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Question 1 of 5

An elderly client refuses to take her daily medication for hypertension. Which action should the nurse take at this time?

Correct Answer: D

Rationale: Exploring the reason for the client’s refusal respects autonomy and may reveal misunderstandings, fears, or side effects that can be addressed. Administering by injection or with help violates autonomy, and skipping the dose delays treatment without addressing the issue.

Question 2 of 5

The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:

Correct Answer: B

Rationale: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.

Question 3 of 5

Which client should be assigned to the nursing assistant?

Correct Answer: C

Rationale: The elderly client four days post-thyroidectomy is stable and suitable for a nursing assistant’s care (e.g., basic hygiene, ambulation). The other clients require skilled nursing due to critical conditions (cervical fracture, meningitis, recent thoracotomy).

Question 4 of 5

The predominant purpose of the first Apgar scoring of a newborn is to:

Correct Answer: C

Rationale: Apgar scores are not related to the infant's care, but to the infant's physical condition. Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. Congenital malformations are not one of the areas assessed with Apgar scores.

Question 5 of 5

The nurse is evaluating the evidence-based practice used for the units' client care standards. Which of the following provides the most support for evidence-based practice?

Question Image

Correct Answer: B, D, E

Rationale: Evidence-based practice relies on practice guidelines (
B), research articles (
D), and systematic reviews (E) for high-quality evidence. Client preference (
A) and care plans (
C) are individualized but less rigorous.

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