The nurse learns that a client will be discharged in 2 days. On what should the nurse
focus when planning for this client’s discharge? Select all that apply.
1. Needs
2. Goals of care
3. Measureable outcomes
4. Implementation strategies
5. Compliance with medical treatment
A client scheduled for surgery has a history of venous stasis problems. Which strategies
should the nurse consider to reduce the risk of postoperative venous stasis?
Standard Text: Select all that apply.
1. Pneumatic compression device
2. Sequential compression device
3. Antiembolism stockings
4. Getting the client out of bed as soon as possible
5. Keeping the legs lower than the level of the heart
During an assessment a client answers no questions and tells the nurse to talk with the
spouse who is due to arrive later in the day. What can occur with this situation?
1. Noncompliance
2. Enhanced rapport
3. Situational awareness
4. Dysfunctional communication
After fitting the sleeve of the sequential compression device onto the client’s legs,
which action should the nurse take next?
1. Documenting the procedure
2. Turning the machine on
3. Connecting the sleeve to the control unit
4. Adjusting the alarms
The nurse administering a bolus tube feeding inserts a 60 mL syringe into the tube.
After pouring formula into the syringe, where should the nurse hold the syringe?
1. 1″3 inches above the ostomy opening
2. 3″6 inches above the ostomy opening
3. 12-18 inches above the ostomy opening
4. 12 inches above the ostomy opening
The nurse is completing a health history with a client. Which information is least likely
to be the focus of this assessment?
1. Health promotion
2. Biographic data
3. Chief complaint
4. Family history
The nurse assists the health care provider with the collection of cerebrospinal fluid.
Which is an important safety measure for the nurse to follow immediately after
collection of the sample?
1. Maintain sterility of the procedure tray.
2. Discard all sharps in a puncture-proof container.
3. Label specimens and send to the lab.
4. Remove PPE and discard.
After report the nurse reviews a standardized care plan for an assigned client. Where
should the nurse find the current active problems identified for the client?
1. Look at the problem list area on the Kardex
2. Read the notes written about specific problems
3. Ask the charge nurse where the problems are located
4. Identify the areas with check marks placed on the care plan
The nurse places lead aVR on a client. What tracing will this lead produce?
1. Activity between the center of the heart and left arm
2. Activity between the center of the heart and right arm
3. Activity between the center of the heart and the fourth ICS
4. Activity between the center of the heart and the left leg or foot
The nurse is performing passive range of motion on the client and notes that the client’s
ankle is red, edematous, and painful to the touch. Which action by the nurse is the most
appropriate?
1. Perform range of motion very gently to the ankle.
2. Perform normal range of motion to the ankle.
3. Skip range of motion in this joint and move on to the next joints.
4. Notify the health care provider before performing range of motion to this joint.
The nurse is concerned that a client is experiencing urinary effects of immobility. What
did the nurse assess to make this clinical determination?
1. Urine retention
2. Bladder distention
3. Shortness of breath
4. Urinary tract infection
The nurse is caring for a client with abdominal distention who is unable to expel flatus.
Which type of enema should the nurse anticipate administering?
1. Cleansing enema
2. Carminative enema
3. Retention enema
4. Soapsuds enema
The nurse is caring for a client who has no cough or gag reflex and is unable to take
nutrients orally. Which device would be an appropriate choice for providing nutrition to
this client?
1. A nasogastric tube
2. An orogastric tube
3. A nasoenteric tube
4. A jejunostomy tube
During an assessment the nurse suspects that a client is experiencing a disorder of the
cerebellum. What did the nurse assess to make this clinical determination?
1. Tremors
2. Auditory hallucinations
3. Loss of short-term memory
4. Poor hand-eye coordination
A client with a massive sacral wound is prescribed a 2800 calorie diet. Of these calories
55% are to be carbohydrates and 25% fats. How many calories should the client ingest
of protein? Calculate to the nearest whole number.