d d d d d d
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d d d d d d
Guarantee d
1. Adnursedisdperformingdadstraightdurinarydcatheterizationdfordadfemaledclientdwhodhasdurinarydretentio
d
n.dWhichdofdthedfollowingdactionsdindicatesdthednursedisdmaintainingdsteriledtechnique?
Wipingdthedlabiadminoradindandanteroposteriorddirection
2. Adnursedindadrehabilitationdfacilitydisdobservingdandassistivedpersonneld(AP)dhelpdadclientdtransferdfromd
adbeddtodadwheelchair.dWhichdofdthedfollowingdactionsdindicatesdtodthednursedthatdthedAPdunderstands
howdtodperformdthisdtask?
d
Lockingdthedbrakesdondthedbeddanddthedwheelchairdbeforedmovingdthedclient
3. Adnursedisdpreparingdtodadministerdadtuberculindskindtestdtodadclient.dAfterdperformingdhanddhygiene
,dwhichdofdthedfollowingdactionsdshoulddthednursedtake?
Circledthedinjectiondareadwithdadpen
4. Adnursedisdcaringdfordadclientdwhodhasdmajordfecaldincontinencedanddreportsdirritationdindthedperiana
ldarea.dWhichdofdthedfollowingdactionsdshoulddthednursedtakedfirst?
Checkdthedclient'sdperineum
5. Adnursedisdcaringdfordadclientdwhodisdpostoperativedfollowingdadvaginaldhysterectomydanddasksdfordad
drink.dHerdpostoperativeddietdprescriptiondstatesd“cleardliquids;dadvanceddietdasdtolerated.”dWhichdo
fdthedfollowingdresponsesdshoulddthednursedmake?
Idamdgoingdtodlistendtodyourdabdomen.
6. Adnursedisdchangingdtheddressingsdfordadclientdrecoveringdfromdandappendectomydfollowingdadrupture
ddappendix.dThedclient'sdsurgicaldwounddisdhealingdbydsecondarydintention.dWhichdofdthedfollowingdob
servationsdshoulddthednursedreportdtodthedprovider?
Halodofderythemadondthedsurroundingdskin
7. Adnursedisdcaringdfordadclientdwhodjustdreceiveddaddiagnosisdofdcancer.dThedclientdstates,d"Idjustddon'
tdknowdwhatdI'mdgoingdtoddodnow.dWhichdofdthedfollowingdresponsesdshoulddthednursedmake?
Candyoudexplaindthedconcernsdyou'redhavingdrightdnow?
8. AdnursedisdcaringdfordadclientdwhodhasdadstagedIIIdpressuredulcerdondthedheel.dWhendpreparingdt
odirrigatedthedwound,dwhichdofdthedfollowingdactionsdshoulddthednursedtakedfirst?
Checkdthedclient'sdpaindlevel
9. Adnursedisdcalculatingdadclient'sdintakedfordad12-
hrdshift.dThedclientdhadddextrosed5%dind0.45%dsodiumdchloridedinfusingdatd125dml/hr,dgentamicind15
0dmgdind100dmLdatd1400,dfamotidined20dmgdind50dmLdatd1000dandd1600,d250dmLdofdblooddoverd2dhr,da
nddadnasogastricdflushdofd30dmldeveryd2dhr.dWhatdisdthedtotaldintakedindmillilitersdthatdthednursedshou
, ldddocumentdfordthisdclientdfordthisd12-hrdperiod?
2130
10. Adnursedisdcaringdfordadclientdwhodisdreceivingdadblooddtransfusion.dThedclientdreportsdflankdpain,dandd
thednursednotesdreddish-
browndurinedindthedclient'sdurinarydcatheterdbag.dThednursedrecognizesdthesedmanifestationsdasdwhich
ofdthedfollowingdtypesdofdtransfusiondreactions?
d
Hemolytic
11. Adnursedisdcaringdfordadclientdwhodhasdadterminaldillness.dThedclientdasksdseveraldquestionsdaboutdthe
nurse'sdreligiousdbeliefsdrelateddtoddeathdandddying.dWhichdofdthedfollowingdactionsdshoulddthednurs
d
edtake?
Encouragedthedclientdtodexpressdthoughtsdaboutddeathdandddying
12. Adnursedisdcaringdfordadclientdwhodreportsdfeelingdadpopdafterdcoughingdwithoutdproperlydsplintingda
ndabdominaldincision.dOndassessment,dthednursednotesdthatdthedclient'sdwounddhasdeviscerated.dWhi
chdofdthedfollowingdactionsdshoulddthednursedtake?d(SATA)
Placedthedclientdindadsupinedpositiondwithdthedhipsdanddkneesdflexedd
Coverdthedwounddanddintestinedwithdadsterile,dmoistenedddressingd
Monitordthedclientdfordmanifestationsdofdshock
13. Adnursedisdprovidingdteachingdtodadclientdregardingdproteindintake.dWhichdofdthedfollowingdfood
sdshoulddthednursedincludedasdandexampledofdandincompletedprotein?
Lentils
14. Adnursedisdprovidingddischargedteachingdfordadclientdwhodhasdtyped2ddiabetesdmellitusdanddwilldbedcari
ngdfordherselfdatdhome.dThedclientdexpressesdconcernsdaboutdpreparingdandappropriateddietdfordherddia
betesdduedtodherdculturaldbeliefsdanddpreferences.dWhichdofdthedfollowingdresponsesdshoulddthednurs
edoffer?
Theddietitiandwilldhelpdyoudchoosedfoodsdyoudareduseddtodthatdalsodmeetdyourdhealthdneeds.
15. Adnursedisdcaringdfordadclientdwhodhasdemphysema.dThedclientdhasdnotdstoppeddsmokingdcigarettesdan
ddstates,d"it'sdtoodlatedfordmedtodquit."dWhichdofdthedfollowingdactionsdshoulddthednursedtake?
Assistdthedclientdindfindingdlocaldsmokingdcessationdassistancedprograms
16. Adnursedisdcollectingdadspecimendfordculturedfromdadclientsdinfecteddwound.dWhichdofdthedfollowin
gdactionsdshoulddthednursedperform?
Cleansedthedwounddwithd0.9%dsodiumdchloridedirrigation
17. Adnursedisdprovidingdteachingdaboutdproperdcaredtodadclientdwhodhasdadnewdcolostomy.dWhichdofdth
edfollowingdpiecesdofdinformationdshoulddthednursedincludedindthedteaching?
Cleansedthedskindarounddthedstomadwithdwarmdwater
,18. Adnursedisdpreparingdtodadministerdandafternoonddosedofdampicillindtodadclient.dThedclientdappear
sdupsetdanddrefusesdtodtakedthedmedicationdbeforedthrowingdthedpilldondthedfloor.dWhichdofdthedf
ollowingdentriesdshoulddthednursedenterdintodthedclient'sdmedicaldrecord?
Thedclientdthrewdthedmedicationdondthedfloor.
19. Adnursedisdcaringdfordadclientdwhodisd48dhrdpostoperativedfollowingdadsmalldboweldresection.dThedclien
tdreportsdgasdpainsdindthedperiumbilicaldarea.dThednursedshoulddplandcaredbaseddondwhichdofdthedfollo
wingdfactorsdcontributingdtodthisdpostoperativedcomplication?
Impaireddperistalsisdofdthedintestines
20. AdnursedisdexplainingdPiaget'sdtheorydofdcognitiveddevelopmentdtodadgroupdofddaycaredprovidersdfo
rdemployees'dchildrendatdandacutedcaredfacility.dWhichdofdthedfollowingdactivitiesdshoulddthednursed
includedasdandexampledofdconcretedoperationaldthinking?
Collectingdanddtradingdgamedcards
21. Adnursedisdplanningdcaredfordadgroupdofdclientsdreceivingdoxygendtherapy.dWhichdofdthedfollowin
gdclientsdshoulddthednursedplandtodseedfirst?
Adclientdwhodhasdheartdfailuredanddisdreceivingd100%doxygendviadpartialdrebreatherdmask
22. Adnursedisdcaringdfordadgroupdofdclients.dWhichdofdthedfollowingdtasksdshoulddthednursedassigndtoda
ndassistivedpersonneld(AP)?
Providedoraldcaredtodadclientdwhodcannotdtakedoraldfluids
23. Adnursedisdassessingdadclientdwhodreportsdnauseadanddvomitingdford2ddays.dWhichdofdthedfollowin
gdfindingsdshoulddindicatedtodthednursedthatdthedclientdisdexperiencingdfluiddvolumeddeficit?dIncre
aseddheartdrate
24. AdnursedisdcaringdfordadclientdwhodhasdadBMIdofd29danddexpressesdaddesiredtodlosedweight.dWhichdofdth
edfollowingdactionsdshoulddthednursedtakedfirst?
Determinedthedclient'sdintentiondtodchangedcurrentdeatingdhabits
25. Adnursedisdbeginningdadtherapeuticdrelationshipdwithdadclient.dWhichdofdthedfollowingdactionsdshoul
ddthednursedtakedtodconveydempathydwhendusingdthedtherapeuticdcommunicationdtechniquedofdactiv
edlistening?
Assumedandopendposition
26. Adnursedisdcaringdfordadclientdwhodhasdthedheaddofdhisdbeddelevateddtodad45°dangledwithdhisdknee
sdslightlydflexed.dWhichdofdthedfollowingdpositionsdshoulddthednurseddocumentdfordthedclient?dF
owler's
, 27. Adnursedisdassessingdadclientdwhodhasdadtotaldcalciumdleveldofd12.7dmg/dL.dWhichdofdthedfollowin
gdfindingsdshoulddthednursedexpect?
Depressedddeep-tendondreflexes
28. Adnursedisdpreparingdtodinsertdandindwellingdurinarydcatheterdfordadmaledclient.dWhichdofdthedfollowin
gdlocationsdshoulddthednursedsecuredthedurinarydcatheterdtubing?
Lowerdabdomen
29. Adnursedisdteachingdadclientdaboutdthedusedofdadstraight-
leggeddcane.dWhichdofdthedfollowingdclientdactionsdindicatesdandunderstandingdofdthedteaching?
Thedclientdholdsdthedcanedondthedunaffecteddside.
30. Adnursedisdplanningdtodobtaindthedvitaldsignsdofdad2-year-
olddchilddwhodisdexperiencingddiarrheadanddmaydhavedadrightdeardinfection.dWhichdofdthedfollowing
routesdshoulddthednursedusedtodobtaindthedchild'sdtemperature?
d
Temporal
31. Adnursedisdteachingdrange-of-
motiondexercisesdtodadclientdwhodhasdosteoarthritis.dWhichdofdthedfollowingdclientdpositionsdde
monstratesdandunderstandingdofdsupinationdofdthedhand?
Thedclientdholdsdthedhanddwithdthedpalmdup.
32. Adnursedisdassessingdadclientdwhodhasdadsuddendonsetdofdseveredbackdpaindofdunknowndorigin.dWhichdo
fdthedfollowingdquestionsdshoulddthednursedaskdtodencourageddiscussiondwithdthedclient?
Whatddodyoudthinkdcauseddthedonsetdofdyourdpain?
33. Adnursedisdpreparingdtodadministerdandintramusculardinjectiondtodadclientdwhodisdoverweight.dWhichdo
fdthedfollowingdsitesdshoulddthednursedselectdfordthedinjection?
Sidedhipdbetweendthediliacdcrestdanddanteriordiliacdspine
34. Adnursedisdcaringdfordadmiddle-
ageddadultdclient.dThednursedshoulddidentifydwhichdofdthedfollowingdstatementsdasdandindicationdth
atdthedclientdhasdcompleteddErikson'sddevelopmentaldtaskdfordherdagedgroup?
IdthinkdIdhaveddonedadgooddjobdwithdmydchildrendsincedtheydaredalldindependentdnow.
35. Adnursedisdsupervisingdadnewlydlicenseddnursedwhodisdadministeringdadcontrolleddsubstance.dWhichdo
fdthedfollowingdactionsdbydthednewlydlicenseddnursedindicatesdandunderstandingdofdthedprocedure?dA
skingdanotherdnursedtodobservedtheddisposaldofdandunuseddportiondofdthedmedication