1.Therapeutic communication techniques by the nurse include which of the following?
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1.    Therapeutic communication techniques by the nurse include which of the following? select all that apply.

a.     Asking a clarifying question

b.    Giving all client hug

c.     Expressing advice that will be best for the client

d.    Encouraging the client on social media

e.     Being attentive, and listening

f.      Restating what the client said

2.    A client states that he is Muslim. The client has type two diabetes mellitus and has been prescribed a long-acting insulin. The client states that he fasts for Ramadan. what intervention is most appropriate for this client?

a.     Educate the client that fasting is not an option

b.    Tell the client to not take his insulin the night before

c.     Inform the client that he will need to change his lifestyle completely

d.    Collaborate with the patient and provider to develop a patient-centered plan of care

3.    A client adheres to her beliefs as a Christian Scientist. She arrives in the emergency room with an infected wound that has purulent drainage. What does the nurse do first?

a.     Assess the wound

b.    Educate the client about wound care

c.     Tell the client they should have come in sooner

d.    Administer an antibiotic

4.    A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include in the plan? select all that apply.

a.     Teaching about balance and strengthening exercises

b.    Providing information about home safety checks

c.     Locking beds and wheelchairs during transfers

d.    Placing a bedside table within the client's reach

e.     Administering a sedative at bedtime

5.    A nurse is discharging a client who is unsteady on his feet at night. Which of the following statements by the client requires further education?

a.     "I will take my water pill in the morning rather than in the evening"

b.    "I will turn on my hallway lights at night."

c.     "I will place several throw rugs throughout my house."

d.    "My wife helps me to the bathroom at night."

6.    An ambulatory and oriented patient who gets out of bed at night to void will be at lower risk for injury when the nurse implements which of the following interventions?

a.     Limit fluid intake after 6 pm

b.    Illuminating the pathway to the bathroom

c.     Awaken the client every hour to use the bathroom

d.    Arriving immediately when the bed alarm sounds

 

7.    The client had an appendectomy one day ago. what vital sign data may indicate that the client is experiencing post-surgical pain?

a.     Heart rate 60 breaths/minutes

b.    Blood pressure of 175/90mm Hg

c.     Oxygen saturation of 97%

d.    Respiration of 10 breath per minute

8.    Which of these is important to teach a mother of five school-age children? select all that apply.

a.     Have the children lay on their backs when sleeping?

b.    Lock up all guns that may be in the home

c.     Ensure children's seat belts are fastened while riding in a vehicle

d.    Place all medications in a locked cabinet

e.     Let your children swim alone frequently

9.    Which of the following responses by the nurse could barrier to communication?

a.     What you did was wrong. You shouldn't do that

b.    Good morning Mrs. Nightingale is there anything I can do to make you more comfortable

c.     Let's see what we can do to find a solution

d.    Is it a good time to discuss your new diagnosis?

10. Sleepwalking may occur in which stage of sleep?

a.     REM sleep

b.    Stage 4 NREM sleep

c.     Stage 2 NREM sleep

d.    NERM Motion induced sleep

11. What is the mission of the occupational Safety and Health Administration (OSHA)?

a.     Protect patient

b.    Prevent work-related injuries and deaths

c.     Prevent injuries may incur at home

d.    Reduce patient falls, and provide emotional support

12. A nurse is discharging a client who is unsteady on his feet at night. Which of the following statement by the client requires further education?

a.     I will take my water pill in the morning rather than in the evening

b.    I will turn on my hallway lights at night

c.     I will place several throw rugs throughout my house

d.    My wife helps me to the bathroom at night

13. The nurse is caring for several clients on a busy medical-surgical floor. Which of the following clients should the nurse assess first?

a.     A client who falls last month at home, but has had no issue while in the hospital

b.    A client who wants more coffee

c.     A client with chronic pain of 3/10

d.    A client in a room where a loud crashing noise has just emerged

14. A client just received a diagnosis of cancer. which statement by the nurse demonstrate empathy?

a.     Tomorrow will be better

b.    This must be hard news to hear. Tell me more about it

c.     What's your biggest fear about this diagnosis?

d.    I believe you can overcome this because I've seen how strong you are.

15. Which organization publishes the National Patients Safety Goals?

a.     Medicare

b.    The American Nurses Association

c.     The Join Commission

d.    The institute of medicine

16. Which of these is the greatest danger to toddlers?

a.     Mistletoe tightly secured to the ceiling

b.    Medication locked in a cabinet

c.     Large toys with large parts

d.    Unattended pools

17. A client has a reddened area on his right heels. What is the best positioning for the client to reduce the risk of further injury to the heel?

a.     Prop the heel up onto a support pillow with sheepskin

b.    High Fowler's position

c.     Place a pillow under the client's knee, to allow the heel to rest on the bed

d.    Place the pillow under the client's calf, so the heel is suspended

18. What is the leading cause of accidental death in individuals between the ages of 35-64?

a.     Poisoning

b.    Motor vehicle accident

c.     Workplace injury

d.    Pneumonia

19. Which statement by the new nurse demonstrates an understanding of idiopathic pain?

a.     This is pain from your lungs

b.    This is pain caused by inactivity

c.     This means you have pain from the car accident you were in five years ago.

d.    This means that we don't know the exact cause of your chronic pain.

20. A fire is found in a client's room during a routine medication pass. what is the nurse's first action?

a.     Activate the fire alarm

b.    Call 9-1-1

c.     Notify the supervisor

d.    Remove the client from the room

21. A client begins to fall while the nurse is assisting with ambulation. what is the priority nursing intervention?

a.     Initiate a code

b.    Notify the charge nurse

c.      Guide the client safely down to the floor

d.    Alert the client's healthcare provider

22. When a labor and delivery nurse tells a coworker that an Asian client probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing a belief known as what?

a.     Bias

b.    Ethnic slur

c.     Stigma

d.    Stereotype

23. The nurse knows that which of the following is a never event?

a.     No blood incompatibility occurs during a blood transfusion

b.    A surgical is left in a client's incision

c.     A client falls in his own home

d.    Inserting a urinary catheter prior to surgery

24. What position reduces the risk of aspiration in a client on bedrest while eating?

a.     Supine

b.    High Fowler's

c.     Prone position

d.    Lithotomy position

25. A client recently had an above the knee amputation and complains of pain distal to the amputation. What type of pain is the client experiencing?

a.     Radiating

b.    Phantom

c.     Referred

d.    Psychogenic

26. Which of these can be classified as complementary medicine? select all that apply.

a.     the use of diet and exercise instead of the recommended cholesterol-lowering medication.

b.    The use of diet and exercise in conjunction with the recommended cholesterol-lowering medication

c.     The use of needles in specific healing points throughout the body are used in conjunction with the recommended cholesterol-lowering medication.

d.    The use of needles in specific healing points throughout the body is used instead of the recommended cholesterol-lowering medication

e.     A long walk in the woods

27. You overhear the following comments throughout the day by coworkers. Which of these statements warrants immediate intervention?

a.     I'm turning your light off for the night. Do not turn it on when you use the restroom. It will wake your roommate.

b.    You can have chicken for dinner, but after midnight you have restrictions for your surgery tomorrow, and will not be able to have anything to eat or drink

c.     I'm placing your call light next to you, press this button for assistance

d.    I would like to have you participate in your discharge planning. Tell me how many stairs are in your home

28. A nurse is assisting with a transfer of a client from the bed to a wheelchair, which of the following is a priority action of the nurse to ensure client safety?

a.     Encourage the client to push up from the wheelchair

b.    Ensure the client is bathed before getting into the wheelchair

c.     Lock the wheelchair

d.    Place the bed in the lithotomy position

29. The client asks the nurse about reducing the risk of a urinary tract infection. What would be an appropriate response by the nurse?

a.     Take long bubble baths

b.    Increase your sugar consumption

c.     Cleansing should be performed in a dirty-to-clean fashion

d.    Cleanse your perineal area from front-to-back

30. A new mother asks for advice to keep her infant safe. Which of these are true? select all that apply.

a.     The infant should be put to bed on their back

b.    The infants should car seat should be rear-facing in the back seat

c.     The infant should remain in their car seat at all time

d.    Do not warm formula in the microwave

e.     Children do not need sunscreen at this age

31. What is the primary purpose of an incident report?

a.     A tool used for disciplinary action

b.    To eliminate unforeseen errors

c.     A tool used in identifying opportunities for improvement

d.    To hold persons accountable for their errors

32. A nurse and client work on strategies to reduce weight. What phase therapeutic relationship is the nurse and client in?

a.     Pre-interaction

b.    Orientation

c.     Working

d.    Termination

33. A nurse may safely delegate vital signs to the unlicensed assistive personnel (UAP) for the client with which problem?

a.     A history of myocardial infarction three years ago

b.    New onset of slurred speech

c.     Chest discomfort that started one hour ago

d.    A respiratory rate of 30

34. Which set of vital signs, taken on an adult is cause for concern and requires further evaluation?

a.     Temperature 96.9degree f; pulse 100 bpm; respirations 20 breaths/minute; blood pressure120/80 mmHg.

b.    Temperature 97.0degree; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.

c.     Temperature 98degree f, pulse 54 bpm; respirations, 12 breaths/minute; blood pressure 110/76 mmHg.

d.    Temperature 99degree f; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg

35. Proper foot care can provide what therapeutic benefits for the client?

a.     Reduced risk of infection

b.    Increased risk infection

c.     Reduced blood flow

d.    pain

36. Which organization publishes the National Patient Safety Goals?

a.     Medicare

b.    The American Nurses Association

c.     The Joint Commission

d.    The Institute of Medicine

37. A client adheres to her beliefs as a Christian Scientist. She arrives in the emergency room with an infected wound that has purulent drainage. What does the nurse do first?

a.     Assess the wound

b.    Educate the client about wound care

c.     Tell the client they should have come in sooner

d.     Administer an antibiotic

38. What is the best source of pain assessment?

a.     The family

b.    The provider

c.     The client

d.    A drug reference app

39. An older client is wearing a hearing aid. What intervention can the nurse implement to improve communication?

a.     Chew gum

b.    Turn off the television

c.     Speak loudly and clearly

d.    Use paper and pencil

40. Accepting pauses or silences that may extend for some time without interjecting a verbal response is considered which of the following?

a.     Rude behavior

b.    A barrier to communication

c.     Therapeutic communication

d.    A form of verbal communication

41. The nurse knows that repositioning a patient every two hours will help to reduce:

a.     Pressure ulcer

b.    Staffing need

c.     Medication needs

d.    Pressure postulates

42. A nurse has administered oral pain medication. How soon after this intervention should the nurse evaluate its effectiveness?

a.     30 to 60 minutes

b.    1 to 2 hours

c.     10 to 15 minutes

d.    Every 5 minutes

43.  The community health nurse is aware of health disparities among racial and ethnic groups. The following disparities are current societal issues. Select all that apply.

a.     Infant death rate among black Americans. American Indians and Alaska Native are significantly higher than that of the white. non-Hispanic population.

b.    Quality of care in certain neighborhoods can be quite variable based on the income levels of surrounding communities.

c.     Some ethnic groups suffer from difficulty with access to healthcare.

d.    There are no variations in access and quality of care for different populations in the United States.

44. When providing a routine bed bath, what action does the nurse complete first?

a.     Cleanse the client's hands

b.    Cleanse the client's feet

c.     Cleanse the client's perineal area

d.    Cleanse the client's face

45. What intervention is most appropriate to decrease the risk of falling for an elderly client admitted to the hospital?

a.     Insist on the client only using the bedpan

b.    Placing all four rails up to avoid accidentally falling out of bed.

c.     Orient the client to the environment and ensure that the call light is within reach.

d.    Place the client in a shared room with a client who is stable and oriented.

46. A nurse is assessing a client's vital signs. His oxygen saturations are 85%. which interventions should the nurse perform first?

a.     Call the provider, order labs, and recommend a chest x-ray

b.    Place the client in the lithotomy position and listen to bowel sounds

c.     Raise the head of the bed, promote coughing and apply oxygen

d.    Leave the room to order pain medication from the pharmacy

47. Which of the following responses by the nurse could barrier to communication?

a.     What you did was wrong. You shouldn't do that

b.    Good morning Mrs. Nightingale. Is there anything I can do to make you more comfortable?

c.     Let's see what we can do to find a solution

d.    Is it a good time to discuss your new diagnosis?

48. A client states "I am worried about my insulin; I have no money and my insurance doesn't cover the insulin. I can't control my sugar," The nurse responds by stating "you are worried about affording insulin, what type of therapeutic communication is this an example of?

a.     Establishing trust

b.    Using silence

c.     Restating

d.    Reassuring

49. Which of these is the priority nursing assessment?

a.     A client needing to void

b.    A recently divorced client

c.     A client who has recently lost their job

d.    A client who is homeless

50. A client diagnosed with narcolepsy. What is the nurse's priority intervention?

a.     Encourage the client to stop drinking caffeine after 7 pm

b.    Inform the client to drink two cups of regular coffee

c.     Encourage the client to participate in his normal activities

d.     Inform the client that driving would be dangerous.

51. A client with dementia is being admitted to the medical-surgical unit after a period of syncope. Does the charge nurse know that placement of this patient's bed is best in what type of setting to promote nighttime safety and decrease the risk of falling?

a.     In a room close to the nurse's station and with a tightly applied Posey restraint

b.    In a room close to the nurse' station, and a quiet atmosphere

c.      On the floor

d.    In a room with a really nice television for distraction

 

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