Question And Answer
RN on a MS. Which of the following clients needs will the nurse assign to an AP? - ANSWER -
Reapplying a condom catheter for a client who has urinary incontinence
RN delegating the ambulation of a client who had knee arthroplasty . Which of the following
info should the nurse share with the AP? - ANSWER -client ambulates with his slippers on over
his antiembolic stockings
client uses a front wheeled walker when ambulating
client had pain meds 30 minutes ago
RN is making assignments. Which of the following assignments should the LPN question? -
ANSWER -D. Replacing the cartridge and tubing on a PCA pump
inservice program about delegation. Which of the following elements should she identify when
presenting the 5 rights of delegation. - ANSWER -B. Right supervision/evaluation
C. Right direction/communication
E. Right circumstances
A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which
staff member should the nurse assign the client? - ANSWER -B. RN
A nurse is caring for a client who decides not to have surgery despite significant blockages in his
coronary arteries. The nurse understands that this clients choice is an example of what
principles? - ANSWER -A. Fidelity
,A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands
that this aspect of care delivery is an example of which of the following ethical principles? -
ANSWER -D. Beneficience
A nurse is instructing a group of nursing students about the responsibilities involved with organ
donation and procurement. When the nurse explains that all clients waiting for a kidney
transplant have to meet the same qualifications, the students should understand that this
aspect of care delivery is an example of which ethical principle - ANSWER -C. Justice
A nurse questions a med prescription as too extreme and light of the clients advanced age and
unstable status. The nurse understands that this action is an example of which ethical principle
- ANSWER -D. Non-Malificence
Which of the following situations can be identified as an ethical dilemma? - ANSWER -C. A
family has conflicting feelings about the initiation of enteral tube feedings of their father who is
terminally ill
A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of
105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment
finding would indicate an increase in intracranial pressure? - ANSWER -2.High-pitched cry
A client is receiving total parenteral nutrition (TPN). To determine the
client's tolerance of this treatment, the nurse should assess for which of the Following? -
ANSWER -4.Urine output of at least 30cc per hour.
The client is exhibiting symptoms of myxedema. The nursing assessment should reveal -
ANSWER -2. decreased temperature
A nonstress test is scheduled for a client at 34-weeks gestation who
developed hypertension, periorbital edema, and proteinuria. Which of the following nursing
actions should be included in the care plan in order to BEST prepare the client for the diagnostic
test? - ANSWER -3. Instruct client to push a button when she feels fetal movement.
,Which of the following nursing interventions is MOST important for a
45-year-old woman with rheumatoid arthritis? - ANSWER -4. Assist her with heat application
and ROM exercises.
The nurse is caring for a young adult admitted to the hospital with a
severe head injury. The nurse should position the patient. - ANSWER -1. with his neck in a
midline position and the head of the bed elevated 30°.
The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to
perform intermittent self-catheterization at home. The nurse should instruct the client to -
ANSWER -2. perform the Valsalva maneuver "holding breath and bearing down" before doing
the catheterization.
A client is being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to. - ANSWER -4. avoid abrupt changes in posture.
A 38-year-old woman is returned to her room after a subtotal
thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse
at the patient's bedside, is nonessential? - ANSWER -1. Potassium chloride for IV administration.
A nurse recognizes that an initial positive outcome of treatment for a
victim of sexual abuse by one parent would be that the client - ANSWER -3. verbalizes that s/he
is not responsible for the sexual abuse.
An adolescent client is ordered to take tetracycline HCL
250 mg PO bid. Which of the following instructions should be given to this client by the nurse? -
ANSWER -2. "Wear sunscreen and a hat when outdoors."
, After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a
decrease in muscle tone. Which of the following nursing diagnoses would be a priority to
include in his care plan? - ANSWER -2. Alteration in skin integrity related to decrease in tissue
oxygenation.
A client has a history of oliguria, hypertension, and peripheral edema.
Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the
client's diet?. - ANSWER -1. Protein
An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the
psychiatric emergency room. The MOST important nursing intervention is to. - ANSWER -1.
monitor vital signs, especially blood pressure, every 30 minutes.
The nurse is caring for clients in the skilled nursing facility. Which of the following clients
require the nurse's IMMEDIATE attention? - ANSWER -1. A client admitted for a cerebral
vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two days ago.
The nurse is observing care given to a client experiencing severe to
panic levels of anxiety. The nurse would intervene in which of the following situations? -
ANSWER -3. The staff helps the client identify thoughts or feelings that occurred prior to the
onset of the anxiety.
A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD).
Which of the following would require an ntervention by the nurse? - ANSWER -3. The dialysate
outflow is cloudy.
The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse
should teach the client to limit his intake of - ANSWER -1. red meat and shellfish.