A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's par-
ents tells the nurse that it is too difficult to cope any longer and has decided to move out of
the house. Which of the following responses should the nurse make? - ANSWER A: "Let's
talk about a few ways you have dealt with stress in the past."
A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis.
Which of the following information should the nurse include in the teaching? - ANSWER
A: "Maintain bone health by eating fruits, vegetables, and protein."
A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of
the following statements should the nurse make? - ANSWER B: "This medication causes
adverse effects if the dosage is too high or too low."
A nurse in an emergency department is assessing a preschooler who has severe dehydration
as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following find-
ings should the nurse identify as an indication that the treatment is effective? - ANSWER
D: Brisk skin turgor
A nurse is caring for a client who has left hemiparesis following a stroke. Which of the follow-
ing actions should the nurse take? - ANSWER B: Encourage the client to use wide-grip
utensils when eating with the right hand.
A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which
of the following herbal supplements should the nurse include in the teaching for treating hy-
perlipidemia? - ANSWER D: Garlic
1
,A nurse is admitting a client who has an acute bacterial wound infection and a temperature
of 39.8° C (103.6° F). Which of the following actions should the nurse take? - ANSWER D:
Set the temperature of the client's room to 22.2° C (72°
A nurse is planning care for a client who had surgery for osteomyelitis from a past musculo-
skeletal trauma to the lower leg. Which of the following interventions should the nurse in-
clude in the plan of care? - ANSWER C: Check for paresthesia of the affected leg.
A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of
the following findings should the nurse report to the provider? - ANSWER B: Presence of
strabismus
A nurse is teaching a client who has atherosclerosis about self-care. Which of the following
instructions should the nurse include in the teaching? - ANSWER C: Increase fiber intake
to at least 30 g per day.
A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of
the following findings should the nurse identify as an indication that the client has a venous
ulcer rather than an arterial ulcer? - ANSWER B: Discoloration and edema of the right an-
kle
A nurse is providing discharge teaching to a client who is postoperative following a tran-
surethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia.
Which of the following instructions should the nurse include in the teaching? - ANSWER
D: "Perform Kegel exercises several times throughout the day."
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse expect? (Select all the apply.) - ANSWER A: Nocturia
C: Dyspnea
D: Hacking cough
2
, A nurse is assessing a client who is 1 hour postoperative following a transurethral resection
of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the follow-
ing assessment findings should the nurse notify the provider? - ANSWER C: The catheter
tubing has multiple red clots.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent
reflux. Which of the following information should the nurse include in the teaching? - AN-
SWER D: Plan to finish eating at least 3 hr before bedtime.
A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyper-
plasia (BPH). Which of the following instructions should the nurse include to promote elimi-
nation? - ANSWER B: "Void as soon as you feel the urge."
A nurse is assessing for manifestations of hyponatremia in a client who has been taking
twice the prescribed dose of a diuretic. Which of the following findings should the nurse ex-
pect? - ANSWER C: Decreased level of consciousness
A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the fol-
lowing statements should the nurse identify as an indication the client understands the
teaching? - ANSWER C: "I will base my peak flow meter score on the best of three at-
tempts."
A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level
of 250 mg/dL. Which of the following findings should the nurse expect? - ANSWER B:
Fruity breath odor
A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of
36.1° C (97° F). Which of the following manifestations should the nurse expect? - AN-
SWER A: Hypoglycemia
A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when hav-
ing manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL.
3
ents tells the nurse that it is too difficult to cope any longer and has decided to move out of
the house. Which of the following responses should the nurse make? - ANSWER A: "Let's
talk about a few ways you have dealt with stress in the past."
A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis.
Which of the following information should the nurse include in the teaching? - ANSWER
A: "Maintain bone health by eating fruits, vegetables, and protein."
A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of
the following statements should the nurse make? - ANSWER B: "This medication causes
adverse effects if the dosage is too high or too low."
A nurse in an emergency department is assessing a preschooler who has severe dehydration
as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following find-
ings should the nurse identify as an indication that the treatment is effective? - ANSWER
D: Brisk skin turgor
A nurse is caring for a client who has left hemiparesis following a stroke. Which of the follow-
ing actions should the nurse take? - ANSWER B: Encourage the client to use wide-grip
utensils when eating with the right hand.
A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which
of the following herbal supplements should the nurse include in the teaching for treating hy-
perlipidemia? - ANSWER D: Garlic
1
,A nurse is admitting a client who has an acute bacterial wound infection and a temperature
of 39.8° C (103.6° F). Which of the following actions should the nurse take? - ANSWER D:
Set the temperature of the client's room to 22.2° C (72°
A nurse is planning care for a client who had surgery for osteomyelitis from a past musculo-
skeletal trauma to the lower leg. Which of the following interventions should the nurse in-
clude in the plan of care? - ANSWER C: Check for paresthesia of the affected leg.
A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of
the following findings should the nurse report to the provider? - ANSWER B: Presence of
strabismus
A nurse is teaching a client who has atherosclerosis about self-care. Which of the following
instructions should the nurse include in the teaching? - ANSWER C: Increase fiber intake
to at least 30 g per day.
A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of
the following findings should the nurse identify as an indication that the client has a venous
ulcer rather than an arterial ulcer? - ANSWER B: Discoloration and edema of the right an-
kle
A nurse is providing discharge teaching to a client who is postoperative following a tran-
surethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia.
Which of the following instructions should the nurse include in the teaching? - ANSWER
D: "Perform Kegel exercises several times throughout the day."
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse expect? (Select all the apply.) - ANSWER A: Nocturia
C: Dyspnea
D: Hacking cough
2
, A nurse is assessing a client who is 1 hour postoperative following a transurethral resection
of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the follow-
ing assessment findings should the nurse notify the provider? - ANSWER C: The catheter
tubing has multiple red clots.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent
reflux. Which of the following information should the nurse include in the teaching? - AN-
SWER D: Plan to finish eating at least 3 hr before bedtime.
A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyper-
plasia (BPH). Which of the following instructions should the nurse include to promote elimi-
nation? - ANSWER B: "Void as soon as you feel the urge."
A nurse is assessing for manifestations of hyponatremia in a client who has been taking
twice the prescribed dose of a diuretic. Which of the following findings should the nurse ex-
pect? - ANSWER C: Decreased level of consciousness
A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the fol-
lowing statements should the nurse identify as an indication the client understands the
teaching? - ANSWER C: "I will base my peak flow meter score on the best of three at-
tempts."
A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level
of 250 mg/dL. Which of the following findings should the nurse expect? - ANSWER B:
Fruity breath odor
A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of
36.1° C (97° F). Which of the following manifestations should the nurse expect? - AN-
SWER A: Hypoglycemia
A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when hav-
ing manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL.
3
