a. "You don't have to go through with the treatment." - 1. A nurse is caring for
a client who has given informed consent for ECT. Just before the procedure,
the client tells the nurse she is considering not going forward with the
treatment. Which of the following statements by the nurse is appropriate?
c. Remove the device from the room - 2. While performing a routine
assessment, a nurse notices fraying on the electrical cord of a client's CPM
device. Which of the following actions should the nurse take first?
c. Count the current number of unit doses available in the medication
dispensing system - 3. A nurse is caring for a client who is postoperative and
has a new prescription for hydromorphone. Which of the following actions
should the nurse take?
c. 2 hr. post cast placement and has 2+ pitting edema and pallor - 4. A nurse
performing a change-of-shift assessment. Which of the following clients has
the priority finding?
c. "I will take the sustained-release methylphenidate every morning." - 5. A
nurse in an outpatient mental health facility is providing teaching to a group of
adolescents. Which of the following statements by a client indicates an
understanding of the teaching?
b. Implement seizure precautions for the client - 6. A nurse in the emergency
department is assessing client who has major depressive disorder. Which of
the following actions should the nurse take first? [View Exhibit]
d. Preoccupied with aging - 7. A nurse is completing an admission
assessment for a client who ahs narcissistic personality disorder. Which of the
following should the nurse expect?
(no answer provided) - 8. Drug Calc: Client weighs 99 lb. Prescribed diet of
1.5 g protein/kg/day. How many grams of protein perday should the nurse
include in the client's dietary plan?
, c. Determine goals of the day - 9. A nurse is planning care for a group of
clients and is working with one LPN and one AP. Which of the following
actions should the nurse take first to manage her time effectively?
b. Measure the client's urine output every hour - 10. A nurse is developing a
plan of care for a client who has preeclampsia and is to receive magnesium
sulfate via continuous IV infusion. Which of the following actions should the
nurse include in the plan?
c. Approximated surgical incision - 11. A nurse is caring for a group of clients.
Which of the following wounds should the nurse expect to heal by primary
intention?
a. Client taking clozapine to treat schizophrenia and reports sore throat
(pharm pg. 72: monitor for infection [fever, sore throat, etc.]) - 12. A nurse in
an acute mental health care facility is prioritizing care for multiple clients.
Which of the following clients should the nurse see first?
c. A noncoring needle - 13. A nurse is caring for a client who has an implanted
venous access port. Which of the following should the nurse use to assess the
port?
b. 12 lead ECG - 14. A nurse is caring for a client who has pneumonia and
tells the nurse, "I feel like an elephant is sitting on my chest." The client is
weak and unable to walk. After the nurse indicates chest pain protocol, which
of the following is the priority diagnostic test?
c. "Can your child ride a tricycle?" - 15. A nurse is assessing the growth and
development of a 3 y/o child. Which of the following questions should the
nurse ask the parent to determine if the child is exhibiting typical
developmental expectations?
c. Position the ultrasound stethoscope above the symphysis pubis to assess
the FHR - 16. A nurse is preparing to assess fetal heart tones for a client who
is at 12 weeks of gestation. Which of the following actions should the nurse
take?
b. The system is working properly (medsurg pg. 104: tidaling in the water seal
chamber and continuous bubbling only in the suction chamber) - 17. A nurse
is assessing a client who has a chest tube with a water seal drainage system.