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The nurse is asking a client about lifestyle patterns and spiritual practices. For which
admission document is this information needed?
1. Care plan
2. Health history
3. Demographics
4. Discharge needs
A client in intensive care has a multi-lumen, balloon-tipped, flow-directed catheter in
place. What hemodynamic measurements should the nurse expect from this catheter?
Select all that apply.
1. Right atrial pressure
2. Mean arterial pressure
3. Pulmonary artery pressure
4. System vascular resistance
5. Pulmonary arterial wedge pressure
The client is started on 90% oxygen by nonrebreather mask at 0800. The nurse working
the night shift assesses the client, who complains of substernal pain and dyspnea and
has rales audible in the lower lung field bilaterally. Based on these assessment findings,
what should the nurse suspect?
1. Myocardial hypoxia
2. Pulmonary emboli
3. Oxygen toxicity
4. Congestive heart failure
The nurse is planning care for a newly admitted client. Which behavior indicates that
the nurse is using critical thinking?
1. Recalls a similar client situation
2. Asks the healthcare provider for suggestions
3. Looks at a care plan written for another client
4. Expects the oncoming nurse to complete the care plan
Which nursing action should be questioned when applying a transdermal medication
patch?
1. Removing the old patch prior to placing the new patch
2. Donning gloves prior to administering the medication
3. Applying the patch to the same area where the old patch was removed
4. Cleansing the site where the patch is to be applied with soap and water
The nurse is preparing to lift a client up in bed. What should the nurse do prior to
beginning this task in order to maintain safety?
Standard Text: Select all that apply.
1. Plan the move
2. Face the head of the bed
3. Raise the bed to waist level
4. Stand close to the bed with the legs close together
5. Straighten the knees
The manager is identifying staff who would qualify to be a member of a lift team. What
information does the manager need before finalizing this decision?
1. Date of last back injury
2. Reports of spinal x-rays
3. Evidence of daily back exercises being done
4. Staff signature relinquishing organization liability
Emergency personnel are establishing a hot zone to decontaminate victims of a nuclear
blast. What should be a priority when caring for these victims?
1. Remove the victims' clothing
2. Rinse the victims' bodies' hot water
3. Wash the victims' bodies' with chlorine
4. Wash and rinse the bodies with cold water
The nurse working with a student nurse is providing care for a client requiring
mechanical ventilation. The student nurse asks the meaning of assist control. Which
response by the nurse is the most appropriate?
1. "Assist control is a means of delivering ventilation that delivers a preset volume
and/or pressure each time the client begins an inspiration."
2. "Assist control allows the client to breathe independently, but supplies a breath if the
client does not begin an inhalation in a specified period of time."
3. "Assist control is used when weaning a client from the ventilator because the client
must exercise the muscles of respiration in order to get a full breath."
4. "Assist control is often used when a client is receiving a paralytic agent."
The nurse is preparing an ice bag to apply to the client's sprained left ankle. How should
the nurse fill the bag?
1. One-third full of ice, and add water to make it more pliable
2. One-half to two-thirds full of crushed ice
3. Completely full to make it last longer
4. One-third to two-thirds full of ice cubes
Routine hygienic care has been provided to 1 client, with no abnormal findings
assessed. What should the nurse document in the medical record?
1. Foot care
2. Hair care
3. Removal or insertion of a hearing aid
4. Type of bath provided and client's ability to provide self-care
Which specimens could the nurse safely delegate to the unlicensed assistive personnel
(UAP) to collect?
Standard Text: Select all that apply.
1. Wound culture
2. Routine urine specimen
3. Cerebrospinal fluid
4. Stool specimen
5. Sputum specimen
Which procedure should the registered nurse delegate to unlicensed assistive personnel
(UAP)?
1> Making a nursing diagnosis
2> Assisting a client to bedside commode
3> Performing assessments on client
4> Giving the client pain medication
When performing catheter care, which action is least appropriate to perform?
1. Applying sterile gloves
2. Washing the meatus and proximal catheter with soap and water
3. Drying the catheter and urinary meatus
4. Performing hand hygiene
The nurse identifies the client using two forms of identification. Which methods would
be acceptable?
Standard Text: Select all that apply.
1. Ask the client, "Is your name Mr. xyz?"
2. Check the client's identification band.
3. Check the client's room number.
4. Ask the client for the birthdate.
5. Ask the client for the telephone number.
A hurricane levels several homes and businesses in a small southwestern community. At
which point should the nurse expect to become involved in the care of those affected by
the storm?
1. Immediately when the storm ends
2. Once a state of emergency is declared
3. It depends upon where the nurse lives
4. When victims are brought to the hospital
The nurse notes that a client is having difficulty deciding to have surgery, has a heart
rate of 110 beats per minute and is diaphoretic. What should the nurse consider this
client is demonstrating?
1. Verbal cues of anger
2. Physical cues of anxiety
3. Physical cues of depression
4. Emotional cues of depression
The nurse is going to apply a cold compress to a client's lower forearm. What nursing
intervention would be indicated?
1. Decrease the length of time the cold compress would normally be applied.
2. Increase the length of time that the compress would be applied.
3. Keep the length of time the same as it would be when applying to other areas of the
body.
4. Leave the cold compress in place until it is no longer cool.
The nurse is caring for a client with a central line. What criteria should be used to
determine if the access cap needs to be changed?
1. Fluid being administered
2. Cap was changed 3 days ago
3. The line is used for blood samples
4. Length of time the catheter will be in place
A victim of radiation exposure from a dirty bomb several weeks ago comes into the
emergency department because of excessive bleeding. For which acute radiation
syndrome should the nurse plan care for this client?
1. Cutaneous
2. Hematopoietic
3. Cardiovascular
4. Gastrointestinal
