What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed?         A. Taking a full set of vital sign measurements.      B. Completing a brief neurologic assessment.      C. Monitoring pulse oximetry reading.      D. Palpating and auscultating the abdomen.     … Read More »

The nurse is caring for four clients receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infection?         A. A client who has a non-tunneled central line in the left internal jugular vein.      B. A client with an implanted port in the right subclavian vein.      C. A client with… Read More »

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?         A. Suggest that the patient’s oxygen be humidified.      B. Suggest that a… Read More »

You are admitting a patient for whom a diagnosis of pulmonary embolism must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolism?         A. The patient was recently in a motor vehicle accident      B. The patient participated in an aerobic exercise program… Read More »

Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation?         A. Give supplemental oxygen      B. Allow the student to breathe into a paper bag      C.… Read More »

The school nurse is asked which action will take to have the most impact on the incidence of infectious diseases in school. The correct response is:         A. Grant written information about infection control to all parents.      B. Ensure that students are immunized according to national guidelines.      C. Make soap and water easily… Read More »

When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?         A. “Everyone in my family needs to go and see the doctor for TB testing.”      B. “I will continue to take my isoniazid until I am feeling completely well.”      C. “I… Read More »

You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?         A. Assessing the patient’s respiratory status every 4 hours      B. Taking vital signs and pulse oximetry readings every 4 hours      C. Checking the ventilator settings to make sure they… Read More »

The nurse is caring for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action can be delegated to the nursing assistant?         A. Implement contact precautions when caring for the client.      B. Monitor the results of ordered laboratory culture and sensitivity tests.      C. Teach the client and family members about means to… Read More »

You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?         A. Administer ordered antibiotics as scheduled      B. Hyperoxygenate the patient before suctioning      C. Maintain the head of… Read More »