,1. A nurse in a long term care facility notices a client who has Alzheimer’s disease standing at
the exit doors at the end of the hallway. The clients appears to be anxious and agitated. Which
of the following actions should the nurse take?
Escort the client to a quiet area on the nursing unit
2. A nurse is assisting with the plan of care for a client who has a continent urinary division.
Which of the following interventions should the nurse plan to implement to facilitate urinary
elimination?
Use intermittent urinary catheterization for a client at regular intervals
3. A nurse is assisting with a educational program about car restraint safety for a group of
parents. Which of the following statements by a parent indicates an understanding of the
instructions?
My 12 year old child should place the shoulder lap belt low across his hips
4. A nurse is reinforcing teaching about strategies to promote eating with a client who has
COPD. Which of the following instructions should the nurse include in the teaching?
Drink high protein and high calorie nutritional supplements
5. A nurse is supervising an assistive personnel who is preparing to remove her personal
protective equipment after providing direct care to a client who requires airborne and contact
precautions. The nurse should recognize that the AP understands the procedure when she
removes which of the following PPE first?
Gloves
, 6. A nurse is caring for a client who is crying and states that his provider informed him that
he has a tumor and will need a biopsy. Which of the following responses should the nurse
make?
What have you done in the past to help yourself get through stressful situations before?
7. A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse
report to the provider
Generalized petechiae
8. A nurse is contributing to a teaching plan for a group of male adolescents about the adverse
effects of anabolic steroid use. Which of the following manifestations should the nurse include
Reduced height potential
9. A nurse is reinforcing teaching with an older adult client who has a severe left sided heart
failure. Which of the following statements should the nurse make
Rest 15 minutes between activities
10. A nurse in a long term care facility is documenting the care of an older client. Which of the
following information should the nurse include in the weekly nursing care summary
Hydration status
11. A nurse is caring for a client who has a head injury. Using the gasgow coma scale collection
data, the nurse should obtain which of the following information
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