Module 7 Capstone/Transition to Practice PRACTICE QUIZ
A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? a. "The car seat is rear-facing in the front passenger seat". b. "Our car seat is an infant model and is anchored in the car" c. "I can fit my hand between the baby and the car seat harness" d. "Our car seat is front-facing in the back seat"
b. "Our car seat is an infant model and is anchored in the car"
56. A nurse is assisting with the admission of a child who has measles. Which of the following isolation precaution should the nurse initiate? a. Droplet b. Airborne c. Contact d. Protective environment
b. Airborne
A nurse is interviewing a female client who is Hispanic. The client's answers the questions and states. "she speaks only a little English." Which of the following actions should the nurse take? a. Ask the client's partner to translate questions and answer for the client b. Arrange to complete the assessment with only the client and a translator's present c. Use an internet website ending in.com to translate for the client d. Ask a male student nurse to translate for the client
b. Arrange to complete the assessment with only the client and a translator's present
A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' client while lunch. The charge nurse is demonstrating which of the following types of conflict management? a. Avoiding b. Cooperating c. Compromising d. Competing
b. Cooperating
A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? (Select all that apply). a. Dominator b. Coordinator c. Energizer d. Self-confessor e. Evaluator
b. Coordinator c. Energizer e. Evaluator
A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include? a. Make sure a family member is present to interpret for the staff b. Encourage the client to nod to indicates understanding c. Determine the client's level of fluency in his primary language d. Speak directly to the interpreter when teaching the client
b. Encourage the client to nod to indicates understanding
A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene? a. Holds gauze package 15cm (6in) above the sterile field. b. Holds a bottle of solution with the label away from the palm of the hand c. Wears sterile gloves when moving when moving sterile items on the sterile field d. Position the wrapped package on the bedside table so the outer flap is away from her.
b. Holds a bottle of solution with the label away from the palm of the hand
A nurse working on a surgical unit receives a phone call from a client's neighbor who request a postoperative update of the client's condition. Which of the following actions by the nurse is appropriate? a. Provide the neighbor with a brief statement about the client, condition b. Inform the neighbor that you do not have information about the client c. Suggest that the neighbor call the client's health care provider for the information d. Transfer the neighbor's call to the telephone in the client's hospital room
b. Inform the neighbor that you do not have information about the client
A nurse is reviewing a provider's prescriptions for four clients. Which of the following prescriptions is outside the legal scope of practice for the nurse? a. Complete a Glasgow coma scale on a client b. Insert a tunneled central venous catheter of a client c. Perform a type and cross match on a client for 2 units of packed RBCs d. Provide initial education for a client who has type 1 diabetes mellitus
b. Insert a tunneled central venous catheter of a client
A nurse is planning care for a client who is to undergo a stem cell transplant. Which of the follow actions should the nurse plan to take? a. Provide the client with 1,000 ML of water of drink to drink every 12hr. b. Keep blood pressure equipment in the client's room c. Place the client in a negative airflow room d. Monitor the client's vital signs once every 8hr.
b. Keep blood pressure equipment in the client's room
A nurse is assessing the medical record of a female client who has anorexia nervosa. Which of the following findings should the nurse expect? a. Heat intolerance b. Low bone density c. Heavy monthly period d. Decreased cholesterol levels
b. Low bone density
A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should consult with which of the following members of the interdisciplinary team to assist the client? a. Recreational therapist b. Occupational therapist c. Psychiatric social worker d. Psychiatric clinical nurse specialist
b. Occupational therapist
A nurse teaching about safety recommendations for car seats with the parents of a 24- month-old toddler who is in the 50th percentile for height and weight. Which of the following instructions should the nurse include in the teaching? a. Position a convertible seat forward facing in the front passenger side and inactive the airbag b. Position the toddler rear-facing in the middle of the back seat c. Position a booster sat forward facing in the middle of the back seat d. Position a convertible seat rear facing in the front passenger side
b. Position the toddler rear-facing in the middle of the back seat
A nurse observing assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following action by the AP should the nurse identify as an indication of the need to intervene? a. Lowers the side rail on the side of the bed closest to the AP b. Reaches over the bed to straighten the fitted sheet c. Rolls the client to one side of the bed d. Raises the bed to waist level
b. Reaches over the bed to straighten the fitted sheet
A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus(HIV) He states, I don't care what the doctors say, there is no way I can have HIV and I don't need treatment for something I don't have. The nurse identifies the client is experiencing which of the following types of crisis? a. Maturational b. Situational c. Adventitious d. Internal
b. Situational
A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take? a. Use sign language when communicating with the client b. Speak directly to the client in a normal, clear voice c. Sit by the client's side and speak very slowly. d. Speak loudly and into the client's good ear.
b. Speak directly to the client in a normal, clear voice
A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? a. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift b. Suction the tracheotomy of a client who has copious secretions c. Ask the provider about advancing a client's diet d. Reinsert an intravenous catheter that was received due to infiltration
b. Suction the tracheotomy of a client who has copious secretions
A nurse is planning care for a newly admitted client who has major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority? a. The client assumes an active role in her care planning process b. The client makes a contract not to harm herself c. The client identifies positive qualities about herself. d. The client exhibits expected grieving behaviors
b. The client makes a contract not to harm herself
A nurse on a medical surgical unit is assigning task to assistive personnel (AP). Which of the following task should the nurse delegate to the AP? (select all that apply) a. Irrigate a wound b. Transfer a client to a stretcher c. Demonstrate the technique to instill eye drops d. Ambulate client who has a cane e. Record urinary output
b. Transfer a client to a stretcher d. Ambulate client who has a cane e. Record urinary output
A nurse is planning care for 4-year-old child who requires airborne precautions. Which of the following activities should the nurse plan for child? a.Constructing a model airplane b.Putting a large piece puzzle together c.Pulling a wagon with toys in the hallway d.Watching a video game in the playroom
b.Putting a large piece puzzle together
A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today". Which of the following responses should the nurse make? a. "Would a backrub ease your nervousness?" b. "What is making you feel nervous?" c. "Please explain what you mean by the word nervous" d. "You shouldn't feel nervous"
c. "Please explain what you mean by the word nervous"
] A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make? a. "It doesn't appear as though you are feeling anxious" b. "Do you think your anxiety is worse than everyone else" c. "Tell me what has been happening lately" d. "I think you should see a therapist"
c. "Tell me what has been happening lately"
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? a. Cocaine b. Caffeine c. Alcohol d. Inhalant's
c. Alcohol
A nurse is planning care for a client who has generalized anxiety disorder. Which of the following intervention should the nurse implement to promote relaxation? a. Help the client to identity his previous accomplishments b. Encourage the client to identity his positive qualities c. Assist the client in practicing meditation d. Recognize the client's spiritual preferences.
c. Assist the client in practicing meditation
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts? a. Negligence b. Assault c. Battery d. False imprisonment
c. Battery
A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select all that apply) a. Partner's full name b. Facility room number c. Client's full name d. Provider's name
c. Client's full name
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? a. Rephrase statements the client does not hear b. Speak using his usual tone of voice c. Determine if the client uses hearing aids d. Stand directly in front of the client.
c. Determine if the client uses hearing aids
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? a. Bradycardia b. Hypotension c. Hand tremors d. Stuporous level of consciousness
c. Hand tremors
A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? a. Apply a tourniquet to the affected extremity b. Raise the affected extremity above the level of the heart c. Immobilize the affected extremity with a splint d. Apply ice to the bite area.
c. Immobilize the affected extremity with a splint
A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first? a. Obtain a blood specimen b. Insert an IV access site c. Implement seizure precautions d. Perform a neurological exam
c. Implement seizure precautions
A nurse needs to lift a box in a supply room .Which of the following actions should the nurse take to prevent an injury due to lifting? a. Bend at the waist to pick up the box b. Stand with his feet close together while lifting c. Keep the box close to his body as he lifts d. Twist when placing the box to his side
c. Keep the box close to his body as he lifts
A nurse has completed care procedures for client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? a. Gloves b. Gown c. Mask d. Goggles
c. Mask
A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make? a. "You said that you feel guilty about your daughter's diagnosis. Lets talk about what is causing you to feel this way". b. "Your provider has explained the causes of schizophrenia why you feel guilty about your daughter diagnosis?" c. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable". d. "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment".
a. "You said that you feel guilty about your daughter's diagnosis. Lets talk about what is causing you to feel this way".
A nurse is providing home safety information for an older client who uses a cane. Which of the following statements should the nurse include in the teaching? a. "You should advance your weak leg forward to the cane, then move your stronger leg" b. "You should hold the cane in your weak hand when ambulating" c. "The cane's height should be the same as the distance from the floor to the crest of your hip bone" d. "you should advance the cane 12 to 14 inches before taking a step"
a. "You should advance your weak leg forward to the cane, then move your stronger leg"
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? a. A client who has measles b. A client who has pertussis c. A client who has streptococcal pharyngitis d. A client who has scabies
a. A client who has measles
A nurse is caring for a client who has depressive disorder and is assessing his ability to perform activities of daily living (ADSLs) prior to discharge. Which of the following activities should the nurse include the assessment? (Select all that apply). a. Ability to bathe himself b. Ability to dress himself c. Ability to perform oral hygiene d. Ability to identify how often he should schedule his car for an oil change e. Ability to balance his bank account
a. Ability to bathe himself b. Ability to dress himself c. Ability to perform oral hygiene
A nurse is planning for a client who has become increasingly anxious and confused. Which of the following actions should the nurse include to avoid the use of physical restraints? (select all that apply) a. Attend to the client's needs for toileting b. Elevate all side rails on the bed. c. Ensure effective pain management d. Orient client frequently to the environment e. Assign the client to a room near the nurse station
a. Attend to the client's needs for toileting c. Ensure effective pain management d. Orient client frequently to the environment e. Assign the client to a room near the nurse station
A nurse is caring for a client who is experiencing a normal grief reaction following the loss of her spouse. Which of the following finding should the nurse expect? a. Chest pain b. Insomnia c. Hypertension d. Dry month
a. Chest pain
A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following? a. Determine the client's level of understanding about the procedure b. Ensuring the charge nurse is available to witness the client's signature on the consent form c. Discussing alternative treatment options d. Explaining the risks involved with the procedure
a. Determine the client's level of understanding about the procedure
A nurse is caring for a client who is scheduled for surgery. The nurse's role regarding informed consent is which of the following? a. Determining the client's level of understanding about the procedure b. Ensuring the charge nurse is available to witness the client's signature on the consent form c. Discussing alternate treatment options d. Explaining the risk involved with the procedure
a. Determining the client's level of understanding about the procedure
A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply). a. Diagnosis of schizophrenia, depressive, personality, bipolar, substance use disorders b. Bachelor's degree c. Male gender d. Recent marriage e.Military personnel/veterans f.Lesbians, gay, bisexual, transgender g.Age greater than 15
a. Diagnosis of schizophrenia, depressive, personality, bipolar, substance use disorders c. Male gender e.Military personnel/veterans f.Lesbians, gay, bisexual, transgender g.Age greater than 15
A mental health nurse is referring a client who has an alcohol addiction to a 12-step Alcoholics Anonymous program. The nurse should inform the client that which of the following is the basic concept of a 12-step program. a. Including family in counseling sessions. b. Detoxifying from the addictive substance c. Identifying stimuli that promote drinking d. Admit life is unmanageable
a. Including family in counseling sessions.
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take? a. Inspect the client's personal belongings b. Place metal utensils on the client's meal tray c. Tuck bedcovers over client's hands and arms d. Assign the client to a private room.
a. Inspect the client's personal belongings
A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? a. Keep familiar personal items at the bedside b. Always turn the television on c. Hang abstract pictures on the walls d. Encourage bright glaring lighting in the room.
a. Keep familiar personal items at the bedside
A nurse on a medical surgical unit is planning to delegate tasks to an adult volunteer. Which of the following task should the charge nurse avoid assignment to the volunteer? a. Observing a postoperative client who is confused b. Assisting a client who has difficult seeing the foods on the tray while eating c. Delivering a routine urine specimen to the laboratory d. Delivering meal trays to clients in their rooms
a. Observing a postoperative client who is confused
A nurse is caring for a client who has dementia. The client is agitated and is have difficulty staying in his chair. Which of the following actions should the nurse take first? a. Place a seat alarm in the client's chair b. Place the client in bed with the two side rails raised c. Apply a vest restraint on the client d. Administer lorazepam the client
a. Place a seat alarm in the client's chair
A nurse is planning care at the beginning of a shift. Which of the following tasks could a nurse assign to assistive personnel (AP)? a. Providing a client's postmortem care b. Inserting indwelling urinary catheter c. Assisting the client to select a low-residue diet d. Removing a client's nasogastric tube
a. Providing a client's postmortem care
A nurse is caring for a client who experienced an infection site of intravenous catheter. Which of the following findings should the nurse expect? a. Purulent drainage is noted from the site b. The client reports numbness at the site c. Skin over the site is sloughing d. The vein appears cordlike
a. Purulent drainage is noted from the site
A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching? a. Remove the stinger by scraping it off with a knife blade b. Suck the wound c. Apply a tourniquet d. Apply a warm pack
a. Remove the stinger by scraping it off with a knife blade
A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BIPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client? a. Respiratory therapist b. Physical therapist c. Case manager d. Occupational therapist
a. Respiratory therapist
A nurse is caring for a client who is experiencing dysphagia. The nurse should recommend a referral to which of the following members of the health care team? a. Speech therapist b. Social worker c. Respiratory therapist d. Occupational therapist
a. Speech therapist
A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching? a. Washes hands with soap and water before the procedure b. Shaves the selected insertion site with a razor prior to the procedure c. Applies the tourniquet 1 inch above the selected insertion site d. Applies sterile gloves prior to inserting the IV catheter
a. Washes hands with soap and water before the procedure
A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take? a. Wear a mask when providing care to the client b. Ensure the client's room has HEPA filtration c. Place the client in a room with negative airflow d. Wear a gown when providing care to the client
a. Wear a mask when providing care to the client
A nurse in a mental health facility is caring for a client who is a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication? a. "You need to calm down before discussing this matter any further" b. "I understand that you are angry. However, I followed the appropriate protocol c. "You were made aware of the consequences of negative behavior" d. "Why did you make the choice to behave negatively?"
b. "I understand that you are angry. However, I followed the appropriate protocol
A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? a. "Good Samaritan laws prohibit the victim from filing lawsuit against the nurse". b. "If you render aid in an accident, do not leave the scene until another competent person can take over" c. "Federal laws require a licensed nurse to render aid in an emergency" d. "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws".
b. "If you render aid in an accident, do not leave the scene until another competent person can take over"
An older adult is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide? a. " You provider needs to talk with you concerning your request" b. "You need to let you provide know your wishes after the procedure" c. "You need to discuss your request with the hospital chaplain" d. "This is a minor procedure, there is no need for this request"
a. " You provider needs to talk with you concerning your request"
A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition? a. "Postpartum depression usually begins 48 hours after childbirth" b. "Postpartum depression is more likely to occur in women who have a history of depression". c. "The most common manifestation of postpartum depression is harming the infant". d. "It is common for clients who have postpartum depression to exhibit psychotic behavior".
a. "Postpartum depression usually begins 48 hours after childbirth"
A nurse is reviewing information about the Health Insurance Portability and accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? a. "A client's address would be an example of personally identifiable information". b. "Information about a client can be disclosed to family members at any time". c. "HIPAA established regulations of individually identifiable health information in verbal, electronic or written form" d. "HIPAA is a federal law, not a state law"
b. "Information about a client can be disclosed to family members at any time".
Assistive personnel (AP) contact a nurse manager and reports that on the last shift a nurse seemed distracted and that a client reported that the nurse smelled of alcohol. The AP alleges that nurses were drinking alcohol during the shift. Which of the following actions should the nurse manager take first? a. Confront them b. Develop a disciplinary plan for the nurse c. Perform an investigation into the facts surrounding the incident d. Refer the nurse to the state board of nursing diversion program
c. Perform an investigation into the facts surrounding the incident
A nurse is caring for a client who is confused and has pulled out her peripheral IV catheter three times. Which of the following actions should the nurse consider? a. Move the client close to the nurses' station b. Administer a mild sedative to the client c. Place mitten restraints on the clients' hands d. Reorient the client to time, place, and person
c. Place mitten restraints on the clients' hands
A nurse is assessing a client following a natural disaster who is having trouble sleeping due to nightmares, feelings of survivor guilt and difficulty concentrating. Which of the following diagnoses describe the client's symptoms? a. Dissociative identity syndrome b. Histrionic personality disorder c. Post-traumatic stress syndrome d. Generalized anxiety disorder
c. Post-traumatic stress syndrome
A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? a. Document the occurrence in a personal log b. Complete an incident report c. Quietly tell the APs that this is not appropriate d. Ask the nurse manager to provide an in-service program about confidentiality to the staff on the unit.
c. Quietly tell the APs that this is not appropriate
A nurse is providing discharge teaching to a client who had a total hip arthroplasty. Which of the following information should the nurse include in the teaching? a. Use a twisting motion when turning to pick an object up b. Bend at waist to put shoes on when sitting c. Sit with legs apart at the ankles d. Cleanse the incision with hydrogen peroxide
c. Sit with legs apart at the ankles
A nurse is teaching a community education course about the physical complication related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use? a. Nasal septum perforation b. Permanent short-term memory loss c. Slowed breathing d. Acute pancreatitis
c. Slowed breathing
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use? a. Nasal septum perforation b. Permanent short-term memory loss c. Slowed breathing d. Acute pancreatitis
c. Slowed breathing
A nurse sees assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first? a. Notify the charge nurse about the AP's need for training b. Provide the appropriate PPE to the AP c. Speak with AP when he exits the room about the appropriate protocol d. Volunteer to provide an in-service about infection control
c. Speak with AP when he exits the room about the appropriate protocol
A nurse is observing client care provided by assistive personnel (AP). Which of the following actions should prompt the charge nurse to intervene? a. The AP puts on clean gloves prior to brushing a client's teeth. b. The AP attaches a client's urinary drainage bag to the bed frame. c. The AP instructs a client who needs assistance with turning to place his arms at his side before the turn. d. The AP applies moisturizing cream to the feet of a client who has diabetes mellitus.
c. The AP instructs a client who needs assistance with turning to place his arms at his side before the turn.
A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30lb and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving? a. The client is 48 years old b. The client is having difficulty sleeping c. The client has lost 30lb d. The client's husband died seven months ago
c. The client has lost 30lb
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide? a. Services are centered in long-term care facilities b. This service focuses on teaching the primary caregivers to meet the client's needs c. The emphasis is on the client's complete recovery from the illness or injury d. This service began with the client's admission to the hospital
c. The emphasis is on the client's complete recovery from the illness or injury
A nurse is applying wrist restraints to a client who is confused and attempting to pull out a chest tube. Which of the following actions should the nurse taking when using restraints? a. Ensue that 1 finger breath of space is between the client's wrists and the restraint b. Remove the restraint to check integrity of the skin every 4hr c. Tie the restraint using a quick release knot d. Secure the restraints to the side rails.
c. Tie the restraint using a quick release knot
A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statement indicates an understanding of the teaching? a. "I will use dishwashing gloves when cleaning the dishes " b. "I will buy balloons for my son's birthday" c. "I will apply elastic bandages to cuts" d. " I will use ink pens for writing"
d. " I will use ink pens for writing"
A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statement s by the client indicates he is ready for discharge? a. "Taking care of myself is important but it's okay if I want to take a break and not do anything " b. "When I get home, I'm going to let the people who put me he know how I angry I am" c. Right now, I can't bathe or dress myself but that's not important d. "I will take my medicine as I should and know to call the number you gave me if I have bad thoughts".
d. "I will take my medicine as I should and know to call the number you gave me if I have bad thoughts".
A nurse is teaching new parents the proper way to use an infant safety seat. Which of the following should indicate to the nurse a need for further teaching? a. " I will dress my baby in a one piece outfit so I can use the harness to secure her in the car seat". b. "I will place the infant safety seat in the middle of the back seat, away from the window". c. "We will need to go by the weight and height of the child when deciding to change to a booster seat". d. "My baby will be able to watch me drive while sitting in the back seat".
d. "My baby will be able to watch me drive while sitting in the back seat".
A nurse is assessing four clients for indications of general adaptation syndrome (GAS). Which of the following clients should the nurse monitor closely for GAS? a. A 22year old client who has type 1 diabetes mellitus b. A 59year old client who has stage II Alzheimer's disease c. A 68-year-old client who has viral pneumonia d. A 40-year-old client who has ulcerative colitis
d. A 40-year-old client who has ulcerative colitis
A nurse is caring for four clients. The nurse should identify which of the following clients as having contraindication to receiving moist heat. a. A client who is T Day postoperative and has deep vein thrombosis b. A client who has osteoarthritis and has pain of lower extremity joints c. A client has a spinal cord injury and muscle spasm of the lower back d. A client who broke his ankle 2 hr ago and has swelling of the low extremity
d. A client who broke his ankle 2 hr ago and has swelling of the low extremity
Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge? a. An older adult who was admitted for diabetic ketoacidosis and his most recent ABGs show his pH is now 7.32 b. Middle adult who is 36hr postoperative from an open laminectomy c. An adolescent client who was admitted 24hr ago due to a spontaneous pneumothorax d. A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy
d. A young adult client who has Crohn's disease and is 1 day preoperative for an ileostomy
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? a. Plan of care changes for upcoming shift b. Glasgow results c. Intracranial pressure readings d. Code status
d. Code status
A nurse is assessing an adolescent client who has attention deficit hyperactivity disorder (ADHD). Which of the following findings should the nurse expect? a. Elevated mood b. Anxiety c. Emotional numbing d. Impulsivity
d. Impulsivity
A nurse is caring for a client whose informed consent form has been signed in preparation for a procedure. The client states, "I have decided not to have the procedure. "Which of the following actions should the nurse take? a. Remind the client the consent form has already been signed b. Discuss alternatives to the procedure c. Explain why this procedure is necessary d. Inform the provider that the client is withdrawing consent
d. Inform the provider that the client is withdrawing consent
A nurse is preparing to apply wrist restraints to a client to prevent them from pulling out an IV catheter. Which of the following actions should the nurse take? a. Ensure enough room to fit one finger between the restraint and the wrist b. Attach the ties of the restraint to a non-movable part of the bed frame. c. Use a knot that will tighten as the client moves d. Keep the padded portion of the restraints against the wrists.
d. Keep the padded portion of the restraints against the wrists.
A charge nurse is observing the actions of an assistive personnel (AP).Which of the following actions by the AP is appropriate? a. Posting the client's medical diagnosis on a message board in the client's room b. Discarding her nursing activity work sheet in a waste basket at the nurses' station c. Providing her password to a new nurse in orientation so that the new nurse d. Logging off the computer after entering a client's intake and output total.
d. Logging off the computer after entering a client's intake and output total.
A nurse is planning for a client who has manifestations of a clostridium diffficile (Diffficile ) infection. Which of the following actions should the nurse plan to take? a. Obtain a blood specimen to test for C. diffficile b. Place a surgical mask on the client during transport c. Use an alcohol-based agent to perform hand hygiene when caring for the client d. Place the client on contact precaution
d. Place the client on contact precaution
A nurse in the emergency department is assessing a client who has experienced intimate partner abuse. The nurse should monitor the client for which of the following behavioral findings? a. Body image disturbance b. Altered role performance c. Personal identity disturbance d. Self- esteem disturbance
d. Self- esteem disturbance
A community mental health nurse is assessing client who has schizophrenia. Which of the following findings indicates the client might be relapsing? a. The client reports feelings of anger toward her provider b. The client states have started smoking again c. The client is wearing mismatched clothing d. The client reports difficulties with sleeping and concentrating
d. The client reports difficulties with sleeping and concentrating
A nurse is caring for an older adult client who has a terminal illness and is ventilator- dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles? a. Fidelity b. Autonomy c. Justice d. Veracity
d. Veracity
A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples should the nurse include in the instructions? a. Desmopressin .1mL intranasal qd b. Metformin 500mg 1 tablet po daily c. Losartan 50.0mg POQD d. Zolpidem,5mg PD,HS
d. Zolpidem,5mg PD,HS
A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety a.The client pushes downward on the handgrip b.The client keeps the elbow in a flexed position c.The client stands in a tripod position prior to walking d.The client places partial weight on the affected leg
d.The client places partial weight on the affected leg
