A charge nurse reviews the plan of care formulated
by a new nursing graduate for a child returning from
the operating room following a tonsillectomy.
The charge nurse assists the new nursing graduate
in changing the plan if which incorrect intervention
is documented ?
1 Offer clear, cool liquids when awake
2 Eliminate milk or milk products from the diet
3 Monitor for bleeding from the surgical site
4 Suction whenever necessary
A physician orders a chemotherapy medication dose
that the nurse believes is too high.
The nurse calls the physician, but the physician has
left the office for the weekend.
The nurse appropriately :
1 Checks with the pharmacist, who agrees the dose
is too high, and then reduces the dose accordingly
2 Withhold giving the medication until the physician's
partner makes rounds the following day
3 Reschedules the client's chemotherapy until the
following week
4 Calls the answering service, and confers with the
on-call physician
A client has an order for seizure precautions,
and a nursing student develops a plan of care
for the client.
The registered nurse reviews the plan of care
with the student and identifies which incorrect
intervention ?
1 Monitor the client closely while the client
is showering
2 Push the lock-out button on the electric bed
to keep the bed in the lowest position
3 Keep all the lights on in the room at night
4 Assist the client to ambulae in the hallway
A nurse is observing a nursing assistant talking
to a client who is hearing impaired.
The nurse would intervene if which of the following
were performed by the nursing assistant during
communication with the client ?
1 The nursing assistant is facing the client when
speaking
2 The nursing assistant is speaking clearly to the
client
3 The nursing assistant is speaking directly into
the impaired ear
4 The nursing assistant is speaking in a normal tone
A registered nurse suspects that a colleague
is substance impaired and notes signs of
alcohol intoxication in the colleague.
The Nurse Practice Act requires that the
registered nurse do which of the following ?
1 Talk with the colleague
2 Report the information to a nursing
supervisor
3 Call the impaired nurse organization
4 Ask the colleague to go to the nurses'
lounge to sleep for a while
A nurse enters the client's room and finds
the client lying on the floor.
Following assessment of the client, the nurse
calls the nursing supervisor and the physician
to inform them of the accurrence.
The nursing supervisor instructs the nurse to
complete an incident report.
The nurse understands that incident report
allow the analysis of adverse client events by:
1 Evaluating quality care and the potential
risks for injury to the client
2 Determining the effectiveness of nursing
interventions in relation to outcmes
3 Providing a method of reporting injuries to
local,state,and federal agencies
4 Providing clients with necessary stabilizing
treatment
A nurse is caring for a client with a serious
condition who is a potential organ donor.
Before approaching the family to discuss organ
donation, the nurse reviews the client's medical
record for contraindications to organ donation,
which would include:
1 Allergy to penicillin-type antibiotics
2 Age of 38 years
3 Hepatitis B infection
4 Negative rapid plasma reagin (RPR)
laboratory result
A hospitalized client with a diagnosis of anorexia
nervosa and in a state of stavetion is in a two bed
hospital room.
A newly admitted client will be assigned to this
client room.
Which client would be inappropriate to assign to this
two bed room.
1 A client with pneumonia
2 A client with leg that is casted
3 A client who can care for self
4 A client who is scheduled for a diagnostic test
A client who is scheduled for gallbladder surgery
is mentally impaired and is unable to communicate.
With regard to obtaining permission for the surgical
procedure, which nursing intervention would
be appropriate?
1, Ensure that the family has signed the
informed consent
2, Ensure that the client has signed the
informed consent
3, Inform the family about the advanced
directive process
4, Inform the family about the process of
a living will
A registered nurse id delegating activities to the
nursing staff.Which activity is least appropriate
for the nursing assistant ?
1 Assisting a post-cardiac catheterization client
who needs to lie flat to eat lunch
2 Obtaining frequent oral temperatures on a client
3 Accompanying a man being discharged to his
transportation to home
4 Collecting a urine specimen from a client
A nurse enters a client's room and finds the
client sitting on the floor.
The nurse performs a though assessment and
assist the client back into bed.
The nurse complete an incident report and notifies
the physician of the incident.
Which of the following is the next appropriate nursing
action regarding the incident?
1 Make a copy of the incident report for the physician
2 Place the incident report in the client's chart
3 Document a complete entry in the client's record
concerning the incident
4 Document in the client's record that an incident
report had been completed
A registered nurse( RN ) is observing a licensed
practical nurse ( LPN ) caring for a deceased client
whose eyes will be donated.
The RN intervenes if the LPN performs which action?
1 Elevates the head of the bed
2 Closes the client's eyes
3 Places wet saline gauze pads and an ice pack on the eyes
4 Closes the client's eyes and places a dry sterile dressing
over the eyes
1. A nurse is planning the client assignments for the shift. Which client would the nurse assign to the nursing assistant?
１ A client requiring dressing changes
2 A client requiring frequent ambulation
3 A client on a bowel management program requiring rectal suppositories and a daily enema
4 A client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures