When the nurse documents a client’s wound, which is the best means of describing the
wound?
1. Measuring the wound and documenting size
2. Comparing the wound to a universally understood object, such as a quarter or cashew
3. Using terms such as small, medium, or large
4. Taking a picture and inserting it into the record
The nurse initiating IV therapy is preparing a solution to which potassium chloride has
been added. After adding the medication, which action by the nurse regarding the IV
label is appropriate?
1. Writing the time the IV solution needs to be changed
2. Placing it upside-down on the container
3. Putting it around the IV tubing
4. Documenting the size of the angiocatheter inserted to obtain IV access
The nurse is caring for a client who had extensive surgery, and is now 6 days
postoperative and getting out of bed for the first time later this morning. When the nurse
assesses the client for pain, the client responds, “It hurts, but I don’t want to take any
more drugs. I don’t want to end up addicted.” Which response by the nurse is the most
appropriate?
1. “If you don’t take the pain medication on a regular schedule, you won’t get addicted.”
2. “People who have real pain are unlikely to become addicted to analgesics provided to
treat the pain.”
3. “You are wise to be concerned, and after 6 days it is probably time to stop taking
narcotics if you can manage the pain in other ways.”
4. “Don’t worry about getting addicted. I will make sure you don’t get addicted.”
The nurse is palpating a client’s systolic blood pressure. What should the nurse identify
as being the systolic reading?
1. The last palpated beat
2. The first palpated beat
3. The pressure when the arterial pulse is obliterated
4. The pressure where the client says the fingers are numb
The nurse is working in a day care center where there recently has been an outbreak of
viral conjunctivitis. What should the nurse instruct the staff to stop the spread of this
infection?
1> Require all children with conjunctivitis to stay home until there is a reduction in
drainage.
2> Require all children with an infection to be on otic antibiotics for at least 24 hours
prior to returning to school.
3> Isolate all children with conjunctivitis in the same room away from those who are
not infected.
4> Perform hand hygiene after providing personal care for all children.
A client asks why a BIOPATCH is being used as part of a central line dressing. What
should the nurse respond to this client?
1. “It ensures no air gets into the line.”
2. “It reduces the risk of an infection.”
3. “It keeps the catheter from moving.”
4. “It stops germs for a minimum of 3 days.”
Which term is not used interchangeably with urinary elimination?
1. Micturition
2. Voiding
3. Urination
4. Incontinence
A client with intractable acute pain is undecided about the use of epidural pain
management. What should the nurse explain about epidural analgesia? Select all that
apply.
1. “The chance of becoming addicted to pain medication is lower.”
2. “The effects of pain medication last much longer when this route is used.”
3. “The dose of medication can be lower because it isn”t metabolized in the liver.”
4. “The narcotic moves quickly into the spinal cord and blocks the reception of pain.”
5. “The risk of developing side effects from pain medication is eliminated this route.”
Which items should the nurse use with all clients to prevent the transmission of
potentially infective organisms among the nurse, client, and other individuals?
Standard Text: Select all that apply.
1. Hand hygiene
2. Standard precautions
3. Personal protective equipment
4. Isolation procedures
5. Antimicrobial soap
The nurse is preparing to assess a pregnant client’s abdomen. In which order should the
nurse complete this assessment?
1. Locate the fetal back
2. Locate the fetal head
3. Determine engagement
4. Identify the fetal part in the fundus
The nurse is preparing to teach an adult client about dietary changes required in the
treatment of hypertension. What adult learning principles should the nurse utilize during
this teaching? Select all that apply.
1. Reinforce positive behaviors
2. Progress from simple to complex topics
3. Invite family to participate in the teaching
4. Ask the client to verbally repeat instructed material
5. Assess what the client knows about the health issue
A client wearing a diamond engagement and wedding band set does not want to send
the rings home with the spouse. What should the nurse do?
1. Cover the rings with adhesive tape
2. Suggest the rings be placed in the night stand
3. Provide a “Release from Responsibility” form
4. Ask Security to explain the risk of losing the items
A client is being evaluated for arterial line placement. What should the nurse do after
compressing both arteries at the client’s right wrist?
1. Count the client’s radial pulse rate
2. Instruct the client to flex and extend the forearm several times
3. Instruct the client to clench and unclench the fist several times
4. Have unlicensed assistive personnel measure the blood pressure
The nurse is preparing to measure a client’s temperature. Which factors could influence
this measurement?
Standard Text: Select all that apply.
1. Smoking
2. Eating or drinking
3. Exercise
4. Perfusion
5. Time of day
While preparing a care plan the nurse adds interventions to address stress. What
behavioral manifestation did the nurse assess to make this decision?
1. Acne
2. Anger
3. Confusion
4. Hair twisting
After emptying the urine from a urinal, which actions by the nurse are appropriate?
Standard Text: Select all that apply.
1. Rinsing the urinal
2. Recording the output on the intake and output record, if indicated
3. Returning the urinal to the bedside area, where the client can reach it, if the male
client prefers
4. Placing the urinal between the client’s legs and propping the penis in the opening, if
the client is unable to do this independently
5. Donning clean gloves
The nurse is helping a student understand the techniques used when completing a
physical assessment. Which definitions should the nurse use to define these techniques?
1. Palpation is visualizing, inspection is feeling or touching, percussion is hearing, and
auscultation is tapping and listening.
2. Palpation is touching, inspection is feeling, percussion is tapping and listening, and
auscultation is listening.
3. Palpation is touching, inspection is looking, percussion is tapping, and auscultation is
listening.
4. Palpation is tapping and listening, inspection is listening, percussion is touching, and
auscultation is smelling.
Upon receiving the client from the postanesthesia care unit, which nursing action is the
priority?
1. Apply clean linens to the bed.
2. Assemble required equipment, such as suction, IV pole, or oxygen equipment.
3. Assess the client.
4. Notify the family of the client’s return to the room.
The nurse notes that a client is scheduled to receive conscious sedation for a surgical
procedure. What should the nurse review prior to preparing the client for this type of
anesthesia?
1. Adverse effects
2. Reversal agents
3. State nurse practice act
4. Assignment of a student nurse
A pregnant client has a friend who used yoga to help prepare for childbirth and asks
where to learn how to do this. What should the nurse respond?
1. “Yoga is too strenuous while pregnant.”
2. “Have you asked your friend to teach you?”
3. “There are teachers who can teach you how to do this.”
4. “Yoga is just glorified stretching which you can do on your own.”