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WITH COMPLETE SOLUTION GUIDE) (MULTIPLE
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A client states, "I feel funny." The nurse uses electronic equipment to obtain vital signs and notes these findings: blood pressure 100/56 mm Hg, pulse 38, respirations 26. The client's previous reading: blood pressure 130/88 mm Hg, pulse 82, respirations 21. List the correct order
of actions the nurse should now take (with 1 being the top priority). - ✅✅Simultaneously check
an apical and radial pulse manually Assess for chest pain, dyspnea, low oxygen saturation, restlessness or other signs of respiratory or cardiac impairment Notify the health care provider Anticipate the need for ECG, oxygen administration, and emergency pacing The nurse enters the client's room and finds the client, who was previously alert, lethargic and slow to respond.
Prioritize the nursing actions by dragging and dropping the options below. - ✅✅Attempt to
elicit a response by physically shaking the client and loudly stating "open your eyes and talk to me." Complete a quick neurological assessment: orientation, pupil response, ability to follow commands Call the rapid response team and report the client's situation; request immediate assistance Remain with the client; send another staff member to get the list of medications and the chart
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The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission? -
✅✅A middle-aged client with a seven-year history of being ventilator dependent and who was
admitted with bacterial pneumonia eight days ago The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that
apply.) - ✅✅The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to
ambulate in the hall The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor A nurse has been assigned to four clients in the emergency department, with each client
experiencing one of these conditions. Which client should the nurse check first? - ✅✅Tension
pneumothorax with slight tracheal deviation to the right The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrate
the shared governance model? - ✅✅Nursing departments share responsibility for client
outcomes The triage nurse identifies that a 16-year-old client is legally married and has signed the consent
form for treatment. What would be an appropriate action by the nurse? - ✅✅Proceed with the
triage process in the same manner as any adult client
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"My wishes for end-of-life treatment are stated in writing." "I will need to identify someone to be my health care proxy." A client who is unconscious is brought to the emergency department by an ambulance. What
document should the nurse give priority to when preparing the care for this client? - ✅✅A
notarized original of the advance directive brought in by the partner A client's uncle calls for an update on the condition of his nephew. What should the nurse do
first before providing the information to the caller? - ✅✅Consult with the client and obtain
permission to update the client's uncle of his condition A client is being prepped for a surgical procedure and the nurse is reviewing the informed consent with the client. The client asks, "Is there any other way to take care of this without
having surgery?" The nurse has a duty to first: - ✅✅Notify the surgeon that the client has
additional questions about alternatives to surgery A nurse has unintentionally given an incorrect dose of medication to their client. No harm was
done to the client. What is the next action, if any, required by the nurse? - ✅✅The nurse will
report the incident to their nurse manager and follow their organizational procedures for reporting
Which of these activities can be assigned to an unlicensed assistive person (UAP)? - ✅✅Provide
basic care to the client
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A nurse can delegate a task to a team member by determining their responsibility through
which of the following documents? (Select all that apply.) - ✅✅Nurse practice act
Organization's standard of care Organization's job description The nurse has called a physician to obtain orders about their mutual client. Below is the transcript of the call:Hello Dr. B this is Nurse A calling about our client Mr. F. The client is a 63-year-old male 24 hours post-surgical appendectomy who is having pain. He has a history of hearing loss and urinary tract infections. I would like to increase Mr. F's morphine from 0.5 mg per hour as needed to 1 mg per hour as needed.
What communication step did the nurse forget to include? - ✅✅Assessment
A nurse receives an illegible hand-written medication order. Which statement to the health care
provider reflects appropriate assertive communication? - ✅✅"Would you please clarify what
you have written so I am sure I am reading it correctly?" The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following
clients? - ✅✅A middle-aged person who has been on the unit for 72 hours with a diagnosis of
persistent depressive disorder All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are
two days post-op. Which client should the nurse check first? - ✅✅62 year-old following knee
replacement surgery, BP 120/68, pulse 68, respirations 8
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would be most appropriate for the charge nurse? - ✅✅Change the assignment; reassign the
client with the lumbar drain to a different nurse The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has been a two car accident with multiple casualties. What action would the
nurse take first, before the victims arrive in the ED? - ✅✅Notify the nursing supervisor and
request additional staff The registered nurse (RN) has just accepted a position as a public health nurse. Which question
might be the most relevant as the nurse begins employment? - ✅✅"Which groups are at the
greatest risk for problems?" A woman dressed in a business suit with no visible identification is at the nurses station looking
at client charts. What nursing action is most appropriate? - ✅✅Request to see identification
and an explanation as to why the woman is viewing client charts A registered nurse from the float pool is assigned to the critical care unit on the evening shift.
Which of these clients should be assigned to the float pool nurse? - ✅✅Pacemaker insertion on
the day shift The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse checks and then confirms that the client is not progressing on any part of the
mobility training program. What action is the nurse's priority? - ✅✅Inform the case manager
of the variance in the critical pathway The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the
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catheter. What should the nurse do at this time? - ✅✅Walk up and whisper in the student's
ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter." The nurse is caring for a client whose pain is not well controlled. Which statement about pain
management is a priority ethical consideration that can help guide the nurse? - ✅✅The client's
self-report of pain is the most important consideration A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medications." The nurse should respond with
an understanding of which statement? - ✅✅The client has a right to know about the use and
side effects of the prescribed medications The charge nurse is making assignment for the health care team. Which of these tasks can be
safely delegated to the licensed practical nurse (LPN)? - ✅✅Provide stoma care for a client with
a well-functioning ostomy The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should
complete the orders listed below (with 1 being the top priority). - ✅✅Oxygen 2 liters nasal
cannula Blood and sputum cultures IV normal saline at 100 mL/hr Ceftriaxone (Recephin) 1 gram every 12 hours IVPB Fingerstick before each meal and at bedtime
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Complete an incident report A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? -
✅✅"I know you are upset. But please control yourself and sit down. Otherwise I will have to
call security." The nurse is checking on clients in the unit. Which of these findings indicates that an infusion pump set to deliver a morphine drip basal rate of 10 mL per hour, plus PRN dosages for
breakthrough pain, is not functioning correctly? - ✅✅The level of the drug is 100 mL at 8 am
and is 80 mL at 12 noon The client, who is diagnosed with dementia, wanders throughout the long-term care facility.
How can the nurse best ensure the safety of a client who wanders? - ✅✅Attach a monitoring
band to the client's wrist A client arrives in the emergency department after a radiolgical accident at a local factory. After placing the client in a decontamination room, the nurse gives priority to which intervention? -
✅✅Ensure physiological stability of the client
A parent calls the hospital hotline and is connected to the triage nurse. The caller states: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would provide the best information to help the nurse to determine if the
child has swallowed a corrosive substance? - ✅✅"Ask the child if their mouth is burning or
throat pain is present."
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The clinic nurse assists the health care provider with physical examinations and the collection of laboratory specimens. Which of these findings should the nurse report to the public health
department? - ✅✅Positive stool culture for shigella
The nurse is caring for a client with a chest injury that required a chest tube placement. The client is confused and pulls out the chest tube as the physician has just finished replacing it. The nurse applies soft restraints on the client's wrist. Is this an appropriate nursing action? -
✅✅Yes, the nurse can apply a restraint to protect the client from injury or harm, then obtain an
order. A client's wound has tested positive for Staphylococcus aureus (MRSA). What level of precaution
should the nurse place the client on? - ✅✅Standard and contact precautions
A client falls while in the nurse's care. What is the appropriate action the nurse should take first
once the client is safe? - ✅✅The nurse will report the incident and fill out an incident report
A nurse is preparing to enter a disaster scene. What assessment priorities must the nurse adhere
to? (Select all that apply.) - ✅✅The nurse will allocate resources to those with the strongest
probability of survival. The nurse will assess clients by considering their airway, breathing, circulation and neurological function. The charge nurse is making client room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3
year-old child diagnosed with minimal change disease? - ✅✅4 year-old with bilateral inguinal
hernia repair
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The nurse is to administer a new medication to a client. Which of the following actions best
demonstrates an awareness of safe and proficient nursing practice? - ✅✅Prior to
administration of the medication, the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the
client's dinner. What action should the nurse take next? - ✅✅Serve the dinner in the seclusion
room, maintaining observation A nurse is performing well-child assessments at a day care center when a staff member interrupts the examinations for assistance with another child. The nurse finds a crying 3 year-old child on the floor with bleeding gums and two unlabeled open bottles nearby. What should be
the nurse's first action? - ✅✅Ask the staff member about the contents of the bottle
The charge nurse on the evening shift is asked to determine which client is a candidate for discharge. Which of these clients should the nurse select as a potential candidate for discharge?
- ✅✅A middle-aged adult with a history of type 1 diabetes and one day post diabetic ketoacidosis The nurse understands that which situations require hand hygiene such as handwashing or hand
sanitation? (Select all that apply.) - ✅✅Prior to and after eating
Before having direct contact with a client After cleaning a wound After contact with objects in the immediate vicinity of the client The nurse is caring for a client who is not oriented to time, place or person and has repeatedly attempted to pull out intravenous lines and a feeding tube. The nurse receives an order from the
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health care provider to apply a vest and soft wrist restraints. Which of the following actions by
the nurse are appropriate? (Select all that apply.) - ✅✅Tie the restraints using quick-release
knots Conduct a thorough assessment of the client Explain the rationale for restraints to the client Document which alternative interventions were used or attempted The school nurse is providing information for teachers at a school where a 10 year-old child with epilepsy attends. What is the most important action a teacher can take when the child
experiences a tonic-clonic seizure in the classroom? - ✅✅Place something soft and flat under
the child's head After an explosion at a factory, one of the employees approaches the nurse and says, "I am a certified nursing assistant (CNA) at the local hospital." Which of these tasks would be appropriate for the nurse to assign to this worker who is assisting in the care of the injured? -
✅✅Palpate pulses
The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in
an automobile. What is the nurse's best response to the parents? - ✅✅"Your child must use a
car seat until he weighs at least 40 pounds." A nurse is conducting a community-wide seminar on childhood safety issues. Which of these
children is at the highest risk for poisoning? - ✅✅A 20 month-old who has just learned to climb
stairs
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A nurse in the labor and delivery unit is caring for several clients. For which of these mother- baby pairs should the nurse review the results of the Coombs test to decide whether to
administer Rho(D) immune globulin within 72 hours of birth? - ✅✅Rh negative mother with Rh
positive baby The nurse is assessing a client in the labor and delivery unit. Which of the following actions is correct when using palpation to assess the characteristics and pattern of uterine contractions? -
✅✅Evaluate intensity by pressing fingertips into the uterine fundus
A nurse is assessing a client to verify pregnancy. What information from the client will provide
presumptive findings? (Select all that apply.) - ✅✅Fatigue
Breast sensitivity Amenorrhea Nausea The nurse is caring for a patient who has just experienced a spontaneous abortion (miscarriage).
What is a priority nursing action the nurse must implement first? - ✅✅Assess and monitor
bleeding and pain The nurse is providing education to a client in her first trimester of pregnancy. Which statement
indicates the client needs further education? - ✅✅"I will schedule visits with my health care
provider only as needed." The nurse is providing information to a pregnant client about the risk of an amniocentesis.
Identify which risk factors the nurse will discuss. (Select all that apply.) - ✅✅Preterm labor
Premature rupture of membranes
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Spontaneous abortion A pregnant client calls the nurse and reports that she is experiencing contractions regularly and they are increasing in intensity. What is an additional assessment to determine if the client is in
labor? - ✅✅"Where are you experiencing discomfort?"
A nurse is monitoring a client that is in labor and has received an epidural. Which of these assessments is the nurse's first priority to be done immediately? (Select all that apply.) -
✅✅Blood pressure
Fetal heart rate A client who has just given birth asks the nurse what an APGAR score means. The correct
response by the nurse would be: - ✅✅"The score is a general overview of how well your
newborn is doing." During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old
child. Which of these developmental activities should the child be able to perform? - ✅✅Sits
without support A nurse enters a 2-year-old child's hospital room in order to administer an oral medication. When the nurse asks the child, "Are you ready to take your medicine?" the response is an
immediate, "No!" What would be an appropriate next action by the nurse? - ✅✅Leave the
room and return five minutes later and give the medicine A nurse is anticipating providing guidance to parents of a toddler about readiness for toilet training. Which statements describe what the nurse should know in order to provide such
guidance? (Select all that apply.) - ✅✅Myelination of the spinal cord is completed by this age
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Clinical trials have led to improved cancer prevention and treatment A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that
apply.) - ✅✅Color of bowel movements
Bruising Frequency and amount of naproxen used The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure? -
✅✅Involve the client in the decision making process
The nurse is explaining an illness to a 10 year-old child. What should the nurse keep in mind
about the cognitive development of children at this age? - ✅✅They are able to think logically in
the organization of facts The nurse is assessing a pregnant client in her third trimester. The client is informed that the ultrasound suggests the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with what
factor? - ✅✅Maternal hypertension
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The nurse is performing the following actions immediately following the delivery of a healthy, normal newborn. Indicate the correct sequence of actions by dragging and dropping the options
below into the correct order. - ✅✅Assess infant's airway and breathing
Perform bulb suctioning if excess mucus is present Assess infant's HR Place identification bracelets on mom and baby Administer Vitamin K shot to infant A nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would
identify the need for additional teaching if the client makes which statement? - ✅✅"I will trim
corns and calluses regularly." A nurse prepares for a Denver Screening II of a 3 year-old child in the clinic when the mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the
purpose of the Denver Screening II? - ✅✅"It assesses a child's development."
A client referred for mammography questions the nurse about the cancer risks from radiation
exposure. What is an appropriate response by the nurse? - ✅✅"The radiation from a
mammography is equivalent to one hour of sun exposure." The nurse is providing discharge education about how to avoid joint stress for a client hospitalized with an acute exacerbation of rheumatoid arthritis. Which statement by the client
