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1. a nurse is planning care for a client who is receiv- elevate the affected leg
ing heparin to treat a deep vein thrombosis of the
left lower leg. which of the following interventions ambulation should be en-
should the nurse include in the plan of care? couraged
A. Maintain the client on bed rest.
B. Restrict the client to 1 L of fluid per day.
C. Place cool compresses on the edematous area.
D. Elevate the affected leg.
2. a nurse is teaching a group of guardians about child I should have my child avoid
safety measures. which of the following statements sun exposure between 10
by a guardian indicates an understanding of the am and 2 pm
teaching?
A. I will make sure my 4-year-old child wears a hel-
met when using a skateboard.
B. I should have my child avoid sun exposure be-
tween 10 am and 2 pm.
C. I can give my 2-year-old child a whole hotdog on
a bun.
D. When my infant is in the carrier, I will place it on a
raised, flat surface whenever possible
3. a home health nurse is providing teaching about I will walk for short distances
infection prevention to a client who has cancer and throughout the day
is receiving chemotherapy. Which of the following
statements by the client indicates an understanding
of the teaching?
a) I will leave my drinking water out of my refrigera-
tor for at least 1 hour so it will be room temperature.
b) I will clean my toothbrush in my dishwasher once
each month.
c) I will take my temperature once each week and let
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my doctor know if it is high.
d) I will walk short distances throughout the day.
4. a nurse is providing dietary teaching to the parents Introduce new foods one at
of a 6 month old infant. which of the following in- a time over 5 to 7 days
structions should the nurse include?
A. Provide the infant with 1 cup of cereal.
B. Give the infant 240 mL (8 oz) of juice per day.
C. Introduce new foods one at a time over 5 to 7
days.
D. Give whole milk first, then small amounts of solid
food.
5. a charge nurse is planning care for a client who has Provide a staff member to
mechanical restraints in place. which of the following stay with the client continu-
interventions should the nurse include in the plan? ously
a) Remove the client's restraints while sleeping
b) Document the client's status every 60 minutes can be physically or using an
c) Check for a new prescription every 6 hours audiovisual device
d) Provide a staff member to stay with the client
need to document every
continuously
15-30 minutes, a new pre-
scription should be in every
4 hrs for adults, every 3
hrs for 9-17 years and every
hour for those younger
6. a community health nurse is assisting with the devel- performing a rapid needs
opment of a disaster management plan. the nurse assessment
should include which of the following nursing re-
sponsibilities in the disaster response stage of the
plan?
A) Performing a rapid needs assessment
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B) Organizing an immunization campaign
C) Identifying the specific roles of disaster workers
D) Conducting home visits to identify health hazards
7. a nurse manager is assisting with the orientation tells the hospital chaplain a
of a newly licensed nurse. which of the following clients diagnosis
actions by the nurse requires the nurse manager to
intervene?
8. a nurse is caring for a client who is in labor at 39 continue observing the fetal
weeks of gestation. during the second stage of labor, heart rate
the nurse observes early deceleration on the moni-
tor tracing. which of the following actions should the these are an expected find-
nurse take? ing
A. Continue observing the fetal heart rate
B. Assist the client to a knee-chest position
C. Prepare the client for continuous internal moni-
toring
D. Prepare for an emergency cesarean birth
9. A nurse manager is planning to make changes to the provide information about
current scheduling system on the unit. To facilitate scheduling issues to the
the staff's acceptance of this change, which of the staff
following actions should the nurse manager take
first? unfreezing stage - in-
A) Provide information about scheduling issues to crease understanding of
the staff. why change is needed
B) Ask staff members to participate in a trial of the
new scheduling system.
C) Encourage staff to offer alternate scheduling so-
lutions.
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D) Develop goals to implement the new scheduling
system.
10. a nurse is planning teaching about allowable foods oranges
for a client who has a history of uric acid based uri-
nary calculi formation. which of the following foods can eat citrus fruits
should the nurse include in the teaching?
no chicken, no organ meats
like liver, no red wine (avoid-
ing purine)
11. A charge nurse is teaching a newly licensed nurse the cervix transitions to an
how to identify true labor. Which of the following anterior position
should the nurse include in the teaching?
A. Irregular contractions that decrease with walking contractions will be felt in the
B. Back pain relieved by changing positions lower abdomen and back,
C. Progressive cervical dilation and effacement intensity increases with am-
D. Discomfort primarily in the lower abdomen bulation, cervix shortens and
thins
12. A nurse on a medical-surgical unit is caring for a the client is able to accu-
client prior to a surgical procedure. Which of the fol- rately describe the upcom-
lowing findings should indicate to the nurse that the ing procedure
client has the ability to sign the informed consent?
A) The client is anxious and asks many questions.
B) The client has not had anything to eat or drink for
8 hours.
C) The client is alert and oriented to person, place,
and time.
D) The client has a family member present who will
make decisions.
13.
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