A nurse is planning to collect a stool specimen for ova and parasites from a client who has
diarrhea. Which of the following actions should the nurse
... [Show More] take when collecting the specimen?
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the
following actions should the nurse take?
A nurse is caring for a client who has bilateral cats on her hands. Which of the followingactions
should the nurse take when assisting the client with feeding?
A nurse is providing teaching to a client regarding protein intake. Which of the followingfoods
should the nurse include as an example of an incomplete protein?
A nurse is caring for a client who was admitted to a long-term care facility for rehabilitationafter a
total hip arthroplasty. At which of the following times should the nurse begin discharge planning?
A nurse is preparing to administer a cleansing enema to a client. Which of the followingactions
A nurse is administering an IM injection to a 5-month-old infant. Which of the following
injection sites should the nurse use?
A nurse is caring for a client who has major fecal incontinence and reports irritation in theperianal
area. Which of the following actions should the nurse take first?
A nurse is caring for a client who is postoperative following an abdominal surgery. Which ofthe
following actions should the nurse perform first after discovering the client’s wound has eviscerated?
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurseshould
identify that which of the following findings is an indication of infiltration?
A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to
function during the day. Which of the following interventions should the nurse suggest
to this client?
A nurse is conducting an admission interview with a client. Which of the following pieces of
assessment information should the nurse collect during the introductory phase of the interview?
A nurse is performing an abdominal assessment of a client. Which of the following positionsshould
the nurse tell the client to assume for this examination?
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which ofthe
following actions should the nurse take first?
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?
A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and hasingested
4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should
document for this client? (round to nearest whole number)
A nurse is performing a physical examination of a client. The nurse should use percussion toevaluate
which of the following parts of the client’s body?
A nurse is supervising a newly licensed nurse who is administering a controlled substance.Which
of the following actions by the newly licensed nurse indicates an understanding of the procedure?
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?
A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicates an understandingof the teaching?
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?
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?
A nurse discovers that a client received the wrong medication. Which of the followingactions
should the nurse take first?
A nurse is performing a breast examination for a female client. Which of the following
techniques should the nurse use first?
A nurse is helping a client change his hospital gown. The client has an IV infusion via an
infusion pump. Which of the following actions should the nurse take first?
A nurse is preparing to administer a unit of packed RBC’s to a client when she discovers that the IV
line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min.
Which of the following actions should the nurse take?
A nurse is planning an in-service training session about nutrition. Which of the following
statements should the nurse include in the teaching?
A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of waterwith
each oral medication. How many milliliters of water should the nurse document as intake for the 3
separate medications the client receives during 12-hour night shift? (round to the nearest whole number)
A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluidloss of
approximately 500 to 600 mL occurs each day through which of the following organs?
A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the
following client statements should indicate to the nurse that the client is experiencing spiritual distress?
While in the hospital, a client who has a terminal illness tells the nurse, “I can’t believe I’m dying. A
lot of bad people in the world are healthy and here I am dying!” Which of the followingresponses should
the nurse provide?
A nurse is administering medication to a client who asks the nurse to leave the medication at the
bedside to be taken at a later time. Which of the following responses should the nurse make?
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of thefollowing
actions should the nurse direct the client to take first?
A nurse is admitting a client who will undergo a craniotomy. During the planning phase ofthe
nursing process, which of the following actions should the nurse take?
A nurse in a provider’s office is teaching a client about foods that are high in fiber. Which of the
following food choices made by the client indicate an understanding of the teaching? (SATA)
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?
A middle-aged adult client is discussing future plans with the nurse. Which of the following
statements should the nurse identify as an indication that the client is having difficulty achieving
Erikson’s developmental task for this age group?
A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube.
The specific gravity of the client’s urine is 1.035. Which of the following actions should the nurse
take?
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin.Which
of the following questions should the nurse ask to encourage discussion with the client?
A nurse is planning care for a client who is confused and requires a prescription for wrist
restraints. Which of the following interventions should the nurse include in the plan of care?
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?
A nurse is caring for a middle-aged adult client. The nurse should identify which of the following
statements as an indication that the client has completed Erikson’s developmental taskfor her age group?
A nurse is inserting an NG tube into a client who begins to gag and cough. Which of the
following actions should the nurse take?
An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow
his treatment plans because his friends discourage him. Which of the following statementsshould the
nurse make?
A nurse is teaching a client about the use of a straight-legged cane. Which of the followingclient
actions indicates an understanding of the teaching?
A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided
equally every 12 hr. The medication is available in 80 mg tablets. How many tabletsshould the nurse
administer per dose? (nearest tenth)
A nurse is caring for a client who had a mastectomy and has a self-suction drainage
evacuator in place. Which of the following actions should the nurse take to ensure proper
operation of the device?
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?
A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To
perform adduction, which of the following instructions should the nurse include?
A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which ofthe
following results should the nurse identify as an indication that the client has conductive hearing loss of
the left ear?
A nurse is admitting a client who has decreased circulation in his left leg. Which of the
following actions should the nurse take first?
A new resident provider asks the charge nurse for an access code to review clients’ online records.
The resident is not scheduled to attend the facility’s orientation computer class until nextweek. Which of
the following actions should the nurse take?
A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which ofthe
following client statements should the nurse address first?
A nurse is preparing a client for discharge and providing instructions about performing dressing
changes at home. Which of the following statements should the nurse identify as anindication that
the client understands medical asepsis?
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?
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from abed to a
wheelchair. Which of the following techniques should the nurse use?
A nurse is preparing to provide tracheostomy care for a client. Which of the followingactions
should the nurse perform first?
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent ofstool.
Which of the following personal protective equipment (PPE) items should the nurse don prior to
providing client care? (SATA)
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA)
infection. A dietary assistant asks the nurse what precautions are necessary for entering the client’s room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant?
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires interventions?
A nurse is providing nutritional teaching to a group of clients. Which of the following
definitions for the recommended dietary allowance (RDA) should the nurse include in the
teaching?
A nurse is reviewing a client’s 24 hr dietary recall. The client reports eating a slice of toastedwhite
bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked
potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken,
2 cups of steamed broccoli, and a glass of milk for dinner. This client’s diet is deficient in which of the
following food groups?
A nurse is assessing a client’s pulses of the lower extremities. The nurse should identifywhich
of the following as the location of the most distal pulse?
A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights.
The nurse should identify these findings as manifestations of which of the followingabnormalities?
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention.
Which of the following pieces of information should the nurse include in the teaching?
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular sized cuff for a client who is obese. Which of the following explanations should thenurse give the
AP?
A home health nurse is planning to provide health promotion activities for a group of clientsin the
community. Which of the following activities is an example of primary prevention?
A nurse is performing an admission assessment for a client who has asthma and reportsseveral
food allergies. Which of the following actions should the nurse take first?
A nurse is evaluating the development of a group of clients. According to Erikson, the
developmental task of intimacy vs. isolation occurs during which of the following stages of
development?
A nurse is caring for a client who has cancer and refuses visitors because of his debilitated
physical appearance. Which of the following comments should the nurse make?
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovariancancer.
Which of the following statements by the client indicates she is experiencing psychological distress?
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at
home. Which of the following statements indicates that the nurse understands family-centered care?
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of thefollowing
actions should the nurse take?
A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking
along the hallway and bumping into walls and does not respond to his name. Which ofthe following
actions should the nurse take first?
A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the
following actions should the nurse take to promote the client’s ability to fall asleep?
A nurse is caring for a client who has cancer and is experiencing pain. The nurse should
implement which of the following interventions to assist the client with pain relief?
A nurse is planning care for a client who has a wound infection following abdominal surgery.To
promote healing and fight infection, which of the following vitamins and minerals should the nurse plan
to increase in the client’s diet?
A nurse is caring for a client who has a terminal illness. The client is restless and reports severe
pain but refuses the prescribed opioid pain medication. Which of the following actionsshould the
nurse take first?
A nurse is monitoring a client’s fluid intake. For breakfast, the client consumed 8 oz of milk,10 oz of
water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How
many mL should the nurse record as the client’s fluid intake? (Nearest whole number)
A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the followingclient
positions demonstrates an understanding of supination of the hand?
A nurse has received a prescription for dextran to administer to a client. The nurse should
recognize that dextran belongs in which of the following functional classifications?
A nurse is preparing to administer liquid medication from a bottle to a client. Which of the
following actions should the nurse take first?
A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver
morphine for pain management. Which of the following statements should the nurseidentify as an
indication that the client understands the instructions?
A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the
administration of enteral feeding. Which of the following methods should the nurse use toverify correct
tube placement? (SATA)
A nurse is preparing to insert an NG tube for a client. Which of the following actions willhelp
facilitate the insertion of the tube? (SATA)
A nurse is caring for a client who is receiving IV fluid replacement. Which of the followingfindings
should the nurse identify as infiltration of the IV infusion site?
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? (SATA)
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Whichof the
following actions should the nurse take?
A nurse is planning care for a client who has a prescription for collection of a sputum specimen for
culture and sensitivity. Which of the following actions should the nurse take whenobtaining the
specimen?
After assessing a client, the nurse documents “1+ pedal edema bilaterally.” This indicates that the
nurse observed an indentation of which of the following depths after applying pressure?
A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous
enteral feedings. Which of the following actions should the nurse perform to reducethe client’s risk of
aspiration?
A nurse is caring for a client who requires a dressing change. Which of the following actionsshould
the nurse take?
A nurse is planning care for a group of clients receiving oxygen therapy. Which of the
following clients should the nurse plan to see first?
A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with
both hands and appears frightened. Which of the following actions should the nurse takefirst?
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular
accident. Which of the following actions should the nurse take when assisting the client at mealtime?
A nurse is caring for a client who reports feeling a pop after coughing without properly
splinting an abdominal incision. On assessment, the nurse notes that the client’s wound has
eviscerated. Which of the following actions should the nurse take? (SATA)
A nurse documents the presence of clubbing of the fingernails for a client who has
emphysema. Which of the following is the underlying cause of this finding?
A nurse delegates the collection of a client’s temperature to an AP. The nurse notes inthe
documentation that the AP obtained the client’s axillary temperature; however, the nurse wanted an
oral temperature. The nurse should identify that which of the following rights of delegation should
have prevented this situation from occurring? [Show Less]