1. A home health nurse is caring for a child who has Lyme disease. Which of
the following is an appropriate action for the nurse to take?
Ensure the state health department has been notified.
2. A nurse is caring for a client who has a vented NG tube set to low
intermittent suction and has vomited. Which of the following actions
should the nurse perform first?
Evaluate functioning of the suction device.
3. While performing a routine assessment, a nurse notices fraying onto the
electrical cord of a client's continuous passive motion (CPM)device. Which
of the following actions should the nurse take first?
Remove the device from the room.
4. A nurse is setting up a sterile field to perform wound irrigation for a client.
Which of the following actions should the nurse take when pouring the
sterile solution?
Remove the cap and place it sterile side up on a clean surface.
5. A nurse is creating a plan of care for a female client who has recurrent
urinary tract infections. Which of the following interventions should the
nurse include in the plan?
Wear loose fitting underwear.
,6. A nurse is caring for an infant who has gastroenteritis. Which of the
following assessments findings should the nurse report to the provider?
Sunken fontanels and dry mucous membranes.
7. A nurse is conducting health promotion education regarding
contraindications to combination oral contraceptive use to a group of
women. Which of the following conditions should the nurse include in the
teaching?
Hypertension
8. A nurse is providing teaching to a client who has a depressive disorder and
a new prescription for amitriptyline. Which of the following statements by
the client indicates understanding of the teaching?
"I know it will be a couple of weeks before the medication helps me feel better."
9. A nurse is caring for a client who is immobile. Which of the following
interventions is appropriate to prevent contracture?
Align a trochanter wedge between the client's legs.
10. A nurse is assessing a client who is postoperative following abdominal
surgery and has an indwelling urinary catheter that is draining dark yellow
urine at 25 mL/hr. Which of the following interventions should the nurse
anticipate?
Obtain a urine specimen for culture and sensitivity
11. A nurse is reporting a client's laboratory tests to the provider to obtain a
prescription for the client's daily warfarin. Which of the following laboratory
, tests should the nurse plan to report to obtain the prescription for the
warfarin?
INR
12. A nurse is assessing a client who is taking haloperidol and is experiencing
pseudoparkinsonism. Which of the following findings should the nurse
document as a manifestation of pseudoparkinsonism?
Shuffling gait
13. A nurse is caring for a client who is experiencing expressive aphasia and
right hemiparesis following a stroke. Which of the following actions by the
nurse best promotes communication among staff caring for the client?
Having interdisciplinary team meetings for the client on a regular basis.
14. A nurse is caring for a 2-year-old toddler. Which of the following food
choices should the nurse recommend to promote independence in eating?
Banana slices
15. A nurse on a medical-surgical unit is notified that a mass casualty event
has occurred in the community. Which of the following actions should the
nurse plan to take?
Recommend to the provider specific acute care clients for discharge.
16. A nurse is receiving change-of-shift report for four clients. Which of the
following clients should the nurse assess first?
A client who was just given a glass of orange juice for low blood glucose level.
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