The nurse collects data slowly and methodically from a new client. Why is the nurse
using this approach during this phase of the nursing process?
1. Ensures accuracy of data
2. Identifies client outcomes
3. Establishes a rapport with the client
4. Highlights the importance of the therapeutic relationship
A client in the intensive care unit is having an arterial line inserted. For what should the
nurse anticipate using this client’s line? Select all that apply.
1. Analyze acid-base status
2. Determine respiratory status
3. Evaluate treatment for alterations in arterial blood gases
4. Easy access to blood sampling for arterial blood gases and other lab values
5. Continuous measurement of the systolic, diastolic, and mean arterial pressures
The nurse is caring for a client with a deep draining abdominal wound. Which factor
would require the nurse to wear a mask and goggles when caring for this client?
1. The wound is infected.
2. The client is confused and disoriented.
3. The wound is covered by wet-to-damp dressings.
4. The client is HIV-positive.
Emergency response personnel are caring for a victim of a nuclear blast. In which order
should the trauma assessment be completed?
1. Ensure breathing
2. Plan to evacuate
3. Establish an airway
4. Determine circulation status
5. Assess level of consciousness
6. Identify contaminant exposure
For which client would the rapid response team be least indicated?
1. Asthmatic client with a respiratory rate greater than 30 breaths per minute, oxygen
saturation of 84%, and a heart rate of 142 beats per minute
2. A client with no history of seizures who has a sudden change in mentation and has a
seizure
3. A client who suddenly begins to talk with difficulty and is not able to move the left
arm and leg
4. The client with a history of angina who has a PRN order for nitroglycerin who
reports crushing chest pain
The nurse is caring for an older adult male client who demonstrates frequent urinary
incontinence. Which option should the nurse use to reduce the risk of skin damage
secondary to urinary incontinence for this client?
1. Coude catheter
2. Straight catheter
3. Condom catheter
4. Foley catheter
The nurse assists the client to ambulate for the first time, and documents the distance,
pace, and support required. What should the nurse include in the documentation for this
client?
1. Activity tolerance
2. Client’s sense of security
3. Use of a gait belt
4. Where the client walked
Which aspect of intravenous therapy could the nurse safely delegate to the unlicensed
assistive personnel (UAP)?
1. Watching the IV insertion site of the client who complained of pain at the site
2. Changing the IV site dressing on the client’s left hand
3. Reporting client’s complaints of pain or leakage from the IV site when bathing the
client
4. Replacing client’s IV solution when bag runs dry if it is only D5W, without
medications added
What should the nurse recognize as the difference between standard precautions and
transmission-based isolation precaution systems?
1. Standard precautions protect the nurse, whereas transmission-based precautions
protect the client.
2. Standard precautions require the use of clean gloves, whereas transmission-based
precautions require the use of sterile gloves.
3. Standard precautions are used in addition to transmission-based precautions when
standard precautions would not completely block the chain of infection.
4. Transmission-based precautions block the chain of infection, whereas standard
precautions protect the nurse but do not block the chain of infection.
The nurse is caring for a client scheduled for surgery the next day. On what should the
nurse focus to determine this client’s level of stress? Select all that apply.
1. The surgical procedure
2. The client’s religious beliefs
3. If the surgery is going to alter the client’s life
4. Client’s perception of the surgical experience
5. Number of stress-producing events in the client’s recent past
An organization is updating the policy for pain management. What should be included
in the updated policy that addresses the Joint Commission’s pain management
standards? Select all that apply.
1. Complete a baseline pain assessment
2. Monitor the acute pain the client is experiencing
3. Follow guidelines of pharmacologic management
4. Educate client and family about pain management
5. Limit the use of nonpharmacological management
The nurse is caring for a client who has an order for Lofstrand crutches to assist with
mobility. The client asks what the crutch looks like. Which description of the crutch by
the nurse is the most accurate?
1. It rests just under the axilla with a hand bar.
2. It has a cuff for the upper arm.
3. It extends to the forearm and has a metal cuff around the forearm to stabilize the
wrist.
4. It has a rubber tip to prevent slippage on a floor surface.
The nurse working in the emergency department (ED) is assisting the health care
provider with cast application. Which nursing action is the most appropriate after the
health care provider completes application of the cast?
1. Holding the casted arm from the top of the cast to place it in a splint
2. Holding the casted arm from the top of the cast to place it on pillows
3. Using the palm of the hand to place the casted arm into a splint
4. Using the palm of the hand to place the casted arm on pillows
The nurse is obtaining a pain history. The client reports pain in the right ear. Which
response by the nurse is the most appropriate?
1. “Is the pain minor?”
2. “Do you have anything else that hurts?”
3. “Tell me more about the pain and what you do for it when it hurts.”
4. “I’ll note that in the record. Is there anything else I should know?”
The charge nurse on a neurologic care area is assigning clients. What should be a
priority when making staff assignments?
1. Limit number of allowed lifts per worker per day
2. Identify a team of staff who are responsible for all lifts
3. Ask staff to volunteer to participate when lifting clients
4. Assign the clients requiring to be lifted evenly among all staff
The charge nurse is reviewing a list of clients scheduled for discharge. Which client
should have a referral for home care?
1. Client scheduled for outpatient radiation treatments
2. Client recovering from total knee replacement surgery
3. Client treated in the emergency department for a bee sting
4. Client admitted for 12 hours for fluids to treat dehydration
The nurse educator is preparing an inservice presentation about communication. What
should the nurse emphasize during this training?
1. Communication is an optional task
2. Communication is a sense of self-pride
3. Communication is an essential part of nursing care
4. Communication ensures the provision of quality nursing care