The nurse is caring for a client who complains of frequent constipation. Which factor in
the client’s history is least likely to be the cause of the constipation?
1. Inadequate fluid intake
2. Repeated inhibition of the urge to defecate
3. Inadequate fiber intake
4. The presence of Escherichia coli
Which clients may benefit from central venous IV access?
Standard Text: Select all that apply.
1. The client requiring long-term IV therapy
2. The client receiving caustic IV therapy
3. The client requiring numerous IV infusions that are not compatible and cannot be
infused together
4. The unstable client requiring reliable IV access for administration of medications
required immediately
5. The client who is afraid of needles and does not want a catheter in the peripheral
extremity
An older client on Medicare has physical limitations and telephones a local home care
agency to schedule a nurse to visit. What should the nurse do first before proceeding
with this client’s request?
1. Determine homebound status
2. Identify available staff to visit the client
3. Discuss the challenges the client is facing
4. Find out when the client was last hospitalized
The nurse is applying an aquathermia pad to a client complaining of arthritic pain in the
right knee. Which filler is appropriate for this unit?
1. Sterile water
2. Normal saline
3. Tap water
4. Distilled water
When is it appropriate for the nurse to prepare a new ostomy pouch for a client?
1. After removing the old pouch in all instances
2. Before removing the old pouch in all instances
3. Before removing the old pouch whenever possible
4. After removing the old pouch whenever possible
The nurse working in a surgical center is caring for a client who had an abdominal
nevus removed. The client is complaining of intense pain. Which action by the nurse is
the most appropriate?
1. Administer a nonnarcotic analgesic because the client had minor surgery.
2. Attempt to divert the client without administering an analgesic because the surgery
was so minor.
3. Administer the stronger analgesic ordered by the primary care provider.
4. Notify the health care provider that the client’s pain is excessive for the minor
surgery performed.
The nurse is coming out of an isolation room. Which item is removed first to prevent
any exposure of infectious materials?
1. Gloves
2. Mask
3. Gown
4. Goggles
The nurse is teaching the client who requires maximum support secondary to
generalized weakness to walk with a walker. Which technique used by the nurse is the
most appropriate?
1. Move the walker ahead while moving the weak leg forward, bearing weight on the
strong leg.
2. Move the walker ahead while moving the strong leg forward, bearing weight on the
weak leg and the arms.
3. Move the walker ahead, then move the right foot up to the walker while body weight
is borne by the left leg and both arms, then move the left foot, bearing weight on the
right leg and both arms.
4. Walk forward and push the walker ahead before taking the next step.
A client is highly anxious about an upcoming surgical procedure. What action should
the nurse take to reduce this client’s anxiety?
1. Answer the client’s questions
2. Provide written teaching material
3. Instruct on range of motion exercises
4. Assign to review videotapes prior to teaching
Which joint will the nurse circumduct when performing range of motion on the
hospitalized client?
1. Neck
2. Shoulder
3. Foot
4. Knee
A newly admitted client says desires to have surgery to replace a knee and then return
home as soon as possible to resume living. On which part of the care plan should the
nurse document this information?
1. Client problems
2. Short-term goals
3. Assessment data
4. Nursing interventions
The nurse is providing care to a client who has an order for a jacket restraint. Which
action by the nurse is appropriate when applying this restraint to the client?
1. Placing the vest with the opening on the side
2. Pulling the tie on the end of the vest flap across the chest and placing it through the
slit on the same side of the chest
3. Using a slipknot to secure the tie around the solid leg of the bed frame
4. Using a half-bow knot to secure the tie around the movable bed frame
The nursing student is using a data collection tool while researching a client assignment
before clinical the next day. In which category should the student document the client’s
use of oxygen?
1. Medications
2. Biographical data
3. Nursing interventions
4. Physical assessment findings
The nurse is caring for a client with a newly created urinary diversion ostomy
appliance. Which is the priority when caring for this client?
1. Increasing fluid intake
2. Limiting fluid intake
3. Administering IV fluids, because the client will be NPO
4. Teaching the client self-care and support persons’ care
The nurse is preparing to lift a client from the bed to a chair using a sling. Which action
should the nurse perform to ensure for the client’s safety?
1. Raise the bed to waist level
2. Unhook the sling from lift arm
3. Move the lift away from the bed
4. Keep the client’s arms inside of the sling
The nurse is caring for a client who has been on complete bed rest for the past week. As
the nurse assists the client to sit in the chair, the client becomes dizzy when the legs are
dangled over the side of the bed. Which action by the nurse is the priority?
1. Returning the client to bed in the Trendelenburg position
2. Calling for help
3. Measuring the client’s blood pressure
4. Having the client sit on the edge of the bed for several minutes, and encourage a few
deep, slow breaths