1. The nurse is teaching a client with numerous allergies how to avoid allergens.
Which instruction should be included in this teaching plan?
A. avoid any types of sprays, powders, and perfumes
B. wearing a mask while cleaning will not help to avoid allergens.
C. purchase any type of clothing, but be sure it is washed before wearing it.
D. pollen count is related to hay fever, not to allergens - ANS☑☑---A.
Avoid any types of sprays, powders, and perfumes.
2. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition
(TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse
notes that the TPN solution has run out and the next TPN solution is not available.
What immediate action should the nurse take?
A. infuse normal saline at a keep vein open rate
B. discontinue the IV and flush the port with heparin
C. infuse 10% dextrose and water at 54 ml/hr
D. obtain a stat blood glucose level and notify the healthcare provider -
ANS☑☑---C. Infuse 10% dextrose and water at 54 ml/hr.
3. The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for the
nurse to implement?
A. tell the UAP to use a larger cuff at the next scheduled assessment
B. reassess the client's blood pressure using a larger cuff
C. have the unit educator review this procedure with the UAPs
, D. Teach the UAP the correct technique for assessing blood pressure. -
ANS☑☑---B. Reassess the client's blood pressure using a larger cuff
4. A young mother of three children complains of increased anxiety during her
annual physical exam. What information should the nurse obtain first?
A. Sexual activity patterns
B. Nutritional history
C. leisure activities
D. financial stressors - ANS☑☑---B. Nutritional history.
5. The nurse is using a genogram while conducting a client's health assessment and
past medical history. What information should the genogram provide?
A. genetic and familial health disorders.
B. chronic health problems
C. reason for seeking health care
D. undetected disorders - ANS☑☑---A. genetic and familial health
disorders
6. A client with acute hemorrhagic anemia is to receive four units of packed RBCs as
rapidly as possible. Which intervention is most important for the nurse to
implement?
A. obtain the pre-transfusion hemoglobin level
B. prime tubing and prepare a blood pump set-up
C. monitor vital signs q15 minutes for the first hour
D. ensure the accuracy of the blood type match - ANS☑☑---D. ensure the
accuracy of the blood type match
7. An obese male client discusses with the nurse his plans to begin a longterm
weight loss regimen. In addition to dietary changes, he plans to begin an
intensive aerobic exercise program 3 to 4 times a week and to take stress
, management classes. After praising the client for his decision, which instruction is
most important for the nurse to provide?
A. "be sure to have a complete physical examination before beginning your
planned exercise program"
B. "be careful that the exercise program doesn't simply add to your stress
level, making you want to eat more."
C. "increased exercise helps to reduce stress, so you may not need to spend
money on a stress management class"
D. "make sure to monitor your weight loss regularly to provide a sense of
accomplishment and motivation" - ANS☑☑---A. "Be sure to have a
complete physical examination before beginning your planned exercise
program."
8. During the admission interview, which technique is most efficient for the nurse to
use when obtaining information about signs and symptoms of a client's primary
health problem?
A. restatement of responses
B. open-ended questions
C. closed-ended questions
D. problem-seeking responses - ANS☑☑---C. closed-ended questions
9. A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the
preoperative assessment?
A. what is your daily calorie consumption?
B. what vitamin and mineral supplements do you take?
C. do you feel that you are overweight?
D. will a clear liquid diet be okay after surgery? - ANS☑☑---B. "What
vitamin and mineral supplements do you take?"
10. When assisting an 82-year-old client to ambulate, it is important for the nurse to
realize that the center of gravity for an elderly person is the
, A. arms
B. upper torso
C. head
D. feet - ANS☑☑---B. upper torso
11. The nurse is teaching a client proper use of an inhaler. When should the client
administer the inhaler-delivered medication to demonstrate correct use of the
inhaler
A. immediately after exhalation
B. during the inhalation
C. at the end of three inhalations
D. immediately after inhalation - ANS☑☑---B. During the inhalation.
12. Which snack food is best for the nurse to provide a client with myasthenia graves
who is at risk for altered nutritional status?
A. chocolate pudding
B. graham crackers
C. sugar free gelatin
D. apple slices - ANS☑☑---A. Chocolate pudding
13. The nurse notices that the Hispanic parent of a toddler who returns from surgery
offer the child only the broth that comes on the clear liquid tray. Other liquids,
including gelatin, popsicles, and juices, remain untouched. What explanation is
most appropriate for this behavior?
A. the belief is held that the "evil eye" enters the child if anything cold is
ingested
B. after surgery the child probably has refused all foods except broth
C. eating broth strengthens the child's innate energy called "chi"
D. "hot" remedies restore balance after surgery, which is considered a "cold"
condition - ANS☑☑---D. "Hot" remedies restore balance after surgery,
which is considered a "cold" condition.
Which instruction should be included in this teaching plan?
A. avoid any types of sprays, powders, and perfumes
B. wearing a mask while cleaning will not help to avoid allergens.
C. purchase any type of clothing, but be sure it is washed before wearing it.
D. pollen count is related to hay fever, not to allergens - ANS☑☑---A.
Avoid any types of sprays, powders, and perfumes.
2. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition
(TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse
notes that the TPN solution has run out and the next TPN solution is not available.
What immediate action should the nurse take?
A. infuse normal saline at a keep vein open rate
B. discontinue the IV and flush the port with heparin
C. infuse 10% dextrose and water at 54 ml/hr
D. obtain a stat blood glucose level and notify the healthcare provider -
ANS☑☑---C. Infuse 10% dextrose and water at 54 ml/hr.
3. The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for the
nurse to implement?
A. tell the UAP to use a larger cuff at the next scheduled assessment
B. reassess the client's blood pressure using a larger cuff
C. have the unit educator review this procedure with the UAPs
, D. Teach the UAP the correct technique for assessing blood pressure. -
ANS☑☑---B. Reassess the client's blood pressure using a larger cuff
4. A young mother of three children complains of increased anxiety during her
annual physical exam. What information should the nurse obtain first?
A. Sexual activity patterns
B. Nutritional history
C. leisure activities
D. financial stressors - ANS☑☑---B. Nutritional history.
5. The nurse is using a genogram while conducting a client's health assessment and
past medical history. What information should the genogram provide?
A. genetic and familial health disorders.
B. chronic health problems
C. reason for seeking health care
D. undetected disorders - ANS☑☑---A. genetic and familial health
disorders
6. A client with acute hemorrhagic anemia is to receive four units of packed RBCs as
rapidly as possible. Which intervention is most important for the nurse to
implement?
A. obtain the pre-transfusion hemoglobin level
B. prime tubing and prepare a blood pump set-up
C. monitor vital signs q15 minutes for the first hour
D. ensure the accuracy of the blood type match - ANS☑☑---D. ensure the
accuracy of the blood type match
7. An obese male client discusses with the nurse his plans to begin a longterm
weight loss regimen. In addition to dietary changes, he plans to begin an
intensive aerobic exercise program 3 to 4 times a week and to take stress
, management classes. After praising the client for his decision, which instruction is
most important for the nurse to provide?
A. "be sure to have a complete physical examination before beginning your
planned exercise program"
B. "be careful that the exercise program doesn't simply add to your stress
level, making you want to eat more."
C. "increased exercise helps to reduce stress, so you may not need to spend
money on a stress management class"
D. "make sure to monitor your weight loss regularly to provide a sense of
accomplishment and motivation" - ANS☑☑---A. "Be sure to have a
complete physical examination before beginning your planned exercise
program."
8. During the admission interview, which technique is most efficient for the nurse to
use when obtaining information about signs and symptoms of a client's primary
health problem?
A. restatement of responses
B. open-ended questions
C. closed-ended questions
D. problem-seeking responses - ANS☑☑---C. closed-ended questions
9. A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the
preoperative assessment?
A. what is your daily calorie consumption?
B. what vitamin and mineral supplements do you take?
C. do you feel that you are overweight?
D. will a clear liquid diet be okay after surgery? - ANS☑☑---B. "What
vitamin and mineral supplements do you take?"
10. When assisting an 82-year-old client to ambulate, it is important for the nurse to
realize that the center of gravity for an elderly person is the
, A. arms
B. upper torso
C. head
D. feet - ANS☑☑---B. upper torso
11. The nurse is teaching a client proper use of an inhaler. When should the client
administer the inhaler-delivered medication to demonstrate correct use of the
inhaler
A. immediately after exhalation
B. during the inhalation
C. at the end of three inhalations
D. immediately after inhalation - ANS☑☑---B. During the inhalation.
12. Which snack food is best for the nurse to provide a client with myasthenia graves
who is at risk for altered nutritional status?
A. chocolate pudding
B. graham crackers
C. sugar free gelatin
D. apple slices - ANS☑☑---A. Chocolate pudding
13. The nurse notices that the Hispanic parent of a toddler who returns from surgery
offer the child only the broth that comes on the clear liquid tray. Other liquids,
including gelatin, popsicles, and juices, remain untouched. What explanation is
most appropriate for this behavior?
A. the belief is held that the "evil eye" enters the child if anything cold is
ingested
B. after surgery the child probably has refused all foods except broth
C. eating broth strengthens the child's innate energy called "chi"
D. "hot" remedies restore balance after surgery, which is considered a "cold"
condition - ANS☑☑---D. "Hot" remedies restore balance after surgery,
which is considered a "cold" condition.
