1. A nurse is caring for a client who has a Correct Answer: A
new diagnosis of type 2 diabetes mellitus This statement encourages the
and has a referral for a dietary consult. client's involvement by offer-
The client tells the nurse, "I will have to eat ing assistance in creating a
whatever the dietitian tells me." Which of personalized list of preferred
the following statements by the nurse en- foods, which can then be dis-
courages the client's involvement in their cussed with the dietitian. It
plan of care? promotes a collaborative ap-
A. "I can assist you with making a list of proach to the dietary plan, al-
foods you like for the dietitian." lowing the client to have a say
B. "I understand that the dietary choices in their food choices, which is
can seem overwhelming." essential for long-term adher-
C. "Managing your diabetes will require ence and management of type
you to make accommodations." 2 diabetes.
D. "The dietitian will provide you with the
best food choices to manage your dia-
betes."
2. A patient is exhibiting an altered level Correct Answer: B
of consciousness and is unresponsive to Pinching the trapezius muscle
verbal stimuli. To elicit a response from a is a common method to elicit a
painful stimulus, the nurse would: response to painful stimuli. It is
A. Press down on the orbital area of the considered a less invasive and
eye. safer initial approach to assess
B. Pinch the trapezius muscle. the patient's response to pain
C. Use a 25-gauge needle. without causing harm.
D. Elicit a reflex with a reflex hammer
3. A hospice nurse is planning care for a Correct Answer: B
client who has lung cancer. Which of the Saying We will respect what is
following statements should the nurse important to you is a statement
make to incorporate the client's and fam- that acknowledges and incor-
ily's cultural beliefs? porates the client's and fami-
A. "You should limit discussing past ly's cultural beliefs. It shows a
events with the client." willingness to understand and
B. "We will respect what is important to prioritize their values, customs,
you." and preferences in the care
C. "We will arrange all burial services." plan. This approach is aligned
with culturally competent care,
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D. "Grieving should not be done in front of which is crucial in hospice set-
the client." tings.
4. A nurse is preparing to assist with an oc- Correct Answer: D
ular irrigation for a client who had a chem- we alwaays irrigate the eye
ical splash to the left eye. Which of the first...netflix has something dif-
following actions should the nurse plan to ferent but txbk says irrigate the
take? eye.
A. Irrigate the affected eye from the inner
corner toward the outer corner.
B. Sit the client up with their head turned
toward the right side.
C. Place a strip of pH paper under the
upper lid of the affected eye.
D. Irrigate the affected eye using sterile
water.
5. A nurse is caring for a client who has Correct Answer: B
AIDS. Which of the following isolation pre- Since HIV/AIDS can be trans-
cautions should the nurse implement? mitted through blood and cer-
A. Droplet precautions tain body fluids, standard pre-
B. Standard precautions cautions are essential when
C. Airborne precautions caring for clients with AIDS.
D. Contact precautions
6. A nurse is performing an abdominal as- Correct Answer: D
sessment for a client. Which of the follow- Rebound tenderness with pal-
ing findings should the nurse identify as pation is a sign of peritoneal
the priority? irritation and can be an indica-
A. Gurgling bowel sounds every 10 sec- tion of conditions such as ap-
onds pendicitis, which is a surgical
B. Centrally located umbilical protrusion emergency. This finding should
C. Abdominal distention during breathing be considered a priority as it
D. Rebound tenderness with palpation may require immediate inter-
vention.
7. A charge nurse receives a call from the Correct Answer: D
house supervisor requesting room as- A client who reports having
signments for four new clients. Based on fever, night sweats, and cough
the admission diagnoses, which of the fol- for 2 days may require a pri-
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lowing clients requires a private room? vate room due to the possibil-
A. A client who has diabetes mellitus and ity of an infectious disease that
is presenting with acute ketoacidosis could be transmitted to oth-
B. An older adult client who was admitted ers, such as tuberculosis (TB).
with aspiration pneumonia These symptoms are concern-
C. A client who has a compound fracture ing for TB, which is an airborne
of the right femur infectious disease and would
D. A client who reports having fever, night require airborne precautions,
sweats, and cough for 2 days including a private room with
negative pressure ventilation.
8. A nurse is caring for a group of clients. Correct Answer: D
From which of the following clients For a client with a right upper
should the nurse obtain a blood pressure extremity arteriovenous fistula,
reading using only the left extremity? typically created for dialysis ac-
A. A client who has a peripherally inserted cess, blood pressure measure-
central catheter (PICC) in the left arm ments should not be taken on
B. A client who has left-sided Bell's palsy that arm to avoid damaging the
C. A client who has right-sided weakness fistula. Therefore, the left arm
due to Parkinson's disease should be used for blood pres-
D. A client who has a right upper extremity sure readings in this case
arteriovenous fistula
9. A nurse is assessing a client who has in- Correct Answer: C
creased intracranial pressure. The nurse An altered level of conscious-
should recognize that which of the follow- ness is often the first sign of
ing is the first sign of deteriorating neuro- deteriorating neurological sta-
logical status? tus in a patient with increased
A. Cheyne-Stokes respirations intracranial pressure. Changes
B. Pupillary dilation in consciousness can range
C. Altered level of consciousness from slight disorientation or
D. Decorticate posturing confusion to complete unre-
sponsiveness.
10. A nurse is assessing a client who has Correct Answer: C
myasthenia gravis. Which of the following Having a hard time with brush-
client statements should indicate to the ing hair is directly related to the
nurse that the client needs a referral for performance of ADLs, which
occupational therapy? is the primary focus of occu-
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A. "I've been having problems with blad- pational therapy. An occupa-
der control." tional therapist can assist the
B. "I have difficulty swallowing food." client by teaching energy con-
C. "I have a hard time with brushing my servation techniques, provid-
hair." ing adaptive equipment, and
D. "I would rather be in a wheelchair than modifying the task to make it
use a walker to get around." easier for the client to main-
tain personal grooming inde-
pendently.
11. A nurse is providing discharge teaching Correct Answer: D
for a client who is receiving treatment The duration of medication
for genital herpes. Which of the following for genital herpes depends on
statements by the client indicates the ef- whether the treatment is for
fectiveness of the teaching? an initial outbreak, chronic sup-
A. "I should apply antibiotic ointment to pression, or episodic therapy.
the lesions." For an initial outbreak, antivi-
B. "I should use natural skin condoms ral medication is typically taken
during sexual intercourse." for 7 to 10 days. For chronic
C. "I should expect my lesions to resolve suppression, medication might
in 6 weeks." be taken daily for an extended
D. "I should expect to take my medication period to prevent or reduce the
for 3 weeks." frequency of outbreaks.
12. A nurse is caring for a client who has Correct Answer: C
acute angina. Which of the following ac- Administering nitroglycerin is a
tions should the nurse take first? priority action for acute angina
A. Administer aspirin. as it helps to dilate the coro-
B. Measure blood pressure. nary arteries and relieve chest
C. Administer nitroglycerin. pain. However, it is typically ad-
D. Initiate IV access. ministered after aspirin unless
contraindicated.
13. A nurse is reinforcing teaching with a Correct Answer: B
client who has osteoporosis and is pre- This statement indicates a
scribed (Fosamax) alendronate 70 mg PO need for further instruction.
weekly. Which of the following statements Alendronate should be taken
by the client indicates a need for further with plain water, not milk. Milk
instruction? and other dairy products can
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