1. A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was
so angry I went to the gym and worked out." The nurse should recognize the client is
demonstrating which of the following defense mechanisms? --CORRECT ANSWER--
Sublimation
Rationale: The client is exhibiting behaviors consistent with sublimation, which is
displayed when a client substitutes socially unacceptable behavior for acceptable behavior.
2. A nurse is caring for a client who has generalized anxiety disorder and is to begin taking
alprazolam. Which of the following actions should the nurse take? --CORRECT
ANSWER-- Initiate fall precautions for the client
Rationale: The nurse should initiate fall precautions for a client who has a new
prescription for alprazolam because common adverse effects associated with this
,medication are orthostatic hypotension, dizziness, confusion, and lethargy.
3. A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the
following findings should indicate to the nurse that the client has the ability to sign the
informed consent? --CORRECT ANSWER-- The client is able to accurately describe the
upcoming procedure
Rationale: The ability of the client to accurately describe the upcoming procedure indicates that
the provider adequately informed the client and that the client is able to sign the informed consent
4. An assistive personnel (AP) and a nurse are turning a client onto the right side. Which
of the following actions by the AP requires the nurse to intervene? --CORRECT
ANSWER-- Places a pillow under the client's right arm.
Rationale: The AP should place a pillow under the client's left arm to prevent internal
rotation of the left shoulder.
5. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the
following instructions should the nurse include? --CORRECT ANSWER-- Introduce
new foods one at a time over 5 to 7 days.
6. A nurse is caring for a client who has MRSA in an abdominal wound. Which of the
following precautions should the nurse implement? --CORRECT ANSWER-- Contact
,Rationale: The nurse should implement contact precautions for a client who has an
infection spread by direct contact, such as MRSA.
7. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy
lochia. Which of the following actions should the nurse take first --CORRECT ANSWER-
Massage the uterus to expel clots
Rationale: Using the EBP approach to client care, the nurse should identify that the
priority action is massaging the client's uterus. Uterine massage will expel clots and
increase uterine firmness, resulting in decreased bleeding.
8. A nurse is providing discharge teaching to a new parent about car seat safety. Which of
the following statements should the nurse include in the teaching? --CORRECT
ANSWER-- "Secure the retainer clip at the level of your baby's armpits"
9. A nurse is providing discharge teaching to a client who has colorectal cancer and a new
colostomy. The client states, "I'm worried about being discharged because I live alone, and
my insurance doesn't cover ostomy supplies. "Which of the following actions should the
nurse take? (SATA) --CORRECT ANSWER-- -Refer the client to a community based
social workers
-Initiate a consult with a home health care provider
-Give the client information about local support groups
, Rationale:
-A social worker is necessary to help a client with self-care, as well as assist in locating agencies
who can help the client face challenges with self-care and paying for necessary ostomy supplies
-A home health nurse can assist the client in learning to care for the colostomy as well as provide
medication management and emotional support
-A client who has cancer and a new colostomy can get help with coping from a support group and
possibly receive assistance obtaining supplies from local agencies
10. A nurse manager is reviewing unit records and discovers that client falls occur most
frequently during the hours of 0530 and 0730. Which of the following actions should the
nurse take when conducting a root cause analysis? --CORRECT ANSWER--
Investigate environmental factors that might be contributing to client injury during these hours.
Rationale: When conducting a root cause analysis, the nurse should look at the factors
that could possibly lead to the clients' falls. This can include environmental factors that
might be causing the problem.
11. A nurse is caring for a client who has terminal illness and requests lifesaving measures
if a cardiac arrest occurs. Which of the following statements should the nurse make? --
CORRECT ANSWER-- "I will provide you with information about medical treatment to
include in your living will"
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