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 actions by the
nurse are appropriate in this situation?
Standard Text: Select all that apply.
1. Replacing the parenteral nutrition with a normal saline solution
2. Changing the IV tubing
3. Saving the remaining TPN
4. Recording the lot number of the TPN
5. Notifying the health care provider.
The nurse is assessing a newly admitted client. What information should be
documented about the client’s current medications? Select all that apply.
1. Allergies to drugs
2. List of nutritional supplements
3. List of all prescribed medications
4. Pharmacy used to fill prescriptions
5. List of all over-the-counter medications
The nurse is caring for a postoperative client, who is on strict bed rest, after having a
rod placed for scoliosis. The client is currently supine. Which action by the nurse is
necessary prior to logrolling this client?
1. Moving the client closer to the side of the bed that the client will be turned toward
2. Placing a pillow under the client’s head
3. Placing one or two pillows between the client’s legs
4. Having the client fold the arms on the chest
The nurse is completing a tool to help coordinate care needed for several clients. What
should the nurse identify as a task that must be completed at a specific time for a client?
1. Evaluating the amount of food a client ingested after lunch
2. Providing intravenous medication before a peak blood level is drawn
3. Measuring urine in a collection bag before attending afternoon report
4. Checking the results of laboratory tests before documenting end of shift care
During morning rounds the nurse notes that a client is packing clothing and personal
items in preparation for leaving the hospital. What should the nurse do with the signed
against medical advice form?
1. Place it on the client’s medical record
2. Fax it to the healthcare provider’s office
3. Send it to the Risk Management department
4. Send a copy to the organization’s legal department
The nurse notes that a client’s blood pressure reading was unusually elevated. For what
should the nurse assess to determine the reason for this reading?
1. Presence of pain
2. Cuff inflation was too slow
3. Blood pressure cuff too wide
4. Arm placed above the heart level
The nurse is preparing to document care provided to a client who received rescue
breathing while being transported to radiology. What should the nurse include in the
documentation for this client?
Standard Text: Select all that apply.
1. Date and time of event
2. Factors that precipitated the event
3. Length of time with no breathing
4. Response to rescue breathing
5. Tasks assigned to the unlicensed assistive personnel
During a health history a client relates a history of drug abuse. Where should the nurse
document this information?
1. Health History
2. Biographic information
3. Psychosocial Factors
4. Lifestyle
The nurse is documenting care for a ventilated client. Which items are appropriate for
the nurse to include in the documentation?
Standard Text: Select all that apply.
1. Assignment of suctioning to the unlicensed assistive personnel (UAP)
2. Client response to ventilator changes
3. Pertinent laboratory values, such as arterial blood gas results
4. Physical assessment findings
5. Pain rating using an appropriate pain rating scale
The nurse notes that a client being prepared for discharge is not to continue taking two
medications at home. Where should the nurse find additional information about this
change in medications?
1. Laboratory reports
2. Previous nurse’s documentation
3. Healthcare provider’s documentation
4. Summary of diagnostic testing completed
The nurse admits an older adult client, who reports following a full liquid diet over the
past 3 months. The nurse anticipates this client will have which problems?
1. Low serum iron and high serum albumin
2. Low serum iron and high serum potassium
3. Low serum iron and serum albumin, high serum cholesterol
4. Low serum cholesterol and high serum albumin
The health care provider performs a specimen collection by inserting a needle into the
abdomen to collect fluid. Which term should the nurse use when documenting this
procedure?
1. Paracentesis
2. Thoracentesis
3. Lumbar puncture
4. Venogram
A client with gastric ulcers has been taking licorice root. Which finding should suggest
to the nurse that the client should stop taking this herbal preparation?
1. Diarrhea
2. Insomnia
3. Dry mouth
4. Elevated blood pressure
The nurse is completing a home safety assessment during the first care visit. What
should be the focus when assessing the client’s bedroom? Select all that apply.
1. Adequate space
2. Night light availability
3. Flooring in good repair
4. Handrails fastened to wall
5. Ease in getting into and out of bed
The nurse is caring for a client who is on bed rest with bathroom privileges. While the
client is in the bathroom, the nurse changes the client’s bed and should make the bed in
what way?
1. Unoccupied open bed
2. Occupied open bed
3. Unoccupied closed bed
4. Surgical bed
The nurse is assisting with a thoracentesis. Place the steps of the procedure for assisting
the client in the correct order.
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Help position the client and cover the client as needed with a bath blanket.
Response 2. Observe the client for signs of distress, such as dyspnea, pallor, and
coughing.
Response 3. Support the client verbally and describe the steps as needed.
Response 4. Support the client throughout the procedure.
Response 5. Collect drainage and laboratory specimens. Then apply small sterile
dressing over the site.
The nurse is preparing to assess a client who has lived in the United States for 6
months. What should the nurse include to ensure cultural sensitivity? Select all that
apply.
1. Education
2. Nutrition practices
3. Family relationships
4. Cultural background
5. Access to a computer
The nurse applies an aquathermia heat pack to the client’s right leg and removes it after
no more than 45 minutes. What is the nurse trying to avoid by completing this action?
1. Vasodilation
2. Rebound phenomenon
3. Heat tolerance
4. Systemic effects
A client is scheduled for a CT scan of the brain with and without contrast. What needs
to be done to prepare the client for this diagnostic test? Select all that apply.
1. Explain what happens during the test
2. Review what needs to be done after the test is completed
3. Discuss what needs to be done before arriving for the test
4. Obtain information about the client’s health insurance plan
5. Ask if the client has any questions after receiving instructions
The nurse is applying a warm moist compress to the client’s right calf. Prior to putting
the compress in place, which action by the nurse is the most appropriate?
1. Turn the client onto the left side.
2. Position the client appropriately.
3. Turn the client onto the right side.
4. Elevate the head of the bed.