1. Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is
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the amount of:
2. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client:
3. A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client’s skin turgor, the nurse should:
4. A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve commitment to a long-term goal of weight loss?
5. When admitting a client, the nurse records which information in the clients record first?
6. A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following is an appropriate nursing response?
7. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statements?
8. An assistive personnel (AP) says to the nurse, “This client is incontinent of stool three to four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?
9. At a mobile screening clinic, a nurse is assessing a client who reports a history of heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location?
10. A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?
11. A nurse is caring for a client who requires rectal temperature monitoring. Available at the client’s bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take?
12. A nurse is teaching a client who has cardiovascular disease how to reduce his intake f sodium and cholesterol The nurse understands that the most significant factor in planning dietary changes for this client is the
13. A nurse is caring for an older adult who is confused and continually grabs at the nurses. Which of the following is a nursing action?
14. An assistive personnel (AP) tells the nurse, “I am unable to find a large BP cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?” The nurse replies that taking the BP of a morbidly obese client with a regular BP cuff will result in a reading that is:
15. Which of the following should the nurse do first when preparing to provide a tracheostomy care?
16. A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. The client’s surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that:
17. To use proper body mechanics while making an occupied bed for a client on a bed rest, the nurse should:
18. Which of the following should a group of community health nurses plan as part of primary prevention program for occupational pulmonary diseases?
19. When initiating cardiopulmonary resuscitation (CPR), the nurse must conform which of the following assessment findings prior to beginning chest compressions?
20. A nurse on a rehab unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?
21. An older adult client appears agitated when the nurse requests that the client’s dentures be removed prior to surgery and states, “I never go anywhere without my teeth.” Which of the following is an appropriate nursing response?
22. To use the nursing process correctly, the nurse must first
23. A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be:
24. While starting an IV for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?
25. A nurse is precepting a newly licensed who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included:
26. A nurse is caring for a client diagnosed with a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to:
27. When assessing a client’s heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a(n):
28. A client is admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client’s temperature is 102.6F, her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority attention?
29. At the surgical scrub sink, a surgical nurse demonstrates the proper surgical hand washing technique by scrubbing:
30. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should:
31. What is the correct order of the abdominal assessment?
32. When measuring a client’s vitals, the nurse notices an irregularity in the heart rate. Which is the nursing action appropriate?
33. A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the client’s BP?
34. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room the priority action is to:
35. An older adult client just diagnosed with colon caner asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?
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