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 pain
2. Reason for the anxiety
3. Fear of health problems
4. Frustration with waiting
During an intravenous pyelogram the nurse suspects that a client is experiencing an
allergic reaction to the contrast medium. What did the nurse assess to make this clinical
determination? Select all that apply.
1. Onset of nausea
2. Hives on the neck
3. Respiratory rate 28
4. Complaint of being thirsty
5. Blood pressure 88/50 mm Hg
The nurse demonstrating proper placement of the stethoscope when assessing the apical
pulse. Where should the diaphragm be placed?
1. The brachial site
2. The apex of the heart
3. The carotid site
4. The radial site
A client newly diagnosed with heart failure asks what herbal preparations can be taken
to help reduce the symptoms of the disorder. What should the nurse consider discussing
with the client?
1. Turmeric
2. Green tea
3. Hawthorne
4. Black cohosh
The nurse is having difficulty maintaining rapport with a client. What should the nurse
do to facilitate this relationship?
1. Establish mutual goals
2. Demonstrate consistent behavior
3. Use a warm, accepting manner during interactions
4. Accept client as having value and worth as an individual
The nurse decides to use tapotement when providing a client with an evening back rub.
What should the nurse keep in mind when using this massage stroke?
1. Avoid the kidney area
2. Use a continuous motion
3. Maintain constant skin contact
4. Focus on the shoulders and along back
The nurse is preparing a consent form for a client’s signature. For which reason is this
form most likely needed?
1. Chest x-ray
2. Drawing a blood sample
3. Measuring blood pressure
4. Biopsy of an abdominal mass
A client, recovering from a motor vehicle crash, has no damage to the neurologic
system despite being thrown from the car. What anatomical feature most likely
protected this client’s neurologic system?
1. Cervical vertebrae
2. Cerebrospinal fluid
3. Intervertebral cartilage
4. Thoracic and lumbar spinal curves
A newborn is admitted to the nursery after delivery. Which site should the nurse use to
measure this infant’s temperature?
1. Axillae
2. Temporal artery
3. Tympanic membrane
4. Oral cavity
The nurse is caring for a client with a fracture of cervical vertebrae 4. Which piece of
equipment connects the client to traction for this type of injury?
1. Pearson attachment
2. Buck’s extension
3. Thomas splint
4. Crutchfield tongs
The nurse is caring for a client with a medical diagnosis of HIV/AIDS admitted to the
hospital with Pneumocystis carinii infection. In order to reduce the spread of infection,
which is the priority nursing intervention?
1. Teaching the client to provide self-care
2. Teaching respiratory/cough etiquette
3. Teaching the use of sexual barriers
4. Teaching the use of standard precautions
The nurse is preparing to bathe clients assigned for the shift. Which client should the
nurse wear gloves to bathe?
1. The client diagnosed with HIV/AIDS
2. The newborn just admitted from the delivery room
3. The client with psoriasis
4. The postoperative client
A postoperative client displays sudden chest pain, shortness of breath, cyanosis,
tachycardia, and low blood pressure. Which complication should the nurse suspect is
occurring?
1. Pneumonia
2. Atelectasis
3. Hypovolemia
4. Pulmonary embolism
A victim who witnessed the deaths of several coworkers during a terrorist attack is
attending therapy sessions. Currently the victim client is dealing with event by
confronting it, talking about it, and working through feelings. In which phase of
recovery is this client?
1. Recovery
2. Avoidance
3. Adjustment
4. Reconsideration
The nurse is providing care to several clients on a medical’surgical unit. Which clients
would benefit from the application of heat?
Standard Text: Select all that apply.
1. Client with muscle spasms in the lower back
2. Client with traumatic injury and bleeding
3. Client with joint contracture
4. Client in pain
5. Client with inflammation
During a home care visit the nurse needs to change a client’s infected wound dressing.
In which order should the nurse perform actions when additional supplies are needed
once the soiled dressing has been removed from the client?
1. Wash hands
2. Apply gloves
3. Remove gloves
4. Access equipment bag
5. Place items on clean surface
The nurse is caring for a client who is to have a peripherally inserted central catheter
(PICC) line inserted tomorrow afternoon. The client’s peripheral access line is
infiltrated, and needs to be restarted. Which site would the nurse avoid using?
1. Median cubital vein
2. Cephalic vein
3. Radial vein
4. Dorsal metacarpal veins
When examining an older adult client’s sense of smell, which finding would the nurse
anticipate?
1. Heightened sense of smell
2. Normal sense of smell
3. Diminished sense of smell
4. Development does not impact the sense of smell
A client who plays professional football reports having no symptoms and has the
following vital signs: 98.6F; 48; 10; 88/54. Which action by the nurse is the priority?
1. Notify the health care provider.
2. Encourage fluids.
3. Document the client’s vital signs and continue the history.
4. Place client in the Trendelenburg position.
The nurse is asked to perform a task that is beyond the scope of practice. What should
the nurse use as a reason when refusing to complete the task?
1> “It is not a part of the National Patient Safety Goals.”
2> “The Joint Commission does not identify it as a nursing task.”
3> “It is not identified as permitted within the Nurse Practice Act.”
4> “The task can be delegated to unlicensed assistive personnel (UAP).”