Exam Review

A nurse is providing teaching to a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?
A)
"Once I sign my living will, a family member must co-sign it."
B)
"My durable power of attorney for health care is part of my advance directives."
C)
"I will wait until I have a serious health problem to sign my advance directives."
D)
"My doctor will need to provide approval for the decisions outlined in my living will."
A nurse case manager is reviewing the electronic medical record of a postoperative client. Click to highlight the findings that require follow-up by the case manager. To deselect a finding, click on the finding again. Exhibit 1 Nurses' Notes 1315: Client is postoperative following an open cholecystectomy, Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment Plan of Care 1300: Case management referral for discharge planning. Client will need home health referral for dressing changes Client to follow up with the provider at the clinic in 1 week.
A
A)
Client reports being unable to find transportation to follow-up appointment
B)
Client expresses concern regarding the cost of prescription medications
A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?
A)
Discuss with the client her concerns regarding the procedure.
B)
Initiate a mental health consult to determine the client's reasons for refusing surgery.
C)
Provide the client with information on treatment options and outcomes,
D)
Inform the client of the consequences of uterine prolapse and the need for intervention.
A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN?
A)
Providing postmortem care for a client who has just died
B)
Reinforcing dietary teaching with a client who has heart disease
C)
Accompanying a client who just had a wound debridement to physical therapy
D)
Obtaining a urine specimen from an older adult client

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Exam Review

A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
A)
offer to store the purse at the nurses' station.
B)
Tell the client to leave her purse in a drawer of the bedside table.
C)
Place the purse in the clothing bag with the client's other belongings.
D)
Offer to place the purse in the facility safe.
A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?
A)
Notify the client's provider about the incident.
B)
Instruct the AP to discontinue the conversation.
C)
Complete an incident report about the breach of client confidentiality.
D)
Reassign the AP to other clients on the unit.
A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?
A)
Change total parenteral nutrition IV tubing every 48 hr.
B)
Replace total parenteral nutrition solution bags every 48 hr.
C)
Replace peripheral IV solution bags every 96 hr.
D)
Change peripheral IV primary tubing every 96 hr.
A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?
A)
The client's preferred time for bathing
B)
The belief that the client has a difficult relationship with his son
C)
The time the client received his last dose of pain medication
D)
The steps to follow when providing wound care

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Exam Review

A nurse is teaching a class of newly licensed nurses about evidence-based practice. The nurse should include which of the following as the first step in evidence-based practice?
A)
Develop a clinical question.
B)
Collect evidence from a variety of sources.
C)
Apply research to client care practice.
D)
Critically assess the evidence.
A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?
A)
A client who experienced a brief loss of consciousness
B)
A client who has major burns covering 70% of their body
C)
A client who has fixed pupils
D)
A client who has a compromised airway
A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take?
A)
Place a surgical mask on the client during transfer to the unit
B)
Prepare to administer antibiotics to the client
C)
Plan to administer an antiviral medication to the client
D)
Wear an N95 respirator mask while caring for the client
A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
A)
A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.
B)
A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
C)
A nurse explains to a client's family that a DNR order includes withholding comfort measures.
D)
A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.

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Exam Review

A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)
A)
Cotton balls
B)
Obturator
C)
Petroleum jelly
D)
Oxygen tank
Nurses on an inclient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost- containment plan?
A)
Use clean gloves rather than sterile gloves for colostomy care.
B)
Store opened bottles of normal saline in a refrigerator for up to 48 hr.
C)
Return unused supplies from the bedside to the unit's supply stock.
D)
wait to dispose of sharps containers until they are completely full.
A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
A)
“You should contact the provider about your wishes for your family member”
B)
“You should speak with the facility’s ethics committee about your concerns”
C)
“We’ll need to have the nursing supervisor review the client’s advance directives”
D)
“As the health care surrogate, the client’s partner can make this decision”
A nurse is caring for a client who is scheduled for placement of a central venous access device. Which of the following actions is the nurse's responsibility in the informed consent process?
A)
Discuss alternative treatment options with the client.
B)
Review the risks and benefits of the procedure with the client.
C)
Place a photocopy of the signed informed consent in the client's medical record.
D)
Assess the client's understanding after the provider has talked with her.

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Exam Review

A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
A)
Close the fire doors and the doors to the clients' rooms.
B)
Extinguish the fire,
C)
Activate the fire alarm
D)
Remove all clients from the unit.
A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take?
A)
Encourage the client to research Crohn's disease on websites that have a gov" address.
B)
Ask a licensed practical nurse to explain Crohn's disease to the client.
C)
Recommend podcasts that discuss Crohn's disease to the client.
D)
Suggest that the client read articles that recommend specific treatments for Crohn's disease.
A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to assistive personnel?
A)
Instructing a client on self-administration of a tap water enema
B)
Suctioning a client's long-term tracheostomy
C)
Performing a dressing change on a client's peripherally inserted central catheter
D)
Using a pain rating scale to monitor a client's pain level
A nurse is teaching a newly licensed nurse about the role of nurses during a facility disaster. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A)
"A nurse can recommend clients who are stable for discharge during a disaster."
B)
"A unit nurse has the authority to prescribe emergency medications during a disaster."
C)
"A nurse should communicate with the performance improvement committee during a disaster to improve client outcomes."
D)
"A unit nurse can provide information to the media during a disaster."

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Exam Review

A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A)
A client who reports shortness of breath and left neck and shoulder pain
B)
A client who has active bleeding from a puncture wound of the left groin area
C)
A client who has a raised red skin rash on his arms, neck, and face
D)
A client who reports right-sided flank pain and is diaphoretic
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
A)
"It's not too late to cancel the surgery if you want to."
B)
"This won't take long and it will be over before you know it."
C)
"Why did you make the decision to have this procedure?"
D)
"You shouldn't be worried because the procedure is very safe."
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
A)
"I will instruct visitors to wear a mask when visiting a client who is on contact precautions."
B)
"I will place a client who has compromised immunity in a negative-pressure airflow room."
C)
"I will have a client who is on airborne precautions wear a mask when out of their room."
D)
"I will wear an N95 respirator mask when caring for a client who is on droplet precautions."
A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?
A)
State nurse practice act
B)
ANA Standards of Practice
C)
ANA Code of Ethics
D)
Institute of Medicine

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