When the nurse performs hand hygiene properly, which aspect in the chain of infection
is the nurse breaking?
1. Portal of entry
2. Portal of exit
3. Mode of transmission
4. Etiologic agent
A client recovering with left leg weakness needs to learn how to walk stairs. Which
approach is the safest for the nurse to review with the client?
1. Lift the left leg to the step and then bring the right leg up
2. Lift the right leg to the step and then bring the left leg up
3. Step down on the right leg and then bring the left leg down
4. Turn to the side and bring the right leg down followed by the left leg
The nurse finds a client pulseless and not breathing. What tasks could the nurse safely
assign to the unlicensed assistive personnel (UAP) in this situation?
Standard Text: Select all that apply.
1. Perform chest compressions.
2. Get the crash cart.
3. Call a code blue.
4. Administer emergency medications.
5. Bag the client using a bag-valve mask until the doctor arrives to intubate the client.
The nurse observing the unlicensed assistive personnel (UAP) using alcohol-based rubs
for hand hygiene would recognize that further teaching is required when the UAP
performs which act?
1> Rubs palm against palm when washing hands.
2> Applies a palmful of product into cupped hands.
3> Interlaces fingers palm to palm.
4> Dries hands with clean paper towel.
Prior to beginning a client’s intravenous antibiotics the nurse needs to culture the
wound. In which order should the nurse perform the steps to obtain this culture?
2. Use non”cotton-tipped swab
6. Place swab in culture medium
3. Rotate swab while obtaining specimen
1. Rinse wound thoroughly with sterile saline
5. Do not take specimen from exudate or eschar
4. Swab edges starting at top, crisscross wound to bottom
A client’s ventriculostomy catheter has stopped draining. What should the nurse do?
1. Notify the health care provider
2. Inject heparin through the drain
3. Aspirate the drain with a 10 mL syringe
4. Flush the drain with sterile normal saline
When administering otic drops, which action by the nurse when pulling the pinna is the
most appropriate?
1. Down and back for the child under 3 years of age
2. Down and back for the adult client
3. Down and back for the child under 5 years of age
4. Up and back for the child under 3 years of age
Which finding should the nurse report to the health care provider as soon as possible?
1. After beginning sequential compression device application, the client’s toes are found
to be cool to the touch and mottled, with absent pedal pulses.
2. After applying antiemboli stockings, the client says the stockings feel snug.
3. When applying antiemboli stockings, the nurse finds they are too small for this client.
4. The client asks the nurse to wait to apply the antiembolism stockings until after
breakfast.
The nurse is using a disposable system to wash a client’s hair. What should the nurse do
before using the system?
1. Heat the package in the microwave
2. Apply gloves
3. Place cap on the client’s head
4. Rinse the hair with water
Which is the most effective way for the nurse to apply an appliance such as a hot water
bottle or disposable hot pack to a client?
1. Directly to the client’s skin
2. Directly to the client’s skin with a towel or blanket wrapped over the appliance to
hold it to the leg
3. If possible, have the client lay on top of the appliance
4. Wrap the appliance in a towel and lay it on the site on the client
The nurse is explaining to student nurses the different heart sounds that are assessed
during the cardiac assessment. Which statement made by a student indicates
understanding of the expected normal heart sounds?
1. “If I hear the S1 as lub and S2 as dub, then that is normal and means that the valves
are working.”
2. ” If I hear a “lub-dub-ee” it means the client has a ventricular gallop.”
3. “If I hear “dee-lub-dub” then the client may have an atrial gallop. This occurs near
the very end of diastole just before S1 and creates the sound.”
4. “If I hear the “dee-lub-dub” sound in an older adult, then I should know that is
considered normal for the older client.”
The nurse is preparing to assess a wound on a new admission on a medical’surgical unit.
Which items should the nurse review in the medical record prior to assessing the client’s
wound?
Standard Text: Select all that apply.
1. The cause of the wound
2. The length of time the wound has been present
3. The previous treatments and client responses
4. The equipment used by other nurses
5. The current medication list
The nurse is attending a football game when another spectator reports chest pain and
collapses. The nurse assesses the client and finds he is pulseless and not breathing. After
the nurse calls for help, someone brings an AED. Which action by the nurse is the most
appropriate?
1. Not using the device, because it needs to be plugged in and there is no electricity
2. Turning the machine on, placing the patches, and then plugging in the cable
3. Connecting the cables, placing the patches, and then turning on the machine
4. Placing the patches, turning on the machine, and then plugging in the cable
The nurse is caring for a client newly diagnosed with heart failure. Which nursing
statement encourages the client to express thoughts and feelings?
1. “Please tell me how I can help you learn to manage this health problem.”
2. “Oftentimes heart failure can be prevented with proper diet and exercise.”
3. “Many of my clients have your same health problem and they are doing very well.”
4. “Would you mind holding any questions until I review your healthcare provider’s
care orders?”
What actions should the nurse take to assist a client adapt to being hospitalized? Select
all that apply.
1> Ensuring for the client’s comfort
2> Completing the admission assessment
3> Attempting to accommodate the client’s wishes
4> Communicating with the client as an individual
5> Accepting the client’s perception of the environment
The nurse is explaining evidence-based practice to a group of new nursing students.
Which statement should the nurse use during this explanation?
1. “Evidence-based nursing practice generates new knowledge.”
2. “Evidence-based nursing practice applies knowledge to practice.”
3. “Evidence-based nursing practice is measurable, time specific, quantifiable, and
realistic.”
4. “Evidence-based nursing practice is based on the best evidence available from
nursing research.”
The nurse is completing the planning phase of the nursing process with a client. Which
should the nurse perform during this phase? Select all that apply.
1. Identify short- and long-term goals
2. Strategize approaches for goal outcomes
3. List nursing measures when delivering care
4. Create outcomes that are measurable and realistic
5. Organize defining characteristics of data into meaningful patterns
Which explanation is the most accurate when describing PM care to a client?
1. Providing for elimination needs, washing face and hands, giving oral care, and
possibly a back massage.
2. Providing care when the client awakens to include providing urinal or bedpan,
washing of face and hands, and giving oral care
3. Providing care that includes elimination needs, a bath or shower, perineal care, and
oral, nail, and hair care.
4. Providing care required by the client such as changing of linen and clothes when they
become soiled.