Board Exam Nursing Test I NLE Quiz

1. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?

An elderly woman complaining of a loss of appetite and fatigue for the past week

A football player limping and complaining of pain and swelling in the right ankle

A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw

A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon

These are likely signs of an acute myocardial infarction (MI). An acute MI is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately.

Explanation

These are likely signs of an acute myocardial infarction (MI). An acute MI is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately.

2. A newly hired nurse on an adult medicine unit with 3 months of experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receives an interesting assignment that feels overwhelming. The nurse should:

Resign on the spot from the nursing position and apply for a position that does not require floating

Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment

Refuse the assignment and leave the unit requesting a vacation a day

The nurse is ethically obligated to inform the person responsible for the assignment and the person responsible for the unit about the nurse’s skill level. The nurse therefore avoids a situation of abandoningclients and exposing them to greater risks

Explanation

The nurse is ethically obligated to inform the person responsible for the assignment and the person responsible for the unit about the nurse’s skill level. The nurse therefore avoids a situation of abandoningclients and exposing them to greater risks

3. A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?

Take no action because it is the family member saying that to the client

Talk to the family member and explain that what she/he has said is not appropriate for the client

Give the family member the number for an Elder Abuse Hot line

Document what the family member has said

This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.

Explanation

This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.

4. Which is true about informed consent?

A nurse may accept responsibility signing a consent form if the client is unable

Obtaining consent is not the responsibility of the physician

The nurse who witness a consent for treatment or surgery is witnessing only that the client signed the form and that the client’s condition is as indicated at the time of signing. The nurse is not witnessing that the client is “informed”.

Explanation

The nurse who witness a consent for treatment or surgery is witnessing only that the client signed the form and that the client’s condition is as indicated at the time of signing. The nurse is not witnessing that the client is “informed”.

5. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?

Tell them it is not appropriate to discuss the condition of the client

Ignore them, because it is their right to discuss anything they want to

Join in the conversation, giving them supportive input about the case of the client

Report this incident to the nursing supervisor

The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated

Explanation

The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated

6. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means:

The patient releases the physician from all responsibility for the procedure.

The immediate family may make decision against the patient’s will.

It best explains what informed consent is and provides for legal rights of the patient

Explanation

It best explains what informed consent is and provides for legal rights of the patient

7. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included?

“Get a weekly WBC count”

“Do not share a bathroom with children or pregnant woman”

“Avoid contact with others while receiving chemotherapy”

“Do frequent hand washing and maintain good hygiene”

Frequent hand washing and good hygiene are the best means of preventing infection.

Explanation

Frequent hand washing and good hygiene are the best means of preventing infection.

8. A staff nurse has had a serious issue with her colleague. In this situation, it is best to:

Discuss this with the supervisor

Not discuss the issue with anyone. It will probably resolve itself

Try to discuss with the colleague about the issue and resolve it when both are calmer

Tell other members of the network what the team member did

Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.

Explanation

Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.

9. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:

Mentor

Team leader

Case manager

Change agent

This describes a mentor

Explanation

This describes a mentor

10. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:

Normal Saline

Heparinized normal saline

5% dextrose in water

Lactated Ringer’s solution

Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.

Explanation

Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.

11. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?

Aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning

Removing oral and nasal secretions

Encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions

Administering 100% oxygen to reduce the effects of airway obstruction during suctioning.

Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing hypoxemia which occurs when the flow of gases in the airway is obstructed by the suctioning catheter.

Explanation

Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing hypoxemia which occurs when the flow of gases in the airway is obstructed by the suctioning catheter.

12. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:

Get a court order making the baby a ward of the court

Do nothing except record the mother’s statement in the medical record

Although the statements by the mother may not create a suspicion of neglect, when they are coupled with observations about impaired bonding and maternal attachment, they may impose the obligation to report child neglect. The nurse is further obligated to notify caregivers of refusal to consent to treatment

Explanation

Although the statements by the mother may not create a suspicion of neglect, when they are coupled with observations about impaired bonding and maternal attachment, they may impose the obligation to report child neglect. The nurse is further obligated to notify caregivers of refusal to consent to treatment

13. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas?

Elbow restraints to the arms

Mittens to the hands

Clove-hitch restraints to the hands

A posey jacket to the torso

The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens restraint would prevent scratching, while allowing the most movement permissible.

Explanation

The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens restraint would prevent scratching, while allowing the most movement permissible.

14. A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?

Eat solid food

Give liquids with meals

Feed the client

Sit in an upright position to eat

Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.

Explanation

Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.

15. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is:

Pruritus

Pus in the urine

WBC in the urine

Dysuria

Pus is usually the first symptom, because the bacteria reproduce in the bladder.

Explanation

Pus is usually the first symptom, because the bacteria reproduce in the bladder.

16. The nurse in the medication unit passes the medications to all the clients in the nursing unit. The head nurse makes rounds with the physician and coordinates clients' activities with other departments. The nurse assistant changes the bed lines, and answers call lights. A second nurse is assigned to change wound dressings; a licensed practitioner nurse takes vital signs and bathes the clients. This illustrates what method of nursing care?

Case management method

Primary nursing method

Team method

Functional method

It describes functional nursing. Staff is assigned to specific tasks rather than specific clients.

Explanation

It describes functional nursing. Staff is assigned to specific tasks rather than specific clients.

17. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern?

Picture windows

Unwashed dishes in the sink

Clear and shiny floors

Brightly lit rooms

It is a safety hazard to have shiny floors because they can cause falls.

Explanation

It is a safety hazard to have shiny floors because they can cause falls.

18. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to:

Provide care to the most acutely ill client on the team

Know the condition and needs of all the patients on the team

Document the assessments completed by the team members

Supervise direct care by nursing assistants

The team leader is responsible for the overall management of all clients and staff on the team, and this information is essential in order to accomplish this

Explanation

The team leader is responsible for the overall management of all clients and staff on the team, and this information is essential in order to accomplish this

19. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?

“abnormally felt area in the right breast, drainage noted”

“hard nodular mass in right breast nipple”

“firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’

“mass in the right breast 4cmx1cm

It describes the mass in the greatest detail.

Explanation

It describes the mass in the greatest detail.

20. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?

Call a family meeting

Discuss the religious beliefs with the physician

Encourage the client to have the surgery

Inform the client of other options

The physician may not be aware of the role that religious beliefs play in making a decision about surgery.

Explanation

The physician may not be aware of the role that religious beliefs play in making a decision about surgery.

21. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?

Warm, flushed skin

Hunger and thirst

Increase urinary output

Palpitation and weakness

here has been too little food or too much insulin. Glucose levels can be markedly decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected

Explanation

here has been too little food or too much insulin. Glucose levels can be markedly decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected

22. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:

There is no way to determine this preoperatively

Their baby was born with this condition

Their baby developed this condition during the first few weeks of life

Their baby acquired it due to a formula allergy

Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.

Explanation

Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.

23. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?

Examine the infant for any observable abnormalities

Confirm identification of the infant and apply bracelet to mother and infant

Instill prophylactic medication in the infant’s eyes

Wrap the infant in a prewarmed blanket and cover the head

The first priority, beside maintaining a newborn’s patent airway, is body temperature.

Explanation

The first priority, beside maintaining a newborn’s patent airway, is body temperature.

24. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following tasks could the registered nurse safely assign to a UAP?

Monitor the I&O of a comatose toddler client with salicylate poisoning

Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall

Check the IV of a preschooler with Kawasaki disease

Give an oatmeal bath to an infant with eczema.

Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can be competently performed by an aide.

Explanation

Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can be competently performed by an aide.

25. The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother?

“You and I need to review your rationale for this decision”

“Your baby will not be able to attend day care without immunizations”

“Your decision can be viewed as a form of child abuse and neglect”

“You are needlessly placing other people at risk for communicable diseases”

The mother may have many reasons for such a decision. It is the nurse’s responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist.

Explanation

The mother may have many reasons for such a decision. It is the nurse’s responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist.

26. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by:

The Physician

The Registered Nurse caring for the client

The 15-year-old mother of the baby boy

The mother of the girl

Even though the mother is a minor, she is legally able to sign consent for her own child.

Explanation

Even though the mother is a minor, she is legally able to sign consent for her own child.

27. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer?

Tender, movable lump

Pain on breast self-examination

Round, well-defined lump

Dimpling of the breast tissue

The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.

Explanation

The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.

28. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?

Call the surgeon

Ask the spouse to sign the consent

Obtain a consent from the client as soon as possible

Get a verbal consent from the parents of the client

The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.

Explanation

The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.

29. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:

Outline the kidney vasculature

Determine the size, shape, and placement of the kidneys

Test renal tubular function and the patency of the urinary tract

Measure renal blood flow

Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium.

Explanation

Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium.

30. Which of the following would be the most important goal in the nursing care of an infant client with eczema?

Preventing infection

Maintaining the comfort level

Providing for adequate nutrition

Decreasing the itching

Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.

Explanation

Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.

31. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?

Administering insulin-replacement therapy

Providing a low-sodium diet

Restricting fluids to 1500 ml/day

Reducing physical and emotional stress

Because the client’s ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial.

Explanation

Because the client’s ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial.

32. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?

“Your baby eats too rapidly and overfills the stomach, which causes vomiting

“Your baby can’t empty the formula that is in the stomach into the bowel”

“The vomiting is due to the nausea that accompanies pyloric stenosis”

“Your baby needs to be burped more thoroughly after feeding”

Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter.

Explanation

Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter.

33. The nurse in charge of the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse?

A child who had multiple injuries from a serious vehicle accident

A child diagnosed with Kawasaki disease and with cardiac complications

A child who has had a nephrectomy for Wilm’s tumor

A child receiving an IV chelating therapy for lead poisoning

RN floated from the obstetrics unit should be able to care for a client with major abdominal surgery, because this nurse has experienced caring for clients with cesarean births.

Explanation

RN floated from the obstetrics unit should be able to care for a client with major abdominal surgery, because this nurse has experienced caring for clients with cesarean births.

34. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:

The nurse discusses the condition of the client in a clinical conference with other nurses

The client asks the nurse to discuss the her condition with the family

A researcher from an institutionally approved research study reviews the medical record of a patient

The nurse has no idea who the person is on the phone and therefore may not share the information even if the patient gives permission

Explanation

The nurse has no idea who the person is on the phone and therefore may not share the information even if the patient gives permission

35. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this?

Reactivation of an old tuberculosis infection

Increased incidence of new cases of tuberculosis in persons over 65 years old

Greater exposure to diverse health care workers

Respiratory problems are characteristic in this population

Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly.

Explanation

Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly.

36. The registered nurse is planning to delegate tasks to a certified nursing assistant. Which of the following clients should not be assigned to a CNA?

A client diagnosed with diabetes and who has an infected toe

A client who had a CVA in the past two months

A client with Chronic renal failure

A client with chronic venous insufficiency

The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN

Explanation

The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN

37. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?

Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow

Low Fowler’s with knees gatched at 30 degrees

Supine with the head turned to the left

Bed sloped at a 45 degree angle with the head lowest and the legs highest

This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion

Explanation

This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion

38. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?

Limit suction pressure to 150-180 mmHg

Suction for 15-20 seconds

Wear eye goggles

Remove the inner cannula

It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions

Explanation

It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions

39. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?

Check the laboratory data for serum albumin, hematocrit, and hemoglobin

Talk to the client about the caregiver and support system

Complete a police report on elder abuse

Complete a gastrointestinal and neurological assessment

Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent falls, vertigo or medication.

Explanation

Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent falls, vertigo or medication.

40. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk?

“I do not get along with one of the nurses on the pediatrics unit”

“I have a vacation day coming and would like to take that now”

“I do not feel competent to go and work on that area”

“ I am afraid I will get the most serious clients in the unit”

This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.

Explanation

This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.

41. A client visits the clinic for screening of scoliosis. The nurse should ask the client to:

Bend all the way over and touch the toes

Stand up as straight and tall as possible

Bend over at a 90-degree angle from the waist

Bend over at a 45-degree angle from the waist

This is the recommended position for screening for scoliosis. It allows the nurse to inspect the alignment of the spine, as well as to compare both shoulders and both hips.

Explanation

This is the recommended position for screening for scoliosis. It allows the nurse to inspect the alignment of the spine, as well as to compare both shoulders and both hips.

42. A nurse manager assigned a registered nurse from the telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse?

A 4-year-old with VSD following cardiac catheterization

A 5-month-old with Kawasaki disease

A 9-year-old child diagnosed with rheumatic fever

A young infant after pyloromyotomy

The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen.

Explanation

The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen.

43. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding?

Facial edema with ecchymosis and handprint mark: crackles and wheezes

Facial edema, with red marks; crackles in the lung

Facial edema with ecchymosis that looks like a handprint

Red bruise mark and ecchymosis on face

This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.

Explanation

This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.

44. The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?

Assess the level of consciousness and circulation

Check respirations, circulation, neurological response

Align the spine, check pupils, check for hemorrhage

Check respiration, stabilize spine, check circulation

Checking the airway would be a priority, and a neck injury should be suspected

Explanation

Checking the airway would be a priority, and a neck injury should be suspected

45. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?

Chart that the patient fell

Call the physician

Chart that the client was found on the floor next to the bed

Fill out an incident report

This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.

Explanation

This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.

46. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:

The adult visiting, “The child’s name is ____________________?”

The child, “Is your name____________?”

Another staff nurse to identify this child

The other children in the room what the child’s name is

The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.

Explanation

The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.

47. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:

Wash their hands when leaving

Put on gowns, gloves and masks

Avoid contact with the client’s roommate

Keep the client’s room door open

Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.

Explanation

Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.

48. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care, such as formulating the care plan, and intervention, and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. What kind of method does this nursing care illustrate?

Primary nursing method

Case method

Team method

Functional method

Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.

Explanation

Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.

49. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure:

Both the areas that look red and feel raised