3100 quizzes

incontinence

involuntary leakage of urine

enuresis

involuntary urination; most often used to refer to a child who involuntarily urinates during the night

dysuria

painful or difficult urination

frequency

voiding frequently

W1: The nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A. Adjust the water temperature to feel hot. B. Rub hands and arms to dry. C. Apply 4 to 5 mL of liquid soap to the hands. D. Hold the hands higher than the elbows.

C. Apply 4 to 5 mL of liquid soap to the hands.

W2: A client presents to the emergency department reporting chest pain. The nurse obtains the client's vital signs. The nurse is performing which phase of the nursing process? A. Implementing B. Diagnosing C. Assessing D. Planning

C. Assessing

W2: A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation

C. Assessment

W6: A patient calls the nurse at the health clinic and reports that since his trip to another country, he has been experiencing diarrhea. The nurse suggests he try the antidiarrheal drug A. polycarbophil (FiberCon). B. senna (Senokot). C. loperamide (Imodium). D. docusate sodium (Colace).

C. loperamide (Imodium).

W5: As the nurse, you are providing care for a client who has extreme paleness, the nurse should document this area as A. jaundiced. B. erythema C. pallor D. flushing

C. pallor

W6: The nurse is caring for a client who has urinary urgency. The nurse is aware that a common cause of urgency can include: A. decreased fluid intake B. heart failure C. urinary tract infection D. family history of enuresis

C. urinary tract infection

W1: A nurse is caring for a patient that is unconscious. The nurse knows that in order to promote drainage of secretions when performing oral care, which position is best to place them in? A. Lateral Position B. Reverse Trendelenburg's C. High Fowlers Position D. Prone Position

A. Lateral Position

W1: The nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene? A. Nonantimicrobial soap B. Alcohol-based hand rub C. Povidone-iodine D. Chlorhexidine

A. Nonantimicrobial soap

W1: A nurse is preparing bathing supplies for a client during the morning shift. The client refuses to shower, stating they want to sleep instead. How should the nurse respond to the client's request? A. "You can bathe during the evening shift." B. "Is there a time of day when you prefer to bathe?" C. "Bathing will make you sleep more comfortably." D. "Why don't you want to bathe in the morning?"

B. "Is there a time of day when you prefer to bathe?"

W1: The nurse is assisting a client with denture care. Which of the following actions is appropriate? A. Rinse the dentures in hot water. B. Line the sink with a towel when cleaning. C. Leave the dentures to air dry. (WRONG) D. Use toothpaste when brushing the dentures.

??? B. Line the sink with a towel when cleaning.

W1: The nurse has delegated the task of giving a bed bath to a non-American male client who practices traditional Islamic customs. Which of the following communications to the female unlicensed assistive personnel (UAP) demonstrates appropriate cultural sensitivity to the client? A. "Ask the client's wife if she would like to give the bed bath." B. "Do not make eye contact with the client during the bath." C. "The client may prefer for the UAP not to talk to him during the bath." D. "Touching the head is a sign of disrespect; let the client wash his own face."

A. "Ask the client's wife if she would like to give the bed bath."

W2: Which of the following is an example of an open-ended question that the nurse may use in the interview process? A. "How have you been feeling lately?" B. "Did you take your medication today?" C. "Have you ever had to undergo surgery?" D. "Are you a student at the local college?"

A. "How have you been feeling lately?"

W2: The nurse is providing discharge education for the patient who is going home with a walker. Which statements by the patient indicate a good level of understanding of safety in the home? (Select all that apply.) A. "I need to place a nonskid mat in front of the kitchen sink." B. "I wish I had two ways of leaving the house." C. "I need to remove the throw rugs." D. "I should make sure I only take a bath." E. "I cannot use the stairs."

A. "I need to place a nonskid mat in front of the kitchen sink." C. "I need to remove the throw rugs."

W1: A nurse is performing an intake assessment on a client who is homeless. Which statement by the nurse best assesses the client's hygiene practices? A. "Tell me about your bathing habits." B. "How do you obtain supplies to bathe?" C. "Let me know when you'd like to shower." D. "When was the last time you showered?"

A. "Tell me about your bathing habits."

W5: You are caring for the following clients on the unit. Select all of the patients below who are at risk for a pressure injury: (Select all that apply.) A. 19-year-old female who is a quadriplegic. B. 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. C. 55-year-old female who has controlled diabetes and is ambulating three times a day. D. 76-year-old male with an elevated ammonia level and is excessively sweaty. E. 45-year-old with a Braden Scale score of 7.

A. 19-year-old female who is a quadriplegic. B. 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. D. 76-year-old male with an elevated ammonia level and is excessively sweaty. E. 45-year-old with a Braden Scale score of 7.

W4: When a nurse is providing care for a client who has been diagnosed with rubeola (measles), the nurse should implement which precaution method? A. Airborne B. Droplet C. Contact

A. Airborne

W4: When a nurse is providing care for a client who has been diagnosed with E. Coli, the nurse should implement which precaution method? A. Contact B. Droplet C. Airborne

A. Contact

W6: When a nurse is providing care for a client who has been diagnosed with MRSA, the nurse should implement which precaution method? A. Contact B. Airborne C. Droplet

A. Contact

W2: Which of the following are true related to nursing diagnoses? (Select all that apply.) A. Describes human response to a health problem B. Relates contributing factors or relationships to identified health problem C. Include descriptors and risk factors D. There are not associated legal ramifications E. Describes a disease or pathology of body systems F. Actual or potential physiologic complications related to disease or treatment

A. Describes human response to a health problem C. Include descriptors and risk factors

W5: As the nurse you are providing care for Ms. Rose who has several skin tears on her arms. In providing care for the dressing changes for Ms. Rose, which of the following is an appropriate bandage for these types of wounds? A. Gauze/Bandage B. Hydrocolloid C. Alginate D. Impregnated

A. Gauze/Bandage

W5: As the nurse, you are providing care to a client who is to have ice applied to their knee surgery three times a day. Which of the following is appropriate about the application of ice? A. Ice should be applied in time frames to not exceed 20 minutes. B. Ice can be placed directly on the skin. C. Ice helps with vasodilation. D. Ice helps with chronic conditions.

A. Ice should be applied in time frames to not exceed 20 minutes

W1: The nurse is bathing a client who has a fever. Why should the nurse use tepid bath water for this procedure? A. Increase heat loss B. Reduces surface tension of skin C. Stimulates peripheral circulation D. Removes surface debris

A. Increase heat loss

W5: Mrs. Giles is an 82- year old admitted to the inpatient cardiac unit. Lately, Mrs. Giles has had problems with confusion and has been diagnosed with malnutrition. Identify the interventions that should be implemented by the nurse to prevent pressure ulcer development. (Select all that apply.) A. Keep the HOB at 30 degrees or less. B. Use a moisture barrier ointment on the skin. C. Position the heels and elbows flat on the mattress. D. Turn the client at least every 2 hours. E. Use hot water for bathing. F. Avoid use of antibacterial soaps.

A. Keep the HOB at 30 degrees or less. D. Turn the client at least every 2 hours F. Avoid use of antibacterial soaps.

W2: The nurse is caring for a client who needs to improve support during sleep and relieve pressure on the sacrum. Which position would be appropriate? A. Lateral B. Orthopneic C. Semi-Fowler's D. Dangling

A. Lateral

W4: A nurse is performing a sterile dressing change for a client. Which of the following actions by the nurse would compromise the sterility of the procedure? (Select all that apply.) A. Opening a sterile package and then dropping the item onto a non-sterile field. B. The nurse opens a sterile package and drops a sterile item in the one inch border around the field. C. The nurse leans across the sterile field. D. The nurse turning their back on the sterile field.

A. Opening a sterile package and then dropping the item onto a non-sterile field. B. The nurse opens a sterile package and drops a sterile item in the one inch border around the field. C. The nurse leans across the sterile field. D. The nurse turning their back on the sterile field.

W1: A nurse notes that a client's bed has a frayed cord that plugs into the outlet. Which of the following is the best response? A. Put a sign on the bed that says "do not use", call engineering, and find a different bed B. Be sure it's plugged into a grounded outlet only C. Plug the bed in to see if it's still functional D. Ask engineering for electrical tape to cover the areas that are frayed, and then check to see if the bed is still functional.

A. Put a sign on the bed that says "do not use", call engineering, and find a different bed

W1: A nurse is observing an unlicensed assistive personnel (UAP) change the linens of a client's bed. Which of the following observations requires follow-up? A. The UAP reaches across the bed to straighten the fitted sheet. B. The UAP rolls the client back and forth from one side of the bed to the other to make access easier C. The UAP lowers the side rail on the side closest to them. D. The UAP raises the bed to waist level

A. The UAP reaches across the bed to straighten the fitted sheet.

W2: The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? (Select all that apply.) A. The belt is secure, leaving only enough room for the nurse to grasp the belt. B. The nurse stands behind the patient while ambulating. C. The belt is placed around the patient's hips. D. The nurse holds the belt on the side of the patient. E. The nurse stands on the weaker side.

A. The belt is secure, leaving only enough room for the nurse to grasp the belt. E. The nurse stands on the weaker side.

W1: A nurse is changing a client's bed linens. Which action, if observed, requires follow up by the preceptor? A. The nurse puts all 4 side rails up prior to leaving the room. B. The nurse puts on gloves and a gown before removing bed sheets. C. The nurse makes sure the call-light is in reach before leaving the room. D. The nurse places the drawsheet under the client's hips for transfer.

A. The nurse puts all 4 side rails up prior to leaving the room.

W1: The nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? A. Turn the client on his side before starting oral care. B. Apply petroleum jelly to the client's lips after oral care. C. Use the thumb and index finger to keep the client's mouth open. D. Use a stiff toothbrush to clean the client's teeth.

A. Turn the client on his side before starting oral care.

W4: The nurse is preparing to leave a client's isolation room. Which action should the nurse take first when removing a grossly soiled gown? A. Untie the strings at the waist first. B. Release the neck ties of the gown and allow the gown to fall forward. C. Untie the strings at the neck first. D. Grasp the sleeve of the dominant arm, and remove it with a gloved hand.

A. Untie the strings at the waist first.

W4: The nurse is providing care for a client with hepatitis A. Which technique should the nurse use to promote proper handwashing? A. Use approximately a teaspoon of soap. B. Hold the hands upward under the faucet. C. Allow the water to splatter forcibly when it is turned on. D. Clean the faucet after use.

A. Use approximately a teaspoon of soap.

W1: The charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching? A. Use chlorhexidine to wash hands if the client is immunosuppressed. B. Keep artificial nails trimmed. C. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile. D. Use alcohol-based hand rubs before administering eye drops for a client.

A. Use chlorhexidine to wash hands if the client is immunosuppressed.

W6: The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? (Select all that apply.) A. Use each towelette once, and discard. B. Clean the perineal area from back to front. C. Use all towelettes provided. D. Clean the perineal area from front to back. E. Clean the perineal area using a circular motion.

A. Use each towelette once, and discard. C. Use all towelettes provided. D. Clean the perineal area from front to back.

W4: When a nurse is providing care for a client who has been diagnosed with mumps, the nurse should implement which precaution method? A. droplet B. contact C. airborne

A. droplet

W2: While going down the stairs with crutches the client will move the crutches down onto the step followed by A. moving the injured leg down onto the step. B. moving both legs down onto the step. C. moving the non-injured leg down onto the step.

A. moving the injured leg down onto the step.

W6: The nurse has assessed that a patient's stool has changed from brown to dark black and sticky. The nurse suspects A. presence of occult blood. B. recent excessive intake of milk products. C. blockage of the bile duct. D. blockage of the pancreatic duct.

A. presence of occult blood.

W5: Which of the following interventions is appropriate for preventing excessive heel pressure? A. flexing the knees B. suspending the heels with a pillow C. placing a doughnut-shaped cushion under the feet

B. suspending the heels with a pillow

W6: The nurse is providing instructions to a client at home via telehealth regarding collecting a clean catch urine sample. Which of the following is appropriate client teaching? A. "Collect at least 5 mL of urine." B. "Collect the first voided specimen in the am." C. "Keep the specimen on ice until you bring it to the doctor's office." D. "Void into the sterile cup."

B. "Collect the first voided specimen in the am."

W5: You are performing patient teaching for a client who is going home with a Jackson-Pratt (JP) drain. Which of the following statements by the client would require follow-up? A. "It is important for me to call the doctor if I recognize redness or swelling at the incision site." B. "I should not take showers until the drain is removed." C. "I should call the doctor if the drainage from the JP drain has an odor." D. "I should make sure I eat protein for wound healing."

B. "I should not take showers until the drain is removed."

W1: The nurse is teaching a new group of unlicensed assistive personnel (UAP) about the importance of hand hygiene. Which of the following statements should the nurse include? A. "If you wear gloves, you do not have to wash your hands." B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." C. "If you don't have an infection, your hands won't infect others." D. "Use an alcohol rub when your hands are visibly soiled."

B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."

W1: A charge nurse is making room assignments. Which of the following clients should be moved closer to the nursing station to prevent falls? A. A middle-aged adult who is postoperative following a laparoscopic appendectomy. B. An older adult who is postoperative following a left below the knee amputation. C. A teenager who is on telemetry for dysrhythmias. D. A young adult who is in a cast for a broken tibia.

B. An older adult who is postoperative following a left below the knee amputation.

W5: Down the hall from Ms. Rose, you are providing care and developing a plan of care for a patient who is at risk for pressure injury development. The patient is 75 years old and weighs 95 lbs. The patient is confused and has right and left leg contractures. In addition, the patient has a urinary tract infection and is incontinent of urine. The patient is on aspiration precautions and is ordered a honey thick liquid diet with pureed foods. Select all the nursing intervention you will include in the patient's plan of care to prevent a pressure injury: A. When feeding the patient keep the head of bed elevated at 45′ degree and avoid elevating the foot of the bed. B. Apply barrier cream as needed to the skin daily. C. Turn the patient every 4 hours. D. Keep linens and gowns dry and wrinkle free. E. Use a wedge pillow for the right and left legs daily.

B. Apply barrier cream as needed to the skin daily. D. Keep linens and gowns dry and wrinkle free. E. Use a wedge pillow for the right and left legs daily.

W1: The nurse is providing nail care for a client. Which of the following actions should the nurse take? A. Push the cuticles back with a metal nail file. B. Clean under the nail with an orange stick C. Trim the nails at the lateral corners. D. File the nails in a rounded shape.

B. Clean under the nail with an orange stick

W6: The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? A. Rinse the mouth with mouthwash prior to the collection. B. Cough to bring up secretions. C. Apply sterile gloves. D. Clear the throat.

B. Cough to bring up secretions.

W5: While performing a skin assessment on a patient who is immobile, you note a purplish-black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this: A. Stage 1 pressure injury B. Deep-tissue injury C. Stage 4 pressure injury D. Stage 2 pressure injury

B. Deep-tissue injury

As the nurse, you are positioning clients who had spinal surgery. Which of the following positions is appropriate? A. Sim's B. Dorsal recumbent C. Prone D. Lateral

B. Dorsal recumbent

W2: The nurse is caring for a client who is at risk for contracture after orthopedic surgery. Which of the following would be an appropriate position to place the client in? A. Dangling B. Dorsal recumbent C. Orthopneic D. Lateral

B. Dorsal recumbent

W4: When a nurse is providing care for a client who has been diagnosed with epiglottitis, the nurse should implement which precaution method? A. Contact B. Droplet C. Airborne

B. Droplet

W6: When a nurse is providing care for a client who has been diagnosed with meningitis the nurse should implement which precaution method? A. Contact B. Droplet C. Airborne

B. Droplet

W2: An older adult client is at a greater risk for infection. Which of the following nursing interventions is appropriate to reduce the risk of infection? A. Provide as much opportunity for rest as possible by encouraging bed rest and limited physical exercise. B. Encourage deep-breathing and increased intake of fluids to keep respiratory secretions thin and keep them from accumulating in the lower lungs. C. Provide meals and snacks that are high in calories and fat to provide for weight gain rather than loss. D. Encourage the use of indwelling urinary catheters to drain urine to decrease the likelihood of stagnant urine remaining in the bladder resulting from incomplete emptying.

B. Encourage deep-breathing and increased intake of fluids to keep respiratory secretions thin and keep them from accumulating in the lower lungs.

W1: The nurse is giving a client a bed bath. Which nursing action is most important? A. Lower the 2 side rails on the working side of the bed. B. Ensure that the bathwater is at least 110°F. C. Raise the bed to the highest position. D. Fold the washcloth like a mitt on the hand.

B. Ensure that the bathwater is at least 110°F.

W1: A nurse is educating a client on the effects of immobility. Which of the following, if stated by the patient, indicates they needs additional teaching? A. I may experience more frequent UTI's B. I may develop diarrhea which can lead to skin breakdown C. I may experience pooling of respiratory secretions D. I may experience stiff joints or contractures

B. I may develop diarrhea which can lead to skin breakdown

W2: A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? A. Petechiae B. Nausea C. Blood pressure D. Cyanosis

B. Nausea

W2: The nurse reassesses a client's temperature 45 minutes after administering acetaminophen. This is an example of what type of assessment? A. Routine B. Ongoing C. Intermittent D. Terminal

B. Ongoing

Ms. Rose is lying in the right lateral recumbent position. As the nurse you know which sites below are at most risk for pressure injury in this position? (Select all that apply.) A. Sacral B. Patella C. Ankle D. Ear E. Elbow F. Hip G. Heel I. Shoulder

B. Patella C. Ankle D. Ear F. Hip I. Shoulder

W1: The nurse is teaching a newly hired group of unlicensed assistive personnel (UAP) about infection-control measures on the unit. It is crucial for the nurse to remind the UAPs that which of the following is the most effective way to prevent the spread of pathogens during client care? A. Properly disposing of contaminated equipment B. Performing hand hygiene frequently and consistently C. Changing soiled linens daily for clients who have draining wounds D. Discarding used syringes in appropriate containers

B. Performing hand hygiene frequently and consistently

W1: The nurse in a long-term care facility is observing an unlicensed assistant personnel (UAP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the UAP understands the principles of infection control? A. Holds the soiled linen against her body while carrying it to the linen bag B. Places clean linen that touched the floor in the soiled linen bag C. Places the soiled linen on the floor before bagging it D. Shakes the soiled linen to remove any toilet paper remnants

B. Places clean linen that touched the floor in the soiled linen bag

W5: As the nurse, you are to prevent decubitus ulcerations, which of the following are appropriate measures by the nurse? (Select all that apply.) A. Turn and reposition the client every 4 hours. B. Position the heels to be suspended off the mattress. C. Encourage adequate nutrition and fluid intake. D. Position the client with the head of bed at 90 degrees. E. Use moisture barrier ointment on client's skin.

B. Position the heels to be suspended off the mattress. C. Encourage adequate nutrition and fluid intake. E. Use moisture barrier ointment on client's skin.

W2: The nurse is caring for a client who needs to be positioned after oral surgery. Which position would be appropriate? A. Supine B. Prone C. Fowler's D. Lateral

B. Prone

W5: After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? A. Stage II pressure ulcer B. Reactive hyperemia C. Stage III pressure ulcer D. Stage I pressure ulcer

B. Reactive hyperemia

W1: A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? Select all that apply. A. Wash the client's extremities from proximal to distal. B. Shave the client's hair in the direction of the hair growth. C. Place a clean gown on the strongest arm first. D. Check for personal items when changing the bed linens. E. Keep the bath water temperature between 43.3° C (110° F) and 46.1° C (115° F).

B. Shave the client's hair in the direction of the hair growth. D. Check for personal items when changing the bed linens. E. Keep the bath water temperature between 43.3° C (110° F) and 46.1° C (115° F).

W6: A client needs to be placed in contact isolation. What items should the nurse ensure are included in this client's room? A. Paper towels, sink, and blood pressure cuff, sink, and blood pressure cuff B. Sign on the door C. Surgical masks and sterile gloves D. Cards and records

B. Sign on the door

W7: This member of the healthcare team performs swallow studies for patients who either have or have suspected dysphagia. A. Respiratory therapists B. Speech therapists C. Nursing

B. Speech therapists

W2: When a client uses a cane to ambulate, the client will hold the cane on the: A. It does not matter. The client should choose what side is the most comfortable for them. B. Strong side C. Strong side

B. Strong side

W1: A client who needs maximum support is ambulating with a cane for the first time. After educating the client on proper ambulation with a cane, you assess how well the client understood the instructions. Which findings below demonstrate the proper technique? (Select all that apply.) A. The client moves the weak leg past the cane while walking. B. The cane should hold the cane 6 inches in front and 6 inches to the side of the stronger leg. C. The arm that is holding the cane is flexed at 40-degrees. D. The top of the cane should be level with the hip joint.

B. The cane should hold the cane 6 inches in front and 6 inches to the side of the stronger leg. D. The top of the cane should be level with the hip joint.

W1: The nurse preceptor is observing a new nurse wash their hands. Which of the following, if observed, would require the preceptor to intervene? A. The nurse washes their hands as opposed to using hand gel when they notice blood on their palms B. The nurse rinses from fingertips to wrists, keeping hands with fingers pointing upward, hands slightly together. C. The nurse will use a clean paper towel to dry hands thoroughly in the same order (from wrists to fingers) using a patting motion. D. The nurse washes their hands for 15-20 seconds in a circular motion using lots of friction

B. The nurse rinses from fingertips to wrists, keeping hands with fingers pointing upward, hands slightly together.

W1: A nurse is caring for a client in restraints. When reviewing the order, what should the nurse question? A. The provider states the purpose of the restraint is to prevent the client from physically cutting themselves B. The provider says to only use wrist restraints when the patient shows signs of physical aggression C. The provider states that the staff is to use soft wrist restraints bilaterally D. The provider states the restraint is good for 12hrs until the patient gets his psychiatric evaluation

B. The provider says to only use wrist restraints when the patient shows signs of physical aggression

W2: A client who is ambulating with crutches moves both crutches forward along with the injured leg and then moves the non-injured forward. What type of gait did the client use while ambulating with crutches? A. Four-point gait B. Three-point gait C. Swing-to-gait D. Two-point gait

B. Three-point gait

W6: The nurse is providing care for a client who has scabies. Which of the following is appropriate when providing care to this client? A. Permit no pregnant visitors B. Wear gloves when entering the room C. Place a mask on the client when taking them to X-Ray D. Wear a mask when within 3 feet of this client

B. Wear gloves when entering the room

W6: The nurse is providing care for a client with nocturia. The nurse knows that noctoria is: A. a client who is unable to void at all B. a client who voids two or more times at night C. common with decreased fluid intake D. a symptom of urge incontinence

B. a client who voids two or more times at night

W6: The nurse is providing care for a client who has had a bowel movement which is red in color. The nurse is aware that red stools can often indicate A. malabsorption of fats B. bleeding C. infection D. absence of bile

B. bleeding

W6: As the nurse you are providing care for clients who have continuous bladder leakage as a complication to illnesses such as enlarged prostate, multiple sclerosis, Parkinson's disease which leads to an inability to empty the bladder completely. The nurse would be correct to document this type of incontinence as A. urge B. overflow C. stress D. both stress and urge

B. overflow

W3: The unlicensed assistive personnel (UAP) is obtaining vital signs for a group of clients. It requires intervention if the UAP is observed obtaining oral temperatures for which of the following clients? (Select all that apply). A. the client who is going to surgery in 1 hour B. the client who has had something to drink within the last 10 minutes C. the client who is confused D. client with a high fever

B. the client who has had something to drink within the last 10 minutes C. the client who is confused

W1: The nurse is assessing the client with a hearing deficit for pre-existing knowledge of hearing aid care. Which of the following statements by the client demonstrates correct care? A. "I use a paper clip to clean the microphone port." B. "A whistling sound means I need to have my hearing aid checked." C. "I open the battery door at night." D. "I clean my hearing aids with a disinfectant cleanser weekly."

C. "I open the battery door at night."

W3: The nurse is teaching a client about foot care. The nurse understands that additional teaching is necessary if the client states: A. "I will clean under the nails to prevent infection." B. "I will inspect my feet daily using a mirror to view all surfaces." C. "I will trim my nails with rounded edges using toenail clippers." D. "I will wash my feet daily with soap and water."

C. "I will trim my nails with rounded edges using toenail clippers."

W6: A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? A. It produces a three-dimensional image of an organ. B. It is the use of a magnetic field to produce an image of a body part or organ. C. A radioisotope will be injected to determine organ functioning as being either hot or cold. D. It is more sensitive than an x-ray image.

C. A radioisotope will be injected to determine organ functioning as being either hot or cold.

W5: A student nurse is providing a physical assessment on a client. The student nurse finds a bruised area on the client's right upper arm. Which of the following would indicate a correct understanding of skin assessment terminology? A. A small area of petechia noted on the client's right upper arm. B. A small area of mottling noted on client's right upper arm. C. A small ecchymotic area noted on client's right upper arm. D. A small area of cyanosis noted on client's right upper arm.

C. A small ecchymotic area noted on client's right upper arm.

W2: A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? A. Determining the client's length of stay B. Providing anticipatory guidance to a client in crisis C. Assigning tasks to an unlicensed assistive personnel (UAP)AP) D. Establishing the client's secondary medical diagnoses

C. Assigning tasks to an unlicensed assistive personnel (UAP)AP)

W2: A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? A. Set client-centered, measurable and realistic goals. B. Critically analyze client data to determine priorities. C. Collect and organize client data D. Determine effectiveness of interventions.

C. Collect and organize client data

W4: When a nurse is providing care for a client who has been diagnosed with C. diff, the nurse should implement which precaution method? A. Airborne B. Droplet C. Contact

C. Contact

W3: The nurse is caring for a client who needs to be lying flat on the back in neutral anatomic positioning. Which position is this? A. Dorsal recumbent B. Prone C. Dorsal (supine) D. Orthopneic

C. Dorsal (supine)

W4: When a nurse is providing care for a client who has been diagnosed with mycoplasma pneumonia the nurse should implement which precaution method? A. Standard B. Airborne C. Droplet D. Contact

C. Droplet

W2:The nurse is caring for a client who is having difficulty breathing and is at risk for aspiration. Which position should the nurse place this client in? A. Dorsal B. Prone C. Fowler's D. Orthopneic

C. Fowler's

W6: A nurse is providing patient teaching to a client who has been diagnosed with urinary incontinence. The nurse would be appropriate to educate the client to perform exercises to strengthen the muscles and sphincters which control urine flow. The name of the these exercises is A. Kregmet B. Krempt C. Kegel D. Kalluget

C. Kegel

W1: The nurse is planning a staff development conference about culturally competent care. Which of the following information should the nurse include? A. Culture plays no role in determining when a client will seek medical care. B. Nonverbal communication is important in few cultures. C. Nurses should focus on clients' culture rather than their ethnicity when providing care D. Nurses should expect clients to adapt to the care provided regardless of culture.

C. Nurses should focus on clients' culture rather than their ethnicity when providing care

W2: The nurse is caring for a client who needs to be placed in a general position to facilitate respiration. Which position would be appropriate? A. Lateral B. Prone C. Semi-Fowler's D. Supine

C. Semi-Fowler's

W2: A client fell at home and is reporting severe pain in the right ankle. The nurse assesses the client's ankle and visualizes inflammation of the joint. Which of the following findings indicates inflammation? A. Purple in color B. Rash with itching C. Swelling and warmth D. Bruising around the ankle

C. Swelling and warmth

W2: A client attempts to sit down in the bedside chair after ambulating in the hallway with crutches. What finding requires you to re-educate the client on how to sit down in the chair correctly while using crutches? A. The client holds both crutches on the affected side, holding on to the hand bars, then reaches for the armrest of the chair with the arm on the stronger side. B. The client keeps the injured leg extended out in front of him while sitting down. C. The client places both crutches on the non-injured side before sitting down in the chair. D. The client backs up to the chair's seat until he feels it with his non-injured leg and stops.

C. The client places both crutches on the non-injured side before sitting down in the chair.

W1: A nurse is educating a client who has excessively dry skin. Which of the following recommendations indicates good nursing judgment? A. The nurse encourages the client to go on a fluid restriction, so they void less. B. The nurse encourages the client to apply baby powder daily C. The nurse encourages the client to bathe less frequently, only a few times a week. D. The nurse encourages the client to bathe daily.

C. The nurse encourages the client to bathe less frequently, only a few times a week.

W1: A nurse is educating a new graduate nurse on body mechanics. Which of the following statements indicates a good use of body mechanics? A. The nurse suggests the new grad not attempt to lift anything greater than 50lbs without assistance B. The nurse suggests the new grad always twist their back towards the direction of the transfer as opposed to away from it C. The nurse suggests the nurse sleep on a firm mattress as opposed to a soft one D. The nurse suggests that the new grad keep feet close together when preparing to lift the patient

C. The nurse suggests the nurse sleep on a firm mattress as opposed to a soft one

W5: You are educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury? A. There is full loss of skin tissue that can extend to the muscle, bone, or tendon. B. A hallmark of a stage 3 pressure injury is that the skin will be intact but it not blanch. C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue. D. The wound edges will never roll away (epibole) as with a stage 2 pressure injury.

C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue.

W2: A client will be using crutches for mobility. After educating the client on how to adjust the crutches to fit correctly, you assess how well the client understood the instructions. What findings demonstrate that the crutches were adjusted correctly by the client? (Select all that apply.) A. The hand grips of the crutches are even with the mid-forearm. B. The client places weight on the axillae rather than the hands while ambulating. C. When the client grips the hand grips of the crutches the elbow bends at about 30 degrees. D. The client has 3 finger-widths distance between the axillae and crutch rest pad.

C. When the client grips the hand grips of the crutches the elbow bends at about 30 degrees. D. The client has 3 finger-widths distance between the axillae and crutch rest pad.

W8: The nurse has documented that a patient has had two episodes of steatorrhea, which means that the character of the stool is A. soft and filled with mucus. B. very liquid and streaked with blood. C. frothy and foul smelling. D. hard and clay colored.

C. frothy and foul smelling.

W2: The nurse is conducting a staff education program about holistic healthcare. Which statement by the staff shows that the teaching was effective? A. "The focal point of holistic healthcare is the disease or injury not natural remedies." B. "Holistic healthcare discourages the use of more natural remedies and alternative medicine." C. "Holistic medicine is only effective when self-responsibility of healthcare decisions is made." D. "A holistic approach considers the client's biologic, psychological, sociological, and spiritual needs."

D. "A holistic approach considers the client's biologic, psychological, sociological, and spiritual needs."

W1: A nurse is providing teaching to a group of unlicensed assistive personnel (UAP) about hand hygiene. Which of the following statements by one of the UAPs indicates a need for further teaching? A. "I will not wear artificial nails when providing client care." B. "It is acceptable to use alcohol-based hand products after most client contact." C. "I should wash my hands before I provide client care." D. "As long as I change gloves between clients, it is not necessary to wash my hands."

D. "As long as I change gloves between clients, it is not necessary to wash my hands."

W6: The nursing instructor is teaching a group of nursing students about how to prevent the spread of influenza. The nursing instructor identifies further teaching is necessary when a student states, A. "I will wear gloves, gown, and mask when I enter the room to perform a physical assessment on the client." B. "I will limit the amount of supplies that I bring into the client's room." C. "The client should wear a mask if he/she must leave the room." D. "Hand hygiene must consist of soap and water in order to kill the influenza microorganism."

D. "Hand hygiene must consist of soap and water in order to kill the influenza microorganism."

W1: A nurse is educating a client with diabetes about proper foot care. Which statement indicates the client needs additional teaching? A. "I will inspect my feet carefully each day for signs of redness, swelling, or any breaks in the skin." B. "I will not go barefoot and wear shoes that fit correctly." C. "I will be sure to keep my feet warm and change socks daily." D. "I will cut my nails in a rounded manner so the nail is not sharp."

D. "I will cut my nails in a rounded manner so the nail is not sharp."

W1: A nurse is caring for a client who recently started using crutches for an ankle injury. The client reports tingling and discomfort in the shoulder and armpit area. What is the nurse's best response? A. "That is normal and will decrease as your body gets used to using the crutches." B. "I believe the crutches may be too tall for you, let's re-measure." C. "We need to discontinue the crutches right away and switch to a different option such as a wheelchair." D. "Let me see how you ambulate using your crutches."

D. "Let me see how you ambulate using your crutches."

W3: The nurse is caring for multiple clients for the day. The nurse assesses each client to see if they are at risk for a pressure ulcer. The nurse concludes that the client most at risk for a pressure ulcer would be: A. A 46- year-old male in traction for a fractured femur, who exercises regularly before his accident and is alert and oriented. B. An 84-year-old male with Alzheimer's disease who uses a wheel chair and is incontinent of urine if not toileted every 2 hours. C. A 76-year-old male admitted for elective surgery to replace his hip joint, who is overweight and has a poor diet D. A 54-year-old male who is unconscious following a stroke, has a urinary catheter, and is incontinent of liquid stool since a feeding tube was placed.

D. A 54-year-old male who is unconscious following a stroke, has a urinary catheter, and is incontinent of liquid stool since a feeding tube was placed.

W1: A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should be included in the teaching? A. The lungs are damaged from carbon monoxide inhalation. B. Water heaters should be inspected every 5 years. C. Carbon monoxide has a distinct odor, so report any unusual smells immediately. D. Carbon monoxide binds with the hemoglobin in the body.

D. Carbon monoxide binds with the hemoglobin in the body.

W1: A nurse is providing nail care for a non-diabetic client. Which of the following actions should the nurse take? A. File the nails in a rounded shape. B. Push the cuticles back with a metal nail file. C. Trim the nails at the lateral corners. D. Clean under the nail with an orange stick

D. Clean under the nail with an orange stick

W1: The nurse is discussing the plan of care with an older adult client who wears hearing aids. The nurse notes the client leaning forward and asks the nurse to repeat the noise. Which action should the nurse take to assist the client? A. Position self so that lips can be seen by the client B. Check hearing aids for function C. Provide written materials for any message that cannot be heard D. Decrease background noise

D. Decrease background noise

W1: A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Use a transfer belt to assist B. Call for additional staff to assist with the transfer C. Obtain a walker for the client to use to transfer back to bed D. Determine the client's ability to help with the transfer

D. Determine the client's ability to help with the transfer

When a nurse is providing care for a client who has been diagnosed with pertussis, the nurse should implement which precaution method? A. Airborne B. Standard C. Contact D. Droplet

D. Droplet

W1: The nurse must make the decision to give a client a full or partial bed bath. Which criterion is most important for the basis of this decision? A. Time of client's last bath. B. Primary health-care provider's prescription for the client's activity. C. Client preference D. Immediate need of the client.

D. Immediate need of the client.

W6: A client is having a lumbar puncture. In which position should the nurse place the client? A. Sitting bent over from the waist with legs extended B. Supine with knees pulled toward the chest C. Lying prone, with the knees drawn up toward the abdomen D. Lateral with head bent toward the chest and knees flexed onto the abdomen

D. Lateral with head bent toward the chest and knees flexed onto the abdomen

W1: A nurse is ambulating a client in the hallway that experiences a sudden onset of a tonic clonic seizure. Which of the following is the nurse's priority action? A. Turn the patient on their right side B. Grab O2 and place on the patient C. Call for assistance D. Lower the patient carefully to the ground

D. Lower the patient carefully to the ground

W5: The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? A. The dressing should allow good air circulation through the wound. B. Absorbent material to wick exudates away and support drying should be used. C. Dressings should be simple as they will be changed at least every 4 hours. D. Materials used in dressing this wound should keep the wound bed moist.

D. Materials used in dressing this wound should keep the wound bed moist.

W2: While using crutches the client moves both crutches forward and then moves both legs forward past the placement of the crutches. This is known as the: A. Swing-to-gait B. Two-point gait C. Three-point gait D. Swing-through-gait

D. Swing-through-gait

W1: A nurse is assessing a group of clients for those at risk for falls. Which of the following clients is most at risk? A. The 30 y.o. male client receiving IV narcotics every 2hrs. B. The 25 y.o. client who had a spinal fusion who is completely reliant on staff to turn and reposition. C. The 72 y.o. client taking a beta blocker that is causing orthostatic hypotension. D. The 80 y.o. client who had a stroke with left sided weakness and urinary frequency.

D. The 80 y.o. client who had a stroke with left sided weakness and urinary frequency.

W1: A nurse is observing an unlicensed assistive personnel (UAP) provide care to a client. Which of the following observations requires follow-up? A. The UAP puts lotion on the feet of a client with diabetes B. The UAP puts on clean gloves prior to brushing teeth C. The UAP positions the unconscious client laterally prior to providing oral care D. The UAP puts the arms of a client at their side as they prepare them for transfer

D. The UAP puts the arms of a client at their side as they prepare them for transfer

W2: A client is prescribed to use crutches for ambulation. The client can bear partial weight and needs to be taught how to use the two-point gait while using crutches. Which description below best describes this type of gait with crutches? A. The client moves both crutches forward and then moves both legs forward to the same point as the crutches. B. The client moves the right crutch (injured side), then moves the left foot (non-injured side), then moves the left crutch (non-injured side), and then moves the right foot (injured side). C. The client moves both crutches and injured leg forward together, and then moves the non-injured leg forward. D. The client moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward together.

D. The client moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward together.

W2: A client needs to go up the stairs while using crutches. What finding by the nurse demonstrates the client understands how to ambulate upstairs with crutches? A. The client moves the crutches and non-injured leg forward to the step together, and then the non-injured leg. B. The client moves the injured leg forward onto the steps, then moves the crutches, and then moves the non-injured leg. C. The client moves the crutches forward up the step, then the injured and non-injured leg. D. The client moves the non-injured (unaffected) leg forward on the stairs and then brings crutches up onto the stairs and aligned with the unaffected leg

D. The client moves the non-injured (unaffected) leg forward on the stairs and then brings crutches up onto the stairs and aligned with the unaffected leg

W2: The nurse is measuring the drainage from a Jackson-Pratt (JP) drain. Which of the following is considered objective data? A. The client stated that he has a pain level of 5. B. The client stated, "I did not empty the drain." C. The client is reporting abdominal pain. D. The drainage measurement is 25 mL.

D. The drainage measurement is 25 mL.

W5: The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer? A. The crater extends into the subcutaneous tissue. B. There is undermining of adjacent tissues. C. The ulcer has thick dark eschar over the top. D. The joint capsule of the hip is visible.

D. The joint capsule of the hip is visible.

W1: The nurse on a medical unit is teaching a group of unlicensed assistive personnel (UAP) about handling clients' bed linens safely. Which of the following instructions should the nurse include? A. Return any fresh linen not used for a client to the linen supply area. B. Fill linen bags with as much soiled linen as possible. C. Use double bagging to remove soiled linen from the client's room. D. Tie linen bags securely at the top.

D. Tie linen bags securely at the top.

W2: After completing the health history and the physical assessment, the nurse identifies discrepancies in the information. What is this process called? A. Diagnosing B. Evaluating C. Assessing D. Validating

D. Validating

W5: The nurse is providing care for a client who has a yellow-orange cast to the skin, it would be appropriate for the nurse to document this as A. cyanosis B. pallor C. ecchymosis D. jaundice

D. jaundice

W6: As the nurse, you are providing care for a client who frequently feels an urgency to urinate and often expresses urine prior to getting to the bathroom. The nurse would be accurate to document this type of incontinence as: A. both stress and urge B. overflow C. stress D. urge

D. urge

The nurse is providing care for a client who is reporting difficulty breathing. The nurse would be correct to document this as _____:

dyspnea

urgency

sudden strong desire to void

W3: The nurse is recording vital signs for a client who has a blood pressure of 124/82 mmHg. The nurse is aware that the 124 mmHg represents the pressure that the heart must pump against .

systolic: the pressure that the heart must pump against