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
4. A full-thickness wound
The nurse is completing evening care for a client. What should the nurse do before
documenting that this care has been completed?
1. Straighten top linens
2. Raise upper side rails
3. Remove any unnecessary equipment
4. Fluff pillow and turn cool side next to client
After changing the client’s central line dressing, what should the nurse include when
documenting this procedure?
Standard Text: Select all that apply.
1. Fluid infusing into the catheter
2. Assessment of the central line insertion site
3. Type of dressing applied
4. Aseptic technique under which the dressing was changed
5. Client complaints or concerns
The nurse is determining approaches to teach a client how to perform wound care. What
should the nurse consider when determining appropriate strategies? Select all that apply.
1. Date of discharge
2. Available resources
3. Client reading level
4. Client attention span
5. Best time for teaching
When caring for a client with a chest tube in place, the nurse maintains safety by
keeping which items at the client’s bedside at all times?
1. Bag and mask with oxygen supply
2. Two rubber-tipped clamps, gauze, and petroleum gauze
3. Emergency phone numbers
4. An extra chest tube of the same size inserted into the client
The nurse is working on a surgical unit, and overhears another nurse say, “That client is
asking for pain medication again. He is constantly on the call bell, always reporting
how severe his pain is, and I think he’s just drug-seeking. I’m going to make him wait
the full 4 hours before I give this medication again.” Which action by the nurse is the
most appropriate in this situation?
1. Ignoring the situation because the client in question is not this nurse’s responsibility
2. Entering the nurses’ station, reprimanding the nurse, and completing an incident or
variance report
3. Pulling the second nurse aside and providing a reminder that the sensation of pain is
subjective, and that professionals have a duty to believe clients’ reports of their
symptoms
4. Informing the charge nurse of what was overheard
Which client would benefit from a clear liquid diet?
1. The client recovering from vomiting and diarrhea
2. The client experiencing malnutrition
3. The client requiring increased protein intake
4. The client with a newly placed gastrostomy tube
A client is considering the placement of a continent ileostomy. What should the nurse
explain as an advantage of this type of surgery?
1. Gas may be expelled
2. An appliance is not needed
3. Additional surgery may be required
4. A drainage catheter needs to be inserted several times a day
A client says that the health care provider always seems to be in a hurry which causes
confusion with care expectations. What should the nurse recommend to this client?
1. Write questions to ask when the health care provider makes rounds
2. Suggest telephoning the healthcare provider’s office and speak to the staff
3. Volunteer to discuss the client’s concerns with the provider later in the day
4. Remind that if the healthcare provider does not mention something it probably is not
an issue
A client asks for a copy of the medical record to take home upon discharge. What action
should the nurse take regarding this request?
1> Prepare the requested documentation
2> Tell the client that the record belongs to the hospital
3> Explain to the client that the record cannot be provided
4> Ask the health care provider if the medical record can be provided
A client is having a central venous catheter inserted. After positioning and preparing the
client what should the nurse do?
1. Perform hand hygiene
2. Apply a mask and gloves
3. Open antimicrobial prep pads
4. Open glove packet and sterile drape pack
During morning care a client states that pain medication has been ineffective and wants
to talk with the healthcare provider. How should the nurse categorize this information?
1. A variance
2. A complaint
3. Adverse effect
4. Subjective data
While participating in a religious humanitarian effort in West Africa the nurse sees
several children with symptoms of an acute viral infection. What additional
manifestations should cause the nurse to suspect that these children are experiencing
smallpox? Select all that apply.
1. Rash localized to the trunk
2. Rash contains areas of scabbing
3. Rash located along a nerve track
4. Rash contains macules and papules
5. Rash on both sides of the face and arms
How does the procedure change when a nurse collects a midstream urine specimen
from a woman versus a man?
1. Women should be taught to begin their stream before collecting the specimen.
2. Women would be provided with three antimicrobial wipes, whereas men would be
provided with only one or two.
3. Men should be taught not to touch the inside of the collection container or the lid.
4. Men should be taught to fill the container no more than one-half to one-third full.
The nurse is explaining nursing diagnoses to a group of first-year nursing students.
What should the nurse include in this explanation? Select all that apply.
1. Focuses on client responses
2. Focuses on injury, illness, or disease
3. Requires physician orders to address
4. Remains the same until client discharge
5. Changes according to the client’s needs