Nokea
A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource?
- A. The state nurse practice act in which the assignment is made
- B. With a nurse colleague who has worked in that state 2 years ago
- C. The policies and procedures of the assigned agency in the state
- D. The Nursing Social Policy Statement within the United States
Correct Answer: A
Rationale: The state nurse practice act is the governing document of the scope of practice in the given state.
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During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
- A. Weight gain of 2 pounds or more in a 48 hour period
- B. Urinating 4 to 5 times each day
- C. A significant decrease in appetite
- D. Appearance of non-pitting ankle edema
Correct Answer: A
Rationale: Weight gain of 2 pounds or more in a 48 hour period. It is critical for clients to report and be treated for rapid weight gain, which indicates fluid retention and worsening heart failure.
The nurse's aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck.
Which of the following observations, if made by the nurse, would require an intervention?
- A. The woman removes her dentures and gives them to her husband.
- B. The woman's vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
- C. The woman has a nitroglycerine patch on her right chest area.
- D. The woman has red nail polish on her fingers and toes.
Correct Answer: C
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) should be removed before the Test (2) results are within normal limits (3) correct-should be removed before the Test (4) unnecessary to check capillary refill
A client has just been admitted after sustaining a second-degree thermal injury to his right arm.
Which of the following nursing observations is MOST important to report to the doctor?
- A. Pain around the periphery of the injury.
- B. Gastric pH less than 6.0.
- C. Increased edema of the right arm.
- D. An elevated hematocrit.
Correct Answer: B
Rationale: Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct-decrease in gastric pH could indicate hypersecretion of hydrogen ions, predisposing factor to stress ulcer formation (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution
A client with a total knee replacement returns from surgery. Which finding requires immediate nursing intervention?
- A. There is $30 \mathrm{~mL}$ of bloody drainage from the Davol drain.
- B. The continuous passive motion machine is set on $90^{\circ}$ flexion.
- C. The client is unable to ambulate to the bathroom.
- D. The client is complaining of muscle spasms.
Correct Answer: B
Rationale: A 90° flexion setting on the CPM machine is too aggressive post-surgery, risking injury, and requires immediate adjustment. Drainage , non-ambulation , and spasms are expected or less urgent.