AND ANSWERS
While caring for a client, the nurse experiences a needle stick injury. Which of the following
actions should the nurse take first?
-complete an incident report
-request the risk manager to obtain consent for HIV testing from the client
-wash the site of injury with soap and water
-consent to the postexposure with antiretrovial medication - ANS wash the site of the injury
with soap and water
A nurse is reviewing data for four children. Which of the following children should the nurse
assess first?
-a 10 year old who has sickle cell anemia who reports severe chest pain
-a 7 year old who has diabetes insipid and a urine specific gravity of 1.016
-a 1 year old toddler who has roseola and temperature of 102.2
-a 4 year old child who has asthma and a PCO2 of 37 mm Hg - ANS a 10 year old who has
sickle cell anemia who reports severe chest pain
A nurse is triaging clients in the emergency department. Which of the following clients should
the nurse ask the provider to care for first?
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,-a toddler who has asthma and a pulse oximetry reading of 95% while receiving oxygen at 2
L/min
-a toddler who has otitis media, a temp of 102.6, and purulent ear discharge
-a school-age child who has acute epiglottis, is drooling, and has a absence of spontaneous
cough
-an adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests
pain medication - ANS a school-age child who has acute epiglottis, is drooling, and has a
absence of spontaneous cough
A nurse on the pediatric unit is providing room assignments for children who are to be admitted
to the unit. The nurse should plan a child who is postoperative from an appendectomy with
which of the following clients?
-a child who is experiencing sickle cell crisis
-a child who has streptococcal pharyngitis
-a child who has a head injury
-a child who has a new diagnosis of type 1 diabetes mellitus - ANS a child who has a new
diagnosis of type 1 diabetes mellitus
A nurse is discussing the norming stage of the group development process with a student nurse.
Which of the following statements by the student indicates understanding of the discussion?
-"This stage involves constructive efforts on the part of the group members."
-"This stage is when testing occurs to identify boundaries of interpersonal behaviors."
-"Consensus evolves in this stage."
-"Resistance is evident as subgroups form in this stage." - ANS "consensus evolves in this
stage."
An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the
following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?
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,-A client who has terminal end-stage renal disease
-A client who has acute pancreatitis
-A client who is one-day postoperative following a total abdominal hysterectomy
-A client who had a stroke and is to be admitted - ANS A client who is one-day postoperative
following a total abdominal hysterectomy
When planning delegation of task to assistive personal (AP), a nurse considers the five rights of
delegation. Which of the following should the nurse consider when using one of the five rights
of delegation?
-The Ap's ability to prioritize
-The AP has the knowledge and skill to perform the task
-The AP's rapport with clients
-The AP's ability to complete the task without assistance - ANS The AP has the knowledge
and skill to perform the task
A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority
action of the nurse?
-Taking a telephone prescription about a client who is to be transferred from PACU
-Assessing a client who experiences unilateral calf pain when ambulating
-Reinforcing a client's dressing for the surgical site of an above-the-knee amputation
-reassuring the partner of a client who sustained a closed head injury - ANS Assessing a client
who experiences unilateral calf pain when ambulating
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses.
Which of the following action is an example of a violation of confidentiality?
-Discussing a client's surgical procedure with the nurse manager
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, -Reporting laboratory findings to a member of the client's family
-Notifying the provider of physical examination findings
-Identifying the client by name when making a referral for home health services -
ANS Reporting laboratory findings to a member of the client's family
A nurse has received change of shift report on a group of clients and is preparing her
assignment. Which of the following clients should the nurse assess first?
-A client who has a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for
a hypoglycemic episode
-A client who has admitted for chest pain and is reporting a new onset of indigestion
-A client who has pneumonia and was treated for a temperature of 102 at 0400
-A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose
famotidine at 0800 - ANS A client who has admitted for chest pain and is reporting a new
onset of indigestion
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit
asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to
provide the information requested. The nurse is displaying which of the following ethical
problems?
-Utility
-Paternalism
-Justice
-Nonmaleficence - ANS Nonmaleficence
A nurse is preparing an educational program for a group of newly licensed nurses about client
confidentiality. The nurse should explain that nurses may share a client's protected health
information with which of the following groups?
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