WITH 100% CORRECT UPDATED
ANSWERS
The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should
assign the client to a room with which client? - Answer - A client diagnosed with Cushing's
Syndrome.
The nurse observes client care on a geriatric unit. The nurse should intervene in which situation?
- Answer - A student nurse assists the client to stand from a sitting position by grasping the
client's elbows.
The nurse evaluates the results of the client's purified protein derivative (PPD) 2 1⁄2 days after
the injection. The nurse noted the induration is 4 mm. which action by the nurse is most
appropriate? - Answer - Inform the client the results are negative
The nurse cores for the client with a history of schizophrenia. The nurse expects to note which
speech pattern? - Answer - Repetition of the words used by the nurse.
The nurse cares for a 6-month-old infant. The parents report that the infant had severe diarrhea
for twelve hours. The nurse anticipates which finding? - Answer - Depresses anterior fontanel.
The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The client reports
pain at 1600. The nurse notes that the hydrocodone was last administered at 1200, and the nurse
proceeds to administer hydromorphone at 1615. After discovering the error, how should the
nurse record the occurrence? - Answer - Hydromorphone given at 1615; health care provider
notified. B/P 122/80, RR 16."
The male client asks the nurse, "Why am I experiencing erectile dysfunction (ED)?" The nurse
reviews the client's medications. The nurse recognizes that which classification increases the risk
for ED? - Answer - Antihypertensive medications.
The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP) discuss the
client's condition. What is the PRIORITY action for the nurse to take? - Answer - Inform the
employees about patient confidentiality and the client's right to privacy.
The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to
drink two ounces of fluid every hour. The nurse determines the goal is met if which is recorded
on the intake and output (I&O) sheet for an eight-hour shift? - Answer - 480 ml
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, The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate
which activity to the LPN/LVN? - Answer - Take the blood pressure and heart rate before
administration of enalapril.
The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne
precautions, the nurse must confirm which? - Answer - No acid-fast bacteria are in the sputum.
The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa.
The nurse determines discharge teaching is effective if the client makes which statement to her
husband? - Answer - I'm sorry to tell you we can't have sexual relations
The nurse prepares the client diagnosed with myxedema for discharge. Which action should the
nurse teach related to body temperature? - Answer - "Put on multiple layers of clothes until you
fell comfortably warm."
The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a
candidate for induction of labor? - Answer - The client diagnosed with preeclampsia.
The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST
important? - Answer - Prevent infections.
The nurse educator presents an in-service on acyanotic heart disease. Which is the most common
symptom of this disorder that the nurse educator should include? - Answer - Presence of an
audible heart murmur.
The nurse provides care for the client diagnosed with pneumonia who has postural drainage
twice a day. Which client response indicates to the nurse that treatment is effective? - Answer -
"I am coughing up more sputum."
The risk management department plans a program to reduce errors. Which is the most common
cause of errors in medication administration? - Answer - Failure to follow routine policy and
procedures.
The nurse received report from the previous shift. Which client should the nurse see FIRST? -
Answer - The client scheduled for discharge later in the day and is reporting increased shortness
of breath.
The nurse reviews the arterial blood gas (ABG) report. The PH is 7.50; CO2 is 40mm; HCO3 is
30 mm. Which is the MOST important question to ask the client? - Answer - How long have you
been vomiting?
The nurse prepares a list of delegated tasks for the nursing assistive personnel (NAP). Which
task would be APPROPRIATE? - Answer - Turn and reposition the client diagnosed with
quadriplegia.
The nurse cares for the client diagnosed with anorexia nervosa. The nurse should include which
in the client's plan of care? - Answer - Observe client during and one hour after each meal.
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