Exam 2:
1. The nurse is teaching an adult female client about health promotion. Which of the following
should the nurse recommend as a primary prevention intervention?
a. Performing a breast self-examination (BSE).
b. Having a yearly physical with labs.
c. Receiving family planning services.
d. Checking blood pressure every 3 months.
2. The nurse is caring for a client who has joint pain. The nurse incorporates the nutritional status,
sleep patterns, energy level, and sense of well-bring into the plan of care. Which of the following
concepts is the nurse practicing?
a. Homeostasis
b. Individuality
c. Health promotion
d. Holism
3. The community health nurse is preparing to provide education to an adolescent client regarding
health promotion. Which of the following health promotion topics is most appropriate for this
client?
a. Dental checkups
b. Preventive health screenings
c. Weight control
d. Peer group influences
4. The nurse is caring for a client who has a low serum albumin level. Which statement by the nurse
indicates a correct understanding of albumin levels?
a. “The client is experiencing a rapid breakdown of protein.”
b. “This indicates a low level of iron circulating in the blood.”
c. “The results indicate prolonged malnutrition.”
d. “This indicates that the client has experienced blood loss.”
5. The nurse is preparing to discharge an elderly client who is at risk for aspiration. Which of the
following should the nurse recommend?
a. Prepare liquids at prescribed consistency
b. Tilt the head back when swallowing
c. Drink warm water instead of cold
d. Use extra pillow when eating in bed
6. The nurse is administering an intermittent gastrointestinal (GT) feeding to a client. Which of the
following actions is appropriate for the nurse to take?
a. Aspiration and disposal of any residual prior to feeding delivery.
b. Setting up feeding bag system to deliver the feeding at a fast rate
c. Raising and lowering the syringe to adjust the flow rate of the feeding.
d. Placing the head of the bed at 15 degrees with the client on their left side
7. The nurse is caring for a client who is receiving prescribed medication intravenously (IV). Upon
assessment, the nurse notes the IV site is swollen and cool to the touch. Which of the following is
most appropriate action for the nurse to take?
a. Slow the rate of the infusion and provide a warm blanket
b. Stop the infusion and start supportive treatment
, c. Call the primary health care provider (PHCP) and get order for a new medication
d. Monitor the client closely since they need the medication
8. The nurse is caring for a client who was admitted to the acute care unit with a decreased
phosphorus level. Which of the following should the nurse recommend?
a. Enforce strict isolation protocols
b. Strain all urine
c. Encourage consumption of a high- calorie carbohydrate diet
d. Encourage consumption of milk and yogurt
9. The nurse is caring for a client who is 5-days postoperative and has been on bed rest. Which of
the following interventions should the nurse implement to decrease the client’s possibility of
developing hypercalcemia?
a. Assist the client to turn, cough, and deep breath every 2 hours
b. Measure vital signs every 4 hours
c. Assist the client to ambulate around the room at least 3 times daily.
d. Irrigate the client’s nasogastric (NG) tube every 2 hours.
10. The nurse is caring for a client who has had diarrhea for 48 hours abd has developed fatigue,
restlessness, and disorientation. Which of the following laboratory results should the nurse
correlate to these signs and symptoms?
a. Calcium
b. Sodium
c. Phosphate
d. Magnesium
11. The nurse is caring for a client who has hypokalemia. Which of the following signs and
symptoms should the nurse expect to see?
a. Headache
b. Facial edema
c. Muscle weakness
d. Abdominal cramping
12. The nurse is caring for a client who is diagnosed with an elevated aldosterone level. The nurse
should expect to find
a. An increased urine output
b. Urinary frequency
c. A decreased urine output
d. Urinary urgency
13. The nurse is caring for a client who has oliguria. The nurse recognized that the client is
experiencing
a. A urine output greater than 120 ml/hr
b. Increased hesitancy with voiding
c. A urine output less than 30 ml/hr
d. A foul odor associated with urination
14. The nurse is assessing the following assigned older adult clients who have urinary catheters in
place. Which client should the nurse recognizes as being at greatest risk for developing a urinary
tract infection (UTI)?
a. The 65- year- old client who has a condom catheter
, b. The 80-year-old male client who reports frequent urination at night.
c. The 25-year-old female client who has low self-esteem
d. The 78-year- old male client who has a patent indwelling urethral
15. The nurse is caring for the following assigned clients on a medical unit. Which client should the
nurse recognize as being at greatest risk for experiencing difficulty with urinary elimination?
a. The client who is complaining of leg pain
b. The client who drinks coffee until noon each day
c. The client who ambulates independently
d. The client who has confusion and a mild fever
16. The nurse is caring for a female client with limited mobility who is having difficulty voiding.
Which of the following actions should the nurse take first?
a. Request a prescription for an indwelling urinary catheter
b. Provide bed side commode
c. Insert a straight catheter
d. Assist the client into an upright position
17. The nurse is assessing a client who has steatorrhea. Which of the following finding is consistent
with this condition?
a. Liquid and clumps of stool
b. Dark-red blood in the stool
c. Fat, loose stool
d. Frequent small hard stools
Exam 3:
1. When changing the dressing on a clients partial-thickness wound, the nurse observes a beefy-red
translucent wound bed. Which of the following actions should the nurse take?
a. Contact the primary health care provider (PCP) immediately.
b. Document the findings as abnormal and continue to observe.
c. Culture the wound and place the client in isolation.
d. Discard the old dressing and cover the wound with a new dressing.
2. The nurse is teaching a newly hired nurse about the risk factors for dehiscence for clients who
have surgical incisions. Which of the following factors should the nurse include in the teaching?
a. Altered mental status.
b. Nutritional deficiencies
c. Advanced age
d. Immobility
3. The nurse is caring for a client who is being discharged home with surgical wound on the coccyx
that is to heal by secondary intention. Which of the following complications should the nurse
prioritize on the clients care plan?
a. Contractures
b. Increased tissue perfusion
c. Self-care deficit
d. Disturbed body image.
1. The nurse is teaching an adult female client about health promotion. Which of the following
should the nurse recommend as a primary prevention intervention?
a. Performing a breast self-examination (BSE).
b. Having a yearly physical with labs.
c. Receiving family planning services.
d. Checking blood pressure every 3 months.
2. The nurse is caring for a client who has joint pain. The nurse incorporates the nutritional status,
sleep patterns, energy level, and sense of well-bring into the plan of care. Which of the following
concepts is the nurse practicing?
a. Homeostasis
b. Individuality
c. Health promotion
d. Holism
3. The community health nurse is preparing to provide education to an adolescent client regarding
health promotion. Which of the following health promotion topics is most appropriate for this
client?
a. Dental checkups
b. Preventive health screenings
c. Weight control
d. Peer group influences
4. The nurse is caring for a client who has a low serum albumin level. Which statement by the nurse
indicates a correct understanding of albumin levels?
a. “The client is experiencing a rapid breakdown of protein.”
b. “This indicates a low level of iron circulating in the blood.”
c. “The results indicate prolonged malnutrition.”
d. “This indicates that the client has experienced blood loss.”
5. The nurse is preparing to discharge an elderly client who is at risk for aspiration. Which of the
following should the nurse recommend?
a. Prepare liquids at prescribed consistency
b. Tilt the head back when swallowing
c. Drink warm water instead of cold
d. Use extra pillow when eating in bed
6. The nurse is administering an intermittent gastrointestinal (GT) feeding to a client. Which of the
following actions is appropriate for the nurse to take?
a. Aspiration and disposal of any residual prior to feeding delivery.
b. Setting up feeding bag system to deliver the feeding at a fast rate
c. Raising and lowering the syringe to adjust the flow rate of the feeding.
d. Placing the head of the bed at 15 degrees with the client on their left side
7. The nurse is caring for a client who is receiving prescribed medication intravenously (IV). Upon
assessment, the nurse notes the IV site is swollen and cool to the touch. Which of the following is
most appropriate action for the nurse to take?
a. Slow the rate of the infusion and provide a warm blanket
b. Stop the infusion and start supportive treatment
, c. Call the primary health care provider (PHCP) and get order for a new medication
d. Monitor the client closely since they need the medication
8. The nurse is caring for a client who was admitted to the acute care unit with a decreased
phosphorus level. Which of the following should the nurse recommend?
a. Enforce strict isolation protocols
b. Strain all urine
c. Encourage consumption of a high- calorie carbohydrate diet
d. Encourage consumption of milk and yogurt
9. The nurse is caring for a client who is 5-days postoperative and has been on bed rest. Which of
the following interventions should the nurse implement to decrease the client’s possibility of
developing hypercalcemia?
a. Assist the client to turn, cough, and deep breath every 2 hours
b. Measure vital signs every 4 hours
c. Assist the client to ambulate around the room at least 3 times daily.
d. Irrigate the client’s nasogastric (NG) tube every 2 hours.
10. The nurse is caring for a client who has had diarrhea for 48 hours abd has developed fatigue,
restlessness, and disorientation. Which of the following laboratory results should the nurse
correlate to these signs and symptoms?
a. Calcium
b. Sodium
c. Phosphate
d. Magnesium
11. The nurse is caring for a client who has hypokalemia. Which of the following signs and
symptoms should the nurse expect to see?
a. Headache
b. Facial edema
c. Muscle weakness
d. Abdominal cramping
12. The nurse is caring for a client who is diagnosed with an elevated aldosterone level. The nurse
should expect to find
a. An increased urine output
b. Urinary frequency
c. A decreased urine output
d. Urinary urgency
13. The nurse is caring for a client who has oliguria. The nurse recognized that the client is
experiencing
a. A urine output greater than 120 ml/hr
b. Increased hesitancy with voiding
c. A urine output less than 30 ml/hr
d. A foul odor associated with urination
14. The nurse is assessing the following assigned older adult clients who have urinary catheters in
place. Which client should the nurse recognizes as being at greatest risk for developing a urinary
tract infection (UTI)?
a. The 65- year- old client who has a condom catheter
, b. The 80-year-old male client who reports frequent urination at night.
c. The 25-year-old female client who has low self-esteem
d. The 78-year- old male client who has a patent indwelling urethral
15. The nurse is caring for the following assigned clients on a medical unit. Which client should the
nurse recognize as being at greatest risk for experiencing difficulty with urinary elimination?
a. The client who is complaining of leg pain
b. The client who drinks coffee until noon each day
c. The client who ambulates independently
d. The client who has confusion and a mild fever
16. The nurse is caring for a female client with limited mobility who is having difficulty voiding.
Which of the following actions should the nurse take first?
a. Request a prescription for an indwelling urinary catheter
b. Provide bed side commode
c. Insert a straight catheter
d. Assist the client into an upright position
17. The nurse is assessing a client who has steatorrhea. Which of the following finding is consistent
with this condition?
a. Liquid and clumps of stool
b. Dark-red blood in the stool
c. Fat, loose stool
d. Frequent small hard stools
Exam 3:
1. When changing the dressing on a clients partial-thickness wound, the nurse observes a beefy-red
translucent wound bed. Which of the following actions should the nurse take?
a. Contact the primary health care provider (PCP) immediately.
b. Document the findings as abnormal and continue to observe.
c. Culture the wound and place the client in isolation.
d. Discard the old dressing and cover the wound with a new dressing.
2. The nurse is teaching a newly hired nurse about the risk factors for dehiscence for clients who
have surgical incisions. Which of the following factors should the nurse include in the teaching?
a. Altered mental status.
b. Nutritional deficiencies
c. Advanced age
d. Immobility
3. The nurse is caring for a client who is being discharged home with surgical wound on the coccyx
that is to heal by secondary intention. Which of the following complications should the nurse
prioritize on the clients care plan?
a. Contractures
b. Increased tissue perfusion
c. Self-care deficit
d. Disturbed body image.
