The nurse delegates the making of an occupied bed to unlicensed assistive personnel
(UAP). Which statement made by the UAP indicates the need for further instruction
prior to this assignment?
1. “I will be sure to inform you of any wound drainage.”
2. “I will inform you if any of the client’s tubes are loose.”
3. “I will assess the client’s IV tubing.”
4. “I will inform you of any problems.”
The nurse is going to perform light palpation. Which statement regarding light
palpation is true?
1. It is a gentle downward movement of the hand in a circular fashion.
2. It is done by using two hands to apply pressure.
3. It is only done by the health care provider.
4. It should cause the client pain.
A client has a deep wound with areas of exudate and eschar. Which would be the fastest
way to debride this wound?
1. Surgical
2. Chemical
3. Autolytic
4. Mechanical
A client is being transferred from a critical care area to the telemetry unit. What
information should the nurse include when communicating this client’s care needs?
1. Last doses of medication
2. Where the spouse is employed
3. Number of children the client has
4. Family members’ opinions about the hospital
While emptying the urinal of a client with radioactive bladder implants several drops of
urine splash on the nurse’s upper arm. What should the nurse do first?
1. Pour the urine in the commode
2. Complete an occurrence report
3. Notify the radiation safety officer
4. Wash the arm with soap and water
The nurse is providing care to a client who is diagnosed with a terminal illness. When
meeting the physiological needs of this dying client, which items will the nurse include
in the assessment process?
Standard Text: Select all that apply.
1. Determine if the client has advance directives.
2. Determine if the client is experiencing any physiological signs of impending death.
3. Ask questions to determine ways to support the client and family.
4. Ask the family if they want to view the body after death.
5. Provide adequate pain control.
The nurse is instructing a client on the use of a peak flow meter. In which order should
the nurse provide these instructions?
1. Inhale deeply
2. Clean the unit
3. Slide the indicator to zero
4. Blow out through the mouth
5. Attach mouthpiece to the meter
After completing an assessment the nurse asks the client questions about stress. What
observations caused the nurse to focus on this area of the client’s health? Select all that
apply.
1. Hives
2. Neck ache
3. Blurred vision
4. Excessive thirst
5. Heart palpitations
The nurse is preparing to conduct a mental health assessment with a client. What should
be included in this assessment? Select all that apply.
1. Past medical history
2. General motor activity
3. Past and present memory
4. Coherency, logic, and relevance
5. General appearance, manner, and attitude
The health care provider suspects the postoperative client has an infection, but is not
sure of the source, and orders sputum, wound, urine, and nasal cultures. Which culture
should be collected when the client wakes in the morning?
1. Urine
2. Sputum
3. Wound
4. Nasal
The nurse is caring for a group of clients. Which nursing behaviors exemplify
communication about these clients’ care? Select all that apply.
1. Making a check mark on a care tracking sheet
2. Initialing and dating an entry in the medical record
3. Volunteering to participate in an upcoming seminar
4. Reading the results of laboratory and diagnostic tests
5. Discussing a client’s response to pain medication with the care provider
The nurse is preparing to assist with the debridement of a client’s wounds. In which
order should the nurse complete surgical hand antisepsis?
1. Remove all jewelry
2. Wet hands with warm water.
3. Turn on water using foot pedal
4. Completely dry hands and forearms
5. Rub hands together for at least 20 sec
6. Apply 3″5 mL of antimicrobial soap to hands
7. Scrub hands and forearms up to 3 in. above elbows
8. Rinse hands and arms from finger tips to elbows
The nurse determines that a teaching session scheduled with a client should be
postponed for a few hours. What information caused the nurse to make this decision?
1. Family members visiting
2. Laboratory tests scheduled
3. Pain level 8 on a scale from 0 to 10
4. Healthcare provider making rounds
A person maintains balance as long as the line of gravity passes through which item?
1. The base of support
2. The center of gravity
3. The center of gravity and base of support
4. The moving body part
The nurse is caring for a client with a hearing aid. In which order should the nurse care
for this hearing device?
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Perform hand hygiene and wear appropriate personal protective
equipment.
Response 2. Wipe the casing with dry cloth.
Response 3. Check the batteries.
Response 4. Cleanse the outer ear gently with a cotton-tipped applicator.
Response 5. Determine ability of client to perform all or part of cleaning procedure.
Response 6. Insert ear mold and turn the switch to ON.
A client asks why a neighbor has a cane that has one tip and the one provided by
physical therapy has four tips. What should the nurse respond to this client?
1. “A cane with one tip is more expensive.”
2. “A cane with 4 tips has a better hand grip.”
3. “A cane with one tip has a better hand grip.”
4. “A cane with 4 tips provides more stability.”
The nurse is hanging a secondary bag with an antibiotic for a client. Which action
should the nurse take when performing this skill?
1. Lower the secondary bag
2. Clamp the primary bag tubing
3. Regulate the flow with the primary bag
4. Regulate the flow with the secondary bag
The nurse asks to attend a seminar on cultural diversity. What was the primary reason
for the nurse making this request?
1. Improve ability to care for pediatric clients
2. Decide if a home care position should be accepted
3. Recognize the special needs of an aging population
4. Understand care issues of non-English speaking clients
A client is newly diagnosed with heart failure. Which interventions should the nurse
prepare to provide this client? Select all that apply.
1. Bed rest
2. Elevate legs
3. Oxygen therapy
4. Fluid restriction
5. Low sodium diet