Exit Exam 1 Complete Questions & Answers

Assistive personal (AP) are caring for a client who takes a PRN pain medication. After the nurse administers the medication, which of the following tasks should the the nurse assign to the AP? - check the client's response the medication in 1 hour A client is assisting with triaging clients in a mass casualty situation. the nurse should recommend the following client receive care first? - A client who has diminished breath sounds and paradoxical chest movement Following discharge from an acute mental health facility, the clients states intentions to harm a friend when he leaves the facility. Which of the following actions should the nurse take? - Notify local law enforcement about the client's threat A nurse delegates a task to an assistive personnel (AP) and the AP refuses the assigned task. Which of the following actions should the nurse take first? - Notify the charge nurse A nurse discovers a fire in a trash can in a patients room. Which of the following action should the nurse take first? - walk the client to the waiting room A nurse from a medical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept? - a client who had a cesarean delivery 24 hours ago A nurse in a long-term care facility has received change of shift report about four clients. Which of the following client should the nurse attend to first? - a client who has COPD and dementia and as agitated during the night shift A nurse in a mental health unit asks a client who has schizophrenia, "How are you" Which of the following responses should the nurse identify as the speech alteration of echolalia? - how are you A nurse added urgent care facility is collecting data from an adolescent whom the nurse suspects has meningitis. Select the location the nurse should flex to check for Brudzinski's sign. - Spot A - on the neck a nurse in a providers office is talking on the phone with a parent of a school age child who has varicella period the parent asked when a child can return to school period the nurse should tell the parent that which of the following is an indication that the child is no longer contagious - all vesicles have crusted over A nurse in mental healthy facility is reviewing the laboratory reports for four clients. Which of the following results should the nurse reports to the provider immediately? - Sodium level of 130 mEq/L for a client who has bipolar disorder and take lithium A nurse in the newborn nursery is collecting data about a newborn's moro reflex. Which of the following actions should the nurse take to elicit this reflex? - Strike the crib surface on which the newborn is lying A nurse is at prenatal clinic is reinforcing teaching with a client about a nonstress test. Which of the following statements should the nurse include? - you will be asked to press a button when you feel the baby move A nurse is assisting in the development of an in-service for staff members about physical abuse of children. Which of the following children are at an increased risk for physical abuse? - Children who live in crowded homes A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception? - Hallucinations A nurse is assisting with the admission of a client who attempted suicide. When the nurse processes the client’s belongings which is the following items should the nurse remove from the client suitcase? - Perfume A nurse is assisting with the admission of a client who has mononucleosis. Which of the following isolation precautions should the nurse initiate? - contact A nurse is assisting with the admission of an older client with impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first - check the client’s ability to use the call light A nurse is assisting with the admission of a client who has Hodgkin's disease and is receiving chemotherapy. Because a private room is not available the nurse should recommend that the client share room with a client who has which of the following diagnosis - sickle-cell anaemia A nurse is caring for a client who was recently admitted to an inpatient mental health unit. The client tells the nurse he is not coming out of his room anymore because the other clients on the unit make fun of him. Which of the following response by the nurse is appropriate? - you feel upset by the response of others A nurse is caring for 17-year-old client who is admitted for an emergency appendectomy which of the following is an appropriate action by the nurse in obtaining informed consent? - obtain verbal consent from the client while waiting for the parents to arrive A nurse is caring for a child who has COPD. The client tells the nurse "I get short of breath during meals. It is too much trouble to eat" Which of the following instructions should the nurse suggest? - Have several small meals during the day A nurse is caring for a child who has terminal cancer. Which of the following responses by the child siblings should the nurse expect - The school-age sister is concerned about the impact of her sibling’s death on herself A nurse is caring for a child who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take - remove the restraint when the client falls asleep A nurse is caring for a client and begins to suspect he is experiencing transference. which of the following client statements should the nurse identify as an indicator of transference? - I feel really close to you because you remind me of my ex-boyfriend A nurse is caring for a client who attempted suicide. Which of the following actions should the nurse take? - serve meals with plastic utensils. A nurse is caring for a client who has a methicillin-resistant Staphylococcus Aureus (MARSA) infection. - Don a gown and gloves when providing perineal care A nurse is caring for a client who has a new colostomy. he voices a reluctance about resuming sexual relations. which of the following is an appropriate response by the nurse? - "I'm available if you'd like to talk about your concerns." A nurse is caring for a client who has a new prescription for a protective safety restraint. Which of the following actions should the nurse take? - A nurse is caring for a client who has a new prescription for a protective safety restraint. Which of the following actions should the nurse take? A nurse is caring for a client who has a new prescription for furosemide. The client asks the nurse about the purpose of the medication. The nurse tells the client, " This mediation is a diuretic, and you should monitor your weight while taking it. " Which of the following ethical concepts is the nurse exhibiting? - Veracity. A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate? - Monitor the client's skin integrity on a regular schedule. A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take? - Allow the client to pick her own choice of clothing. A nurse is caring for a client who has urolithiasis.. Which of the following action should the nurse take? - strain the client's urine. A nurse is caring for a client who has viral pneumonia. which of the following actions should the nurse take? - Place the client in a private room A nurse is caring for a client who heart failure and having difficulty limiting sodium in his diet. Which of the following recommendations should the nurse provide? - replace bottled salad dressing with homemade vinegar and oil dressing. A nurse is caring for a client who is receiving morphine 2mg subcutaneously every 4hr for pain the medication is available in a vial 10 mg/ml how many mL should the nurse administer. Round the answer to the nearest tenth. - 0.2mL A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory results indicates a possible complication of this therapy? - Serum calcium 12.5 mg/dL. A nurse is caring for a client who is receiving warfarin 5mg po daily. Which of the following laboratory values should the nurse check prior to administering the medication? - PT INR BUN A nurse is caring for a client who was diagnosed with hyperemesis gravidarum. Which of the following findings should the nurse anticipate? - Poor skin turgor. A nurse is caring for a school-age child who has epistaxis. Which of the following actions should the nurse take? - Apply pressure at the bridge of the child's nose. A nurse is caring for a school-age child whose family adheres to vegan diet in the home. the nurse should recognize the child is at risk for deficiency of which of the following? - Vitamin D A nurse is caring for a toddler who is admitted to paediatric unit and is 2hr postoperative following a tonsillectomy. which of the following findings is a sign of haemorrhage? - Frequent swallowing. A nurse is caring for four clients. Which of the following client statements should the nurse attend to first? - "My heartburn pain is going into jaw now." A nurse is caring for postoperative client and obtains a pulse oximeter reading of 86%. Which of the following interventions should the nurse take first? - repeat the test on another finger. A nurse is checking the home environment of a client for safety hazards. which of the following items require intervention by the nurse? - The dining room table has low chairs with no armrest A nurse is collecting data from a client who has a long-leg cast on his left leg and report pain. which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? select all that apply. - - pallor in the exposed portion of the left foot. - inability to move the left foot. - paresthesia in the left foot. A nurse is collecting data from a client who has diabetes mellitus. which of the following findings indicates the client might be experiencing ketoacidosis? - Kussmaul respirations A nurse is collecting data from a client who has hepatitis A. which of the following findings should the nurse expect? - Abdominal pain A nurse is collecting data from a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following findings should the nurse report to the provider.? - urine output 20mL/hr