practice questions
a nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?
1. "I will be sure to keep the crutch tips dry" 2."I will hold a crush in each hand when sitting down" 3."I will place my weight on my underarms" 4."I will lead with my right leg when going up stairs" ANSWER is 1. "I will be sure to keep the crutch tips dry"
A nurse is reinforcing teaching with a client who is receiving PCA. Which of the following statements by the client indicates an understanding of the teaching?
1. "I will not allow anyone to press the PCA but and for me" 2. "I will overdose if I press the PCA button more than 6 times an hour" 3. "I will wait to press the PCA button until my pain is intolerable" 4. Call I will inform my nurse of my pain level before I press the PCA button." ANSWER is 1. "I will not allow anyone to press the PCA but and for me"
A nurse is caring for a client who has metastatic cancer and practices Catholicism. The ckient asks the nurse to discuss the after life with her. Which of the following statements by the nurse assist in meeting the client's spiritual needs?
1. "tell me what the afterlife means to you." 2. "you should discuss the after life with your priest." 3."keep praying. A miracle could happen." 4."maybe your condition will lead you closer to God."
A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching?
1. "we will make sure she eats 3 meals A-day." 2. "we will decrease her pain medication if she gets too drowsy." 3. "we will keep her broom cool to help her breathe better." 4. "we will make sure to provide oral care twice A-day. Who nation mark ANSWER is 3. "we will keep her broom cool to help her breathe better."
A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching?
1. 1 cup of Cantaloupe 2. One large baked potato 3. 4 oz of Banana chips 4. 1 cup of Apple sauce ANSWER is 4. 1 cup of Apple sauce
A nurse is reinforcing preoperative teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?
1. Ask a family member who speaks the client's primary language to interpret 2. Plan a long teaching session initially to introduce the necessary material 3. Provide the least important information first 4. Provide handouts written in the client's primary language ANSWER is 4. Provide handouts written in the client's primary language
A nurse is assisting with the plan of care a four clients. Which of the following task should the nurse assign to an assistive personnel (AP) ?
1. Ensure a client can use crutches before discharge. 2. Check a client's ability to swallow following a stroke. 3. obtain a client's pain rating prior to physical therapy 4.assist a client to get out Iof bed after a breathing treatment ANSWER is 4.assist a client to get out Iof bed after a breathing treatment
A nurse is caring for a female client who has urinary incontinence. Which of the following actions should the nurse take?
1. Instruct the client to perform the valsalva for maneuver during urinary urges 2. Cleanse the clients labia minora before cleansing the labia majora 3. Apply a moisture skin barrier to the clients perineal area 4. Implement a toileting schedule for the client with 4 hour intervals ANSWER is 3. Apply a moisture skin barrier to the clients perineal area
A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment shed the nice select to provide the highest concentration of oxygen to the client?
1. Nasal cannula 2. Simple face mask 3. Ventral mask 4. Nonrebreather mask ANSWER is 4. Nonrebreather mask
A nurse is reinforcing teaching with a client who has a prescription for a transcutaneous electrical nerve simulation (TENS) unit. Which of the following information should the nurse include in the teaching?
1. Place the electrodes near the pain site 2. The TENS unit has one constant frequency 3. The TENS creates a sharp burning sensation when turned on 4.the electrodes can be placed over hair ANSWER is 1. Place the electrodes near the pain site
a nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
1. check for capillary refill proximally to the elastic bandages every 12 he. 2.compare the client's pedal pulses bilaterally every 4 hr 3.place the client's legs in a dependent position for 30 mins before applying the elastic bandages. remove the elastic bandages every other day to inspect the skin ANSWER is 2.compare the client's pedal pulses bilaterally every 4 hr
A nurse is caring for a client who has a rig simply undergone a total bilateral mastectomy. Which of the following statements by the client or requires the immediate action by the nurse?
1."I don't understand why everyone is so worried about me." 2."I don't know if I'll ever find someone who wants to marry me." 3. "when I look at myself in the mirror, I don't know if I can go on." 4. "I feel like the doctor pressured me into having the mastectomy." ANSWER is "when I look at myself in the mirror, I don't know if I can go on."
A client who had a recent below the knee ampitation says. "i dont know how I can continue to live my life without my leg." Which of the following responses should the nurse make?
1."You can have a prosthesis after your recovery has progressed." 2."I am so sorry. I know I would hate to lose my leg." 3."Tell me what concerns you have about your future." 4."Your focus right now should be on recovering from surgery." ANSWER is 3. "Tell me what concerns you have about your future."
A nurse is collecting data from a client who is menopausal. Which of the following statements indicates that the nurse should screen the client for depression?
1."everything is fine. I started a glass blowing class this week." 2."I am really not old enough to be going through menopause." 3."My family doesn't need me anymore. I've failed them in so many ways." 4."I am only 50 and my children treat me like I am old." ANSWER is 3."My family doesn't need me anymore. I've failed them in so many ways."
A nurse's speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalize is anger about having to take insulin. Which of the following responses should the merest make?
1."why are you angry about taking the insulin?" 2. "don't worry. Diabetes runs in my family as well." 3."I see that you are angry. Let's sit down and talk. 4. "you should take insulin, because it reduces the risk for complications." ANSWER is 3."I see that you are angry. Let's sit down and talk.
A nurse is assisting with the plan of care for a client who has a bacterial infection and persistent oral temperature of 38.9 Celsius (102 Fahrenheit). which of the following interventions should the nurse include in the plan of care to treat the fever?
1.Administer acetaminophen 2.apply ice packs to the client's axillae 3.maintain the room temperature at 18.3 Celsius (64.9 Fahrenheit 4.assist the client to ambulate four times a day ANSWER is 1. Administer acetaminophen
A nurse is caring for a client who has a clostridium difficile infection. Which of the following solutions should the nurse used to perform hand hygiene while caring for this client?
1.Alcohol 2.Mild soap 3.chlorhexidine 4.tridosan ANSWER is 2.Mild soap
A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching?
1.Carbon monoxide gas smells like rotten eggs 2.headache is a manifestation of carbon monoxide poisoning 3.a pulse oximeter is used to diagnose carbon monoxide positioning 4.Dusky mucous membranes are an elderly indication of carbon monoxide poisoning. ANSWER is 2.headache is a manifestation of carbon monoxide poisoning
A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?
1.Check the pH of the gastirc aspirate 2.observe the color of the gastric aspirate after adding blue dye to the formula. 3.auscultate over the epigastrium 4.measure the length of the inserted NG tube ANSWER is 1.Check the pH of the gastirc aspirate
A charge nurse smell smoke, and turns the visitors Room, and sees flames in the trash can. What is the sequence of actions that the nurse should take? ( move the steps into the Box on the right, placing them in order of performance. Use all the steps.)
1.Evacuate clients from the area. 2.Close the fire doors on the unit. 3.Pull the lever on the fire alarm Box. 4.Use a fire extinguisher to put out the fire. ANSWER is 1,3,2,4
A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?
1.Explain the negative consequences of the refusal. 2.Discuss with the client's partner why the treatment is necessary. 3.Document the client's refusal of treatment. 4.Try to convince the client that the treatment is needed. ANSWER is 3.Document the client's refusal of treatment.
A nurse is assisting with the admission of a client who has active tuberculosis. Which other following actions should the nurse plan to take?
1.Restrict the clients visitors to that immediate family 2. assign the client to a negative pressure air flow Room 3.Discard personal protective equipment outside the client's Room 4.Have the client where HEPA mask during transportation throughout the facility ANSWER is 2. assign the client to a negative pressure air flow Room
A charge nurse smells smoke, enters the visitor restroom and sees flames in the trash can. What is the sequence of actions that the nurse should take?
1.Use a fire extinguisher to put out the fire 2.close the fire doors on the unit 3.pull the lever on the fire alarm box 4.evacuate clients from the area ANSWER is 4,3
A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?
1.Young adults should receive a dental assessment every 6 months 2.Young adult males should have a testicular examination every 5 years 3.Young adult females should have a routine physical examination every 4 years 4.Young adults should receive a tuberculosis skin test every 3 years ANSWER is 1.Young adults should receive a dental assessment every 6 months
A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention?
1.a stage 3 pressure ulcer on the coccyx 2.a contaminated wound that is closed after 72 hr 3.a puncture wound that is sutured 4.an abdominal surgical wound with intact staples ANSWER is 1.a stage 3 pressure ulcer on the coccyx
A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. which of the following actions should the nurse plan to take?
1.administer an analgesic 30 min before starting the procedure 2.hold the syringe 5 cm (2 in) above the upper end of the wound 3.place the irrigation solution in a basin of cool water 4.perform the wound irrigation with a 10- mL syringe with an angiocatheter ANSWER is 1. administer an analgesic 30 min before starting the procedure
a nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. which if the following is a priority modification that the nurse should include?
1.alarm clock that shakes the bed 2.flashing smoke alarm 3.low pitched buzzer doorbell 4.telephone with an amplified receiver ANSWER is 2.flashing smoke alarm
A nurse is assisting with the admission of a client who has brought her medications to the facility.which of the following actions should the nurse take?
1.allow the client to continue taking the medications as she did at home? 2.take the medications from the client and discard them 3.compare the medications the provider has prescribed with the client's medications from home 4.place the medications in the medication cart and administer them as the client took them at home. ANSWER is 3.compare the medications the provider has prescribed with the client's medications from home
A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse demonstrating which of the following ethical principles?
1.autonomy 2.beneficence 3.justice 4. nonmaleficence ANSWER is 2. beneficence
A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes?
1.body regulation of heat and cold increases with age 2.circulation become less efficient with age 3.increased metabolic rate occurs with age , increasing body temperature 4.sweat gland activity is increased with age ANSWER is 2.circulation become less efficient with age
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?
1.bone pain 2.drowsiness 3.bowel hypomotility 4.positive Chvostek's sign ANSWER is 4.positive Chvostek's sign
A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
1.check for capillary refill proximally to the elastic bandages every 12 hr 2.compare the client's pedal pulses bilaterally every 4 hr 3.place the client's legs in a dependent position for at least 30 min before applying the elastic bandages 4.remove the elastic bandages every other day to inspect the skin ANSWER is 2.compare the client's pedal pulses bilaterally every 4 hr
A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?
1.check that the restraint is tied to a fixed frame of the bed 2.pad bony prominences on the wrist 3.remove the restraint every 4 hr to allow movement 4.tie the restraint with a knot that will tighten when pulled ANSWER is 2.pad bony prominences on the wrist
a nurse is preparing to administer an internal feeding to a client who has an NG tube in place. which of the following methods should the nurse use to verify correct placement of the NG tube?
1.check the pH of the gastric aspirate 2.observe the color of the gastric aspirate after adding blue dye to the formula 3.ascultate over the epigastrium 4.measure the length of the inserted NG tube ANSWER is 1.check the pH of the gastric aspirate
A nurse is preparing to remove a clients peripheral IV catheter. After performing hand hygiene and applying clean gloves. Which of the following actions should the nurse take first?
1.clamp the infusion tubing 2.remove the dressing 3.withdraw the catheter from the vein 4.ensure the catheter is intact ANSWER is 1.clamp the infusion tubing
A nurse in a long-term care facility is contributing to the plan of care for a client who is at risk for pressure ulcers. Which of the following recommendations should the nurse include in the plan?
1.complete a Branden scale at the first indication pf pressure ulcer formation 2.perform a thorough skin inspection each day 3.gently massage skin over bony prominences 4.place a dehumidifier on the client's room ANSWER is 2. perform a thorough skin inspection each day
A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example a which of the following ethical principles?
1.confidentiality 2.nonmaleficence accountability 4.autonomy ANSWER is 4.autonomy
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?
1.empty the urine drainage bag every 12 hr 2.drain urine from the tubing before ambulation 3.use clean technique for urine specimen collection 4.hang the urine drainage bag at the level of the bladder ANSWER is 2.drain urine from the tubing before ambulation
A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take? select all the apply
1.ensure that the client is wearing nonskid slippers 2.move the bedside table away from the bedside 3.place the client in a room near the nurse's station 4.keep the bed's full side rails in the up position 5.reinforce teaching about how to use the call bell ANSWER is 1,3,5
A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? select all that apply
1.full bounding pulse 2.deceased skin turgor 3.moist crackles in the lungs 4.orthostatic hypotension 5.flat neck veins ANSWER is 2,4,5
A nurse writes a clients information on a piece of paper while receiving report. Which of the following actions should the nurse take to depose of the paper?
1.give the paper to a member of the client's family 2.place the paper in a receptacle at the nurse's station 3.shred the paper in a secure container 4.discard the paper at home ANSWER is 3. shred the paper in a secure container
A nurse is caring for a client who has an NG tube and is receiving a continuous enteral feeding. Which of the following actions should the nurse take?
1.hold the feeding for two consecutive gastric residuals greater than 250 mL 2.change the bag and tubing ever 12 hr. 3.flush the tube with 0.9% sodium chloride irrigant ever 8 hr. 4.heat the formula to body temperature before administering ANSWER is 1. hold the feeding for two consecutive gastric residuals greater than 250 mL
a nurse is reinforcing teaching with a client about using guided imagery. which of the following actions should the nurse take?
1.instrcut the client to alternately tighten and relax muscles 2.evaluate the client's energy field 3.attach electronic sensors to the client's prior to beginning therapy 4.direct the client to visualize tension leaving the body ANSWER is 4.direct the client to visualize tension leaving the body
a client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. which of the following actions should the nurse take to encourage therapeutic communications.
1.keep the conversation moving by asking about his family 2.let the client know that he is available and willing to listen 3.ask if the client understands what to expect in the advanced stages of the illness 4.ask the client's visitors to not say anything about the advanced disease ANSWER is 2.let the client know that he is available and willing to listen
A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?
1.keep your knees in a locked position when standing for prolonged periods 2.bend at the waist when lifting a heavy object 3.keep your feet close together when lifting a heavy object 4.when lifting a heavy object,keep it close to your body ANSWER is 4. when lifting a heavy object,keep it close to your body
A nurse is caring for a client who is alert and in a long term care facility. which of the following actions should the nurse take to protect the client's privacy?
1.place laboratory results on the bedside table while ambulating the client 2.give report about the client's status while standing in the hallway 3.ask the client before discussing his condition when family is present 4.place a message board in the client's room to post vital sign values ANSWER is 3. ask the client before discussing his condition when family is present
a nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. which of the following interventions should the nurse recommend to be included in the plan of care?
1.place the client in a room with another client who has pharyngitis 2.ensure that the client wears a surgical mask during transportation throughout the facility 3.limit the client's family member visitations to 30 min 4.provide the client a room with negative pressure air flow of six air changes per hr ANSWER is 2.ensure that the client wears a surgical mask during transportation throughout the facility
A nurse is palpating the pulse located on top of a client's foot. which of the following pulses should the nurse document that she is palpating?
1.posterior tibial 2.dorsal pedis 3.popliteal 4.femoral ANSWER is 2.dorsal pedis
A nurse is palpating the pulse located on top of the client's foot. Which of the following pulses should the nurse document that she is palpating?
1.posterior tibial 2.dorsalis pedis 3.popliteal 4.femoral ANSWER is 2.dorsalis pedis
A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change?
1.precontemplation 2.preparation 3.maintenance 4.action ANSWER is 1.precontemplation
A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?
1.provide an artificial voice box 2.avoid using facial gestures 3.speak to the client in a louder voice 4.ask the client close-ended questions ANSWER is 4.ask the client close-ended questions
a charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. which of the following information should the nurse include in the teaching?
1.select an alternate site to place the oximerty probe of the capillary refill is less than 2 seconds 2.use an adhesive oximetry probe for a client who has latex allergy 3.remove polish from the client's fingernails before applying the oximetry probe 4.lubricate the tip of the oximetry probe ANSWER is 3.remove polish from the client's fingernails before applying the oximetry probe
A nurse is preparing to administer a tropical medication to a client. Which of the following actions should the nurse take?
1.show the assistive personnel where to apply the medication 2.ask the client when the previous nurse last applied the medication 3.identify the client by comparing the medication administration record with the client's room number 4.compare the label of the medication container with the medication administration record three times ANSWER is 4.compare the label of the medication container with the medication administration record three times
A nurse is moving a client up in the bed with the assistance of a second nurse. Which of the following actions should the nurse take?
1.stand facing the center of the bed at the client's side 2.place the feet apart with the foot nearest to the head of the client's bed in front of the other foot. 3.keep knees and hips straight while bending at the waist towards the client 4.encourage the client to keep his legs straight and remain still. ANSWER is 2.place the feet apart with the foot nearest to the head of the client's bed in front of the other foot.
A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?
1.stand facing the center of the bed at the client's side. 2.place feet apart with the foot nearest the head of the client's bed in front of the other foot 3.keep knees and hips straight while bending at the waist towards the client. encourage the client to keep his legs straight and remain still. ANSWER is 2.place feet apart with the foot nearest the head of the client's bed in front of the other foot
A nurse is collecting data from an older client. what information should the nurse report to the provider
1.the client has smooth, brown, irregular lesions on the bad of each hand. 2.the client has glossy, white circles around the periphery of the corenas. known as arcus senilis, are an expected age-related change 3.client reports urinary incontinence 4.client reports a decrease in sense of taste ANSWER is 3.client reports urinary incontinence
A nurse is reinforcing teaching with an older adult client who reports an inability to sleep. Which of the following information should the nurse include when teaching the client about aging and sleep?
1.the need for sleep diminishes with age 2.older adults have longer rapid eye movement (REM) periods. 3.sleep patterns change with age 4.sleep apnea decrease with age. ANSWER is 3. sleep patterns change with age
A nurse had delegated various client care tasks to the assistive personnel(AP) on the care team. Which of the following actions by the AP should the nurse identify as correct?
1.using hand sanitizer to cleanse her hands of spilled food from the client's meal tray 2.setting aside her gown for future use in the room of a client who has a wound infection 3.removing her gloves after exiting the client's room 4.Donning a mask to measure the vital signs of a client who has pertussis ANSWER is 4. Donning a mask to measure the vital signs of a client who has pertussis
A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. which of the following activities should the nurse recommend as the priority for this client?
1.volunteer at the local food pantry 2.attend an exercise program 3.find an enjoyable hobby 4.support environmental conservation ANSWER is 2.attend an exercise program
A nurse is calculating the intake and output for a client over the last 8 hours. The client is receiving a continuous IV infusion at a 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the clients and take for the last 8 hours? Round your answer to the nearest whole number.
1820mL
