1. A nurse is admitting a client who has pulmonary tuberculosis. Which of
the followingtransmission-based precautions should the nurse initiate?
, • Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted
by airbornedroplets smaller than 5 microns in diameter. Therefore,
this client requires airborne precautions to prevent communicating
this infection to others
2. A nurse in a mental health facility is preparing an educational program
for a group ofstaff nurses about the proper use of restraints. Which of the
following information should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or
older may be ina restraint for no more than 4 hr. Children who are 9
to 17 years old are limited to 2 hr and children who are younger than 9
years old are limited to 1 hr
3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of
the followingstatements should the nurse make?
• Exercise in the morning after arising
• Rationale: Daily exercise has many benefits, including enhancing
cardiovascular, psychological, and musculoskeletal health. The nurse
should recommend that theclient avoid exercising within 2 hr of
bedtime to limit stimulation and enhance sleep
4. A nurse is preparing to leave the room of a client who is on isolation
precautions. Whichof the following actions should the nurse take when
removing a tied surgical mask?
• Remove the mask by securely holding the ties and moving it away from
the face
• Rationale: The nurse should untie the bottom strings and then the top
, strings. Finally, while still holding the strings, the nurse should
remove the mask from herface. This action prevents the nurse from
touching the front of the mask, which iscontaminated
5. A nurse is caring for an adolescent client who is in critical condition
following a motor vehicle crash in which he was the passenger. The
client's parent shouts at the nurse, asking why her son is dying instead of
the driver. Which of the following actions shouldthe nurse take to provide
emotional support to the parent?
• Inform the parent that anger is a natural response when dealing with
loss
• Rationale: The nurse should identify that the parent is in the anger
stage of grief. The nurse should assist the parent to understand that
anger is a natural response to loss and encourage her to talk about her
feelings
6. A community health nurse is planning prevention strategies for hypertension
among members of her community. The nurse should identify that which of
the following ethnicgroups in the community is at greatest risk of
developing hypertension?
• African Americans
, • Rationale: Evidence-based practice indicates that individuals of
African-Americanethnicity have the highest prevalence of
hypertension. Therefore, the nurse should identify community
members of this ethnicity are at greatest risk of developing
hypertension.
7. A community health nurse is planning interventions to promote Healthy
People 2020 initiatives in the community. Which of the following actions
should the nurse plan totake first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a
Healthy People 2020 initiative. Using the nursing process, the first
action the nurse should take isto assess the needs of the community.
By identifying disparities in community health, the nurse can develop
interventions targeted at the community's specificneeds.
8. A nurse is reviewing a client's new prescriptions that were just documented
in the client's medical record by the provider. Which of the following
abbreviations should thenurse clarify with the provider?
• Enoxaparin 40 mg SQ QD
• Rationale: The nurse should clarify this prescription with the
provider. The abbreviations "SQ" and "QD" are considered error-
prone and should not be usedin documentation. The nurse should
clarify that the provider intends the prescription to be administered
subcutaneously once daily. "Subcutaneous" or "subcut" should be
used instead of "SQ" and "daily" should be used instead of "QD."
9. A nurse is talking with a client who has major depressive disorder. The
client states, "Nobody cares if I'm around or not." Which of the following
responses should the nursetake?
• It sounds as though you’re feeling hopeless
the followingtransmission-based precautions should the nurse initiate?
, • Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted
by airbornedroplets smaller than 5 microns in diameter. Therefore,
this client requires airborne precautions to prevent communicating
this infection to others
2. A nurse in a mental health facility is preparing an educational program
for a group ofstaff nurses about the proper use of restraints. Which of the
following information should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or
older may be ina restraint for no more than 4 hr. Children who are 9
to 17 years old are limited to 2 hr and children who are younger than 9
years old are limited to 1 hr
3. A nurse is teaching sleep hygiene to a client who has insomnia. Which of
the followingstatements should the nurse make?
• Exercise in the morning after arising
• Rationale: Daily exercise has many benefits, including enhancing
cardiovascular, psychological, and musculoskeletal health. The nurse
should recommend that theclient avoid exercising within 2 hr of
bedtime to limit stimulation and enhance sleep
4. A nurse is preparing to leave the room of a client who is on isolation
precautions. Whichof the following actions should the nurse take when
removing a tied surgical mask?
• Remove the mask by securely holding the ties and moving it away from
the face
• Rationale: The nurse should untie the bottom strings and then the top
, strings. Finally, while still holding the strings, the nurse should
remove the mask from herface. This action prevents the nurse from
touching the front of the mask, which iscontaminated
5. A nurse is caring for an adolescent client who is in critical condition
following a motor vehicle crash in which he was the passenger. The
client's parent shouts at the nurse, asking why her son is dying instead of
the driver. Which of the following actions shouldthe nurse take to provide
emotional support to the parent?
• Inform the parent that anger is a natural response when dealing with
loss
• Rationale: The nurse should identify that the parent is in the anger
stage of grief. The nurse should assist the parent to understand that
anger is a natural response to loss and encourage her to talk about her
feelings
6. A community health nurse is planning prevention strategies for hypertension
among members of her community. The nurse should identify that which of
the following ethnicgroups in the community is at greatest risk of
developing hypertension?
• African Americans
, • Rationale: Evidence-based practice indicates that individuals of
African-Americanethnicity have the highest prevalence of
hypertension. Therefore, the nurse should identify community
members of this ethnicity are at greatest risk of developing
hypertension.
7. A community health nurse is planning interventions to promote Healthy
People 2020 initiatives in the community. Which of the following actions
should the nurse plan totake first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a
Healthy People 2020 initiative. Using the nursing process, the first
action the nurse should take isto assess the needs of the community.
By identifying disparities in community health, the nurse can develop
interventions targeted at the community's specificneeds.
8. A nurse is reviewing a client's new prescriptions that were just documented
in the client's medical record by the provider. Which of the following
abbreviations should thenurse clarify with the provider?
• Enoxaparin 40 mg SQ QD
• Rationale: The nurse should clarify this prescription with the
provider. The abbreviations "SQ" and "QD" are considered error-
prone and should not be usedin documentation. The nurse should
clarify that the provider intends the prescription to be administered
subcutaneously once daily. "Subcutaneous" or "subcut" should be
used instead of "SQ" and "daily" should be used instead of "QD."
9. A nurse is talking with a client who has major depressive disorder. The
client states, "Nobody cares if I'm around or not." Which of the following
responses should the nursetake?
• It sounds as though you’re feeling hopeless
