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A nurse is caring for a client who has an indwelling urinary catheter. The
nurse notes that sediment is present in the urine. Which of the following
actions should the nurse take to obtain a sterile urine specimen? A. Use the
balloon port to obtain the sterile specimen.
B. Unclamp the collection port below the bag.
C. Disconnect the catheter from the collection tubing.
D. Obtain the specimen from the retention port. - ANSWER-D. Obtain the
specimen from the retention port.
A nurse is caring for a client who has been admitted to the antepartum unit.
The client is at risk for developing which of the following 2 complications?
Select 2 complications the client is at risk of developing.
A. Placenta previa
B. Disseminated intravascular coagulation
C. Preeclampsia
D. Sepsis
E. Preterm prelabor rupture of membranes (PROM)
F. Seizures - ANSWER-C. Preeclampsia
E. Preterm prelabor
,A charge nurse on a medical-surgical unit is assisting with the emergency
response plan following an external disaster in the community. In anticipation
of multiple client admissions, which of the following current clients should the
nurse recommend for early discharge?
A. A client who is receiving heparin for deep-vein thrombosis
B. A client who is 1 day postoperative following a vertebroplasty
C. A client who has COPD and a respiratory rate of 44/min
D. A client who has cancer and a sealed implant for radiation therapy -
ANSWER-B or D
A nurse is teaching a prenatal class about infection prevention at a community
center. Which of the following statements by a client indicates an understanding
of the teaching?
A. "I can visit my nephew who has chickenpox 5 days after the sores have
crusted."
B. "I should take antibiotics when I have a virus."
C. "I should wash my hands for 10 seconds with hot water after working in the
garden."
D. "I can clean my cat's litter box during my pregnancy." - ANSWER-A. "I can
visit my nephew who has chickenpox 5 days after the sores have crusted."
A nurse is providing teaching to an older adult client about methods to promote
night time sleep. Which of the following instructions should the nurse include?
A. Take a 1-hr nap during the day.
B. Perform exercises prior to bedtime.
C. Eat a light snack before bedtime.
D. Stay in bed at least 1 hr if unable to fall asleep.. - ANSWER-C. Eat a light
snack before bedtime.
,A nurse is preparing to reposition a client who had a stroke. Which of the
following actions should the nurse take?
A. Evaluate the client's ability to help with repositioning.
B. Reposition the client without the use of assistive devices.
C. Discuss the client's preferences for determining a repositioning schedule.
D. Raise the side rails on both sides of the client's bed during repositioning. -
ANSWER-A. Evaluate the client's ability to help with repositioning.
The nurse continues to care for the client.
Nurses' Notes Day 1, 0900:
Client reports lower back pain and pinkish vaginal discharge. Uterine
contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variabilityWhich of the following actions should
the nurse take? Select all that apply.
A. Urine culture
B. Ibuprofen 600 mg every 6 hr for mild to moderate pain
C. Obtain provider prescription for phenazopyridine
D. Vaginal culture
E. Obtain provider prescription for antibiotics - ANSWER-A C E
A nurse is caring for a client who has an implanted venous access port. Which
of the following should the nurse use to access the port?
A. A butterfly needle
B. An angiocatheter
C. A 25-gauge needle
D. A noncoring needle - ANSWER-D. A noncoring needle
A nurse is administering furosemide IV bolus to a client who has fluid volume
excess. The nurse should recognize which of the following findings as an
indication that the medication has been effective?
, A. Weight loss
B. Increased blood pressure
C. Decreased pain
D. Decreased inflammation - ANSWER-A. Weight loss
A nurse is planning teaching for a client and their family about home oxygen
therapy. Which of the following information should the nurse plan to include in
the teaching?
A. Clean the equipment with an alcohol-based cleaning product.
B. Apply petroleum jelly to soothe the mucous membranes.
C. Use synthetic fabrics for the client's bedding.
D. Avoid using nail polish remover around the client. - ANSWER-D. Avoid
using nail polish remover around the client.
A nurse is assessing a client who is taking haloperidol and is experiencing
pseudo parkinsonism. Which of the following findings should the nurse
document as a manifestation of pseudo parkinsonism?
A. Nonreactive pupils
B. Smacking lips
C. Serpentine limb movement
D. Shuffling gait - ANSWER-D. Shuffling gait
A nurse in a mental health clinic receives a request from a client who is
undergoing psychotherapy to obtain a copy of the therapist's notes. Which of
the following responses should the nurse make?
A. "Why are you interested in seeing your therapist's notes?"