(Detail Solutions and Resource for the test)
1. A nurse working in a long-term care facility is caring for an older adult client has
dementia. The clients often agitated and frequently wanders the halls. Which of
the following intervention should the nurse include in the plan of care?
a) Give the client several choices when scheduling activities.
b) Confront the client regarding unacceptable behavior
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c) Maintain Nutritional requirements by offering finger foods
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d) Stimulate the client by leaving the television on throughout the day
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2. A nurse on a mental health unit receives report on four clients. Which of the
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following client should the nurse attend to first?
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a. A client who has begun to demonstrate catatonic behavior
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b. The client was compulsive behavior and is frequently drinking
from the water fountain c) Client was having auditory hallucinations
is becoming agitated
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d) A client was making sexual comments to clients of the opposite sex
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3. A nurse is caring for the full term newborn immediately following birth. Which of
the following actions should the nurse take first?
a. Instill erythromycin ophthalmic ointment and the newborn’s eyes.
b. Place identification bracelets on the newborn.
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c. Weigh the newborn.
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d. D ry the newborn
4. A nurse receives report on a group of clients. Which of the following client should the
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nurse attend to first?
a. A client who was admitted with asthma and has an SaO2 of 92% long
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receiving oxygen at 1 L per minute via nasal cannula
b. ) A client was admitted with angina and reports left arm pain of 4 on a scale
of 0 to 10
c. The client was type II diabetes mellitus in his blood with glucose level is at 80
mg/dL
d. A client who had a gastric endoscopy and whose nasogastric tube is draining
30 mL per hour of green fluid
5. A client at 38 weeks of gestation enters the emergency department. The nurse should
recognize that which of the following indicates that the client is in the latent phase of
labor?
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, a. The client
reports the urge
to push b) The
cervix is dilated
2 cm
c) Contractions are 2 to 3 minutes apart
d) The client reports nausea and vomiting
6. The charge nurse for medical surgical units discovers client care assignments that
should be reassigned. Which of the following delegated tasks should be
reassigned?
a. An AP is to calculate intake and output every two hours for client in acute renal
failure.
b. An AP is to collect vital signs every 30 minutes for client who had a
cholecystectomy
c. A licensed practical nurse is to check nasogastric tube placement for client list
had a bowel resection. d) A licensed practical nurses to provide initial feeding for
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client who had a cerebrovascular accident.
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7. A nurse caring for the client who has a cast due to a compound fracture to the
right ankle. Which of the following findings requires immediate intervention?
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a. pruiritus under the cast
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b. Localized stabbing
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pain upon movement c)
paresthesia of the distal
extremity
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d) Edema present when leg is in the dependent position
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8. The nurses providing care for preschoolers with acute gastroenteritis. Basing
information below which of the following is an appropriate nursing action? Click on
the links of this below for additional client information
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a. Offer the child a cup of chicken broth.
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b. Encourage the
child’s intake of
gelatin. c) Administer
oral rehydration
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d) Institute a banana, Rice, applesauce, and toast diet.
9. A nurse is caring for a client on the cardiac care unit who is hemodynamically
unstable. Which of the following dysrhythmias should the nurse plan for
cardioversion?
a. Ventricular asystole
b. T
hird-
degre
e AV
block
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