C2
1. The nurse is assisting with discharge planning for assigned clients. Which of the
following referrals is appropriate for the nurse to make?
a. A physical therapy referral for a client who had total knee replacement (TNR) and
needs use of a walker.
b. A speech therapy referral for a client who is scheduled to undergo an outpatient
esophagogastroduodenoscopy (EGD).
c. An occupational therapy (OT) referral for a client who had an amputation and
requires long term IV antibiotics.
d. A social worker referral for a client who has diabetes mellitus (type 2) and has
developed neuropathy.
2. The nurse has attended a continuing education program on legal issues in nursing
practice. Which of the following statements by the nurse indicates a correct
understanding of the conference?
a. “Threatening to touch a client without the client's consent is an example of
battery.” No, that’s assault.
b. “Failure to communicate concerns of an older adult client who is confused and is
being discharged home is an example of negligence.”
c. “Giving clients false assurance about a healthcare condition or expected outcome
is an example of libel.” No, libel means a false statement to damage someone’s
reputation.
d. “Posting information about a client on social media without the client's
permission is an example of slander.” No, slander is making a false statement about
someone orally.
3. The nurse working in a medical surgical unit is caring for assign clients which of the
following tests is appropriate to delegate?
a. Asking a licensed practical nurse to teach a client who has a newly created
ileostomy how to change the appliance. No LVN’s do not teach, especially when it’s
something NEW.
b. Asking a licensed practical nurse to obtain a capillary blood glucose reading on a
client who has become diaphoretic.
c. Asking a UAP to flush the closed wound drainage system of a client who is two
days postoperative from an open appendectomy. UAPs don't flush wounds.
d. Asking a UAP to turn off the tube feeding for a client who is receiving continuous
tube feedings and is vomiting. UAP should not be touching tube feedings.
4. The nurse working on the pediatric unit is caring for the following clients. It is most
appropriate for the nurse to initiate an interdisciplinary conference for a client who is
a. 2 years old, has impaired fine and gross motor skills, and was just diagnosed with
cerebral palsy.
, b. 7 months old, has intussusception, is vomiting, has colicky abdominal pain, and is
having jelly like stools.
c. 6 months old, has respiratory syncytial virus (RSV), is wheezing, and has copious
nasal discharge.
d. 2 months old, has developmental dysplasia of the hip, unequal leg lengths, limited
abduction of the left hip, and asymmetry of the gluteal folds.
5. The nurse has been aware of the following client situations. It is necessary for the nurse
to initially assess the client who has
a. Status asthmaticus, had wheezing on inspiration and expiration upon admission
30 minutes ago, received a nebulizer treatment, and now has vesicular breath
sounds. Vesicular breath sounds are normal, which means improvement.
b. Heart failure (CHF), received labetalol 2 hours ago, and has a pulse (P) rate that
has decreased from 77 to 63 over the past hour. Within normal limits
c. Emphysema, has an oxygen saturation (SaO2) level of 89%, and is using pursed
lip breathing while sitting up in a chair. Emphysema is a chronic lung disease that
causes permanent damage to the alveoli, the tiny air sacs in the lungs. EXPECTED.
d. Coronary artery disease (CAD), is receiving a continuous heparin infusion, and
has a partial thromboplastin time of 90 seconds. At risk for bleeding. An aPTT of 90
seconds is above the therapeutic range, indicating excessive anticoagulation and a high
risk of bleeding.
6. The nurse is caring for a client who weighs 150 pounds (68 kg) and has developed
hepatic encephalopathy. It is a priority for the nurse to notify the primary healthcare
provider if the client develops: Hepatic encephalopathy is when the liver is unable to filter out
toxins in the blood. Toxins accumulate in the brain.
a. An increase in urine output to 1.450 mL/day.
b. A change in pupil size from 7 to 5 mm. Normal range is 2-5
c. An increase in alanine aminotransferase (ALT) levels.
d. The development of flaccidity to the lower extremities. softness
7. The nurse working in the emergency department (ED) has received the following
prescriptions for newly admitted clients. Which prescription should the nurse implement
first?
a. Initiate an IV of 0.9% sodium chloride (normal saline) for a client who was
admitted with a urinary tract infection (UTI) and has a blood pressure of 122/68
mm Hg. stable
b. Administer labetalol IV to a client who has a blood pressure of 192/98 mm Hg
and a pulse (P) of 138. unstable
c. Administer a second unit of packed red blood cells (PRBCs) to a client who has
hemoglobin (Hgb) of 8 mg/dL. <7 is critical.
d. Administer lactulose to a client who has portal hypertension and is reporting
nausea. Not life threatening.
1. The nurse is assisting with discharge planning for assigned clients. Which of the
following referrals is appropriate for the nurse to make?
a. A physical therapy referral for a client who had total knee replacement (TNR) and
needs use of a walker.
b. A speech therapy referral for a client who is scheduled to undergo an outpatient
esophagogastroduodenoscopy (EGD).
c. An occupational therapy (OT) referral for a client who had an amputation and
requires long term IV antibiotics.
d. A social worker referral for a client who has diabetes mellitus (type 2) and has
developed neuropathy.
2. The nurse has attended a continuing education program on legal issues in nursing
practice. Which of the following statements by the nurse indicates a correct
understanding of the conference?
a. “Threatening to touch a client without the client's consent is an example of
battery.” No, that’s assault.
b. “Failure to communicate concerns of an older adult client who is confused and is
being discharged home is an example of negligence.”
c. “Giving clients false assurance about a healthcare condition or expected outcome
is an example of libel.” No, libel means a false statement to damage someone’s
reputation.
d. “Posting information about a client on social media without the client's
permission is an example of slander.” No, slander is making a false statement about
someone orally.
3. The nurse working in a medical surgical unit is caring for assign clients which of the
following tests is appropriate to delegate?
a. Asking a licensed practical nurse to teach a client who has a newly created
ileostomy how to change the appliance. No LVN’s do not teach, especially when it’s
something NEW.
b. Asking a licensed practical nurse to obtain a capillary blood glucose reading on a
client who has become diaphoretic.
c. Asking a UAP to flush the closed wound drainage system of a client who is two
days postoperative from an open appendectomy. UAPs don't flush wounds.
d. Asking a UAP to turn off the tube feeding for a client who is receiving continuous
tube feedings and is vomiting. UAP should not be touching tube feedings.
4. The nurse working on the pediatric unit is caring for the following clients. It is most
appropriate for the nurse to initiate an interdisciplinary conference for a client who is
a. 2 years old, has impaired fine and gross motor skills, and was just diagnosed with
cerebral palsy.
, b. 7 months old, has intussusception, is vomiting, has colicky abdominal pain, and is
having jelly like stools.
c. 6 months old, has respiratory syncytial virus (RSV), is wheezing, and has copious
nasal discharge.
d. 2 months old, has developmental dysplasia of the hip, unequal leg lengths, limited
abduction of the left hip, and asymmetry of the gluteal folds.
5. The nurse has been aware of the following client situations. It is necessary for the nurse
to initially assess the client who has
a. Status asthmaticus, had wheezing on inspiration and expiration upon admission
30 minutes ago, received a nebulizer treatment, and now has vesicular breath
sounds. Vesicular breath sounds are normal, which means improvement.
b. Heart failure (CHF), received labetalol 2 hours ago, and has a pulse (P) rate that
has decreased from 77 to 63 over the past hour. Within normal limits
c. Emphysema, has an oxygen saturation (SaO2) level of 89%, and is using pursed
lip breathing while sitting up in a chair. Emphysema is a chronic lung disease that
causes permanent damage to the alveoli, the tiny air sacs in the lungs. EXPECTED.
d. Coronary artery disease (CAD), is receiving a continuous heparin infusion, and
has a partial thromboplastin time of 90 seconds. At risk for bleeding. An aPTT of 90
seconds is above the therapeutic range, indicating excessive anticoagulation and a high
risk of bleeding.
6. The nurse is caring for a client who weighs 150 pounds (68 kg) and has developed
hepatic encephalopathy. It is a priority for the nurse to notify the primary healthcare
provider if the client develops: Hepatic encephalopathy is when the liver is unable to filter out
toxins in the blood. Toxins accumulate in the brain.
a. An increase in urine output to 1.450 mL/day.
b. A change in pupil size from 7 to 5 mm. Normal range is 2-5
c. An increase in alanine aminotransferase (ALT) levels.
d. The development of flaccidity to the lower extremities. softness
7. The nurse working in the emergency department (ED) has received the following
prescriptions for newly admitted clients. Which prescription should the nurse implement
first?
a. Initiate an IV of 0.9% sodium chloride (normal saline) for a client who was
admitted with a urinary tract infection (UTI) and has a blood pressure of 122/68
mm Hg. stable
b. Administer labetalol IV to a client who has a blood pressure of 192/98 mm Hg
and a pulse (P) of 138. unstable
c. Administer a second unit of packed red blood cells (PRBCs) to a client who has
hemoglobin (Hgb) of 8 mg/dL. <7 is critical.
d. Administer lactulose to a client who has portal hypertension and is reporting
nausea. Not life threatening.
