2019 A / 150 QUESTIONS AND
ANSWERS WITH RATIONALES
GRADED A+
A nurse is caring for a client who states, "My boss accused me of
stealing yesterday. I was so angry I went to the gym and worked out."
The nurse should recognize the client is demonstrating which of the
following defense mechanisms? - :ANSWER- Sublimation
Rationale: The client is exhibiting behaviors consistent with
sublimation, which is displayed when a client substitutes socially
unacceptable behavior for acceptable behavior.
,An RN is planning care for a group of clients and is working with a
licensed practical nurse (LPN) and an assistive personnel (AP). Which
of the following tasks should the RN delegate to the LPN? -
:ANSWER- Insertion of a nasogastric tube
Rationale: The nurse should delegate the insertion of a nasogastric tube
to the LPN because this task is within the LPN's scope of practice.
A nurse is caring for a client who has generalized anxiety disorder and is
to begin taking alprazolam. Which of the following actions should the
nurse take? - :ANSWER- Initiate fall precautions for the client
Rationale: The nurse should initiate fall precautions for a client who
has a new prescription for alprazolam because common adverse
effects associated with this medication are orthostatic hypotension,
dizziness, confusion, and lethargy.
A nurse on a med surg unit is caring for a client prior to a surgical
procedure. Which of the following findings should indicate to the nurse
that the client has the ability to sign the informed consent? - :ANSWER-
The client is able to accurately describe the upcoming procedure
Rationale: The ability of the client to accurately describe the
upcoming procedure indicates that the provider adequately
informed the client and that the client is able to sign the informed
consent
An assistive personnel (AP) and a nurse are turning a client onto the
right side. Which of the following actions by the AP requires the nurse to
intervene? - :ANSWER- Places a pillow under the client's right arm.
,Rationale: The AP should place a pillow under the client's left arm
to prevent internal rotation of the left shoulder.
, A nurse is providing dietary teaching to the parents of a 6-month-old
infant. Which of the following instructions should the nurse include? -
:ANSWER- Introduce new foods one at a time over 5 to 7 days.
A nurse is teaching a group of guardians about child safety measures.
Which of the following statements by guardian indicates an
understanding of the teaching? - :ANSWER- "I should have my child
avoid sun exposure between 10 am and 2 pm"