A nurse in a long-term care facility is performing a fall risk assessment on a newly
admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod
cane for ambulation. Which of the following actions should the nurse take when using
this test?
A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test
B. Instruct the client to perform the TUG test without the use of the cane
C. Assist the client to stand up from the chair when starting the TUG test
D. Advise the client to use the arms of the chair to stand when starting the TUG test - A.
Observe the client ambulating a distance of 3m(10 feet) during the TUG test
The nurse should instruct the client to stand, ambulate to the marked spot, turn,
ambulate back to the chair, and sit down. The nurse should observe the client's ability to
perform the test and use a stopwatch to time the client. The nurse should identify that
the client is at increased risk of falls if it takes longer than 14 seconds to complete the
test
A nurse in an emergency room is caring for an infant who required emergency surgery.
The infant is accompanies by his 16 year old mother and his sternal grandfather. Which
of the following should the nurse take when assisting with informed consent
A. Witness consent obtained from the infants mother
B. Inform the family that informed consent is not needed due to the emergency surgery
C. Notify the maternal grandfather that he is required to give informed consent
D. Request that a court-appointed representative provide consent - A. Witness consent
obtained from the infants mother
The nurse should assist in obtaining informed consent from the infant's mother by
witnessing her signature. Statutory guidelines indicate that a minor, even if
unemancipated, can provide consent for her infant
A nurse is planning care to prevent a catheter-related blood stream infection for a client
who is receiving IV fluid therapy. Which of the following interventions should the nurse
include in the plan
A. Change bags of IV solution every 72 hours
B. Perform hand hygiene before touching the IV tubing
C. Use hydrogen peroxide to cleanse the IV insertion site
D. Assess the IV insertion site every 12 hours for redness - B. Perform hand hygiene
before touching the IV tubing
A nurse is caring for an adolescent client who is in critical condition following a motor
vehicle crash in which he was the passenger. The client's parent shouts at the nurse,
asking why her son is dying instead of the driver. Which of the following actions should
the nurse take to provide emotional support to The parent?
,A. Encourage the parent to speak with the family of the driver of the car.
B. Inform the parent that anger is a natural response when dealing with loss.
C. Ask the parent to leave and come back later after she has calmed down.
D. Contact a clergy member to come and speak with the parent. - B. Inform the parent
that anger is a natural response when dealing with loss.
A nurse is teaching about advance directives with an older adult client who has a
terminal illness. Which of the following statements should the nurse make?
A. "Having advance directives means that you don't want to receive CPR."
B. "Your next of kin can amend your advance directives for you if you are unconscious."
C. "Advance directives are verbal or written instructions."
D. "Your advance directives can designate a friend to make your health care decisions."
- D. "Your advance directives can designate a friend to make your health care
decisions."
A nurse is assessing a preschooler who has a UTI. Which of the following should the
nurse inspect?
A. Diarrhea
B. Abdominal Pain
C. Increased Thirst
D. Skin Rash - B. Abdominal Pain
Other manifestations include constipation, dysuria, foul-smelling urine, fever
A nurse is counseling a client who has a family history of colorectal cancer about
management of nutrition to help prevent GI cancers. Which of the following images
indicated a food or beverage the nurse should encourage?
A. Wine
B. Fruit
C. Fried Chicken
D. Bread - B. Fruit
Consume at least 2.5 cups of fruit and vegetables per day to help reduce the risk of
cancers of the GI system
A nurse is preparing to extinguish a small fire in a client's room. Which of the following
actions should the nurse take?
A. Aim the extinguisher at the top of the flames
B. Pump the handles of the extinguisher up and down three times
C. Sweep the fire extinguisher in a circular motion until fire is extinguished
,D. Slide the pin on the top of the fire extinguisher straight out - D. Slide the pin on the
top of the fire extinguisher straight out
A nurse is caring for a child who has celiac disease. Which of the following items should
be removed from the meal tray?
A. Corn-flake cereal
B. Orange juice
C. Scrambled eggs
D. Oatmeal with raisins - D. Oatmeal with raisins
Celiac disease is the intolerance to dietary gluten, which is a protein in wheat, rye, oats,
and barley. This intolerance causes diarrhea, weight loss, abdominal pain, and fatigue
A nurse at a provider's office is counseling a client who reports insomnia. Which of the
following statements should the nurse make to include the clients preferences into sleep
promotion plan?
A. "If alcoholic beverages are desires, consume them in the early evening"
B. "Sleep in the location of your home where you feel you rest best."
C. "Turn on a favorite television show just before going to bed."
D. "Allow your sleep and wake times to vary depending on how you feel each day." - B.
"Sleep in the location of your home where you feel you rest best."
Whether it be a bed, couch, or chair
A nurse is assessing the spiritual wellbeing and development of a preschooler. The
nurse asks "why is it wrong to kick your baby sister?" Which of the following responses
should the nurse expect?
A. "Its not wrong because she made me mad"
B. "Its wrong because my dad said I cant kick her"
C. "It wrong to kick her because the gods wont like it"
D. "Its wrong because she would get hurt and be sad" - B. "Its wrong because my dad
said I cant kick her"
The nurse should expect the preschooler to be motivated to choose right from wrong
because of rules taught to him by his parents. The nurse should understand that, even
though the preschooler might know the rules, he is not yet able to understand the
rationale for the rules
A nurse in a long-term care facility is admitting a new client following a brief stay in
acute care. In adherence with the Joint Commission National Patient Safety Goals
regarding medication administration, which of the following actions should the nurse
take?
, A. Inform the client that he will not be receiving medications he took prior to his
hospitalization
B. Compare a list of the clients current medications with the ones he will take in long-
term care
C. Eliminate any OTC products from the clients current medication list
D. Omit the medication indications when listing the clients medication dose information -
B. Compare a list of the clients current medications with the ones he will take in long-
term care
The Joint Commission National Patient Safety Goals regarding medication reconciliation
includes maintaining and communicating accurate client medication information. The
nurse should complete a medication reconciliation to identify and resolve any
discrepancies by comparing the client's list of current medications with the medications
he will take in the long-term care facility and addressing any duplications, omissions, or
interactions
A nurse is caring for a client who is 2 days postoperative following an above-the- knee
amputation. The client states he is experience in a dull, burning pain in the leg that was
amputated. Which of the following should the nurse take to treat the client's neuropathic
pain
A. Inform the client that phantom limb pain is not real
B. Administer a beta-blocking medication to the client
C. Place the client on a soft mattress
D. Loosen the bandage on the client's residual limb - B. Administer a beta-blocking
medication to the client
This classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain
A nurse is teaching the parent of a toddler about home injury prevention. When
discussing snacks, which of the rolling statements by the parent indicates an
understanding of the teaching?
A. "I can offer her grapes as long as I peel them first?"
B. "I can give her watermelon pieces after I remove the seeds."
C. "I should give her popcorn that is air-popped and without salt or butter."
D. "I should cut hot dogs into thin, round slices before giving them to her." - B. "I can
give her watermelon pieces after I remove the seeds."
The nurse should inform the parent that toddlers can easily choke on seeds from fruits,
such as watermelon seeds or cherry pits, because of their round shape and size.
Removing the seeds and cutting the watermelon into pieces provides the toddler with a
nutritious snack that does not increase the toddler's risk of foreign body obstruction
admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod
cane for ambulation. Which of the following actions should the nurse take when using
this test?
A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test
B. Instruct the client to perform the TUG test without the use of the cane
C. Assist the client to stand up from the chair when starting the TUG test
D. Advise the client to use the arms of the chair to stand when starting the TUG test - A.
Observe the client ambulating a distance of 3m(10 feet) during the TUG test
The nurse should instruct the client to stand, ambulate to the marked spot, turn,
ambulate back to the chair, and sit down. The nurse should observe the client's ability to
perform the test and use a stopwatch to time the client. The nurse should identify that
the client is at increased risk of falls if it takes longer than 14 seconds to complete the
test
A nurse in an emergency room is caring for an infant who required emergency surgery.
The infant is accompanies by his 16 year old mother and his sternal grandfather. Which
of the following should the nurse take when assisting with informed consent
A. Witness consent obtained from the infants mother
B. Inform the family that informed consent is not needed due to the emergency surgery
C. Notify the maternal grandfather that he is required to give informed consent
D. Request that a court-appointed representative provide consent - A. Witness consent
obtained from the infants mother
The nurse should assist in obtaining informed consent from the infant's mother by
witnessing her signature. Statutory guidelines indicate that a minor, even if
unemancipated, can provide consent for her infant
A nurse is planning care to prevent a catheter-related blood stream infection for a client
who is receiving IV fluid therapy. Which of the following interventions should the nurse
include in the plan
A. Change bags of IV solution every 72 hours
B. Perform hand hygiene before touching the IV tubing
C. Use hydrogen peroxide to cleanse the IV insertion site
D. Assess the IV insertion site every 12 hours for redness - B. Perform hand hygiene
before touching the IV tubing
A nurse is caring for an adolescent client who is in critical condition following a motor
vehicle crash in which he was the passenger. The client's parent shouts at the nurse,
asking why her son is dying instead of the driver. Which of the following actions should
the nurse take to provide emotional support to The parent?
,A. Encourage the parent to speak with the family of the driver of the car.
B. Inform the parent that anger is a natural response when dealing with loss.
C. Ask the parent to leave and come back later after she has calmed down.
D. Contact a clergy member to come and speak with the parent. - B. Inform the parent
that anger is a natural response when dealing with loss.
A nurse is teaching about advance directives with an older adult client who has a
terminal illness. Which of the following statements should the nurse make?
A. "Having advance directives means that you don't want to receive CPR."
B. "Your next of kin can amend your advance directives for you if you are unconscious."
C. "Advance directives are verbal or written instructions."
D. "Your advance directives can designate a friend to make your health care decisions."
- D. "Your advance directives can designate a friend to make your health care
decisions."
A nurse is assessing a preschooler who has a UTI. Which of the following should the
nurse inspect?
A. Diarrhea
B. Abdominal Pain
C. Increased Thirst
D. Skin Rash - B. Abdominal Pain
Other manifestations include constipation, dysuria, foul-smelling urine, fever
A nurse is counseling a client who has a family history of colorectal cancer about
management of nutrition to help prevent GI cancers. Which of the following images
indicated a food or beverage the nurse should encourage?
A. Wine
B. Fruit
C. Fried Chicken
D. Bread - B. Fruit
Consume at least 2.5 cups of fruit and vegetables per day to help reduce the risk of
cancers of the GI system
A nurse is preparing to extinguish a small fire in a client's room. Which of the following
actions should the nurse take?
A. Aim the extinguisher at the top of the flames
B. Pump the handles of the extinguisher up and down three times
C. Sweep the fire extinguisher in a circular motion until fire is extinguished
,D. Slide the pin on the top of the fire extinguisher straight out - D. Slide the pin on the
top of the fire extinguisher straight out
A nurse is caring for a child who has celiac disease. Which of the following items should
be removed from the meal tray?
A. Corn-flake cereal
B. Orange juice
C. Scrambled eggs
D. Oatmeal with raisins - D. Oatmeal with raisins
Celiac disease is the intolerance to dietary gluten, which is a protein in wheat, rye, oats,
and barley. This intolerance causes diarrhea, weight loss, abdominal pain, and fatigue
A nurse at a provider's office is counseling a client who reports insomnia. Which of the
following statements should the nurse make to include the clients preferences into sleep
promotion plan?
A. "If alcoholic beverages are desires, consume them in the early evening"
B. "Sleep in the location of your home where you feel you rest best."
C. "Turn on a favorite television show just before going to bed."
D. "Allow your sleep and wake times to vary depending on how you feel each day." - B.
"Sleep in the location of your home where you feel you rest best."
Whether it be a bed, couch, or chair
A nurse is assessing the spiritual wellbeing and development of a preschooler. The
nurse asks "why is it wrong to kick your baby sister?" Which of the following responses
should the nurse expect?
A. "Its not wrong because she made me mad"
B. "Its wrong because my dad said I cant kick her"
C. "It wrong to kick her because the gods wont like it"
D. "Its wrong because she would get hurt and be sad" - B. "Its wrong because my dad
said I cant kick her"
The nurse should expect the preschooler to be motivated to choose right from wrong
because of rules taught to him by his parents. The nurse should understand that, even
though the preschooler might know the rules, he is not yet able to understand the
rationale for the rules
A nurse in a long-term care facility is admitting a new client following a brief stay in
acute care. In adherence with the Joint Commission National Patient Safety Goals
regarding medication administration, which of the following actions should the nurse
take?
, A. Inform the client that he will not be receiving medications he took prior to his
hospitalization
B. Compare a list of the clients current medications with the ones he will take in long-
term care
C. Eliminate any OTC products from the clients current medication list
D. Omit the medication indications when listing the clients medication dose information -
B. Compare a list of the clients current medications with the ones he will take in long-
term care
The Joint Commission National Patient Safety Goals regarding medication reconciliation
includes maintaining and communicating accurate client medication information. The
nurse should complete a medication reconciliation to identify and resolve any
discrepancies by comparing the client's list of current medications with the medications
he will take in the long-term care facility and addressing any duplications, omissions, or
interactions
A nurse is caring for a client who is 2 days postoperative following an above-the- knee
amputation. The client states he is experience in a dull, burning pain in the leg that was
amputated. Which of the following should the nurse take to treat the client's neuropathic
pain
A. Inform the client that phantom limb pain is not real
B. Administer a beta-blocking medication to the client
C. Place the client on a soft mattress
D. Loosen the bandage on the client's residual limb - B. Administer a beta-blocking
medication to the client
This classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain
A nurse is teaching the parent of a toddler about home injury prevention. When
discussing snacks, which of the rolling statements by the parent indicates an
understanding of the teaching?
A. "I can offer her grapes as long as I peel them first?"
B. "I can give her watermelon pieces after I remove the seeds."
C. "I should give her popcorn that is air-popped and without salt or butter."
D. "I should cut hot dogs into thin, round slices before giving them to her." - B. "I can
give her watermelon pieces after I remove the seeds."
The nurse should inform the parent that toddlers can easily choke on seeds from fruits,
such as watermelon seeds or cherry pits, because of their round shape and size.
Removing the seeds and cutting the watermelon into pieces provides the toddler with a
nutritious snack that does not increase the toddler's risk of foreign body obstruction
