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A Nurse Is Caring For A Clients On The Med-Surg Unit. Which Client Is Most At Risk To
Develop A Nosocomial Infection?
A- Clinet With Alcohol Abuse Admitted For Detox
B- Client With Type I Diabetes And Peripheral Neuropathy
C- Client Recovering From A Choleystectomy
D- Client With Full Thickness Burns, An Ng Tube And A Foley
Correct Answer: D- Full Thickness Burn, Ng Tube And Foley
*Think Immunosupression And Avenues For Infection
A Nurse Is Caring For Clients In The Icu. Which Client May Be Transferred To The Step-Down
Neuro Unit?
A- Client With Head Injury And Seizure
B- Client With An Ischemic Stroke 4 Days Ago With Confusion
C- Client Who Is 1-Day Post Op After A Transshpenoidal Craniotomy With A Cerebrospinal
Fluid Leak
D-Client With Bacterial Meningitis And A Glasgow Coma Sale Of 7
Correct Answer: B- Client With An Ischemic Stroke 4 Days Ago With Confusion.
*Think What Is Normal And What Is Abnormal- Who Is Most Stable
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After A Change Of Shift, You Are Assinged To Care For The Following Clients, Which Client
Should You Assess First?
A- 60 Year Old Client On A Ventilator For Whom A Sterile Sputum Specimen Must Be Sent To
The Lab
B- 55 Year Old With Copd And A Pulse Oximetry Reading From The Previous Shift Of 90%
C- 70 Year Old With Pneumonia Who Needs To Be Started On Iv Antibiotics
D- 50 Year Old With Asthma Who Complains Of Shortness Of Breath After Using A
Bronchodilator
Correct Answer: D- 50 Year Old With Asthma Who Complains Of Shortness Of Breath After
Using A Brochodilator
*Think Abcs, Also Not The Desired Effect Of The Brochodilator Treatment; Should Be
Improved.
The Nurse Just Received Report On The Surgical Ward. Which Client Should Be Assessed
First?
A- Peptic Ulcer Disease Scheduled For A Laparosopic Choleycystectomy In 4 Hours
B- Multiple Injuries After A Motor Vehicle Crash
C- Graves Disease Scheduled For A Thyroidectomy
D- Post-Appendectomy Waiting For Discharge
Correct Answer: B- Multiple Injuries Following A Motor Vehicle Crash
*Think Who Is Most Unstable
A Hospital Will Receive A Large Number Of Clients Because Of A Magor Disaster In The City.
Which Client Can Be Discharged First?
A- 49 Year Old Female 24 Hours Postop After Hysterectomy
B- 66 Year Old Male 5 Days Post Op After Total Hip Replacement
C- 79 Year Old Female Admitted 12 Hours Ago With Pyrlonephritis
D- 82 Year Old Female Admitted 5 Days Ago With A Stage 3 Pressure Ulcer
Correct Answer: B- 66 Year Old Male 5 Days Post Op After Total Hip Replacement
*Think Who Is Most Stable And Would Be Safest To Go Home
A Nurse Just Received Report On Her Client's At The First Of The Shift. Which Client Should
Be Assessed First?
A- 45 Year Old Woman With A Bp Of 90/60 And Hot, Dry Skin
B- 37 Year Old Man With Bp 130/70, Sleeping Quietly In His Bed
C- 25 Year Old Woman With Fruity Breath, Excessive Thrist And Polyphagia
D- 16 Year Old Boy With Irritability And Tremor
Correct Answer: C- 25 Year Old Woman With Fruity Breath, Excessive Thirst And Polyphagia
*Who Is Showing Definite Signs Of A Problem Not Just Questionable Ones