1. A nurse is delegating client care assignments. Which of the following tasks
should the nurse assign to the assistive personnel?
Apply an anti-embolic stocking for a client who is 2 days post-op
2. A nurse is caring for a client following an electroconvulsive therapy. What nursing
action?
Continuously reorient client after ECT
3. A nurse is caring for a client who is taking multiple medications about the
possible interactions. Which of the following members of the interdisciplinary
team should the nurse make a referral to?
Advance practice nurse
4. A nurse manage is taking measures to increase cost effective. In which of the
following client situations should the nurse manager intervene?
A nurse uses sterile gauze pads to place a dressing on a surgical wound.
5. A nurse is contributing to the plan of care for client who has ascites due to
cirrhosis. Which of the following interventions should the nurse recommend
including in the plan?
Measure the client's abdominal girth daily
6. A nurse in an urgent care clinic is caring for a client who reports recently using
methylenedioxy-methamphetamine. Which of the following findings should the
nurse expect?
Hallucinations
7. A nurse preparing a sterile field to perform a dressing change for a client's leg
wound. Which of the following actions should the nurse take?
Place sterile objects at least 2.5 cm from the edge of the sterile field.
8. A nurse is reinforcing teaching with a client who has a new rx for transdermal
nitroglycerin patches. Which of the following statements by the client indicates an
understanding of the teaching?
I will place the patch on a hairless area of skin
9. A nurse is reinforcing with a new mother on facility security measures. Which of
the following statements by the mother indicates an understanding of the
teaching?
I will have an ID band that matches the one my baby wears
10. A nurse begins to bathe a newly admitted client who reports that she has not had
anything to eat that day, the nurse interrupts the bath and obtains a healthy meal
for the client. This action by the nurse is an example of which of the following?
Boundary crossing
,11. A nurse enters the room of a school aged child and finds him on the floor
experiencing a tonic colonic seizure, which of the following actions should the
nurse take?
Place a pillow under the client's head
12. A nurse is providing support to the family of a school aged child who has a new
diagnosis of a terminal illness, which of the following actions should the nurse
take?
Provide the family with time to talk openly
13. A nurse is checking for gastric residual volume on the client who is scheduled to
receive an intermittent enteral feeding. The nurse finds that the client has a GRV
greater than 250 mLs on two consecutive measurements, which of the following
actions should the nurse take?
Hold the feeding and recheck the GRV in one hour
14. A nurse in a clinic is reviewing the medical record of a toddler and notes that he
previously had a severe allergic reaction to a gelatin, which of the following
immunizations should the nurse identify as unsafe for this client to receive?
Measles Mumps and Rubella (MMR)
15. A nurse is reinforcing teaching with a client who has a prescription for antibiotic
therapy. The client tells the nurse that he always experiences diarrhea when
taking antibiotics, which of the following food choices should the nurse
recommend to lessen the occurrence of diarrhea?
Yogurt
16. A home health nurse is caring for a client who has Alzheimer's disease. the
client's son is concerned about his mother becoming frustrated. which of the
following interventions should the nurse include?
make a schedule for daily tasks
17. A nurse is caring for an adolescent client who has bulimia nervosa, which of the
following actions should the nurse take?
Observe the client during and after meals
18. A nurse is participating in a performance improvement program which of the
following actions should the nurse take to evaluate the effectiveness of the
program?
perform chart audits
19. A nurse is talking to a client who refuses a blood transfusion for religious
reasons. which of the following responses should the nurse make?
you have the right to change your mind
,20. A nurse is assisting with staff education about hand hygiene. which of the
following should the nurse include in the teaching?
wash your hands with soap and water for 20 seconds
21. A nurse is assisting with a community health course for family members of clients
who half Alzheimer's disease. which of the following should the nurse include?
limit the number of choices for the client
22. A nurse in a provider's office is collecting data from an 18-month-old toddler
which of the following should the nurse identify as a potential indication of child
mal-treatment?
the toddler is overly affectionate towards the nurse
23. A nurse is contributing to the plan of care for a client who has ascites due to
chromosols, which of the following should the nurse recommend including in the
plan?
measure the client's abdominal girth
24. A nurse is caring for a client who is experiencing alcohol withdrawal the nurse
should prepare to administer which of the following medications?
diazepam
25. A nurse is preparing to delegate care to assistive personnel. Which of the
following information should the nurse verify prior to delegation?
The AP's job description
26. A nurse is caring for a client who has paranoid schizophrenia and believes that
she is being followed by the FBI agents who are pretending to be psychiatric
staff. Which of the following responses should the nurse make?
What makes you think the staff is following you?
27. A nurse is reinforcing teaching with a client who has GERD and a prescription for
ranitidine. Which of the following statements by the client indicates an
understanding of the teaching?
I should take this medication in the morning and at bedtime
28. A nurse is reinforcing teaching with new parents about car seat safety. Which of
the following instructions should the nurse include?
Position the car seat at 90-degree angle
29. A nurse is collecting data from a client who is 2 days postpartum. The client tells
the nurse she cannot afford to pay for baby formula. The nurse should refer the
client to which of the following members of the intra-professional team?
Case manager
, 30. A community health center is assisting in the development of a brochure about
hypertension. Which of the following action should the nurse take?
explain medical terminology using basic one syllable words
31. A community health nurse is assisting with the development of a pamphlet
regarding choking hazard for toddlers. Which of the following foods should the
nurse include?
Grapes
32. A nurse is caring for a who has a new diagnosis of diabetes mellitus and is
refusing to learn how to self-administer insulin. Which of the following responses
should the nurse make?
"I'd like to hear your thoughts about giving yourself this medication"
33. A nurse is implementing a bladder training program for a client who had a stroke.
Which of the following interventions should the nurse make?
check for residual after voiding
34. A nurse is preparing change of shift report on a client who is 2 days
postoperative following a total knee arthroscopy (or arthroplasty). Which of the
following information about the client should the nurse include in the report?
time of last pain medication
35. A nurse is caring for a client who is 2 days following an above-the-knee
amputation. Which of following actions should the nurse take to promote
progression to independence and mobility for the client?
Encourage the client to use the overhead trapeze
36. A nurse at a pediatric clinic is checking the vital signs of a 2 month old infant prior
to administering immunization. The nurse should recognize respiratory rate is
30/min. This indicates that the respiratory rate is?
Within the expected range
37. A nurse in a clinic is collecting data with a client who had a vaginal birth 6 weeks
ago. Which of the following findings should the nurse expect
Reported Lochia Alba
38. A nurse is reinforcing discharge teaching with a family of a client who has
dependent personality disorder. What action should the nurse take?
Encourage the client to be assertive
39. A charge nurse in the long-term care facility notices the smell of alcohol from one
of the nurse's breath. Which of the following actions should the nurse take first?
Remove the nurse from the client care area
should the nurse assign to the assistive personnel?
Apply an anti-embolic stocking for a client who is 2 days post-op
2. A nurse is caring for a client following an electroconvulsive therapy. What nursing
action?
Continuously reorient client after ECT
3. A nurse is caring for a client who is taking multiple medications about the
possible interactions. Which of the following members of the interdisciplinary
team should the nurse make a referral to?
Advance practice nurse
4. A nurse manage is taking measures to increase cost effective. In which of the
following client situations should the nurse manager intervene?
A nurse uses sterile gauze pads to place a dressing on a surgical wound.
5. A nurse is contributing to the plan of care for client who has ascites due to
cirrhosis. Which of the following interventions should the nurse recommend
including in the plan?
Measure the client's abdominal girth daily
6. A nurse in an urgent care clinic is caring for a client who reports recently using
methylenedioxy-methamphetamine. Which of the following findings should the
nurse expect?
Hallucinations
7. A nurse preparing a sterile field to perform a dressing change for a client's leg
wound. Which of the following actions should the nurse take?
Place sterile objects at least 2.5 cm from the edge of the sterile field.
8. A nurse is reinforcing teaching with a client who has a new rx for transdermal
nitroglycerin patches. Which of the following statements by the client indicates an
understanding of the teaching?
I will place the patch on a hairless area of skin
9. A nurse is reinforcing with a new mother on facility security measures. Which of
the following statements by the mother indicates an understanding of the
teaching?
I will have an ID band that matches the one my baby wears
10. A nurse begins to bathe a newly admitted client who reports that she has not had
anything to eat that day, the nurse interrupts the bath and obtains a healthy meal
for the client. This action by the nurse is an example of which of the following?
Boundary crossing
,11. A nurse enters the room of a school aged child and finds him on the floor
experiencing a tonic colonic seizure, which of the following actions should the
nurse take?
Place a pillow under the client's head
12. A nurse is providing support to the family of a school aged child who has a new
diagnosis of a terminal illness, which of the following actions should the nurse
take?
Provide the family with time to talk openly
13. A nurse is checking for gastric residual volume on the client who is scheduled to
receive an intermittent enteral feeding. The nurse finds that the client has a GRV
greater than 250 mLs on two consecutive measurements, which of the following
actions should the nurse take?
Hold the feeding and recheck the GRV in one hour
14. A nurse in a clinic is reviewing the medical record of a toddler and notes that he
previously had a severe allergic reaction to a gelatin, which of the following
immunizations should the nurse identify as unsafe for this client to receive?
Measles Mumps and Rubella (MMR)
15. A nurse is reinforcing teaching with a client who has a prescription for antibiotic
therapy. The client tells the nurse that he always experiences diarrhea when
taking antibiotics, which of the following food choices should the nurse
recommend to lessen the occurrence of diarrhea?
Yogurt
16. A home health nurse is caring for a client who has Alzheimer's disease. the
client's son is concerned about his mother becoming frustrated. which of the
following interventions should the nurse include?
make a schedule for daily tasks
17. A nurse is caring for an adolescent client who has bulimia nervosa, which of the
following actions should the nurse take?
Observe the client during and after meals
18. A nurse is participating in a performance improvement program which of the
following actions should the nurse take to evaluate the effectiveness of the
program?
perform chart audits
19. A nurse is talking to a client who refuses a blood transfusion for religious
reasons. which of the following responses should the nurse make?
you have the right to change your mind
,20. A nurse is assisting with staff education about hand hygiene. which of the
following should the nurse include in the teaching?
wash your hands with soap and water for 20 seconds
21. A nurse is assisting with a community health course for family members of clients
who half Alzheimer's disease. which of the following should the nurse include?
limit the number of choices for the client
22. A nurse in a provider's office is collecting data from an 18-month-old toddler
which of the following should the nurse identify as a potential indication of child
mal-treatment?
the toddler is overly affectionate towards the nurse
23. A nurse is contributing to the plan of care for a client who has ascites due to
chromosols, which of the following should the nurse recommend including in the
plan?
measure the client's abdominal girth
24. A nurse is caring for a client who is experiencing alcohol withdrawal the nurse
should prepare to administer which of the following medications?
diazepam
25. A nurse is preparing to delegate care to assistive personnel. Which of the
following information should the nurse verify prior to delegation?
The AP's job description
26. A nurse is caring for a client who has paranoid schizophrenia and believes that
she is being followed by the FBI agents who are pretending to be psychiatric
staff. Which of the following responses should the nurse make?
What makes you think the staff is following you?
27. A nurse is reinforcing teaching with a client who has GERD and a prescription for
ranitidine. Which of the following statements by the client indicates an
understanding of the teaching?
I should take this medication in the morning and at bedtime
28. A nurse is reinforcing teaching with new parents about car seat safety. Which of
the following instructions should the nurse include?
Position the car seat at 90-degree angle
29. A nurse is collecting data from a client who is 2 days postpartum. The client tells
the nurse she cannot afford to pay for baby formula. The nurse should refer the
client to which of the following members of the intra-professional team?
Case manager
, 30. A community health center is assisting in the development of a brochure about
hypertension. Which of the following action should the nurse take?
explain medical terminology using basic one syllable words
31. A community health nurse is assisting with the development of a pamphlet
regarding choking hazard for toddlers. Which of the following foods should the
nurse include?
Grapes
32. A nurse is caring for a who has a new diagnosis of diabetes mellitus and is
refusing to learn how to self-administer insulin. Which of the following responses
should the nurse make?
"I'd like to hear your thoughts about giving yourself this medication"
33. A nurse is implementing a bladder training program for a client who had a stroke.
Which of the following interventions should the nurse make?
check for residual after voiding
34. A nurse is preparing change of shift report on a client who is 2 days
postoperative following a total knee arthroscopy (or arthroplasty). Which of the
following information about the client should the nurse include in the report?
time of last pain medication
35. A nurse is caring for a client who is 2 days following an above-the-knee
amputation. Which of following actions should the nurse take to promote
progression to independence and mobility for the client?
Encourage the client to use the overhead trapeze
36. A nurse at a pediatric clinic is checking the vital signs of a 2 month old infant prior
to administering immunization. The nurse should recognize respiratory rate is
30/min. This indicates that the respiratory rate is?
Within the expected range
37. A nurse in a clinic is collecting data with a client who had a vaginal birth 6 weeks
ago. Which of the following findings should the nurse expect
Reported Lochia Alba
38. A nurse is reinforcing discharge teaching with a family of a client who has
dependent personality disorder. What action should the nurse take?
Encourage the client to be assertive
39. A charge nurse in the long-term care facility notices the smell of alcohol from one
of the nurse's breath. Which of the following actions should the nurse take first?
Remove the nurse from the client care area
