1. A nurse in a long-term care facility is assisting with an inservice for newly hired assistive personnel about legal issues within the facility. Which

ofIthe following should the nurse include as an example ofIassault?

ANS: Informing a client the nurse is going to administer an injection even thoug

h the client refuses

.

2. A nurse is collecting data from who is severe pain. Which ofIthe following questions s

hould the nurse ask first?

ANS: "Where is your pain located?"

3. A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. F

or which of the following results should the nurse notify the provider?

ANS: Platelet count 95,000 mm3

4. A nurse is performing a dressing change for a client who had abdominal surgery 5 day

s ago. The nurse notes organs protruding from the incision. Which ofIthe following act

ions should the nurse take?

ANS: Cover the exposed area with sterile, saline-soaked dressings.

5. A nurse is speaking with the adult daughter ofIa client who has Alzheimer's disease. T

he daughter states, "I love my dad, but caring for him is wearing me out." Which ofIth

e following response should the nurse make?

.

.

ANS: "Let's discuss how caring for your father is afollowingecting your health.

6. A nurse is contributing to the plan ofIcare for a care for a client who has chest tube co

nnected to a closed drainage system. Which ofIthe following actions should the nurse i

nclude in the plan of care?

ANS: Maintain the drainage system below the level ofIthe client's chest.

7. A nurse in an acute mental health facility is caring for a client who has borderline pers

onality disorder and reports. "I am going to kill my girlfriend when I get out ofIhere."

Which ofIthe following actions should the nurse take?

ANS: Notify the client's care team of the threats against the partner