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A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (SATA) A) Home health care |
A) Home health care B) Rehabilitation facilities D) Skilled nursing facilities |
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A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (SATA) A) Preferred provider organization (PPO) |
B) Medicare E) Medicaid |
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A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A) Collaborating with providers to perform obesity screenings during routine office visits. |
A) Collaborating with providers to perform obesity screenings during routine office visits. |
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A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A) Monitoring evidence-based practice for clients who have a specific diagnosis |
B) Ensuring that HCP comply with regulations |
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A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse identify as tertiary care? (SATA) A) ICU |
A) ICU B) Oncology treatment center C) Burn center |
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A nurse is caring for a client who is 24 hours post operative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurses report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A) Basic |
A) Basic |
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A nurse receives a RX for an antibiotic for a client who has cellulitis. The nurse checks the clients medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a RX for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A) Fairness |
B) Responsibility |
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A nurse is caring for a client who is 24 hours postoperative following abdominal surgery. The nurse suspects the clients pain management is inadequate. Which of the following data reinforce this suspicion? (SATA) A) The client seems easily agitated |
B) The client is nonadherent with coughing, deep breathing, and dangling. C) The client may have pain medication every 4 to 6 hr but accepts it every 6 to 7 hr. E) The clients vital signs are HR 110/min, RR 20/min, temp 98.6 F, and BP 136/80 mm Hg. |
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A nurse is caring for a client who has a new RX for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A) Knowledge |
A) Knowledge |
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A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A) Confidence |
D) Discipline |
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A nurse in a providers office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a hx of three vaginal births, but no serious accidents of illnesses. Which of the following interventions should the nurse suggest for helping to control of eliminate the clients incontinence? (SATA) A) Limit total daily fluid intake |
B) Decrease of avoid caffeine D) Avoid drinking alcohol |
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A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A) Check to see whether the catheter is patent. |
A) Check to see whether the catheter is patent. |
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A nurse is caring for a client who has a RX for a 24-hr urine collection. Which of the following actions should the nurse take? A) Discard the first voiding |
A) Discard the first voiding |
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A nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? (SATA) A) Frequent sexual intercourse |
A) Frequent sexual intercourse D) Location of the urethra in relation to the anus E) Frequent catheterization |
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A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (SATA) A) Establish a schedule of urinating prior to meal times. |
B) Have the client record urination times C) Gradually increase the urination intervals D) Remind the client to hold urine until the next scheduled urination time |
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A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of which of the following ethical principles? A) Fidelity |
B) Autonomy |
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A nurse offers pain meds to a client who is post-op prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A) Fidelity |
D) Beneficence |
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A nurse is instructing a group of nursing students about the responsibilities of organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A) Fidelity |
C) Justice |
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A nurse questions a medication RX as too extreme in light of the clients advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A) Fidelity |
D) Nonmaleficence |
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A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A) A nurse on a med-surg unit demonstrates signs of chemical impairment |
C) A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. |
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A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault |
A. Assault |
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An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client’s best interest, so she administers a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed? |
B. False imprisonment |
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A client who will undergo neurosurgery the following week tells the nurse in the surgeon’s office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I’d rather have my brother make decisions for me, but I know it has to be my wife." |
C. "I plan to write that I don’t want them to keep me on a breathing machine." |
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A client is about to undergo an elective surgical procedure. Which of the following actions are A. Make sure the surgeon obtained the client’s consent. |
A. Make sure the surgeon obtained the client’s consent. B. Witness the client’s signature on the consent form. |
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A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? |
C. Report her observations to the nurse manager on the unit. |
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A nurse is caring for a 20 YO client who is sexually active and has come to the college health clinic for the first time for a checkup. Which of the following interventions should the nurse perform first to determine the client’s need for health promotion and disease prevention? |
C. Determine the client’s risk factors. |
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A nurse at a provider’s office is talking with a 45-year-old client who has no specific family history of |
B. "For now, I should continue to have a mammogram each year." |
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A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy |
B. Nutrition presentation |
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A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for CV disease. Which of the following interventions should the nurse include? (SATA) A) Help the client see the benefits of her actions |
A) Help the client see the benefits of her actions B) Identify the clients support systems C) Suggest and recommend community resources E) Teach stress management stratagies |
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A nurse in a health clinic is caring for a 21 YO client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A) Testicular examination |
A) Testicular examination |
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By the second post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief |
A. Reassess the client to determine the reasons for inadequate pain relief |
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A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain med 6 hr ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment |
A. Assessment |
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A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (SATA) A. RR of 22/min with even, unlabored respirations |
A. RR of 22/min with even, unlabored respirations D. Skin in pink, warm, and dry E. The AP reports the client walked with a limp |
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A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (SATA) A. Writing a prescription for morphine sulfate as needed for pain |
C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure ulcer risk |
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A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." |
A. "I will determine the most important client problems that we should address." |
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A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. decreased subQ fat |
C. Pressure ulcer |
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A nurse is caring for a client who is post-op. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (SATA) A. instruct client not to perform Valsalva maneuver |
B. apply elastic stockings E. assist client to change position often |
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A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. encourage the client to perform antiembolic exercises every 2 hr |
A. encourage the client to perform antiembolic exercises every 2 hr |
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A nurse is evaluating teaching on a client who has a new RX for a sequential compression device. Which of the following client statements should indicate the client understands? A. "This device will keep me from getting sores on my skin." |
B. "This thing will keep the blood pumping through my leg." |
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A nurse is instructing a client who has an injury to the left lower extremity about the use of a cane. Which of the following instructions should the nurse include? (SATA) A. hold cane to right side |
A. hold cane to right side B. keep 2 points of support on floor D. after advancing care, more weaker leg forward |
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A nurse in a provider’s office is preparing to assess a young adult male client’s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA) A. Concave thoracic spine posteriorly |
C. Concave lumbar spine posteriorly E. Muscles slightly larger on his dominant side |
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A nurse is assessing a client’s neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items? A. A word she whispers 30 cm from his ear |
D. A familiar object she places in his hand |
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A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the clients ability to perform which of the following activities? A. Mopping her floors |
C. Fastening her bra being her back |
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A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client’s balance? (SATA) A. Romberg test |
A. Romberg test B. Heel-to-toe walk |
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A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the A. Slower light touch sensation |
B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline |
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When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing A. keep the sterile field at least 6 ft away from the client’s bedside. |
C. place a mask on the client to limit the spread of micro-organisms into the surgical wound. |
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A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in A. The flap closest to the body |
D. The flap farthest from the body |
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A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the A. A bottle containing a sterile solution |
C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand |
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A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the A. Apply 3 to 5 mL of liquid soap to dry hands. |
B. Wash the hands with soap and water for at least 15 seconds D. Use a clean paper towel to turn off hand faucets. |
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A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the A. The provider drops a sterile instrument onto the near side of the sterile field. |
B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. |
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A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is A. Planning and evaluating control and prevention strategies |
A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks |
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A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some A. Allergic reaction |
D. Herpes zoster |
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A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal |
D. Illness |
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A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a A. Fever |
A. Fever B. Malaise E. Increase in pulse and respiratory rate |
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A nurse is contributing to the plan of care for a client who is being admitted to the facility with a A. Place the client in a room that has negative air pressure of at least six exchanges per hour. |
B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable E. Wear a gown when performing care that may result in contamination from secretions. |
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A nurse in a provider’s office is preparing to assess a client’s skin as part of a comprehensive physical A. Capillary refill in 2 seconds |
A. Capillary refill in 2 seconds D. Thick skin on the soles of the feet E. Numerous light brown macules on the face |
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A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? A. Thin, parchment like skin |
B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity |
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A nurse is assessing post-op circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (SATA) A. ROM |
B. Skin color C. Edema E. Skin temperature |
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A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (SATA) A. Acne |
D. Herpes simplex E. Varicella |
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A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor |
B. Cyanosis |
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A nurse is caring for a client who recently had a CVA and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (SATA) A. Increase the volume in your voice |
B. Make sure only one person speaks at a time D. Allow plenty of the time for the client to respond E. Use brief sentences with simple words |
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A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment |
C. Provide a quiet room and limit stimulation |
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A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (SATA) A. Weber test showing lateralization to the right ear |
A. Weber test showing lateralization to the right ear D. Rinne test showing less time for air and bone conduction |
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A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (SATA) A. Furosemide |
A. Furosemide B. Ibuprofen |
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A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." |
D. "I take the batteries out of my hearing aids when I take them off at night." |
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A nurse is caring for an adolescent who client who is 2 days post-op following an appendectomy and has type I DM. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (SATA) A. Extremes in age |
B. Impaired circulation C. Impaired/suppressed immune system |
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A nurse is collecting data from a client who is 5 days post-op following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (SATA) A. Increase in incisional pain |
A. Increase in incisional pain B. Fever and chills C. Reddened wound edges |
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A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (SATA) A. Stage III pressure ulcer |
A. Stage III pressure ulcer E. Open burn area |
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A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (SATA) A. Cover the area with saline-soaked sterile dressings. |
A. Cover the area with saline-soaked sterile dressings. D. Position the client supine with his hips and knees bent. |
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A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (SATA) A. Keep the head of the bed elevated 30 degrees. |
A. Keep the head of the bed elevated 30 degrees. D. Have the client sit on a gel cushion when in a chair. |
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A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (SATA) A. Place a belt restraint on the client when he is sitting on the bedside commode |
C. Make sure that the clients call light is within reach D. Provide the client with nonskid footwear E. Complete a fall-risk assessment |
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A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." |
B. "I will go to the nurses station for assistance." |
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A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurses priority? A. Extinguish the fire |
C. Move clients who are near by |
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A nurse is caring for a client who has a history of falls. Which of the following is the nurses priority? A. Complete a fall-risk assessment |
A. Complete a fall-risk assessment |
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A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses station? A. A middle adult who is post-op following a laproscopic cholecystectomy |
D. An older adult who is post-op following a below-the-knee amputation |
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A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. |
B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home. |
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A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states that the client who has heat stroke will have which of the following? A. Hypotension |
A. Hypotension |
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A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130 F." |
D. "Once my infant starts to push up, I will remove the mobile from over the crib." |
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A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of A. Carbon monoxide has a distinct odor. |
D. Carbon monoxide binds with hemoglobin in the body. |
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A home health nurse is discussing the dangers of food poisoning with a client. Which of the following A. Most food poisoning is caused by a virus. |
B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. E. Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning. |
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A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following A. Supine |
B. Semi-Fowler’s |
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A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is A. Obtain a walker for the client to use to transfer back to bed. |
D. Assess the client’s ability to help with the transfer. |
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A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow. |
C. Sit on the side of her bed and rest her arms over follows on top of her bedside table. |
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A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following A. Request assistance when repositioning a client. |
A. Request assistance when repositioning a client. B. Avoid twisting the spine or bending at the waist. D. Use smooth movements when lifting and moving clients. |
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A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (SATA) A. "My line of gravity should fall outside my base of support." |
B. "The lower my center of gravity, the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." |
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A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority? A. A client who received crush injuries to the chest and is expected to die |
C. A client who has partial thickness and full thickness burns to the face, neck, and chest |
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A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (SATA) A. Open doors to client rooms |
B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes |
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An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water |
C. Brush the chemical off the skin and clothing |
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A nurse on a med-surg unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (SATA) A. A client who is dehydrated and receiving IV fluid and electrolytes |
C. A client who is scheduled for elective surgery D. A client who has chronic HTN and BP 135/85 mm Hg |
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A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids. |
B. Instruct the client to tuck her chin when swallowing. |
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A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat |
D. Carbohydrates |
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A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the A. Cooked barley |
C. Vanilla custard |
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A nurse in a senior center is counseling a group of older adults about their nutritional needs and A. Older adults are more prone to dehydration than younger adults are. |
A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. |
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A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent A. "Water helps clear the tube so it doesn’t get clogged." |
A. "Water helps clear the tube so it doesn’t get clogged." |
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A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the A. Check how long the feeding container has been open. |
B. Verify the placement of the NG tube. |
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A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following A. Auscultate breath sounds. |
B. Stop the feeding. |
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A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (SATA) A. Auscultate bowel sounds. |
A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. |
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A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the A. Review a signal the client can use if feeling any distress. |
A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client’s chest. |
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A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the A. Eating more protein is optimal prior to testing. |
D. The specimen cannot be contaminated with urine. |
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A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni and cheese |
B. Fresh fruit and whole wheat toast |
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A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the A. Bradycardia |
B. Hypotension C. Fever D. Poor skin turgor |
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A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic A. Warm the enema solution prior to instillation. |
A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. |
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While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the A. Have the client hold his breath briefly. |
D. Lower the enema fluid container. |
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A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (SATA) A. Restlessness |
A. Restlessness B. Tachypnea E. Pallor |
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A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already A. Increase the oxygen flow. |
B. Assist the client to Fowler’s position. |
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A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are A. Apply suction while withdrawing the catheter. |
A. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Limit suctioning to two to three attempts. |
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Which of the following actions should the nurse A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. |
A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. |
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A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client A. Apply petroleum jelly around and inside the nares. |
C. Check the position of the cannula frequently. D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location. |
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A nurse is using an interpreter to communicate with a client. Which of the following are appropriate A. Talk to the interpreter about the family while the family is in the room. |
B. Ask the family one question at a time. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk. |
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A nurse is caring for a client who shares the same religious background. Which of the following information should the nurse anticipate? A. members of the same religion share similar feelings about their religion. |
C. the same religious beliefs may influence individuals differently. |
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A nurse is caring for a client who is crying while reading from his devotional book. Which of the A. Contact the hospital’s spiritual services. |
C. Provide quiet times for these moments. |
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A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a A. "I will make sure the menu includes kosher options." |
B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer." |
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A nurse is caring for a client who is a Jehovah’s Witness and is scheduled for surgery as a result of a A. "I believe in this case you should really make an exception and accept the blood transfusion." |
D. "Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution." |
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A nurse in a providers office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following responses should the nurse ask when collecting data about the clients difficulty sleeping? (SATA) A. "Does your lack of sleep interfere with your ability to function during the day?" |
A. "Does your lack of sleep interfere with your ability to function during the day?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds when you are asleep?" E. "Tell me about any personal stress you are experiencing." |
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A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (SATA) A. Practice muscle relaxation techniques |
A. Practice muscle relaxation techniques B. Exercise each morning D. Alter the sleep environment for comfort E. Limit fluid intake to at least 2 hr before bed |
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A nurse is caring for an older adult client who has been following the facilities routines and bathing in the morning. However, at home, she always takes a warm bath just before bed time. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the clients back for 15 minutes before bedtime |
C. Allow the client to take a bath in the evening |
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A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining REM sleep, which of the following characteristics should the nurse include? (SATA) A. REM sleep provides cognitive restoration |
A. REM sleep provides cognitive restoration C. It is difficult to awaken a person in REM sleep E. Vivid dreams are common during REM sleep |
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A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I’ll add plenty of carbs to my meals." |
B. "I’ll take a short nap whenever I feel sleepy." |
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A nurse is caring for a client whose partner passed away 4 months ago and who has been recently A. "It takes time to get over the loss of a loved one." |
B. "You are right; I cannot really understand. Perhaps you’d like to tell me more about what you’re feeling." |
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A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client’s vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage |
C. Alarm reaction |
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A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following A. Suggest coping skills for the client to utilize in this situation. |
B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client’s priorities. E. Encourage the client in the expression of feelings and concerns. |
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A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client’s role problem? A. Role conflict |
A. Role conflict |
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A nurse caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally |
D. Convening a family meeting |
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A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing |
B. Reflecting |
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Which of the following actions should the nurse take when using the communication technique of active listening? (SATA) A. Use an open posture |
A. Use an open posture C. Establish and maintain eye contact E. Respond positively when giving feedback |
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A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (SATA) A. "You will do great! You just have to get used to it." |
C. "Your daily routines will be different when you get home." D. "Tell me about your support system you’ll have after you leave the hospital." E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming." |
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Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and client |
B. Encourage the client to communicate his thoughts and feelings |
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A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the childs arm |
B. Sit at eye level with the child |
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A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether or not he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associate manifestations |
A. Presence of associate manifestations |
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A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the clients pain? A. Ask the client what precipitates the pain |
C. Offer the client a pain scale to measure his pain |
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A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain |
D. A client who has episodic back pain following a fall 2 yr ago |
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A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (SATA) A. Urinary incontinence |
C. Bradypnea D. Orthostatic hypotension E. Nausea |
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A nurse is caring for a client who is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I’ll wait to use the device until it’s absolutely necessary." |
C. "I should tell the nurse if the pain doesn’t stop while I am using the device." |
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A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? A. Offer info on a relaxation technique and ask the client if he is interested in trying it |
A. Offer info on a relaxation technique and ask the client if he is interested in trying it |
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A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes which of the following ingredients? A. Chamomile |
A. Chamomile |
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A nurse is reviewing CAM therapies with a group of nursing students. The nurse should classify which of the following as a mind-body therapy? (SATA) A. Art therapy |
A. Art therapy C. Yoga E. Biofeedback |
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A nurse is teaching a group of nursing students on CAM therapies the can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (SATA) A. Guided imagery |
A. Guided imagery C. Meditation D. Music therapy |
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A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? A. Tell the client the goal of the therapy as to promote healing |
B. Ask whether the client is comfortable with using prayer |
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A nurse is preparing information for change-of-shift report. Which of the following information should A. The client’s input and output for the shift |
C. A bone scan that is scheduled for today |
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A nurse is reviewing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse include? (SATA) A. A single electronic records password is provided for nurses on the same unit |
B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client can request a copy of her medical record E. A nurse may photocopy a clients medical record for transfer to another facility |
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A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a clients record? (SATA) A. Cover errors with correction fluid and write in the correct information |
B. Put the date and time in all entries C. Document objective data, leaving out opinions |
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A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (SATA) A. Medication error |
A. Medication error B. Needlesticks D. Omission of prescription |
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A nurse is receiving a providers RX by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (SATA) A. Repeat the details of the RX back to the provider |
A. Repeat the details of the RX back to the provider B. Have another nurse listen to the telephone RX C. Obtain the providers signature on the RX within 24 hr |
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A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? A. client is able to discuss the appropriate technique |
B. client is able to demonstrate appropriate technique |
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A nurse in a providers office is collecting data from the mother of a 12 month old infant. Client states her son is old enough for toilet training. Following an educational session with a nurse the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the domains? A. cognitive |
B. affective |
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A nurse is providing pre-op education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. i dont want my spouse to see my incision |
C. can you tell me about how long the surgery will take |
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A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following actions should the nurse take when first meeting with the client? A. encourage client to participate actively in learning |
D. determine what the client know about stress incontinence |
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A nurse is evaluating how well a client learned the info he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the clients learning? A. encourage client to ask questions |
B. ask client to explain how to select or prep meals |
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A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to his room |
A. Orient the client to his room |
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A nurse is admitting a client who has acute cholecystitis to a med-surg unit. Which of the following actions are essential steps of the admission procedure? (SATA) A. Explain the roles of other care delivery staff |
A. Explain the roles of other care delivery staff B. Begin discharge planning C. Provide info about advance directives E. Introduce the client to his roommate |
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A nurse is caring for a client who has had a stroke and is scheduled for transfer to a rehab center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (SATA) A. Ensure that the client has possession of his valuables |
A. Ensure that the client has possession of his valuables B. Conform the the rehab center has room available at the time of transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility |
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A nurse is preparing for the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following info about the client should the nurse include in the discharge summary? (SATA) A. Advance directive status |
B. Follow-up care C. Instructions for diet and medications E. Contact info for the home health care agency |
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As part of the admission process, a nurse at a long-term facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the clients family? A. BMI |
D. Any difficulty swallowing |
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Trust vs. Mistrust |
Infancy (0-1) A sense of trust requires a feeling of physical comfort & minimal amount of fear about the future. Infant’s basic needs are met by responsive, sensitive caregivers. Important event: feeding |
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Autonomy vs. Shame and doubt |
Toddler (1-3) after gaining trust infants discover they have a will. They assert their sense of autonomy or independence. If restrained or punished too harshly, they are likely to develop a sense of shame & doubt Important event: toilet training |
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Initiative vs. guilt |
Preschool (3-5) learn to initiate tasks and carry out plans or they feel guilty about efforts to be independent Important event: independence |
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Industry vs. Inferiority |
Elementary school (6-puberty) Children direct their energy toward mastering knowledge & intellectual skills. The danger at this stage involves feeling incompetent & unproductive. Important event: school |
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Identity vs. Role confusion |
Adolescence (teens-20s) Teenagers work at refining a sense of self by testing roles and then intergrating them in form a single idenity or become confused about who they are Important event: peer relationships |
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Intimacy vs. Isolation |
Young adulthood (20s-early 40s) Young adults struggle to from close relstionships and to gain the capacity for intimate love, or they feel socially isolated Important event: love relationships |
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Generatively vs. Stagnation |
Middle adulthood (40s-60s) The middle-aged discover a sense of contrbuting to the world usually through family and work, or they feel a lack of purpose Important event: parenthood |
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Integrity vs. despair |
Late adulthood (late 60s and up) When reflecting on his or her life the older adult may feel a sense of satisfaction or failure Important event: reflection on/acceptance of ones life |
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