Complete Review | Graded A+
1. Client who is HIV positive receives a Mantoux test. Nurse identifies a 7mm
induration at the test site. Which interpretation does nurse make?
False positive, previous Bacilli Calmette-Guerin vaccine
Negative reaction, less than 15 mm
Positive reaction, greater than 5 mm
Negative reaction, less than 10 mm
2. What should the nurse intervene on when assisting a Nursing Assistant
Personnel (NAP) providing care to a comatose client?
The NAP log-rolls the client to provide back care.
The NAP positions the client on the left side, head elevated.
The NAP places an incontinence diaper under the client.
The NAP answers the phone while wearing gloves.
3. What is the primary action a nurse should take if they notice fluid leaking
from a central line dressing?
Place the client's head lower than his feet.
Verify that the client is on antibiotics.
Secure the Y-port where the lipids are infusing.
Prepare to change the central line dressing.
4. You and an aide are giving a bed bath to an incontinent client. Which action
requires you to intervene?
, The aide answers the phone while wearing gloves.
The aide log rolls the client toward themselves.
The aide leaves the client laying on their left side with the head
elevated.
The aide places an incontinence pad under the client.
5. Describe the importance of using personal protective equipment during the
insertion of a nasogastric tube.
Personal protective equipment is optional for nasogastric tube
insertion.
Personal protective equipment is only required for patients with
known infections.
Personal protective equipment is only necessary for surgical
procedures.
Using personal protective equipment helps prevent infection and
protects both the nurse and the patient.
6. A client who is human immunodeficiency virus (HIV) positive has had a
Mantoux skin test. The results show a 7-mm area of induration. The nurse
evaluates that this result is:
Negative
Positive
7. What is the most important question a nurse should ask a client reporting off-
white vaginal discharge with a curdlike appearance?
Are you sexually active?
What kind of birth control do you use?
, Have you taken any cough medicine?
Do you douche?
8. To determine the structural relationship of one hospital department with
another, the nurse should consult which of the following?
Job descriptions
Policies and procedures manual
Personnel policies
Organizational chart
9. If a primipara woman in labor expresses fear of complications from an
amniotomy, what should the nurse do to address her concerns effectively?
Encourage her to refuse the procedure outright.
Suggest that she speak with a different healthcare provider.
Dismiss her concerns as unfounded.
Provide education on the procedure and discuss monitoring
protocols.
10. What is the best initial response by a nurse when assessing a pregnant
woman with headaches and bruises?
You may be more clumsy due to your size.
Tell me about your headaches.
Are you battered by your partner?
How do you feel about being pregnant?
, 11. What is a potential risk associated with a client who appears suddenly
cheerful after being treated for suicidal ideation?
The client may have finalized a suicide plan.
The client is responding to treatment and is no longer depressed.
The client is likely sleeping well because of the medication.
The client has made new friends and has a support group.
12. What is the most appropriate response by the nurse when a patient reports
insomnia and anorexia after losing a job?
Tell me what happened.
Focus on the fact that you have a healthy, happy family.
Losing a job is common nowadays.
Did your company give you a severance package?
13. If the pediatrician confirms that the newborn has oral thrush, what would be
the most appropriate nursing intervention following the diagnosis?
Educate the parents on the importance of oral hygiene only.
Increase the newborn's fluid intake to prevent dehydration.
Monitor the newborn's weight for any changes.
Administer antifungal medication as prescribed by the pediatrician.
14. Which complication is most likely to occur within the first 12 to 48 hours post
femoral fracture?
Acute compartment syndrome
Fat embolism