A client arrives to the emergency department with a self inflected GSW. The
client tells the nurse he lost his job and does not want to live anymore. What
is the nurses priority action?
A. Assess client for injury
B. Obtain a social worker consult
C. Locate the clients family
D. Administer pain meds - ANSWER A
A nurse is caring for several clients on a medical unit. What order should the
nurse perform the follow action based on Maslow's Hierarchy of Needs?
A. Administer 2 liters of O2
B. Encourage family to visit
C. Encourage the client to reflect on hospital experience
D. Place call light within reach - ANSWER A. Administer 2 liters of O2
D. Place call light within reach
B. Encourage family to visit
C. Encourage the client to reflect on hospital experience
A RN is caring for a client who is recently returned from surgery for an
,appendetomy. The current VS are BP 92/65, HR 110, RR 28, Temp 98..8. What
is the nurse's priority intervention?
A. Continue to monitor the client
B. Retake the VS in 1 hr
C. Notify the healthcare provider
D. Turn the client - ANSWER C.
Rank the following in order of Maslow's Hierarchy of Needs:
1. I am having a difficult time breathing (physio)
2. I am scared, i do not have a safe place to stay (safety)
3. I divorced my husband 3 months ago and I am lonely (love and belonging)
4. I am feeling great bc I made an A on my last exam (self esteem)
5. I am proud to be a nurse (self actualization) - ANSWER
A RN is caring for a client that is one day post op total hip replacement. The
client complains of SOB, dizziness, pain 10/10. Which interventions should
the RN implement first?
A. Administer pain meds
B. Obtain vitals
C. Notify healthcare provider
D. Ambulate the client - ANSWER B
The nurse is preparing to teach a client how to use crutches. What is the
nurses priority assessment related to teaching this topic?
,A. Clients feelings abt restricted mobility
B. Clients fear related to crutches
C. Clients muscle strength and previous activity
D. The clients understanding of needs for increased mobility - ANSWER C
A nurse is caring for a pt who needs to use the bathroom. The client can
ambulate w/o assistance. What is the priority action for the nurse?
A. Ensure the client has nonskid foot wear
B. Place the client on fall precautions
C. Instruct the client on how to use a walker
D. Instruct the client on how to use a bedside commode - ANSWER A
A nurse is caring for several clients. What client should the nurse assess first?
A. A client w a pain level 10/10
B. Client with an acute mental status change
C. A client that needs discharge instructions
D. A client that needs insulin before eating breakfast - ANSWER B
A nurse is preparing to administer medication to a newly admitted client. The
nurse notes the client has a difficulty swallowing. What is the nurses most
appropriate response?
A. Hold med and notify healthcare provider
B. Reschedule the med to a later time
C. Crush med and administer w apple sauce
, D. Consult the pharmacist to change the route of meds - ANSWER A
A nurse is preparing to administer meds to a newly admitted client. The client
states, "I am 6 weeks pregnant." What is the nurses most appropriate
response?
A. Administer the med as prescribed
B. Review the clients EHR
C. Request a pregnancy test
D. Hold the med and notify the healthcare provider - ANSWER D
A nurse is preparing to administer meds to a newly admitted client. The client
has an unsteady gait - ANSWER
The nurse is caring for 5 clients. What client should the nurse see first?
A client who is confused and crawling out of bed
B. A client who is crying about a new cancer diagnosis
C. A client that urgently needs an emesis basic to vomit
D. A client that require discharge teaching
E. A client with a temp of 101.1 and is shaking - ANSWER A client who is
confused and crawling out of bed
A client is admitted to the hospital with SOB and receiving O2 by NC. During
the bath, the client reports feeling tired and an increase level of SOB. What
actions should the nurse implement?
A. Continue w bath as planned
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