vt vt vt vt vt vt vt
Answers| LATEST, With Correct Answers & Rationale
vt vt vt vt vt vt vt
1. A nurse in a long-term care facility is assisting with an inservice for newly hired
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
assistive personnel about legal issues within the facility. Which of the following should the
vt vt vt vt vt vt vt vt vt vt vt vt vt
nurse include as an example of assault?
vt vt vt vt vt vt vt
ANS: Informing a client the nurse is going to administer an injection even though the client refuses
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
2. Anurse is collecting data from those who are in severe pain. Which of The following
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
questions should the nurse ask first?
vt vt vt vt vt vt
ANS: "Where is your pain located?"
vt vt vt vt vt
3. Anurse is reviewing the laboratory results for a client who is at 29 weeks gestation. For
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
which of the following results should the nurse notify the provider?
vt vt vt vt vt vt vt vt vt vt vt
ANS: Platelet count 95,000 mm3
vt vt vt vt
4. A nurse is performing a dressing change for a client who had abdominal surgery 5
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
days ago. The nurse notes organs protruding from the incision. Which ofIthe following
vt vt vt vt vt vt vt vt vt vt vt vt vt
actions should the nurse take?
vt vt vt vt vt
ANS: Cover theexposed area with sterile, saline-soaked Dressings.
vt vt vt vt vt vt vt vt
5. A nurse is speaking with the adult daughter of a client who has Alzheimer's disease.
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
The daughter states, "I love my dad, but caring for him is wearing me out." Which of the
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
following responses should the nurse make?
vt vt vt vt vt vt
ANS: "Let's discuss how caring for your father is affecting your health.
vt vt vt vt vt vt vt vt vt vt vt
6. A nurse is contributing to the plan of care for a client who has a chest tube connected to
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
a closed drainage system. Which ofIthe following actions should the nurse include in the
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
plan of care?
vt vt vt
ANS: Maintain the drainage system below the level of the client's chest.
vt vt vt vt vt vt vt vt vt vt vt
, 7. A nurse in an acute mental health facility is caring for a client who has borderline
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
personality disorder and reports. "I am going to kill my girlfriend when I get out of here."
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
Which ofIthe following actions should the nurse take?
vt vt vt vt vt vt vt vt
ANS: Notify the client's care team of the threats against the Partner
vt vt vt vt vt vt vt vt vt vt vt
8. Anurse is admitting a client who is at high risk for suicide.Which ofIthe following
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
actions is the nurse's priority?
vt vt vt vt vt
ANS: Searchthe client'spersonal belongings
vt vt vt vt vt
9. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate.
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
Which of the following actions should the nurse take to promote the client's venous
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
return?
vt
ANS: Maintainthesequential compressiondevice.
vt vt vt vt vt
10. Anurse in an acute care unit is collecting data from a school age Child who has
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
cystic fibrosis. Which ofIthe following findings is the priority for the nurse?
vt vt vt vt vt vt vt vt vt vt vt vt
ANS: Reports lack of appetite
vt vt vt vt
11. Anurse working in a provider's following receives a phone call from the parent of a
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
school age child who has varicella. The parent asked the nurse when the child could
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
return to school. Which of the following responses should the nurse make?
vt vt vt vt vt vt vt vt vt vt vt vt
ANS: "Whenthelesions have scabbed over."
vt vt vt vt vt vt
12. A nurse in a pediatric clinic is collecting the data from a school age child whose
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
injuries are inconsistent with the parent's stated cause. Which ofIthe following actions
vt vt vt vt vt vt vt vt vt vt vt vt
should the nurse take?
vt vt vt vt
ANS: Report the suspected abuseto anappropriate agency.
vt vt vt vt vt vt vt vt
13. A nurse is collecting data from a middle adult female client who is taking
vt vt vt vt vt vt vt vt vt vt vt vt vt
melatonin.Which ofIthe following responses to the med should the nurse expect?
vt vt vt vt vt vt vt vt vt vt vt
ANS: Improved sleep
vt vt vt
14. Anurse on a pediatric unit is collecting data from four newly admitted clients. Which
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
, vt ofIthe following clients should the nurse identify as being at risk for urinary retention?
vt vt vt vt vt vt vt vt vt vt vt vt vt
ANS:Aschoolage childwho has allergic rhinitis and is taking Diphenhydramine.
vt vt vt vt vt vt vt vt vt vt vt vt
15. Anurse is preparing to administer a purified protein derivative(PPD) to a client who ha
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
s suspected TB. Which ofIthe following actions should the nurse plan to take?
vt vt vt vt vt vt vt vt vt vt vt vt vt
ANS: Ensure the injection produces a wheal on the skin
vt vt vt vt vt vt vt vt vt
16. A client who is diagnosed with Parkinson's disease verbalizes frustration due to
vt vt vt vt vt vt vt vt vt vt vt
increased difficultywith ambulation. Which of the following responses should the nurse
vt vt vt vt vt vt vt vt vt vt vt vt
take?
ANS: Perform active ROM with your arms and legs two times a day
vt vt vt vt vt vt vt vt vt vt vt vt
17. A nurse is collecting data from a client who has multiple fractures following a
vt vt vt vt vt vt vt vt vt vt vt vt vt
motor-vehicle crash. For which of the following client statements should the nurse
vt vt vt vt vt vt vt vt vt vt vt vt
recommend a referral to an occupational therapist?
vt vt vt vt vt vt vt
i am so frustrated i cannot even open my milk carton for breakfast
vt vt vt vt vt vt vt vt vt vt vt vt
18. Anurse is caring for a client who is 4 hr postoperative following a total thyroidectomy
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
Which of the following manifestations should the nurse report to the provider as
vt vt vt vt vt vt vt vt vt vt vt vt vt
indicating possible hypocalcemia?
vt vt vt
ANS:Tingling of fingers
vt vt vt
19. A nurse is caring for a client who has a Penrose drain. To ensure proper placement
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
and functioning of the drain, which of the following should the nurse expect to observe?
vt vt vt vt vt vt vt vt v t vt vt vt vt vt vt
ANS: The safety pin is present at the distal end of the drain.
vt vt vt vt vt vt vt vt vt vt vt vt
20. A community health nurse is helping to reinforce teaching about hepatitis A with a
vt vt vt vt vt vt vt vt vt vt vt vt vt
group of employees at a childcare facility. Which of the following characteristics should the
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
nurse identify as an external factor that can impede learning for the participants?
vt vt vt vt vt vt vt vt vt vt vt vt vt
, ANS: Poor lighting in thelearning setting
vt vt vt vt vt vt
21. A nurse is observing a newly licensed nurse who is providing tracheostomy care for a
vt vt vt vt vt vt vt vt vt vt vt vt vt vt
client. The nurse identifies proper performance of the procedure when the newly
vt vt vt vt vt vt vt vt vt vt vt vt
licensed nurse selects which of the following solutions to clean the inner cannula?
vt vt vt vt vt vt vt vt vt vt vt vt vt
ANS: Hydrogen peroxide
vt vt
22. A nurse is caring for a client who has right sided heart failure. The client's partner
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
expresses concern that the client will die. Which ofIthe following responses should the
vt vt vt vt vt vt vt vt vt vt vt vt vt
nurse make?
vt vt
ANS: "It is difficult to see someone so sick. What have you been told about your partner's prognosis?"
vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt vt
23. A nurse is reinforcing discharge instructions with the parent of an infant who has
vt vt vt vt vt vt vt vt vt vt vt vt vt