The nurse reviews a client’s teaching plan, activity level, and referral agencies
contacted. What is the nurse most likely preparing?
1. Care plan
2. Critical pathway
3. Discharge summary
4. Admission assessment
After receiving morning report the nurse categorizes an assigned client’s care according
to priority needs. How does this behavior support the nursing process?
1. Organizes and structures care
2. Emphasizes client preferences
3. Follows Maslow’s hierarchy of needs
4. Considers time needs for each nursing action
The Apgar score for a newborn is 4 and 5 minutes, 5 at 10 minutes, and 6 at 15 and 20
minutes. What should the nurse prepare when caring for this client?
1. Radiant heat
2. Intravenous fluids
3. Vitamin K injection
4. Emergency intubation equipment
The nurse is changing the client’s dressing on a postoperative nondraining wound.
Which personal protective equipment (PPE) should the nurse apply prior to the dressing
change?
1. Sterile gown, mask, and sterile gloves
2. Sterile gown, mask, and goggles
3. Sterile gloves and mask
4. Sterile gloves
Which action by the nurse is least appropriate when applying antiemboli stockings?
1. Assisting the client to a lying position in bed
2. Turning the stocking right-side-out
3. Washing and drying the legs
4. Having the client point the toes
After providing medications and changing a dressing the nurse accesses the client’s
computerized medical record and enters the information about the care provided. Why
is the nurse documenting at this time? Select all that apply.
1. Evaluates individual performance
2. Helps determine the staffing needs of the care area
3. Estimates the amount of time required to provide care
4. Communicates information to other members of the team
5. Provides a permanent record of the care provided to the client
A client is scheduled for a diagnostic test using radioactive isotopes. What should the
nurse expect to be provided to this client before the test?
1. A sedative
2. A blocking agent
3. Intravenous fluids
4. A dose of an antibiotic
The nurse is preparing several medications to administer via nasogastric tube. Which
action by the nurse demonstrates correct technique?
1. Administering one medication at a time every 15 minutes
2. Giving one medication at a time, flushing the tube with water, and then administering
another medication
3. Mixing the medications together and giving them at one time
4. Calling the pharmacy to ask if all of the medications may be safely mixed together
The nurse working in the emergency department is caring for a client who experienced
deep-thickness burns over 40% of the body and is in shock. Which order should the
nurse anticipate for this client?
1. Electrolyte solutions
2. Volume expanders
3. Nutrient solutions
4. Total parenteral nutrition
The nurse suspects that a new widow is demonstrating a morbid reaction to grief. What
did the nurse observe to come to this conclusion?
1. Will not eat
2. Continually cries
3. Has not slept for several days
4. Has the deceased spouse’s symptoms
What action should the nurse take to ensure the safe administration of prescribed
medications to a client? Select all that apply.
1> Validating the healthcare provider’s order
2> Checking two forms of client identification
3> Leaving a client’s medications at the bedside
4> Returning a mislabeled medication to the Pharmacy
5> Deciding to report a medication error later in the shift
The nurse is assisting a client with postural drainage. What should be included when
explaining the process to the client? Select all that apply.
1. Expectorate secretions
2. Return to a sitting position slowly
3. Remain in each position for 3 to 15 minutes
4. Take a deep breath between position changes
5. The head of the bed will be in the flat position
The nurse is assessing a newly admitted client. What should the nurse include when
discussing advanced directives with this client? Select all that apply.
1. It is the same for every state
2. It is sometimes called a living will
3. It includes preferences for health care
4. A copy is placed in the medical record
5. It specifies treatments desired at end of life
A client is admitted with suspected gastrointestinal anthrax. Which type of precautions
should the nurse anticipate being prescribed for this client?
1. Droplet
2. Contact
3. Airborne
4. Standard
The nurse is preparing to assess a client recovering from an arteriogram. What should
be the priority for this client?
1. Monitor pulses distal to the puncture site
2. Elevate the extremity used for the puncture site
3. Place a pillow under the extremity used for the puncture sit
4. Increase intravenous fluids to ensure an adequate urine output
The nurse is caring for a client diagnosed with osteoarthritis. Which intervention should
the nurse advise the client to do in order to reduce discomfort?
1. Apply ice to the painful joint.
2. Immerse the painful joint in cold water.
3. Apply heat pack once a day.
4. Apply heat to the painful joint several times a day.
An adolescent client newly placed in traction says, “Lying in this bed all the time is
going to turn my body into mush. Is there any way I could exercise while I’m in
traction?” Which response by the nurse is the most appropriate?
1. “Many people worry about muscle weakness when they are confined to bed. You
could perform range of motion, isometric, and specific exercises.”
2. “Don’t worry about your muscles, because you can get them back after you get out of
traction.”
3. “You’re young and in great shape. Your muscles won’t weaken with a few weeks in
bed.”
4. “I’ll put a referral in for physical therapy to come and work with you.”
Immediately after moving the oral endotracheal airway to the other side of the client’s
mouth, the low pressure alarm sounds. What should the nurse do first?
1. Providing oral care
2. Suctioning the airway
3. Checking for correct tube placement
4. Checking tube cuff inflation
A client with a new case is complaining of itching under the cast. Which should the
nurse instruct this client?
1. Use a back scratcher to scratch under the cast.
2. Use a wooden spoon to scratch inside the cast.
3. Blow air from a hair dryer set to cool under the cast, or apply ice.
4. Take an antihistamine to reduce itching.