1. Which intervention is an example of primary prevention? Show
2. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
3. Which statement regarding heart sounds is correct?
4. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
5. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
6. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
7. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
8. When positioned properly, the tip of a central venous catheter should lie in the:
9. Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
10. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
11. One aspect of implementation related to drug therapy is:
12. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
13. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
14. While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
15. A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
16. A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
17. Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
18. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
19. A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
20. Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
21. Which document addresses the client’s right to information, informed consent, and treatment refusal?
22. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
23. Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
24. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
25. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
26. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
27. Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
28. Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
29. The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
30. A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular
vein
What action is most important for the nurse to take?What action is most important for the new staff nurse to take? Refuse to perform the task that is beyond the nurse's experience.
Which nursing action indicates that the nurse is actively listening to the client?Which nursing action indicates that the nurse is actively listening to the client? The nurse interprets what the client is saying and reiterates in his or her own words. The nurse is listening actively if he or she is able to take in what the client says.
Which nursing action would be most effective in helping a client learn self care behaviors?The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.
Which are important components of a neurovascular assessment performed by the nurse?The components of the neurovascular assessment include pulses, capillary refill, skin color, temperature, sensation, and motor function. Pain and edema are also assessed during this examination. Comparison of assessment findings bilaterally is extremely important. Even subtle changes can have significant implications.
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