IDEAL PROFESSIONAL INSTITUTE NURSING EXAM PART 1

IDEAL PROFESSIONAL INSTITUTE NURSING EXAM PART 1 1. The nurse is teaching a client about self-examination. The client asks the nurse where masses are most often found. Which response(s) by the nurse are most appropriate? Select all that apply. A. In the axlla B. Beneath the nipple C. Lower inner quadrant D. Upper outer quadrant E. Lower outer quadrant 2. The nurse is assessing a client with herpes zoster. Which characteristic(s) does not the nurse expect to note when assessing the lesions of this infection? Select all that apply. A. Clustered skin vesicles B. A generalized body rash C. Small blue-white spots with a red base D. A fiery red edematous rash on the cheeks E. Grouped vesicles on an erythematous base. 3. A client is scheduled for a craniotomy to remove a brain tumor. To prevent the development of cerebral edema after surgery, the nurse anticipates the use of: A. Steroids B. Diuretics C. Anticonvulsants D. Antihypertensive 4. A nurse driving along the scene of an accident and stops to assist with a deep laceration his hand, a fractured arm and leg, and abdominal pain. The nurse wraps the man’s hand in asoiled cloth and drives him to the nearest hospital. The nurse is: A. Practicing her skills as a nurse B. Negligent and can be sued for malpractice C. Practicing under guidelines of the Nurse Practice Act. D. Protected for these actions, in most states, by Good Samaritan legislation 5. A visitor in the room adjacent to a client asks the nurse what disease the client has. The nurse responds, “I will not discuss my client’s illness. Are you worried about it?” Tis response is based on the nurse’s knowledge that to discuss a client’s condition with someone not directly involved with the client is an example of: A. Negligence B. Breach of confidentiality C. Libel D. Defamation of character 6. When approaching homosexual clients with acquired immunodefiency syndrome (AIDS), it is most important for nurses to: A. Establish a meaningful rapport with clients B. Having strong sense of their own sexual identity C. Admit their own feelings or discomfort towards them D. Become aware of their own attitude towards homosexuality 7.The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for: A. Constipation B. Hyperphosphatemia C. Hypomagnesaemia D. Diarrhea 8. Heparin has been ordered for a client with pulmonary embolis. Which of the following statement. Made by the graduate nurse, indicated a lack of knowledge regarding the medication A. “I will administer the medication 1-2 inches away from the umbilicus.” B. “I will administer the medication in the abdomen area.” C. “I will check the PTT before administering the medication.” D. “I will need to aspirate when I give the Heparin.” 9. The nurse is preparing a client with an axillo-politeal bypass for discharge. The client should be taught to avoid: A. Using a recliner to rest. B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim’s position 10. The nurse has just receive the shift report and is preparing to make rounds. Which client should be seen first? A. The client with a history of a cerebral aneurysm with oxygen saturation rate of 99% B. The client three days post-coronary artery bypass graft with temperature of 100.3 degree F. C. The client admitted 1 hour ago with shortness of breath. D. The client being prepared for discharge following a femoral politeal bypass graft 11. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would indicate further teaching in required? A. “I will have my blood drawn every month.” B. “I will assess my skin for a rash.” C. “I will take aspiring for my headache.” D. “I will use an electric razor to shave.” 12. If an interpreter is not available when a patient speaks a language different from the nurse’s language, it is appropriate for the nurse to A. Use specific medical terms in the latin form. B. Talk slowly so that each word is clearly heard. C. Repeat important words so that the patient recognize their importance D. Use simple gestures to demonstrate meaning while talking to the patient. 13. which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient (Select all that apply)? A. Assess for bradycardia B. Ask about epihastric pain C. Observe for increased appetite D. Check for elevated blood glucose levels E. Monitor for a decrease in respiratory rate 14. A patient who has fibromyalgia tells the nurse, “My life feels very chaotic and out of my control will not be able to manage if anything else happens.” Which response shpuld the nurse make initially? A. “Regular massages may help reduce muscle pain.” B. “Guided imagery can be helpful in regaining control.” C. “Tell me more about how your life has been recently.” D. “Your previous coping mechanisms can help you now.” 15. The health care provider plans to titrate a patient-controlled analgesia (PCA. Machine to provide pain relief for a patient with acute surgical pain who has never received opoids in the past. Which of the following nursing actions regarding opoid administration are appropriate at this time(select all that apply)? A. Assessing for signs that the patient is becoming addicted to the opiod B. Monitoring for therapeutic and adverse effects of opiod administration C. Emphasizing that the risk of some opiod side effects increases over time D. Educating the patient about how analgesics improve postoperative activity levels. E. Teaching about the need to decrease opiod doses by the second postoperative day 16. A terminally ill patient is admitted to the hospital. Which action should the nurse include in the initial plan of care? A. Determine the patient’s wishes regarding end of life care B. Emphasize the importance of addressing any families issues C. Discuss the normal grief process with the patient and family D. Encourage the patient to talk about any fears or unresolved issues. 17. A patient’s temperature has been 101 F. (38.3 C. for several days. The patient’s normal caloric intake to meet nutritional needs is about 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree about 100 degrees in body temperature, calculate the total calories the patient should receive each day__________ 18. On the examination the following will ask to put in order: A patient who has an infected abdominal wound develops a temperature of 104 degree F. ( 40 C. All the following interventions are included in the patient’s plan of care. In which order should the nurse perform the following actions? A. Sponge patient with water B. Administer intravenous antibiotics C. Perform wet to dry dressing change. D. Administer acetaminophen (Tylenol) 19. The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? A. The patient’s radial pulse is 105 beats/minute B. There is sediment and blood in the patient’s urine C. The blood pressure increases from 120/80 to 142/94 D. There are crackles audible throughout both lung fields 20. The following data are prohibited by the nurse when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding Is most important to report to the health care provider immediately? A. The bibasilar breath sounds are decreased. B. The patellar and triceps reflexes are absent C. The patient has been sleeping most of the day. D. The patient reports feeling “sick to my stomach.” 21. A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which laborarotory values will require the most immediate action by the nurse? A. Arterial blood pH is 7.32. B. Serum calcium is 18 mEq/L. C. Serum potassium is 5.1 mEq/L D. Arterial oxygen saturation is 91% 22. A home care nurse is preparing to visit a client with a diagnosis of Meniere’s disease. The nurse review’s the physician’s orders and expects to note that which of the following dietary measures will be prescribed? A. Low fiber diet with decreased fluids B. Low sodium diet and fluid restriction C. Low carbohydrate diet and elimination of red meats D. Low fat with restriction of citrus fruits 23. A nurse is assigned to care for a client who has just undergone eye surgery. The nurse plans to instruct the client that which of the following activities Is permitted in the postoperative period? A. Reading B. Watching television C. Bending over D. Lifting objects 24. A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the clients? A. Wound healing usually takes 12 weeks B. Expected the vision will be permanently impaired C. A shield or eye patch should be worn to protect the eye D. The structures are removed after 1 week 25. When the nurse prepares the client or the myringotomy , the best explanation as to the purpose for the procedures is that it will: A. Prevent permanent hearing loss B. Provide a pathway for drainage C. Aid in administering medications D. Maintain motion of the ear bones 26. A nurse is reviewing the record of the client with a disorder involving the inner ear. Which of the following would the nurse expect to see documented as an assessment finding in this client? A. Severe hearing loss B. Complaints of severe pain in the affected ear C. Complaints of burning in the ear D. Complaints of tinnitus 27. The nurse cares for a toddler diagnosed with pneumonia caused by Haemophilusinfluenzae. The nurse should follow which of the following transmission based precautions? A. Standard precautions B. Airborne precautions C. Droplet precautions D. Contact precautions 28. The nurse expects the emotional responses of a client with a cerebral vascular accident (CVA. Of the left hemisphere to be MOST influenced by which of the following? A. The client’s ability to understand the illness and treatment B. The client’s perception of the care received during his illness C. The client’s personality and general health prior to the CVA D. The type of lesion that caused the CVA 29. The nurse that which of the following clients are at risk to develop pneumonia? Select all that apply. A. A 16 year old male who has experimented with cigarettes B. A 25 year old female diagnosed with cystic fibrosis C. A 36 year old male diagnosed with Addison’s disease D. A 47 old male diagnosed with hypertension E. A 68 year old with a fracture rib due to an auto accident F. A 79 year old female in Buck’s traction due to a fractured hip. 30. Health teaching for Barbara includes ensuring that she understands that A. Proper prophylactic medication can control the incidences of seizures B. Moderate use of alcohol is permitted C. Forcing fluids helps to reduce the incidence of seizures D. The incidence of seizures is related to hyperglycemia 31. to prepare Barbara for EEG, the nurse should explain that A. During the test she will experience small electrical shocks that feel like pin pricks B. The test measures mental status as well as electrical brain waves C. During the hyperventilation portion of the test, she may experience dizziness D. She will be unconscious during the test 32.Situstion: Barbara is a 23 year old woman who lives with her mother, sister and brother in a private residence. She is attending the neurological out-patient clinic for the first name. her health history includes two grand mal seizures/A diagnosis of idiopathic epilepsy has been made. The physician has ordered an electroencephalogram (EEG) and phenytoin sodium (Dilantin), 300 mg/day. While doing a nursing history on Barbara, the nurse should recognize that A. Persons with idiopathic epilepsy have a lower intelligence level B. Grand mal seizures do not cause mental deterioration C. A common characteristics of idiopathic epilepsy is committing acts of violence D. Idiopathic epilepsy is a form of mental illness 33. A client has been hospitalized after an automobile accident. A full leg cast applied while inside the emergency room. The most important reason for the nurse to elevate the casted leg is to: A. Reduce the drying time B. Decrease irritation to the skin C. Improve venous return D. Promote the client’s comfort 34. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A. Clean the meatus, begin vomiting, and then catch the urine stream B. Void a little, clean the meatus, then collect specimen C. Clean the meatus, then urinate into container D. Void continuously and catch some of the urine. 35 The client is admitted to the telemetry unit diagnosed wit acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing the client? A. Apical pulse rate of 110 and 4 + pitting edema of feet B. Thick white sputum and crackles that clear with cough C. The client sleeping with no pillow and eupnea D. Radial pulse rate of 90 and capillary refill time less than 3 seconds 36. The nurse is assessing the client with congestive heart failure. Which signs and symptoms would indicate that the medical treatment has been effective? A. The client’s peripheral pitting edema has globe from 3+ to 4+ B. The client is able to take the radial pulse accurately C. The client is able to perform activities of daily living without dyspnea D. The client has minimal jugular vein distention 37. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of “decreased cardiac output related to inability of the heart to pimp effectively” is written. Which short-term goal would be best for the client? The client will: A. Be able to ambulate in the hall by date of discharge B. Have an audible S1 and S2 with no S3 heard be end of shift C. Turn, cough, and deep breather every two (2) hours D. Have a pulse oximeter reading of 98% by say two (2) of care 38. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which intervention should be included in the plan? Select all that apply. A. Notify health care provider of more than 1 pound a week B. Teach client how to count the radial pulse when taking dixogin, a cardiac glycoside C. Instruct client to remove the saltshaker from the dinner table D. Encourage client to monitor urine output for change in color to become dark E. Discuss the importance of taking the loop diuretic Furosemide at bedtime 39. The nurse Is caring diagnosed with myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? A. Administer morphine via IV B. Administer an aspirin orally C. Apply oxygen via nasal cannula D. Place the client in a supine position E. Administer nitroglycerin subcutaneously 40. which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. A. Encourage a low-fat, low-cholesterol diet B. Instruct client to walk 30 minutes a day C. Decrease the salt intake to 2 grams a day D. Refer to counselor for stress reduction techniques E. Increase fiber in the diet 41.Which signs and symptoms should the nurse assess in any client who has a long term valvular heart disease? Select all that apply. A. Paroxysmal nocturnal dyspnea B. Orthopnea C. Cough D. Pericardial friction rub E. Pulsusparadous 42. The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. A. Start cardiopulmonary resuscitation B. Prepare to administer the antidyrhtymic adenosine IVP C. Prepare to defibrillate the client D. Bring the crash cart to the bedside E. Prepare to administer the antidysrhythmicamiodacrone IVP 43. The health care provider orders a medication in a dose that us considered toxic. The nurse administers the medication to the client, who later suffers cardiac arrest and dies. What consequence can the nurse expect from this situation? Select all that apply. A. The health care provider can be charged with negligence, being the person who ordered the dose B. As the employing agency, only the hospital can be charged with negligence C. The nurse and physician may be terminated from employment to prevent a charge of negligence to the hospital; D. Negligence will not be charged, as this event could happen to any reasonable person E. The nurse can be charged with negligence for administering the toxic dose 45. Which action would the nurse take to maintain medical asepsis when caring for a client with diabetes mellitus on the medical nursing unit who requires irrigation of a leg ulcer and insulin injections? Select all that apply. A. Wash hands before and after client care. B. Wear personal protective equipment during the dressing change C. Recap a needle after administering insulin D. Change the dressing for a diabetic ulcer using sterile globes E. Wipe the rubber stopper on the insulin vial before withdrawing dose 46. Following a liver transplant the client is taking prednisone and other medications to prevent organ rejection. The nurse should instruct the client to make priority to report which manifestation to the heath care provider? A. Moon face B. Diminished pigmentation C. Dysphasia D. bleeding 47. Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study? A. Date of admission B. Length of stay C. Age of patients D. Absence of complications 48. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation? A. Martha Rogers B. Sr. Callista Roy C. Florence Nightingale D. Jean Watson 49. He opts to use a self-report method. Which of the following is NOT TRUE about this method? A. Most direct means of gathering information B. Versatile in terms of content coverage C. Most accurate and valid method of data gathering D. Yields information that would be difficult to gather by anther method 50. Which of the following articles would Kevin least consider for his review of literature? A. “Story-Telling and Anxiety Reduction Among Pediatric Patients.” B. “Turnaround Time in Emergency Rooms.” C. “Outcome Standards in Tertiary Health care Institutions.” D. “Environment Manipulation and Client Outcomes.” 51. Which of the following variables will he likely EXCLUDE in his study? A. Competence of nurses B. Caring attitude of nurses C. Salary of nurses D. Responsiveness of staff 52. He plans to use a Likert Scale to determine A. Degree of agreement and disagreement B. Compliance to expected standards C. Level of satisfaction D. Degree of acceptance 53. A patient in the ICU is status post embolectomy after a pulmonary embolus. What does the nurse measure on a patient who is postoperative from an embolectomy? A. Left atrial pressure B. Pressure in the vena cava C. Pulmonary venous pressure D. Pulmonary arterial pressure 54. A 52 year old mother of three has just been diagnosed with lung cancer. The physician discusses treatment options and makes recommendations to this patient. After the physical leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse’s best response? A. “The type of treatment depends on the patient’s age and health status.” B. “The type of treatment depends on what the patient wants when given the options.” C. “The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient’s heath status.” D. “The type of treatment depends on the discussion between the patient and the physician of which treatment is best.” 55. Chest trauma to at least one of the several pathologic states; what are they? Select all that apply. A. Hypovolemia B. Cardiac failure C. Pulmonary embolus D. Hypoxemia E. Aortic rupture 56.The occupational heath nurse is assessing new employee at her company. What would be important to assess in employee with a potential occupational respiratory history? (Mark all that apply.) A. Time frame of exposure B. Effectiveness of respiratory protection used C. General hygiene D. Outside interests E. Other areas lived 57. The home care nurse is planning to begin retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing restraining is especially indicated in patients with which diagnosis? A. Emphysema B. Chronic bronchitis C. Lung cancer D. COPD 58. You are caring for a client who is scheduled for a PTCA this evening. The patient asks you what complications can happen during the procedure. What should the nurse answer? A. “Complications that can occur during a PTCA include dissection of the ductusarteriosa.” B. “Complications that can occur during a PTCA include hyposensivity of the heart muscle.” C. “Complications that can occur during a PTCA include vasospasm of the coronary artery.” D. “Complications that can occur during a PTCA include closure of the pulmonary artery.” 59. You are caring for a patient who has developed pulmonary edema. What is a priority nursing action? A. Lay the patient flat B. Notify the family of patient’s critical state C. Stay with the patient D. Call the physician 60. A patient presents to the emergency department complaining of severe headaches, nosebleeds, and anxiety. What might the nurse suspect is the protein with this patient? A. Hypertensive emergency B. Hypertensive crisis C. Hypertension D. Hypertensive urgency 61. A nurse is teaching a female client newly diagnosed with Helicobacter pylori infection. The nurse anticipated that which medication will not be used learning the client is pregnant? A. Metronizadole B. Amoxicillin C. Clarithromycin D. Ciprofloxacin 62. A 3 month old infant is diagnosed with leukemia. Which of the following does the nurse anticipate ill part of the plan of care for this infant? A. The baby will be placed in isolation B. Leukemia is familial and other children should be assessed C. Immunizations will be withheld during exacerbations D. The baby will be NPO during chemotherapy 63. The registered nurse is assigned to the postpartum unit. Which task could the RN safely delegate to a beginning student nurse? A. Ambulate a client who delivered cesarean 2 days ago B. Complete the admission assessment on a newly delivered client C. Call the physician to report a low hemoglobin level D. Verify a unit of blood prior to transfusion 64. A client with cancer has a calcium level of 11.8mg/dL. Which symptom would indicate a need for the nurse to call the physician for treatment orders? A. Increased gastric motility B. Peaked T waves on 12 lead ECG C. Muscle spasms D. Muscle weakness 65. A patient presents to the emergency department complaining of severe headaches, and anxiety. What might the nurse suspect s the problem with this patient? A. Hypertensive emergency B. Hypertensive crisis C. Hypertension D. Hypertensive urgency 66. The nurse is assessing the chart of a client with a stroke. MRI results reveal a hemorrhage stroke to the brain. Which physician prescription would the nurse ? A. Normal saline IV at 50mL/hr B. 02 at 3L/min by nasal cannula C. Heparin infusion per pharmacist protocol D. Insert a Foley catheter 67. The nurse is assessing an ECG strip for a 42 year old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds , and a p:QRS ration 1:1. What is the nurse’s interpretation of this rhythm? A. Premature atrial complex B. Sinus tachycardia C. Atrial flutter D. Supravetricular tachycardia 68. The client who’s a member of Jehovah’s Witness refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle? A. The right to die B. Advance directive C. Autonomy of the client D. Substituted judgment 69. Which statement by a student nurse demonstrates that further instruction about cyotoxic drugs is a needed? A. “Cytotoxic parenteral infusion containers should be marked with a special hazard labels.” B. “infusion set administration connections should be tight.” C. “Nurses who are pregnant must wear gloves during administration of cyotoxic drug.” D. “The infusion line should be primed into a gauze inside a sealable plastic bag.” 70. A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client’s room. The client becomes very agitated and declares, “The aliens have arrived!” which actions are appropriate for the nurse to take? Select all that apply. A. Leaving the room but telling the client she’ll return soon B. Telling the client that there’s no danger and that everything’s fine C. Telling the client that the alarm is just a drill and that he shouldn’t be afraid. D. Staying with the client until she receives further instructions E. Continuing to speak to the client in a reassuring tone 71. A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC. With her preceptor. Which planned action by the graduate nurse should the preceptor correct? A. Measuring the length of the removed catheter and comparing it with the documented length of the inserted catheter. B. Discarding the catheter in a trash container C. Flushing the PICC with 0.9% sodium chloride before removing it. D. Applying a dressing over the site and leaving it in place for 24 hours 72. Moments after birth, a neonate of 32 weeks’ gestation develops asphyxia. As a neonatal team starts resuscitation, the nurse must: A. Hyperextend the neonate’s neck B. Keep the neonate’s head in the “sniff” position. C. Maintain the neonate’s head in a neutral position D. Turn the neonate’s head slightly to one side 73.A charge is making arrangements for an elderly client newly admitted from the emergency department for treatment of suspected pyleonephritis. The charge nurse noted that the client has been assigned to a semiprivate room with another client who has the same last name. what should the nurse do first? A. Make signs to alert staff members that both clients in the room have the same last name B. Ask the admissions department to assign the elderly client to a new room C. Ask the client if he’d be willing to answer to a different last name D. Verbally remains the staff to check client’s identification bracelet before administering medications 74. After an upsetting divorce, a client who threatens to commit suicide with a handgun is voluntarily admitted to the psychiatric until with major depression. Which nursing diagnosis takes highest priority for this client? A. Hopelessness related to recent divorce B. Ineffective coping related to inadequate stress management C. Spiritual distress related to conflicting thought about suicide and sin D. Risk for self directed violence related to planning to commit suicide with a handgun 75. A client recruited to participate in a clinical trial to treat non-Hodgkin’s lymphoma tells a nurse and physician that he’s willing to start the trial, but doesn’t know if adverse effects of the treatment will prevent him from completing it. To protect the ethical principle of autonomy, the nurse tell the client: A. How long the trial will last B. The name of the company sponsoring the trial C. That he may withdraw at any time D. The risks and benefits associated with trail participation 76. A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he required nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client? A. Use standard precautions, which require gloves for suctioning B. Put on gloves, a mask ,and eye protection C. Put on gloves, a mask, and eye protection during suctioning, and then apply mask to the client’s face for transport. D. Take no special precautions for this client 78. For an infant who’s undergo a lumbar puncture, the nurse should place the infant in: A. An arched, side-lying position , with the neck flexed onto the chest B. An arched, side-lying position, avoiding flexion of the neck onto the chest C. A mummy restraint D. A prone position, with the head over the edge of the head 79. A nurse observes a nursing assistant bending over a bed as she helps an obese client sit up. The nurse discusses her observations with the nursing assistant to reinforce the need for proper body mechanics. Which response indicates that the nursing assistant understands these principles? Select all that apply. A. “I need to keep my back straight and lift with my tight muscles.” B. “I need to keep my elbows bent and use my thigh muscles to bear the weight.” C. “I should bend at the knees , keep my back straight, then pull the client up.” D. “I should stand at the client’s side, grasp the draw sheet, and pull the client up.” 80. After a traumatic back injury, a client skeletal traction. Which intervention takes priority? A. Monitoring the client for skin breakdowns B. Maintain traction continuously to ensure its effectiveness C. Supporting the traction weights with a chair or table to prevent accidental slippage D. Restricting the client’s fluid and fiber intake to reduce the movement required for bedpan use 81. A client with sever acute respiratory syndrome privately inform a nurse that he doesn’t want to be placed on a ventilator if his condition worsens. The clients wife and children repeatedly expressed their desire that every measure be taken for the client. The most appropriate action by the nurse would be to: A. Inform the family of the client wishes B. Assure the family that all possible measures will be taken. C. Support the client’s decision D. Assure the client that all possible measures will be taken’ 82. A nurse is caring for a client who is scheduled for a anibuicenetisis. What information about the procedure should the nurse provide before the client signs the consent form? A. Name of procedure, how its performed, description of alternate methods available, potential risk to monitor and fetus, risks associated if the procedure isn’t performed. B. Name of procedure , risk to mother, name of physician who will perform procedure C. Name of procedure, risk to the fetus D. Description of alternate methods available, duration of the procedure, day and time the scheduled procedure will be performed 83. A client , who is bound to a wheelchair, comes to the clinic for follow up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to5 days. During the past weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair he uses a cushion. During his appointment the nurse notes that he isn’t using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse approach the client about his treatment regimen? A. Do nothing because the client is able to make his own care decisions B. Tell the client not to return to the clinic because he isn’t following the treatment plan. C. Explain pressure ulcer development in terms he understands D. Provide a brief anatomy and physiology lesson on how pressure ulcers develop 84. The nurse identifies which of the following clients as being at HIGHEST risk for injury? A. A 3month old child is in an infant seat that he mother places on the coffee table B. A 2 year old is laying alone in the living room C. A 2 1⁄2 year old with a tracheotomy is eating raisins D. A 10 year old stays home alone for half an hour after school 85. The nurse supervises an LPN/LVN provide care to a patient with an infected abdominal wound. The nurse noted a Penrose drain in place and the wound is draining copious amount of purulent drainage, the nurse determines

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