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A nurse is providing teaching to the family of a client who is at the end
stage of life. Which of the following client manifestations should the
nurse instruct the family to expect?
A. Increased periods of wakefulness
B. Altered breathing patterns
C. Increased salivation
D. Warm and dry extremities - ANSWER-b


A nurse is preparing to obtain informed consent from a client who
speaks a different language than the nurse and is scheduled for
surgery. Which of the following actions should the nurse take?
a. recommend an interpreter who is the same gender as the client. -
ANSWER-a


A nurse is caring for a client who is receiving continuous enteral
feedings through a gastrostomy tube. Which of the following actions
should the nurse take?
a. Aspirate residual volume every 4 hr - ANSWER-a


A nurse is preparing to insert an IV catheter for a client following a
right mastectomy. Which of the following veins should the nurse
select when initiating IV therapy?
a. The cephalic vein in the left distal forearm - ANSWER-a

,A nurse is caring for a client who is postoperative and has a new
prescription to advance her diet to full liquids. Which of the following
foods should the nurse offer the client as a part of a full liquid diet?
a. Plain yogurt - ANSWER-a


A nurse is planning care for a client who has a latex allergy and is
scheduled for surgery. Which of the following actions is appropriate to
include in the client's plan of care?
a. Schedule the client as the first procedure - ANSWER-a


Type 2 diabetes mellitus patient with corns and calluses.
a. I can apply lotion to soften calluses as long as i don't put lotion
between my toes - ANSWER-a


A nurse is caring for a male client who has a prescription for
intermittent catheterization with a coude catheter. Which of the
following images show the type of catheter the nurse should use?
a. The picture with the curled end of the catheter - ANSWER-a


A nurse is caring for a client following a bilateral mastectomy. The
client is often tearful and avoids looking at her dressings. Which of the
following actions should the nurse take first?
A. Provide the client with a mirror to look at her mastectomy incisions
B. refer the client to a breast cancer support group

,C. identify the impact of the mastectomy on the client's body image
D. encourage the client to assist with her dressing change - ANSWER
A nurse is planning care for a group of clients. Which of the following
tasks should the nurse delegate to an assistive personnel?
a. Changing the dressing for a client who has a stage 3 pressure injury
b. Determining a client's response to a diuretic
c. Comparing radial pulses for a client who is postoperative
d.Providing postmortem care to a client - ANSWER-d


A nurse is conducting a health assessment for a client who takes
herbal supplements. Which of the following statements by the client
indicates an understanding of the use of the supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick
D. I use garlic for my menopausal symptoms - ANSWER-c


A nurse is caring for a client who has influenza and isolation
precautions in place. Which of the following actions should the nurse
take to prevent the spread of infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.

, D. Place the client in a negative airflow room. - ANSWER-a


A nurse obtains a prescription for wrist restraints for a client who is
trying to pull out his NG tube. Which of the following actions should
the nurse take?
A. Attach the restraints securely to the side rails of the client's bed.
B. Apply the restraints to allow as little movement as possible
C.Allow room for two fingers to fit between the clients skin and the
restraints
d. remove the restraints every 4 hours - ANSWER-c


A nurse is admitting a client who has tuberculosis. Which of the
following types of transmission precautions should the nurse plan to
initiate?
A. Droplet
B. Airbornes
c. protective environment
d. contact - ANSWER-b


A nurse in a well-child clinic receives a telephone call from a parent
who states that their child accidentally swallowed paint thinner. The
child is awake and alert. Which of the following responses should the
nurse make?
A. Have your child drink one large glass of water.

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