After delegating an aspect of care to unlicensed assistive personnel (UAP) the nurse
answers any questions and is available while the care is being provided. Which “right of
delegation” is this nurse performing?
1. Person
2. Direction
3. Supervision
4. Circumstances
The nurse is transferring the client who is able to provide minimal assistance from the
bed to the wheelchair. Which nursing action will provide for the safest transfer for this
client?
1. Raising the bed height to waist height
2. Placing the wheelchair on the client’s strong side
3. Placing the wheelchair with the feet pointing toward the side of the bed
4. Locking the wheels of the wheelchair and lowering the footplate
Family has arrived to take a client home. What should the nurse provide to the client
before leaving the healthcare organization?
1. Written instructions
2. Results of diagnostic testing
3. Names of health plan approved pharmacists
4. Telephone number of the healthcare provider
The nurse is caring for a healthy young adult client who was involved in a motor
vehicle crash resulting in a fractured femur. The femur was pinned, and the client was
placed in traction. Which type of bath should the nurse provide for this client?
1. Complete bath
2. Therapeutic bath
3. Partial bath
4. Commercial product bath
The nurse is caring for a client being weaned from the ventilator. When performing a
spontaneous breathing trial, which item is not a priority assessment?
1. Mental status
2. Oxygen saturation
3. Vital signs
4. Ability to speak
The nurse is explaining to the client the role of inspection during an assessment. Which
client statement indicates understanding about this assessment technique?
1. “So, you are going to listen to my heart.”
2. “So, you will be touching my abdomen.”
3. “So, you will be looking at my skin.”
4. “So, you are going tap my abdomen.”
The nurse is preparing a care plan for a client with a stage IV pressure ulcer. What
should be the goals of care for this client? Select all that apply.
1. Speed healing
2. Absorb drainage
3. Prevent infection
4. Prevent from injury
5. Remove necrotic tissue
The family of a client undergoing treatment for cancer is concerned about the client’s
unwillingness to spend time or talk with any family members. Which category of stress
is this client demonstrating? Select all that apply.
1. Behavioral
2. Physiologic
3. Interpersonal
4. Psychological
5. Developmental
The nurse is making beds on the medical’surgical unit. What should the nurse do
differently when making a surgical bed versus an open unoccupied bed?
Standard Text: Select all that apply.
1. Strip the bed.
2. Do not tuck, miter, or toe-pleat the top covers.
3. Fold top sheets into a triangle at the side of the bed.
4. Place pillows on the chair beside the bed.
5. Raise the bed to a comfortable working height.
The nurse suspects that a client is experiencing stress. Which observation indicates that
the client’s manifestations fit Hans Selye’s definition of this disorder? Select all that
apply.
1. Weight gain
2. Loss of appetite
3. Inability to sleep
4. Planning a vacation
5. Increased blood glucose level
The nurse is attempting to withdraw 1 mL of fluid into a 3 mL syringe, and is pulling on
the plunger. The fluid is not flowing into the syringe, and the nurse has withdrawn the
plunger to the 2.5 mL line. Which action should the nurse take to correct this problem?
1. Change the needle because the current needle is clogged.
2. Inject air into the vial and draw out the remaining fluid.
3. Throw the vial away and obtain a new one, because this one is defective.
4. Obtain a larger syringe to withdraw the medication.
The nurse is preparing to brush a client’s teeth. Which technique should the nurse use?
1. Gum line
2. Xerostomia
3. Gingivitis
4. Pyorrhea
An implanted subcutaneous port is occluded. What should the nurse do first?
1. Aspirate the clot
2. Change the needle
3. Instill a fibrinolytic agent
4. Forcefully flush the catheter
The health care provider prescribes 1,500 milligrams of medication. The nurse finds
tablets in the client’s drawer that are 1 gram each. How many tablets should the nurse
administer to the client?
____ Tablets
Standard Text: Record the answer rounding to the nearest tenth.
The nurse receives an order to collect a midstream urine specimen from the client.
Which is not a part of collecting this specimen?
1. Teaching the client how to clean the genitals prior to collecting the specimen
2. Labeling the specimen and sending it to the lab
3. Assuring that the specimen is collected following sterile technique
4. Documenting that the specimen has been collected and what was done with it
A client is scheduled for surgery the new day. Which type of teaching should the nurse
provide?
1. Postoperative
2. Preoperative
3. Perioperative
4. Intraoperative
The nurse observes a client while using the prescribed incentive spirometer. Which
items will the nurse include when documenting this observation in the nursing notes?
Standard Text: Select all that apply.
1. Type of spirometer
2. Number of breaths taken
3. Education provided
4. Medications administered
5. Code status
The nurse is assessing a client’s peripheral pulses. For what should the nurse assess for?
Standard Text: Select all that apply.
1. Bilaterality
2. Regularity
3. Strength
4. Rate
5. Arrhythmia
The nurse is reviewing bed making with newly hired unlicensed assistive personnel
(UAP). What should the nurse explain as the reason for mitering the corners of the bed
linen?
1. Keeps the bed linens tight
2. Helps the client stay in bed
3. Makes raising the side rails easier
4. Prevents the mattress from moving