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1. Which of these instructions should a nurse include in d
the teaching plan for a client who had removal of a
cataract in the left eye?
a. "Forcefully cough and take deep breaths every two
hours to keep your airway clear."
b. "Perform the prescribed eye exercises each day to
strengthen your eye muscles."
c. "Rinse your eyes with saline each morning to pre-
vent postoperative infection."
d. "Take the prescribed stool softener to avoid increas-
ing intraocular pressure."
2. A client vomits during a continuous nasogastric tube D
feeding. A nurse should stop the feeding and take
which of these actions?
a. Suction the nasogastric tube.
b. Flush the tube with 30 mL of sterile water.
c. Remove the nasogastric tube.
d. Check the residual volume.
3. Which of these actions best demonstrates cultural B
sensitivity by a nurse?
a. The nurse talks in a slow-paced speech.
b. The nurse asks clients about their beliefs and prac-
tices toward pregnancy.
c. The nurse uses charts and diagrams when teaching
pregnant clients.
d. The nurse can speak several different languages.
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4. Which of these manifestations should a nurse expect B
to observe in a 3-month-old infant who is diagnosed
with dehydration?
a. Hyperreflexia.
b. Tachycardia.
c. Bradypnea.
d. Agitation.
5. When assessing a client's risk of developing nosoco- A
mial infection, a nurse plans to determine potential
entry portals, which include:
a. the urinary meatus.
b. vomitus.
c. contaminated water.
d. sexual intercourse.
6. A client who is on the inpatient psychiatric unit has a A
history of violence. Which of these actions should a
nurse take if the client is agitated?
a. Encourage the client to verbalize feelings.
b. Lock the client in a secluded room.
c. Ask the other clients to give feedback regarding the
client's behavior.
d. Ignore the client's inappropriate behavior.
7. Which of these measures should a nurse include when B
planning care for a school-aged child during a sickle
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cell crisis episode?
a. Monitoring for signs of bleeding.
b. Providing pain relief.
c. Administering cool sponge baths to reduce fevers.
d. Offering a high calorie diet.
8. Which of these instructions should a nurse include in B
the plan of care for a 32-week gestation client who had
an amniocentesis today?
a. "Drink at least six glasses of fluids during the next
six hours after the test."
b. "Call the clinic if you experience any abdominal
cramps."
c. "Don't be concerned if you have some vaginal spot-
ting in the next 12 hours."
d. "When you get home, stay on bed-rest for the next
48 hours."
9. An adolescent has a nursing diagnosis of fatigue relat- D
ed to inadequate intake of iron-rich foods. Selection of
which of these lunches by the client indicates a correct
understanding of foods high in iron content?
a. Peanut butter and jam sandwich.
b. Chicken nuggets with rice.
c. Tuna salad sandwich.
d. Beefburger with cheese.
10. B
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A client has been admitted with acute pancreatitis.
Which of these laboratory test results supports this
diagnosis?
a. Elevated serum potassium level.
b. Elevated serum amylase level.
c. Elevated serum sodium level.
d. Elevated serum creatinine level.
11. Which of these manifestations, if assessed in a A
client who is two-hours postoperative after abdominal
surgery, should a nurse report immediately?
a. Vomiting and a pulse rate of 106/minute.
b. Respiratory rate of 12/minute and urine dribbling.
c. Blood pressure of 100/60 mm Hg and wound dis-
comfort.
d. Urine output of 100 mL/hr and flushed skin.
12. Which of these observations of a student nurse's be- C
havior while interacting with a client who is crying
indicates a correct understanding of therapeutic com-
munication?
a. The student maintains continuous eye contact with
the client.
b. The student places one arm around the client's
shoulder?
c. The student sits quietly next to the client.
d. The student leaves the room to provide privacy for
the client.