#101.
Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention?
A
To permit veins in the legs to fill with blood
B
To observe the lower extremities
C
To allow the leg muscles to stretch and relax
D
To increase blood flow to the heart
Answer: To observe the lower extremities
#102.
Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood transfusion?
A
Assessing the client’s vital signs when the transfusion ends.
B
Documenting blood administration in the client care record.
C
Informing the client that the transfusion usually take 1 ½ to 2 hours.
D
Instructing the client to report any itching, swelling, or dyspnea.
Answer: Instructing the client to report any itching, swelling, or dyspnea.
#103.
A male client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
A
Change the feeding container every 12 hours.
B
Give the feedings at room temperature.
C
Place the client in semi-Fowler’s position while feeding.
D
Decrease the rate of feedings and the concentration of the formula.
Answer: Decrease the rate of feedings and the concentration of the formula.
#104.
Nurse Patricia is reconstituting a powdered medication in a vial. After adding the solution to the powder, she nurse should ___________.
A
Do nothing.
B
Invert the vial and let it stand for 3 to 5 minutes.
C
Shake the vial vigorously.
D
Roll the vial gently between the palms.
Answer: Roll the vial gently between the palms.
#105.
Which intervention should the nurse Trish use when administering oxygen by face mask to a female client?
A
Secure the elastic band tightly around the client’s head.
B
Loosen the connectors between the oxygen equipment and humidifier.
C
Apply the face mask from the client’s chin up over the nose.
D
Assist the client to the semi-Fowler position if possible.
Answer: Assist the client to the semi-Fowler position if possible.
#106.
The maximum transfusion time for a unit of packed red blood cells (RBCs) is _____________________.
A
6 hours
B
2 hours
C
3 hours
D
4 hours
Answer: 4 hours
#107.
Nurse Monique is monitoring the effectiveness of a client’s drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level?
A
Immediately after administering the next dose.
B
1 hour before administering the next dose.
C
30 minutes after administering the next dose.
D
Immediately before administering the next dose.
Answer: Immediately before administering the next dose.
#108.
Nurse May is aware that the main advantage of using a floor stock system is:
A
The nurse can implement medication orders quickly.
B
The system reinforces accurate calculations.
C
The system minimizes transcription errors.
D
The nurse receives input from the pharmacist.
Answer: The nurse can implement medication orders quickly.
#109.
Nurse Oliver is assessing a client’s abdomen. Which finding should the nurse report as abnormal?
A
Dullness over the liver.
B
Shifting dullness over the abdomen.
C
Vascular sounds heard over the renal arteries.
D
Bowel sounds occurring every 10 seconds.
Answer: Shifting dullness over the abdomen.
#110.
The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:
A
The client asks the nurse to discuss the her condition with the family
B
The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
C
A researcher from an institutionally approved research study reviews the medical record of a patient
D
The nurse discusses the condition of the client in a clinical conference with other nurses
Answer: The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
#111.
A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?
A
Get a verbal consent from the parents of the client
B
Obtain a consent from the client as soon as possible
C
Ask the spouse to sign the consent
D
Call the surgeon
Answer: Call the surgeon
#112.
The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?
A
assess the level of consciousness and circulation
B
check respirations, circulation, neurological response
C
check respiration, stabilize spine, check circulation
D
align the spine, check pupils, check for hemorrhage
Answer: check respiration, stabilize spine, check circulation
#113.
A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?
A
Give the family member the number for an Elder Abuse Hot line
B
Talk to the family member and explain that what she/he has said is not appropriate for the client
C
Take no action because it is the family member saying that to the client
D
Document what the family member has said
Answer: Talk to the family member and explain that what she/he has said is not appropriate for the client
#114.
Which is true about informed consent?
A
Obtaining consent is not the responsibility of the physician
B
A nurse may accept responsibility signing a consent form if the client is unable
C
If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing
D
A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent
Answer: If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing
#115.
A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:
A
Get a court order making the baby a ward of the court
B
Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother
C
Do nothing except record the mother’s statement in the medical record
D
Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
Answer: Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
#116.
The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client's room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means:
A
The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.
B
The patient releases the physician from all responsibility for the procedure.
C
The immediate family may make decision against the patient’s will.
D
The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
Answer: The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
#117.
A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?
A
Encourage the client to have the surgery
B
Inform the client of other options
C
Call a family meeting
D
Discuss the religious beliefs with the physician
Answer: Discuss the religious beliefs with the physician
#118.
While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?
A
Report this incident to the nursing supervisor
B
Join in the conversation, giving them supportive input about the case of the client
C
Tell them it is not appropriate to discuss the condition of the client
D
Ignore them, because it is their right to discuss anything they want to
Answer: Tell them it is not appropriate to discuss the condition of the client
#119.
A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
A
Try to discuss with the colleague about the issue and resolve it when both are calmer
B
Tell other members of the network what the team member did
C
Discuss this with the supervisor
D
Not discuss the issue with anyone. It will probably resolve itself
Answer: Try to discuss with the colleague about the issue and resolve it when both are calmer
#120.
The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when ____________________.
A
A researcher from an institutionally approved research study reviews the medical record of a patient .
B
The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
C
The client asks the nurse to discuss the her condition with the family
D
The nurse discusses the condition of the client in a clinical conference with other nurses
Answer: The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
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