A nurse is preparing to measure a client's oxygen saturation and notes edema of the clients
hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of
the following locations? - ANSWER Earlobe
A nurse is assisting with implementation of a bowel training program for a client. For the
program to be effective, the nurse should take the client to the bathroom At which of the
following times? - ANSWER When the client has the urge to defecate
A nurse is collecting data from a client who sustained blood loss. Which of the following
findings should the nurse identify as a manifestation of hypovolemia? -
ANSWER thready pulse
A nurse at a long term care facility is performing client checks and observes a fire in a client's
room. Which of the following should be the first action by the nurse? -
ANSWER Evacuate the client from the room
A nurse is caring for a client on Bedrest. Which of the following is the priority action to
include in the client's plan of care? - ANSWER Change clients position at least every
2hr
A nurse is performing tracheostomy care for a client. Which of the following actions should
the nurse take? - ANSWER Secure new trach ties before removing old ones
1
, A nurse is providing discharge teaching to a client following a right mastectomy. Which of
the following statements should indicate to the nurse that the client has a healthy body
image ? - ANSWER "The incision looks like it is healing."
A nurse is assisting with the care of a client who arrives at the emergency department after
an industrial explosion. The nurse inspects the wound on the client's leg has and finds torn
skin tissue underneath. The nurse should report this as which of the following types of
wounds? - ANSWER Laceration
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why
he needs to have oxygen tubing in his nose, which of the following explanations about the
cannula should the nurse give him? - ANSWER "It delivers the low concentration of
oxygen you need"
A nurse is assisting with the admission of a client who is dehydrated. Which of the following
BUN levels should the nurse expect the client to have? - ANSWER <24mg/dL
A nurse is working to develop a develop a therapeutic relationship with a client. The nurse
understands that which of the following is an example of the working phase of a therapeutic
relationship? - ANSWER Instructing the client on methods to achieve goals
While collecting data from an older adult client, the nurse learns that she has had difficulty
sleeping at night for several months. When evaluating the client's sleep disturbances, the
nurse should remember which of the following? - ANSWER Chronic pain and illness
interfere with sleep patterns
A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take to help prevent an incisional infection? - ANSWER Perform hand hygiene
prior to dressing changes
A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy.
When the nurse enters the client's room, he states that, following a bout of coughing,
"something popped in my belly." The nurse lifts the sheets and sees that the client's gown is
2
hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of
the following locations? - ANSWER Earlobe
A nurse is assisting with implementation of a bowel training program for a client. For the
program to be effective, the nurse should take the client to the bathroom At which of the
following times? - ANSWER When the client has the urge to defecate
A nurse is collecting data from a client who sustained blood loss. Which of the following
findings should the nurse identify as a manifestation of hypovolemia? -
ANSWER thready pulse
A nurse at a long term care facility is performing client checks and observes a fire in a client's
room. Which of the following should be the first action by the nurse? -
ANSWER Evacuate the client from the room
A nurse is caring for a client on Bedrest. Which of the following is the priority action to
include in the client's plan of care? - ANSWER Change clients position at least every
2hr
A nurse is performing tracheostomy care for a client. Which of the following actions should
the nurse take? - ANSWER Secure new trach ties before removing old ones
1
, A nurse is providing discharge teaching to a client following a right mastectomy. Which of
the following statements should indicate to the nurse that the client has a healthy body
image ? - ANSWER "The incision looks like it is healing."
A nurse is assisting with the care of a client who arrives at the emergency department after
an industrial explosion. The nurse inspects the wound on the client's leg has and finds torn
skin tissue underneath. The nurse should report this as which of the following types of
wounds? - ANSWER Laceration
A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why
he needs to have oxygen tubing in his nose, which of the following explanations about the
cannula should the nurse give him? - ANSWER "It delivers the low concentration of
oxygen you need"
A nurse is assisting with the admission of a client who is dehydrated. Which of the following
BUN levels should the nurse expect the client to have? - ANSWER <24mg/dL
A nurse is working to develop a develop a therapeutic relationship with a client. The nurse
understands that which of the following is an example of the working phase of a therapeutic
relationship? - ANSWER Instructing the client on methods to achieve goals
While collecting data from an older adult client, the nurse learns that she has had difficulty
sleeping at night for several months. When evaluating the client's sleep disturbances, the
nurse should remember which of the following? - ANSWER Chronic pain and illness
interfere with sleep patterns
A nurse is caring for a client who is postoperative. Which of the following actions should the
nurse take to help prevent an incisional infection? - ANSWER Perform hand hygiene
prior to dressing changes
A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy.
When the nurse enters the client's room, he states that, following a bout of coughing,
"something popped in my belly." The nurse lifts the sheets and sees that the client's gown is
2
