The nurse is providing ostomy care for a client with a colostomy. Which assessment
findings should the nurse report to the health care provider if noted during the
procedure?
Standard Text: Select all that apply.
1. No change in stoma size
2. A stoma that appears dry and grey in color
3. The presence of skin irritation
4. The amount of drainage
5. The odor of the drainage
The nurse is caring for a client who is on complete bed rest secondary to a deep vein
thrombosis in the right leg. When placing the client on the bedpan, which position is
most appropriate?
1. Prone
2. Semi-Fowler’s
3. Fowler’s
4. Supine
The nurse is obtaining a gum swab for an HIV test. What should the nurse include when
performing this procedure? Select all that apply.
1. Check window display on device
2. Swab outer gum with device included in kit
3. Insert swab into vial containing special solution
4. Have the client flush the mouth with mouthwash
5. Instruct client to confirm results with a Western blot test
The nurse reviews palliative care with a client experiencing a chronic illness. Which
client statement indicates that teaching has been effective?
1. “I can be on palliative care for 6 months.”
2. “The expected outcome of palliative care improved quality of life.”
3. “Palliative care neither slows down nor speeds up the dying process.”
4. “Palliative care supports the philosophy that death is an integral part of the life
cycle.”
The nurse is caring for a client who has just died. When performing postmortem care,
which nursing actions are appropriate for this client?
Standard Text: Select all that apply.
1. Positing the client in a supine position
2. Placing the client’s arms crossed over the chest
3. Closing the client’s eyes
4. Inserting the client’s dentures in the mouth
5. Pulling the top linens to the client’s shoulder.
The nurse is reviewing data collected during a health history. Which statement should
the nurse use to clarify information?
1. “I hear what you”re saying.”
2. “When you say that, it makes me feel uncomfortable.”
3. “I don”t understand. Can you say it in a different way?”
4. “You were telling me how hard it is to talk to your spouse.”
The nurse caring for a client in traction inspects the apparatus and determines all is well
when noting which finding?
1. The weight is sitting on the floor.
2. The rope is on the side of the pulley.
3. The knots are positioned 5 inches from the pulley.
4. All ropes are intact and connected with slipknots, and short ends are taped.
A critically ill client needs to be repositioned in bed. Which action will help prevent
tearing this client’s skin?
1. Sliding with a lift sheet
2. Raising the foot of the bed
3. Pulling to one side of the bed
4. Pulling up from the head of the bed
When assessing the client’s nutritional status and needs, which type of assessment is the
most important for the nurse to use?
1. A complete nutritional assessment
2. A nutritional screening
3. A comprehensive nutritional assessment
4. An in-depth nutritional assessment
For which situation should the nurse apply clean disposable gloves?
1> Providing denture care
2> Bathing a client
3> Applying antiemboli stockings
4> Assessing vital signs
Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?
1. Changing ventilator settings according to the primary care provider’s order
2. Moving the location of the endotracheal tube from one side of the mouth to the other
side
3. Measuring airway cuff pressure
4. Assist with repositioning a client
The nurse is preparing to collect a stool specimen. Place the steps involved in the
procedure 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. Provide for client privacy.
Response 2. Assist the clients who need help, either with bedside commode or a
bedpan.
Response 3. Perform hand hygiene and observe other appropriate infection control
procedures.
Response 4. Apply gloves to prevent contamination, and clean the client as required.
Inspect the skin around the anus for any irritation, especially if the client defecates
frequently and has liquid stools.
Response 5. Transfer the required amount of stool to the stool specimen container. Use
tongue blades to transfer some or the entire stool specimen container, taking care not to
contaminate the outside of the container.
Response 6. Prior to beginning of procedure, introduce self and verify the client’s
identity. Explain what is going to be done, why it is necessary, and how the client can
help.
The nurse administers the preoperative medication to the client 1 hour before elective
surgery, and then discovers the preoperative consent is not signed. Which action by the
nurse is the most appropriate?
1. Have the client sign the consent quickly, before the medication begins taking effect.
2. Have a family member or medical power of attorney sign the consent.
3. Send the client to the holding area without a signed consent.
4. Notify the health care provider that surgery will need to be canceled.
The nurse obtains a specimen from the client’s wound. Which items will the nurse
include when documenting this procedure in the medical record?
Standard Text: Select all that apply.
1. Source of specimen
2. Type of culture obtained
3. Appearance of wound
4. Dispersal of the specimen
5. Microorganism causing infection
The nurse is preparing to make an entry into a client’s medical record after completing
morning care and providing medications. What should the nurse ensure when
completing this documentation? Select all that apply.
1. Time care was provided
2. Client’s response to care provided
3. Time medications were administered
4. Estimated date for goals to be achieved
5. Client’s reaction to medications provided
The nurse is unable to palpate a client’s pedal pulse even though the foot is pink and
warm. Which action by the nurse is the most appropriate?
1. Apply a warm soak to the foot.
2. Notify the health care provider that the client has lost circulation to the foot.
3. Elevate the foot.
4. Auscultate the pulse using an ultrasound Doppler.
The nurse is assisting the health care provider collect cerebrospinal fluid for testing to
rule out meningitis. Which are the nurse’s responsibilities?
Standard Text: Select all that apply.
1. Explain the procedure and obtain signed consent.
2. Teach the client how to assist during the procedure by maintaining proper
positioning.
3. Observe sterile technique when preparing the equipment for the procedure.
4. Label all specimens collected and send them to the lab.
5. Assess the client before, during, and after the procedure.