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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 physical condition
4. Assessing medication lists
5. Assessing mental status
The nurse is caring for a client who had surgery a day ago. Which observation indicates
that the client was physically prepared for the procedure?
1. Does leg exercises 3 times a day
2. Rates pain as 5 on a scale from 0 to 10
3. Permits staff to reposition in bed every 2 to 4 hours
4. Deep breathes and coughs every 2 hours while awake
The nurse is using a curved hard plastic tube to suction the client's oral cavity. Which
term should the nurse use when referring to this piece of equipment?
1. Whistle-tipped catheter
2. Yankauer suction tube
3. Open-tipped catheter
4. Closed suctioning system
A client asks for help with combing the hair. In which order should the nurse assist this
client?
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Brush or comb client's hair from scalp to hair ends, using gentle, even
strokes.
Response 2. Place all hair care items within reach.
Response 3. Place towel over client's shoulders.
Response 4. Replace hair care items in appropriate place and clean items as needed.
Response 5. Style hair in a manner suitable to client.
The nurse is explaining to the client the need to do an assessment at the beginning of
the shift. This type of assessment involves obtaining which type of information?
1. Information regarding the client's overall assessment
2. Information of a specific medical condition
3. Information specific to the client's current condition
4. Information regarding past medical history
The nurse is caring for a client. What action should the nurse take to determine this
client's teaching needs?
1. Speak in plain language
2. Ask if the client understands
3. Select 5th grade reading material
4. Use questions beginning with "why"
The charge nurse is observing a new graduate care for a client with a Groshong catheter.
For which observation should the charge nurse interrupt this client's care?
1. Preparing fluids for infusion
2. Clamp applied to the catheter
3. Catheter not flushed with heparin
4. Client response to medication assessed
The nurse is caring for a pediatric client who is focused on pulling out the IV line in the
right arm. Which type of restraint is the most appropriate for this client?
1. Elbow restraint to the right arm
2. Elbow restraint to the left arm
3. Mitt restraint to the right hand
4. Wrist restraint to the left arm
A client is recovering from a myelogram in the outpatient ambulatory surgical center.
What is a priority when caring for this client?
1. Restrict fluids
2. Keep the bed flat
3. Encourage ambulation
4. Raise the head of the bed to a 60 degree angle
A client is prescribed a medication to be administered IV push that is incompatible with
the primary intravenous solution. What should the nurse do to safely administer this
medication?
1. Insert a new angiocatheter
2. Change the route to an oral dose
3. Flush the angiocatheter with normal saline
4. Discontinue the primary infusion for several hours
The nurse discontinues the client's IV prior to discharge. After removing the catheter,
which actions by the nurse are appropriate?
Standard Text: Select all that apply.
1. Applying pressure to the insertion site until bleeding stops
2. Examining the removed catheter to ensure that it is intact
3. Teaching the client to inform the nurse if the site begins to bleed at any time
4. Holding the client's extremity below the level of the heart if bleeding persists
5. Covering the venipuncture site with a sterile dressing
When performing rescue breathing in a hospital, which is the preferred method for the
nurse to use until the health care provider arrives to intubate the client?
1. Mouth-to-mouth
2. Mouth-to-mask
3. Bag-valve-mask method
4. The jaw-thrust maneuver
The nurse is researching nursing interventions appropriate for a particular nursing
diagnosis. Which classification system should the nurse use when researching this
information?
1. NIC
2. PES
3. NOC
4. NANDA
A client's blood pressure us144/82 which is higher than the usual baseline which has
been normal. For what factors should the nurse assess the client based on the current
blood pressure reading?
Standard Text: Select all that apply.
1. Diet
2. Medication history
3. Activity
4. History of recent symptoms of hypertension
5. Recent stress factors the client has experienced
The nurse is analyzing a client's tracing for a pulmonary arterial wedge pressure. For
which characteristic should the nurse analyze this tracing?
1. Dicrotic notch
2. Wandering baseline
3. Premature ventricular contractions
4. Higher and more pronounced pressure waveform,
An organization uses the SOAP documentation format. In which area should the nurse
document the appearance of a client's abdominal wound?
1. Plan
2. Objective
3. Subjective
4. Assessment
The nurse notes that the skin around the stoma of a client with an ileostomy is partially
denuded. What should the nurse do?
1. Keep the appliance off
2. Apply skin barrier paste
3. Apply Stomahesive powder
4. Increase the size of the stoma opening on the barrier
A client with a terminal illness is in the depression stage of the grieving process. What
should the nurse do to help this client?
1. Offer support and reassurance to family
2. Encourage client to talk when ready to do so
3. Remain with client and share on a nonverbal level
4. Assist with contacting spiritual counselor or hospital chaplain
The nurse is caring for a client with induced hypothermia for major thoracic surgery.
For which potential health problems should the nurse assess this client? Select all that
apply.
1. Acidosis
2. Afterdrop
3. Hypotension
4. Hypertension
5. Rebound fever
