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A client is observed in the clinic waiting room bouncing both legs and snapping the fingers. After a short while the client stands and begins to pace. On what should the nurse focus when assessing this client? 1. Level of […]

The client experiences a burn on the arm that is confined to the skin. How should the nurse describe this burn when documenting this client’s care? 1. A clean wound 2. A dirty or infected wound 3. A partial-thickness wound […]

Which items are appropriate for the nurse to include when assessing a client for falls? Standard Text: Select all that apply. 1. Reviewing for a history of falls before admission 2. Talking with family about concerns 3. Assessing the overall […]

The nurse notes that a client has an elevated cholesterol level. Which health problem is this client at risk for developing? 1. Osteoarthritis 2. Ischemic stroke 3. Hemorrhagic stroke 4. Traumatic brain injury Before beginning a surgical procedure the safety […]

A client is demonstrating manifestations of increased intracranial pressure. Which finding supports that this increased pressure is being caused by an increase in brain tissue? 1. Oxygen saturation 86% 2. Mass in the parietal lobe 3. Subarachnoid hemorrhage 4. Fractured […]

The nurse caring for a client receiving parenteral nutrition via a central venous catheter determines that the client’s temperature is elevated, white blood cell count is elevated, and the client is lethargic. The nurse suspects the client is septic. Which […]

The nurse reviews a client’s teaching plan, activity level, and referral agencies contacted. What is the nurse most likely preparing? 1. Care plan 2. Critical pathway 3. Discharge summary 4. Admission assessment After receiving morning report the nurse categorizes an […]

The nurse is assisting the client to eat. Which action by the nurse is the most appropriate? 1. Sitting on the side of the bed while feeding the client 2. Telling the client to sit back and relax while the […]

The nurse is providing ostomy care for a client with a colostomy. Which assessment findings should the nurse report to the health care provider if noted during the procedure? Standard Text: Select all that apply. 1. No change in stoma […]

The nurse is asking a client about lifestyle patterns and spiritual practices. For which admission document is this information needed? 1. Care plan 2. Health history 3. Demographics 4. Discharge needs A client in intensive care has a multi-lumen, balloon-tipped, […]

The nurse notes that within several hours four clients arrived to the emergency department experiencing symptoms of shortness of breath, chest tightness, and burning eyes. What should the nurse suspect is occurring with these clients? 1. Chemical exposure 2. Botulism […]

The nurse is reviewing data collected during a client assessment. Which information should the nurse identify as a client need? Select all that apply. 1. Desires to walk without a cane 2. License to drive has been suspended 3. Attends […]

The nurse notes that a client intervention has a deadline occurring in 3 days. What should this information indicate to the nurse? 1. The action should be observed every 3 days 2. The action should be completed every 3 days […]

The nurse stops on the way home to assist in the care of victims of a multi-motor vehicle crash site. The emergency response team uses a five level triage system. In which order should the nurse triage victims? 1. Victim […]

The nurse suspects the client at the urgent care center might have a urinary tract infection. Based on this, which type of urine specimen should the nurse prepare to collect from the client? 1. 24-hour urine specimen 2. Midstream urine […]

Which activity can the nurse safely delegate to unlicensed assistive personnel (UAP)? 1. Sterile warm soak to client’s infected postoperative wound 2. Application of warm moist soak to client’s left leg 3. Determine effectiveness of cold application to reduce client’s […]

The spouse of a recently deceased client is observed crying and expressing anger to anyone who asks if any help is needed. In which stage of grieving is this spouse? 1. Resolution 2. Restitution 3. Idealization 4. Developing awareness Answer: […]

After completing an assessment the nurse analyzes all data collected. What is the significance of the nurse performing this analysis? 1. Confirms observations 2. Identifies client outcomes 3. Establishes a foundation for the client’s care 4. Prioritizes interventions according to […]

A client refuses to complete an advance directive because he is not “ready to die.” What should the nurse respond to this statement? 1> “It’s best to be safe than sorry.” 2> “You are right ” it is more appropriate […]

The nurse collects data slowly and methodically from a new client. Why is the nurse using this approach during this phase of the nursing process? 1. Ensures accuracy of data 2. Identifies client outcomes 3. Establishes a rapport with the […]

The nurse is preparing to discharge a client with a new ileostomy. What should the nurse include when documenting discharge information about this client? 1. Last weight calculated and BMI 2. Most recent vital signs measurements 3. Findings from the […]

The nurse working in the emergency department (ED) is providing discharge teaching for a client with a newly applied cast to the left arm. Which statement by the client indicates additional teaching is required? 1. “When I take a shower, […]

When the nurse documents a client’s wound, which is the best means of describing the wound? 1. Measuring the wound and documenting size 2. Comparing the wound to a universally understood object, such as a quarter or cashew 3. Using […]

After delegating an aspect of care to unlicensed assistive personnel (UAP) the nurse answers any questions and is available while the care is being provided. Which “right of delegation” is this nurse performing? 1. Person 2. Direction 3. Supervision 4. […]

When delegating bed-making to unlicensed assistive personnel (UAP), on which items should the nurse instruct the UAP? Standard Text: Select all that apply. 1. Proper disposal of linens that contain drainage 2. What tubes or dressings the client might have […]

The nurse is providing care to a client requiring restraints. How often should the nurse assess the client and document the assessment? 1. Once per shift 2. Once a day 3. Once every 4″6 hours 4. Once every 1″2 hours […]

When the nurse performs hand hygiene properly, which aspect in the chain of infection is the nurse breaking? 1. Portal of entry 2. Portal of exit 3. Mode of transmission 4. Etiologic agent A client recovering with left leg weakness […]

The nurse delegates the making of an occupied bed to unlicensed assistive personnel (UAP). Which statement made by the UAP indicates the need for further instruction prior to this assignment? 1. “I will be sure to inform you of any […]

The nurse is instructing unlicensed assistive personnel (UAP) on fall prevention for the clients. Which statement made by the UAP warrants further instruction? 1. “I will ensure that the call light is within reach of the client.” 2. “I will […]

The nurse learns that a client will be discharged in 2 days. On what should the nurse focus when planning for this client’s discharge? Select all that apply. 1. Needs 2. Goals of care 3. Measureable outcomes 4. Implementation strategies […]

The nurse is caring for a client who complains of frequent constipation. Which factor in the client’s history is least likely to be the cause of the constipation? 1. Inadequate fluid intake 2. Repeated inhibition of the urge to defecate […]

The nurse is teaching the client to use a metered-dose inhaler. Which information should the nurse provide to the client? 1. Take a deep breath, hold it, and then gently squeeze the inhaler to dispense the medication. 2. Take several […]