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1. Which could be related to the charge of negligence for a nursing team leader?

Lack of development of policies and procedures.
• Failure to discipline unsafe staff.
• Inadequate staff training.
• Delegation of care tasks.

2. Which client should the nurse assess first?

Post-op hysterectomy reporting feeling hot.
Bilateral amputee with a pain score of 7.
Post-op open heart surgery with chest tubes present.
Placement of a new tracheostomy.

3. Who can provide legal informed consent for medical treatment?

• sibling for a 21-year old sibling
15-year-old for own child
16-year-old presently in Emergency for treatment.
• After receiving pre-operative sedation

4. Which nursing intervention would be best to achieve the expected outcome of central venous pressure measurement for a client who is hemodynamically unstable?

Ensure that the head of client’s bed is flat.
Elevate head of bed to client’s comfort level.
Perform focused assessment.
Obtain baseline vital signs.

5. Which is the best nursing intervention when a client coughs out the tracheostomy tube?
. Insert an obturator.
• Cover the stoma.
• Elevate the head of the bed.
. Call the physician.

6. A client who attempted suicide is admitted to an inpatient psychiatric unit. The client states
* fail at everything.” Which response by the nurse is appropriate?

You fail at everything?”
• ‘It’s frustrating to fail.”
“What is something you have done that you haven’t failed?”
• ‘Why do you think you fail at everything?”

7. A child with a family history of heart disease has a total cholesterol level of 180 mg/dL, and a LDL level of 110 mg/dL. Based on these lab results, what are the best evaluation and initial plan of care by the nurse?

Lab values are acceptable given the child’s family history.
Lab values are high and dietary changes with drug therapy should begin.
Lab values are high and dietary changes are made by nutritionist.
Lab values are borderline and refer to nutritionist.

8. Which intervention should the nurse leading an inpatient group take if a client who is psychotic says, “I will not stay in this foul place. I am not a member of this group. I am a member of the upper class. I do not associate with poor people?”

• Remind the client that they have been admitted to a psychiatric unit.
Tell the client that privileges are dependent on group participation.
Inform the client that these remarks are inappropriate.
• Disregard the client’s comments and continue with the group discussion.

9. A nurse is preparing to give discharge instructions to a client following a stapedectomy.
Which instruction should be included to promote the client’s recovery?

• Avoid traveling by air for at least six months.
• Avoid foods that have a high sodium content.
• Stay out of places where the noise level is extremely loud.
Sleep with your head elevated for at least three weeks.

10. Which client should the nurse assess first?
Post-op hysterectomy reporting feeling hot.
.Placement of a new tracheostomy.
• Bilateral amputee with a pain score of 7.
• Post-op open heart surgery with chest tubes present.

11. Which finding is primary evidence that a client is ready to deliver?

Bulging of the perineum.
Frequent uterine contractions.
Dissolution of the mucus plug.
Expulsion of the mucus plug.

12. Which behavior would indicate that a client with bipolar disorder is ready for discharge?

the client expresses appreciation to the nurse .
The client abides by unit policies.
The client reports feeling better.
The client sleeps eight hours each night.

13. The morning report on the nursing unit indicates that a client had a cerebrovascular accident (brain attack) yesterday. A nurse enters the room and performs the ordered neurological assessment. The nurse obtains a Glasgow Coma Scale score of 11. What is the next nursing assessment?

• Presence of paresthesia.
Vital signs.
Time of onset of symptoms.
Findings of previous assessment.

14. A client recovering from surgery for laryngeal cancer is to receive tube feedings via nasogastric tube. Which action must be done to confirm placement of the tube prior to initiating the feedings?

Injecting 30 mL of air and listening over the stomach.
Aspirating contents from the tube.
Obtaining an x-ray of the chest and stomach area.
verifying the mark on the tube where it is taped to the nose.

15. The following information is collected while conducting an admission health history. Which client statement would indicate additional assessment is needed?

I don’t have anyone to take care of me.
I use a walker to get to the bathroom.
I was involved in a motor vehicle accident.
I have fallen twice in the past two months!
 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 260G

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