An older client is being admitted to a rehabilitation unit from a medical-surgical unit follow-
ing a left hip replacement. When reviewing the client's prescribed medications, which inter-
vention should the nurse implement FIRST?
a. reconcile prescribed medication dosages with published recommended dosage ranges
b. compare admission prescriptions with the list of medications previously taken by the cli-
ent
c. determine which medications may be given in generic form rather than brand name only
d. provide client teaching regarding the desired effects of the client's admission prescriptions
- ANSWER b. compare admission prescriptions with the list of medications previously
taken by the client
Assessment findings for a client following a colectomy for familial polyposis include an ileos-
tomy bag that contains large amount of fecal liquid and an IV infusion of dextrose 5% in lac-
tated ringer's infusing at a rate of 100ml/hour. Which assessment is most important for the
nurse monitor? Serum electrolytes.
a. urinary output
b. serum electrolytes
c. peristomal skin integrity
d. skin turgor - ANSWER b. serum electrolytes
A new nurse preparing to irrigate an intravenous cath is attaching a 24-gauge action should
the charge nurse implement
A. Suggest the nurse use a 20-gauge
B. Direct the nurse to change IV tubing
C. Instruct the nurse to remove the needle
D. Prompt the nurse to apply pressure to the site - ANSWER C-Instruct the nurse to re-
move the needle
1
,The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand
rub while leaving a client's room after taking vital signs. What action should the nurse take?
A. Instruct the UAP to return to the client's room to perform handwashing
B. Supervise the UAP in the next client's room to evaluate hand hygiene
C. Remind the UAP to continue rubbing the hands together until they are dry
D. Advice the UAP to wear gloves when obtaining vital signs for all clients - ANSWER C.
Remind the UAP to continue rubbing the hands together until they are dry
A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is dis-
tended, blood pressure is elevated, and 6500 mL were infused while 5,500 mL were drained.
In response to this finding, what action should the nurse take?
A. Instruct the client to cough
B. turn the client from side to side
C. irrigate the drainage tube with normal Saline
D.lower the head of the bed - ANSWER B.turn the client from side to side
The nurse is developing the plan of care for a client with pneumonia and includes the nurs-
ing problem of Ineffective airway clearance related to thick pulmonary secretions. Which in-
tervention is most important for the nurse to include in the client's plan of care?
A. Provide frequent rest periods.
B. Administer at minute per nasal cannula.
C. Increase fluid intake to 3,000 mL/ daily.
D. Maintain the client in a semi-Fowler's position. - ANSWER C. Increase fluid intake to
3,000 mL/ daily.
10. The adult child of an older adult client who has Parkinson's disease, calls the clinic and
reports that the client has been confused for the past week. Which action Should the nurse
take? Select all that apply.
A.
2
, Determine if the mother has recently experienced a fall.
B.
Review the client's current food and medication allergies.
C.
Encourage increased intake of high-protein foods.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination. - ANSWER A.
Determine if the mother has recently experienced a fall.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination.
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse's immediate attention?
A.
16 year old client diagnosed with major depression who refuses to participate in group
B.
a 17 year old client diagnosed with bipolar disorder who is pacing around the lobby
C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
D.
a 14 year old client with anorexia nervosa who is refusing to eat the evening snack. - AN-
SWER C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
3
ing a left hip replacement. When reviewing the client's prescribed medications, which inter-
vention should the nurse implement FIRST?
a. reconcile prescribed medication dosages with published recommended dosage ranges
b. compare admission prescriptions with the list of medications previously taken by the cli-
ent
c. determine which medications may be given in generic form rather than brand name only
d. provide client teaching regarding the desired effects of the client's admission prescriptions
- ANSWER b. compare admission prescriptions with the list of medications previously
taken by the client
Assessment findings for a client following a colectomy for familial polyposis include an ileos-
tomy bag that contains large amount of fecal liquid and an IV infusion of dextrose 5% in lac-
tated ringer's infusing at a rate of 100ml/hour. Which assessment is most important for the
nurse monitor? Serum electrolytes.
a. urinary output
b. serum electrolytes
c. peristomal skin integrity
d. skin turgor - ANSWER b. serum electrolytes
A new nurse preparing to irrigate an intravenous cath is attaching a 24-gauge action should
the charge nurse implement
A. Suggest the nurse use a 20-gauge
B. Direct the nurse to change IV tubing
C. Instruct the nurse to remove the needle
D. Prompt the nurse to apply pressure to the site - ANSWER C-Instruct the nurse to re-
move the needle
1
,The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand
rub while leaving a client's room after taking vital signs. What action should the nurse take?
A. Instruct the UAP to return to the client's room to perform handwashing
B. Supervise the UAP in the next client's room to evaluate hand hygiene
C. Remind the UAP to continue rubbing the hands together until they are dry
D. Advice the UAP to wear gloves when obtaining vital signs for all clients - ANSWER C.
Remind the UAP to continue rubbing the hands together until they are dry
A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is dis-
tended, blood pressure is elevated, and 6500 mL were infused while 5,500 mL were drained.
In response to this finding, what action should the nurse take?
A. Instruct the client to cough
B. turn the client from side to side
C. irrigate the drainage tube with normal Saline
D.lower the head of the bed - ANSWER B.turn the client from side to side
The nurse is developing the plan of care for a client with pneumonia and includes the nurs-
ing problem of Ineffective airway clearance related to thick pulmonary secretions. Which in-
tervention is most important for the nurse to include in the client's plan of care?
A. Provide frequent rest periods.
B. Administer at minute per nasal cannula.
C. Increase fluid intake to 3,000 mL/ daily.
D. Maintain the client in a semi-Fowler's position. - ANSWER C. Increase fluid intake to
3,000 mL/ daily.
10. The adult child of an older adult client who has Parkinson's disease, calls the clinic and
reports that the client has been confused for the past week. Which action Should the nurse
take? Select all that apply.
A.
2
, Determine if the mother has recently experienced a fall.
B.
Review the client's current food and medication allergies.
C.
Encourage increased intake of high-protein foods.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination. - ANSWER A.
Determine if the mother has recently experienced a fall.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination.
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse's immediate attention?
A.
16 year old client diagnosed with major depression who refuses to participate in group
B.
a 17 year old client diagnosed with bipolar disorder who is pacing around the lobby
C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
D.
a 14 year old client with anorexia nervosa who is refusing to eat the evening snack. - AN-
SWER C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
3
