A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth
every day." Which of the following components of the
... [Show More] prescription should the nurse question? -
The dose
2. A client who reports shortness of breath requests her nurse's help in changing positions. After
repositioning the client, which of the following actions should the nurse take next? - Observe
the rate, depth, and character of the client's respirations.
3. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of
the following actions should the nurse take? - Lower the client to the floor and place a pad
under the client's head.
4. A home health nurse is planning to provide health promotion activities for a group of clients in
the community. Which of the following activities is an example of the nurse promoting primary
prevention? - Educating clients about the recommended immunization schedule for adults
5. A nurse is using the I-SBAR communication tool to provide the client's provider with information
about the client. The nurse should convey the client's pain status in which portion of the report?
- Assessment
6. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse
should identify that which of the following findings is an indication of infiltration? - Edema at the
infusion site
7. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client? - Washing dishes8. A nurse is caring for a client who has acute renal failure. Which of the following assessments
provides the most accurate measure of the client's fluid status? - Daily weight
9. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several
weeks. Which of the following methods of assessment should the nurse use first? - Inspection
10. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse
should ensure that a written consent form has been signed by which of the following clients? - A
client who has a prescription for a transfusion of packed red blood cells
11. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of
urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the
smell. Which of the following responses should the nurse make? - "It must be difficult to care for
someone who is confined to bed."
12. A nurse in a provider's office is assessing a client who has heart failure. The client has gained
weight since her last visit and her ankles are edematous. Which of the following findings by the
nurse is another clinical manifestation of fluid volume excess? - Bounding pulse
13. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the
following actions should the nurse take first after discovering that the client's wound has
eviscerated? - Cover the incision with a moist sterile dressing.
14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch
gait. Which of the following instructions should the nurse include in the teaching? - "Bear weight
on both of your legs."
15. A nurse in a provider's office is collecting information from an older adult client who reports
that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should
instruct the client that large doses of acetaminophen could cause which of the following adverse
effects? - Liver Damage
16. A nurse is planning to document care provided for a client. Which of the following abbreviations
should the nurse use? - PC for after meals17. A nurse is responding to a parent's question about his infant's expected physical development
during the first year of life. Which of the following information should the nurse include? - A 10-
month-old infant can pull up to a standing position.
18. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an
indwelling urinary catheter. Which of the following actions by the AP indicates a need for
further teaching? - The AP hangs the collection bag at the level of the bladder.
19. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that
the provider has prescribed a medication that is unfamiliar to her. Which of the following
actions should the nurse take? - Consult the medication reference book available on the unit.
20. A nurse is providing oral care for a client who is unconscious. Which of the following actions
should the nurse take? - Place the client in a lateral position with the head turned to the side
before beginning the procedure.
21. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the
following actions should the nurse take? - Repeat each joint motion five times during each
session.
22. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive
spirometer. Which of the following instructions should the nurse include? - Cough deeply after
each use.
23. A nurse is teaching a client how to self-administer insulin. Which of the following actions should
the nurse take to evaluate the client's understanding of the process within the pyschomotor
domain of learning? - Have the client demonstrates the procedure.
24. A nurse is providing teaching about food choices to a client who has a prescription for a clear
liquid diet. Which of the following selections by the client indicates an understanding of the
teaching? - Gelatin
25. A nurse is performing a neurological assessment for a client. Which of the following
examinations should the nurse use to check the client's balance? - Romberg test26. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills
and aching joints. The nurse should identify which of the following findings as an indication that
the client has an infection? - WBC 15,000 mm3
27. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of
the following injection sites is the safest for this client? - Ventrogluteal
28. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the
following actions should the nurse take? - Fill the bag two-thirds full with ice.
29. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The
client reports gas pains in the periumbilical area. The nurse should plan care based on which of
the following factors contributing to this postoperative complication? - Impaired peristalsis of
the intestines
30. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the
following instructions should the nurse provide to the client and family? - Wear cotton clothing
to avoid static electricity.
31. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The
client states, "You are not putting that hose down my throat." Which of the following
statements should the nurse make? - "I can see that this is upsetting you."
32. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions
should the nurse plan to take? - Position the client on his left side.
33. A nurse on a surgical unit is receiving a client who had abdominal surgery from the
postanesthesia care unit. Which of the following assessments should the nurse make first? -
Airway
34. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following
actions should the nurse take? - Tie the restraint with a quick-release knot.35. A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass,
which of the following types of enemas should the nurse plan to administer to soften the feces?
- Oil retention
36. A nurse is providing education about cultural and religious traditions and rituals related to death
for the assistive personnel on the unit. Which of the following information should the nurse
include? - People who practice Judaism stay with the body of the deceased until burial.
37. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following
actions should the nurse direct the client to take first? -
38. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe
atelectasis. Which of the following actions should the nurse plan to take? - Place the client in
Trendelenburg's position.
39. A nurse is planning care for a client who is postoperative and has a history of poor nutritional
intake. Which of the following actions should the nurse include in the plan of care to promote
wound healing? - Provide a protein intake of 1.5 g/kg of body weight per day.
40. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates
that the client's death is imminent? - Cold extremities
41. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain
and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse
recognizes these manifestations as which of the following types of transfusion reactions? -
Hemolytic
42. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a
client who no longer requires care. Which of the following concepts should the nurse and client
discuss in the termination phase of the relationship? - Loss
43. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions
should the nurse take when assisting the client with feeding? - Sit at the bedside while feeding
the client.44. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the
following actions should the nurse take? - Wear gloves when changing the client's gown.
45. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric
decompression. Which of the following actions should the nurse include in the plan of care?
(Select all that apply.) - -Provide oral hygiene frequently.
-Measure the amount of drainage from the NG tube every shift.
-Secure the NG tube to the client's gown.
46. A nurse is called away for an emergency while conversing with a client who is concerned about
his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the
following ethical principles is the nurse demonstrating? - Fidelity
47. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of
the following assessment findings should the nurse identify as an indication of hypovolemic
shock? - Tachycardia
48. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which
of the following laboratory findings should the nurse expect? - Decreased calcium
49. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to
follow his treatment plans because his friends discourage him. Which of the following
statements should the nurse make? - "Tell me more about how your friends discourage you."
50. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of
the following instructions should the nurse include? - When lifting an object, spread your feet
apart to provide a wide base of support. [Show Less]