Upon completing the admission documents, the nurse learns that the 87 year-old client does
not have an advance directive. What action should the nurse take? - ANSWER Give infor-
mation about advance directives
The nurse knows that which statement by the mother indicates that the mother understands
safety precautions with her four month-old infant and her 4 year-old child? - ANSWER "I
have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I
make supper."
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the
immunization was given, the client complains of itchy and watery eyes, increased anxiety,
and difficulty breathing. The nurse expects that the first action in the sequence of care for
this client will be to - ANSWER Administer epinephrine 1:1000 as ordered
Which of these children at the site of a disaster at a child day care center would the triage
nurse put in the "treat last" category? - ANSWER A toddler with severe deep abrasions
over 98% of the body
When admitting a client to an acute care facility, an identification bracelet is sent up with the
admission form. In the event these do not match, the nurse's best action is to - ANSWER
Notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was writ-
ten right before the shift change. What action should be taken? - ANSWER Call the pro-
vider for clarification
1
,An adult client is found to be unresponsive on morning rounds. After checking for respon-
siveness and calling for help, the next action that should be taken by the nurse is to: - AN-
SWER open the client's airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that
800 ml has been infused after 4 hours. What is the priority nursing action? - ANSWER
Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see
first? - ANSWER 72 year-old recovering from surgery after a hip replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the client lie on
the left side for the administration. The family member pushed the suppository until the fin-
ger went up to the second knuckle. After 10 minutes the client was told by the family mem-
ber to turn to the right side and the client did this. What is the appropriate comment for the
nurse to make? - ANSWER That was done correctly. Did you have any problems with the
insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died.
Which type of precautions is the appropriate type to use when performing postmortem
care? - ANSWER contact precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which se-
quence is appropriate teaching? - ANSWER clean the meatus, begin voiding, then catch
urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which
of these foods would the nurse reinforce for the client to eat at least daily? - ANSWER
watermelon
As the nurse observes the student nurse during the administration of a narcotic analgesic IM
injection, the nurse notes that the student begins to give the medication without first
2
, aspirating. What should the nurse do? - ANSWER Walk up and whisper in the student's
ear "Stop. Aspirate. Then inject."
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse
take? - ANSWER Immediately wash the hands with vigor
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breath-
ing is independent. What should the nurse document to most accurately describe the cli-
ent's condition? - ANSWER Glascow Coma Scale 8, respirations regular
A client enters the emergency department unconscious via ambulance from the client's
work place. What document should be given priority to guide the direction of care for this
client? - ANSWER A notarized original of advance directives brought in by the partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive person-
nel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse
manager? - ANSWER An admission at the change of shifts with atrial fibrillation and heart
failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spit-
ting up all the time and has a lot of gas. The nurse expects to find which of the following on
the initial history and physical assessment? - ANSWER Restlessness and increased mucus
production
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the par-
ents require follow-up and are consistent with the diagnosis? - ANSWER "Clothes are be-
coming tighter across her abdomen."
A 16 year-old enters the emergency department. The triage nurse identifies that this teen-
ager is legally married and signs the consent form for treatment. What would be the appro-
priate action by the nurse? - ANSWER Proceed with the triage process in the same man-
ner as any adult client
3
not have an advance directive. What action should the nurse take? - ANSWER Give infor-
mation about advance directives
The nurse knows that which statement by the mother indicates that the mother understands
safety precautions with her four month-old infant and her 4 year-old child? - ANSWER "I
have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I
make supper."
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the
immunization was given, the client complains of itchy and watery eyes, increased anxiety,
and difficulty breathing. The nurse expects that the first action in the sequence of care for
this client will be to - ANSWER Administer epinephrine 1:1000 as ordered
Which of these children at the site of a disaster at a child day care center would the triage
nurse put in the "treat last" category? - ANSWER A toddler with severe deep abrasions
over 98% of the body
When admitting a client to an acute care facility, an identification bracelet is sent up with the
admission form. In the event these do not match, the nurse's best action is to - ANSWER
Notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's written order that was writ-
ten right before the shift change. What action should be taken? - ANSWER Call the pro-
vider for clarification
1
,An adult client is found to be unresponsive on morning rounds. After checking for respon-
siveness and calling for help, the next action that should be taken by the nurse is to: - AN-
SWER open the client's airway
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that
800 ml has been infused after 4 hours. What is the priority nursing action? - ANSWER
Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the nurse see
first? - ANSWER 72 year-old recovering from surgery after a hip replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the client lie on
the left side for the administration. The family member pushed the suppository until the fin-
ger went up to the second knuckle. After 10 minutes the client was told by the family mem-
ber to turn to the right side and the client did this. What is the appropriate comment for the
nurse to make? - ANSWER That was done correctly. Did you have any problems with the
insertion?
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died.
Which type of precautions is the appropriate type to use when performing postmortem
care? - ANSWER contact precautions
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which se-
quence is appropriate teaching? - ANSWER clean the meatus, begin voiding, then catch
urine stream
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which
of these foods would the nurse reinforce for the client to eat at least daily? - ANSWER
watermelon
As the nurse observes the student nurse during the administration of a narcotic analgesic IM
injection, the nurse notes that the student begins to give the medication without first
2
, aspirating. What should the nurse do? - ANSWER Walk up and whisper in the student's
ear "Stop. Aspirate. Then inject."
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse
take? - ANSWER Immediately wash the hands with vigor
A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breath-
ing is independent. What should the nurse document to most accurately describe the cli-
ent's condition? - ANSWER Glascow Coma Scale 8, respirations regular
A client enters the emergency department unconscious via ambulance from the client's
work place. What document should be given priority to guide the direction of care for this
client? - ANSWER A notarized original of advance directives brought in by the partner
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive person-
nel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse
manager? - ANSWER An admission at the change of shifts with atrial fibrillation and heart
failure - PN
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spit-
ting up all the time and has a lot of gas. The nurse expects to find which of the following on
the initial history and physical assessment? - ANSWER Restlessness and increased mucus
production
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the par-
ents require follow-up and are consistent with the diagnosis? - ANSWER "Clothes are be-
coming tighter across her abdomen."
A 16 year-old enters the emergency department. The triage nurse identifies that this teen-
ager is legally married and signs the consent form for treatment. What would be the appro-
priate action by the nurse? - ANSWER Proceed with the triage process in the same man-
ner as any adult client
3
