NURS 465 PRACTICE QUESTIONS VERIFIED
ACCURATE ANSWERS
A nurse is caring for a client who has dementia. The client is agitated and is having
difficulty staying in his chair. Which of the following actions should the nurse take first? -
Answers -place a seat alarm in the client's chair
A nurse is caring for a client who is in the first stage of labor. The nurse observes the
umbilical cord protruding from the vagina. Which of the following actions should the
nurse perform first? - Answers -Insert a gloved hand into the vagina to relieve pressure
on the cord
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan
with contrast media. For which of the following client finding should the nurse intervene
first? - Answers -stridor
A nurse is caring for a client who has CHF and is taking digoxin daily. The client refused
breakfast and is complaining of nausea and weakness. Which of the following actions
should the nurse take first? - Answers -check the client's vital signs
A nurse is removing PPE after giving direct care to a client who requires isolation.
Which of the following PPE items should the nurse remove first? - Answers -Gloves
A nurse in an emergency department is caring for a client who has anaphylaxis
following a bee sting. Which of the following actions should the nurse take first? -
Answers -Auscultate for wheezing
A nurse sees and assistive personnel (AP) entering the room of a client who requires
transmission based precautions without using the appropriate PPE. Which of the
following actions should the nurse take first? - Answers -Provide the appropriate PPE
to the AP
A nurse is working with an assistive personnel (AP) to care for a group of clients on the
pediatric unit. Which of the following tasks should the nurse have the AP perform first? -
Answers -check to see if the elbow restraint is in place for an infant who is postoperative
from a surgical correction of a cleft palate
A nurse is caring for a client who attacked one of her friends and is administered to the
psychiatric unit. Which of the following actions should the nurse take first? - Answers -
Set behavioral limits for the client
, A nurse is caring for a client who has a spinal cord injury and suspects the client is
developing autonomic dysreflexia. Which of the following actions should the nurse take
first? - Answers -Place the client in a sitting position
A nurse is assessing four clients on a medical surgical unit. Which of the following client
should the nurse care for first? - Answers -A client who has a cast on the left leg and
reports numbness and paresthesia
A nurse is caring for a client who develops a pulmonary embolism. Which of the
following interventions should the nurse implement first? - Answers -Administer oxygen
therapy
While caring for a client, the nurse experiences a needle stick injury. Which of the
following actions should the nurse take first? - Answers -Wash the site of the injury with
soap and water
A nurse is assessing a client's abdomen who reports stomach pain. Which of the
following actions should the nurse take first? - Answers -Inspect
A nurse in a clinic is collecting a history from a client who reports that a member of his
family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that
the provider will prescribe which of the following diagnostic tests first? - Answers -
Nucleic acid amplification test (NAAT)
A nurse is caring for a client who is in active labor and notes late deceleration in the
FHR. Which of the following actions should the nurse take first? - Answers -Change the
client's position
A nurse has been reassigned from her regular area of work to a unit that is short
staffed. Which of the following actions should the nurse take first? - Answers -Ask what
she will be assigned to do
A nurse is bathing a toddler and notices that she has several bruises. Which of the
following actions should the nurse take first? - Answers -Ask the parents what caused
the bruises
A nurse is caring for a client who is vomiting. Which of the following actions should the
nurse take first? - Answers -Prevent the client from aspirating
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. The client pulls out his endotracheal tube. Which of the following actions
should the nurse take first? - Answers -Assess the client's airway
A nurse is receiving change of shift report and is delegating tasks to the assistive
personnel. The nurse should tell the AP to complete which of the following tasks first? -
ACCURATE ANSWERS
A nurse is caring for a client who has dementia. The client is agitated and is having
difficulty staying in his chair. Which of the following actions should the nurse take first? -
Answers -place a seat alarm in the client's chair
A nurse is caring for a client who is in the first stage of labor. The nurse observes the
umbilical cord protruding from the vagina. Which of the following actions should the
nurse perform first? - Answers -Insert a gloved hand into the vagina to relieve pressure
on the cord
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan
with contrast media. For which of the following client finding should the nurse intervene
first? - Answers -stridor
A nurse is caring for a client who has CHF and is taking digoxin daily. The client refused
breakfast and is complaining of nausea and weakness. Which of the following actions
should the nurse take first? - Answers -check the client's vital signs
A nurse is removing PPE after giving direct care to a client who requires isolation.
Which of the following PPE items should the nurse remove first? - Answers -Gloves
A nurse in an emergency department is caring for a client who has anaphylaxis
following a bee sting. Which of the following actions should the nurse take first? -
Answers -Auscultate for wheezing
A nurse sees and assistive personnel (AP) entering the room of a client who requires
transmission based precautions without using the appropriate PPE. Which of the
following actions should the nurse take first? - Answers -Provide the appropriate PPE
to the AP
A nurse is working with an assistive personnel (AP) to care for a group of clients on the
pediatric unit. Which of the following tasks should the nurse have the AP perform first? -
Answers -check to see if the elbow restraint is in place for an infant who is postoperative
from a surgical correction of a cleft palate
A nurse is caring for a client who attacked one of her friends and is administered to the
psychiatric unit. Which of the following actions should the nurse take first? - Answers -
Set behavioral limits for the client
, A nurse is caring for a client who has a spinal cord injury and suspects the client is
developing autonomic dysreflexia. Which of the following actions should the nurse take
first? - Answers -Place the client in a sitting position
A nurse is assessing four clients on a medical surgical unit. Which of the following client
should the nurse care for first? - Answers -A client who has a cast on the left leg and
reports numbness and paresthesia
A nurse is caring for a client who develops a pulmonary embolism. Which of the
following interventions should the nurse implement first? - Answers -Administer oxygen
therapy
While caring for a client, the nurse experiences a needle stick injury. Which of the
following actions should the nurse take first? - Answers -Wash the site of the injury with
soap and water
A nurse is assessing a client's abdomen who reports stomach pain. Which of the
following actions should the nurse take first? - Answers -Inspect
A nurse in a clinic is collecting a history from a client who reports that a member of his
family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that
the provider will prescribe which of the following diagnostic tests first? - Answers -
Nucleic acid amplification test (NAAT)
A nurse is caring for a client who is in active labor and notes late deceleration in the
FHR. Which of the following actions should the nurse take first? - Answers -Change the
client's position
A nurse has been reassigned from her regular area of work to a unit that is short
staffed. Which of the following actions should the nurse take first? - Answers -Ask what
she will be assigned to do
A nurse is bathing a toddler and notices that she has several bruises. Which of the
following actions should the nurse take first? - Answers -Ask the parents what caused
the bruises
A nurse is caring for a client who is vomiting. Which of the following actions should the
nurse take first? - Answers -Prevent the client from aspirating
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. The client pulls out his endotracheal tube. Which of the following actions
should the nurse take first? - Answers -Assess the client's airway
A nurse is receiving change of shift report and is delegating tasks to the assistive
personnel. The nurse should tell the AP to complete which of the following tasks first? -
