The nurse in an outpatient care facility has received the following telephone messages from clients who were previously seen
at the facility. The nurse should first telephone the client who is reporting
1. no memory of the postprocedure instructions following an esophagogastroduodenoscopy (EGD)
2. a sore throat and cough following a bronchoscopy
3.shortness of breath following a bronchoscopy
4.abdominal cramping following a colonoscopy - answer-3.shortness of breath following a bronchoscopy
The nurse is reinforcing teaching with a client with chronic lymphocytic leukemia who is at risk for developing
thrombocytopenia. Which of the following information should the nurse reinforce?
1. "You should use a disposable razor rather than an electric razor when shaving."
2. "Frequent deep-breathing exercises should be performed, but avoid coughing and blowing your nose."
3. "Frequent oral hygiene should be performed, including flossing your teeth and using alcohol-based mouthwashes."
4. "You may take over-the-counter (OTC) ibuprofen for any discomforts, but avoid using OTC acetaminophen." -
answer-2."Frequent deep-breathing exercises should be performed, but avoid coughing and blowing your nose."
The nurse is contributing to a staff development conference about electronic medical records. Which of the following
information should the nurse suggest including? Select all that apply.
1. "An advantage of using electronic medical records is improved legibility in documentation."
2. "The nurse should log off the computer system before leaving a computer terminal."
3. "An issue surrounding computerized documentation is access to secure information."
4. "A nurse with experience documenting in 1 electronic medical record system can use another system without training."
5. "The nurse should refrain from sharing security passwords for the electronic medical record system."
6. "A disadvantage of the use of electronic medical records is that departments are unable to interact within the system." -
answer-1,2,3,5
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The charge nurse in a long-term care facility has made client care assignments for unlicensed assistive personnel (UAP).
Which of the following statements by the charge nurse would provide the best directions to a UAP about the assignment?
1. "Your clients will need assistance to ambulate once in the morning and once in the afternoon."
2. "Obtain vital signs for clients every 4 hours and report any abnormal measurements."
3. "Assist clients who are on special diets to eat their meals."
4. "Turn clients who are on bed rest onto the left side for 2 hours and then onto the right side for 2 hours until lunch is served."
- answer-4."Turn clients who are on bed rest onto the left side for 2 hours and then onto the right side for 2 hours until lunch
is served."
The nurse is contributing to the plan of care for a client who sustained a spinal cord injury at T1 five days ago. Which of the
following interventions should the nurse recommend including in the client's plan of care?
1. Limit the client's fluid intake to one liter daily.
2. Encourage the client to increase the intake of foods high in carbohydrates.
3. Request a prescription for a stool softener to be administered to the client daily.
4. Perform lower extremity passive range-of-motion (ROM) exercises for the client once daily. - answer-
3. Request a prescription for a stool softener to be administered to the client daily.
The nurse is checking a client with disseminated herpes zoster (shingles) who is in a private room. The nurse should
understand the client may be developing sensory isolation if the client reports the onset of
1.photophobia
2.headaches 3.anxiety
4. tremors - answer-1.photophobia
A client is admitted with severe pain in the left lower extremity. The client is scheduled for a complete blood count (CBC),
urinalysis, chest x-ray, and x-ray of the lower extremities. The client asks the nurse, "Why do I have to have all these tests?
The pain is in my leg." Which of the following responses by the nurse will best help the client deal with feelings of anxiety?
1. "The tests will not take long to complete."
2. "These tests are part of the admission procedure."
3. "It must be difficult not understanding what is happening to you."
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4. "Perhaps that is something you need to discuss with your physician." - answer-3."It must be difficult not understanding
what is happening to you."
The nurse is reinforcing teaching with a client who is at risk for coronary artery disease (CAD). Which of the following
information should the nurse reinforce? Select all that apply.
1. "Exercising once a week will decrease the risk for CAD."
2. "You should maintain a body mass index (BMI) of less than 25."
3. "You may continue to consume alcoholic beverages as you desire."
4. "You should avoid exposure to environmental tobacco smoke."
5. "A diet high in fruits, vegetables and unsaturated fats will decrease your risk for CAD." - answer-1,2,5
The nurse is reinforcing teaching with a client who is receiving prescribed insulin glargine. Which of the following
information should the nurse reinforce?
1. After administering the insulin glargine the same syringe can be used to administer regular insulin.
2. Extra vials of insulin glargine that have not been opened can be stored in the freezer.
3. Insulin glargine does not have a peak action time.
4. Insulin glargine should be administered 3 times each day 15 minutes before meals. - answer-3.Insulin glargine does not
have a peak action time.
The nurse is preparing to insert an indwelling urethral catheter for an assigned client. Which of the following statements by
the client would be a priority to follow up?
1. "I have had a catheter before and felt pressure when the catheter was placed."
2. "I developed a rash on my neck when I ate shrimp several months ago."
3. "I just urinated so I won't need a catheter placed."
4. "I haven't been drinking many fluids lately." - answer-2."I developed a rash on my neck when I ate shrimp several
months ago."
The nurse in a rehabilitation facility is caring for a client who had a right knee arthroplasty 8 days ago and has been
diagnosed with pneumonia. The client is being transferred to an acute care facility. It would be essential for the nurse to
communicate in the transfer report that
1. the discharge to home is anticipated for the client after 1 more week of physical therapy
2. the client lives in a ranch home that requires climbing 2 stairs to get into the house
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3. the most recent focused data collection reveals bilateral crackles (rales) auscultated in the client's lungs
4. the client's spouse will be visiting the client at the hospital later today after leaving work - answer-
2.the client lives in a ranch home that requires climbing 2 stairs to get into the house
The nurse is measuring a client for crutches. Which of the following actions should the nurse take?
1. Measure the client's height and subtract 8 in (20 cm) to obtain the correct crutch length.
2. Ask the client to stand upright and position the shoulder rest of the crutch 6 in (15 cm) below the axilla.
3. Adjust the crutches so the client's elbows are at a 30-degree angle while the client's hands are resting on the hand grips.
4. Measure from the anterior fold of the axillae to the toes of the client's feet and add 1 in (2.5 cm) while the client is in a
supine position. - answer-3.Adjust the crutches so the client's elbows are at a 30-degree angle while the client's hands are
resting on the hand grips.
The nurse is contributing to the plan of care for a client with gestational hypertension who is at 32 weeks gestation. Which of
the following should the nurse recommend be included in the plan of care?
1. monitoring the client's urinary output
2. instructing the client to report any increase in fetal activity 3.instructing the client to
use relaxation techniques to relieve a headache
4.minimizing the client's dietary intake of high-calcium foods - answer-1.monitoring the client's urinary output
The nurse is collecting data from a client who has hypovolemic shock. Which of the following findings would be consistent
with hypovolemic shock? Select all that apply.
1.confusion 2.hypertension
3.decreased urine output
4.elevated respiratory rate
5.jugular vein distention (JVD) - answer-1,3,4
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