1. A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating? A. Assign an assistive personnel to feed the client. This is incorrect because this is not promoting independence in eating as someone is feeding her rather than teaching herself to feed again with temporary vision out of one eye. B. Explain to the client that her tray is here and place her hands on it. This is incorrect because although letting the client know her tray has arrived and placing her hands on it is useful, it still is not promoting independence in food as the nurse isn’t explaining where each food item is on the tray when aiding food independence. C. Describe to the client the location of the food on the tray. This is correct because since the client cannot see their food, the nurse should describe each item on the tray starting with explaining the position and size to help them navigate their meal. D. Ask the client if she would prefer a liquid diet. This is incorrect because asking the client if she would prefer a liquid diet doesn’t promote independence in eating. 2. A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? A. A negative-pressure isolation room This is incorrect because this room is used for clients who have airborne infections such as TB or chickenpox and not scabies. It prevents the contaminated air from escaping and infecting other patients. B. A semi-private room with a client who has pediculosis capitis This is incorrect because it is not suitable for someone who has scabies. Pediculosis capitis is an infestation of head lice that can easily spread through direct contact or sharing personal items such as combs and hats. Sharing a room with another client who has this infection can increase the risk of cross infection and worsen both conditions of the patients. C. A positive-pressure isolation room This is incorrect because this room is not suitable for a client with scabies. A positive pressure room is used for clients who have compromised immune systems and are undergoing bone marrow transplants or chemo. D. A private room This is correct because a private room is suitable for a patient who has scabies. Scabies is a skin infection that can spread easily through direct skin to skin contact or sharing personal items such as clothing or bedding. A private room can help prevent the transmission of scabies to staff and other patients. 3. A nurse is caring for a client who is scheduled for surgery. The nurse’s role in regard to informed consent is which of the following? A. Ensuring the charge nurse is available to witness the client’s signature on the consent form This is incorrect because although a nurse should witness a client’s signature on the consent form is important, education should be informed about the procedure, complications etc. before the patient signs consent. B. Explaining the risks involved with the procedure This is incorrect because although explaining the risks with the procedure is important it doesn’t fully justify whether the client understands the procedure he is about to have performed. C. Discussing alternate treatment options This is incorrect because discussing alternate treatments isn’t the main priority for a client who is about to go into surgery as his main treatment. It also doesn’t assess patient education on the procedure. D. Determining the client’s level of understanding about the procedure This is correct because ensuring the patient is fully informed about the procedure, they are undergoing is important before obtaining their consent. 4. A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? A. Document the bruises in the client's chart. This is incorrect because although the nurse should document the bruises in the client chart, this is not the nurse’s priority when providing safety for the client. B. Report the findings to a supervisor. This is the correct answer because a nurse has a legal and ethical obligation to report any suspected abuse of a client. Reporting the findings is the first action a nurse should take to protect the patient and imitative further investigation. C. Provide the client with a crisis hotline number. This is incorrect because providing the client with a crisis number is not adequate when providing client safety. D. Discuss respite care with the client’s family. This is incorrect because the nurse discussing respite care with the client family is not priority when providing safety. 5. A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? A. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of < 2 seconds This is incorrect because the client has respiratory distress, however, is conscious and considered to be stable. It is urgent but doesn’t need immediate attention compared to the other critical conditions. B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds This is correct because the pt is unconscious with a sucking chest wound and a high respiratory rate which indicates severe respiratory comprise which needs immediate attention, so the client doesn’t plumet and get worse. C. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of < 2 seconds This is incorrect because the client has a dislocated shoulder which does need attention but is not considered to be life threatening. D. An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results. This is incorrect because although the client has no respirations, the patient has been attempted airway management and a potential need for CPR but it is not as life threatening. 6. A nurse is completing an admission assessment on an adolescent client who is a vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking in his diet? A. Peanut butter and jelly sandwich The following answer is correct because the patient is a vegetarian which ultimately lacks protein in his diet, considering he does not like beans this also condenses the options he has for protein rich foods. However, the peanut butter is a good source of protein as well as healthy fats, also delivering a good source of fiber to the meal as well as in the bread to aid in his diet. B. Baked potato topped with sour cream This is incorrect because baked although baked potatoes have a good carbs and the sour cream contains dairy as well as healthy fats this meal is lacking in protein which is an important factor for this adolescent. C. Bagel with cream cheese This is incorrect because peanut butter is a better source of protein and healthy fats for the patient compared to cream cheese. Cream cheese has other nutritional benefits however not that this patient needs. D. Fruit salad This answer is incorrect because fruit salad is an overall good snack and fruit can be very healthy and hydrating, however, is not sustainable and fulfilling. It also lacks major components such as protein, fats and carbs 7. A nurse notices that a patient has pain while the doctor palpated the patient's left costovertebral angle. ? Which of the following is the most likely diagnosis? A. Cholecystitis This is incorrect because it is a condition that causes the gallbladder to become inflamed, swollen and red. However, pain with this is normally experienced in the upper right side or middle of the abdomen and not on the costovertebral angle which is in the upper back. B. Pyelonephritis This is correct because it is characterized by an infection of the kidney and can be persistent with presenting with fever, flank pain and CVA tenderness located in the upper back. C. Appendicitis This is incorrect because appendicitis pain normally starts near the belly button and moves to the lower right side of the abdomen and not in the costovertebral angle located in the upper back. D. Small bowel obstruction. This is incorrect because the pain is normally felt in the upper abdomen and around the belly button and not in the upper back. 8. Following an open appendectomy a patient is unable to pass a bowel movement and has persistent nausea and vomiting. ?Which of the following should the nurse suspect as the most likely diagnosis. A. C. difficile??colitis This is incorrect because CDIFF is marked by diarrhea, fever, stomach pain, dehydration and is an uncommon sign after an appendectomy. B. Toxic megacolon This is incorrect because it the sign and symptoms are marked by abdominal pain, diarrhea, fever, rapid heart rate but is not marked by being unable to pass a bowel movement and nausea and vomiting. C. Intussusception This is incorrect because it is a condition that is marked by the blockage of intestines and is not common after an appendectomy. D. Ileus This is correct because following an appendectomy Ileus is a common complication after abdominal surgery which is marked by being unable to pass a bowel movement and nausea and vomiting. 9. A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? A. The client has a history of hypothyroidism. This is not the correct answer because hypothyroidism is characterized where the thyroid gland doesn’t produce enough thyroid hormones. Propranolol can interfere with the absorption and conversion of thyroid hormones. This finding is not a contraindication to the use of propranolol. B. The client has a history of bronchial asthma. This is the correct answer because bronchial asthma is a chronic inflammatory disorder of the airways causing wheezing, coughing and SOB. Propranolol is contraindicated in clients who have bronchial asthma and the nurse should report this finding. C. The client has a history of hypertension. This is not the correct answer because Hypertension is a condition in which the blood pressure is abnormally high around 140/90. Propranolol is a beta blocker which lowers blood pressure which is indicated for the treatment of hypertension and angina pectoris which the nurse doesn’t need to report because it is consistent with the prescription. D. The client has a history of migraine headaches. This is incorrect because migraine headaches are recurrent episodes of severe and throbbing pain. Propranolol is effective in preventing migraine headaches which the nurse doesn’t need to report this finding to the provider because it is consistent with the prescription. 10. A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client’s medical record? A. "There were no injuries sustained." This answer is incorrect because this might not collect all the relevant information pertaining to the fall. B. "An incident report was completed." This answer is correct because it is essential to document the incident when a client falls. Documenting the incident is standard procedure in healthcare facilities in order to record details pertaining to the fall. C. "An incident report was forwarded to risk management." This is incorrect because reporting the incident to risk management is considered to be a subsequent action however not it’s not the initial documentation that a nurse should report. D. "The provider was notified." This is incorrect because it is considered to be not a complete documentation of the incident. The documentation should include the fall, actions that were taken, and any follow up plans.