When the nurse administers the morning dose of a medication during the evening,
which of the rights of medication administration has he or she failed to follow? -
CORRECT ANSWERS-time
A nurse is preparing to administer a prescribed antiarrhythmic agent to a client. The
nurse would evaluate which aspect to determine the drug's effectiveness? -CORRECT
ANSWERS-cardiac rate and rhythm
A client has arrived in the same-day surgery suite. He or she states, "I am so worried
about being put to sleep and having the surgery." What would be the nurse's best -
CORRECT ANSWERS-Tell me what you are most worried about.
Which nursing action provides the greatest assistance in healing? -CORRECT
ANSWERS-maintaining a restful environment
A client is being discharged following surgery for cancer care. The client will require
extensive dressing changes two times per day. The client is on a fixed income and
cannot afford to purchase dressing supplies. The nurse contacts a local nonprofit
agency to assist in the provision of dressings. This contribution in care will assist in
improving the client's: -CORRECT ANSWERS-self-concept
When an older adult client is brought to the recovery room and presents with irregular,
loud respirations, the nurse determines that this is most likely a result of: -CORRECT
ANSWERS-a partial airway obstruction
A client states to the nurse during a sleep assessment that it takes her more than 60
minutes to fall asleep. The nurse documents this time period as the client's: -CORRECT
ANSWERS-sleep latencey
Because of high divorce rates and separations in recent years, there has been a
significant increase in the family structure termed: -CORRECT ANSWERS-single parent
When a client tells the nurse about being divorced and remarried with one child from the
first marriage, the nurse documents the client's family structure as: -CORRECT
ANSWERS-blended
During an interview, the client states, "When my stress is really high, I have diarrhea."
The physiologic response affects: -CORRECT ANSWERS-Gastrointestinal status
1|Page
,A client is discussing stressors with the nurse and is describing feeling better after
taking a brisk walk. The client's action is an example of: -CORRECT ANSWERS-
adaption
Which manifestation of grief by the client who lost his wife 3 years earlier is considered
abnormal? -CORRECT ANSWERS-leaving the wife's room and belongings intact
The hospice nurse is caring for a client with lung cancer. The client's daughter states,
"My mom isn't happy with anything I do for her. She is constantly yelling at me." -
CORRECT ANSWERS-anger
"My father has been dead for over a year and my mother still can't talk about him
without crying. Is that normal?" What is the best response by the nurse? -CORRECT
ANSWERS-The inability to talk about your dad without crying, even after a year, is still
considered normal."
During a routine vital sign assessment, the nurse notes the client's blood pressure is
212/110. Why is this finding particularly significant? -CORRECT ANSWERS-It deviates
from normal and is significant.
The normal adult temperature obtained through the oral route ranges from: -CORRECT
ANSWERS-97.6°F to 99.6°F (36.4°C to 37.6°C).
To assess the client's pulse, the nurse knows the normal range for pulse rate of a
healthy adult is: -CORRECT ANSWERS-60 to 100 beats per minute.
Infants and children's pulses vary most with: -CORRECT ANSWERS-Respirations
An ultrasonic Doppler is used for: -CORRECT ANSWERS-Auscultating a pulse that is
difficult to palpate.
An adult pulse greater than 100 beats per minute is: -CORRECT ANSWERS-
Tachycardia
A client has smoked most of his life and has labored respirations. He is experiencing: -
CORRECT ANSWERS-Dyspnea
Which outcome best reflects achievement of the goal, "The client will demonstrate
correct steps in taking his own pulse rate"? -CORRECT ANSWERS-Palpation of the
radial pulse on the thumb side of the inner aspect of the wrist.
What is the most common reason people contact healthcare providers? -CORRECT
ANSWERS-infectious disease
2|Page
, The nurse performs hand hygiene with soap and water before caring for a client. What
is the primary rationale for this action? -CORRECT ANSWERS-To eliminate disease-
producing organisms from the nurse's skin
A nursing student presents to the university health center reporting a sore throat,
malaise, and loss of appetite. The nurse assesses the student and determines he or
she has large, white-yellow exudates in the back of the throat and a fever. The student
is presenting with: -CORRECT ANSWERS-An infectious disease
When a nurse picks up a client's contaminated tissue without gloves and fails to wash
the hands sufficiently, the nurse provides for the client's organisms to be spread by
which type of transmission? -CORRECT ANSWERS-Contact
What is the most common client site for development of healthcare-associated
infections (HAl)? -CORRECT ANSWERS-UTI
When the client who has been diagnosed with hepatitis B has been hospitalized, the
type of isolation the nursing staff should observe is: -CORRECT ANSWERS-Droplet
precautions.
A client has an inguinal hernia repair and later develops a methicillin-resistant
Staphylococcus aureus (MRSA) infection at the surgical site. What is the most important
factor to prevent this infection? -CORRECT ANSWERS-Surgical asepsis
The nurse explains to the client that the first line of defense against infection is: -
CORRECT ANSWERS-Intact skin and mucous membranes.
When a female African American adolescent client asks the nurse how to care for her
long hair, which is braided into small braids, the nurse should instruct the client that: -
CORRECT ANSWERS-Hair should be washed as often as necessary
A new mother has brought her infant into the pediatric clinic. The infant has an
excoriation on the buttocks. What should the nurse instruct the mother? -CORRECT
ANSWERS-Keep the diaper and buttocks clean and dry and apply zinc oxide.
The nurse is caring for a woman who informs the nurse that she needs assistance to
remove and clean her glass eye. What actions by the nurse are most appropriate to
accomplish the task? -CORRECT ANSWERS-Pull down on the lower lid and exert slight
pressure below the lid.
A parent reports that their water is not fluoridated and questions the nurse whether her
9-year-old child needs fluoride supplements. Which response by the nurse is most
appropriate? -CORRECT ANSWERS-In the absence of fluoridated water supplies,
supplementation is recommended
3|Page
which of the rights of medication administration has he or she failed to follow? -
CORRECT ANSWERS-time
A nurse is preparing to administer a prescribed antiarrhythmic agent to a client. The
nurse would evaluate which aspect to determine the drug's effectiveness? -CORRECT
ANSWERS-cardiac rate and rhythm
A client has arrived in the same-day surgery suite. He or she states, "I am so worried
about being put to sleep and having the surgery." What would be the nurse's best -
CORRECT ANSWERS-Tell me what you are most worried about.
Which nursing action provides the greatest assistance in healing? -CORRECT
ANSWERS-maintaining a restful environment
A client is being discharged following surgery for cancer care. The client will require
extensive dressing changes two times per day. The client is on a fixed income and
cannot afford to purchase dressing supplies. The nurse contacts a local nonprofit
agency to assist in the provision of dressings. This contribution in care will assist in
improving the client's: -CORRECT ANSWERS-self-concept
When an older adult client is brought to the recovery room and presents with irregular,
loud respirations, the nurse determines that this is most likely a result of: -CORRECT
ANSWERS-a partial airway obstruction
A client states to the nurse during a sleep assessment that it takes her more than 60
minutes to fall asleep. The nurse documents this time period as the client's: -CORRECT
ANSWERS-sleep latencey
Because of high divorce rates and separations in recent years, there has been a
significant increase in the family structure termed: -CORRECT ANSWERS-single parent
When a client tells the nurse about being divorced and remarried with one child from the
first marriage, the nurse documents the client's family structure as: -CORRECT
ANSWERS-blended
During an interview, the client states, "When my stress is really high, I have diarrhea."
The physiologic response affects: -CORRECT ANSWERS-Gastrointestinal status
1|Page
,A client is discussing stressors with the nurse and is describing feeling better after
taking a brisk walk. The client's action is an example of: -CORRECT ANSWERS-
adaption
Which manifestation of grief by the client who lost his wife 3 years earlier is considered
abnormal? -CORRECT ANSWERS-leaving the wife's room and belongings intact
The hospice nurse is caring for a client with lung cancer. The client's daughter states,
"My mom isn't happy with anything I do for her. She is constantly yelling at me." -
CORRECT ANSWERS-anger
"My father has been dead for over a year and my mother still can't talk about him
without crying. Is that normal?" What is the best response by the nurse? -CORRECT
ANSWERS-The inability to talk about your dad without crying, even after a year, is still
considered normal."
During a routine vital sign assessment, the nurse notes the client's blood pressure is
212/110. Why is this finding particularly significant? -CORRECT ANSWERS-It deviates
from normal and is significant.
The normal adult temperature obtained through the oral route ranges from: -CORRECT
ANSWERS-97.6°F to 99.6°F (36.4°C to 37.6°C).
To assess the client's pulse, the nurse knows the normal range for pulse rate of a
healthy adult is: -CORRECT ANSWERS-60 to 100 beats per minute.
Infants and children's pulses vary most with: -CORRECT ANSWERS-Respirations
An ultrasonic Doppler is used for: -CORRECT ANSWERS-Auscultating a pulse that is
difficult to palpate.
An adult pulse greater than 100 beats per minute is: -CORRECT ANSWERS-
Tachycardia
A client has smoked most of his life and has labored respirations. He is experiencing: -
CORRECT ANSWERS-Dyspnea
Which outcome best reflects achievement of the goal, "The client will demonstrate
correct steps in taking his own pulse rate"? -CORRECT ANSWERS-Palpation of the
radial pulse on the thumb side of the inner aspect of the wrist.
What is the most common reason people contact healthcare providers? -CORRECT
ANSWERS-infectious disease
2|Page
, The nurse performs hand hygiene with soap and water before caring for a client. What
is the primary rationale for this action? -CORRECT ANSWERS-To eliminate disease-
producing organisms from the nurse's skin
A nursing student presents to the university health center reporting a sore throat,
malaise, and loss of appetite. The nurse assesses the student and determines he or
she has large, white-yellow exudates in the back of the throat and a fever. The student
is presenting with: -CORRECT ANSWERS-An infectious disease
When a nurse picks up a client's contaminated tissue without gloves and fails to wash
the hands sufficiently, the nurse provides for the client's organisms to be spread by
which type of transmission? -CORRECT ANSWERS-Contact
What is the most common client site for development of healthcare-associated
infections (HAl)? -CORRECT ANSWERS-UTI
When the client who has been diagnosed with hepatitis B has been hospitalized, the
type of isolation the nursing staff should observe is: -CORRECT ANSWERS-Droplet
precautions.
A client has an inguinal hernia repair and later develops a methicillin-resistant
Staphylococcus aureus (MRSA) infection at the surgical site. What is the most important
factor to prevent this infection? -CORRECT ANSWERS-Surgical asepsis
The nurse explains to the client that the first line of defense against infection is: -
CORRECT ANSWERS-Intact skin and mucous membranes.
When a female African American adolescent client asks the nurse how to care for her
long hair, which is braided into small braids, the nurse should instruct the client that: -
CORRECT ANSWERS-Hair should be washed as often as necessary
A new mother has brought her infant into the pediatric clinic. The infant has an
excoriation on the buttocks. What should the nurse instruct the mother? -CORRECT
ANSWERS-Keep the diaper and buttocks clean and dry and apply zinc oxide.
The nurse is caring for a woman who informs the nurse that she needs assistance to
remove and clean her glass eye. What actions by the nurse are most appropriate to
accomplish the task? -CORRECT ANSWERS-Pull down on the lower lid and exert slight
pressure below the lid.
A parent reports that their water is not fluoridated and questions the nurse whether her
9-year-old child needs fluoride supplements. Which response by the nurse is most
appropriate? -CORRECT ANSWERS-In the absence of fluoridated water supplies,
supplementation is recommended
3|Page
