A nurse is teaching a client and his family how to care for the client's tracheostomy at home.
Which of the following instructions is appropriate for the client and family?
a. Remove the outer cannula cautiously for routine cleaning.
b. Use tracheostomy covers when outdoors.
c. Use sterile technique when performing tracheostomy care at home.
d. Cleanse irritated skin with full-strength hydrogen peroxide. -correct answers b
A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia.
Which of the following pieces of information is most essential to provide?
A. Admitting diagnosis
B. Diagnostic test results
C. Body temperature
D. Breath sounds -correct answers D
A nurse is checking blood pressures at a community health screening. Which of the following
clients is at high risk for primary hypertension?
A. A client who is pregnant
B. A client who has an elevated LDL
C. A client who takes oral contraceptives
,D.A client who has kidney disease -correct answers B
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia.
Which of the following tasks should the nurse assign to an AP? (Select all that apply.)
A. Assist the client with a partial bed bath.
B. Measure the client's BP after the nurse administers an antihypertensive medication.
C. Test the client's swallowing ability by providing thickened liquids.
D. Use a communication board to ask what the client wants for lunch.
E. Irrigate the client's indwelling urinary catheter. -correct answers A, B, C
A nurse is caring for a client who is combative in the emergency department. The provider
orders wrist restraints after the client attempts to assault the admitting nurse. Which of the
following actions is appropriate for the nurse to take?
A. Tie restraints to the lower edge of the side rail.
B. Remove each restraint one at a time every 2 hr.
C. Ensure 3 finger-widths of space between the restraint and the client's wrist.
D. Use a square knot to securely tie the restraints to the bed. -correct answers b
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine
5mg/mL. Which of the following is an appropriate nursing intervention?
a. Return the unused medication to the automatic dispensing system.
b. Keep the remaining medication at the client's bedside for later use.
c. Have a second nurse witness the disposal of remaining medication.
d. Lock remaining medication in secure cabinet. -correct answers C
,A nurse is caring for a client who asks about the purpose of advance directives. Which of the
following is an appropriate response by the nurse?
A. "It allows the court to overrule an adult client's refusal of medical treatment."
B. "It permits a client to withhold medical information from health care personnel."
C. "It indicates the form of treatment a client is willing to accept in the event of a serious
illness."
D. "It allows health care personnel in the emergency department to stabilize a client's
condition." -correct answers C
A nurse finds a client on the floor upon entering the client's room. The roommate reports that
the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the
following is correct documentation of this incident?
A. Incident report completed.
B. Client climbed over the bedrails.
C. Client found lying on floor.
D. Client was trying to get out of bed. -correct answers C
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse
understands that the preoperative teaching regarding pain control has been effective when the
client states which of the following?
A. "I think I should take my pain medication more often, since it is not controlling my pain."
B. "Breathing faster will help me keep my mind off of the pain."
C."It may help me to listen to music while I'm lying in bed."
D. "I don't want to walk today, because I'm experiencing some pain." -correct answers C
, A client demonstrates anger when the nurse does not respond within 5 min of ringing for the
nurse. Which of the following is an appropriate response by the nurse?
A. "I'm sorry, but another client needed my attention."
B. "I arrived as soon as I could. What can I do for you?"
C. "It must be frustrating. I have a few minutes now."
D. "We had an emergency on the unit, but now I'm here." -correct answers C
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this
client's care, when should the nurse initiate discharge planning?
A. During the admission process
B. As soon as the client's condition is stable
C. During the initial team conference
D. After consulting with the client's family -correct answers A
A nurse manager is overseeing the care of a unit. Which of the following should the nurse
manager identify as a violation of HIPAA guidelines?
A. The assigned nurse reviews the medical chart with a nursing student.
B. A nursing student discusses a client's status with the assigned nurse at the bedside.
C. The assigned nurse returns a call to a client's Power of Attorney to discuss the client's care.
D. A nursing student consults a former classmate to assist with her documentation. -correct
answers D
Which of the following instructions is appropriate for the client and family?
a. Remove the outer cannula cautiously for routine cleaning.
b. Use tracheostomy covers when outdoors.
c. Use sterile technique when performing tracheostomy care at home.
d. Cleanse irritated skin with full-strength hydrogen peroxide. -correct answers b
A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia.
Which of the following pieces of information is most essential to provide?
A. Admitting diagnosis
B. Diagnostic test results
C. Body temperature
D. Breath sounds -correct answers D
A nurse is checking blood pressures at a community health screening. Which of the following
clients is at high risk for primary hypertension?
A. A client who is pregnant
B. A client who has an elevated LDL
C. A client who takes oral contraceptives
,D.A client who has kidney disease -correct answers B
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia.
Which of the following tasks should the nurse assign to an AP? (Select all that apply.)
A. Assist the client with a partial bed bath.
B. Measure the client's BP after the nurse administers an antihypertensive medication.
C. Test the client's swallowing ability by providing thickened liquids.
D. Use a communication board to ask what the client wants for lunch.
E. Irrigate the client's indwelling urinary catheter. -correct answers A, B, C
A nurse is caring for a client who is combative in the emergency department. The provider
orders wrist restraints after the client attempts to assault the admitting nurse. Which of the
following actions is appropriate for the nurse to take?
A. Tie restraints to the lower edge of the side rail.
B. Remove each restraint one at a time every 2 hr.
C. Ensure 3 finger-widths of space between the restraint and the client's wrist.
D. Use a square knot to securely tie the restraints to the bed. -correct answers b
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine
5mg/mL. Which of the following is an appropriate nursing intervention?
a. Return the unused medication to the automatic dispensing system.
b. Keep the remaining medication at the client's bedside for later use.
c. Have a second nurse witness the disposal of remaining medication.
d. Lock remaining medication in secure cabinet. -correct answers C
,A nurse is caring for a client who asks about the purpose of advance directives. Which of the
following is an appropriate response by the nurse?
A. "It allows the court to overrule an adult client's refusal of medical treatment."
B. "It permits a client to withhold medical information from health care personnel."
C. "It indicates the form of treatment a client is willing to accept in the event of a serious
illness."
D. "It allows health care personnel in the emergency department to stabilize a client's
condition." -correct answers C
A nurse finds a client on the floor upon entering the client's room. The roommate reports that
the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the
following is correct documentation of this incident?
A. Incident report completed.
B. Client climbed over the bedrails.
C. Client found lying on floor.
D. Client was trying to get out of bed. -correct answers C
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse
understands that the preoperative teaching regarding pain control has been effective when the
client states which of the following?
A. "I think I should take my pain medication more often, since it is not controlling my pain."
B. "Breathing faster will help me keep my mind off of the pain."
C."It may help me to listen to music while I'm lying in bed."
D. "I don't want to walk today, because I'm experiencing some pain." -correct answers C
, A client demonstrates anger when the nurse does not respond within 5 min of ringing for the
nurse. Which of the following is an appropriate response by the nurse?
A. "I'm sorry, but another client needed my attention."
B. "I arrived as soon as I could. What can I do for you?"
C. "It must be frustrating. I have a few minutes now."
D. "We had an emergency on the unit, but now I'm here." -correct answers C
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this
client's care, when should the nurse initiate discharge planning?
A. During the admission process
B. As soon as the client's condition is stable
C. During the initial team conference
D. After consulting with the client's family -correct answers A
A nurse manager is overseeing the care of a unit. Which of the following should the nurse
manager identify as a violation of HIPAA guidelines?
A. The assigned nurse reviews the medical chart with a nursing student.
B. A nursing student discusses a client's status with the assigned nurse at the bedside.
C. The assigned nurse returns a call to a client's Power of Attorney to discuss the client's care.
D. A nursing student consults a former classmate to assist with her documentation. -correct
answers D
