Question: The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage to the subcutaneous tissues has occurred. How would the nurse document this wound?
Answer Choices:
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Stage 4 pressure injury
Answer: C. Stage 3 pressure injury
Question: While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event?
Answer Choices:
A. Submerge the end of the chest tube in a container of sterile water
B. Clamp the tube near the end and also near the insertion point
C. Place the end of the tube on a sterile surface and seek help promptly
D. Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit
Answer: A. Submerge the end of the chest tube in a container of sterile water
Question: To promote health of the fetus, what instruction will the nurse provide a client in the first trimester of pregnancy?
Answer Choices:
A. Eliminate high-fiber foods
B. Eat foods high in folic acid
C. Consume saturated fats
D. Consume milk products when you reach the last trimester
Answer: B. Eat foods high in folic acid
Question: What is the route of administration for PN?
Answer Choices:
A. Oral
B. Subcutaneous
C. Intramuscular
D. Intravenous
Answer: D. Intravenous
Question: What role will the nurse play in transferring a client to a long-term care facility?
Answer Choices:
A. Provide a verbal report to the nurse at the long-term care facility on the client, the hospital care, and the client’s current status
B. Assure that the client’s original chart accompanies the client
C. Arrange for the client’s belongings to remain at the hospital until discharge from the long-term care facility
D. Inform the client that transferring should be a stress-free situation
Answer: A. Provide a verbal report to the nurse at the long-term care facility on the client, the hospital care, and the client’s current status
Question: The nurse is caring for a client admitted to home care after total knee replacement surgery. Which home health care goal for the client will be the nurse’s priority?
Answer Choices:
A. Help the client regain mobility and independence
B. Facilitate deep breathing exercises to prevent pneumonia
C. Minimize the risk of infection
D. Assist the client in achieving consistent bowel movements
Answer: C. Minimize the risk of infection
Question: What is the term used to describe a pharmaceutical agent that relieves pain?
Answer Choices:
A. Antacid
B. Antihistamine
C. Analgesic
D. Antibiotic
Answer: C. Analgesic
Question: The nurse is providing hygiene care to an older adult client diagnosed with Alzheimer disease and experiencing confusion, when the nurse is called to the nursing station. To ensure client safety the nurse must do what?
Answer Choices:
A. Ask a family member to stay with the older adult client
B. Cover the older adult client with a blanket for warmth
C. Reattach the restraints
D. Put side rails up before leaving the older adult client
Answer: D. Put side rails up before leaving the older adult client
Question: A nurse who provides care in a long-term care facility recognizes the need to promote health rather than solely treating illness. Which measures should the nurse encourage among the older adult resident population of the facility? Select all that apply.
Answer Choices:
A. Encourage frequent naps in order to ensure adequate sleep and rest
B. Encourage residents to take dietary supplements when safe
C. Conduct activities at a slower pace and allow residents time to respond
D. Encourage residents to engage in the present rather than perform reminiscence
E. Promote self-care and only assist residents when it is necessary
Answer: B. Encourage residents to take dietary supplements when safe; C. Conduct activities at a slower pace and allow residents time to respond; E. Promote self-care and only assist residents when it is necessary
Question: Which illness has been associated with long-term stress?
Answer Choices:
A. Bacterial infections
B. Cardiovascular disease
C. Renal disease
D. Fractures
Answer: B. Cardiovascular disease
Question: A 2-year-old child arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. What is the priority nursing intervention?
Answer Choices:
A. Giving the child a favorite stuffed animal to hold
B. Assessing respirations and administering oxygen
C. Raising the side rails and restraining the child’s arms
D. Asking the child’s parent about favorite foods
Answer: B. Assessing respirations and administering oxygen