07/01/2017

1st Day - Priorities-Omar

Hammad-0561523465 ... Total Questions: 45
Most Correct Answers: #3 Least Correct Answers: #31

1.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

During the initial data gathering, the patient reveals a weight loss of 17 pounds
since the death of his spouse 5 weeks ago. He says that he is not sleeping and has
no appetite.

Using Maslow’s Hierarchy of Needs, the nurse assesses that the unmet needs are in
the category of:
A Physiologic.
68/99
B safety and security.
10/99
C Love and belonging.
12/99
D Self-actualization.
7/99

2.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

A 46 year-old client in a long-term care facility has had a series of gastrointestinal

(GI) diagnostic tests, including an upper and lower GI series and endoscopies.

Upon return to the long-term care facility, which priority assessment should the
nurse focus on?
A The comfort level
6/99
B Activity tolerance
2/99
C The level of consciousness
11/99
D The hydration and nutrition status
72/99

3.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : The nurse is assigned to care for a child with juvenile idiopathic arthritis
(JIA).

What is the child’s priority problem?

A Acute pain
73/99
B Potential difficulty with everyday tasks
0/99
C Impaired mobility causing potential injury
9/99
D Negative view of body because of activity intolerance
6/99

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4.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : You are working in the triage area of an ED, and four patients approach
the triage desk at the same time. List the order in which you will assess these
patients.

a. An ambulatory, dazed 25-year-old male with a bandaged head wound

b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting
A C, A, D, B
10/99
B A, B, D, C
17/99
C D, B, A, C
9/99
D B, A, D, C
50/99

5.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : Which of the following nursing actions has the HIGHEST priority for a
teenager admitted with burns to 50% of his body?
A Maintain aseptic technique during procedures.
56/99
B Maintain airborne precautions.
13/99
C Counseling regarding problems of body image.
8/99
D Encourage peers to visit on a regular basis.
2/99

6.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

During report, the previous nurse emphasized that one of the newly admitted
patients is on seizure precautions.

The incoming nurse is correct when she performs which of the following actions to
the client?
A Serve the client’s food in paper and plastic containers.
10/99
B Move the client to a room closer to the nurses’ station.
17/99
C Maintain the client’s bed in the lowest position.
44/99
D Ensure that soft limb restraints are applied to upper extremities.
7/99

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7.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A 37 years-old client complains of severe pain 2 days after surgery.

Which action should the nurse perform first?
A Offer reassurance to the client that he will feel less pain tomorrow.
1/99
B Allow the client time to verbalize his feelings.
7/99
C Check the client’s vital signs.
49/99
D Administer an analgesic.
19/99

8.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

The elderly client diagnosed with deep vein thrombosis is complaining of chest pain
during inhalation.

Which intervention should the nurse implement first?

A Ask the physician to order a stat lung scan.
11/99
B Place oxygen on the client via nasal cannula.
55/99
C Prepare to administer intravenous heparin.
4/99
D Tell the client not to ambulate and remain in bed.
6/99

9.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

The client is admitted to the emergency department (ED) with a third-degree burn
over the front of both legs. Which priority intervention should the nurse
implement?

A Maintain sterile environment when caring for the client.

28/99
B Insert two large-bore intravenous access routes.
29/99
C Administer intravenous antibiotic therapy.
5/99
D Assess the client’s pain level on a 1 to 10 pain [Link] facility
13/99

Page 3 of 13
10.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A 52 years old client with a known history of panic disorder comes to the
emergency department and states to the nurse, “Please help me. I think I’m having
a heart attack.”

What is the priority nursing action?.

A Check the client’s vital signs.
51/99
B Encourage the client to use relaxation techniques.
13/99
C Identify the manifestations related to the panic disorder.
5/99
D Determine what the client’s activity involved when the pain started.
6/99

11.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A 48 years-old client returns from an endoscopic procedure during

which he was sedated.

Before offering the client food, which action should the nurse take?
A Assess the client’s respiratory status.
14/99
B Check the client’s gag reflex.
43/99
C Place the client in a side-lying position.
5/99
D Have the client drink a few sips of water.
11/99

12.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A 45 years old patient with a heart rate of 250 beats per minute
complains of chest pain and dizziness. Difficulty of breathing and pallor are noted.

What is the initial management for this condition?

A Start ECG
11/99
B Cardioversion
3/99
C Oxygen administration
59/99
D Initiate vagal maneuver
0/99

Page 4 of 13
13.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : You are assessing a patient who has sustained a cat bite to the left hand.
The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is
unknown.

Which of the following is the priority nursing diagnosis?

A Risk for Infection related to organisms specific to cat bites
52/99
B Impaired Skin Integrity related to puncture wounds
8/99
C Ineffective Health Maintenance related to immunization status
10/99
D Risk for Impaired Mobility related to potential tendon damage
3/99

14.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A nurse is assigned to a client who has returned from the recovery room
following surgery for a colorectal tumor. After an initial assessment, the nurse
anticipates the need to monitor the client's abdominal dressing, intravenous
infusion, and drainage tubes. The client is in pain and will not be able to eat or
drink until intestinal function returns.

The nurse will have to establish priorities of care in which of the following
situations?
A The family comes to visit the client.
4/99
B The client expresses concern about pain control.
16/99
C The client's vital signs change showing a drop in blood pressure.
47/99
D The charge nurse approaches the assigned nurse and requests a report at the end of the
6/99
shift.

15.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : An older adult client has been identified as a victim of physical abuse.

Which is the priority nursing intervention?

A Obtaining treatment for the abusing family member
7/99
B Adhering to federal mandatory abuse reporting laws
7/99
C Notifying the case worker to intervene in the family situation
13/99
D Removing the client from any situation that presents immediate danger
45/99

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16.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : In a multiple-trauma victim, which assessment finding signals the most

serious and life-threatening condition?
A A deviated trachea
44/99
B Gross deformity in a lower extremity
7/99
C Decreased bowel sounds
6/99
D Hematuria
13/99

17.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A patient in a one-car rollover presents with multiple injuries. Prioritize

the interventions that must be initiated for this patient.

a. Secure/start two large-bore IVs with normal saline

b. Use the chin lift or jaw thrust method to open the airway.
c. Assess for spontaneous respirations
d. Give supplemental oxygen per mask.
e. Obtain a full set of vital signs.
f. Remove patient’s clothing.
g. Insert a Foley catheter if not contraindicated.
A B, D, C, A, E, F, G
20/99
B G, F, D, E, A, B, C
3/99
C G, B, C, A, E, F, D
3/99
D C, B, D, A, E, F, G
43/99

18.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : The nurse is assigned to care for a hospitalized toddler. Which measure
should the nurse plan to implement as the highest priority of care?
A Providing a consistent caregiver
10/99
B Protecting the toddler from injury
46/99
C Advice about contacting the police
3/99
D Allowing the toddler to participate in play and diversional activities
10/99

Page 6 of 13
19.    Question : A female client who received general anesthesia returns from
surgery.

Postoperatively, which nursing diagnosis takes highest priority for this client?
A Acute pain related to surgery
18/99
B Deficient fluid volume related to blood and fluid loss from surgery
3/99
C Impaired physical mobility related to surgery
4/99
D Risk for aspiration related to anesthesia
44/99

20.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A maintenance man falls from a ladder into the unit hall, striking his
head on some equipment. The man is unconscious and not breathing; the Code
Team has already been paged and is on its way. The nurse should:
A wait for the team to start CPR
4/99
B open airway with a jaw thrust
34/99
C give two rescue breaths after extending the neck(head tilt chin lift)
15/99
D check patient responsiveness
15/99

21.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : Which aspect(s) of the client should the nurse focus on when assessing a
client for the vegetative signs of depression?
A Level of self-esteem
9/99
B Level of suicidal ideation
16/99
C Ability to think, concentrate, and make rational decisions
1/99
D Appetite, weight, sleep patterns, and psychomotor activity
42/99

22.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : One-person CPR principles, as taught and practiced by professional

nurses, require that the initial intervention for an unconscious patient who is not
breathing is to:
A lift the jaw to clear the airway.
27/99
B call for assistance
22/99
C start chest compressions.
15/99
D make two rescue breaths
4/99

Page 7 of 13
23.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : The client with a diagnosis of cancer is receiving a morphine sulphate 10

mg subcutaneously every 3-4 hours for pain.

When preparing the plan of care for the client, the nurse includes which priority
action?
A Encourage fluid intake.
9/99
B Encourage the client to cough and deep breath.
43/99
C Monitor the urine output
12/99
D Monitor stools.
3/99

24.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : The patient is admitted to the emergency room after having been bitten
on the hand by a black widow spider.

The nursing intervention that is indicated is to:

A monitor for respiratory distress.
49/99
B wrap the hand in a warm compress.
5/99
C seat the patient upright in a chair.
1/99
D elevate the patient’s hand above his or her heart.
12/99

25.    Omar Hammad-Training Specialist For SNLE-2017- 0565123465

Question : A visitor cuts herself badly on the arm and is bleeding profusely. The
nurse’s immediate treatment for this condition is to:
A call any doctor and send the visitor immediately to the ER
5/99
B apply direct pressure to the arm with sterile dressing.
48/99
C take the visitor’s blood pressure and pulse
7/99
D immobilize the injured arm and send the visitor immediately to the ER.
6/99

26.    Question : A prisoner, with a known history of alcohol abuse, has been in police
custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now,
disorientation, hallucination, and hyper-reactivity are observed. The medical
diagnosis is delirium tremens. What is the priority nursing diagnosis?
15/99 A Risk for Nutritional Deficit related to chronic alcohol abuse‫ش‬

B Risk for Other-Directed Violence related to hallucinations

19/99
C Risk for Situational Low Self-esteem related to police custody
3/99
D Risk for Injury related to seizures
29/99

Page 8 of 13
27.    Question : Immediately after a CVA, a major nursing priority is ensuring:
A preservation of motor function.
7/99
B airway maintenance.
57/99
C adequate hydration.
1/99
D control of elimination.
1/99

28.    Question : The greatest danger in the early postoperative period after an

amputation is:
A Infection
14/99
B hemorrhage.
47/99
C Pain
4/99
D edema
1/99

29.    Question : The client has experienced an electrical injury, with the entrance
site on the left hand and the exit site on the left foot. What are the priority
assessment data to obtain from this client on admission?
A Airway patency
23/99
B Heart rate and rhythm
24/99
C Orientation to time, place, and person
10/99
D Current range of motion in all extremities
9/99

30.    Question : Which is the priority nursing diagnosis during the first 24 hours for
a client with chemical burns to the legs and arms that are red in color, edematous,
and without pain?
A Decreased Tissue Perfusion
46/99
B Disturbed Body Image
3/99
C Risk for Disuse Syndrome
5/99
D Risk for Ineffective Breathing Pattern
12/99

31.    Question : What is the priority nursing diagnosis for a client in the

rehabilitative phase of recovery from a burn injury?
A Acute Pain
27/99
B Impaired Adjustment
14/99
C Deficient Diversional Activity
6/99
D Imbalanced Nutrition: Less than Body Requirements
19/99

Page 9 of 13
32.    Question : The burned client on admission is drooling and having difficulty
swallowing. What is the nurse’s best first action?
A Assess level of consciousness and pupillary reactions.
21/99
B Ask the client at what time food or liquid was last consumed
12/99
C Auscultate breath sounds over the trachea and mainstem bronchi.
30/99
D Measure abdominal girth and auscultate bowel sounds in all four quadrants.
3/99

33.    Question : A patient is dyspneic with a respiratory rate of 26 breaths per

minute. What is the Nurse’s first action?
A Obtain an arterial blood gas immediately
3/99
B Raise the head of the bed to a 45 degree angle
26/99
C Notify the health care provider of the patient’s status
3/99
D Administer 100% percent oxygen per nasal cannula
34/99

34.    Question : The Nurse is caring for a patient recovering from a broken femur.
When assessing the unaffected leg, edema is noted and the patient complains of
calf pain.

Which of the following interventions should be included in the plan of care?

A Perform a complete respiratory assessment
19/99
B Apply ice to the patient’s calf
10/99
C Elevate the extremity
30/99
D Massage the patient’s calf
7/99

35.    Question : woman at 32 weeks’ gestation is brought into the emergency

department after an automobile accident. The client is bleeding vaginally and fetal
assessment indicates moderate fetal distress.

Which action should the nurse take first in an attempt to reduce the stress on the
fetus?
A Start intravenous (IV) fluids at a keep open rate.
15/99
B Set up for an immediate cesarean section delivery.
10/99
C Elevate the head of the bed to a semi-Fowler’s position.
5/99
D Administer oxygen via a face mask at 7 to 10 liters per minute.
36/99

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36.    Question : A mother brings her 2-month-old child in to the urgent care clinic
reporting that shortly after the child developed a fever, his voice became muffled,
and he began drooling. Inspiratory stridor is present.

The priority action of the Nurse is to:

A Obtain an order for an antibiotic
6/99
B Call for immediate assistance
19/99
C Inspect the child’s throat for a foreign object
22/99
D Ask the mother if the child has any allergies
19/99

37.    Question :The home care nurse visits a client with chronic obstructive
pulmonary disease (COPD) who is on home oxygen at 2 L per minute. The client’s
respiratory rate is 22 breaths per minute, and the client is complaining of increased
dyspnea.

The nurse should take which initial action?

A Determine the need to increase the oxygen.
30/99
B Call emergency services to come to the home.
15/99
C Reassure the client that there is no need to worry.
3/99
D Collect more information about the client’s respiratory status.
18/99

38.    Question : A client is admitted to the emergency department with complaints

of severe chest pain. The client is extremely restless, frightened, and dyspneic.
Immediate admission prescriptions include oxygen by nasal cannula at 4 L per
minute, troponin, creatinine phosphokinase and isoenzymes blood levels, a chest
x-ray, and a 12-lead electrocardiogram (ECG).

Which action should the nurse take first?

A Obtain the 12-lead ECG
9/99
B Draw the blood specimens.
1/99
C Apply the oxygen to the client.
52/99
D Call radiology to obtain the chest x-ray study.
3/99

Page 11 of 13
39.    Question : A client with a wound infection and osteomyelitis is to receive
hyperbaric oxygen therapy.

During the therapy, which priority intervention should the nurse implement?
A Maintain an intravenous access.
15/99
B Ensure that oxygen is being delivered.
45/99
C Administer sedation to prevent claustrophobia.
4/99
D Provide emotional support to the client’s family.
1/99

40.    Question : while assessing a 2-hour-old neonate , a nurse observes the neonate

to have acrocyanosis .

which nursing action should be performed initially ??

A Activate the code blue or emergency system
6/99
B Do nothing because acrocyanosis is normal in the neonate .
28/99
C immediately take the neonates temperature according to facility policy
13/99
D Notify the physician of the need for a cardiac consult
18/99

41.    Question : A male client is admitted to the hospital with blunt chest trauma
after a motor vehicle accident.

The first nursing priority for this client would be to:

A Splint the chest wall with a pillow
4/99
B Encourage deep breathing and coughing
8/99
C Provide pain relief
5/99
D Assess the client's airway
48/99

42.    Question : You respond to a call for help from the ED waiting room. There is an
elderly patient lying on the floor. List the order for the actions that you must
perform.

A. Establish unresponsiveness.
B. Initiate cardiopulmonary resuscitation (CPR).
C. Call for help and activate the code team.
D. Instruct a nursing assistant to get the crash cart.
A A, D, B, C
6/99
B B, A, D, C
5/99
C A, C, B, D
44/99
D B, C, D, A
10/99

Page 12 of 13
43.    77-year-old man was admitted 1 hour ago with signs and symptoms of
myocardial infarction. The patient was attached to a cardiac monitor for frequent
assessment.

If the nurse notes premature ventricular contractions on the ECG rhythm strip,
which of the following must be the priority action of the nurse?
A Review electrolytes; check for the patient’s serum potassium levels.
8/99
B Monitor for escalating PVCs
3/99
C Inform the physician.
13/99
D Administer oxygen
41/99

44.    The client is 2 days postoperative abdominal aortic aneurysm. Which

interventionshould RN implement first when making initial rounds?
A Auscultate the client’s bowel sounds.
26/99
B Assess the client’s surgical dressing.
25/99
C Encourage the client to splint the incision.
4/99
D Monitor the client’s intravenous therapy.
10/99

45.    A client is hospitalized with numerous acute health problems. According to

Maslows basic needs model, which nursing diagnosis would take the highest
priority?
A Risk for Injury related to unsteady gait
13/99
B Altered Nutrition, Less than Body Requirements related to inability to absorb nutrients
40/99
C Self-Care Deficit related to weakness and debilitation
8/99
D Powerlessness related to chronic disease state
4/99

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