TRANSITIONS TEST 1

The nurse provides care for clients in the emergency department. Which client does the nurse assess first? 1)A client reporting a beestings, causing diffuse redness 2)A client with a burn to the palm of the hand. 3)A client reporting blood and blood clots in the urine 4)A client reporting right lower leg pain, edema, and warmth.

1)A client reporting a beestings, causing diffuse redness

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. What should the nurse do first? 1)Assess for changes in vital signs 2)Draw an arterial blood gas 3)Evaluate heart sounds with the client leaning forward 4) Obtain a 12-Lead electrocardiogram

1)Assess for changes in vital signs`

The nurse is reviewing the laboratory results of an infant suspected of having pyloric stenosis. Which laboratory finding should the nurse most likely expect to note in this infant? 1)A blood pH of 7.50 2)A blood pH of 7.30 3)A blood bicarbonate of 21mEq/L (21 mmol/L 4) A blood bicarbonate of 28 mEq/L (28 mmol/L)

1

The nurse provides care for school age clients at summer camp. Which client in the infirmary does the camp nurse assess first? 1)A child with leukemia who was stung by a bee and reports feeling hot and itchy "everywhere 2)A child with asthma reporting a sore throat and demonstrating restlessness 3)A child with type 1 diabetes who is nervous, pale, and diaphoretic 4) A child with hemophilia reporting a headache and experiencing slurred speech

1) A child with leukemia who was stung by a bee and reports feeling hot and itchy "everywhere

The nurse collaborates with an unlicensed assistive personnel (UAP) to provide care to a client admitted for evaluation of dyspnea. The nurse delegates collection of which data to the UAP? 1) blood pressure 2)chest symmetry 3)apical pulse 4) lung sounds

1) blood pressure

A nurse is caring for a client on a four-medication regimen to treat tuberculosis. The nurse discovers that the client isn't taking all medications. What is appropriate for the nurse to say to the client? 1)"Taking several medications can be difficult. Tell me about the difficulties you're having." 2)"Why aren't you taking your medications? Don't you want to get better?" 3)"You must take your medication as instructed. Do you need supervision?" 4)"Don't you realize that resistance can develop if you don't take your medications properly?"

1)"Taking several medications can be difficult. Tell me about the difficulties you're having."

A client is admitted involuntarily to the psychiatric unit for assaultive behaviour toward others. The client demands to leave the hospital today. Which response by the nurse is best? 1)"You may be unsafe to yourself and others and need to stay for observation." 2)"You will be able to leave after your health care provider talks to you." 3)"You will be able to leave after your health care provider talks with your family." 4) "You can leave at any time after signing an against medical advice form."

1)"You may be unsafe to yourself and others and need to stay for observation."

Which client is at greatest risk for coronary artery disease? 1)A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L) 2)A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin 3)A 43-year-old male with a family history of coronary artery disease (CAD) and cholesterol level of 158 (8.8 mmol/L) 4) A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago

1)A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L)

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding. What should the nurse do first? 1)Assess respiratory status 2)Draw blood for laboratory studies 3)Insert a Foley catheter 4)Weigh the client.

1)Assess respiratory status

The nurse understands that debates over client's abortion rights are often based on conflict between which pairs of ethical principles? 1)Beneficence and justice 2) Veracity and fidelity 3)Paternalism and restitution 4) Autonomy and non-maleficence

1)Beneficence and justice

A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse? 1)Inform the charge nurse of the family's concerns. 2)Notify the health care provider and social services. 3)Explain to the client's family the previous nurse's actions were accidental. 4)Complete grievance paperwork for the family and hand it to them to submit.

1)Inform the charge nurse of the family's concerns.

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first? 1)Reduce pain and myocardial oxygen demand. 2)Provide client education on medications and diet 3)Limit visitation by family and friends 4) Monitor daily weights and urine output

1)Reduce pain and myocardial oxygen demand.

Each morning, a nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops, and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the nurse should have completed the tasks no matter what happened. Which leadership style is the nurse-manager exhibiting? 1)autocratic 2)laissez-faire 3)permissive 4)democratic

1)autocratic

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. During admission, what should the nurse assess first? 1)blood pressure 2)skin breakdown 3)potassium 4) Urine output

1)blood pressure

The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. The nurse should: 1)notify the health care provider immediately. 2)implement passive range-of-motion (ROM) exercises. 3)elevate the extremity on one pillow. 4)implement passive range-of-motion (ROM) exercises.

1)notify the health care provider immediately.

A child biking to school hit the curb and then fell, injuring the leg. The school nurse was called and found the child alert an conscious, but in severe pain with a possible right femur fracture. Which of the following is the first action that the nurse should take? 1)Assess the circumstances surrounding the accident. 2)Immobilize the affected limb with a splint and ask the client not to move. 3)Place the client in semi-Fowler's position for comfort 4) Assess the neurovascular status of both legs and compare the findings.

2

The industrial nurse provides care for a worker who has a radiation burn. The worker appears anxious and reports lower right, intermittent abdominal pain. Which action does the nurse take first? 1)Encourage the client to relax 2)Assess the abdominal pain 3)Obtain a prescription of pain medication 4)Begin the documentation process

2

The nurse receives a phone call from a person who states, "the client in room 203 is my family member. Can you give me a status update?" Which response by the nurse is appropriate? 1)"The client is scheduled for a colonoscopy in the morning." 2)"I am unable to give you any information at this time." 3)"The client is requiring intravenous pain medications." 4) "The client is receiving aggressive antibiotic therapy."

2)"I am unable to give you any information at this time."

Which symptoms should the nurse teach the client with unstable angina to report immediately to the health care provider? 1)Pain during sexual activity 2)A change in the pattern of the chest pain 3)Pain during an argument 4) Pain during or after a physical activity

2)A change in the pattern of the chest pain

The nurse provides care for clients in the intensive care unit (ICU). A client diagnosed with a head injury requires admission, but there are no empty beds. Which client does the nurse anticipate as being the most stable for a transfer to the stepdown neurological unit? 1)A client diagnosed with bacterial meningitis and who has a Glasgow Scale of 7 2)A client diagnosed with a frontal lobe stroke 4 days ago and who is exhibiting confusion. 3)A client with a head injury and who is having seizures. 4) A client 1 day postoperative after a transsphenoidal craniotomy with a possible cerebrospinal leak.

2)A client diagnosed with a frontal lobe stroke 4 days ago and who is exhibiting confusion.

The nurse is planning client assignments for the day and needs to assign four clients. There is a registered nurse, a licensed practical nurse, and 2 unlicensed assistive personnel on the nursing team. Which client should the nurse most appropriately assign to the registered nurse? 1)A client requiring a bed bath 2)A client who was admitted to the hospital during the night after experiencing an acute asthma attack 3)A client who requires frequent ambulation 4)A client with a right above-the-knee amputation who requires a dressing change

2)A client who was admitted to the hospital during the night after experiencing an acute asthma attack

A client with chest pain is prescribed intravenous nitroglycerin. Which finding is of greatest concern for the nurse initiating the nitroglycerin drip? 1)Heart rate is 61 bpm. 2)Blood pressure is 88/46 mm Hg 3)Serum potassium is 3.5 mEq/L (3.5 mmol/L) 4) ST elevation is present on the electrocardiogram.

2)Blood pressure is 88/46 mm Hg

The nurse with postpartum care experience gets reassigned to a medical-surgical care area. Which client will the charge nurse assign to the postpartum care nurse? 1)A client having a systemic reaction to latex 2)Client diagnosed with progressive systemic sclerosis and experiencing Raynaud phenomenon 3)A client diagnosed with heatstroke 4)A client with signs of facial trauma after experiencing a motor vehicle crash

2)Client diagnosed with progressive systemic sclerosis and experiencing Raynaud phenomenon

The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1,000 units per hour. During the second post procedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. What should the nurse do first? 1)Observe and document the bleeding 2)Don gloves and apply direct pressure over the site 3)Notify the health care provider (HCP) 4) Prepare protamine sulfate for intravenous administration.

2)Don gloves and apply direct pressure over the site

The nurse provides care to a client who is newly diagnosed with breast cancer. Which nursing action best represents the ethical principle of beneficence? 1)Make a treatment decision for the client. 2)Remain with the client when the client experiences anxiety 3)Explain to the client about the right to privacy at this time. 4)Tell the client that the breast tumor is non-malignant.

2)Remain with the client when the client experiences anxiety

A severe storm has blown out the window on a 30-bed medical-surgical unit. The nurse determines that clients have to evacuated to other rooms throughout the hospital. Which client does the nurse transfer first? 1)An adult client diagnosed with a peptic ulcer and receiving a blood transfusion. 2)An adult client transferred from cardiac intensive care earlier in the day post-myocardial infarction. 3)An adult client admitted with exacerbation of asthma and receiving nebulizer treatments. 4)An adult client diagnosed with type 1 diabetes and a recent blood glucose of 124 mg/dL (6.88 mmol/L)

3

The nurse is assessing the client's condition after cardioversion. Which observation would be of highest priority? 1)Oxygen flow rate 2)Blood pressure 3)Status of airway 4)Level of consciousness

3

The nurse on the day shift is assigned to care for 4 clients. After the report from the night shift, which client should the nurse plan to assess/collect data from first? 1) Client scheduled to have an electrocardiogram (ECG) at 11:00am 2)Client newly diagnosed with diabetes mellitus who is scheduled for discharge to home. 3) Client with pulmonary edema who was treated with furosemide at 5:00am 4) Client scheduled for a cardiac catherization at 10:00am

3

The nurse is caring for a client after a cardiac catherization. The client suddenly reports a feeling of wetness in the groin at the catheter insertion site. The nurse checks the site, notes that the client is actively bleeding, and should take which best action? 1)Contact the primary health care provider 2) Check the client's peripheral pulse in the affected extremity 3) Don a sterile glove and place pressure on the insertion site using sterile gauze 4)Don a clean glove and place pressure on the insertion site with the gloved hand

3) Don a sterile glove and place pressure on the insertion site using sterile gauze

The nursing student ask the nurse, "What are Good Samaritan laws?" Which response by the nurse is accurate? 1)"Good Samaritan laws require health care facilities to provide material to clients about rights." 2)"Good Samaritan laws provide clients with the right to be free from chemical restraints." 3)"Good Samaritan laws limit the liability of professionals in emergency situations." 4)"Good Samaritan laws require the reporting of threatened suicide or harm to others."

3)"Good Samaritan laws limit the liability of professionals in emergency situations."

The nurse provides care for clients on the medical-surgical unit. Which situation requires immediate intervention by the nurse? 1)A client scheduled for a cardiac catherization is expressing anxiety and reservations about undergoing the procedure 2) A client who had a cholecystectomy 2 days ago is draining purulent fluid through the T-tube 3)A client who had a liver biopsy is resting quietly on their back after procedure. 4) A visitor is sitting without a mask just inside the doorway of a client on droplet precautions

3)A client who had a liver biopsy is resting quietly on their back after procedure.

The nurse receives hand-off communication from the previous shift about assigned clients diagnosed with mental health disorder. Which client will the nurse see first? 1)Client diagnosed with delusions and who is stating a plan to kill the spouse after being discharged 2)Client diagnosed with mania and bipolar disease and who is threatening to sue the primary nurse for negligence 3)Client diagnosed with depression and who is stating that things are better and is expecting to be leaving soon. 4)Client diagnosed with schizophrenia and who is denying hearing voices

3)Client diagnosed with depression and who is stating that things are better and is expecting to be leaving soon.

A client has risk factors for coronary artery disease, including smoking cigarettes, eating a diet high in saturated fat, and leading a sedentary lifestyle. Which coaching strategies from the nurse will be most effective in assisting the client improve his or her health? 1)Explaining how the risk factors lead to poor health 2)Withholding praise until the client changes the risky behavior 3)Helping the client establish a wellness vision to reduce the health risks 4) Instilling mild fear into the client about the potential outcomes of the risky health behaviors

3)Helping the client establish a wellness vision to reduce the health risks

An older adult is admitted to the telemetry unit for placement of permanent pacemaker because of sinus bradycardia. What is a priority goal for the client within 24 hours after insertion of a permanent pacemaker? 1) Maintain skin integrity. 2)Increase activity level. 3)Maintain cardiac conduction stability 4) Decrease cardiac output.

3)Maintain cardiac conduction stability

Which position is best for a client with heart failure who has orthopnea? 1)Semi sitting (low Fowler's position) with legs elevated on pillows 2)Lying on the back with the head lowered (Trendelenburg's position) and legs elevated 3)Sitting upright (high Fowler's position) with legs resting on the mattress 4) Lying on the right side (Sim's position) with a pillow between the legs

3)Sitting upright (high Fowler's position) with legs resting on the mattress

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first? 1)Prepare for transcutaneous pacing. 2)Auscultate for abnormal heart sounds. 3)Take the client's blood pressure 4)Administer atropine 0.5mg IV push

3)Take the client's blood pressure

A nurse working on the adolescent unit has a strained working relationship with a coworker and finds it difficult to work well with the coworker. What is the best way for the nurse to go about defusing this situation? 1)Ask other nurses assigned to the unit to see what they think might improve the situation.. 2)Complain to the nurse-manager about the coworker's attitude.. 3)Talk with the coworker and try to work out differences so they don't affect client care. 4)Avoid the coworker by working different shifts.

3)Talk with the coworker and try to work out differences so they don't affect client care.

A child biking to school hit the curb and then fell. The child tells the school nurse, "I think my leg is broken." Which of the following actions is the first action the nurse should take? 1)Immobilized the affected limb with a splint and ask the client not to move. 2)Ask the client to explain what happened. 3)Place the client in semi-Fowler's position to facilitate breathing. 4)Check the appearance of the client's leg

4

An adult comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Prescriptions include oxygen by nasal cannula at 4L/ min, complete blood count, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given given IV. What should the nurse do first? 1)Prescribe the chest radiograph 2)Obtain the blood work. 3)Obtain a 12-lead ECG 4) Administer the morphine

4) Administer the morphine

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? 1)Weight gain of 1 kg in 3 days, blood pressure 130/80 mmHg, mild dyspnea with exercise 2)SpO2 92 on 2L nasal cannula, respirations 20, 1+ edema of lower extremities 3)Blood pressure of 110/62 mmHg, atrial fibrillation with heart rate 82, bilateral basilar crackles 4) Confusion, urine output 15mL over the last 2 hours, orthopnea

4) Confusion, urine output 15mL over the last 2 hours, orthopnea

Which is the most appropriate diet for a client during the acute phase of myocardial infarction (MI)? 1)Nothing by mouth 2) Three regular meals per day 3) Liquids as deisred 4) Small, Easily digested meals

4) Small, Easily digested meals

The nurse is planning the client assignments for the day and is reviewing client data and the needs of the clients on the nursing team. To maintain continuity of care, the nurse should ensure that which client is cared for by the nurse who cared for the client on the previous day? 1)A client with active tuberculosis 2)A client with herpes zoster (chickenpox) 3)A client with a cervical radiation implant 4)A client recently diagnosed with inoperable cancer

4)A client recently diagnosed with inoperable cancer

The nurse is reviewing the plan of care for a client with a diagnosis of sickle cell anemia. Which client problem, if stated on the plan of care, should the nurse select as receiving the highest priority? 1)Inability to cope with lifestyle limitations imposed as a result of the disease 2)Embarrassment about appearance 3)Nervousness about the disease 4)Dehydration

4)Dehydration

Negligence

careless neglect, often resulting in injury

The new graduate nurse observes another nurse signing off medications for the entire shift for multiple clients. The new graduate nurse reports the situation to the nursing supervisor based on which legal principle? 1)Slander 2)Libel 3)Battery 4) Negligence

Negligence

A quarterly audit is now due to evaluate implementation of an electronic medical record system on the nursing unit. As the unit representative who supervised the adaptation of this documentation system, how can the nurse best determine if nursing staff have accepted this change? 1)Nursing staff likes the electronic record because they believe it saves them time 2)Nursing staff uses the electronic record sporadically to monitor clients' progress 3)Nursing staff uses the electronic medical record daily in routine documentation 4)Nursing staff verbalizes the need for the electronic record but still hand-write nursing notes into the clients' charts

Nursing staff uses the electronic medical record daily in routine documentation

Slander

Slander is speaking falsely about another person.

Orthopnea

left-sided heart failure

Breach in confidentiality-

violations of HIPAA and a client's privacy

Libel

writing falsey about others

Malpractice-

•administering the incorrect dose of medication due to calculation error or "look alike, sound alike" •- failing to implement safety measures for patients

Defamation of character:

•libel (written) or slander (verbal)