A nurse is performing a skin assessment for a client who expresses concern about skin
cancer. Which of the following findings should the nurse identify
... [Show More] as a potential indication
of a skin malignancy?
a. A lesion with uniform pigmentation
b. New appearance of petechiae
c. A mole with asymmetrical appearance
d. The presence of a papule
2. A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the
client’s pain?
a. “Is your pain constant or intermittent?”
b. “What would you rate your pain on a scale of 0 – 10?”
c. “Does the pain radiate?”
d. “Is your pain sharp or dull?”
3. A nurse is admitting a new client. Which of the following actions should the nurse take
while performing medication reconciliation?
a. Verify the client’s name on their identification bracelete with the medication
administration record.
b. Call the pharmacy to determine whether the client’s medications are available.
c. Compare the client’s home medications with the provider’s prescriptions.
d. Place the client’s home medication bottles in a secure location.
4. A nurse is auscultating the anterior chest of a client who has newly admitted to a
medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the
stethoscope and identify the type of breath sounds.
a. Normal breath sounds.
5. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the
following actions should the nurse take?
a. Administer the medications with the needle at a 45 degree angle.
b. Administer the medication into the client’s nondominant arm.
c. Pull the client’s skin laterally or downward prior to administration.
d. Massage the injection site after administration.
6. A nurse is using an open irrigation technique to irrigate a client’s indwelling urinary
catheter. Which of the following actions should the nurse take?
a. Place the client in a side-lying position.
b. Instill 15 mL of irrigation fluid into the catheter with each flush.
c. Subtract the amount of irrigant used from the client’s urine output.
d. Perform the irrigation using a 20-mL syringe.
7. A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury.
Which of the following types of dressing should the nurse use?
a. Alginate
b. Gauze
c. Transparent
d. Hydrocolloid
8. A nurse is providing discharge teaching to a client about self-administering heparin.
Which of the following instructions should the nurse include in the teaching?
a. Insert the needle at a 15 degree angle.
b. Aspirate for blood return prior to administration
c. Administer the medication into the abdomen
d. Massage the site following the injection.
9. A nurse on a medical-surgical unit is caring for a client who has a new prescription for
wrist restraints. Which of the following actions should the nurse take?
a. Pad the client’s wrist before applying the restraints.
b. Evaluate the client’s circulation every 8 hr after application
c. Remove the restraints every 4 hr to evaluate the client’s status
d. Secure the restraint ties to the bed’s side rails.
10. A nurse is initiating a protective environment for a client who has had an allogeneic stem
cell transplant. Which of the following precautions should the nurse plan for this client?
a. Make sure the client’s room has at least six air exchanges per hour.
b. Make sure the client wears a mask when outside her room if there is
construction in the area.
c. Place the client in a private room with negative-pressure airflow.
d. Wear an N95 respirator when giving the client direct care.
11. A nurse is caring for a client who has dementia. Which of the following interventions
should the nurse take to minimize the risk for injury to the client?
a. Use a bed exit alarm system
b. Raise four side rails while the client is in bed
c. Apply on soft wrist restraint
d. Dim the lights in the client’s room.
12. A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr.
The nurse should set the infusion pump to deliver how many mL/hr?
a. _107_ mL/hr
13. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of
complementary and alternative therapies for pain control. The nurse should inform the
client that this condition is a contraindication for which of the following therapies?
a. Biofeedback
b. Aloe
c. Feverfew
d. Acupuncture
14. A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To
prevent self-injury, which of the following actions should the nurse take when lifting this
object?
a. Bend at the waist
b. Keep his feet close together
c. Use his back muscles for lifting
d. Stand close to the cabinet when lifting it.
15. A nurse is talking with an older adult client who is contemplating retirement. The client
states, “I keep thinking about how much I enjoy my job. I’m not sure I want to retire.”
Which of the following responses should the nurse make?
a. “You would have so much more time to spend with your family.”
b. “You should consider getting a part-time job or doing volunteer work.”
c. “Let’s talk about how the change in your job status will affect you.”
d. “Why wouldn’t you want to retire and relax?” [Show Less]