A client refuses to complete an advance directive because he is not “ready to die.” What
should the nurse respond to this statement?
1> “It’s best to be safe than sorry.”
2> “You are right ” it is more appropriate for someone who has a terminal illness.”
3> “That’s fine. I”ll just document that you refuse to decide your medical treatment.”
4> “It is a document that allows you to make legal decisions about how you wish to
receive future medical treatment.”
The nurse who is planning the day will perform morning care at which point?
1. When the client first awakens
2. Before breakfast
3. Before retiring for the night
4. Whenever the client requests it
The nurse has delegated the collection of a clean catch urine specimen to the unlicensed
assistive personnel (UAP). Which statement by the UAP indicates an appropriate
understanding of the procedure?
1. “I will have the client urinate in the specimen container the next time he or she
urinates.”
2. “I will provide the client with sterile gloves for collecting the urine specimen.”
3. “I will ask the client to cleanse the urethra to avoid contamination of the urine
specimen.”
4. “I will watch the client obtain the urine specimen to ensure correct obtainment.”
The nurse is performing tracheostomy care. Which portion of the trach should the nurse
use when tying the new trach ties?
1. Inner cannula
2. Outer cannula
3. Obturator
4. Flange
The nurse manager determines that a staff nurse uses critical thinking when planning
the outcomes for a client’s care. What did the manager observe to come to this
conclusion?
1. Prioritized client problems
2. Critically analyzed all client outcomes
3. Clustered data to determine relationships
4. Used a systematic approach to collect data
The nurse is working with unlicensed assistive personnel (UAP) in a long-term care
facility. Which tasks can the nurse delegate to the UAP?
Standard Text: Select all that apply.
1. Administering an enema to a stable client
2. Removing a fecal impaction for an unstable client
3. Assisting a client to perform ostomy care after hand surgery
4. Helping a client onto a bedpan
5. Assessing skin during an ostomy appliance change
A client with paranoid schizophrenia is threatening the staff and believes the staff is
trying to harm him. When the nurse enters the client’s room, the client is agitated, and
attempts to slap the nurse. The nurse gets assistance from other staff members and
restrains the client. Which nursing action is the priority at this time?
1. Requesting a psychiatric referral
2. Notifying the health care provider of the need to see the client
3. Padding the side rails
4. Obtaining consent from the client for use of restraints
In which is a capillary blood specimen least likely to be indicated?
1. Testing a serum glucose level
2. Measuring a client’s hematocrit
3. Obtaining blood specimens on an infant
4. Measuring an arterial blood gas
The nurse is visiting the home of a newly discharged client. What should the nurse plan
to complete at the conclusion of the physical assessment?
1. List for teaching
2. List of supplies the client will need to purchase
3. Method the client intends to pay for home care services
4. Outcome and Assessment Information Set (OASIS) forms
Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?
1. Inserting a urinary retention catheter
2. Inserting a straight catheter
3. Applying a condom catheter
4. Collecting data for a urinary elimination history
A client seeks medical attention for the onset of lower extremity paralysis after eating
food prepared during a camping trip. Which disease process should the nurse anticipate
planning care for this client?
1. Plague
2. Botulism
3. Typhoidal tularemia
4. Viral hemorrhagic fever
The nurse wants to assess consciousness, agitation, anxiety, sleep, and ventilatory
synchrony in a client with a traumatic brain injury. Which scale should the nurse use for
this assessment?
1. Ramsay Sedation
2. Riker Sedation-Agitation
3. AACN Sedation Assessment
4. Richmond Agitation-Sedation
The nurse is caring for a client with a medical diagnosis of increased intracranial
pressure. Which IV fluid order should the nurse accept without questioning?
1. Normal saline at 125 mL/hour.
2. Dextrose 5% and water at 80 mL/hour.
3. Dextrose 5% and 0.45% NaCl at 75 mL/hour.
4. Normal saline 0.45% at 200 mL/hour.
The nurse educator is reviewing Elisabeth Kubler-Ross’s stages of grief with a group of
oncology nurses. In which order should the nurse review these stages?
1. Anger
2. Denial
3. Depression
4. Acceptance
5. Bargaining
A client who has difficulty raising the hips needs to urinate. What should the nurse do?
1. Use a fracture pan
2. Raise the head of the bed
3. Ambulate to the bathroom
4. Call for a bedside commode
The nurse is caring for a client who had major abdominal surgery yesterday. Which
assessment finding would indicate inadequate airway clearance that might be cleared
with coughing and deep breathing?
1. Tachypnea with rales heard in the upper lobes and over the trachea
2. Bradypnea with wheezing heard throughout all lung fields
3. Tachypnea with wheezing heard throughout all lung fields
4. Tachypnea with rhonchi heard in the lower lobes
The nurse is admitting a client with a pressure ulcer to the long-term care facility. When
assessing the wound, the nurse finds partial-thickness skin loss free of eschar. In which
stage is this client’s ulcer?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
After learning of having cancer a client begins to demonstrate psychological symptoms
of grief. What did the nurse most likely assess in this client?
1. Crying
2. Insomnia
3. Anorexia
4. Gastrointestinal disturbances
The client is recovering from a fractured left femur, and has just had the cast removed.
Which technique is the most appropriate for the nurse to use when assisting this client
to ambulate?
1. Standing on the client’s left side
2. Standing on the client’s right side
3. Standing behind the client and holding the client’s belt
4. Standing in front of the client and having the client lean on the nurse’s shoulders
Which clients should the nurse consider as candidates for an enteral access device?
Standard Text: Select all that apply.
1. The client who is NPO in preparation for surgery
2. The client with an absent cough and gag reflex
3. The postoperative client who returns to the unit following bowel resection who is
unconscious secondary to sedation
4. The client who needs stomach contents sent for laboratory analysis
5. The client who overdosed on an oral medication