1. A nurse in a long term care facility notices a client who has alzheimers disease standing at the exit
doors at the end of the hallway. The clients
... [Show More] appears to be anxious and agitated. Which of the following
actions should the nurse take?
Escort the client to a quiet area on the nursing unit
2. A nurse is assisting with the plan of care for a client who has a continent urinary division. Which of the
following interventions should the nurse plan to implement to facilitate urinary elimination?
Use intermittent urinary catheterization for a client at regular intervals
3. A nurse is assisting with an educational program about car restraintsafety for a group of parents.
Whichof the following statements by a parent indicates an understanding of the instructions?
My 12 year old child should place the shoulder lap belt low across his hips
4. A nurse is reinforcing teaching aboutstrategies to promote eating with a client who has COPD. Which
of the following instructions should the nurse include in the teaching?
Drink high protein and high calorie nutritional supplements
5. A nurse is supervising an assistive personnel who is preparing to remove her personal protective
equipment after providing direct care to a client who requires airborne and contact precautions. The
nurse should recognize that the AP understandsthe procedure when she removes which of the following
PPE first?
Gloves
6. A nurse is caring for a client who is crying and states that his provider informed him that he has a
tumor and will need a biopsy. Which of the following responses should the nurse make?
What have you done in the past to help yourself get through stressful situations before?
7. A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report to
the provider
Generalized petechiae
8. A nurse is contributing to a teaching plan for a group of male adolescents about the adverse effects of
anabolic steroid use. Which of the following manifestations should the nurse include
Reduced height potential
9. A nurse is reinforcing teaching with an older adult client who has a severe leftsided heart failure.
Which of the following statements should the nurse make
Rest 15 minutes between activities
10. A nurse in a long term care facility is documenting the care of an older client. Which of the following
information should the nurse include in the weekly nursing care summary
Hydration status
11. A nurse is caring for a client who has a head injury. Using the Glasgow coma scale collection data,
thenurse should obtain which of the following information
Motor response
12. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to
decrease peripheral edema. Which of the following instructions should the nurse include?
Apply stockings in the morning
13. A nurse in a providers office is obtaining a health history from a client who is scheduled to undergo a
cardiac catheterization in 2 days. Which of the following questions is the nurse likely to ask?
Do you know if your allergic to iodine?
14. A nurse is planning to administer nystatin oral suspension to a client who has oral candiasis. Which of
the following instructions should the nurse give to the client?
Hold the medication in your mouth forseveral minutes prior to swallowing
15. A nurse is preparing to care for the assigned clients on her upcoming shift. Which of the following
time management strategies should the nurse plan to use?
Prepare a priority list of client needs for the shift
16. A nurse is preparing to witness a client who is scheduled for surgery sign an informed consent.
Whichof the following actions should the nurse take?
Ask the client if he understands the procedure
17. A nurse in an inpatient mental health clinic is caring for a newly admitted client who has alcohol use
disorder. During a therapy session, the client asks about alcoholics anonymous. Which of the following
responses should the nurse make?
What is your current understanding about the purpose of AA?
18. A nurse is assisting with the care of a client who is 2 days postop following a total knee arthroplasty.
Which of the following tasks should the nurse assign to an assistive personnel?
Reapply antiembolic stockings to the client following a shower
19. A client in a mental health facility unjustly accuses a nurse of stealing money from his room. Which of
the following therapeutic responses should the nurse make?
Tell me how you decided who took your money
20. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the
larynx. Which of the following statements made by the client indicates understanding of the teaching?
I will wear a softscarf around my neck when I am outside
21. A nurse is using the FLACC scale to determine the level of pain for an 11 month old infant who is
postop. Which of the following factors should the nurse consider when using this pain scale?
Level of activity
22. A nurse is reviewing the techniques for transferring a client from bed to chair with a group of
assistive personnel. Which of the following instructions should the nurse include?
Use lower body strength
23. A nurse is reinforcing teaching with a client who is to self administer epoetin alfa. Which of
thefollowing instructions should the nurse include?
Administer the medication subcutaneously
24. A nurse is collecting data from a 5 year old child at a well child visit. The parents reports that the
child is having frequent nightmares. Which of the following statements by the parent indicates to the
nurse that the child is experiencing sleep terrors rather than nightmares
My child goes back to sleep right away
25. A nurse assisting with the care of a school age child immediately following surgery. The child weighs
21.8kg and has a chest tube applied to suction. Which of the following findings should the nurse report
to the provider?
250ml ofsanguineous drainage over the last 3hr
26. A nurse is reinforcing teaching about advanced directives with a client. Which of the following
statements by the client indicates an understanding of the teaching?
I can change my health care decisions even if I have advanced directives
27. A nurse is assisting with the admission of a client who has rubella. Which of the following
transmission-based precautions should the nurse plan to initiate for this client?
Airborne
28. A nurse is administering morning medications to clients on the unit. A client questions the nurse
regarding a medication thatshe does not recognize. Which of the following actions should the nurse take
first?
Verify the prescription in the clients medical record
29. A nurse in an urgent care clinic is collecting data from four clients. Which of the following clients
should the nurse recommend for treatment?
A client who is experiencing shortness of breath after taking amoxicillin
30. A nurse enters a client’s room and sees smoke coming from a wastebasket next to the bed. Which
ofthe following actions should the nurse take first?
Assist the client to a nearby waiting area
31. A nurse is caring for a client who is in the final stages of cancer. Which of the following situations
should the nurse identify as an ethical dilemma?
The client asks the nurse to help her die peacefully in her sleep
32. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which of the
following instructions should the nurse includes?
Apply capsaicin cream 4 times daily
33. A nurse in a urgent care clinic is caring for a child who has a minor burn on his palm after touching
the burner on a hot stove. Which of the following actions should the nurse take?
1. clean the burn with soap and tepid water 2. Remove any embedded debris
3. Apply an antimicrobial ointment 4. Wrap the hand in a gauze dressing
5. Inform the parent of dressing change schedule
34. A nurse on a medical unit is reviewing a clients medical record. Which of the following procedures
should the nurse identify requires the client to sign a separate informed consent?
Lumbar puncture
35. A nurse is reinforcing teaching about managing manifestations of anxiety with a client who has
generalized anxiety disorder. Which of the following information should the nurse include
Say the word stop when upsetting thoughts occur
36. A nurse is performing a dressing change for a client who is 3 days postop. Which of the following
findings should the nurse report to the provider?
Yellow green drainage at the incision line
37. A nurse ina long term care facility is collecting data from a client who has been receiving betaxolol to
treat glaucoma. Which of the following findings in an adverse effect of this medication?
Bradycardia
38. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client following a
lithotripsy for uric acid stones. Which of the following instructions should the nurse plan to include in the
teaching?
Strain the urine to collectstone fragments
39. A nurse is caring for a client who is scheduled for a peritoneal dialysis. Which of the following actions
should the nurse take first?
Ensure the dialysate solution is at room temperature
40. A nurse in a provider’s office is reinforcing teaching with a client who is to follow a 2000mg
sodiumrestricted diet. Which of the following client food selections indicates an understanding of the
teaching?
Canned peaches
41. A nurse enters the room of an adolescent client and finds him on the floor experiencing a tonic clonic
seizure. Which of the following actions should the nurse take when the seizure subsides?
Keep the client in a side lying position
42. A nurse is preparing to perform a bladder scan for a client. Which of the following actions should the
nurse take?
Tell the clientshe should not experience any discomfort
43. A nurse is assisting with the admission of an older adult client. Which of the following actions should
the nurse take first?
Complete a fall risk assessment on the client
44. A nurse is contributing to the plan of care for a client who has a prescription for range of motion
exercises of the shoulder. Which of the following exercises should the nurse recommend to promote
shoulder hyper-extension?
Move her arm behind her body with her elbow straight
45. A nurse is receiving change ofshift report for four clients. The nurse should plan to collect data from
which of the following client’s first
A client who has asthma and had frequently exacerbation on the previous shift
46. A nurse in a providers office is caring for a client who is at 34 weeks of gestation. Which of the
following instructions sh.............................................................CONTINUED [Show Less]