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To assess the quality of an adult client’s pain, what approach should the nurse use? C
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) AskAtheAclientAtoAdescribeAtheApain.
D) Identify effective pain relief measures.
A client who has been diagnosed with terminal cancer tells the nurse, “The docto
r told me I have cancer and do not havelong to live.” Which response is best for
the nurse to provide?
A) “That’s correct, you do not have long to live” D
B) “Would you like me to call your minister?”
C) “Don't give up, you still have chemotherapy to try.”
D) “Yes, your condition is serious.”
A A A A
When performing blood pressure measurement to assess for orthostatic h
ypotension, which action should thenurse implement first? C
A) Apply the blood pressure cuff securely.
B) Record the client’s pulse rate
and rhythm. C) Position the clie
A A A
nt supine for a few minutes.
A A A A A
D) Assist the client to stand at bedside.
Female unlicensed assistive personnel (UAP) are assigned to take the vital signs
of a client with pertussis for whom droplet precautions have been implemented.
A
The UAP request a change in assignment, stating she has not yet been fittedfor a
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particulate filter mask. What action should the nurse take? D
When evaluating the effectiveness of a client’s nursing care, the nurse first revie
ws the expected outcomes identified in the plan of care. What action should the n
urse take next?
A) Modify the nursing interventions to achieve the client’s goals.
B) Determine if the expected outcomes were realistic.
C) Review related professional standards of care.
D) Obtain current client data to compare with expected outcomes.
A policy requiring the removal of acrylic nails by all nursing personnel was imple
mented six months ago. Which assessment measure best determines if theintended
outcome of the policy is being achieved?
A) Number of the staff-induced skin injuries.
B) Client satisfaction survey.
C) Rate of needlestick injuries by nurses.
D) Healthcare-associated infection rates.
A A
A client with limited tolerance for activity needs to walk in the hallway with a
ssistance. Which instructions should the nurse give to the unlicensed assistive
personnel (UAP) who assisting with client’s care? (Select all that apply.)
A) Instruct the client about signs of orthostatic hypertension
B) Determine if the client needs to have a gait belt applied
C) Measure the clients vital signs before the c
A A A A A A A
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lient walks.
A
D) Offer to assist the client to void prior to wal
A A A A A A A A A
king in the hall.
A A A
E) Report the onset of any dizziness or light headedness.
A A A A A A A A
A client has begun a long-
term maintenance therapy with lithium, which hasa narrow therapeutic index
. Which adverse effect is most important for nurse to include in the teaching
plan?
A) Dependence.
B) Toxicity.
C) Interaction.
D) Tolerance.
While interviewing a client, the nurse records the assessment in the electronic
health record. Which statement is most accurate regarding electronic documentation
during an interview?
A) The interview process is enhanced with electronic documentation and allows the client to
speak at a normal pace.
B) Completing the electronic record during an interview is a legal obligation of the examinin
g nurse.
C)
The nurse has limited ability to observe nonverbal co
A A A A A A A
mmunication while entering the assessment electronically.
A A A A A
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D) The client’s comfort level is increased when the nurse breaks eye contact to type notes in
to the record.
A client who lives in an assisted living facility develops cognitive impairmen
tfollowing a stroke. Informed consent is needed to provide additional nursing
services. Who should nurse contact?
A) The client’s oldest living child, a lawyer, who is visiting from out of town.
B) A daughter -in-law designated as the client’s Durable Power of Attorney (DPOA).
A A A A A A A A A A A
C) The client’s youngest son, identified by family members as the family spokesperson.
D) The client’s spouse who lives in the independent living unit of the facility.
A client is in contact isolation due to stage IV coccyx wound infected with methicil
lin resistant staphylococcus aureus (MRSA). The nurse plans interventionsto preve
nt multiple re-
entries to the client’s room. In which order should the nurse perform the interventio
ns?
A) Change coccyx dressing, perform tracheostomy care, restart the IV.
B) Perform tracheostomy care, change coccyx dressing, restart the IV.
C) Restart the IV, perform tracheotomy care, change coccyx dressing.
D) Change coccyx dressing, restart the IV, perform tracheostomy care.
A
What self-
care outcome is best for the nurse to use in evaluating a client’s recoveryform a stro
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