A home care nursde finds a client who has sustained partial-thickness burns to the face and
arms. After removing the client from danger and securing their airway, which of the following
interventions is the nurse's priority?
1. Remove smoldering clothes
2. Perform a head-to-toe evaluation
3. Restrict fluid intake
4. Elevate the arms and legs - ANS-1. Remove smoldering clothes
A home health nurse is reinforcing teaching with a client who has HIV. Which of the following
instructions should the nurse reinforce to maintain infection control in the clients home?
1. Wash dishes in hot soapy water
2. Wear a face mask when visitors enter the home
3. Clean their pets litter box daily
4. Clean blood spills with a 1:20 part dilution of chlorhexidine and water - ANS-1. Wash dishes
in hot soapy water
A nurse in a long-term care facility is delegating client care tasks to staff members. Which of the
following tasks should the nurse delegate to an AP?
1. Identify the stage of a clients pressure injury
2. Evaluate the effectiveness of a pain med
3. change the dressing over an abrasion on the elbow
4. Teaching a client to use a walker - ANS-3. Change the dressing over an abrasion on the
elbow
A nurse is admitting a client who has gastroenteritis. Which of the following lab values indicated
that the client is experiencing hypovolemia?
1. Hgb 15g/dL
2. Urine specific gravity 1.010
3. Sodium level 137 mEq/L
4. BUN 32 mg/dL - ANS-4. BUN 32 mg/dL
A nurse is assisting a client who is having a pelvic examination for the first time. The client
states, "I am really nervous". Which of the following statements should the nurse make?
1. "This procedure will be over in 20 min"
2. "Ill be in the room with you throughout the exam"
3. "hold your breath during the examination"
, 4. "You will feel so much better once it is over" - ANS-2. "ill be in the room with you throughout
the examination"
A nurse is assisting with administering packed RBCs to a client. Which of the following actions
should the nurse plan to take?
1. Begin the transfusion of packed RBCs within 1 hr of the bloods arrival on the unit
2. Ensure the packed RBCs are infused within 4hr
3. Increase the infusion rate by 10 mL/hr every hour
4. Observe the client for the first 5 min - ANS-2. Ensure the packed RBCs are infused within 4hr
A Nurse is assisting with teaching a class of clients about health promotion and prevention.
Which of the following statements should the nurse make?
1. "You should have a mammogram starting at age 30"
2. "Schedule a colonoscopy every 10 years starting at age 55"
3. "You should have a skin checkup every year after 20"
4. "You should receive a tetanus booster every 10 years" - ANS-4. "You should receive a
tetanus booster every 10 years"
A nurse is cairng for a client who had a sigmoid colon resection 2 days ago. Which of the
following findings should the nurse report to the provider?
1. Dark green drainage from the NG tube
2. 2cm (0.78in) of serosanguineous drainage on the dressing
3. Oral temp of 101.3 F
4. Hypoactive bowel sounds in all quadrants - ANS-3. Oral temp of 101.3 F
A nurse is caring for a client who had a stroke and is having difficulty with fine motor skills when
performing ADLS. Which of referral should the nurse recommend? - ANS-Occupational
Therapist
A nurse is caring for a client who has a prescription for enalapril 10mg PO daily and reports
dizziness and weakness. Which of the following actions should the nurse take first?
1. Gather supplies to start IV access
2. Instruct the client to use the call light before getting out of bed
3. consult with the provider about holding the next dose of med
4. Check the clients BP - ANS-4. Check the clients BP
A nurse is caring for a client who has a tracheostomy tube. Which of the following actions
should the nurse take?
1. Change the tracheostomy dressing every 48 hours
2. Suction the tracheostomy tube once every 6 hours
3. Leave old tracheostomy ties in place while applying new ties
4. Use aseptic technique for tracheostomy care - ANS-3. Leave old tracheostomy ties in place
while applying new ties
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