The nurse is instructing unlicensed assistive personnel (UAP) on fall prevention for the
clients. Which statement made by the UAP warrants further instruction?
1. “I will ensure that the call light is within reach of the client.”
2. “I will make sure to have at least one side rail up at all times.”
3. “I don’t have to worry about the clients who are bedridden, as they are moved by the
staff.”
4. “I will make sure that the bed is in the lowest position prior to leaving the room.”
What should the nurse include when reviewing the Patient Care Partnership brochure
with a newly admitted client?
1> Visiting hours
2> Times for meals
3> Help with billing claims
4> How to avoid paying for medications
The nurse is observing a student nurse performing a respiratory assessment on a client.
Which statement indicates that the student nurse is performing the assessment
correctly?
1. The student nurse has the client in either a sitting or lying position.
2. The client is placed in a sitting position and uncovered to the waist.
3. The client is placed in a sitting position with gown and blanket.
4. The client is placed in the semi-Fowler’s position with gown removed.
A client scheduled for surgery is demonstrating mild levels of stress. How should this
stress level affect the client’s recovery? Select all that apply.
1. Increased alertness
2. Increased wound healing
3. Increased ability to learn
4. Increased ability to adjust to stressors
5. Increased adjustment to the environment
When providing preoperative teaching for the client who is scheduled for coronary
artery bypass surgery in the morning, the nurse should include which dimensions?
Standard Text: Select all that apply.
1. Information
2. Psychosocial support
3. The role of the client and support people
4. Skills training
5. Coughing and deep breathing
Several individuals arrive to the emergency department experiencing manifestations
that cannot be immediately determined. Which action is a priority when caring for these
individuals?
1. Contact the Poison Control Center
2. Institute standard, airborne, and contact precautions
3. Contact the organization’s disaster preparedness committee
4. Notify the Centers for Disease Control and Prevention (CDC)
When the nurse delegates measurement of vital signs to unlicensed assistive personnel
(UAP), which are the nurse’s responsibilities?
Standard Text: Select all that apply.
1. Assessment of vital sign readings obtained by UAP
2. Assessment of the UAP’s skills in measuring vital signs
3. Determination that the vital signs were obtained correctly
4. Follow up on vital sign measurements that are abnormal or unexpected
5. Observe the UAP as vital signs are being measured
After applying a condom catheter, what should the nurse document?
Standard Text: Select all that apply.
1. Appearance of the penis, such as swelling or discoloration
2. Amount of urine flow
3. Assessment 30 minutes after application and every 8 hours thereafter
4. Any client complaints or concerns
5. Time of application
The nurse is preparing to cleanse a client’s denture. Which action should the nurse take
to prevent damaging the dentures?
1. Using hot water
2. Placing a towel in the sink
3. Cleansing them at the bedside
4. Rinsing them with mouthwash
The nurse is preparing to provide an intramuscular injection. For which reason should
the nurse use the Z-track technique?
1. Takes less time
2. Is an easier method
3. Prevents leakage into subcutaneous tissue
4. Able to use the deltoid muscle for the injection
For which reasons should a registered nurse contact the Board of Registered Nursing
(BRN)? Select all that apply?
1> Renewing nursing license
2> Determining nursing standards
3> Identifying the date for a disciplinary hearing
4> Checking the dates for continuing education programs
5> Ascertaining when a nurse applicant became licensed
A client asks why a central line is being placed in the right arm. What should the nurse
respond to this client?
1. “It is more stable.”
2. “It costs less than another site for a central line.”
3. “It doesn”t get infected as often as other central lines.
4. “It is the best approach for the medicine that you need to receive.”
A client is instructed on the proper way to apply nitroglycerin ointment. What should
the nurse use to evaluate the effectiveness of teaching provided?
1. Questionnaire
2. Verbal response
3. Teach back method
4. Paper and pencil test