,A nurse is caring for a client who is postoperative Make sure two fingers can fit under the sleeves
following a knee arthroplasty and requires the use of
thigh-high sequential compression sleeves. Which of the
following actions should the nurse take?
A nurse if evaluating a client's use of a cane. Which of the The client holds the cane on the stronger side of their body
following actions should the nurse identify as an
indication of correct use?
A nurse if calculating a client's fluid intake over the past 8 oz of ice chips
8hr. Which of the following items should the nurse plan to
document in the client's intake and output record as 120
mL of fluid?
A nurse is providing teaching to a client who is on "I will wear a face mask when leaving my hospital room"
protective isolation precautions. Which of the following
client statements indicates understanding of the
teaching?
A nurse is educating a client who has a terminal illness "We would give you oxygen through a tube in your nose"
about declining resucitation in a living will. The client asks,
"What would happen if I arrived at the emergency
department and I had difficulty breathing?" Which of the
following responses should the nurse make?
A nurse is providing discharge teaching for a client who -Check the cord routinely for frays or tearing
has a new prescription for a home oxygen concentrator. -Consider purchasing a generator for power backup
Which of the following instructions should the nurse -Observe for signs of hypoxia
provide to the client and their family?
A nurse is reviewing evidence based practice principles Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
about administration of oxygen therapy with a newly
licensed nurse. Which of the following actions should the
nurse take?
A nurse is caring for a client who has a prescription for Cleanse the wound from the center outward
wound irrigation. Which of the following actions should
the nurse take?
A nurse is caring for a client who requires an NG tube for Have the client take sips of water to promote insertion of the NG tube into the
stomach decompression. Which of the following actions esophagus
should the nurse take while inserting the NG tube?
A nurse is providing discharge instructions to a client who "I will hire someone to trim the tree that overhangs the front porch stairs"
will be using a walker. Which of the following statements
by the client indicates the teaching as been effective?
A nurse is caring for a group of clients on a medical A client who is unaware of their recent cancer diagnosis asks the nurse if they had
surgical unit. In which of the following situations does the cancer, and the nurse responds affirmatively
nurse demonstrate the ethic principle of veracity?
, A nurse is planning to insert a peripheral IV catheter for Place the client's arm in a dependent position
an older adult client. Which of the following actions
should the nurse plan to take?
A nurse is teaching a client whose left leg is in a cast "When descending stairs, I will first shift my weight to my right leg"
about using crutches. Which of the following statements
should the nurse identify as an indication that the client
understands the teaching?
A nurse is teaching an older adult client who is at risk for Walking briskly
osteoporosis about beginning a program of regular
physical activity. Which of the following types of activity
should the nurse recommend?
A nurse is caring for a client who has a respiratory Apply intermittent suction when withdrawing the catheter
infection. Which of the following techniques should the
nurse use when performing nasotracheal suctioning for
the client?
A home health nurse is completing an admission The caregiver insists on remaining in the room
assessment of an older adult client who has their
caregiver present. Which of the following findings should
the nurse identify as a potential indication of elder
abuse?
A nurse is caring for a client who has recently started "I will be sure to remove my hearing aid before taking a shower"
using a behind-the-ear hearing aid. Which of the
following statements should the nurse identify as an
indication that the client understands the use of the
assistive device?
A nurse is assessing an older adult client's risk for falls. -Pupil clarity
Which of the following assessments should the nurse use -Visual fields
to identify the client's safety needs? -Visual acuity
A nurse is caring for a client who asks about the purpose "They indicate the form of treatment a client is willing to accept in the event of a
of advance directives. Which of the following statement serious illness"
should the nurse make?
A nurse is responding to a call light and finds a client Check the client for injuries
lying on the bathroom floor. Which of the following
actions should the nurse take first?
A charge nurse is observing a newly licensed nurse The newly licensed nurse places a cap of a bottle of sterile solution on the sterile
prepare a sterile field for a dressing change. Which of the field
following actions by the newly licensed nurse requires
intervention by the charge nurse?
A nurse is caring for a client who has a prescription for 5 -Inject 10 units of air into the bottle of NPH insulin
units of regular insulin and 10 units of NPH insulin -Inject 5 units of air into the bottle of regular insulin
subcutaneously. Determine the correct order of steps for -Withdraw the correct dose of regular insulin from the bottle
this procedure. -Withdraw the correct dose of NPH insulin from the bottle
following a knee arthroplasty and requires the use of
thigh-high sequential compression sleeves. Which of the
following actions should the nurse take?
A nurse if evaluating a client's use of a cane. Which of the The client holds the cane on the stronger side of their body
following actions should the nurse identify as an
indication of correct use?
A nurse if calculating a client's fluid intake over the past 8 oz of ice chips
8hr. Which of the following items should the nurse plan to
document in the client's intake and output record as 120
mL of fluid?
A nurse is providing teaching to a client who is on "I will wear a face mask when leaving my hospital room"
protective isolation precautions. Which of the following
client statements indicates understanding of the
teaching?
A nurse is educating a client who has a terminal illness "We would give you oxygen through a tube in your nose"
about declining resucitation in a living will. The client asks,
"What would happen if I arrived at the emergency
department and I had difficulty breathing?" Which of the
following responses should the nurse make?
A nurse is providing discharge teaching for a client who -Check the cord routinely for frays or tearing
has a new prescription for a home oxygen concentrator. -Consider purchasing a generator for power backup
Which of the following instructions should the nurse -Observe for signs of hypoxia
provide to the client and their family?
A nurse is reviewing evidence based practice principles Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
about administration of oxygen therapy with a newly
licensed nurse. Which of the following actions should the
nurse take?
A nurse is caring for a client who has a prescription for Cleanse the wound from the center outward
wound irrigation. Which of the following actions should
the nurse take?
A nurse is caring for a client who requires an NG tube for Have the client take sips of water to promote insertion of the NG tube into the
stomach decompression. Which of the following actions esophagus
should the nurse take while inserting the NG tube?
A nurse is providing discharge instructions to a client who "I will hire someone to trim the tree that overhangs the front porch stairs"
will be using a walker. Which of the following statements
by the client indicates the teaching as been effective?
A nurse is caring for a group of clients on a medical A client who is unaware of their recent cancer diagnosis asks the nurse if they had
surgical unit. In which of the following situations does the cancer, and the nurse responds affirmatively
nurse demonstrate the ethic principle of veracity?
, A nurse is planning to insert a peripheral IV catheter for Place the client's arm in a dependent position
an older adult client. Which of the following actions
should the nurse plan to take?
A nurse is teaching a client whose left leg is in a cast "When descending stairs, I will first shift my weight to my right leg"
about using crutches. Which of the following statements
should the nurse identify as an indication that the client
understands the teaching?
A nurse is teaching an older adult client who is at risk for Walking briskly
osteoporosis about beginning a program of regular
physical activity. Which of the following types of activity
should the nurse recommend?
A nurse is caring for a client who has a respiratory Apply intermittent suction when withdrawing the catheter
infection. Which of the following techniques should the
nurse use when performing nasotracheal suctioning for
the client?
A home health nurse is completing an admission The caregiver insists on remaining in the room
assessment of an older adult client who has their
caregiver present. Which of the following findings should
the nurse identify as a potential indication of elder
abuse?
A nurse is caring for a client who has recently started "I will be sure to remove my hearing aid before taking a shower"
using a behind-the-ear hearing aid. Which of the
following statements should the nurse identify as an
indication that the client understands the use of the
assistive device?
A nurse is assessing an older adult client's risk for falls. -Pupil clarity
Which of the following assessments should the nurse use -Visual fields
to identify the client's safety needs? -Visual acuity
A nurse is caring for a client who asks about the purpose "They indicate the form of treatment a client is willing to accept in the event of a
of advance directives. Which of the following statement serious illness"
should the nurse make?
A nurse is responding to a call light and finds a client Check the client for injuries
lying on the bathroom floor. Which of the following
actions should the nurse take first?
A charge nurse is observing a newly licensed nurse The newly licensed nurse places a cap of a bottle of sterile solution on the sterile
prepare a sterile field for a dressing change. Which of the field
following actions by the newly licensed nurse requires
intervention by the charge nurse?
A nurse is caring for a client who has a prescription for 5 -Inject 10 units of air into the bottle of NPH insulin
units of regular insulin and 10 units of NPH insulin -Inject 5 units of air into the bottle of regular insulin
subcutaneously. Determine the correct order of steps for -Withdraw the correct dose of regular insulin from the bottle
this procedure. -Withdraw the correct dose of NPH insulin from the bottle
