NSG 280 UNIT PRIOTIZATION PROJECT
1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
a. “You don...
1. A nurse is caring for a client who has given informed consent for ECT. Just before the procedure, the client tells the
nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is
appropriate?
a. “You don’t have to go through with the treatment.”
2. While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s CPM device.
Which of the following actions should the nurse take first?
a. Remove the device from the room
3. A nurse is caring for a client who is postoperative and has a new prescription for hydromorphone. Which of the
following actions should the nurse take?
a. Count the current number of unit doses available in the medication dispensing system
4. A nurse performing a change-of-shift assessment. Which of the following clients has the priority finding?
a. 2 hr. post cast placement and has 2+ pitting edema and pallor
5. A nurse in an outpatient mental health facility is providing teaching to a group of adolescents. Which of the following
statements by a client indicates an understanding of the teaching?
a. “I will take the sustained-release methylphenidate every morning.”
6. A nurse is completing an admission assessment for a client who ahs narcissistic personality disorder. Which of the
following should the nurse expect?
a. Preoccupied with aging
7. A nurse is planning care for a group of clients and is working with one LPN and one AP. Which of the following
actions should the nurse take first to manage her time effectively?
a. Determine goals of the day
8. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via
continuous IV infusion. Which of the following actions should the nurse include in the plan?
a. Measure the client’s urine output every hour
9. A nurse is caring for a group of clients. Which of the following wounds should the nurse expect to heal by primary
intention?
a. Approximated surgical incision
10. A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients
should the nurse see first?
a. Client taking clozapine to treat schizophrenia and reports sore throat
11. A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.” The
client is weak and unable to walk. After the nurse indicates chest pain protocol, which of the following is the priority
diagnostic test?
a. 12 lead ECG
12. A nurse is assessing the growth and development of a 3 y/o child. Which of the following questions should the nurse
ask the parent to determine if the child is exhibiting typical developmental expectations?
a. “Can your child ride a tricycle?”
13. A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes
tidaling in the water seal. Which of the following is an explanation for the tidaling?
a. The system is working properly
14. A nurse is caring for a client who has ESRD. The client’s adult child asks the nurse about becoming a living kidney
donor for her father. Which of the following conditions in the child’s medical history should the nurse identify as a
contraindication to the procedure?
a. HTN
15. A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse
expect? (SATA)
a. Lochia serosa
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,NSG 280
b. Fundus 4 cm (1.6 in) below the umbilicus
16. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions
should the nurse take?
a. Perform the procedure twice a day
17. A home care nurse is making a follow up visit with a client who has COPD and is using a compressed oxygen system
in his home. Which of the following action should the nurse take?
a. Place the oxygen tank away from curtains or drapes
18. A nurse is caring for a newly client who has bacterial meningitis. Which of the following actions should the nurse take?
a. Implement seizure precautions
19. A nurse is reviewing the preadmission lab tests results of a client who is to undergo hip arthroplasty in 2 days. Which of
the following results should the nurse report to the provider?
a. K 3.3 mEq/L
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20. A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain.
Which of the following actions should the nurse take?
a. Reset the vacuum by compressing the container
21. A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse assess first?
a. Leukemia and platelet level of 95,000/mm3
22. A nurse is developing plan of care for a newborn mother tested positive for heroin during pregnancy. Newborn is
experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the
plan?
a. Minimize noise in the newborn’s environment
23. Nutritional teaching for an adult client who has seizure disorder and a new prescription for phenytoin. Which of
the following instructions by the nurse is appropriate?
a. “Increase your intake of vitamin D while taking this medication.”
24. A nurse is assessing a client who presents to the L&D unit reporting the onset of contractions. Which of the following
findings should the nurse identify as a manifestation of false labor?
a. Intermittent, painless contractions
25. A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse plan to
assess first?
a. Hip fracture and a new onset of tachypnea
26. Nurse accidently punctures IV bag causing the medication to leak on the counter. Which of the following
medications requires the nurse to follow facility procedures in the safe handling of a bio hazardous material spill?
a. Doxorubicin hydrochloride
27. Postoperative client following appendectomy and receiving gentamicin. Which is an adverse effect of this medication?
a. Creatinine 2.3 mg/dL
28. Which of the following clients should the nurse recommend referral to a dietitian?
a. Client who has a nonhealing leg ulcer
29. Support group for clients whose family have committed suicide. Which of the following should the nurse plan to
use during the group session?
a. Initiate a discussion with clients about ways to cope with changes in family dynamics
30. Which of the following risk factors should the nurse include as the best predictor of future violence?
a. Previous violent behavior
31. Arial fibrillation places the client at risk for which of the following conditions?
a. Pulmonary emboli
32. Client with schizophrenia and experiences auditory hallucinations. Which actions should the nurse include in the plan?
a. Ask the client directly what he is hearing
33. Circumcised newborn. Which of the following instructions should the nurse include in the teaching?
a. “Apply petroleum jelly to the glans with diaper changes.”
34. Crohn’s disease. Which of the following diagnostic procedures should the nurse plan to teach the client
regarding pernicious anemia?
a. Schilling test
35. A nurse is creating a care plan for a client who is postoperative following a CABG. To prevent complications of cardiac
surgery, which of the following instructions should the nurse include in the plan of care?
a. Check the client’s hemoglobin level if chest tube drainage is 300 mL in the first 1 hr
36. A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day
postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk
for delayed wound healing?
a. Prednisone
37. Client becomes unconscious and monitor displays v-tach. Which action should the nurse take first after determining
the client does not have a palpable pulse?
a. Defibrillate
38. A nurse is caring for several clients on a med surg unit. For which of the following nursing activities is it required that
the nurse use sterile gloves?
a. Performing tracheostomy care
39. Lab results s/p surgery. Which should be reported to the provider?
a. Na 160 mEq/L
40. Client in ER experiencing stimulant withdrawal. Which finding should the nurse expect?
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a. Fatigue
41. Postpartum client with a language barrier. Which of the following actions should the nurse take to gather the
client’s admission data?
a. Request female interpreter through the facility
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