Name: Score:
19 Multiple choice questions
,Term 1 of 19
The nurse employed in a long-term care facility is planning assignments for the clients on a
nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and three
assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately
assign to the licensed practical nurse?
1. A client who requires a bed bath
2. An older client requiring frequent ambulation
3. A client who requires hourly measurement of vital signs
4. A client requiring abdominal wound irrigations and dressing changes every 3 hours
Answer: 4
Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face
meetings to confront the issue at hand will allow verbalization of feelings, identification of
problems and issues, and development of strategies to solve the problem. Option 1 will not
address the problem. Option 2 may produce additional resistance. Option 3 may provide a
temporary solution to the resistance but will not address the concern specifically.
Answer: 3
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L).
Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L).
Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of
hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and
decreased specific gravity of the urine would be noted.
Answer: 4
Rationale: In an emergency department, triage involves brief client assessment to classify
clients according to their need for care and includes establishing priorities of care. The type
of illness or injury, the severity of the problem, and the resources available govern the
process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb
amputation, or acute neurological deficits and those who have sustained chemical splashes
to the eyes are classified as emergent and are the highest priority. Clients with conditions
such as a simple fracture, asthma without respiratory distress, fever, hypertension,
abdominal pain, or a renal stone have urgent needs and are classified as a second priority.
Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified
as nonurgent and are a third priority.
,Answer: 4
Rationale: When delegating nursing assignments, the nurse needs to consider the skills and
educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation,
and taking vital signs can be assigned most appropriately to an AP. The licensed practical
nurse is skilled in wound irrigations and dressing changes and most appropriately would be
assigned to the client who needs this care.
, Definition 2 of 19
Answer: 4
Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing
care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component
of case management. Option 3 identifies primary nursing (relationship-based practice).
. On review of the clients' medical records, the nurse determines that which client is at risk
for uid volume excess? 1. The client taking diuretics who has tenting of the skin 2. The client
with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent
gastrointestinal suctioning 4. The client with kidney disease that developed as a
complication of diabetes mellitu
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing's syndrome
4. The client who is taking corticosteroid
Potassium chloride intravenously is prescribed for a client with heart failure experiencing
hypokalemia. Which actions would the nurse take to plan for preparation and administration
of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of in filtration or phlebitis. 5. Ensure that the medication is
diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled with the volume of potassium in the solution.
3. A nursing graduate is attending an agency orientation regarding the nursing model of
practice implemented in the health care facility. The nurse is told that the nursing model is a
team nursing approach. The nurse determines that which scenario is characteristic of the
team-based model of nursing practice?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and begin discharge
planning.
3. A single registered nurse (RN) is responsible for providing care to a group of six clients
19 Multiple choice questions
,Term 1 of 19
The nurse employed in a long-term care facility is planning assignments for the clients on a
nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and three
assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately
assign to the licensed practical nurse?
1. A client who requires a bed bath
2. An older client requiring frequent ambulation
3. A client who requires hourly measurement of vital signs
4. A client requiring abdominal wound irrigations and dressing changes every 3 hours
Answer: 4
Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face
meetings to confront the issue at hand will allow verbalization of feelings, identification of
problems and issues, and development of strategies to solve the problem. Option 1 will not
address the problem. Option 2 may produce additional resistance. Option 3 may provide a
temporary solution to the resistance but will not address the concern specifically.
Answer: 3
Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L).
Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L).
Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of
hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and
decreased specific gravity of the urine would be noted.
Answer: 4
Rationale: In an emergency department, triage involves brief client assessment to classify
clients according to their need for care and includes establishing priorities of care. The type
of illness or injury, the severity of the problem, and the resources available govern the
process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb
amputation, or acute neurological deficits and those who have sustained chemical splashes
to the eyes are classified as emergent and are the highest priority. Clients with conditions
such as a simple fracture, asthma without respiratory distress, fever, hypertension,
abdominal pain, or a renal stone have urgent needs and are classified as a second priority.
Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified
as nonurgent and are a third priority.
,Answer: 4
Rationale: When delegating nursing assignments, the nurse needs to consider the skills and
educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation,
and taking vital signs can be assigned most appropriately to an AP. The licensed practical
nurse is skilled in wound irrigations and dressing changes and most appropriately would be
assigned to the client who needs this care.
, Definition 2 of 19
Answer: 4
Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing
care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component
of case management. Option 3 identifies primary nursing (relationship-based practice).
. On review of the clients' medical records, the nurse determines that which client is at risk
for uid volume excess? 1. The client taking diuretics who has tenting of the skin 2. The client
with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent
gastrointestinal suctioning 4. The client with kidney disease that developed as a
complication of diabetes mellitu
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
1. The client who is taking diuretics
2. The client with hyperaldosteronism
3. The client with Cushing's syndrome
4. The client who is taking corticosteroid
Potassium chloride intravenously is prescribed for a client with heart failure experiencing
hypokalemia. Which actions would the nurse take to plan for preparation and administration
of the potassium? Select all that apply.
1. Obtain an intravenous (IV) infusion pump.
2. Monitor urine output during administration.
3. Prepare the medication for bolus administration.
4. Monitor the IV site for signs of in filtration or phlebitis. 5. Ensure that the medication is
diluted in the appropriate volume of fluid.
6. Ensure that the bag is labeled with the volume of potassium in the solution.
3. A nursing graduate is attending an agency orientation regarding the nursing model of
practice implemented in the health care facility. The nurse is told that the nursing model is a
team nursing approach. The nurse determines that which scenario is characteristic of the
team-based model of nursing practice?
1. Each staff member is assigned a specic task for a group of clients.
2. A staff member is assigned to determine the client's needs at home and begin discharge
planning.
3. A single registered nurse (RN) is responsible for providing care to a group of six clients
