Which activity can the nurse safely delegate to unlicensed assistive personnel (UAP)?
1. Sterile warm soak to client’s infected postoperative wound
2. Application of warm moist soak to client’s left leg
3. Determine effectiveness of cold application to reduce client’s pain
4. Responsibilities for the application of a warm pack to client’s IV infiltrate
A client is experiencing respiratory distress. In which position should the nurse place
this client?
1. High Fowlers
2. Semi-Fowlers
3. Trendelenburg
4. Reverse Trendelenburg
The hospice nurse is making a home visit to a client with terminal cancer. The client
reports poor pain control and the client’s spouse says, “I’m giving such big doses of
medication, I’m afraid she is going to overdose if I give her more.” Which response by
the nurse is the most appropriate?
1. “You’re wise to be concerned. These are very strong medications you’re
administering.”
2. “You want her to be comfortable but you don’t want to endanger her life. Let’s talk
about the medication you’re giving and warning signs you’ll see if the dosage you’re
administering is too high.”
3. “I hear what you’re saying, but you’re not giving enough pain medication, so she is in
severe pain. You need to give more.”
4. “You aren’t giving adequate pain relief, and she is in severe pain as a result.”
Family members arrive to take home a client desiring to leave against medical advice.
What should the nurse do?
1. Begin medication teaching
2. Refer the client to home care
3. Prepare discharge instructions
4. Notify the healthcare provider
The nurse performs a guaiac stool test and gets a positive result. Based on this test
result, which diagnosis is least expected for this client?
1. Colon cancer
2. Hemorrhoids
3. Bleeding stomach ulcers
4. HIV/AIDS
The nurse receives a written order for ophthalmic medication to be administered OU to
an adult client. Which action by the nurse when administering this medication is the
most appropriate?
1. Pulling the pinna up and back, and dropping the medication into the left ear
2. Pulling the pinna down and forward, and dropping the medication into both ears
3. Exposing the lower conjunctival sac of the left eye, and dropping the medication into
the sac
4. Exposing the lower conjunctival sac of both eyes, and dropping the medication into
the sac
The nurse is caring for several clients, and has unlicensed assistive personnel (UAP)
and LPN/LVN assisting. Which client should the nurse delegate to the LPN/LVN as
opposed to the UAP?
1. Assisting the health care provider with performance of a lumbar puncture
2. Collecting and testing a routine urine specimen for sugar, protein, and specific
gravity
3. Testing stool for the presence of occult blood
4. Collecting a sterile urine specimen by straight-catheterizing the client
A newly admitted client refuses to answer any assessment questions and is seen sitting
in a chair near the window crying. What should the nurse do to help this client become
acclimated to the hospital environment? Select all that apply.
1. Assess emotional needs
2. Consult the case manager
3. Talk with the organization’s clergy
4. Ask the healthcare provider to prescribe a sedative
5. Suggest receiving health care in another environment
A client takes warfarin for atrial fibrillation. Which herbal preparation should the nurse
counsel the client to avoid?
1. Feverfew
2. Echinacea
3. Kava kava
4. Black cohosh
The nurse is preparing materials for client teaching. What should be the goal for this
educational session?
1. Client desires to improve own health
2. Client understands follow-up appointment schedule
3. Client knows what actions to take to care for a health problem
4. Client learns to telephone the healthcare provider with questions
The nurse notes that a client has extremely dry skin. How should the nurse document
this finding?
1. Pallor
2. Cyanosis
3. Xeroderma
4. Poor skin turgor
The family of a client who is comatose asks why there are eye patches over the client’s
eyes. What should the nurse respond to the family?
1. “They prevent the eyes from drying out.”
2. “They reduce the glare caused by the room lights.”
3. “They reduce the amount of stimulation the client receives.”
4. “They are used to keep eye medication in contact with the eyes.”
The nurse is providing postmortem. For which reason should the nurse elevate the
client’s head?
1. Preventrigor mortis
2. Prevent facial discoloration
3. Algor mortis
4. Post mortis
The nurse is reviewing care provided to a client. Which behavior indicates that the
nurse is using critical thinking?
1. Administers prescribed medications
2. Studies the results of diagnostic tests
3. Individually analyzes client problems
4. Documents responses to care provided
The nurse recognizes the client’s death is impending when which assessment finding is
noted?
1. Extremities appear mottled and cyanotic
2. Client requests a meeting with spiritual counselor
3. Heart rate and blood pressure increases
4. Increased appetite