The nurse suspects the client at the urgent care center might have a urinary tract
infection. Based on this, which type of urine specimen should the nurse prepare to
collect from the client?
1. 24-hour urine specimen
2. Midstream urine specimen
3. Routine urine specimen
4. Timed urine specimen
The nurse working on the labor and delivery unit has noticed how differently each
client responds to the pain associated with labor. Which reasons should the nurse
attribute to these various responses to pain?
Standard Text: Select all that apply.
1. Ethnic and cultural values
2. Developmental stage
3. Past experience with pain
4. Physiological functioning of the brain
5. Meaning of pain
The nurse is preparing to electronically enter data in a client’s medical record. For
which reason could a legal issue occur?
1. Obtains password taped under keyboard
2. Logs out of the record before leaving the terminal
3. Shreds laboratory reports after using them during report
4. Turns off the monitor when approached by a family member
The nurse assists the client off the bedpan after defecating. After emptying and cleaning
the bedpan, the nurse finds the bedside table is full, and there is no room for storage of
the pan. Which action by the nurse is the most appropriate?
1. Store the bedpan under the bed, where it is out of sight.
2. Place the bedpan on the overbed table until creating a space in the bedside table.
3. Place the bedpan on the floor of the bathroom behind or on the side of the toilet,
where it is not likely to be tripped over.
4. Remove objects from the bedside stand and return the bedpan to the stand.
The nurse delegates the measurement of vital signs on three clients to unlicensed
assistive personnel (UAP). The nurse evaluates the UAP’s performance and notes that
blood pressure is measured on a client by having the client hold the arm hanging over
the side of the bed. Which is the priority action by the nurse?
1. Commend the UAP for following the proper procedure.
2. Inform the charge nurse that the UAP does not know how to measure blood
pressures.
3. Yell at the UAP and tell her she is incompetent.
4. Instruct the UAP that blood pressure should be measured with the artery at or above
the level of the heart, and demonstrate correct technique.
The nurse is assessing the client’s cardiorespiratory system. Which tool will the nurse
require to perform these examinations?
1. Stethoscope
2. Percussion hammer
3. Nasal speculum
4. Lubricant
The client calls the nurse into the room and says that the heat pack the nurse applied
feels cold, and asks the nurse to turn the heat up on the aquathermia unit. Which
response by the nurse is the most appropriate?
1. “I’ll turn it up a little at a time and you let me know when it feels warm again.”
2. “The doctor wants the aquathermia pad maintained at a specific temperature, so
there’s no need to change it.”
3. “The aquathermia pad still feels warm to me.”
4. “Your body has adjusted to the warmth, and is making it feel cooler, but it’s actually
the same temperature as when it was first applied.”
Which action is required by the nurse prior to putting the bed or chair exit
safety-monitoring device in place?
1. Obtaining a health care provider’s order
2. Documenting the use of the alarm system
3. Testing the alarm
4. Applying the leg band or sensor pad
For which client should the nurse anticipate a plaster cast would be used?
1. The client with a diagnosis of amyotrophic lateral sclerosis (ALS)
2. The client who had a compound fracture and multiple lacerations
3. The older adult client with muscle wasting secondary to cancer
4. The client with a fractured femur who plans to return to construction work before
cast removal
The nurse admits a client from the emergency department (ED) with a newly placed leg
cast. Which actions should the nurse perform to prevent neurovascular impairment?
Standard Text: Select all that apply.
1. Assess the toes for nerve and circulatory impairment every hour for 8 hours.
2. Place the leg on pillows.
3. Apply ice to the site.
4. Elevate the foot of the bed.
5. Report excessive swelling or indications of neurovascular impairment.
The nurse caring for a client requiring mechanical ventilation. Which action by the
nurse would be inappropriate when providing care to this client?
1. Confirming airway placement by auscultating the lungs and checking the length
marking of the tube at the lip
2. Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no
audible air leak
3. Assuring ventilator tubing is secured and does not pull on the client’s airway
4. Verifying correct ventilator settings
The nurse transfers an assigned client from the wheelchair to the hospital bed. Which
items will the nurse include when documenting the client’s response to the transfer?
Standard Text: Select all that apply.
1. Number of assistants needed
2. Type of equipment used
3. Pulse rate before and after the procedure
4. Blood pressure before and after the procedure
5. Safety precautions taken
The nurse is concerned that a client is experiencing an increase in intracranial pressure.
Which anatomical structures most likely are affecting this pressure? Select all that
apply.
1. Brain tissue
2. Lymph drainage
3. Venous integrity
4. Cerebrospinal fluid
5. Cerebral blood volume
When assisting the health care provider with removal of the chest tube, which
instruction should the nurse provide to the client during this procedure?
1. Breathe normally
2. Hold still
3. Hold breath
4. Cough
The manager is reviewing care plans created for newly admitted clients. Which nursing
diagnostic statement should the manager review with the nurse as needing to be
amended?
1. Risk for injury related to left sided paralysis
2. Fluid volume overload related to congestive heart failure
3. Impaired coping related to recent death of spouse and son
4. Imbalanced nutrition: Less than body requirements related to mouth and throat ulcers
A client is nearing death and begins to cry. What should the nurse do to provide
emotional care to this client?
1. Stay physically close
2. Offer the client privacy
3. Remove all noxious odors
4. Move the bed near the window