,A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the
following instructions should the nurse include in the teaching?
1) Take temperature once a day.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and
tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this
client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway..
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and
reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse
take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale
,A bnurse bis bcaring bfor ba bclient bwho bhas ba btemperature bof b39.7° bC b(103.5° bF) band bhas ba bprescription
b for ba bhypothermia bblanket. bThe bnurse bshould bmonitor bthe bclient bfor bwhich bof bthe bfollowing badverse
b effects bofbthe bhypothermia bblanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia
A bnurse bis breinforcing bteaching babout bexercise bwith ba bclient bwho bhas btype b1 bdiabetes bmellitus.
b Which bofbthe bfollowing bstatements bby bthe bclient bindicates ban bunderstanding bof bthe bteaching?
1) "I bwill bcarry ba bcomplex bcarbohydrate bsnack bwith bme bwhen bI bexercise."
2) "I bshould bexercise bfirst bthing bin bthe bmorning bbefore beating bbreakfast."
3) "I bshould bavoid binjecting binsulin binto bmy bthigh bif bI bam bgoing bto bgo brunning."
4) "I bwill bnot bexercise bif bmy burine bis bpositive bfor bketones."
A bnurse bnotes ba bsmall bsection bof bbowel bprotruding bfrom bthe babdominal bincision bof ba bclient bwho bis
b postoperative. bAfter bcalling bfor bassistance, bwhich bof bthe bfollowing bactions bshould bthe bnurse btake bfirst?
1) Cover bthe bclient's bwound bwith ba bmoist, bsterile bdressing.
2) Have bthe bclient blie bsupine bwith bknees bflexed.
3) Check bthe bclient's bvital bsigns.
4) Inform bthe bclient babout bthe bneed bto breturn bto bsurgery.
A bnurse bis bcollecting bdata bfrom ba bclient bwho bhas balcohol buse bdisorder band bis bexperiencing
b metabolicbacidosis. bWhich bof bthe bfollowing bmanifestations bshould bthe bnurse bexpect?
1) bCool, bclammy
b skin.b2)
b Hyperventilation
3) Increased bblood bpressure
4) Bradycardia
A bnurse bis breinforcing bdischarge bteaching bwith ba bclient bfollowing ba bcataract bextraction. bWhich bof
b thebfollowing bshould bthe bnurse binclude bin bthe bteaching?
, 1) Avoid bbending bat bthe bwaist.
2) Remove bthe beye bshield bat bbedtime.
3) Limit bthe buse bof blaxatives bif bconstipated.
4) Seeing bflashes bof blight bis ban bexpected bfinding bfollowing bextraction.
A bnurse bis bcaring bfor ba bclient bwho bhas bheart bfailure band bhas bbeen btaking bdigoxin b0.25 bmg bdaily. bThe
b clientbrefuses bbreakfast band breports bnausea. bWhich bof bthe bfollowing bactions bshould bthe bnurse btake
first?
b
1) Suggest bthat bthe bclient brests bbefore beating bthe bmeal.
2) Request ba bdietary bconsult.
3) Check bthe bclient's bvital bsigns.
4) Request ban border bfor ban bantiemetic.
A bnurse bis bcaring bfor ba bclient bwho bis b3 bdays bpostoperative bfollowing ba bcholecystectomy. bThe
b nurse bsuspects bthe bclient's bwound bis binfected bbecause bthe bdrainage bfrom bthe bdressing bis byellow
b and bthick.bWhich bof bthe bfollowing bfindings bshould bthe bnurse breport bas bthe btype bof bdrainage
b found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
A bnurse bis breinforcing bdischarge bteaching bto ba bclient bfollowing barthroscopic bsurgery. bTo bprevent
b postoperative bcomplications bwhich bof bthe bfollowing bactions bshould bbe breinforced bduring bthe bteaching?
1) Administer ban bopioid banalgesic bto bthe bclient b30 bmin bprior bto binitiating bCPM bexercises.
2) Place bthe bclient’s baffected bleg binto bthe bCPM bmachine bwith bthe bmachine bin bthe
b flexedbposition.
3) Place bthe bclient binto ba bhigh bFowler’s bposition bwhen binitiating bthe bCPM bexercises.
4) Align bthe bjoints bof bthe bCPM bmachine bwith bthe bknee bgatch bin bthe bclient’s bbed.
A bnurse bis bcollecting bdata bfrom ba bclient bwho bhas bemphysema. bWhich bof bthe bfollowing bfindings bshould
b thebnurse bexpect? b(Select ball bthat bapply.)
1) Dyspnea
2) Barrel bchest
following instructions should the nurse include in the teaching?
1) Take temperature once a day.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water.
A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and
tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this
client's secretions?
1) Provide humidified oxygen.
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the airway..
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and
reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse
take to promote the client's comfort?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the
prostate (TURP). Which of the following is the priority finding for the nurse report to the provider?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale
,A bnurse bis bcaring bfor ba bclient bwho bhas ba btemperature bof b39.7° bC b(103.5° bF) band bhas ba bprescription
b for ba bhypothermia bblanket. bThe bnurse bshould bmonitor bthe bclient bfor bwhich bof bthe bfollowing badverse
b effects bofbthe bhypothermia bblanket?
1) Shivering
2) Infection
3) Burns
4) Hypervolemia
A bnurse bis breinforcing bteaching babout bexercise bwith ba bclient bwho bhas btype b1 bdiabetes bmellitus.
b Which bofbthe bfollowing bstatements bby bthe bclient bindicates ban bunderstanding bof bthe bteaching?
1) "I bwill bcarry ba bcomplex bcarbohydrate bsnack bwith bme bwhen bI bexercise."
2) "I bshould bexercise bfirst bthing bin bthe bmorning bbefore beating bbreakfast."
3) "I bshould bavoid binjecting binsulin binto bmy bthigh bif bI bam bgoing bto bgo brunning."
4) "I bwill bnot bexercise bif bmy burine bis bpositive bfor bketones."
A bnurse bnotes ba bsmall bsection bof bbowel bprotruding bfrom bthe babdominal bincision bof ba bclient bwho bis
b postoperative. bAfter bcalling bfor bassistance, bwhich bof bthe bfollowing bactions bshould bthe bnurse btake bfirst?
1) Cover bthe bclient's bwound bwith ba bmoist, bsterile bdressing.
2) Have bthe bclient blie bsupine bwith bknees bflexed.
3) Check bthe bclient's bvital bsigns.
4) Inform bthe bclient babout bthe bneed bto breturn bto bsurgery.
A bnurse bis bcollecting bdata bfrom ba bclient bwho bhas balcohol buse bdisorder band bis bexperiencing
b metabolicbacidosis. bWhich bof bthe bfollowing bmanifestations bshould bthe bnurse bexpect?
1) bCool, bclammy
b skin.b2)
b Hyperventilation
3) Increased bblood bpressure
4) Bradycardia
A bnurse bis breinforcing bdischarge bteaching bwith ba bclient bfollowing ba bcataract bextraction. bWhich bof
b thebfollowing bshould bthe bnurse binclude bin bthe bteaching?
, 1) Avoid bbending bat bthe bwaist.
2) Remove bthe beye bshield bat bbedtime.
3) Limit bthe buse bof blaxatives bif bconstipated.
4) Seeing bflashes bof blight bis ban bexpected bfinding bfollowing bextraction.
A bnurse bis bcaring bfor ba bclient bwho bhas bheart bfailure band bhas bbeen btaking bdigoxin b0.25 bmg bdaily. bThe
b clientbrefuses bbreakfast band breports bnausea. bWhich bof bthe bfollowing bactions bshould bthe bnurse btake
first?
b
1) Suggest bthat bthe bclient brests bbefore beating bthe bmeal.
2) Request ba bdietary bconsult.
3) Check bthe bclient's bvital bsigns.
4) Request ban border bfor ban bantiemetic.
A bnurse bis bcaring bfor ba bclient bwho bis b3 bdays bpostoperative bfollowing ba bcholecystectomy. bThe
b nurse bsuspects bthe bclient's bwound bis binfected bbecause bthe bdrainage bfrom bthe bdressing bis byellow
b and bthick.bWhich bof bthe bfollowing bfindings bshould bthe bnurse breport bas bthe btype bof bdrainage
b found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
A bnurse bis breinforcing bdischarge bteaching bto ba bclient bfollowing barthroscopic bsurgery. bTo bprevent
b postoperative bcomplications bwhich bof bthe bfollowing bactions bshould bbe breinforced bduring bthe bteaching?
1) Administer ban bopioid banalgesic bto bthe bclient b30 bmin bprior bto binitiating bCPM bexercises.
2) Place bthe bclient’s baffected bleg binto bthe bCPM bmachine bwith bthe bmachine bin bthe
b flexedbposition.
3) Place bthe bclient binto ba bhigh bFowler’s bposition bwhen binitiating bthe bCPM bexercises.
4) Align bthe bjoints bof bthe bCPM bmachine bwith bthe bknee bgatch bin bthe bclient’s bbed.
A bnurse bis bcollecting bdata bfrom ba bclient bwho bhas bemphysema. bWhich bof bthe bfollowing bfindings bshould
b thebnurse bexpect? b(Select ball bthat bapply.)
1) Dyspnea
2) Barrel bchest
