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 preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)
(SATA)
A)
Place a copy of the completed report in the client's medical record.
B)
Obtain an order from the client's provider to complete the report.
C)
Identify the medication name and dosage administered to the client in the report.
D)
Make a copy of the incident report for personal record keeping.
E)
Include the time the medication error occurred in the report.
A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
A)
Reorienting the client several times throughout the day
B)
Performing an updated cognitive assessment on the client
C)
Requesting a referral for the client to attend reminiscent therapy sessions
D)
Providing assistance for the client when ambulating down the hall
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 explains to a client's family that a DNR order includes withholding comfort measures.
B)
A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
C)
A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
D)
A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.

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Exam Review

A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
A)
Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
B)
Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago.
C)
Administer a bronchodilator two times a day for child who has cystic fibrosis.
D)
Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low- fiber diet.
A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take?
A)
Speak very slowly during the teaching session.
B)
Use medical terminology while explaining the medications.
C)
Provide the client with written information in their spoken language.
D)
Have the client's family member who is present interpret.
A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?
A)
Gonorrhea
B)
Trichomoniasis
C)
Human papillomavirus
D)
Candidiasis
A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance. Which of the following actions should the nurse take? (Select all that apply.)
(SATA)
A)
Submit an incident report to the risk manager.
B)
Fife an anonymous report of the incident to the nurse manager.
C)
Document a factual account of the incident.
D)
Request that the coworker complete an incident report.
E)
Identify all witnesses to the incident.

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Exam Review

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)
Plan to administer an antiviral medication to the client.
B)
Wear an N95 respirator mask while caring for the client.
C)
Prepare to administer antibiotics to the client.
D)
Place a surgical mask on the client during transfer to the unit.
A nurse manager is attending a meeting about the cost of health care. Which of the following measures should the nurse implement to reduce the cost of treatment in the acute care setting?
A)
Reserve budgetary planning for senior management.
B)
Encourage staff to participate in quality improvement projects.
C)
Staff an additional assistive personnel each shift.
D)
Plan budget needs based on average client stay over 6 months.
A nurse tells the unit manager, "I am tired of all the changes on the unit. If things don't get better. I'm going to quit." Which of the following responses by the unit manager is appropriate?
A)
"So you are upset about all the changes on the unit?"
B)
"You should file a written complaint with hospital administration."
C)
"Just stick with it a little longer. Things will get better soon."
D)
"I think you have a right to be upset. I am tired of the changes, too."
A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
A)
Diminished hand-to-mouth coordination
B)
Altered level of consciousness
C)
Unilateral ptosis
D)
Impaired voluntary cough

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Exam Review

A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?
A)
The nurse puts on a face mask.
B)
The nurse turns her back to the sterile field.
C)
The nurse holds her hands above her waist.
D)
The nurse applies goggles.
A charge nurse is teaching a newly licensed nurse about caring for a client who has COPD. Which of the following instructions should the charge nurse include in the teaching?
A)
"Maintain the client's oxygen saturation level above 95 percent."
B)
"Notify me if you observe that the client has distended neck veins."
C)
"Have an assistive personnel ambulate the client just before meals."
D)
"Call the provider if you note clubbing of the client's fingernails."
A nurse manager notes that the number of medication administration errors has increased on the unit. Which of the following actions should the nurse take first?
A)
Serve on a quality improvement committee.
B)
Conduct a root cause analysis.
C)
Develop preventative measures.
D)
Review current evidence-based practice.
A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?
A)
Withhold the benzodiazepine but continue the opioid.
B)
Continue the medication dosages that relieve the client's pain.
C)
Contact the provider about replacing the opioid with an NSAID.
D)
Administer the benzodiazepine but withhold the opioid.

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Exam Review

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
A)
Decreased level of consciousness
B)
Increased temperature
C)
Generalized rash over the trunk
D)
Report of photophobia
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
A)
Assess the staff nurses' knowledge deficit.
B)
Demonstrate use of the pump during medication administration.
C)
Plan an -service education program on the unit.
D)
Pair an inexperienced nurse with an experienced nurse.
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 is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy? (Select all that apply.)
A)
Documenting a client's refusal to take a prescribed medication.
B)
Providing written information to a client regarding palliative care.
C)
Implementing a client's plan of care based on nursing goals.
D)
Obtaining an interpreter for a client who speaks a different language than the nurse.
E)
Initiating IV access on a client who has dementia while he is sleeping.

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Exam Review

A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
A)
A client who has bipolar disorder and is exhibiting signs of hallucination
B)
A client who has major burns over 75% of their body surface area
C)
A client who has two open chest wounds with a left tracheal deviation
D)
A client who has a neck injury and is unable to breathe spontaneously
A nurse manager is evaluating a nursing unit for cost effectiveness. Which of the following activities demonstrates effective cost containment?
A)
Implementing rigid yearly budget planning
B)
Maintaining budget planning between senior leadership
C)
Ensuring proper documentation of client services
D)
increasing the unit budget above expected needs
A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult?
A)
Physical therapist
B)
Social worker
C)
Occupational therapist
D)
Speech pathologist
A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?
A)
A young adult client who is participating in a medical research study
B)
A middle adult client who leaves the facility against medical advice
C)
An adolescent client whose parents refuse a blood transfusion for religious reasons.
D)
An older adult client who has advance directives on file

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