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The nurse is preparing to discharge a client with a new ileostomy. What should the
nurse include when documenting discharge information about this client?
1. Last weight calculated and BMI
2. Most recent vital signs measurements
3. Findings from the physical assessment
4. Return demonstration on appliance care
A client is prescribed to receive enteral feedings to begin at 25 mL/hr 2 4 hours, 50
mL/hr x 2 hours, 75 mL/hr x 2 hours, and 100 mL/hr x 2 hours. In order to prepare the
feeding bag for the entire 8 hour shift, how many mL of tube feeding should the nurse
place in the feeding bag? Calculate to the nearest whole number.
The nurse is caring for a client diagnosed with a terminal illness and experiencing a
great deal of pain. After administration of IV analgesia, the client continues to complain
of severe pain. Which action by the nurse is the most appropriate in this situation?
1. Explain to the client the need to wait for further medication to prevent overdosage
complications.
2. Ask the family to help divert the client from the discomfort.
3. Call the health care provider, if necessary, to request an order for additional
analgesia.
4. Wait an hour for the medication to take effect.
The nurse is preparing a client for diagnostic studies requiring the administration of
contrast media. Which action by the nurse is the priority in this situation?
1. Obtaining informed consent
2. Obtaining results of lab tests
3. Checking for allergies
4. Checking if routine medications are to be held
The nurse is visiting the home of a client recovering from pneumonia. Which
observation indicates that teaching about infection control practices would be
indicated?
1. Picks up a sandwich after petting the family dog
2. Hands are washed before and after preparing food
3. Washes hands after coughing and blowing the nose
4. Sets out a clean wash cloth and towel at the kitchen sink
The nurse is administering a cleansing enema. Which action would indicate the need for
further instruction on the process?
1. Enema solution is warmed to 40C (105F).
2. The solution container is held 12 inches above the rectum.
3. The client is in the Fowler's position.
4. The client is encouraged to retain the enema for 5"10 minutes.
A client with chronic renal failure is being discharged after surgery to create an
arteriovenous fistula for hemodialysis. Which client statements indicate that teaching
provided about the care of this fistula have been effective? Select all that apply.
1. "I will not lie on the arm with the fistula."
2. "I will not wear clothing with tight sleeves."
3. "I will contact the doctor if my hand feels cold."
4. "I will tell people to use the fistula arm for blood pressures."
5. "I will not carry anything heavy with my arm with the fistula."
The nurse is caring for a female client. In which order should the nurse complete
perineal-genital care?
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Apply gloves.
Response 2. Wipe from the pubis to the rectum.
Response 3. Place a towel under the client's hips.
Response 4. Clean the labia minora.
Response 5. Position and drape the client.
A client is admitted with severe vomiting and diarrhea. On what should the nurse focus
when planning this client's care?
1. Fluid deficit
2. Infection risk
3. Skin integrity
4. Altered tissue perfusion
A client with increased intracranial pressure caused by a traumatic brain injury is in a
coma. What approach should the nurse use to assess this client's impaired
consciousness?
1. Glasgow Coma Scale
2. Determine degree of brainstem reflexes
3. Assess pupillary response to light and accommodation
4. Use the Un-Responsiveness (FOUR) Score Coma Scale
The nurse is instructing the client on how to use the client-controlled analgesia (PCA)
pump. Which statement made by the client indicates an appropriate understanding of
the nurse's instructions regarding the use of the PCA pump?
1. "I will push the button continually until I am pain free."
2. "I will likely overdose on pain medication with the use of the button."
3. "I will let my family control my pain medicine by allowing them to push the button."
4. "I will push the button when the pain becomes severe."
A client from a non-English speaking country is admitted to a care area. Which nursing
behavior exemplifies cultural competence?
1. Asks the family to wait in the visitor's lounge during the assessment
2. Realizes that teaching cannot be completed because of a language barrier
3. Contacts an interpreter to assist with data collection and goal identification
4. Documents "no response" when the client does not answer assessment questions
A client with a rectal tube begins to experience diarrhea. What should the nurse do?
1. Clamp the tube
2. Remove the tube
3. Reposition the client
4. Attach a collection bag
The nurse is participating in attempts to rescue victims of a landslide after an
earthquake in Southern Chile. Several victims are experiencing extreme diarrhea.
Which microorganisms should the nurse anticipate as causing the victims'
manifestations? Select all that apply.
1. Cholera
2. Norovirus
3. Leptospirosis
4. West Nile virus
5. Vibrio vulnificus
A client is being transferred from the neurologic intensive care unit to a general
medical-surgical care area. What should the nurse do first when the client arrives to the
new care are?
1. Update the care plan
2. Validate all nursingtle 2:
Rationale 3:
Rationale 4:
Global Rationale:
general medical-surgical care area. What should the n diagnoses
3. Complete a physical assessment
4. Check the healthcare provider's orders
The nurse is preparing the client for diagnostic testing using contrast media. The client
is questioned regarding allergies. The nurse would contact the health care provider if
the client reported an allergy to which item?
1. Eggs
2. Milk
3. Betadine
4. Scallops
A client scheduled for a mastectomy requests that acupuncture be used instead of
anesthesia. What should the nurse respond to this client?
1. "That's a good idea."
2. "Let's talk to your doctor about that."
3. "No one here in the hospital knows how to do acupuncture."
4. "Your surgery is considered major and acupuncture will not be effective."
The nurse is changing the ostomy appliance for a client with a new loop colostomy.
Which action by the nurse is the most appropriate?
1. Remove the plastic bridge in order to create a tight fit with the ostomy appliance.
2. Cut two holes in the skin barrier for each loop.
3. Cut an opening in the skin barrier for only the afferent or proximal end of the stoma.
4. Place a piece of tissue or gauze over the stoma, and use a guide to measure the size of
the stoma.
The nurse is caring for clients on a medical-surgical care area. Which client observation
should the nurse suspect is being caused by a metabolic disorder?
1. New onset of confusion
2. Poor appetite for breakfast
3. Pain rated as a 5 on a scale from 0 to 10
4. Increased sputum production in the morning
The nurse is performing an assessment of the skin. Which statements regarding this
assessment are correct?
Standard Text: Select all that apply.
1. Assessment of the skin involves inspection, palpation, and auscultation.
2. Assessment of the skin involves using the sense of smell.
3. The nurse assesses the client for edema.
4. The nurse may assess the client's nails and hair while assessing the skin.
5. When assessing the skin, the nurse recognizes the effect of developmental stage on
findings.
The nurse is caring for a client with mild dysphagia. Which diet should the nurse
anticipate being prescribed for this client?
1. Clear liquids
2. Full liquids
3. Pureed diet
4. Regular diet
The nurse is using a nonpharmacologic method to manage a client's pain, and applies a
unit that applies low-voltage electrical stimulation directly over the pain area. When
documenting this intervention, which term is the most appropriate for the nurse to use?
1. TENS unit
2. Nerve block
3. Functional restoration
4. Cutaneous stimulation
A client has an elevated temperature. Which statement is the most clinically appropriate
for the nurse to use when documenting this finding in the medical record?
1. The client is fever.
2. The client is febrile.
3. The client is hyperpyrexia.
4. The client is hyperthermia.
The nurse educator is conducting an in-service to a group of new nurses regarding the
use of ostomy appliances. When discussing the characteristics of ostomy appliances,
which statements are appropriate for the educator to include in the presentation?
Standard Text: Select all that apply.
1. The ostomy appliance comes in a three-piece set.
2. The ostomy appliance should protect the skin near the stoma.
3. The ostomy appliance should collect both stool and urine.
4. The ostomy appliance controls odor.
5. All ostomy appliances can only be used once.
Which actions could the nurse safely delegate to the unlicensed assistive personnel
(UAP)?
Standard Text: Select all that apply.
1. Assist the client to use the bedpan for bowel elimination.
2. Change the ostomy appliance for the new ostomy.
3. Administer a cleansing enema.
4. Remove a fecal impaction.
5. Determine effectiveness of cleansing enema.
A client with a closed urinary drainage system is demonstrating signs of a urinary tract
infection. In which order should the nurse obtain a urine specimen from this system?
1. Remove gloves
2. Clamp the tubing
3. Cleans the access port
4. Perform hand hygiene
5. Remove drainage clamp
6. Aspirate a 2 mL sample of urine
7. Transfer urine to a specimen cup
8. Engage Luer-Lok syringe to the port
The nurse is identifying nursing diagnoses appropriate for a client's health issues.
Which information should the nurse include when creating a three-part diagnostic
statement?
1. Interventions
2. Learning needs
3. Expected outcomes
4. Signs and symptoms
A client receiving an infusion of Dextrose 5% and water complains of a burning pain
along the course of the vein. The site is red, warm, and is mildly edematous. Which
term should the nurse use when documenting these findings?
1. Phlebitis at the IV insertion site
2. IV infiltrate
3. Extravasated vesicant drug
4. Extravasation
The nurse needs to assess a client's abdomen. In which order should the nurse complete
this assessment?
1. Inspection and auscultation
2. Inspection, auscultation, and palpation
3. Inspection, auscultation, palpation, and percussion
4. Auscultation, percussion, and inspection
The nurse is working on the orthopedic unit, and is caring for a client who complains of
back pain. Which responses by the nurse would be appropriate when caring for this
client?
Standard Text: Select all that apply.
1. "I'm sorry you're hurting. I want to make you feel better."
2. "People with back pain experience very different symptoms. Tell me more about your
back."
3. "You had medication for your pain at 4 p.m., so I can't give you any more until 8
p.m., because the health care provider ordered it every 4 hours."
4. "Does anything other than your back hurt?"
5. "Why don't you try another position to make it feel better until it's time for more pain
medication?"
A client receiving an opiate for postoperative pain management is experiencing nausea
and vomiting. What action would be the most beneficial for the client?
1. Provide an emesis basin
2. Maintain on NPO status
3. Keep Narcan at the bedside
4. Administer an antiemetic as prescribed
The nurse is setting up an IV infusion on an electronic infusion pump. After leaving the
room, the pump alarms and reads high pressure. Which is the priority action by the
nurse?
1. Resetting the pump to resume infusion
2. Discontinuing the client's IV access and restarting in a different area
3. Assessing the client's IV site and the tubing for kinks or closed roller clamps
4. Asking the client if the pump has been tampered with in any way
The nurse is performing a head-to-toe assessment. Organize the areas that need to be
assessed into the order in which the nurse would examine them.
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Ears and eyes
Response 2. General appearance
Response 3. Respiratory and cardiac systems
Response 4. Neurologic status
Response 5. Abdomen and GI system
A client who has been on bedrest for several weeks is permitted to sit out of bed in a
chair. What should the nurse do to reduce the client's risk of becoming dizzy when
transferring out of bed to a chair?
1. Position prone for several hours every day
2. Raise and lower the foot of the bed several times
3. Raise and lower the head of the bed several times
4. Assist to roll in bed from side to side several times
The nurse prepares to delegate bathing a client to unlicensed assistive personnel (UAP).
Which actions are appropriate prior to delegating this task to the UAP?
Standard Text: Select all that apply.
1. Informing the UAP what type of bath is appropriate
2. Describing precautions specific to the needs of the client
3. Telling the UAP who to notify if there are any concerns
4. Informing the UAP to encourage the client to perform as much self-care as
appropriate
5. Having the UAP document the bathing experience for the nurse to read later
A client recovering from a head injury has a blood pressure of 158/90 mm Hg and an
intracranial pressure reading of 17 mm Hg. What is this client's cerebral perfusion
pressure?
During a home visit the nurse learns that a client's daughter is investigating naturopathy
to help with the client's health problem. What should the nurse explain about this
alternative therapy approach?
1. Drugs are not used
2. Remedies are prescribed
3. A wide variety of herbs can be used
4. A special instrument is used to measure effectiveness
The nurse is caring for a client who consistently pulls at the IV and urinary catheter.
Restraints are applied that prevent the client from being able to grasp the tubing. Which
term will the nurse use when documenting the restraints used for this client?
1. Jacket restraint
2. Limb restraint
3. Mitt restraint
4. Waist restraint
What would the nurse document after providing hair care to the client?
1. Number of times the hair was combed or brushed throughout the shift
2. Type of brush used to provide hair care
3. Abnormal assessment findings
4. Routine nursing interventions
When conducting a pain history, which data is least essential for the nurse to obtain
regarding the client's pain?
1. Intensity, quality, and patterns
2. Precipitating factors, alleviating factors, and associated symptoms
3. Effects on activities of daily living, coping resources, and affective responses
4. Significant other's assessment of the pain
