WITH CORRECT ANSWERS
A nurse on a medical unit is preparing to discharge a client to home. Which of
the following actions should the nurse take as part of the medication
reconciliation process?
a. Seal unused medications from the facility in a plastic bag.
b. Evaluate the client's ability to self-administer medications.
c. Report an identified discrepancy to The Joint Commission.
d. Compare prescriptions with medications the client received while at the
facility. - ANSWER-d
A nurse is caring for a client who has tuberculosis. Which of the following
actions should the nurse take? (Select all that apply.)
a. Place the client in a room with negative-pressure airflow.
b. Wear gloves when assisting the client with oral care.
c. Limit each visitor to 2-hr increments.
d. Wear a surgical mask when providing client care.
e. Use antimicrobial sanitizer for hand hygiene. - ANSWER-a, b, e
A nurse is caring for a client who has terminal liver cancer. Which of the
following statements should the nurse identify as an indication that the client is
experiencing spiritual distress?
a. "What could I have done to deserve this illness?"
b. "I blame medical science for not curing me."
c. "Where is my daughter at a time like this?"
d. "Will I ever begin to feel in charge of my life again?" - ANSWER-a
,A nurse is preparing a heparin infusion for a client who was admitted to the
facility with deep-vein thrombosis. The prescription reads: 25,000 units of
heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what
rate should the nurse set the infusion pump? (Round the answer to the nearest
whole number. Use a leading zero if it applies. Do not use a trailing zero.) -
ANSWER-8 mL/hr
A home health nurse is completing an admission assessment of an older adult
client who has their caregiver present. Which of the following findings should
the nurse identify as a potential indication of elder abuse?
a. The caregiver is the client's financial power of attorney.
b. The client is in a wheelchair with the wheels locked.
c. The client reports receiving a full bath twice each week.
d. The caregiver insists on remaining in the room. - ANSWER-d
A nurse is caring for a client who reports difficulty falling asleep. Which of the
following recommendations should the nurse make?
a. "Drink a cup of hot cocoa before bedtime."
b. "Maintain a consistent time to wake up each day."
c. "Exercise 1 hour before going to bed."
d. "Watch a television program in bed before going to sleep." - ANSWER-b
A nurse is caring for a client who has a newly placed ileostomy.
Exhibit 1
Nurses' Notes
,0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth
full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds
present in all quadrants.
1200:Stoma site appears dark purple with blistering on the skin around the
stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool.
The nurse should first address the __(1)__ followed by the __(2)__
1.
- stoma color
- hemoglobin level
- ostomy leakage
2.
- ostomy pouch seal
- skin around the stoma
- amount of stool in the pouch - ANSWER-1. stoma color
2. skin around the stoma
A nurse is preparing to administer multiple medications to a client who has an
enteral feeding tube. Which of the following actions should the nurse plan to
take?
a. Dissolve each medication in 5 mL of sterile water.
b. Draw up medications together in the syringe.
c. Push the syringe plunger gently when feeling resistance.
d. Flush the tube with 15 mL of sterile water. - ANSWER-d
A client who is nonambulatory notifies the nurse that his trash can is on fire.
After the nurse confirms the presence of the fire, which of the following
actions should the nurse take next?
, a. Activate the emergency fire alarm.
b. Extinguish the fire.
c. Evacuate the client.
d. Confine the fire. - ANSWER-c
A nurse is preparing to obtain a lower extremity blood pressure from a client
and no longer palpates the popliteal pulse after 92 mm Hg. Which of the
following images displays the measurement in mm Hg to which the nurse
should inflate the cuff when obtaining the blood pressure?
a. 92
b. 102
c. 112
d. 122 - ANSWER-d
A community health nurse is checking blood pressures for a group of clients at
a community health screening. Which of the following clients is at an
increased risk for hypertension?
a. A client who is 52 years old
b. A client who smokes one pack of cigarettes each day
c. A client who walks for 30 min every day
d. A client who drinks one glass of wine three times per week - ANSWER-b
A charge nurse is discussing the responsibility of nurses caring for clients who
have a Clostridium difficile infection. Which of the following information
should the nurse include in the teaching?
a. Assign the client to a room with a negative airflow system.
b. Use alcohol-based hand sanitizer when leaving the client's room.
c. Clean contaminated surfaces in the client's room with a phenol solution.