READINESS BENCHMARK 2. EXAM 11

Question 94

READINESS BENCHMARK 2. EXAM 11. The nurse provides education to a client regarding their new prescription for escitalopram oxalate. Which statement by the client indicates that education was effective?

• “I may need to take this medication for 6 months to a year after I feel better.” (Correct Answer)

• “This is the best medication for my problem, there aren’t any bad side effects.”

• “I don’t mind taking this medication, I know I can stop it as soon as I feel better.”

• “I know I can stop taking this medication if the side effects are bad.”

Question 95

The night shift nurse plans discharge teaching for a client with obsessive-compulsive disorder. After reading the previous shift’s nursing notes, which action by the nurse is most appropriate?

• Ignore the statement and continue with the discharge plan. The client is well known by staff and never acts on his threats.

• Assess the client in the morning to see if he is up for discharge and still feels the same way he felt the night before.

• Hold discharge teaching in the morning and notify the health care provider of the findings. (Correct Answer)  READINESS BENCHMARK 2. EXAM 11

• Call the day shift nurse tonight to verify if the client was joking when the statement was made.  READINESS BENCHMARK 2. EXAM 11

Question 96

A client has a chest tube to treat a pneumothorax. The health care provider removes the chest tube per protocol. What is the next priority nursing action?

• Assess the client’s respiratory rate.

• Monitor the client’s level of consciousness.  READINESS BENCHMARK 2. EXAM 11

• Obtain the client’s oxygen saturation level.

• Assess the client’s breath sounds. (Correct Answer)

Question 97

A client with a history of diabetes is admitted for gout exacerbation. Review the electronic health record. In what areas were errors made by the nursing team in the implementation of the client’s care?

• Health care provider notification and diet. (Correct Answer)

• Medication administration activity.

• Pain assessment and pain medication.

• Use of the bed cradle and blood glucose checks.  READINESS BENCHMARK 2. EXAM 11

Question 98

A client presents to the Emergency Department reporting a painful and swollen ankle after falling while playing soccer and is diagnosed with a sprained ankle. In addition to applying a compression bandage and a splint, which intervention should the nurse perform next?  READINESS BENCHMARK 2. EXAM 11

• Place the ankle on two pillows.

• Administer narcotic medication. READINESS BENCHMARK 2. EXAM 11

• Document neurovascular status. (Correct Answer)

• Apply heat to the ankle.

Question 99

Which information should the nurse manager correct when attending an in-service taught by a staff nurse about client rights and responsibilities?

• The Emergency Medical Treatment and Active Labor Act (EMTALA) means you must assess and stabilize all clients and aims to prevent client dumping.

• The Affordable Care Act requires providers to keep educating and asking for consent until clients allow the care ordered. (Correct Answer)

• Civil laws, like state laws and acts, protect individuals’ rights and must be followed.

• Federal statutes address client rights such as the right to receive visitors in skilled nursing facilities.

Question 100

A client is admitted to the coronary care unit for evaluation of chest pain. Following diagnostic tests, the client is discharged with a diagnosis of chronic angina and a prescription for isosorbide dinitrate. The nurse provides education. Which statement by the client indicates an accurate understanding of teaching?

• “I may have double or blurred vision from this medication.”

• “If I get dizzy when I stand up, I need to get up carefully.” (Correct Answer)

• “I need to call the health care provider immediately if I feel light-headed.”  READINESS BENCHMARK 2. EXAM 11

• “If I have a stomachache from this medication, I can take an antacid with it.”