?
a. Place a Posey vest restraint on the client
b. Move the client to a room near the nurse's station
c. Ask the HCP for an antipsychotic medication
d. Raise all four side rails on the client's bed - correct answer ✔✔ B
The home health agency director of nursing is making assignments for the nurses. Which client
should be assigned to the nurse new to home health nursing?
a. The client diagnosed with AIDS who is dyspneic and confused
b. The client who does not have the money to get prescriptions filled
c. The client with full-thickness burns on the arm who needs a dressing change
d. The client complaining of pain who is diagnosed with diabetic neuropathy - correct answer
✔✔ D
The charge nurse has received laboratory data for clients in the medical department. Which
client would require intervention by the charge nurse?
a. The client diagnosed with a myocardial infarction who has an elevated troponin level
b. The client receiving heparin who has a partial thromboplastin time (PTT) of 68 seconds
c. The client diagnosed with end-stage liver failure who has an elevated ammonia level
, d. The client receiving phenytoin who has levels of 24 mg/dL - correct answer ✔✔ D
The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a
pediatric unit. Which nursing task should be assigned to the LPN?
a. Administer PO medications to a client diagnosed with gastroenteritis
b. Take the routine vital signs for all the clients on the pediatric unit
c. Transcribe the HCP's orders into the computer
d. Assess the urinary output of a client diagnosed with nephrotic syndrome - correct answer
✔✔ A
Which client warrants immediate intervention from the nurse on the medical unit?
a. The client diagnosed with an abdominal aortic aneurysm who has an audible bruit
b. The client with adult respiratory distress syndrome (ARDS) who has bilateral crackles
c. The client diagnosed with bacterial meningitis who has nucal rigidity and neck pain
d. The client with Crohn's disease who has right lower abdominal pain and has diarrhea -
correct answer ✔✔ D
Which assessment data warrants immediate intervention by the nurse for the client diagnosed
with chronic kidney disease (CKD) who is on peritoneal dialysis?
a. The client's serum creatinine level is 2.4 mg/dL
b. The client's abdomen is soft to touch and nontender
c. The dialysate being removed from the abdomen is cloudy
d. The dialysate instilled was 1500 mL and removed was 2100 mL - correct answer ✔✔ C
