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The spouse of a recently deceased client is observed crying and expressing anger to
anyone who asks if any help is needed. In which stage of grieving is this spouse?
1. Resolution
2. Restitution
3. Idealization
4. Developing awareness
When documenting the maximum amount of pain a client can tolerate, which term is
the most appropriate for the nurse to use?
1. Pain threshold
2. Hyperalgesia
3. Pain tolerance
4. Allodynia
A client who wears soft contact lenses is experiencing eye pain and excessive tearing.
What should the nurse suspect is occurring with this client?
1. Corneal ulcers
3. Dry contact lenses
4. Corneal abrasions
2. Lacrimal duct infection
The nurse uses a substance to destroy microorganisms other than spores. Which term
should the nurse use to describe this substance?
1. Antiseptic
2. Disinfectant
3. Sterilizer
4. Aseptic
The nurse is performing venipuncture to initiate IV therapy. The venipuncture site is
chosen based on which indicators?
Standard Text: Select all that apply.
1. Using the client's dominant arm, whenever possible
2. Choosing a relatively straight vein
3. Avoiding sclerotic veins
4. Looking for a site sufficiently distal to joints
5. Choosing a vein that is visible in addition to palpable
The nurse is meeting with physical therapist and a dietitian to review care for a client
recovering from a stroke. Which tool is the nurse most likely using to coordinate this
client's care?
1. Critical pathway
2. Variance analysis
3. Standardized care plan
4. Individualized care plan
The nurse provides information on self-administration of injectable medication to a
client in 15 minute teaching increments. If equating this teaching with the nursing
process in which phase is the nurse providing care?
1. Planning
2. Evaluation
3. Assessment
4. Implementation
The nurse observes the health care provider apply a cast made of strips of open-weave
cotton saturated with powdered calcium sulfate crystals. When documenting this
procedure, which term should the nurse use for this type of cast?
1. Plaster cast
2. Synthetic cast
3. Fiberglass cast
4. Thermoplastic cast
While walking in the hall a client suddenly complains of dizziness. Which action by the
nurse is the priority?
1. Escorting the client back to the room and into bed
2. Calling for help to escort the client back to the room
3. Assisting the client to sit on the nearest chair with the head between the legs and go
find assistance
4. Assisting the client to a horizontal position on the floor if no chair is available
The nurse decides to use the Un-Responsiveness (FOUR) Score Coma Scale to
determine a client's level of consciousness. What client finding caused the nurse to
make this decision?
1. Deafness
2. Fractured left leg
3. Prescribed opioid analgesics
4. Wears prescription eyeglasses
The nurse notes black necrotic tissue on the client's wound. Which term should the
nurse use when documenting this finding?
1. Debridement
2. Eschar
3. Alginate
4. Purulence
The nurse working in an oncology clinic is caring for a client diagnosed with breast
cancer. The client reports anorexia and weight loss. The client's serum albumin is low,
and there is visible muscle and fat wasting. Which term should the nurse use when
documenting this client's appearance?
1. Malnutrition
2. Undernutrition
3. Overnutrition
4. Protein-calorie malnutrition
The nurse is preparing to assess a client new to the out-patient care environment. Which
actions should the nurse expect to complete during this phase of the nursing process?
Select all that apply.
1. Complete a client interview
2. Conduct a physical examination
3. Analyze test results and findings
4. Categorize data into meaningful patterns
5. Identify pertinent family health history issues
The nurse is assigned to accept a new admission expected from the emergency
department. As the client is wheeled off the elevator, which action by the nurse is the
most appropriate?
1. Waiting for the client to be placed in bed, then orienting the client to the unit
2. Accompanying the client and making introductions while assessing the client's
mental status and appearance
3. Entering the client's room as soon as possible to obtain data for admission history
4. Asking the unlicensed assistive personnel to assist the client into bed
A client is being prepared for discharge. What should the nurse perform when
evaluating this client's care? Select all that apply.
1. Reassess care plan
2. Record client responses
3. Determine effects of nursing actions
4. Communicate to client and client's family
5. Examine appropriateness of nursing actions
The nurse is informed during shift report that a client has a wide pulse pressure, is
hypertensive, and has a pulse deficit. When the nurse enters the client's room, which
assessments should the nurse perform in order to confirm this report?
1. Blood pressure and apical pulse assessments
2. Blood pressure and radial pulse assessment
3. Blood pressure and respiratory rate assessment
4. Blood pressure and radial-apical pulse assessment
