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 thoracic vertebrae
Many conditions can increase the risk for injury from heat applications. Which clients
would be at the greatest risk for injury?
Standard Text: Select all that apply.
1. A client with a lot of body fat
2. A client being treated for anxiety
3. A client with peripheral vascular disease
4. A malnourished client
5. A client prescribed steroids
When weaning a client from the ventilator, what should the nurse document in addition
to routine assessments performed for any client requiring mechanical ventilation with
an artificial airway in place?
1. The details and length of the weaning trial
2. The client’s oxygen saturation
3. The client’s breath sounds
4. The client’s respiratory rate
The nurse is providing perineal care to a male client. Which action ensures that
cross-contamination does not occur?
1. Wring washcloth out
2. Use a clean washcloth for each motion
3. Cleanse from the shaft to the tip of the penis
4. Begin cleansing from the scrotum to the shaft
The nurse is caring for a client with atelectasis. Which prescription from the health care
provider should the nurse anticipate to correct this problem?
1. Increase oxygen concentration
2. Increase flow rate
3. Increase tidal volume
4. Set PEEP at 6 cm H2O
While applying a treatment for head lice the client complains that the scalp is stinging.
What should the nurse do first?
1. Comb the hair
2. Wrap the head with a towel
3. Stop applying the medication
4. Contact the Poison Control Center
At the conclusion of an interdisciplinary team meeting it was decided that a client
would benefit from preservative interventions. What should the nurse add to this client’s
care plan? Select all that apply.
1. Measure for a cane
2. Instruct in the use of a walker
3. Active range of motion exercises
4. Consider the use of crutch walking
5. Assist with ambulation three times a day
The nurse applies a warm moist compress to the client’s left wrist. Which item should
the nurse exclude from the documentation of the intervention for this client?
1. Assessment of site before and after the application
2. Client’s response to the compress
3. Assessment of the site every 5″10 minutes
4. Vital signs before, during, and after the treatment
The nurse manager is observing a new graduate provide client care. Which statements
should the manager identify as being barriers to communication? Select all that apply.
1. “What a beautiful day! I love bright sunshine!”
2. “If it were me I would take the new medication.”
3. “You gave yourself the insulin injection very well.”
4. “You shouldn”t worry so much about your surgery.”
5. “I think it was right for you to delay having the surgery.”
The nurse is caring for a client who has seizure precautions. Which actions by the nurse
are appropriate for these precautions?
Standard Text: Select all that apply.
1. Padding the bed around the head, foot, and side rails
2. Placing functional oral suction equipment in the room
3. Placing extremity restraints in the room for use if the client has a seizure
4. Keeping pillows handy to protect the client’s head
5. Taping a bite block to the wall to protect the client from biting his or her tongue
The nurse is unsure if a teaching pamphlet would be appropriate for a client with an 8th
grade reading level. What should the nurse do before providing the client with the
pamphlet?
1. Use a readability formula
2. Read the material for comprehension
3. Contact the manufacturer and ask what the readability level is
4. Ask another staff member to read the material for comprehension
When removing an old central line dressing, which action by the nurse is the priority?
1. Pulling the tape off in the direction of the catheter
2. Inspecting the insertion site for signs of infection
3. Pressing the catheter into the client’s skin while removing the tape
4. Applying sterile gloves
A client is being prepared to go home. For which reason should the nurse identify the
client as being high-risk for discharge?
1. Adjustments made to medications
2. Recovering from open heart surgery
3. Removal of a cast for a fractured limb
4. Treatment provided to correct electrolyte imbalances
The nurse administers an antianxiety (anxiolytic) medication to a client diagnosed with
dementia who has been harming himself. When documenting the use of this medication
as a restraint, which term is the most appropriate for the nurse to use?
1. Chemical restraint
2. Physical restraint
3. Medication restraint
4. Psychological restraint
A client receiving a blood transfusion for 15 minutes complains of suddenly feeling
cold and is shivering. Blood pressure has decreased since the last assessment. Which is
the nurse’s priority action?
1. Notify the health care provider.
2. Monitor the client’s blood pressure every 5 minutes.
3. Stop the blood infusion, and run the normal saline on the other side of the Y tubing.
4. Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with
normal saline.
A client scheduled for an outpatient endoscopy asks when he can eat since the black cup
of coffee wasn”t enough. What should the nurse do?
1. Provide with dry crackers
2. Notify the radiology department
3. Document that the client had black coffee
4. Explain that a meal will be provided shortly
The nurse is initiating closed continuous bladder irrigation using a three-way catheter.
Prior to beginning the flow of the irrigation fluid, which action by the nurse is the most
appropriate?
1. Opening the roller clamp to the desired flow rate
2. Emptying the urine collection bag
3. Documenting the procedure
4. Assessing the drainage for amount, color, and clarity
In the ongoing postoperative period, the nurse independently determines, within the
protocols of the hospital, the need for which provision of care?
1. Type of diet
2. Activity level
3. Assessment intervals
4. Intravenous solutions