Question 1
When assuming care of a client at 1900, the nurse learns in report that a client with a urinary
tract infection had an indwelling urinary catheter removed during the previous shift. Which
information is most important for the nurse to obtain?
A. Intake and output reports for the previous shift.
B Time of the last dose of IV antibiotic administration.
C Color of the urine during the catheter removal.
D When the client voided following catheter removal. (correct)
Question 2
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed
for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL."
How many tablespoons should the nurse instruct the client to take with each dose? (Enter
numerical value only.)
1 (correct)
Question 4
The nurse enters a client's room to perform a physical assessment and finds the client crying.
Which response is best for the nurse to provide?
A "This is a bad time. I can see you are upset. I can come back later."
B While touching the client's forearm, asks, "Would you like to talk about it?" (correct)
C Gives the client a hug and says, "It is okay to cry when you are sad."
D "I am sorry to disturb you at a difficult time. This can wait until later."
Question 5
The palliative care nurse receives a consult for a terminally ill client in the intensive care unit.
The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention
should the nurse include in the plan of care?
A Keep mucous membranes moist. (correct)
B Maintain in high Fowler's position.
C Report any change in urine color.
, D Record the client's daily weight.
Question 6
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not
entered. Which is the best way for the nurse to enter computer documentation of the 0900
occurrence?
A Make an electronic addendum following the 1400 documentation.
B Create an electronic correction after 1400 notes are officially unlocked.
C Enter the occurrence after the 1400 notes and identify as "late entry". (correct)
D Request removal initiated by the Health Information Manager.
Question 7
The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical
record (EMR) copies of a client unattended on a counter top. Which action should the nurse
implement?
A Dispose the copies and continue with client care assignments.
B Warn the colleague that copying health information is unlawful.
C Send an email to facility administrators reporting the action.
D Communicate the colleague's activities to the unit charge nurse. (correct)
Question 8
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a
foot while playing soccer with the grandchildren. Which behavior indicates that the client
understands proper crutch walking?
A Practices bicep and triceps isometric exercises.
B Progresses to foot touchdown and weight bearing of affected leg.
C Bears body weight on the palms of hands during the crutch gait. (correct)
D Inspects crutches to ensure rubber tips are intact.
When assuming care of a client at 1900, the nurse learns in report that a client with a urinary
tract infection had an indwelling urinary catheter removed during the previous shift. Which
information is most important for the nurse to obtain?
A. Intake and output reports for the previous shift.
B Time of the last dose of IV antibiotic administration.
C Color of the urine during the catheter removal.
D When the client voided following catheter removal. (correct)
Question 2
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed
for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL."
How many tablespoons should the nurse instruct the client to take with each dose? (Enter
numerical value only.)
1 (correct)
Question 4
The nurse enters a client's room to perform a physical assessment and finds the client crying.
Which response is best for the nurse to provide?
A "This is a bad time. I can see you are upset. I can come back later."
B While touching the client's forearm, asks, "Would you like to talk about it?" (correct)
C Gives the client a hug and says, "It is okay to cry when you are sad."
D "I am sorry to disturb you at a difficult time. This can wait until later."
Question 5
The palliative care nurse receives a consult for a terminally ill client in the intensive care unit.
The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention
should the nurse include in the plan of care?
A Keep mucous membranes moist. (correct)
B Maintain in high Fowler's position.
C Report any change in urine color.
, D Record the client's daily weight.
Question 6
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not
entered. Which is the best way for the nurse to enter computer documentation of the 0900
occurrence?
A Make an electronic addendum following the 1400 documentation.
B Create an electronic correction after 1400 notes are officially unlocked.
C Enter the occurrence after the 1400 notes and identify as "late entry". (correct)
D Request removal initiated by the Health Information Manager.
Question 7
The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical
record (EMR) copies of a client unattended on a counter top. Which action should the nurse
implement?
A Dispose the copies and continue with client care assignments.
B Warn the colleague that copying health information is unlawful.
C Send an email to facility administrators reporting the action.
D Communicate the colleague's activities to the unit charge nurse. (correct)
Question 8
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a
foot while playing soccer with the grandchildren. Which behavior indicates that the client
understands proper crutch walking?
A Practices bicep and triceps isometric exercises.
B Progresses to foot touchdown and weight bearing of affected leg.
C Bears body weight on the palms of hands during the crutch gait. (correct)
D Inspects crutches to ensure rubber tips are intact.
