Some examples from this set of practice questions
1.
An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.
Answer: D
2.
A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client\'s pain is gone before assisting with personal care. D. This client\'s pain will be difficult to manage, since the cause is unknown.
Answer: A
3.
A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider? A) Potassium 3.1mEq/L (3.1 mmil/L) B) Sodium 142 mEq/L (142 mmol/L) C) Total calcium 9.2 mg/dl (2.3 mmol/L) D) Chloride 98 mEq/L (98 mmil/L)
Answer: A
4.
The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet? A) Between the toes. B) Around the ankles. C) On dorsal surfaces D) Over the heels.
Answer: A
5.
The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with client. When the family leaves, what action should the nurse take first? A) Apply the restraints to maintain the client’s safety. B) Reassess the client to determine the need for continuing restraints. C) Document the time the family left and continue to monitor the client. D) Call the healthcare provider for a new prescription.
Answer: B
6.
When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A. Position the client supine for a few minutes B. Assist the client to stand at the bedside C. Apply the blood pressure cuff securely D. Record the client’s pulse rate and rhythm
Answer: A
7.
A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? A. Document the client’s circadian rhythms B. Assess for flushed, warm skin regularly C. Measure temperature at regular intervals D. Vary sites for temperature measurement
Answer: C
8.
The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states “clean the wound and then apply collagenase.” collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? A. Lightly coat the wound with povidone-iodine solution B. Irrigate the wound with sterile normal saline C. Flush the wound with sterile hydrogen peroxide D. Remove the eschar with a wet-to-dry dressing
Answer: B
9.
The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? A. Page the unit manager to address the situation. B. Close the demographic screen on the computer. C. Instruct the UAP to end the phone call immediately. D. Send a UAP into the client\'s room to relieve the nurse.
Answer: B
10.
A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? A. Use disposable plates and utensils. B. Stay in a room with the door closed. C. Dispose of soiled dressings in plastic bags that are securely closed. D. Others who are in the same room with the client should wear a mask.
Answer: C
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