Download Nursing Documentation and Client Care Practices and more Exams Nursing in PDF only on Docsity!
FUNDS PROCTORED EXAM I ACTUAL EXAM TEST BANK
200 QUESTIONS AND 100% CORRECT VERIFIED
ANSWERS 2024/
. A nurse is documenting clients care, which of the following abbreviation should the nurse use a. SS for sliding scale b. OJ for orange juice c. SQ for subcutaneous d. BRP for bathroom privileges C A nurse is caring for a client who reports pain level 5 on a scale of 0 to 10. The client informs the nurse that the pain medication are not an option for managing pain. which of the following is an appropriate response by the nurse a. Would you like me to give you a massage b. I'm sure it will work if you gave it a chance c. You can take any herbal medication remedies you bring from home d. Why do you think the pain medication is not going to help you C A nurse is caring for a client following a laparoscopic cholecystectomy, The client has a prescription for ondansetron $mg iv bolus every 6hrs PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. Move the sequence into the box on the right.
- Perform hand hygiene.
- Select the injection port of the IV tubing closest to the client.
- Aspirate for a blood return.
- Cleanse the injection port with an antiseptic swab.
- Inject the medication. A charge nurse in a long term care facility is preparing an educational program about delirium for a newly licensed hired nurse. Which of the following should the nurse plan to include a. Delirium is an abrupt unset b. Delirium does not affect the client sleep cycle c. Delirium has a slow progression d. Delirium does not affect t a client perception of her environment A A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child, which of the following statement by the client should indicate to the nurse that the client has adapted to their new situational role a. I've never been the kind of person to ask people for help b. I really don't know what am suppose to do all day c. Im looking forward to being able to be dependent again d. Its nice having other people cook for me D A nurse is preparing a client who has terminal cancer for discharge. Which of the following question should the nurse ask when assessing the client psychosocial history a. Are you experiencing any pain b. Have any of your relative been diagnosed with cancer c. What medication are you currently taking d. What technique do you use to cope with stress D A nurse is conducting a health assessment for a client who takes herbal supplement. Which of the following statement indicates the understanding of the use of the supplement a. I use garlic for a menopausal symptoms b. I take echinacea to control my cholesterol
c. Let me clarify that you want the medication given qid, correct? d. Let me provide you with the client medical record number for identification A A nurse is collecting sputum specimen for a culture from a client who has respiratory infection. Which of the following action should the nurse take a. Collect 1ml of sputum b. Offer the client oral hygiene after the collection c. Wear sterile gloves when collecting the sputum d. Collect the sputum in the evening B A nurse is teaching a client who has diabetes mellitus about mixing regular insulin. Which of the following statement by the client indicates an understanding of the teaching a. I should roll the vial of NPH insulin between my hands before drawing up b. I should wait 3min after mixing the insulin to inject it c. I should inject air into the vial of regular insulin first d. I should draw up NPH insulin before the regular insulin A A nurse is planning for a client who reports having latex allergy. Which of the following interventions should the nurse include in the plan a. Cover the blood pressure cuff with stockinette b. Apply adhesive tape when securing an iv insertion site c. Use plastic syringe for medication administration d. Wear powdered gloves when providing care for the client A A nurse obtains a prescription for wrist restrain for a client who is trying to pull outh is NG tube. Which of the following action should the nurse take a. Attach the restrain securely to the side of the rail b. Remove the restrain every 4hrs
c. Apply the restrain to allow little movement as possible d. Allow room for two fingers to fit between the client skin and the restraint D A nurse is admitting a client who is at risk for a fall to a medical surgical unit. Which of the following action should the nurse take a. Place the bedside table 0.9m(3feet) away for. the bed b. Elevate fill length side rail on both sides of the clients bed c. provide the client with night light d. keep the clients room temperature at 18 C(64.4F) C A nurse manager over hears a nurse telling the client that " I will administer your medication by injection if you don't swallow the pills. The manager should identify that the nurse is committing which of the following torts a. Defamation b. Assault c. Invasion of privacy d. Battery D A nurse is caring for a client who has pneumonia. The nurse should recognize that which of the following should be discarded in the biohazard bag. a. An emesis basin filled with blood from severe coughing b. A calibrated toilet insert filled with urine c. A disposable tissue containing expectorated sputum d. A bedpan containing diarrhea for a client who is receiving antibiotics A A nurse is caring for a client who is receiving an enteral feeding via NG tube. Which of the following should the nurse take prior to administering the form formular a. Encourage the client to take a sip of water b. Flush the tube with sterile 0.9 sodium chloride irrigation
c. have the client bear weight on her stronger leg d. position the chair next to the bed at a 90 degree angle C A nurse is caring foe a client who has a brain cancer and is transferring to hospice care. the client's son tells the nurse. I don't know what to tell my dad if he asks how he is going to die. " which of the following is an appropriate response by the nurse a. I think you should discuss this with the hospice nurse b. lets talk more about your dad's condition c. try to help your dad enjoy this time as much as he can d. the social worker will help you answer those questions B A nurse is admitting a client who has tuberculosis which of the following types of transmission precaution should the nurse plan to initiate a. airborne b. contact c. droplet d. protective environment A A nurse is collaborating with a risk management team about potential legal issue involving client care. The nurse should identify that which of the following situation is an example of negligence a. a nurse administer a medication without first identifying the client b. a nurse begins a blood transfusion without obtaining consent from a client c. an assistive personnel prevents a client from leaving the facility d. an assistive personnel discuss clients care in the facility cafeteria with visitors present A To ensure client's safety a nurse manager is planning to observe a newly licensed nurse perform a straight catherization on a client. which of the following roles is the nurse manager functioning? a. case manager b. client advocate
c. client educator d. client care provider C A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. which of the following actions should the nurse take a. request that an assistive personnel interpret the information for the client b. avoid using gesture when speaking with the client c. offer written information in the client's language d. use proper medical term when giving information to the client C During change-of-shift report , anurse discovers she overlooked a prescription for a type and cross- match of a client who is to have surgery the next day. which of the following actions should the nurse take first a. document the incident in the client medical record b. obtain the client type and cross match c. inform the provider of the delay in obtaining the type and cross match d. prepare an incident report for risk management C A nurse is teaching a client about home care of oxygen equipment. Which of the following information should the nurse include in the teaching. Select all that apply. a. align the middle of the ball in the flow meter with the line of the prescribed flow rate b. check the oxygen delivery rate at lease once per day c. lay the oxygen tank flat when storing d. avoid using wool blankets when receiving oxygen e. keep the oxygen delivery system 0.6m (2 feet) from any heat source A & D A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure .which of the following actions should the nurse take first a. move items in the room away from the client
c. I should make different patterns on each breast when I do my self exam d. I should use the palm of my hand to apply pressure to each breast A A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600ml IV infusion, cefazolin 250mg in dextrose 5% in the water 100ml intermittent IV bolus 200 ml emesis,40ml voided urine, and 20 ml urine from straight catherization. The nurse should record the client's net fluid intake as how many ml. round up the answer to the nearest whole number) 700 A nurse is caring for a client who has recently diagnosed with terminal illness. The client tells the nurse "I am looking forward to seeing my grandchildren grow up. "the nurse should identify that the client is experiencing which of the following stages of grief a. bargaining b. acceptance c. denial d. anger C A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food, he needs to adhere to the diet at home. the nurse should notify which of the following health care team a. social worker b. primary care provider c. registered dietician d. occupational therapy A A nurse is preparing to administer diphenhydramine 20mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5ml oral syrup. Which of the following images indicates the correct number of ML the nurse should administer( round the answer to the nearest whole number)
8ml A nurse is obtaining the medical history of a client who ask about taking ginkgo biloba. The nurse should identify that which of the following medication can interact adversely with this supplement a. albuterol b. levoyyroxine c. atorvastatin d. warfarin D A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following action should the nurse take a. Instruct the client to exhale quickly during vibration b. Schedule pastural drainage after meal c. Cover the area of percussion with a towel d. Perform percussion over the lower back A A nurse is caring for a client who is post operative and has a new prescription to advance her diet to full liquid. which of the following food should the nurse offer the client as a part of full liquid diet a. Applesauce b. Plain yogurt c. Scrambled egg d. Oatmeal A A nurse is providing oral care for a client who is unconscious. Which of the following action should the nurse take a. Rinse the mouth with alcohol based mouthwash b. Brush the client teeth daily c. Place the client in side lying position d. Apply mineral oil to the client lips C
D
A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the clients signature, the client states that I trust my doctor but I don't understand what is meant by resecting my intestine. Which of the following action should the nurse take a. Complete the incidence report b. Describe the surgery to the client c. Provide brochure about the procedure d. Notify the provider D A nurse is assessing an older adult client. Which of the following findings should the nurse expect a. Decrease sense of balance b. Heightened sense of pain c. Increase night time sleeping d. Night time urinary incontinence A A nurse is obtaining consent form from a client who is scheduled for surgery. The client states " I don't want to go through with the procedure" which of the following action should the burse take a. Document the client decision in the medical record b. Explain to the client the risk involve with not having the procedure c. Discuss alternative treatment with the client d. Express approval of the client decision to not have to procedure A A nurse on a medical - surgical unit is receiving a change of shift report for client. Which of the following clients should the nurse see first? a. A client who has acute abdominal pain of 4 on a scale from 0 to 10 b. A client who has new onset of dyspnea 24 hours after a total hip arthroplasty c. A client who has a urinary tract infection and low grade fever d. A client who has pneumonia and an oxygen saturation of 96% B
A nurse is planning discharge for a client who had a stroke and has difficulty holding utensils at mealtime. Which of the following referrals should the nurse anticipate? a. Occupational therapy b. Dietary service c. Respiratory therapy d. Pharmacy service A A nurse is preparing to insert peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein? a. Apply a cool compression to the vein for 10 mins b. Change the client's arm over the edge of the bed. c. Stroke the skin near the vein in an upward direction d. Instruct the client to flex their arm with the hand open C A nurse is creating a plan of care for a client who has left-sided hemiplegia. Which of the following intervention should the nurse include? a. Apply an orthotic boot to the client's left foot. b. Instruct the client to lean toward the left side when auscultating to avoid falls. c. Rest the client left arm over their chest. d. Place a thick pillow behind the client's head to increase cervical flexion. A A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the following responses should the nurse make? a. " It must be very difficult for you to receive this kind of news" b. " It might seem bad now, but things will get better" c. " I would get a second opinion if I were you" d " I think you would benefit from speaking with our chaplian" A
B
A nurse is preparing to administer several medications to a client. Which of the following data should the nurse use to confirm identity a. The client telephone number b. The name of the clients next of kin c. The client admitting diagnosis d. The client room number A A nurse is caring for a client who has urinary incontinence. Which if the following intervention should the nurse take to prevent skin breakdown a. Apply a moisture barrier ointment after perineal hygiene b. Restrict the client fluid intake c. Apply powder to the client perineal area d. Request a prescription for an indwelling urinal catheter A A nurse is caring for a client who has an extra cellular fluid volume deficit. Which of the following findings should the nurse expect a. Bradycardia b. Postural hypotension c. Dependent edema d. Distended neck vein B A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following action should the nurse take to verify proper placement of the tube a. Measure the ph of the gastric aspirate b. Assess the client for gag reflex c. Place the end of the NG tube in water to observe the bubbling d. Auscultate 2.5cm(im) above the umbilicus while injecting 15ml of sterile water B
A nurse is caring for a client who has a colostomy. Which of the following action should the nurse take a. Apply the pouch while the skin barrier is still damp b. Rub the peristomal skin dry after cleaning c. Change the pouch once every 24hrs d. Ensure the pouch is 0.32cm(1/8) larger than the stoma D A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take? a. Place the client in a semi-private room b. use sterile gloves to provide perineal care c. cleanse hands with an alcohol-based hand rub before a client contact d. have the client apply a mask when children are visiting A A nurse on a medical unit is providing care for four clients. The nurse should identify which of the following situations dilemma? a) The family of a client has a terminal illness asks that the provider not tell the client the diagnosis b) A client who has a new colostomy refuses to take instructions from the ostomy therapist because she doesn't like him c) A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions. d) A client who has Crohn's disease reports that his prescription drug plan will not pay for his medication A A nurse is teaching a newly licensed nurse about care of a client who has a Methicillin-resistant staphylococcus aureus (MRSA) infection. Which of the following statement by the newly licensed nurse indicates an understanding of the teaching
