1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a
change in the wound care procedure. Which of the following findings indicate wound
healing.
a) Erythema on the skin surrounding a client's wound
b) Deep red color on the center of the clients wound
c) Inflammation noted on the tissue edges of a client's wound
d) Increase in serosanguineous exudate from the clients wound
2. A nurse received change of shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
a) Obtain a breakfast tray for a client who received a morning dose of insulin as
part
b) Administer pain medication to a client who has rheumatoid arthritis and received the
last dose at 0400
c) Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
d) Replace a client's enteral nutrition feeding solution that has been hanging for 24
hours. (To prevent bacterial contamination, fill the bag with only enough formula to
lastover a 4-8 hour period, and change the feeding bag every 24 hours)
3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the
following clients should the nurse assign to the newly licensed nurse?
a) A client who has multiple sclerosis and ataxia
b) A client who has brain tumor and is admitted for chemotherapy
c) A client who has guillain-barre syndrome and a tracheostomy
d) A client who sustained a concussion and is being monitored for complication
4. A nurse is providing teaching to a client about advance directives. 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) "I will wait until I have a serious health problems to sign my advance directives"
c) "My doctor will need to provide approval for the decisions outlines in my living will
d) "My durable power of attorney for health care is part of my advance
directives"
5. A nurse is chairing a committee about preventing infant abduction in a new birth care
center. Which of the following quality control tasks should the nurse assign to be
completed first?
a) Identify the industry standards for infant safety
b) Evaluate the selected infant safety system
c) Choose an infant safety system
d) Establish measurement criteria for infant safety
systems
, 6. A nurse notes that a client is eating about half of the food on his plate and coughs
frequently during meals. The nurse plans to perform dysphagia screening to determine
the client's need for a referral to which of the following providers?
a) Physical therapist
b) Respiratory therapist
c) Speech therapist
d) Occupational therapist
7. A home health nurse is assessing the home environment during an initial visit to a
client who has a history of falls. Which of the following findings should the nurse identify
as increasing the client's risk for falls (SATA) [repeat]
• A wheeled office chair at the client's computer desk
• A raised vinyl seat on the toilet in the bathroom
• A throw rug covering some cracked floor
• A folding chair without arm rests
• A two wheeled walker used to assist the client with ambulation
• A wheeled office chair at the client's computer desk
• A throw rug covering some cracked floor
• A folding chair without arm rests
8. A nurse manager is planning to assign care for four clients on a medical surgical unit.
Which of the following clients should the nurse assign to a LPN
a) An older adult who has lung cancer and has periodic episodes of severe dyspnea
b) A middle adult client who has a below the knee amputation and requires a
dressing change
c) A young adult client who is postoperative, receiving morphine via epidural,
andreports pruritus
d) An adolescent who requires teaching regarding insulin
administration
9. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance
directives. Which of the following is the priority for the nurse to take?
a) Remind nurses to obtain this information during the admission process
b) Reinforce the potential consequences of not having his information on record to the
nursing staff
c) Meet with nursing staff to review the policy regarding advance directive
d) Ask nurse who are caring for client without his information in the medical record to
obtain it
10. A nurse is caring for a group of clients. Which of the following should the nurse see
first?
a) A client who is postoperative and has a fever.
b) A client whose pressure ulcer has serosanguineous drainage on the dressing
c) A client who has diabetes mellitus and is diaphoretic
d) A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10
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