1 >>The nurse and the unlicensed assistive personnel (UAP) are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP? ?
- (A) Apply a sterile dressing to a Stage IV pressure wound.
- (B) Check the blood glucose level of a resident who is weak and shaky.
- (C) Document the amount of food the residents ate after a meal.
- (D) Teach the residents how to play different types of bingo.
2 >>The director of nurses in a long-term care facility observes the licensed practical nurse (LPN) charge nurse explaining to an unlicensed assistive personnel (UAP) how to calculate the amount of food a resident has eaten from the food tray. Which action should the director of nurses implement? ?
- (A) Ask the charge nurse to teach all the other UAPs.
- (B) Encourage the nurse to continue to work with the UAP.
- (C) Tell the charge nurse to discuss this in a private area.
- (D) Give the UAP a better explanation of the procedure.
3 >>The wound care nurse in a long-term care facility asks the unlicensed assistive personnel (UAP) for assistance. Which task should not be delegated to the UAP? ?
- (A) Apply the wound debriding paste to the wound.
- (B) Keep the resident’s heels off the surface of the bed.
- (C) Turn the resident at least every 2 hours.
- (D) Encourage the resident to drink a high-protein shake.
4 >>The older adult client becomes confused and wanders in the hallways. Which fall precaution intervention should the nurse implement first? ?
- (A) Place a Posey vest restraint on the client.
- (B) Move the client to a room near the station.
- (C) Ask the HCP for an antipsychotic medication.
- (D) Raise all four side rails on the client’s bed.
5 >>The clinic nurse is caring for a client diagnosed with osteoarthritis. The client tells the nurse, “I am having problems getting in and out of my bathtub.” Which intervention should the clinic nurse implement first? ?
- (A) Determine whether the client has grab bars in the bathroom.
- (B) Encourage the client to take a shower instead of a bath.
- (C) Initiate a referral to a physical therapist for the client.
- (D) Discuss whether the client takes nonsteroidal anti-inflammatory drugs (NSAIDs).
6 >>The employee health nurse has cared for six clients who have similar complaints. The clients have a fever, nausea, vomiting, and diarrhea. Which action should the nurse implement first after assessing the clients? ?
- (A) Have another employee drive the clients home.
- (B) Notify the public health department immediately.
- (C) Send the clients to the emergency department.
- (D) Obtain stool specimens from the clients.
7 >>The clinic nurse is caring for clients in a pediatric clinic. Which client should the nurse assess first? ?
- (A) The 4-year-old child who fell and is complaining of left leg pain.
- (B) The 3-year-old child who is drooling and does not want to swallow.
- (C) The 8-year-old child who has complained of a headache for 2 days.
- (D) The 10-year-old child who is thirsty all the time and has lost weight.
8 >>Which statement is an example of community-oriented, population-focused nursing? ?
- (A) The nurse cares for an older adult client who had a kidney transplant and who lives in the community.
- (B) The nurse develops an educational program for the type 2 diabetics in the community.
- (C) The nurse refers a client with Cushing’s syndrome to the registered dietician.
- (D) The nurse provides the client chronic renal disease with pamphlets.
9 >>The home health (HH) agency director of nursing is making assignments for the nurses. Which client should be assigned to the HH nurse new to HH nursing? ?
- (A) The client diagnosed with AIDS who is dyspneic and confused.
- (B) The client who does not have the money to get prescriptions filled.
- (C) The client with full-thickness burns on the arm who needs a dressing change.
- (D) The client complaining of pain who is diagnosed with diabetic neuropathy.
10 >>The home health (HH) nurse along with an HH aide is caring for a client who is 3 weeks postoperative for open reduction and internal fixation of a right hip fracture. Which task would be appropriate for the nurse to delegate to the aide? ?
- (A) Instruct the HH aide to palpate the right pedal pulse.
- (B) Ask the HH aide to change the right hip dressing.
- (C) Tell the HH aide to elevate the right leg on two pillows.
- (D) Request the HH aide to mop the client’s bedroom floor.
11 >>The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? ?
- (A) The client diagnosed with a myocardial infarction (MI) who has an elevated troponin level.
- (B) The client receiving the IV anticoagulant heparin who has a partial thromboplastin time (PTT) of 68 seconds.
- (C) The client diagnosed with end-stage liver failure who has an elevated ammonia level.
- (D) The client receiving the anticonvulsant phenytoin (Dilantin) who has levels of 24 mg/dL.
12 >>Which client would most benefit from acupuncture, a traditional Chinese medicine considered complementary alternative medicine? ?
- (A) The client who is diagnosed with deep vein thrombosis.
- (B) The client who is diagnosed with Alzheimer’s disease.
- (C) The client diagnosed with reactive airway disease.
- (D) The client diagnosed with osteoarthritis.
13 >>Which data indicates therapy has been effective for the client diagnosed with bipolar disorder? ?
- (A) The client only has four episodes of mania in 6 months.
- (B) The client goes to work every day for 9 months.
- (C) The client wears a nightgown to the day room for therapy.
- (D) The client has had three motor vehicle accidents.
14 >>Which legal intervention should the nurse implement on the initial visit when admitting a client to the home healthcare agency? ?
- (A) Discuss the professional boundary-crossing policy with the client.
- (B) Provide the client with a copy of the NAHC Bill of Rights.
- (C) Tell the client how many visits the client will have while on service.
- (D) Explain that the client must be homebound to be eligible for home healthcare.
15 >>The unlicensed assistive personnel (UAP) accidentally pulled the client’s chest tube out while assisting the client to the bedside commode (BSC). Which intervention should the nurse implement first? ?
- (A) Securely tape petroleum gauze over the insertion site.
- (B) Instruct the UAP how to move a client with a chest tube.
- (C) Assess the client’s respirations and lung sounds.
- (D) Obtain a chest tube and a chest tube insertion tray.
16 >>The nurse and licensed practical nurse (LPN) have been assigned to care for clients on a pediatric unit. Which nursing task should be assigned to the LPN? ?
- (A) Administer PO medications to a client diagnosed with gastroenteritis.
- (B) Take the routine vital signs for all the clients on the pediatric unit.
- (C) Transcribe the HCP’s orders into the computer.
- (D) Assess the urinary output of a client diagnosed with nephrotic syndrome.
17 >>The hospital will be implementing a new medication administration record (MAR) for documenting medication administration. Which action should the clinical manager take first when implementing the new MAR? ?
- (A) Discuss the new MAR with each nurse individually.
- (B) Schedule meetings on all shifts to discuss the new MAR.
- (C) Require the nurse to read a handout explaining the new MAR.
- (D) Ask the nurses to watch a video explaining the new MAR.
18 >>Which client warrants immediate intervention from the nurse on the medical unit? ?
- (A) The client diagnosed with an abdominal aortic aneurysm who has an audible bruit.
- (B) The client with adult respiratory distress syndrome (ARDS) who has bilateral crackles.
- (C) The client diagnosed with bacterial meningitis who has nucal rigidity and neck pain.
- (D) The client with Crohn’s disease who has right lower abdominal pain and has diarrhea.
19 >>Which assessment data warrants immediate intervention by the nurse for the client diagnosed with chronic kidney disease (CKD) who is on peritoneal dialysis? ?
- (A) The client’s serum creatinine level is 2.4 mg/dL.
- (B) The client’s abdomen is soft to touch and nontender.
- (C) The dialysate being removed from the abdomen is cloudy.
- (D) The dialysate instilled was 1,500 mL and removed was 2,100 mL.
20 >>The nurse is taking a history on a client in a women’s clinic when the client tells the nurse, “I have been trying to get pregnant for 3 years.” Which question is the nurse’s best response? ?
- (A) “How many attempts have you made to get pregnant?”
- (B) “What have you tried to help you get pregnant?”
- (C) “Does your insurance cover infertility treatments?”
- (D) “Have you considered adoption as an option?”