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The nurse notes that within several hours four clients arrived to the emergency
department experiencing symptoms of shortness of breath, chest tightness, and burning
eyes. What should the nurse suspect is occurring with these clients?
1. Chemical exposure
2. Botulism intoxication
3. West Nile virus infestation
4. Exposure to typhoidal tularemia
A client is recovering from hip arthroplasty using the anterolateral approach. What
should the nurse ensure to maintain the integrity of the joint?
1. Place needed items on operative side
2. Keep needed items on the non-operative side
3. Instruct to avoid bending at the waist to put on shoes
4. Instruct to avoid crossing the operative leg past the body's midline
The nurse is performing a damp-to-damp dressing change, and is removing the old
dressing. Part of the dressing is adhered to the tissue. Which action by the nurse is the
most appropriate?
1. Removing that part of the dressing quickly, to reduce the pain
2. Wetting the dressing with alcohol to release the section adhered to the wound
3. Wetting the dressing with tap water to release the section adhered to the wound
4. Wetting the dressing with sterile saline to release the section adhered to the wound
A client is assessed as: having no sensory deficits; skin is dry and not exposed to
moisture; confined to bed; is completely immobile; requires moderate assistance in
moving; and nutritional status is adequate. Which pressure ulcer risk score is the most
appropriate based on the assessment data?
1. 14, indicating moderate risk
2. 15, indicating high risk
3. 12, indicating risk
4. 14, indicating high risk
The nurse is caring for an older adult client who is weak and has not been eating due to
lack of strength. Which task could the nurse safely delegate to unlicensed assistive
personnel (UAP)?
1. Completing a nutritional screening
2. Determining why the client is feeling weak
3. Using therapeutic communication with the client to determine if psychosocial factors
are influencing the ability to eat
4. Assisting the client with eating meals
The nurse caring for several clients could safely delegate which task to unlicensed
assistive personnel (UAP)?
1. Initial application of the continuous positive motion (CPM) device to the
postoperative client
2. Assessment of client's tolerance for passive range of motion
3. Documentation of joint improvement resulting from active range of motion
4. Performance of passive range of motion to client experiencing a CVA 2 weeks ago
The nurse is caring for a client with a longstanding permanent tracheostomy that has
been in place for several years in order to provide mechanical ventilation. Which type
of tracheostomy should the nurse anticipate this client may have based on the health
history?
1. Uncuffed tracheostomy
2. Cuffed tracheostomy
3. Fenestrated tracheostomy
4. Uncuffed or fenestrated tracheostomy
Which aspect of hand washing is most effective when there is visible dirt on the hands?
1. Using hot water instead of warm water
2. Using plenty of lather with friction
3. Drying the hands vigorously from wrists to fingers
4. Applying lotion to the hands
The nurse is preparing to administer medications via a client's nasogastric feeding tube
that was inserted 4 weeks ago. When attempting to flush the tube, the nurse realizes that
the tube is clogged. Which action by the nurse is the priority?
1. Using coke to unclog the tube
2. Giving the medication orally
3. Using ice water to irrigate the tube
4. Replacing the current tube with a new one
The nurse is preparing a client for a morning bath. What should be assessed prior to
providing personal hygienic care?
Standard Text: Select all that apply.
1. Allergies
2. Culture
3. Ability to provide self-care
4. Social history
5. Diagnosis
A client recovering from rape trauma syndrome who experiences severe anxiety when
out of doors in the evening asks about nonpharmacological approaches to reduce stress.
What should the nurse include when teaching this client controlled breathing?
1. Follow a pant-blow-pant pattern
2. Breathe in air using an open mouth
3. Sit in a chair that supports the spine
4. Take a deep breath and hold it for 10 seconds
The nurse is applying a hydrocolloid dressing to a client's wound, which measures 2
inches by 3 inches. The nurse should cut the dressing to which dimensions?
1. 3.25 inches by 4.55 inches
2. 2 inches by 3 inches
3. 1 1/2 inches by 2 1/2 inches
4. 1 inch by 1 1/2 inches
The nurse observes the newly hired unlicensed assistive personnel (UAP) performing
routine client care. Which behaviors indicate the UAP understands the use of personal
protective equipment?
1. The UAP removes the gown first and then the gloves after providing care.
2. The UAP applies gloves before emptying the client's indwelling catheter bag, then
removes gloves and washes hands before measuring urine output.
3. The UAP applies gloves to clean the client's dentures, then removes gloves and
performs hand hygiene prior to bathing the client.
4. The UAP wears gown and gloves when performing postmortem care.
The nurse is caring for a client who had oromaxillary surgery a few hours ago. The
client is arousable, but is still sedated following anesthesia, and sleeps deeply when not
disturbed. The client's respiratory effort is adequate, but the nurse notes the client is
having issues maintaining an open airway when asleep. Which airway should the nurse
choose for this client?
1. Oropharyngeal airway
2. Nasopharyngeal airway
3. Endotracheal tube
4. Tracheostomy
The nurse completes yearly training regarding the use of restraints. Which situation
should the nurse categorize as a restraint?
1. A safety belt applied across the client's waist when sitting in a geri chair with a quick
release button demonstrated to the client
2. The use of the top side rail to provide something for the client to hold on to when
getting out of bed
3. A safety belt around the infant when placing the child in a swing
4. The use of all four side rails on the bed after administering preoperative sedation
