C. Documenting reasons the client declined taking any medications on the medication ad-
ministration record (MAR)
A. Initializing medications on the medication administration record (MAR) as given prior to
entering ghe room.
The nurse working on a medical-surgical unit is administering medications to an assigned
B. Notifying the primary healthcare provider (PHCP) that the client has received their assigned
client. Which of the following actions is appropriate for the nurse to take?
medications.
C. Documenting reasons the client declined taking any medications on the medication amin-
istration record (MAR)
D. Providing the client with a copy of their medication administration record (MAR) upon
request.
• The nurse is caring for a client diagnosed with anemia. Which of the following should the A. Folic Acid
nurse encourage the client to increase in their diet?
• a) Folic acid. • a) Folic acid.
• b) Vitamin A. • b) Vitamin A.
• c) Vitamin E. • c) Vitamin E.
• d) Niacin. • d) Niacin.
B. Displacement
The nurse observes a coworker who has been dealing with a diflcult family member yell at
unlicensed assistive
• a) Rationalization.
personnel (UAP) for taking a bathroom break without notifying the coworker. The nurse
• b) Displacement.
understands that the
• c) Reaction-formation.
coworker is using which of the following defense mechanisms?
• d) Sublimation.
C. Listen carefully to the client about their concerns.
A nurse is caring for a client who reports feeling anxious about an upcoming procedure.
a) Ask the primary healthcare provider (PHCP) to prescribe anti-anxiety medications.
Which of the following
b) Check on the client every 15 minutes until the anxiety has passed.
actions should the nurse take to help reduce the client's anxiety?
c) Listen carefully to the client about their concerns.
d) Limit the number of visitors until the client is coping more ettectively.
D. Dilation of the pupils
The nurse Is assessing a client for clinical manifestations of stress. Which of the following
• a) Slow, shallow respirations.
findings should the
• b) Decreased blood glucose level.
nurse recognize as an indicator of stress?
• c) Apical pulse (P) of 82.
• d) Dilation of the pupils.
D. Self-esteem needs.
• The nurse preceptor is discussing Maslow's hierarchy of needs with a student nurse. The
student nurse recently
• a) Security needs.
received an award for student of the year. Which of the following levels of Maslow's hierarchy
• b) Love and belonging needs.
of needs has
• c) Safety needs.
been met for the student nurse?
• d) Self-esteem needs.
C. Primary prevention
The nurse encourages a client to receive an annual influenza vaccination. The nurse recognizes
this as which of • a) Tertiary prevention.
the following types of prevention? • b) Secondary prevention.
• c) Primary prevention.
C. Adventitious
• a) Bronchovesicular.
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, • The nurse is performing a respiratory assessment on an assigned client. The nurse auscul- • b) Tracheal.
tates a whistling, high-pitched sound of air when it is forced through narrowed airways. The • c) Adventitious.
nurse documents this as: • d) Vesicular.
A. The client takes a diuretic medication every morning.
The nurse working in a long-term care (LTC) facility is caring for an older adult who has
developed signs and
• a) The client takes a diuretic medication every morning.
symptoms of dehydration. Which of the following does the nurse correlate to the development
• b) The client has a history of renal failure.
of these signs
• c) The client is receiving supplemental tube feeding.
and symptoms?
• d) The client snacks on salted nuts every day.
B. Performing an electrocardiogram (ECG).
The nurse is caring for a client whose morning laboratory findings indicate a potassium level
• a) Determining the client's last bowel movement.
of 3 mEq/L. The
• b) Performing an electrocardiogram (ECG).
nurse understands the need to gather further client data by:
• c) Auscultating the client's lung sounds.
• d) Asking the client if they have any nausea.
The nurse is caring for a client who has hypercalcemia. The nurse expects the client to have: C. Anorexia
• a) Tetany. • a) Tetany.
• b) Dyspnea. • b) Dyspnea.
• c) Anorexia. • c) Anorexia.
• d) Dysphagia. • d) Dysphagia.
D. Obtain the client's medical history.
The nurse is assisting the registered nurse (RN) with a new admission in the acute care setting.
• a) Initiate the client's care plan.
Which of the
• b) Educate the client about procedures.
following actions can the nurse perform to assist the RN with the admission process?
• c) Assess the client's body systems.
• d) Obtain the client's medical history.
D. Full-thickness tissue loss with visible muscle and bone.
The nurse is caring for a client who has a pressure injury (stage 4). Which of the following is
• a) Partial-thickness tissue loss with eschar covering the wound bed.
correct regarding
• b) Full-thickness skin loss with deep crater and subcutaneous necrosis.
the nurse's description of the wound?
• c) Partial-thickness skin loss with a pink, moist wound bed.
• d) Full-thickness tissue loss with visible muscle and bone.
C. Observe the client carefully during the exercises.
The nurse is performing passive range-of-motion (ROM) exercises for a client who is non-
• a) Educate the client on the purpose of the exercises.
verbal. It is most
• b) Perform the exercises twice a day.
important for the nurse to:
• c) Observe the client carefully during the exercises.
• d) Move the joint through each exercise 3 to 5 times
C. Pulmonary embolus
The nurse is caring for a client who is at risk for the development of complications due to
prolonged immobility. • a) Chest discomfort.
Which of the following should the nurse identify as a cardiovascular complication related to • b) Increased bleeding.
immobility? • c) Pulmonary embolus.
• d) Abnormal cardiac rhythms.
The nurse is caring for a client who accidentally had a nail enter their hand with an electric A. Perforation
nail gun. The nurse
• a) A perforation.
documents this as:
• b) A laceration.
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ministration record (MAR)
A. Initializing medications on the medication administration record (MAR) as given prior to
entering ghe room.
The nurse working on a medical-surgical unit is administering medications to an assigned
B. Notifying the primary healthcare provider (PHCP) that the client has received their assigned
client. Which of the following actions is appropriate for the nurse to take?
medications.
C. Documenting reasons the client declined taking any medications on the medication amin-
istration record (MAR)
D. Providing the client with a copy of their medication administration record (MAR) upon
request.
• The nurse is caring for a client diagnosed with anemia. Which of the following should the A. Folic Acid
nurse encourage the client to increase in their diet?
• a) Folic acid. • a) Folic acid.
• b) Vitamin A. • b) Vitamin A.
• c) Vitamin E. • c) Vitamin E.
• d) Niacin. • d) Niacin.
B. Displacement
The nurse observes a coworker who has been dealing with a diflcult family member yell at
unlicensed assistive
• a) Rationalization.
personnel (UAP) for taking a bathroom break without notifying the coworker. The nurse
• b) Displacement.
understands that the
• c) Reaction-formation.
coworker is using which of the following defense mechanisms?
• d) Sublimation.
C. Listen carefully to the client about their concerns.
A nurse is caring for a client who reports feeling anxious about an upcoming procedure.
a) Ask the primary healthcare provider (PHCP) to prescribe anti-anxiety medications.
Which of the following
b) Check on the client every 15 minutes until the anxiety has passed.
actions should the nurse take to help reduce the client's anxiety?
c) Listen carefully to the client about their concerns.
d) Limit the number of visitors until the client is coping more ettectively.
D. Dilation of the pupils
The nurse Is assessing a client for clinical manifestations of stress. Which of the following
• a) Slow, shallow respirations.
findings should the
• b) Decreased blood glucose level.
nurse recognize as an indicator of stress?
• c) Apical pulse (P) of 82.
• d) Dilation of the pupils.
D. Self-esteem needs.
• The nurse preceptor is discussing Maslow's hierarchy of needs with a student nurse. The
student nurse recently
• a) Security needs.
received an award for student of the year. Which of the following levels of Maslow's hierarchy
• b) Love and belonging needs.
of needs has
• c) Safety needs.
been met for the student nurse?
• d) Self-esteem needs.
C. Primary prevention
The nurse encourages a client to receive an annual influenza vaccination. The nurse recognizes
this as which of • a) Tertiary prevention.
the following types of prevention? • b) Secondary prevention.
• c) Primary prevention.
C. Adventitious
• a) Bronchovesicular.
1/6
, • The nurse is performing a respiratory assessment on an assigned client. The nurse auscul- • b) Tracheal.
tates a whistling, high-pitched sound of air when it is forced through narrowed airways. The • c) Adventitious.
nurse documents this as: • d) Vesicular.
A. The client takes a diuretic medication every morning.
The nurse working in a long-term care (LTC) facility is caring for an older adult who has
developed signs and
• a) The client takes a diuretic medication every morning.
symptoms of dehydration. Which of the following does the nurse correlate to the development
• b) The client has a history of renal failure.
of these signs
• c) The client is receiving supplemental tube feeding.
and symptoms?
• d) The client snacks on salted nuts every day.
B. Performing an electrocardiogram (ECG).
The nurse is caring for a client whose morning laboratory findings indicate a potassium level
• a) Determining the client's last bowel movement.
of 3 mEq/L. The
• b) Performing an electrocardiogram (ECG).
nurse understands the need to gather further client data by:
• c) Auscultating the client's lung sounds.
• d) Asking the client if they have any nausea.
The nurse is caring for a client who has hypercalcemia. The nurse expects the client to have: C. Anorexia
• a) Tetany. • a) Tetany.
• b) Dyspnea. • b) Dyspnea.
• c) Anorexia. • c) Anorexia.
• d) Dysphagia. • d) Dysphagia.
D. Obtain the client's medical history.
The nurse is assisting the registered nurse (RN) with a new admission in the acute care setting.
• a) Initiate the client's care plan.
Which of the
• b) Educate the client about procedures.
following actions can the nurse perform to assist the RN with the admission process?
• c) Assess the client's body systems.
• d) Obtain the client's medical history.
D. Full-thickness tissue loss with visible muscle and bone.
The nurse is caring for a client who has a pressure injury (stage 4). Which of the following is
• a) Partial-thickness tissue loss with eschar covering the wound bed.
correct regarding
• b) Full-thickness skin loss with deep crater and subcutaneous necrosis.
the nurse's description of the wound?
• c) Partial-thickness skin loss with a pink, moist wound bed.
• d) Full-thickness tissue loss with visible muscle and bone.
C. Observe the client carefully during the exercises.
The nurse is performing passive range-of-motion (ROM) exercises for a client who is non-
• a) Educate the client on the purpose of the exercises.
verbal. It is most
• b) Perform the exercises twice a day.
important for the nurse to:
• c) Observe the client carefully during the exercises.
• d) Move the joint through each exercise 3 to 5 times
C. Pulmonary embolus
The nurse is caring for a client who is at risk for the development of complications due to
prolonged immobility. • a) Chest discomfort.
Which of the following should the nurse identify as a cardiovascular complication related to • b) Increased bleeding.
immobility? • c) Pulmonary embolus.
• d) Abnormal cardiac rhythms.
The nurse is caring for a client who accidentally had a nail enter their hand with an electric A. Perforation
nail gun. The nurse
• a) A perforation.
documents this as:
• b) A laceration.
2/6
