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The nurse is reviewing data collected during a client assessment. Which information
should the nurse identify as a client need? Select all that apply.
1. Desires to walk without a cane
2. License to drive has been suspended
3. Attends religious services every Sunday
4. Spends time with family every winter in Florida
5. Experiences shortness of breath with ambulation
During an assessment the nurse considers that a client's new onset of symptoms is
because of an increased amount of stress. What did the nurse assess to make this
clinical determination? Select all that apply.
1. Sweating
2. Warm dry skin
3. Rapid heart rate
4. Elevated blood pressure
5. Increased depth of respirations
Place the steps for performing hand hygiene using soap and water in the appropriate
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. Apply lotion to hands.
Response 2. Dry hands thoroughly and use paper towel to turn off faucet.
Response 3. Rinse hands and wrists thoroughly, keeping hands down and elbows up.
Response 4. Wet hands and wrists thoroughly under running water. Apply a small
amount of soap.
Response 5. Perform hand hygiene using plenty of lather and friction for at least 10"15
seconds.
Response 6. Turn on the water and regulate flow so that temperature is warm.
During the orientation phase of a new relationship the nurse explains the activities that
need to be accomplished before the client is discharged back to home. Why should the
nurse do this at this time?
1. Identifies coping mechanisms
2. Establishes trust between the nurse and client
3. Prevents the client from being placed on the defensive
4. Promotes independence and increases sense of self-esteem
Which respiratory finding would indicate the need for further assessment by the nurse?
1. Regular
2. Quiet
3. Deep
4. Rate of 12"20 per minute
The nurse is obtaining a throat culture. Which action indicates correct technique?
1. Inserting the swab into the sterile tube without touching the outside of the container
2. Inserting a tongue blade to depress the anterior two-thirds of the tongue
3. Swabbing along the side of the cheek inside the mouth
4. Swabbing the pharynx gently and quickly, avoiding the tonsils
Which document should the nurse refer to ensure safe care is being provided to a client?
1> Core measure sets
2> Nurse practice act
3> Joint Commission standards
4> National patient safety goals (NPSGs)
The instructor is preparing a lecture on the nursing process. Which statement should the
instructor use that best describes nursing diagnosis?
1. It is an educated judgment about a client's potential or actual health problems
2. It refers to the priority nursing actions or interventions performed to accomplish a
specified goal
3. It involves the careful acquisition and interpretation and use of information to reach a
conclusion
4. It is the action of thinking back about an earlier clinical situation, recalling actions
that worked or didn't work, and determining if this information is helpful in the current
situation
The nurse performs preoperative teaching for a client requiring a surgical intervention.
Which actions by the client indicate appropriate understanding of the information
provided?
Standard Text: Select all that apply.
1. Demonstrating proper coughing and deep breathing
2. Asking questions about and voicing understanding of information provided
3. Having no anxiety about the impending surgery
4. Demonstrating proper performance of leg exercises
5. Demonstrating how to turn and get out of bed
For which client should the nurse consider applying a transparent film for wound care?
1. The client with a postoperative wound held together by sutures
2. A client with a stage I pressure ulcer
3. The client with a venous stasis ulcer
4. A client with a highly exudative wound
The nurse is irrigating a wound with tracts and crevices. Which piece of equipment
should be applied to the syringe in order to irrigate these areas?
1. A 22 gauge needle
2. A small gauge Robinson catheter
3. An IV catheter with the needle removed
4. An IV catheter with the needle in place
The nurse is caring for a client receiving continuous bladder irrigation following
transurethral prostatectomy. When emptying the urine collection bag, the nurse notes
that 500 mL of irrigant has infused with only 100 mL of drainage returned. Which is the
priority action by the nurse?
1. Irrigating the outflow port using an irrigation syringe to determine patency
2. Notifying the health care provider immediately
3. Irrigating the irrigation port to determine patency
4. Continuing to monitor output
The nurse completes a health history with a client scheduled for an MRI of the knee and
immediately notifies the health care provider. What did the nurse assess to make this
clinical decision?
1. Wears religious metals
2. History of heart failure
3. Metal in spine from a spinal fusion
4. Takes insulin for type 1 diabetes mellitus
The nurse receives a bag of total parenteral nutrition (TPN) for the client. Prior to
hanging the solution, which nursing actions are priorities?
Standard Text: Select all that apply.
1. Checking the expiration date
2. Creating a sterile field
3. Checking the nutrients in the bag against the order written by the primary care
provider with another licensed nurse
4. Adding additional medications to the fluid
5. Check rate of infusion on physician's orders
The nurse is preparing a commercial cleansing system to bathe a client. Which action is
the priority for the nurse?
1. Wetting the disposable washcloths
2. Drying the client after using a washcloth
3. Using one washcloth for the lower extremities
4. Warming the washcloth in the microwave
The nurse manager notes that documentation in the medical record about a client's fall
does not match the information identified on the occurrence report. What could be the
potential outcome of this inconsistency?
1. A court case would not occur
2. Valuable information would be forgotten
3. Client's hospitalization could be prolonged
4. Termination of the nurse completing the occurrence form
