1. While administering medications to a group of clients on a medical-surgical unit, a client who is postoperative from an accidental above-the-knee amputation indicates to the nurse that he is ready to talk about his feelings. The nurse keeps her promise and returns to talk with the client as soon...
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1. While administering medications to a group of clients on a medical-surgical unit, a client
who is postoperative from an accidental above-the-knee amputation indicates to the nurse
that he is ready to talk about his feelings. The nurse keeps her promise and returns to talk
with the client as soon as she finishes administering medications. Which of the following
ethical principles is the nurse demonstrating?
A. Veracity
B. Justice
C. Nonmalecence
D. Fidelity
2. A nurse has assigned client care activities to an assistive personnel (AP). Which of the following
statements by the AP indicates a need for assistance with time management?
A. "I will start working with the client in room 1, then work my way to room 10."
B. "I will give this client his meal tray first because he is going to physical therapy early."
C. "After breakfast, I will pack the belongings of clients who will be discharged this morning."
D. "I will start by providing partial baths before breakfast."
3. A nurse is updating the plan of care for a client who has a new diagnosis of hypertension and a
prescription for atenolol. Which of the following referrals should the nurse request from the provider
as the priority referral?
A. Dietitian
B. Physical therapist
C. Pharmacist
D. Social worker
4. A nurse on a pediatric unit is planning care for a group of clients. Which of the following clients
should the nurse plan to assess first?
A. A school-age child who has diabetes mellitus and requires blood glucose monitoring
B. An infant who has pertussis and is receiving oxygen via nasal cannula
C. An adolescent who is 1 day postoperative following an appendectomy
D. A toddler who is scheduled for an upper gastrointestinal X-ray series
,5. A nurse is caring for a client who has terminal lung cancer. The client's provider has recommended
hospice services for the client. Which of the following statements by the client should indicate to the
nurse that the client understands hospice care?
A. I will have to be admitted to a long-term care facility in order to receive hospice care."
B. "I should expect the hospice team to help me manage my difficulty breathing."
C. "Hospice care services are available to anyone who is terminally ill, regardless of life expectancy."
D. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care."
6. A nurse in a provider's office is reviewing the laboratory findings for a client who is receiving
chemotherapy. The client has a platelet count of 60,000/mm3. Which of the following actions should
the nurse take first?
A. Provide the client with information about the treatment.
B. Discuss these findings with the provider.
C. Ask the client to return to the clinic for further laboratory tests.
D. Obtain a referral to a specialized provider.
7. A charge nurse is delegating tasks to nursing personnel on a ten-bed dementia care unit. Which of
the following assignments is an example of overdelegation?
A. Assigning two assistive personnel (AP) to ambulate each client on the unit
B. Assigning a newly licensed nurse to perform a wet-to-dry dressing change
C. Assigning one AP to feed each client on the unit
D. Assigning an experienced RN to perform a central line dressing change
8. A nurse on a medical-surgical unit is delegating care for a group of clients. Which of the following
specimens should the nurse delegate an unlicensed assistive personnel (UAP) to collect?
A. Wound drainage for culture
B. Urine from an indwelling catheter
C. Blood for an ABG test
D. Random stool specimen
9. A nurse accuses a newly licensed nurse of providing inadequate care for a client who underwent hip
arthroplasty. Which of the following responses by the newly licensed nurse demonstrates
assertiveness?
A. "I feel as though I met the standard of care. Would you tell me more about your concerns?"
B. "You shouldn't make accusations. Your nursing care doesn't always set a good example."
C. "I am sorry you are displeased. I always do my best to give good care to my clients."
D. "Yes, you might be right. I haven't had the best role models since I started this position.
, 10. A nurse is caring for a client who is participating in a research study for an experimental
chemotherapy medication. After three treatments, the experimental medication is discontinued due
to evidence of rapidly advancing kidney failure. The nurse should recognize that discontinuing this
medication demonstrates which of the following ethical principles?
A. Justice
B. Autonomy
C. Fidelity
D. Nonmalecence
11. A nurse on a quality assurance team is reviewing unit incident reports that were led within the last
six months. Which of the following incidents meets the criteria for a sentinel event?
A. A client who was postoperative from surgery reported a valuable piece of jewelry was stolen from his
room.
B. A client who was experiencing acute alcohol withdrawal hits a nurse, causing the nurse to fall to the
floor and break their wrist.
C. A client who was having an anaphylactic reaction was administered epinephrine 0.75 mg
intramuscularly. The client experienced a cardiac event and died.
D. An AP left a client on fall precautions unattended in the restroom, where the client fell and sustained a
scrape to the knee.
12. A nurse manager is reviewing the admission history of four adult clients. The nurse is required to
report which of the following situations to an outside agency?
A. An older adult client who is dependent on caregivers and was admitted for the treatment of burns on
the buttocks
B. A young adult client who was admitted for asthma and has track marks that might indicate IV
substance use
C. A young adult client who was admitted for acute glomerulonephritis following a viral infection
D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
13. A nurse is planning an in-service for nursing staff about managing care for clients who develop
disequilibrium syndrome. Which of the following interventions should the nurse include in the
teaching?
A. Administer an opioid medication.
B. Monitor for the development of chest pain.
C. Assess level of consciousness.
D. Start an intravenous infusion of dextrose 50%
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