1. A nurse is collecting data from a client Thirst.
who has an elevated temperature with no
sweating. Which of the following findings Rationale:
is an indication of hypernatremia? Thirst, combined with an elevat-
ed temperature and a lack of
Thirst sweating, can be an indication of
Muscle twitching hypernatremia.
Headache
Abdominal cramps
2. A nurse is caring for a client who reports Close the door to the client's
difficulty sleeping due to the noise on room.
the nursing unit. Which of the following
actions should the nurse take to reduce Rationale:
environmental noise? The nurse should close the door
to the client's room whenever
Close the door to the client's room. possible to reduce environmen-
Turn off the alarms and beeps on moni- tal noise.
toring equipment.
Conduct change-of-shift report outside
the client's door.
Keep the television on low in the client's
room.
3. A nurse is reinforcing teaching about Identify areas of concern.
health promotion with a client. Which of
the following actions should the nurse Rationale:
take first to promote effective learning? The first action the nurse should
take when using the nursing
Identify areas of concern. process is to collect data from
Prioritize learning objectives. the client. Identifying and under-
Demonstrate psychomotor skills. standing the client's concerns
Observe nonverbal communication. prior to reinforcing teaching pro-
motes effective learning.
4. A home health nurse is assisting with Clarify the role of this individual
the plan of care for a client. Which of the nurse.
following should the nurse include dur-
ing the orientation phase of the helping Rationale:
, relationship? The nurse should plan to estab-
lish a warm, caring relationship
Review current client data. while clarifying the role of each
Assist to meet client goals. participant, which occurs during
Review shared memories of interactions the orientation phase of the rela-
with client. tionship.
Clarify the role of this individual nurse.
5. A nurse is preparing to assist with the The wheel locks on the bed are
admission of a client who has pneumo- malfunctioning.
nia. Which of the following observations
about the client's room requires immedi-Rationale:
ate attention? The greatest risk to this client
is injury from a fall when getting
The wall BP gauge is missing. into or out of a bed that is unsta-
The room has no IV infusion pump. ble due to malfunctioning locks.
The examination light above the bed Therefore, the priority is to report
does not work. and replace the bed before ad-
The wheel locks on the bed are malfunc- mitting the client to the room.
tioning.
6. A nurse is reinforcing teaching about Participate in screenings for tu-
health promotion with an older adult berculosis.
client. Which of the following instruc-
tions to the client is an example of sec- Rationale:
ondary prevention? The nurse should encourage the
client to participate in screenings
Participate in screenings for tuberculo- for tuberculosis, a secondary
sis. prevention measure. Secondary
Follow dietary recommendations to re- prevention measures focus on di-
duce the risk for osteoporosis. agnosis and early intervention.
Limit alcohol intake to one drink per day.
Perform yoga exercises three times per
week.
7. A licensed practical nurse (LPN) is re- Staging a pressure ulcer.
ceiving change-of-shift report for a client
who had a stroke. For which of the fol- Rationale:
lowing tasks should the nurse request An LPN can collect data for the
, assistance from a registered nurse (RN)? client and report findings to an
RN. However, staging a pressure
Administering a cleansing enema ulcer requires advance knowl-
Staging a pressure ulcer edge and skill, and is outside the
Inserting an indwelling urinary catheter scope of practice of an LPN. An
Performing passive range-of-motion ex- RN should assess the stage of a
ercises complex wound, such as a pres-
sure ulcer, and provide prima-
ry client teaching about pressure
ulcer prevention and care.
8. A nurse is reinforcing teaching about "I will secure all of my electrical
home safety with a client who is at risk cords to the baseboard."
for falls. Which of the following client
statements indicates an understanding Rationale:
of the teaching? Securing cords along the base-
boards with electrical tape min-
"I will keep my floors well waxed." imizes the tripping hazard for
"I will take my shoes off when I come clients who are at risk for falls.
back into the house."
"I will secure all of my electrical cords to
the baseboard."
"I will place area rugs on my tile floors."
9. A home health nurse is reinforcing teach- "I will wash my hands with soap
ing about infection control with a client and water for 15 seconds after
who has hepatitis A. The nurse should having a bowel movement."
identify that which of the following client
statements indicates an understanding Rationale:
of the teaching? The nurse should inform the
client to wash their hands with
"I will use a 10 to 1 solution of soap and soap and warm water for 15 sec-
water to clean my bathroom fixtures." onds to remove micro-organisms
"I will wear a surgical mask when around after having a bowel movement.
others." This reduces the risk for trans-
"I will wash my hands with soap and wa- mitting the virus to others be-
ter for 15 seconds after having a bowel cause hepatitis A is a virus that
movement." is transmitted via the oral-fecal
"I will avoid contact with house plants." route.
who has an elevated temperature with no
sweating. Which of the following findings Rationale:
is an indication of hypernatremia? Thirst, combined with an elevat-
ed temperature and a lack of
Thirst sweating, can be an indication of
Muscle twitching hypernatremia.
Headache
Abdominal cramps
2. A nurse is caring for a client who reports Close the door to the client's
difficulty sleeping due to the noise on room.
the nursing unit. Which of the following
actions should the nurse take to reduce Rationale:
environmental noise? The nurse should close the door
to the client's room whenever
Close the door to the client's room. possible to reduce environmen-
Turn off the alarms and beeps on moni- tal noise.
toring equipment.
Conduct change-of-shift report outside
the client's door.
Keep the television on low in the client's
room.
3. A nurse is reinforcing teaching about Identify areas of concern.
health promotion with a client. Which of
the following actions should the nurse Rationale:
take first to promote effective learning? The first action the nurse should
take when using the nursing
Identify areas of concern. process is to collect data from
Prioritize learning objectives. the client. Identifying and under-
Demonstrate psychomotor skills. standing the client's concerns
Observe nonverbal communication. prior to reinforcing teaching pro-
motes effective learning.
4. A home health nurse is assisting with Clarify the role of this individual
the plan of care for a client. Which of the nurse.
following should the nurse include dur-
ing the orientation phase of the helping Rationale:
, relationship? The nurse should plan to estab-
lish a warm, caring relationship
Review current client data. while clarifying the role of each
Assist to meet client goals. participant, which occurs during
Review shared memories of interactions the orientation phase of the rela-
with client. tionship.
Clarify the role of this individual nurse.
5. A nurse is preparing to assist with the The wheel locks on the bed are
admission of a client who has pneumo- malfunctioning.
nia. Which of the following observations
about the client's room requires immedi-Rationale:
ate attention? The greatest risk to this client
is injury from a fall when getting
The wall BP gauge is missing. into or out of a bed that is unsta-
The room has no IV infusion pump. ble due to malfunctioning locks.
The examination light above the bed Therefore, the priority is to report
does not work. and replace the bed before ad-
The wheel locks on the bed are malfunc- mitting the client to the room.
tioning.
6. A nurse is reinforcing teaching about Participate in screenings for tu-
health promotion with an older adult berculosis.
client. Which of the following instruc-
tions to the client is an example of sec- Rationale:
ondary prevention? The nurse should encourage the
client to participate in screenings
Participate in screenings for tuberculo- for tuberculosis, a secondary
sis. prevention measure. Secondary
Follow dietary recommendations to re- prevention measures focus on di-
duce the risk for osteoporosis. agnosis and early intervention.
Limit alcohol intake to one drink per day.
Perform yoga exercises three times per
week.
7. A licensed practical nurse (LPN) is re- Staging a pressure ulcer.
ceiving change-of-shift report for a client
who had a stroke. For which of the fol- Rationale:
lowing tasks should the nurse request An LPN can collect data for the
, assistance from a registered nurse (RN)? client and report findings to an
RN. However, staging a pressure
Administering a cleansing enema ulcer requires advance knowl-
Staging a pressure ulcer edge and skill, and is outside the
Inserting an indwelling urinary catheter scope of practice of an LPN. An
Performing passive range-of-motion ex- RN should assess the stage of a
ercises complex wound, such as a pres-
sure ulcer, and provide prima-
ry client teaching about pressure
ulcer prevention and care.
8. A nurse is reinforcing teaching about "I will secure all of my electrical
home safety with a client who is at risk cords to the baseboard."
for falls. Which of the following client
statements indicates an understanding Rationale:
of the teaching? Securing cords along the base-
boards with electrical tape min-
"I will keep my floors well waxed." imizes the tripping hazard for
"I will take my shoes off when I come clients who are at risk for falls.
back into the house."
"I will secure all of my electrical cords to
the baseboard."
"I will place area rugs on my tile floors."
9. A home health nurse is reinforcing teach- "I will wash my hands with soap
ing about infection control with a client and water for 15 seconds after
who has hepatitis A. The nurse should having a bowel movement."
identify that which of the following client
statements indicates an understanding Rationale:
of the teaching? The nurse should inform the
client to wash their hands with
"I will use a 10 to 1 solution of soap and soap and warm water for 15 sec-
water to clean my bathroom fixtures." onds to remove micro-organisms
"I will wear a surgical mask when around after having a bowel movement.
others." This reduces the risk for trans-
"I will wash my hands with soap and wa- mitting the virus to others be-
ter for 15 seconds after having a bowel cause hepatitis A is a virus that
movement." is transmitted via the oral-fecal
"I will avoid contact with house plants." route.
