ASSESMENT LEVEL 1-4 |RATED A+| With
Questions and Correct Answers
A nurse is caring for a client who is 2 days postoperative following
an above-the-knee amputation. The client states he is
experiencing a dull, burning pain in the leg that was amputated.
Which of the following actions should the nurse take to treat the
client's neuropathic pain? - Correct Answer--Administer a beta-
blocking medication to the client.
(The nurse should administer a beta-blocking medication to the
client. This classification of medication has been shown to relieve
the phantom limb pain manifestations of constant dull and
burning type pain.)
A newly licensed nurse asks a charge nurse where to find
information about scope of practice for registered nurses. Which
of the following responses should the charge nurse make? -
Correct Answer--"The state board of nursing can provide this
information"
(each state develops a nurse practice act, which defines scope of
practice for nurses in that state. This practice act is available on
the board of nursing website for each state.)
A nurse is planning care to prevent a catheter-related
bloodstream infection for a client who is receiving IV fluid therapy.
Which of the following interventions should the nurse include in
the plan? - Correct Answer--Perform hand hygiene before touching
the IV tubing.
(The nurse should perform thorough hand hygiene before
touching any part of the infusion system or the client to reduce
the risk of catheter-related blood stream infections.)
,A nurse is creating a plan of care for a client who is non-
ambulatory and has bladder and bowel incontinence. Which of the
following interventions should the nurse include to prevent skin
breakdown? - Correct Answer--Offer the client a glass of water
every two hour when repositioning.
(The nurse should offer the client a glass of water every two hours
on the clients repositioning schedule. This helps prevent
dehydration, which increases the risk of skin breakdown.)
A nurse is teaching a young adult female client about health
screening for breast cancer. Which of the following statements by
the client indicates an understanding of breast self-examination
(BSE)? - Correct Answer--"I should expect to feel a firm ridge along
the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected
along the bottom curve of each breast. The client should be able
to feel this area during the BSE. Performing a BSE promotes
breast self awareness so that the client knows how her breast
normally feel. The awareness increases the clients ability to
identify changes that require further evaluation.)
A nurse is caring for an adolescent who is in critical condition
following a motor vehicle crash which he was the passenger. The
clients parent shout at the nurse, asking why her son is dying
instead of the driver. Which of the following actions should the
nurse take to provide emotional support to the parent? - Correct
Answer--Inform the parent that anger is a natural response when
dealing with loss.
(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.)
A nurse is teaching an older adult client about accessing
electronic resources for healthcare information on the internet.
Which of the following statements should the nurse include in the
teaching? - Correct Answer--"Websites ending in '.gov' are reliable
sites for obtaining health information from government agencies."
(The nurse should teach the client how to select reliable internet
websites when researching health care information. The nurse
should identify that websites ending in '.gov' and '.edu' are
considered reliable and credible sources for health information.
Websites ending in '.com' should not be used for researching
credible healthcare information.)
A nurse enters a clients room and finds the client lying on the
floor. The client states that on the way to the bathroom her "knee
locked," causing her to fall. Which of the following actions should
the nurse take first? - Correct Answer--Check the client for
injuries.
(The first action the nurse should take when using the nursing
process is to assess the client. The nurse should first check the
client for injuries and measure vital signs to help determine
physiologic stability. The nurse should also inform the provider of
the clients fall and of the assessment findings.)
A nurse is teaching a client who has rheumatoid arthritis about
chronic pain management. Which of the following statements by
the client indicates an understanding of the teaching? - Correct
Answer--"I should use a warm paraffin dip for my hands and feet."
, (The nurse should instruct the client to dip her hands and feet in
warm paraffin to alleviate pain and stiffness. The client can more
easily perform hand and finger exercises following the treatment.)
A community health nurse is planning prevention strategies for
hypertension among members of her community. The nurse
should identify that which of the following ethnic groups in the
community is at greatest risk of developing hypertension? -
Correct Answer--African American
(Evidence-based practice indicates that individuals of AA ethnicity
have the highest prevalence of hypertension. Therefore, the nurse
should identify community members of this ethnicity are at
greatest risk of developing hypertension.)
A nurse is preparing to extinguish a small fire in a clients room.
Which of the following actions should the nurse take when using
the fire extinguisher? - Correct Answer--Slide the pin on top of the
fire extinguisher straight out.
(The nurse should pull the pin on top of the fire extinguisher to
allow for use to extinguish the fire.)
A nurse is preparing to administer intermittent external nutrition
via a clients NG tube. In which order should the nurse take the
following actions? - Correct Answer--1. Assist the client to an
upright position.
2. Aspirate 5 mL of gastric contents.
3. Test the pH of gastric aspirate.
4. Measure gastric residual volume.
5. Flush the NG tube with 30 mL of water.