1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of achange

inthe wound care procedure. Which of the following findings indicate wound healing?

a. Erythema on the skin surrounding a client's wound

b. Deep red color on the center of the clients wound

c. Inflammation noted on the tissue edges of a client's wound

d. Increase in serosanguineous exudate from the clients wound

2. A nurse received change of shift report at 0700 for four clients. Which of the

followingactionsshould the nurse perform first?

a. Obtain a breakfast tray for a client who received a morning dose of insulin aspart

b. Administer pain medication to a client who has rheumatoid arthritis and received

thelastdose at 0400

c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900

d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours.

(Toprevent bacterial contamination, fill the bag with only enough formula to lastover a 4–8-

hour period, and change the feeding bag every 24 hours)

3. A nurse is orienting a newly licensed nurse on the neurological unit. Which of

thefollowing clients should the nurse assign to the newly licensed nurse?

a. A client who has multiple sclerosis and ataxia

b. A client who has brain tumor and is admitted for chemotherapy

c. A client who has Guillain-Barre syndrome and a tracheostomy

d. A client who sustained a concussion and is being monitored for complication

4. A nurse is providing teaching to a client about advance directives. Which of

thefollowing statements by the client indicates an understanding of the

teaching?

a. "Once I sign my living will, a family member must cosign it"

b. "I will wait until I have a serious health problem to sign my advance directives"

c. "My doctor will need to provide approval for the decisions outlines in my living will

d. "My durable power of attorney for health care is part of my advance directives"

5. A nurse is chairing a committee about preventing infant abduction in a new birth

carecenter.Which of the following quality control tasks should the nurse assign to be

completed first?

a. Identify the industry standards for infant safety

b. Evaluate the selected infant safety system

c. Choose an infant safety system

d. Establish measurement criteria for infant safety systems

6. A nurse notes that a client is eating about half of the food on his plate and coughs

frequently during meals. The nurse plans to perform dysphagia screening to determinethe

client's need fora referral to which of the following providers?

a. Physical therapist

b. Respiratory therapist