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The nurse is providing care to a client requiring restraints. How often should the nurse
assess the client and document the assessment?
1. Once per shift
2. Once a day
3. Once every 4"6 hours
4. Once every 1"2 hours
A client comes into the emergency department with a soft tissue ankle sprain. In which
order should the nurse instruct the client to treat this injury at home?
1. Apply ice
2. Rest the ankle
3. Elevate the foot
4. Apply an ace bandage
The responsibility for nutritional assessment and support in most health care facilities
belongs to which individuals?
Standard Text: Select all that apply.
1. The client
2. The primary care provider
3. The nurse
4. The dietitian or nutritionist
5. The food service staff
The nurse is completing a spiritual assessment as part of a health history with a newly
admitted client. Which question should the nurse use to learn more about this client's
spirituality? Select all that apply.
1. "Do you like your religion?"
2. "How often do you attend religious services?"
3. "Do you follow any particular religious practices?"
4. "Isn"t it difficult to have to go to church every Sunday?"
5. "How can I ensure that your religious practices are followed in the event of a health
crisis?
A client in the intensive care is prescribed every 1 hour serum electrolyte levels and
arterial blood gases every 2 hours. What should be done to prevent this client from
developing nosocomial anemia?
1. Use a blood conservatory process
2. Place blood obtained in cups of ice
3. Increase intravenous fluids by 50 mL/hr
4. Provided one half of the blood required for each test
The nurse notes that the transducer for a client's hemodynamic monitoring catheter is
above the level of the right atrium. What effect should the nurse expect because of the
location of the transducer?
1. Lower readings
2. Higher readings
3. Monitor tracings will be flat lined
4. Inability to adequately zero the device
The preceptor is reviewing the content of a new graduate's documentation of client care.
What areas should the preceptor easily identify in this notation? Select all that apply.
1. Questions asked by the family
2. Changes in the client's condition
3. Teaching and the client's response
4. Reactions to non-routine medications
5. Assessment made at the beginning of the shift
The nurse is delegating supportive care to unlicensed assistive personnel (UAP) for
several clients on a medical'surgical unit. Which statement made by the UAP warrants
the need for more information?
1. "I can untie the restraint when giving the client a bath."
2. "I will make sure to tie the restraint in a slip-knot."
3. "I will inform you of any changes to the skin."
4. "I will assist the client with hygiene."
A visitor asks the nurse questions about a client's health status. What should the nurse
respond to this individual?
1. "I can tell you that the client is not doing very well."
2. "That information cannot be shared without the client's permission."
3. "Please keep this to yourself. The client needs to go on hospice soon."
4. "Since you are a visitor I can tell you that the client will be here for a few more
days."
The nurse is caring for a client with a colostomy who has continuous liquid drainage
with a fecal odor. Which term should the nurse use when documenting the type of
colostomy for this client?
1. Ileostomy
2. Ascending colostomy
3. Transverse colostomy
4. Descending colostomy
The nurse enters the postoperative client's room and finds the client perspiring with fists
clenched. As the nurse administers routine medications and provides care, the client is
pleasant and cooperative. Which action by the nurse is the most appropriate?
1. Documenting "no complaints of pain offered" and assessing that the client is
comfortable
2. Asking the client if pain is being experienced
3. Informing the client that he looks uncomfortable and asking him to describe his pain
4. Instructing the client to use the call bell if he experiences pain
The home care nurse is reinforcing teaching provided to a postoperative client about
active range-of-motion exercises. Which client statements indicate that teaching has
been effective? Select all that apply.
1. "I stop when I feel pain."
2. "I keep going when I feel pain."
3. "I exercise all my joints every 4 hours."
4. "I exercise my ankles at least every 2 hours."
5. "I exercise once in the morning and may later on."
The nurse is providing care to a client who has a short arm cast. Which nerve areas
should the nurse assess to determine if irritation is occurring?
Standard Text: Select all that apply.
1. Radial
2. Ulnar
3. Median
4. Peroneal
5. Tibial
Which tasks would be appropriate for the nurse to delegate to unlicensed assistive
personnel (UAP)?
Standard Text: Select all that apply.
1> Taking vital signs
2> Measuring and recording intake and output
3> Postmortem care
4> Providing telephone advice
5> Weighing the client
The nurse, triaging victims of a dirty bomb, notes the radiation dosimeter reading of
150R/h. How should the nurse interpret this reading?
1. 150 rad exposure will occur in 1 hour
2. In 1 hour the radiation exposure will decrease by 150
3. Radiation exposure within 150 feet will occur in 1 hour
4. The maximum permitted amount of radiation exposure in 1 hour is 150
A client is returning to the care area after a bronchoscopy. What should the nurse make
a priority when caring for this client?
1. Keep NPO
2. Encourage clear liquids
3. Report hoarseness or a sore throat
4. Assist with deep breathing and coughing
The nurse is caring for a client with body temperature instability. What hypothalamic
reactions should the nurse consider occurring to help control the client's temperature
instability? Select all that apply.
1. Radiation
2. Convection
3. Conduction
4. Evaporation
5. Condensation
A client who speaks English as a second language needs instruction on
self-administration of injectable medications and wound care before being discharged
the next day. What should the nurse identify as potential challenges when teaching this
client? Select all that apply.
1. Lack of time
2. Lack of supplies
3. Various languages
4. Lack of support systems in the home
5. Lack of appropriate readable materials
