1. A nurse is caring for a client who requires a 24-hr urine collection. Which
of the following statements by the client indicates an understanding of the
teaching? - "I flushed what I urinated at 7:00 a.m. and have saved all
urine since."
2. A nurse is assessing a client who has been on bed rest for the past month.
Which of the following findings should the nurse identify as an indication
that the client has developed thrombophlebitis? - Calf swelling
3. A nurse manager is overseeing the care on a unit. Which of the following
situations should the nurse manager identify as a violation of HIPAA
guidelines? - A nurse asks a nurse from another unit to assist with her
documentation.
4. A nurse is caring for a client who requires bed rest and has a prescription
for antiembolic stockings. Which of the following actions should the
nurse take? - Remove the stockings at least once per shift.
5. A nurse is administering IV fluid to an older adult client. The nurse
should perform which priority assessment to monitor for adverse effects?
- Auscultate lung sounds
6. A nurse is assessing a client's readiness to learn about insulin
administration. Which of the following statements should the nurse
identify as an indication that the client is ready to learn? - "I can
concentrate best in the morning."
7. A nurse is performing a Romberg's test during the physical assessment of
a client. Which of the following techniques should the nurse use? - Have
the client stand with her arms at her side and her feet together.
8. A nurse is planning an deduction session for an older adult client who
has just learned that she has type 2 diabetes mellitus. Which of the
following strategies should the nurse plan to use with this client? -
Allow extra time for the client to respond to questions
9. A nurse is teaching an older client who is at risk for osteoporosis about
beginning a program of regular physical activity. Which of the following
types of activity should the nurse recommend? - Walking briskly
10.A nurse is assessing an adult client who has been immobile for the past 3
weeks. The nurse should identify that which of the following findings
requires further intervention? - Erythema on pressure points
, 11.A nurse is preparing to administer 0.5 mL of oral single-dose liquid
medication to a client. Which of the following actions should the nurse
take? - Gently shake the container of medication prior to administration.
12.A nurse is responding to a call light and finds a client lying on the
bathroom floor. Which of the following actions should the nurse take
first? - Check the client for injuries
13.A nurse is caring for a client who is expressing anger over his diagnosis
of colorectal cancer. Which of the following actions should the nurse
take? - Reassure the client that this is an expected response to grief.
14.A nurse in a clinic is caring for a middle adult client who states, "The
doctor says that, since I am at an average risk for colon cancer, I should
have routine screening. What does that involve?" Which of the following
responses should the nurse make? - "You should have a fecal occult
blood test every year."
15.A nurse manager is preparing to review medication documentation with a
group of newly licensed nurses. Which of the following statements should
the nurse manager plan to include in the teaching? - "Use the complete
name of the medication magnesium sulfate."
16.A nurse is caring for a client who has tuberculosis. Which of the
following actions should the nurse take? - Place the client in a room with
negative-pressure airflow.
17.Wear gloves when assisting the client
with oral care. Use antimicrobial sanitizer
for hand hygiene.
18.A charge nurse is discussing the responsibility of nurses caring for clients
who have Clostridium difficile infection. Which of the following
information should the nurse include in the teaching? - Have family
members wear a gown and gloves when visiting.
19.A nurse in a surgical suite notes documentation on a client's medical
record he has a latex allergy. In preparation for the client's procedure,
which of the following precautions should the nurse take? - Wrap
monitoring cords with stockinette and tape them in place.
20.A nurse is caring for a client who is reporting difficulty falling asleep.
Which of the following measures would the nurse recommend? - Use
progressive relaxation techniques at bedtime.
21.A nurse is caring for a client who has a prescription for 5 units of regular
insulin and 10 units of NPH insulin to mix together and administer
subcutaneously. Determine the correct order of steps for this procedure. -
Air into NPH