2023 assessment for nursing
A nurse is caring for a client who is at 33 weeks of gestation following an
amniocentesis. The nurse should monitor the client for which of the following
complications? - ANSWER -Contractions
A nurse is providing teaching to an older client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include? - ANSWER -Eat
a light snack before bedtime
A nurse on a telemetry unit is caring for a client who becomes unconscious and
whose monitor displays ventricular tachycardia. Which of the following actions
should the nurse take first after determining the client does not have a palpable
pulse? - ANSWER -Defibrillate
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding. The nurse does not speak the same language as the client. The client's
partner and 10-year old child are accompanying her. Which of the following actions
should the nurse take to gather the client's admission data? - ANSWER -Request a
female interpreter through the facility
A nurse is caring for a client who is febrile. To reduce the clients fever, the nurse
applies a cooling blanket. Which of the following findings indicates the client is
having an adverse reaction to the cooling? - ANSWER -Shivering
A nurse is caring for a client who is febrile. To reduce the clients fever, the nurse
applies a cooling blanket. Which of the following findings indicates the client is
having an adverse reaction to the cooling? - ANSWER -Administer acetaminophen
A nurse is reviewing assessment data from several clients. For which of the following
clients should the nurse recommend referral to a dietitian? - ANSWER -A client who
has a non healing leg ulcer
A nurse is providing discharge teaching who has chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include
in the teaching? - ANSWER -Eat 1 g/dL of protein per day
A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration? - ANSWER -b. A
history of gastroesophageal reflux disease
A nurse is providing parental teaching to a client who is at 12 weeks of gestation.
The nurse should tell the client that she will undergo which of the following screening
tests at 16 weeks of gestation? - ANSWER -d. Maternal serum alpha-fetoprotein
,A nurse is caring for a client who is on bed rest. The nurse should recognize that
which of the following findings is a complication of immobility? - ANSWER -Swollen
area on calf
A nurse in a acute care mental health facility is participation in a medication-
education group. The leader of the group uses a laissez-faire leadership style. Which
of the following actions should the nurse expect from the leader during the session? -
ANSWER -c. The leader allows the group to discuss whatever they would like to
regarding their medications
A nurse is providing teaching about digoxin administration to the parents of a toddler
who has heart failure. Which of the following
statements should the nurse include in the teaching? - ANSWER -d. "Have your child
drink a small glass of water after swallowing the medication"
A nurse is providing teaching to a client who has a depressive disorder and a new
prescription for phenelzine. Which of the following foods should the nurse instruct the
client to avoid? - ANSWER -Smoked salmon
A nurse is planning care for a client who has COPD and weighs 99 lbs. The provider
has prescribed a diet of 1.5 g protein/kg/day. How many grams of protein per day
should the nurse include in the client's dietary plan? (round the answer to the nearest
whole number. Use a leading zero if it applies. Do not use a trailing zero) - ANSWER
-67.5 (68g/day)
A nurse is planning care for a client who has bipolar disorder and is experiencing
mania. Which of the following intervention should the nurse include in the plan? -
ANSWER -c. Encourage the client to take frequent rest periods
A parish nurse is leading a support group for clients whose family members have
committed suicide. Which of the following strategies should the nurse plan to use
during the group session? - ANSWER -a. Initiate a discussion with clients about
ways to cope with changes in family dynamics
A nurse manager observes two staff nurses reviewing the computer records of a
client who is under their care. Which of the following action should the nurse
manager take first? - ANSWER -a. Instruct the nurses to close the client's computer
record
A nurse is reviewing the medical record of a client who has schizophrenia and ia
taking clozapine. Which of the following findings should the nurse identify as a
contraindication to the administration of clozapine? - ANSWER -d. WBC count
2,900/mm
A nurse is caring for several clients on a medical-surgical unit. For which of the
following nursing activities is it required that the nurse use sterile gloves? - ANSWER
-d. Performing tracheostomy care
A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse recommend? - ANSWER -Influenza
, A nurse is inserting an indwelling urinary catheter for a male client. Which of the
following actions should the nurse take? - ANSWER -Lift the penis so that it is
perpendicular to the clients body
A nurse is providing teaching to a client who is at 14 weeks of gestation about
findings to report to the provider. Which of the following findings should the nurse
include in the teaching? - ANSWER -Swelling of the face
A nurse has received change of-shift report for a group of clients. Which of the
following actions should the nurse take to manage time effectively? - ANSWER -
Make a client to-do list for the day
A nurse is developing a plan of care for a newborn whose mother tested positive for
heroin during pregnancy. The newborn is experiencing neonatal abstinence
syndrome. Which of the following actions should the nurse include in the plan? -
ANSWER -Minimize noise in the newborns environment
The nurse is assessing the fontanels of an 8-month old infant. Which of the following
should the nurse recognize as an expected finding? - ANSWER -The anterior
fontanel is open
A nurse is caring for a client who has acute diverticulitis. Which of the following diets
should the nurse recommend to the client? - ANSWER -Low fiber
A nurse is caring for a client who is 48 hr postoperative following a total hip
arthroplasty. Which of the following actions should the nurse include in the plan of
care? - ANSWER -Administer low dose heparin
A nurse is providing teaching to the parent of an infant who has a cleft lip palate.
Which of the following feeding techniques should the nurse include in the teaching? -
ANSWER -Burp the infant frequently during feedings
A nurse in an acute mental health care facility is prioritizing care for multiple clients.
Which of the following clients should the nurse see first? - ANSWER -A client who is
taking clozapine to treat schizophrenia and reports a sore throat
A nurse is planning care for a group of clients and is working with one LPN and one
AP. Which of the following actions should the nurse take first to manage her time
effectively? - ANSWER -Determine goals of the day
A nurse is performing an admission assessment for a client who is in the manic
phase of bipolar disorder. Which of the following behaviors should the nurse expect?
- ANSWER -Distractibility and poor judgment
A nurse is caring for an infant who has coarctation of the aorta. Which of the
following should the nurse identify as an expected finding? - ANSWER -Weak
femoral pulses