1. A nurse is reviewing a clients labratory results
1. Metabolic alkalosis
2. Hypokalemia
2. A nurse is assessing a client who is receiving continuous blood transfusion. the
nurse notes ling crackles hypoxia and distended neck veins. Following actions
should the nurse take? SATA
a. Place the client in high fowler position 2
b. Administer oxygen to the client 3
c. Obtain a prescription for a diuretic
d. Administer epinephrine to client
e. Stop the transfusion 1
3. A nurse is caring for a client who has a tracheostomy. Which of the following
actions should the nurse take?
a. Secure the tracheostomy ties to allow one finger to fit snugly underneath
b. Use a cotton tip applicator clean inside the inner cannula
c. Soak the outer canula in warm soapy tap water.
d. Cleanse the skin around the stoma with normal saline
4. A nurse is caring for a client who has right sided paralysis following a
cerebrovascular accident. Which of the following prescription should the nurse
anticipate to prevent a planter flexion contracture of the affected extremity?
a. Continuous passive motion machine
b. Ankle foot orthotic
c. Sequential compression device
d. Abduction splint
5. A visitor reports to nurse that she slipped and fell in a client’s room. The visitor
denies any injury, but is walking with a slight limp. Which of the following
actions should the nurse take?
a. Compete an incident report
b. Send the visitor to the risk management office
c. Document the occurrence in the medical record
d. Administer acetaminophen to the client
6. A nurse is caring for a client who is immunocompromised. Which of the
following actions should the nurse take?
a. Have the client apply a mask when children are visiting
b. Cleanse hands with an alcohol-based hand rub before client contact
, c. Use sterile gloves to provide perineal care
d. Place the client in a semiprivate room
7. A nurse is teaching a client who requires maximal support about how to use a
two-wheeled walker. Which of the following actions by the client indicates an
understanding of teaching?
a. The client stoops slightly forward when moving the walker
b. The client moves the walker ahead 25.4 cm (10 in) with each step.
c. The client stands with her elbow slightly flexed while holding the
walker
d. The client picks up the walker with each step
8. A nurse is assessing an older adult client. Which of the following findings should
the nurse expect?
a. Increased nighttime sleeping
b. Night time urinary incontinence
c. Decreased sense of balance
d. Heightened sense of pain
9. A nurse is planning care to prevent skin breakdown for a client who is immobile
and urinary incontinence. Which of the following actions should the nurse
include in the plan of care?
a. Apply cornstarch to the client’s skin
b. Request a prescription for an indwelling urinary catheter
c. Reposition the client every 4 hr.
d. Arrange for an alternating pressure mattress
10. A nurse is performing hand hygiene at the beginning of his shift. Which of the
following actions should the nurse take?
a. Turn off the faucet with a clean dry paper towel
b. Rub his hands together to cause friction for at least 10 seconds
c. Keep his hands above elbow level when washing
d. Dry his hands by working from the forearms down to the fingertips
11. A nurse is caring for a client who has a chest tube following thoracic surgery.
Which of the following tasks should the nurse delegate to assistive personnel?
a. Evaluate the client’s response to pain medication
b. Teach deep breathing and coughing to the client
c. Assist the client to select food choices from the menu
d. Monitor the characteristics of the client’s chest tube drainage
1. Metabolic alkalosis
2. Hypokalemia
2. A nurse is assessing a client who is receiving continuous blood transfusion. the
nurse notes ling crackles hypoxia and distended neck veins. Following actions
should the nurse take? SATA
a. Place the client in high fowler position 2
b. Administer oxygen to the client 3
c. Obtain a prescription for a diuretic
d. Administer epinephrine to client
e. Stop the transfusion 1
3. A nurse is caring for a client who has a tracheostomy. Which of the following
actions should the nurse take?
a. Secure the tracheostomy ties to allow one finger to fit snugly underneath
b. Use a cotton tip applicator clean inside the inner cannula
c. Soak the outer canula in warm soapy tap water.
d. Cleanse the skin around the stoma with normal saline
4. A nurse is caring for a client who has right sided paralysis following a
cerebrovascular accident. Which of the following prescription should the nurse
anticipate to prevent a planter flexion contracture of the affected extremity?
a. Continuous passive motion machine
b. Ankle foot orthotic
c. Sequential compression device
d. Abduction splint
5. A visitor reports to nurse that she slipped and fell in a client’s room. The visitor
denies any injury, but is walking with a slight limp. Which of the following
actions should the nurse take?
a. Compete an incident report
b. Send the visitor to the risk management office
c. Document the occurrence in the medical record
d. Administer acetaminophen to the client
6. A nurse is caring for a client who is immunocompromised. Which of the
following actions should the nurse take?
a. Have the client apply a mask when children are visiting
b. Cleanse hands with an alcohol-based hand rub before client contact
, c. Use sterile gloves to provide perineal care
d. Place the client in a semiprivate room
7. A nurse is teaching a client who requires maximal support about how to use a
two-wheeled walker. Which of the following actions by the client indicates an
understanding of teaching?
a. The client stoops slightly forward when moving the walker
b. The client moves the walker ahead 25.4 cm (10 in) with each step.
c. The client stands with her elbow slightly flexed while holding the
walker
d. The client picks up the walker with each step
8. A nurse is assessing an older adult client. Which of the following findings should
the nurse expect?
a. Increased nighttime sleeping
b. Night time urinary incontinence
c. Decreased sense of balance
d. Heightened sense of pain
9. A nurse is planning care to prevent skin breakdown for a client who is immobile
and urinary incontinence. Which of the following actions should the nurse
include in the plan of care?
a. Apply cornstarch to the client’s skin
b. Request a prescription for an indwelling urinary catheter
c. Reposition the client every 4 hr.
d. Arrange for an alternating pressure mattress
10. A nurse is performing hand hygiene at the beginning of his shift. Which of the
following actions should the nurse take?
a. Turn off the faucet with a clean dry paper towel
b. Rub his hands together to cause friction for at least 10 seconds
c. Keep his hands above elbow level when washing
d. Dry his hands by working from the forearms down to the fingertips
11. A nurse is caring for a client who has a chest tube following thoracic surgery.
Which of the following tasks should the nurse delegate to assistive personnel?
a. Evaluate the client’s response to pain medication
b. Teach deep breathing and coughing to the client
c. Assist the client to select food choices from the menu
d. Monitor the characteristics of the client’s chest tube drainage
