A nurse is planning care for a group of clients. Which of the following tasks should
the nurse delegate to an assistive personnel?
a. Changing the dressing for a client who has a stage 3 pressure injury
b. Determining a client's response to a diuretic
c. Comparing radial pulses for a client who is postoperative
d. d.Providingpostmortem care to a client - ANSWER--d
A nurse is conducting a health assessment for a client who takes herbal
supplements. Which of the following statements by the client indicates an
understanding of the use of the supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick
D. I use garlic for my menopausal symptoms - ANSWER--c
A nurse is caring for a client who has influenza and isolation precautions in place.
Which of the following actions should the nurse take to prevent the spread of
infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.
D. Place the client in a negative airflow room. - ANSWER--a
A nurse obtains a prescription for wrist restraints for a client who is trying to pull
out his NG tube. Which of the following actions should the nurse take?
,A. Attach the restraints securely to the side rails of the client's bed.
B. Apply the restraints to allow as little movement as possible
C.Allow room for two fingers to fit between the clients skin and the restraints
e. remove the restraints every 4 hours - ANSWER--c
A nurse is admitting a client who has tuberculosis. Which of the following types of
transmission precautions should the nurse plan to initiate?
A. Droplet
B. Airbornes
c. protective environment
d. contact - ANSWER--b
A nurse in a well-child clinic receives a telephone call from a parent who states
that their child accidentally swallowed paint thinner. The child is awake and alert.
Which of the following responses should the nurse make?
A. Have your child drink one large glass of water.
B. Hang up and call a poison control center hotline.
C. Bring your child into the clinic later today.
D. Induce vomiting in your child with syrup of ipecac. - ANSWER--a
A nurse is documenting a client's medical record. Which of the following entries
should the nurse record.
A. Oral temperature slightly elevated at 0800
B. Administered pain medication
C. Incision without redness or drainage
,D. Drank adequate amounts of fluid with meals. - ANSWER--b
A nurse is providing oral care for a client who is unconscious. Which of the
following actions should the nurse take?
A. Place the client in a side-lying position.
B. Brush the clients teeth daily
C. Apply mineral oil to the client's lips
D. Rinse the client's mouth with an alcohol-based mouthwash - ANSWER--a
A nurse is collaborating with a risk management team about potential legal issues
involving client care. The nurse should identify which of the following situations is
an example of negligence?
A. A nurse administers a medication without first identifying the client.
B. An assistive personnel discusses client care in the facility cafeteria with visitors
present.
C. A nurse begins a blood transfusion without obtaining consent.
D. An assistive personnel prevents a client from leaving the facility. - ANSWER--c
A nurse is collecting a sputum specimen for culture from a client who has a
respiratory infection. Which of the following actions should the nurse take?
A. Wear sterile gloves when collecting the specimen.
B. Offer the client oral hygiene after the collection
C. Collect the specimen in the evening.
D Collect 1 ml of sputum. - ANSWER--b
, A nurse is assessing an older client. Which of the following findings should the
nurse expect?
a. Decreased sense of balanced
b. Increased nighttime sleeping
c. Heightened sense of pain
d. Nighttime urinary incontinence - ANSWER--a
A nurse is completing discharge teaching about ostomy care with a client who has
a new stoma. Which of the following instructions should the nurse include in the
teaching? (select all that apply)
a. "Cut the opening of the pouch 1⁄8 of an inch larger than the stoma "
b. "Place a piece a gauze over the stoma while changing the pouch"
c. "Use povidone-iodine to clean around the stoma"
d. "Empty the ostomy pouch when it becomes one-third full of contents"
e. expect the stoma to turn a purple-blue color as its heals" - ANSWER--a, b, c, d
A nurse is preparing to obtain informed consent from a client who speaks a
different language than the nurse. Which of the following actions should the nurse
take?
a. "Request that an assistive personnel interpret the information for the client"
b. "Use proper medical terms when giving information to the client"
c. "Offer written information in the client's language"
d. "Avoid using gestures when speaking to the client" - ANSWER--c
A nurse is teaching a client about home care equipment. Which of the following
information should the nurse include in the teaching? (select all that apply)
the nurse delegate to an assistive personnel?
a. Changing the dressing for a client who has a stage 3 pressure injury
b. Determining a client's response to a diuretic
c. Comparing radial pulses for a client who is postoperative
d. d.Providingpostmortem care to a client - ANSWER--d
A nurse is conducting a health assessment for a client who takes herbal
supplements. Which of the following statements by the client indicates an
understanding of the use of the supplements?
A. I take ginkgo biloba for a headache
B. I take echinacea to control my cholesterol
C. I use ginger when I get car sick
D. I use garlic for my menopausal symptoms - ANSWER--c
A nurse is caring for a client who has influenza and isolation precautions in place.
Which of the following actions should the nurse take to prevent the spread of
infection?
A. Wear a mask when working within 3 feet of the client
B. Administer metronidazole
C. Don protective eyewear before entering the room.
D. Place the client in a negative airflow room. - ANSWER--a
A nurse obtains a prescription for wrist restraints for a client who is trying to pull
out his NG tube. Which of the following actions should the nurse take?
,A. Attach the restraints securely to the side rails of the client's bed.
B. Apply the restraints to allow as little movement as possible
C.Allow room for two fingers to fit between the clients skin and the restraints
e. remove the restraints every 4 hours - ANSWER--c
A nurse is admitting a client who has tuberculosis. Which of the following types of
transmission precautions should the nurse plan to initiate?
A. Droplet
B. Airbornes
c. protective environment
d. contact - ANSWER--b
A nurse in a well-child clinic receives a telephone call from a parent who states
that their child accidentally swallowed paint thinner. The child is awake and alert.
Which of the following responses should the nurse make?
A. Have your child drink one large glass of water.
B. Hang up and call a poison control center hotline.
C. Bring your child into the clinic later today.
D. Induce vomiting in your child with syrup of ipecac. - ANSWER--a
A nurse is documenting a client's medical record. Which of the following entries
should the nurse record.
A. Oral temperature slightly elevated at 0800
B. Administered pain medication
C. Incision without redness or drainage
,D. Drank adequate amounts of fluid with meals. - ANSWER--b
A nurse is providing oral care for a client who is unconscious. Which of the
following actions should the nurse take?
A. Place the client in a side-lying position.
B. Brush the clients teeth daily
C. Apply mineral oil to the client's lips
D. Rinse the client's mouth with an alcohol-based mouthwash - ANSWER--a
A nurse is collaborating with a risk management team about potential legal issues
involving client care. The nurse should identify which of the following situations is
an example of negligence?
A. A nurse administers a medication without first identifying the client.
B. An assistive personnel discusses client care in the facility cafeteria with visitors
present.
C. A nurse begins a blood transfusion without obtaining consent.
D. An assistive personnel prevents a client from leaving the facility. - ANSWER--c
A nurse is collecting a sputum specimen for culture from a client who has a
respiratory infection. Which of the following actions should the nurse take?
A. Wear sterile gloves when collecting the specimen.
B. Offer the client oral hygiene after the collection
C. Collect the specimen in the evening.
D Collect 1 ml of sputum. - ANSWER--b
, A nurse is assessing an older client. Which of the following findings should the
nurse expect?
a. Decreased sense of balanced
b. Increased nighttime sleeping
c. Heightened sense of pain
d. Nighttime urinary incontinence - ANSWER--a
A nurse is completing discharge teaching about ostomy care with a client who has
a new stoma. Which of the following instructions should the nurse include in the
teaching? (select all that apply)
a. "Cut the opening of the pouch 1⁄8 of an inch larger than the stoma "
b. "Place a piece a gauze over the stoma while changing the pouch"
c. "Use povidone-iodine to clean around the stoma"
d. "Empty the ostomy pouch when it becomes one-third full of contents"
e. expect the stoma to turn a purple-blue color as its heals" - ANSWER--a, b, c, d
A nurse is preparing to obtain informed consent from a client who speaks a
different language than the nurse. Which of the following actions should the nurse
take?
a. "Request that an assistive personnel interpret the information for the client"
b. "Use proper medical terms when giving information to the client"
c. "Offer written information in the client's language"
d. "Avoid using gestures when speaking to the client" - ANSWER--c
A nurse is teaching a client about home care equipment. Which of the following
information should the nurse include in the teaching? (select all that apply)
