1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of
pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious.
What action is most important for the nurse to implement? Provide written instructions that are easy
to foll...
1 the nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia while the nurse is reviewing the prescribed medications
,1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of
pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious.
What action is most important for the nurse to implement? Provide written instructions that are easy
to follow.
2. Which assessment finding is most significant in determining the level of assistance a client needs
with personal care? Disorientation to time, place, and person
3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and
palpation of the bladder indicates that it is distended and dull percussion. Even after assisting the client
to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the
urinary catheter.
4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about
his pain he denies having any pain. Which intervention should the nurse implement first? Ask the client
what is making him grimace.
5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the
nurse obtain first? Respiratory rate
6. The charge nurse observes a new graduate nurse demonstrate the administration of two different liquid
medications through a gastrostomy tube used for continuous feeding, as seen in the video. What
actions should the nurse take? (SATA)
Confirm that the nurse determined the amount of gastric
residual Add the liquid volumes when documenting fluid
intake
Instruct the nurse to administer each mediation separately
7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action should the
nurse take nest? Apply intermittent suction
8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours
after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a
call to the healthcare provider, what action should the nurse implement? Instruct the client to use
guided imagery and slow rhythmic breathing.
9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has
viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the
UAP? Wear gloves while giving a bath
10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action
indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s
room.
11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which
client should be assessed regularly during the night for sleep apnea? An older male with multiple
problems, including obesity, diabetes, and hypertension.
12. It is most important for the nurse to recalculate the Braden scale for a client who has developed
which problem? Urinary incontinence
,13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the
client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the
top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching
the client how to walk with the crutches.
14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary
pacemaker. When the client expresses concern and fear of the pacemaker, how should the nurse
respond? Encourage discussion about the concern and fears.
15. Prior to initiating digital removal of a fecal impaction, it is important for the nurse to perform
which client assessment? Vital signs
16. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby?
What did I do wrong?” Which response is most helpful? “This must be a very difficult
time for you.”
17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling
urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the
normal saline 20 ml
18. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a
radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit
reading
19. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action
should the nurse take? Stay with the client in silence while touching her forearm
20. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was
accidentally flushed instead of saving in the container. What intervention should the nurse initiate?
Discard the urine and start another 24-hour period
21. A confused elderly male client is having trouble sleeping at night and is sometimes found
wandering the hallway. What nursing intervention should the nurse implement first? Provide a
back rub at bedtime
22. A young male client with testicular cancer has a living will that describes his desire that no
extraordinary measures be taken to save his life. The healthcare provider knows the client has a good
prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the
nurse take? Initiate an ethics committee review of the case
23. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is able to
respond to most commands. Before starting to feed the client, which information is most important
for the nurse to obtain? Client's ability to chew and swallow
24. The nurse enters the room of a client with a Clostridium difficile infection to administer an
intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning
the client’s buttocks and states the client has been incontinent with diarrhea. The UAP is
wearing gloves but not a gown. What action should the nurse implement first? Tell UAP
put a gown on
25. The computer documentation system shuts down while the nurse is entering the client’s physical
assessment data. What should the nurse do first? Wait for notification services department of the
situation
26. In assessing a client who has a nursing diagnosis of spiritual distress, which action should thenurse
take first? Assist and support the client in establishing short-term goals.
, 27. During transfer to the medical unit, a client who experienced an acute change in level of
consciousness became increasingly confused and combative, justifying soft wrist restraints for the
client’s upper and lower extremities. Which intervention is most important for the nurse to
implement on admission? Determine baseline neuro status
28. (PICTURE OF EAR AND EAR DROPS) The nurse prepares to administer ear drops to an adolescent
client as seen in the picture. What should the nurse do next? Pull ear auricle downward
29. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than
the previous reading. What should the nurse do next? (Select all that
apply) Retake the pt's Bp in opposite arm**
Determine the pt's activity and feelings prior to bp measurement
30. A male client with limited mobility is discharged with home health services. When the home health
nurse arrives, the client asks what he can do for the swelling in his leg. Which actin should the nurse
implement? Instruct pt to flex both of his feet several times a day
31. Which information is most important for the nurse to consider when preparing to transfer a client from
the bed to a chair? The pt's ability to bear weight on lower extremities
32. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse
oximeter alarm is flashing without displaying a percentage of oxygen. Which action should the nurse
implement? exchange pulse ox for another monitor
33. Two days after surgery a male client experiences incisional pain while dangling his feet at the
bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, “Activity
intolerance related to pain.” Based in this problem, which outcome statement is best for the nurse
to include in the client’s plan of care? The client will Ambulate without discomfort
34. After assessing a client, the nurse identifies three nursing problems. When developing the client’s
plan of care, which action should the nurse take next? Prioritize the identified nursing
diagnoses
35. After reviewing the admission assessment of a client with chronic pain, which interventions
should the nurse include in this client’s plan of care? (Select all that
apply) Provide comfort measures such as topical warm application and
tactile massage Implement a 24h schedule of routine administration of
prescribed analgesic Determine client's subjective measure of pain using a
numerical pain scale
36. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing
action should be included in the plan of care to reduce the client’s risk for infection related to the
catheter? Encourage increased intake of oral fluids
37. The electronic medication system alerts the nurse that the medication dose scanned is two times
higher than the dose prescribed. What action should the nurse implement? Convert the dose on hand
to match the prescribed dose
38. A male client with chronic debilitating heart disease asks the nurse to help him die because he
believes that he will be better off dead rather than living under the current circumstances. The nurse
supports the client and considers providing the family with a does of medications that can result in
the client’s death. If the nurse acts on this intention, what is the most likely consequence? The nurse
will be prosecuted for the murder of the pt
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