1. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the
... [Show More] following routes should the nurse use to obtain the temperature? - Temporal
2. A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse takes when she observes the client crying? - Sit and hold the client's hand
3. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? - Screening groups of older adults in nursing care facilities for early influenza manifestations
4. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? - "There are times I should use soap and water rather than an alcohol-based rub to clean my hands."
5. A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. - - Inspection
- Auscultation
- Percussion
- Palpation
6. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? - Second intercostal space to the right of the sternum
7. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? - Count the apical pulse rate for 1 minute, and describe the rhythm in the chart
8. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? - "Using a cuff that is too small will result in an inaccurately high reading."
9. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? - Evaluate pedal pulses
10. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? - Perform hand hygiene
11. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? - Identify the client using two identifiers
12. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? - Place the bladder of the cuff over the posterior aspect of the thigh
13. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? - The nurse washes with her hands held higher than her elbows
14. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notes the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? - Disconnect the machine, and measure the blood pressure manually every 15 minutes
15. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? - Raise the level of the bed
16. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? - Carefully remove the gloves and follow with hand hygiene
17. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? - Pericardial friction rub
18. A nurse is teaching a group of older adults about expected changes of aging. Which of the following statement by a group member indicates that the teaching had been effective? - "I should expect my heart rate to take longer to return to normal after exercise as I get older."
19. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? - Confirm unresponsiveness
20. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? - "Donate autologous blood before the surgery."
21. A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? - Attempt to increase the clients' self-motivation
22. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? - Lock the wheels on the bed of the stretcher
23. A nurse is witnessing a client sign an informed consent for surgery. Which of the following describes what the nurse is affirming by this action? - The signature on the preoperative consent form is the client's
24. A nurse is demonstrating postoperative deep breathing and cough exercised to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? - The client reports severe pain
25. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? - Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
26. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? - Encourage the client to express his thoughts about death and dying
27. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 C (102.6 F), heart rate of 105/min, a soft non-tender abdomen, and menses overdue my 2 days. Which of the following findings should be the nurse's priority? - Temperature
28. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? - The involvement of the client in planning the change
29. A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removes prior to surgery. Which of the following responses should the nurse make? - "What worries you about being without your teeth?"
30. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? - Absent bowl sounds with distention
31. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? - Place the wheelchair at a 45 degree angle to the bed
32. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? - Administer analgesics to the child on routine schedule throughout the day and night [Show Less]