The nurse working in the emergency department (ED) is providing discharge teaching
for a client with a newly applied cast to the left arm. Which statement by the client
indicates additional teaching is required?
1. “When I take a shower, I will put a plastic bag over my cast and keep it dry.”
2. “When my fingers feel cold, I will cover them with a blanket.”
3. “I will go home today and put ice on the cast over the fracture and prop it on
pillows.”
4. “If I lose sensation in my fingers, I will call my doctor.”
The nurse is caring for a client who is experiencing acute pain. Which action by the
client, noted by the nurse during the assessment, is considered an associated symptom
of pain?
1. Changing position
2. Crying
3. Grimacing
4. Vomiting
The nurse suspects that a client with a brain tumor is experiencing increasing
intracranial pressure. What findings did the nurse use to make this clinical
determination? Select all that apply.
1. Extreme thirst
2. Projectile vomiting
3. Weak left hand grasp
4. Unresponsive right pupil
5. Blood pressure 180/48 mm Hg
The nurse is caring for an unconscious client who has foot drop. Which items would be
useful in properly aligning the client’s foot?
1. Pillows
2. Footboard
3. Trochanter roll
4. Foot boot
The nurse is checking the client’s nasogastric tube for placement prior to administering
the client’s first tube feeding. Which is the most accurate means of assessing placement?
1. Checking the pH of stomach contents aspirated from the tube
2. Infusing air into the tube and auscultating for the sound of the air over the stomach
3. Obtaining an x-ray
4. Checking for residual
Which role is the nurse least likely to perform when working with families of dying
clients?
1. Providing financial support
2. Providing emotional support
3. Assisting with connecting families with available resources
4. Assessing families’ coping and grieving process
A client needs to learn how to care for a new colostomy. Which teaching strategy
should the nurse select for this instruction?
1. Role playing
2. Group process
3. Lecture-discussion
4. Demonstration”return demonstration
The nurse is caring for an older adult client with a medical diagnosis of benign prostatic
hyperplasia resulting in urinary retention. When attempting to pass the catheter, the
nurse encounters an obstruction, and cannot get the catheter to pass beyond it. Which
action by the nurse is the most appropriate?
1. Documenting that catheterization is not possible, and notifying the health care
provider
2. Attempting to pass a Coud catheter
3. Attempting to push the catheter past the obstruction
4. Applying ice to the base of the penis, and attempting to pass the catheter in 30
minutes
The nurse is caring for a client with dyspnea resulting from pulmonary edema
secondary to congestive heart failure. The health care provider is notified, and the nurse
receives a verbal order for Lasix 40 mg STAT. Which action by the nurse is the most
appropriate?
1. Administer the medication immediately.
2. Clarify the route for administration.
3. Give the medication IV because the client is in distress and rapid effects are needed.
4. Hold the medication until the prescriber comes to the unit to clarify route and sign
the order.
The nurse is preparing to ambulate a client in the hall. Which action by the nurse is a
strategy to reduce the client’s risk of falls?
1. Encouraging client to wear nonskid footwear
2. Cautioning the client about cords or clutter on the floor
3. Encouraging the client to continue walking after complaints of feeling tired
4. Acting as the client’s means of support instead of using a walker to provide additional
support
The nurse is planning care for a client with increased intracranial pressure. Which
intervention should the nurse add to this client’s care plan?
1. Keep the head of the bed flat
2. Provide with opioid analgesic for pain
3. Administer hypertonic saline as prescribed
4. Hyperventilate with 100% oxygen every 2 hours
Pain is a complex phenomenon that affects both the physical and mental areas. When
teaching the client about pain, which statement made by the client would indicate
appropriate understanding?
1. “Cancer pain usually only lasts a short time.”
2. “Acute pain is usually rapid and can vary in intensity.”
3. “Chronic pain may be acute, chronic, or intermittent.”
4. “Chronic pain usually only lasts a little while.”
The nurse is preparing to meet a newly admitted client. What should the nurse do first?
1. Ask the client for feedback
2. Introduce herself to the client
3. Ask if the client has any questions
4. Check client ID with two forms of identification
A client is prescribed to receive a unit of packed red blood cells. What should be
checked prior to administering the blood to this client? Select all that apply.
1. Client name
2. Unit number
3. Blood group
4. Client birthday
5. Expiration date
The nurse receives an order to administer 3 liters of IV fluid over the next 24 hours. The
infusion device would be set to administer how many mL per hour?
____ mL/hour
Standard Text: Record the answer rounding to the nearest whole number.
The nurse is reviewing a client’s vital signs from birth to age 10. Which changes should
the nurse expect to find?
1. Reduction in temperature, increase in heart rate, decrease in respiratory rate, and
increase in blood pressure
2. Reduction in oxygen saturation, decreased heart and respiratory rate, and decreased
blood pressure
3. Reduced heart and respiratory rate and increased blood pressure
4. Decreased temperature, reduced heart and respiratory rate, and increased blood
pressure
The nurse determines that a client’s intracranial pressure waveform is normal. What did
the nurse observe to make this clinical determination?
1. Three pressure peaks
4. Absence of pressure peaks
3. Synchronization with heart rate
2. Synchronization with respiratory rate
When deciding if parenteral nutrition should be given peripherally or centrally, the
nurse recognizes which statement is true?
1. Lipids must be given centrally.
2. The maximum percentage of dextrose that can be given peripherally is up to 10%.
3. Clients requiring long-term parenteral nutrition generally receive it peripherally.
4. Providing parenteral nutrition peripherally cannot meet calorie needs.
The nurse caring for a client with a plaster cast applied several days ago notes crumbs
of plaster on the skin just under the edge of the cast. Which action by the nurse is the
most appropriate?
1. Leaving the crumbs there to avoid injuring the skin
2. Using a surgical scrub brush to remove the crumbs
3. Using a dry cloth to remove the crumbs to avoid wetting the cast
4. Pull inner stockinette out and over the edge and secure with tape