SET G

Review Results Assessment SET-G

Email Address: erikajanern@icloud.com

Full Name: Purificacion, Erika Jane
: mindwebph
Respondent ID: 38907
Date Started: 10/15/2023 04:58:29 PM
Date Completed: 10/15/2023 06:01:35 PM
Attempt: 1

Question Topic
Question
Num
Respondent's Answer Correct Answer
Set G
1. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important
reason for the nurse to elevate the casted leg is to:

( ) Promote the client's comfort ( ) Promote the client's comfort

( ) Reduce the drying time ( ) Reduce the drying time
( ) Decrease irritation to the skin ( ) Decrease irritation to the skin
(X) Improve venous return (X) Improve venous return
2. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the
client?

(X) Clean the meatus, begin voiding, then catch urine stream (X) Clean the meatus, begin voiding, then catch urine stream
( ) Void a little, clean the meatus, then collect specimen ( ) Void a little, clean the meatus, then collect specimen
( ) Clean the meatus, then urinate into container ( ) Clean the meatus, then urinate into container
( ) Void continuously and catch some of the urine ( ) Void continuously and catch some of the urine
3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

( ) 16 year-old who had an open reduction of a fractured wrist ( ) 16 year-old who had an open reduction of a fractured wrist
10 hours ago 10 hours ago
( ) 20 year-old in skeletal traction for 2 weeks since a motor ( ) 20 year-old in skeletal traction for 2 weeks since a motor
cycle accident cycle accident
(X) 72 year-old recovering from surgery after a hip replacement (X) 72 year-old recovering from surgery after a hip replacement
2 hours ago 2 hours ago
( ) 75 year-old who is in skin traction prior to planned hip pinning ( ) 75 year-old who is in skin traction prior to planned hip pinning
surgery. surgery.
4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the
nurse document to most accurately describe the client's condition?

( ) Comatose, breathing unlabored ( ) Comatose, breathing unlabored

(X) Glascow Coma Scale 8, respirations regular (X) Glascow Coma Scale 8, respirations regular
( ) Appears to be sleeping, vital signs stable ( ) Appears to be sleeping, vital signs stable
( ) Glascow Coma Scale 13, no ventilator required ( ) Glascow Coma Scale 13, no ventilator required

Brillium Assessment Software Page 1 10/15/2023 06:01:50 PM

 5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic
response to the drug?

( ) Bleeding time ( ) Bleeding time

( ) Coagulation time ( ) Coagulation time
(X) Prothrombin time (X) Prothrombin time
( ) Partial thromboplastin time ( ) Partial thromboplastin time
6. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured
at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute.
What should the nurse do first?

( ) Notify both the surgeon and provider ( ) Notify both the surgeon and provider
(X) Administer the prn dose of albuterol (X) Administer the prn dose of albuterol
( ) Apply oxygen at 2 liters per nasal cannula ( ) Apply oxygen at 2 liters per nasal cannula
( ) Repeat the peak flow reading in 30 minutes ( ) Repeat the peak flow reading in 30 minutes
7. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift
report?

( ) The client lost 2 pounds in 24 hours ( ) The client lost 2 pounds in 24 hours
( ) The client's potassium level is 4 mEq/liter. ( ) The client's potassium level is 4 mEq/liter.
(X) The client's urine output was 1500 cc in 5 hours (X) The client's urine output was 1500 cc in 5 hours
( ) The client is to rece ive another dose of Lasix at 10 PM ( ) The client is to rece ive another dose of Lasix at 10 PM
8. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing
assessment requires quick intervention by the nurse?

( ) A report of 10 pounds weight loss in the last month ( ) A report of 10 pounds weight loss in the last month
(X) A comment by the client "I just can't sit still." ( ) A comment by the client "I just can't sit still."
( ) The appearance of eyeballs that appear to "pop" out of the (X) The appearance of eyeballs that appear to "pop" out of the
client's eye sockets client's eye sockets
( ) A report of the sudden onset of irritability in the past 2 weeks ( ) A report of the sudden onset of irritability in the past 2 weeks
9. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding
would cause the nurse to call the provider immediately?

( ) prolonged inspiration with each breath ( ) prolonged inspiration with each breath
(X) expiratory wheezes that are suddenly absent in 1 lobe (X) expiratory wheezes that are suddenly absent in 1 lobe
( ) expectoration of large amounts of purulent mucous ( ) expectoration of large amounts of purulent mucous
( ) appearance of the use of abdominal muscles for breathing ( ) appearance of the use of abdominal muscles for breathing
10. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family
members. Which of these interventions would be most helpful at this time?

( ) leave a book about relaxation techniques ( ) leave a book about relaxation techniques
( ) write out a daily exercise routine for them to assist the client ( ) write out a daily exercise routine for them to assist the client
to do to do
( ) list actions to improve the client's daily nutritional intake ( ) list actions to improve the client's daily nutritional intake
(X) suggest communication strategies (X) suggest communication strategies
11. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100
to180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report
immediately to the provider?

(X) Slurred speech (X) Slurred speech

( ) Incontinence ( ) Incontinence
( ) Muscle weakness ( ) Muscle weakness
( ) Rapid pulse ( ) Rapid pulse

Brillium Assessment Software Page 2 10/15/2023 06:01:50 PM

 12. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parentindicates
that teaching has been inadequate?

( ) "I will keep the cast uncovered for the next day to prevent ( ) "I will keep the cast uncovered for the next day to prevent
burning of the skin." burning of the skin."
( ) "I can apply an ice pack over the area to relieve itching inside ( ) "I can apply an ice pack over the area to relieve itching inside
the cast." the cast."
( ) The cast should be propped on at least 2 pillows when my ( ) The cast should be propped on at least 2 pillows when my
child is lying down." child is lying down."
(X) "I think I remember that my child should not stand until after (X) "I think I remember that my child should not stand until after
72 hours." 72 hours."
13. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required?

( ) pH below 7.3 ( ) pH below 7.3

( ) Potassium of 5.0 ( ) Potassium of 5.0
(X) HCT of 60 (X) HCT of 60
( ) Pa O2 of 79% ( ) Pa O2 of 79%
14. The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be
necessary for preparing the client for this test?

( ) Client should be NPO after midnight ( ) Client should be NPO after midnight
( ) Client should receive a sedative medication prior to the test ( ) Client should receive a sedative medication prior to the test
( ) Discontinue anti-coagulant therapy prior to the test ( ) Discontinue anti-coagulant therapy prior to the test
(X) No special preparation is necessary (X) No special preparation is necessary
15. A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?

( ) Dyspnea ( ) Dyspnea
(X) heart murmur (X) heart murmur
( ) macular rash ( ) macular rash
( ) Hemorrhage ( ) Hemorrhage
16. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the
procedure when the client says, "I will receive tissue from

( ) a tissue bank." ( ) a tissue bank."

( ) a pig." ( ) a pig."
(X) my thigh." (X) my thigh."
( ) synthetic skin." ( ) synthetic skin."
17. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be
expected by the nurse?

(X) Diffuse expiratory wheezing (X) Diffuse expiratory wheezing

( ) Loose, productive cough ( ) Loose, productive cough
( ) No relief from inhalant ( ) No relief from inhalant
( ) Fever and chills ( ) Fever and chills
18. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing
interventions should receive priority?

( ) Maintaining proper body alignment ( ) Maintaining proper body alignment

(X) Frequent neurovascular assessments of the affected leg (X) Frequent neurovascular assessments of the affected leg
( ) Inspection of pin sites for evidence of drainage or ( ) Inspection of pin sites for evidence of drainage or
inflammation inflammation
( ) Applying an over-bed trapeze to assist the client with ( ) Applying an over-bed trapeze to assist the client with
movement in bed movement in bed

Brillium Assessment Software Page 3 10/15/2023 06:01:50 PM

 19. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this
condition. What area is a priority for the nurse to discuss at this time?

(X) Daily needs and concerns (X) Daily needs and concerns
( ) The overview cardiac rehabilitation ( ) The overview cardiac rehabilitation
( ) Medication and diet guideline ( ) Medication and diet guideline
( ) Activity and rest guidelines ( ) Activity and rest guidelines
20. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night."
Based on these complaints, the nurse would initially assess for which problem?

( ) Allergies ( ) Allergies
( ) Scabies ( ) Scabies
( ) Regression ( ) Regression
(X) pinworms (X) pinworms
21. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?

( ) Risk for dehydration ( ) Risk for dehydration

(X) Ineffective airway clearance (X) Ineffective airway clearance
( ) Altered nutrition ( ) Altered nutrition
( ) Risk for injury ( ) Risk for injury
22. The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner
menu would be best?

( ) Fish sticks, french fries, banana, cookies, milk ( ) Fish sticks, french fries, banana, cookies, milk
(X) Ground beef patty, lima beans, wheat roll, raisins, milk (X) Ground beef patty, lima beans, wheat roll, raisins, milk
( ) Chicken nuggets, macaroni, peas, cantaloupe, milk ( ) Chicken nuggets, macaroni, peas, cantaloupe, milk
( ) Peanut butter and jelly sandwich, apple slices, milk ( ) Peanut butter and jelly sandwich, apple slices, milk
23. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?

( ) Metabolic acidosis ( ) Metabolic acidosis

(X) Metabolic alkalosis (X) Metabolic alkalosis
( ) Some increase in the serum hemoglobin ( ) Some increase in the serum hemoglobin
( ) A little decrease in the serum potassium ( ) A little decrease in the serum potassium
24. A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by
the nurse should include which statement?

( ) Place the child on clear liquids and gelatin for 24 hours ( ) Place the child on clear liquids and gelatin for 24 hours
(X) Continue with the regular diet and include oral rehydration (X) Continue with the regular diet and include oral rehydration
fluids fluids
( ) Give bananas, apples, rice and toast as tolerated ( ) Give bananas, apples, rice and toast as tolerated
( ) Place NPO for 24 hours, then rehydrate with milk and water ( ) Place NPO for 24 hours, then rehydrate with milk and water
25. The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In
addition to oral rehydration fluids, the diet should include

(X) formula or breast milk (X) formula or breast milk

( ) broth and tea ( ) broth and tea
( ) rice cereal and apple juice ( ) rice cereal and apple juice
( ) gelatin and ginger ale ( ) gelatin and ginger ale
26. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is

( ) call for emergency transport to the hospital ( ) call for emergency transport to the hospital
(X) immobilize the limb and joints above and below the injury ( ) immobilize the limb and joints above and below the injury
( ) assess the child and the extent of the injury (X) assess the child and the extent of the injury
( ) apply cold compresses to the injured area ( ) apply cold compresses to the injured area

Brillium Assessment Software Page 4 10/15/2023 06:01:50 PM

 27. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to
the diet. What should be emphasized as the nurse teaches about infant nutrition?

( ) Solid foods should be introduced at 3-4 months ( ) Solid foods should be introduced at 3-4 months
(X) Whole milk is difficult for a young infant to digest (X) Whole milk is difficult for a young infant to digest
( ) Fluoridated tap water should be used to dilute milk ( ) Fluoridated tap water should be used to dilute milk
( ) Supplemental apple juice can be used between feedings ( ) Supplemental apple juice can be used between feedings
28. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included
in the teaching materials?

(X) Solid foods are introduced one at a time beginning with (X) Solid foods are introduced one at a time beginning with
cereal cereal
( ) Finely ground meat should be started early to provide iron ( ) Finely ground meat should be started early to provide iron
( ) Egg white is added early to increase protein intake ( ) Egg white is added early to increase protein intake
( ) Solid foods should be mixed with formula in a bottle ( ) Solid foods should be mixed with formula in a bottle
29. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which
one of the following as a priority?

( ) Limit fluids ( ) Limit fluids

(X) Client controlled analgesia (X) Client controlled analgesia
( ) Cold compresses to elbow ( ) Cold compresses to elbow
( ) Passive range of motion exercise ( ) Passive range of motion exercise
30. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first?

( ) Perform traumatic procedures ( ) Perform traumatic procedures

(X) Use minimal physical contact (X) Use minimal physical contact
( ) Proceed from head to toe ( ) Proceed from head to toe
( ) Explain the exam in detail ( ) Explain the exam in detail
31. What finding signifies that children have attained the stage of concrete operations (Piaget)?

( ) Explores the environment with the use of sight and ( ) Explores the environment with the use of sight and
movement movement
( ) Thinks in mental images or word pictures ( ) Thinks in mental images or word pictures
(X) Makes the moral judgment that "stealing is wrong" (X) Makes the moral judgment that "stealing is wrong"
( ) Reasons that homework is time-consuming yet necessary ( ) Reasons that homework is time-consuming yet necessary
32. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby
with a neural tube defect. What is the best response by the nurse?

(X) "Folic acid should be taken before and after conception." (X) "Folic acid should be taken before and after conception."
( ) "Multivitamin supplements are recommended during ( ) "Multivitamin supplements are recommended during
pregnancy." pregnancy."
( ) "A well balanced diet promotes normal fetal development." ( ) "A well balanced diet promotes normal fetal development."
( ) "Increased dietary iron improves the health of mother and ( ) "Increased dietary iron improves the health of mother and
fetus." fetus."
33. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse
reinforce for the client to eat at least daily?

( ) Spaghetti ( ) Spaghetti
(X) Watermelon (X) Watermelon
( ) Chicken ( ) Chicken
( ) Tomatoes ( ) Tomatoes
34. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse
to teach them about which of the following actions?

(X) Maintain good oral hygiene and dental care (X) Maintain good oral hygiene and dental care
( ) Omit medication if the child is seizure free ( ) Omit medication if the child is seizure free
( ) Administer acetaminophen to promote sleep ( ) Administer acetaminophen to promote sleep
( ) Serve a diet that is high in iron ( ) Serve a diet that is high in iron

Brillium Assessment Software Page 5 10/15/2023 06:01:50 PM

 35. The nurse is offering safety instructions to a parent with a four month-old infant and a four year-old child. Which statement by the
parent indicates understanding of appropriate precautions to take with the children?

( ) "I strap the infant car seat on the front seat to face ( ) "I strap the infant car seat on the front seat to face
backwards." backwards."
( ) "I place my infant in the middle of the living room floor on a ( ) "I place my infant in the middle of the living room floor on a
blanket to play with my four year-old while I make supper in the blanket to play with my four year-old while I make supper in the
kitchen." kitchen."
( ) "My sleeping baby lies so cute in the crib with the little ( ) "My sleeping baby lies so cute in the crib with the little
buttocks stuck up in the air while the four year-old naps on the buttocks stuck up in the air while the four year-old naps on the
sofa." sofa."
(X) "I have the four year-old hold and help feed the four month- (X) "I have the four year-old hold and help feed the four month-
old a bottle in the kitchen while I make supper." old a bottle in the kitchen while I make supper."
36. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The
parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

( ) "The injury is expected to heal quickly because of thin ( ) "The injury is expected to heal quickly because of thin
periosteum." periosteum."
(X) "In some instances the result is a retarded bone growth." (X) "In some instances the result is a retarded bone growth."
( ) "Bone growth is stimulated in the affected leg." ( ) "Bone growth is stimulated in the affected leg."
( ) "This type of injury shows more rapid union than that of ( ) "This type of injury shows more rapid union than that of
younger children." younger children."
37. The parents of a 4 year-old hospitalized child tell the nurse, "We are leaving now and will be back at 6 PM." A few hours later the
child asks the nurse when the parents will come again. What is the best response by the nurse?

(X) "They will be back right after supper." (X) "They will be back right after supper."
( ) "In about 2 hours, you will see them." ( ) "In about 2 hours, you will see them."
( ) "After you play awhile, they will be here." ( ) "After you play awhile, they will be here."
( ) "When the clock hands are on 6 and 12." ( ) "When the clock hands are on 6 and 12."
38. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes
should be taken

( ) once each day ( ) once each day

( ) 3 times daily after meals ( ) 3 times daily after meals
(X) with each meal or snack (X) with each meal or snack
( ) each time carbohydrates are eaten ( ) each time carbohydrates are eaten
39. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which
of the following is most important to prevent lead poisoning?

( ) Use ready-to-feed commercial infant formula ( ) Use ready-to-feed commercial infant formula
( ) Boil the tap water for 10 minutes prior to preparing the ( ) Boil the tap water for 10 minutes prior to preparing the
formula formula
(X) Let tap water run for 2 minutes before adding to concentrate (X) Let tap water run for 2 minutes before adding to concentrate
( ) Buy bottled water labeled "lead free" to mix the formula ( ) Buy bottled water labeled "lead free" to mix the formula
40. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?

( ) Scratching the head more than usual ( ) Scratching the head more than usual
( ) Flakes evident on a student's shoulders ( ) Flakes evident on a student's shoulders
( ) Oval pattern occipital hair loss ( ) Oval pattern occipital hair loss
(X) Whitish oval specks sticking to the hair (X) Whitish oval specks sticking to the hair
41. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do
immediate follow up rather than delegate care to the nursing assistant? The client

( ) has had a change in respiratory rate by an increase of 2 ( ) has had a change in respiratory rate by an increase of 2
breaths breaths
( ) has had a change in heart rate by an increase of 10 beats ( ) has had a change in heart rate by an increase of 10 beats
(X) was minimally responsive to voice and touch (X) was minimally responsive to voice and touch
( ) has had a blood pressure change by a drop in 8 mmHg ( ) has had a blood pressure change by a drop in 8 mmHg
systolic systolic

Brillium Assessment Software Page 6 10/15/2023 06:01:50 PM

 42. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is

( ) "I must document and report any information." ( ) "I must document and report any information."
(X) "I can't make such a promise." (X) "I can't make such a promise."
( ) "That depends on what you tell me." ( ) "That depends on what you tell me."
( ) "I must report everything to the treatment team." ( ) "I must report everything to the treatment team."
43. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the
unlicensed assistive personnel (UAP)?

(X) Test blood sugar every 2 hours by Accu-Check (X) Test blood sugar every 2 hours by Accu-Check
( ) Review with family and client signs of hyperglycemia ( ) Review with family and client signs of hyperglycemia
( ) Monitor for mental status changes ( ) Monitor for mental status changes
( ) Check skin condition of lower extremities ( ) Check skin condition of lower extremities
44. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would
be appropriate to assign to this nurse? A client with

( ) A Dopamine drip IV with vital signs monitored every 5 ( ) A Dopamine drip IV with vital signs monitored every 5
minutes minutes
(X) A myocardial infarction that is free from pain and (X) A myocardial infarction that is free from pain and
dysrhythmias dysrhythmias
( ) A tracheotomy of 24 hours in some respiratory distress ( ) A tracheotomy of 24 hours in some respiratory distress
( ) A pacemaker inserted this morning with intermittent capture ( ) A pacemaker inserted this morning with intermittent capture
45. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

(X) Be with a client who self-administers insulin ( ) Be with a client who self-administers insulin
( ) B. Cleanse and dress a small decubitus ulcer ( ) B. Cleanse and dress a small decubitus ulcer
( ) Monitor a client's response to passive range of motion ( ) Monitor a client's response to passive range of motion
exercises exercises
( ) D. Apply and care for a client's rectal pouch (X) D. Apply and care for a client's rectal pouch
46. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical
client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are
appropriate to give to the UAP?

( ) Encourage oral fluids to prevent dehydration ( ) Encourage oral fluids to prevent dehydration
(X) Recheck temperature 15 minutes after removing hot liquids (X) Recheck temperature 15 minutes after removing hot liquids
from the bedside from the bedside
( ) Ask the client to drink only cold water and juices ( ) Ask the client to drink only cold water and juices
( ) Chart this temperature elevation on the flow sheet ( ) Chart this temperature elevation on the flow sheet
47. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive
personnel (UAP)?

( ) To observe the type and amount of nasogastric tube ( ) To observe the type and amount of nasogastric tube
drainage drainage
( ) B. Monitor the client for nausea or other complications ( ) B. Monitor the client for nausea or other complications
( ) Irrigate the nasogastric tube with the ordered irrigant ( ) Irrigate the nasogastric tube with the ordered irrigant
(X) Perform nostril and mouth care (X) Perform nostril and mouth care
48. A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first

( ) focus on reality orientation to place and person ( ) focus on reality orientation to place and person
( ) assist with the report of the client's complaint to the police ( ) assist with the report of the client's complaint to the police
(X) obtain more details of the client's claim of abuse (X) obtain more details of the client's claim of abuse
( ) document the statement on the client's chart with a report to ( ) document the statement on the client's chart with a report to
the manager the manager

Brillium Assessment Software Page 7 10/15/2023 06:01:51 PM

 49. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because

(X) normal patterns of behavior may be labeled as deviant, (X) normal patterns of behavior may be labeled as deviant,
immoral, or insane immoral, or insane
( ) the meaning of the client's behavior can be derived from ( ) the meaning of the client's behavior can be derived from
conventional wisdom conventional wisdom
( ) personal values will guide the interaction between persons ( ) personal values will guide the interaction between persons
from 2 cultures from 2 cultures
( ) the nurse should rely on her knowledge of different ( ) the nurse should rely on her knowledge of different
developmental mental stages developmental mental stages
50. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning
which of these tasks to a UAP indicates the student needs further teaching about the delegation process?

( ) Assist a client post cerebral vascular accident to ambulate ( ) Assist a client post cerebral vascular accident to ambulate
( ) Feed a 2 year-old in balanced skeletal traction ( ) Feed a 2 year-old in balanced skeletal traction
(X) Care for a client with discharge orders (X) Care for a client with discharge orders
( ) Collect a sputum specimen for acid fast bacillus ( ) Collect a sputum specimen for acid fast bacillus
51. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days
ago. What is the best care assignment for this client?

( ) Assign an RN to provide total care of the client ( ) Assign an RN to provide total care of the client
( ) Assign a nursing assistant to help the client with self-care ( ) Assign a nursing assistant to help the client with self-care
activities activities
( ) Delegate complete care to an unlicensed assistive personnel ( ) Delegate complete care to an unlicensed assistive personnel
(X) Supervise a nursing assistant for skin care (X) Supervise a nursing assistant for skin care
52. A client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room.
The best response by the charge nurse would be to

( ) keep the client's room door cracked to minimize the ( ) keep the client's room door cracked to minimize the
distractions distractions
(X) assign 1 of the nursing staff to visit the client regularly (X) assign 1 of the nursing staff to visit the client regularly
( ) treassure the client that 1 staff person will check frequently if ( ) treassure the client that 1 staff person will check frequently if
the client needs anything the client needs anything
( ) arrange for each staff member to go into the client's room to ( ) arrange for each staff member to go into the client's room to
check on needs every hour on the hour check on needs every hour on the hour
53. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those
medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should
understand that

( ) a referral is needed to the psychiatrist who is to provide the ( ) a referral is needed to the psychiatrist who is to provide the
client with answers client with answers
(X) the client has a right to know about the prescribed (X) the client has a right to know about the prescribed
medications medications
( ) such education is an independent decision of the individual ( ) such education is an independent decision of the individual
nurse whether or not to teach clients about their medications nurse whether or not to teach clients about their medications
( ) clients with schizophrenia are at a higher risk of psychosocial ( ) clients with schizophrenia are at a higher risk of psychosocial
complications when they know about their medication side complications when they know about their medication side
effects effects
54. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?

( ) Test a stool specimen for occult blood ( ) Test a stool specimen for occult blood
( ) Assist with the ambulation of a client with a chest tube ( ) Assist with the ambulation of a client with a chest tube
system system
(X) Irrigate and redress a leg wound (X) Irrigate and redress a leg wound
( ) Admit a client from the emergency room ( ) Admit a client from the emergency room

Brillium Assessment Software Page 8 10/15/2023 06:01:51 PM

 55. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which
question by the charge nurse would be most appropriate when making delegation decisions?

( ) "How long have you been a UAP and what units you have ( ) "How long have you been a UAP and what units you have
worked on?" worked on?"
( ) "What type of care do you give on the surgical unit and what ( ) "What type of care do you give on the surgical unit and what
ages of clients?" ages of clients?"
( ) "What is your comfort level in caring for children and at what ( ) "What is your comfort level in caring for children and at what
ages?" ages?"
(X) "Have you reviewed the list of expected skills you might need (X) "Have you reviewed the list of expected skills you might need
on this unit?" on this unit?"
56. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social
worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the
nurse should be which of these statements?

( ) "I am sorry. Referral information can only be provided by the ( ) "I am sorry. Referral information can only be provided by the
client's providers" client's providers"
( ) "I can never give any information out by telephone. How do I ( ) "I can never give any information out by telephone. How do I
know who you are?" know who you are?"
( ) "Since this is a referral, I can give you this information" ( ) "Since this is a referral, I can give you this information"
(X) "I need to get the client's written consent before I release any (X) "I need to get the client's written consent before I release any
information to you" information to you"
57. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date.
The nurse's response should be to

( ) ask to not be assigned to this client or to work on another ( ) ask to not be assigned to this client or to work on another
unit unit
( ) tell the client that such behavior is inappropriate ( ) tell the client that such behavior is inappropriate
( ) inform the client that hospital policy prohibits staff to date ( ) inform the client that hospital policy prohibits staff to date
clients clients
(X) discuss the boundaries of the therapeutic relationship with (X) discuss the boundaries of the therapeutic relationship with
the client the client
58. Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical
client to ambulate for the first time?

(X) "Have the client sit on the side of the bed for at least 2 (X) "Have the client sit on the side of the bed for at least 2
minutes before helping him stand." minutes before helping him stand."
( ) "If the client is dizzy on standing, ask him to take some deep ( ) "If the client is dizzy on standing, ask him to take some deep
breaths." breaths."
( ) "Assist the client to the bathroom at least twice on this shift." ( ) "Assist the client to the bathroom at least twice on this shift."
( ) "After you assist him to the chair, let me know how he feels." ( ) "After you assist him to the chair, let me know how he feels."
59. After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just
can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying

( ) "He has a lot of problems. You need to have patience with ( ) "He has a lot of problems. You need to have patience with
him." him."
(X) "I will talk with him and try to figure out what to do." ( ) "I will talk with him and try to figure out what to do."
( ) "He may be scared and taking it out on you. Let's talk to (X) "He may be scared and taking it out on you. Let's talk to
figure out what to do." figure out what to do."
( ) "Ignore him and get the rest of your work done. Someone ( ) "Ignore him and get the rest of your work done. Someone
else can take care of him for the rest of the day." else can take care of him for the rest of the day."
60. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which
newly admitted clients would be most appropriate to assign to the UAP?

( ) A 76-year-old client with severe depression ( ) A 76-year-old client with severe depression
(X) A middle-aged client with an obsessive compulsive disorder (X) A middle-aged client with an obsessive compulsive disorder
( ) An adolescent with dehydration and anorexia ( ) An adolescent with dehydration and anorexia
( ) A young adult who is a heroin addict in withdrawal with ( ) A young adult who is a heroin addict in withdrawal with
hallucinations hallucinations

Brillium Assessment Software Page 9 10/15/2023 06:01:51 PM

 61. Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client
ambulate for the first time after a colon resection?

( ) "Have the client sit on the side of the bed before helping the (X) "Have the client sit on the side of the bed before helping the
client to walk." client to walk."
(X) "If the client is dizzy ask the client to take some slow, deep ( ) "If the client is dizzy ask the client to take some slow, deep
breaths." breaths."
( ) "Help the client to walk in the room as often as the client ( ) "Help the client to walk in the room as often as the client
wishes." wishes."
( ) "When you help the client to walk, ask if any pain occurs." ( ) "When you help the client to walk, ask if any pain occurs."
62. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by
a home health care aide assigned to assist with the care of this client?

( ) Ask the client and family if they are satisfied with the care ( ) Ask the client and family if they are satisfied with the care
given given
(X) Determine if the home health aide's care is consistent with (X) Determine if the home health aide's care is consistent with
the plan of care the plan of care
( ) Investigate if the home health aide is prompt and stays an ( ) Investigate if the home health aide is prompt and stays an
appropriate length of time for care appropriate length of time for care
( ) Check the documentation of the aide for appropriateness and ( ) Check the documentation of the aide for appropriateness and
comprehensiveness comprehensiveness
63. Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?

( ) Assess and document skin turgor and color changes ( ) Assess and document skin turgor and color changes
(X) Test stool for occult blood and urine for glucose and report (X) Test stool for occult blood and urine for glucose and report
results results
( ) Suggest foods high in iron and those easily consumed ( ) Suggest foods high in iron and those easily consumed
( ) Report mental status changes and the degree of mental ( ) Report mental status changes and the degree of mental
clarity clarity
64. The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?

(X) A client with peripheral vascular disease and an ulceration of (X) A client with peripheral vascular disease and an ulceration of
the lower leg. the lower leg.
( ) A pre-operative client awaiting adrenalectomy with a history ( ) A pre-operative client awaiting adrenalectomy with a history
of asthma of asthma
( ) An elderly client with hypertension and self-reported non- ( ) An elderly client with hypertension and self-reported non-
compliance compliance
( ) A new admission with a history of transient ischemic attacks ( ) A new admission with a history of transient ischemic attacks
and dizziness and dizziness
65. A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be
appropriate?

( ) A client admitted with multiple trauma with a history of a ( ) A client admitted with multiple trauma with a history of a
newly implanted pacemaker newly implanted pacemaker
( ) A new admission with left-sided weakness from a stroke and ( ) A new admission with left-sided weakness from a stroke and
mild confusion mild confusion
( ) A 53 year-old client diagnosed with cardiac arrest from a ( ) A 53 year-old client diagnosed with cardiac arrest from a
suspected myocardial infarction suspected myocardial infarction
(X) A 35 year-old client in balanced traction admitted 6 days ago (X) A 35 year-old client in balanced traction admitted 6 days ago
after a motor vehicle accident after a motor vehicle accident
66. The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel
(UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later
as the RN is making rounds, the nurse finds the blood pressure cuff on that client's left arm. Which of these statements is most
immediately accurate?

( ) The RN has no accountability for this situation ( ) The RN has no accountability for this situation
( ) The RN did not delegate appropriately ( ) The RN did not delegate appropriately
( ) The UAP is covered by the RN's license ( ) The UAP is covered by the RN's license
(X) The UAP is responsible for following instructions (X) The UAP is responsible for following instructions

Brillium Assessment Software Page 10 10/15/2023 06:01:51 PM

 67. As the RN responsible for a client in isolation, which can be delegated to the practical nurse (PN)?

(X) Reinforcement of isolation precautions (X) Reinforcement of isolation precautions

( ) Assessment of the client's attitude about infection control ( ) Assessment of the client's attitude about infection control
( ) Evaluation of staffs' compliance with control measures ( ) Evaluation of staffs' compliance with control measures
( ) Observation of the client's total environment for risks ( ) Observation of the client's total environment for risks
68. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility.
To which staff member should the charge nurse assign the client?

( ) Unlicensed assistive personnel (UAP) ( ) Unlicensed assistive personnel (UAP)

( ) Senior nursing student ( ) Senior nursing student
( ) PN ( ) PN
(X) RN (X) RN
69. The charge nurse on a cardiac step-down unit makes assignments for the team consisting of a registered nurse (RN), a practical
nurse (PN), and an unlicensed assistive personnel (UAP). Which client should be assigned to the PN?

( ) A 49 year-old with new onset atrial fibrillation with a rapid ( ) A 49 year-old with new onset atrial fibrillation with a rapid
ventricular response ventricular response
(X) A 58 year-old hypertensive with possible angina (X) A 58 year-old hypertensive with possible angina
( ) A 35 year-old scheduled for cardiac catheterization ( ) A 35 year-old scheduled for cardiac catheterization
( ) A 65 year-old for discharge after angioplasty and stent ( ) A 65 year-old for discharge after angioplasty and stent
placement placement
70. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a
priority to delegate these tasks to?

( ) Practical nurse (PN) ( ) Practical nurse (PN)

( ) Registered Nurse (RN) ( ) Registered Nurse (RN)
(X) Unlicensed assistive personnel (UAP) (X) Unlicensed assistive personnel (UAP)
( ) Volunteer ( ) Volunteer
71. Which of these clients would be appropriate to assign to a practical nurse (PN)?

( ) A trauma victim with multiple lacerations and requires ( ) A trauma victim with multiple lacerations and requires
complex dressings complex dressings
(X) An elderly client with cystitis and an indwelling urethral (X) An elderly client with cystitis and an indwelling urethral
catheter catheter
( ) A confused client whose family complains about the nursing ( ) A confused client whose family complains about the nursing
care 2 days after surgery care 2 days after surgery
( ) A client admitted for possible transient ischemic attack with ( ) A client admitted for possible transient ischemic attack with
unstable neurological signs unstable neurological signs
72. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an
unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?

( ) Assist with plans for any clients discharged ( ) Assist with plans for any clients discharged
(X) Provide basic hygiene care to all clients on the unit (X) Provide basic hygiene care to all clients on the unit
( ) Assess a client after an acute myocardial infarction ( ) Assess a client after an acute myocardial infarction
( ) Gather the vital signs of all clients on the unit ( ) Gather the vital signs of all clients on the unit
73. A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy
and does not restock supplies. The best initial response by the nurse manager is which of these statements?

( ) "I will arrange for a conference with you and the UAP within ( ) "I will arrange for a conference with you and the UAP within
the next week" the next week"
( ) "I can assure you that I will look into the matter" ( ) "I can assure you that I will look into the matter"
(X) "I would like for you to approach the UAP about the problem (X) "I would like for you to approach the UAP about the problem
the next time it occurs" the next time it occurs"
( ) "I will add this concern to the agenda for the next unit ( ) "I will add this concern to the agenda for the next unit
meeting" meeting"

Brillium Assessment Software Page 11 10/15/2023 06:01:51 PM

 74. A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed
assistive personnel (UAP)?

( ) Teach the client how to cough up secretions ( ) Teach the client how to cough up secretions
( ) Changes the tracheostomy trach ties ( ) Changes the tracheostomy trach ties
( ) Monitor if client has shortness of breath ( ) Monitor if client has shortness of breath
(X) Perform routine tracheostomy dressing care (X) Perform routine tracheostomy dressing care
75. An RN from the women's health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would
be most appropriate for this nurse?

( ) A newly diagnosed client with type 2 diabetes mellitus who is ( ) A newly diagnosed client with type 2 diabetes mellitus who is
learning foot care learning foot care
(X) A client from a motor vehicle accident with an external (X) A client from a motor vehicle accident with an external
fixation device on the leg fixation device on the leg
( ) A client admitted for a barium swallow after a transient ( ) A client admitted for a barium swallow after a transient
ischemic attack ischemic attack
( ) A newly admitted client with a diagnosis of pancreatic cancer ( ) A newly admitted client with a diagnosis of pancreatic cancer
76. The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray.
Which statement by the nurse is most appropriate?

( ) "Tell the family they can bring in a pizza if the patient would ( ) "Tell the family they can bring in a pizza if the patient would
prefer that." prefer that."
( ) "Make sure the patient gets at least 2 cartons of milk." ( ) "Make sure the patient gets at least 2 cartons of milk."
( ) "Stop the IV if the patient is able to eat solid food." ( ) "Stop the IV if the patient is able to eat solid food."
(X) "Encourage the patient to eat slowly to prevent gas." (X) "Encourage the patient to eat slowly to prevent gas."
77. Which one of these tasks can be safely delegated to a practical nurse (PN)?

( ) Assess the function of a newly created ileostomy ( ) Assess the function of a newly created ileostomy
( ) Care for a client with a recent complicated double barrel ( ) Care for a client with a recent complicated double barrel
colostomy colostomy
(X) Provide stoma care for a client with a well functioning ostomy (X) Provide stoma care for a client with a well functioning ostomy
( ) Teach ostomy care to a client and their family members ( ) Teach ostomy care to a client and their family members
78. An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one
of the questions by the charge nurse would be most appropriate prior to making delegation decisions?

( ) "How long have you been a UAP?" ( ) "How long have you been a UAP?"
( ) "What type of care did you give in pediatrics?" ( ) "What type of care did you give in pediatrics?"
(X) "Do you have your competency checklist that we can (X) "Do you have your competency checklist that we can
review?" review?"
( ) "How comfortable are you to care for adult clients?" ( ) "How comfortable are you to care for adult clients?"
79. During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for
the nurse manager to use to assess competence?

( ) "What degree of supervision for basic care do you think you ( ) "What degree of supervision for basic care do you think you
need?" need?"
(X) "Let's review your skills check-list for type and level of skill" (X) "Let's review your skills check-list for type and level of skill"
( ) "Are you comfortable working independently?" ( ) "Are you comfortable working independently?"
( ) "What client care tasks or assignments do you prefer?" ( ) "What client care tasks or assignments do you prefer?"
80. A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an
unlicensed assistive personnel (UAP) requires intervention by the supervisor?

( ) Provide decubitus ulcer care and apply a dry dressing ( ) Provide decubitus ulcer care and apply a dry dressing
( ) Bathe and feed a client on bed rest ( ) Bathe and feed a client on bed rest
( ) Oral suctioning of an unresponsive elderly client ( ) Oral suctioning of an unresponsive elderly client
(X) Teaching a family intermittent (bolus) feedings via G-tube (X) Teaching a family intermittent (bolus) feedings via G-tube
before discharge before discharge

Brillium Assessment Software Page 12 10/15/2023 06:01:51 PM

 81. The nurse must know that the most accurate oxygen delivery system available is

(X) the Venturi mask (X) the Venturi mask

( ) nasal cannula ( ) nasal cannula
( ) partial non-rebreather mask ( ) partial non-rebreather mask
( ) simple face mask ( ) simple face mask
82. A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to

( ) begin decontamination procedures for the client ( ) begin decontamination procedures for the client
(X) ensure physiologic stability of the client (X) ensure physiologic stability of the client
( ) wrap the client in blankets to minimize staff contamination ( ) wrap the client in blankets to minimize staff contamination
( ) double bag the client's contaminated clothing ( ) double bag the client's contaminated clothing
83. The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of
deep vein thrombosis?

( ) Elevate the foot of the bed ( ) Elevate the foot of the bed
(X) Apply knee high support stockings ( ) Apply knee high support stockings
( ) Encourage passive exercises ( ) Encourage passive exercises
( ) Prevent pressure at back of knees (X) Prevent pressure at back of knees
84. If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?

( ) Obtain emergency equipment ( ) Obtain emergency equipment

( ) Assess heart rate, rhythm and all pulses ( ) Assess heart rate, rhythm and all pulses
(X) Apply pressure to the vessel insertion site (X) Apply pressure to the vessel insertion site
( ) Use cold packs at the exit incision site ( ) Use cold packs at the exit incision site
85. The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal
infection?

( ) 12 hours post partum, temperature of 100.4 degrees ( ) 12 hours post partum, temperature of 100.4 degrees
Fahrenheit since delivery Fahrenheit since delivery
( ) 2 days post partum, temperature of 101.2 degrees ( ) 2 days post partum, temperature of 101.2 degrees
Fahrenheit this morning Fahrenheit this morning
(X) 3 days post partum, temperature of 100.8 degrees (X) 3 days post partum, temperature of 100.8 degrees
Fahrenheit the past 2 days Fahrenheit the past 2 days
( ) 4 days post partum, temperature of 100 degrees Fahrenheit ( ) 4 days post partum, temperature of 100 degrees Fahrenheit
since delivery since delivery
86. The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the
drainage tube. The first action the nurse should take is

( ) reconnect the tube ( ) reconnect the tube

( ) raise the collection chamber above the client's chest ( ) raise the collection chamber above the client's chest
( ) call the health care provider ( ) call the health care provider
(X) clamp the chest tube (X) clamp the chest tube
87. A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is
appropriate reinforcement of information by the nurse?

(X) "Drink at least 8 glasses of water a day." (X) "Drink at least 8 glasses of water a day."
( ) "Be sure to take the medication with food." ( ) "Be sure to take the medication with food."
( ) "It is safe to take with oral contraceptives." ( ) "It is safe to take with oral contraceptives."
( ) "Stop the medication after 5 days." ( ) "Stop the medication after 5 days."
88. A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given 3 hours ago
and it peaks in 2 hours." What should be the nurse's initial response to the client?

( ) What else do you know about this type of insulin? ( ) What else do you know about this type of insulin?
(X) What are you feeling at this moment? (X) What are you feeling at this moment?
( ) Have you eaten anything today? ( ) Have you eaten anything today?
( ) Are you taking any other insulin or medication? ( ) Are you taking any other insulin or medication?

Brillium Assessment Software Page 13 10/15/2023 06:01:51 PM

 89. The nurse is caring for a client who is receiving total parenteral nutrition (TPN) (hyperalimentation and lipids). What is the priority
nursing action on every 8 hour shift?

( ) Monitor blood pressure, temperature and weight ( ) Monitor blood pressure, temperature and weight
( ) Change the tubing under sterile conditions ( ) Change the tubing under sterile conditions
(X) Check urine glucose, acetone and specific gravity (X) Check urine glucose, acetone and specific gravity
( ) Adjust the infusion rate to provide for total volume ( ) Adjust the infusion rate to provide for total volume
90. The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman following the birth of an Rh positive
baby. Which assessment is a priority before the nurse gives the injection?

( ) Newborn's blood type ( ) Newborn's blood type

(X) Coombs' test results (X) Coombs' test results
( ) Previous RhoGAM history ( ) Previous RhoGAM history
( ) Gravida and parity ( ) Gravida and parity
91. A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?

( ) foul smelling urine ( ) foul smelling urine

( ) burning on urination ( ) burning on urination
(X) elevated temperature (X) elevated temperature
( ) nausea and anorexia ( ) nausea and anorexia
92. The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism following treatment for chronic renal
disease. Which of the following lab data should receive priority attention?

( ) Calcium and phosphorus levels (X) Calcium and phosphorus levels

( ) Blood sugar ( ) Blood sugar
( ) Urine specific gravity ( ) Urine specific gravity
(X) Blood urea nitrogen ( ) Blood urea nitrogen
93. When caring for a client with urinary incontinence, which content should be reinforced by the nurse?

( ) hold the urine to increase bladder capacity ( ) hold the urine to increase bladder capacity
( ) avoid eating foods high in sodium ( ) avoid eating foods high in sodium
( ) restrict fluid to prevent elimination accidents ( ) restrict fluid to prevent elimination accidents
(X) avoid taking antihistamines (X) avoid taking antihistamines
94. A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would
be to

( ) maintain fluid and electrolyte balance ( ) maintain fluid and electrolyte balance
(X) manage post-operative pain (X) manage post-operative pain
( ) ambulate the client within 1 hour of surgery ( ) ambulate the client within 1 hour of surgery
( ) control bladder spasms ( ) control bladder spasms
95. A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the
fingers. The first action of the nurse should be

( ) elevate the arm no higher than heart level ( ) elevate the arm no higher than heart level
( ) remove the cast ( ) remove the cast
(X) assess capillary refill of the exposed hand and fingers (X) assess capillary refill of the exposed hand and fingers
( ) apply a warm soak to the hand ( ) apply a warm soak to the hand
96. A client is 2 days post operative. The vital signs are: BP - 120/70, HR -- 110 BPM, RR - 26, and Temperature - 100.4 degrees
Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment
would have alerted the nurse first to the client's change in condition?

( ) Heart rate ( ) Heart rate

(X) Respiratory rate (X) Respiratory rate
( ) Blood pressure ( ) Blood pressure
( ) Temperature ( ) Temperature

Brillium Assessment Software Page 14 10/15/2023 06:01:51 PM

 97. A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the nurse prior to the
procedure is

( ) Time of the client's last meal ( ) Time of the client's last meal
(X) client's allergy history (X) client's allergy history
( ) assessment of the peripheral pulses ( ) assessment of the peripheral pulses
( ) results of the blood coagulation studies ( ) results of the blood coagulation studies
98. What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)?

( ) Symptom relief occurs in a few days ( ) Symptom relief occurs in a few days
(X) Alcohol use is to be avoided (X) Alcohol use is to be avoided
( ) Medication must be stored in the refrigerator ( ) Medication must be stored in the refrigerator
( ) Episodes of diarrhea can be expected ( ) Episodes of diarrhea can be expected
99. Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?

( ) Measure the vital signs ( ) Measure the vital signs

( ) Palpate the abdomen ( ) Palpate the abdomen
( ) Assess for breath sounds ( ) Assess for breath sounds
(X) Verify tube patency (X) Verify tube patency
100. The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by
the nurse?

( ) pruritic rash ( ) pruritic rash

( ) dry, hacking cough ( ) dry, hacking cough
( ) chronic fatigue ( ) chronic fatigue
(X) elevated temperature (X) elevated temperature

Time Used: 01:03:06 Final Score: 93%

Brillium Assessment Software Page 15 10/15/2023 06:01:51 PM