Answers latest update 2026 Version V1-V3
A policy requiring the removal of acrylic nails by all nursing personnel was
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w implemented six months ago. Which assessment measure best determines if
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sw the intended outcome of the policy is being achieved?
sw sw sw sw sw sw sw sw sw A)swNumberswofswtheswstaf
f- induced skin injuries.
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B)s w Clientswsatisfactionswsurvey.
C)s w Rateswofswneedlestickswinjuriesswbyswnurses.
D)swHealthcare-associatedswinfectionswrates.
To assess the quality of an adult client’s pain, what approach should the nurse use? C A)
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Observe body language and movement.
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B) Provide a numeric pain scale. sw sw sw sw
C) Ask the client to describe the pain.
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D) Identifysweffectiveswpainswreliefswmeasures.
A client who has been diagnosed with terminal cancer tells the nurse, “The doct
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or told me I have cancer and do not have long to live.” Which response is best
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for the nurse to provide?
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A) “That’s correct, you do not have long t
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o live” D
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B) “Would you like me to call your minister?”
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C) “Don't give up, you still have chemotherap
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y to try.”
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D) “Yes, your condition is serious.”
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,When performing blood pressure measurement to assess for orthostati
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c hypotension, which action should the nurse implement first? C A) Ap
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ply the blood pressure cuff securely.
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B) Recordswtheswclient’sswpulseswrateswandswr
hythm. C) Position the client supine
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for a few minutes. D) Assist the clien
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t to stand at bedside.
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Female unlicensed assistive personnel (UAP) are assigned to take the vital signs
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of a client with pertussis for whom droplet precautions have been implemented.
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The UAP request a change in assignment, stating she has not yet been fitted fo
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r a particulate filter mask. What action should the nurse take? D
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When evaluating the effectiveness of a client’s nursing care, the nurse first review
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s the expected outcomes identified in the plan of care. What action should the n
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urse take next? sw sw
A) Modify the nursing interventions to achieve the client’s goals.
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B) Determine if the expected outcomes were realistic.
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C) Review related professional standards of care.
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D) Obtain current client data to compare with expected outcomes.
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A client with limited tolerance for activity needs to walk in the hallway with as
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sistance. Which instructions should the nurse give to the unlicensed assistive per
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sonnel (UAP) who assisting with client’s care? (Select all that apply.)
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A) Instruct the client about signs of orthostati
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c hypertension
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,B) Determine if the client needs to have a gai
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t belt applied
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C) Measure the clients vital signs before the cl
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ient walks. sw
D) Offer to assist the client to void prior to w
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alking in the hall. sw sw sw
E) Report the onset of any dizziness or ligh
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t headedness.
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A client has begun a long-
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term maintenance therapy with lithium, which has a narrow therapeutic inde
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x. Which adverse effect is most important for nurse to include in the teachin
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g plan? A) Dependence.
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B) Toxicity.
C) Interaction.
D) Tolerance.
While interviewing a client, the nurse records the assessment in the electronic heal
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th record. Which statement is most accurate regarding electronic documentation du
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ring an interview?
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A)swTheswinterviewswprocessswisswenhancedswwithswelectronicswdocumentationswandswallowsswtheswclientswtos
w speak at a normal pace.
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B)swCompletingswtheswelectronicswrecordswduringswanswinterviewswisswaswlegalswobligationswofswt
he examining
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nurse.
C)swTheswnurseswhasswlimitedswabilityswtoswobserveswnonverbalswcommunicationswwhileswenteringswth
e assessment electronically.
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, D)swTheswclient’sswcomfortswlevelswisswincreasedswwhenswtheswnurseswbreakssweyeswcontactswtoswtypeswnot
es into the record.
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A client who lives in an assisted living facility develops cognitive impairmen
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t following a stroke. Informed consent is needed to provide additional nursi
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ng services. Who should nurse contact?
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A)swTheswclient’sswoldestswlivingswchild,swaswlawyer,swwhoswisswvisitingswfromswoutswofswtown.
B)swAswdaughtersw-in-lawswdesignatedswasswtheswclient’sswDurableswPowerswofswAttorneysw(DPOA).
C)sw Theswclient’sswyoungestswson,swidentifiedswbyswfamilyswmembersswasswtheswfamilyswspokesperson.
D)swTheswclient’sswspouseswwhoswlivesswinswtheswindependentswlivingswunitswofswtheswfacility.
A client is in contact isolation due to stage IV coccyx wound infected with methi
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cillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to pr
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event multiple re- sw sw
entries to the client’s room. In which order should the nurse perform the interven
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tions?
A) Change coccyx dressing, perform tracheostomy care, restart the IV.
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B) Perform tracheostomy care, change coccyx dressing, restart the IV.
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C) Restart the IV, perform tracheotomy care, change coccyx dressing.
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D) Change coccyx dressing, restart the IV, perform tracheostomy care.
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What self- sw
care outcome is best for the nurse to use in evaluating a client’s recovery form a s
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troke that resulted in left- sided hemiparesis?
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A)swPromoteswindependenceswbyswallowingswclientswtoswperformswallswself-careswactivities.
B)s w Participatesswinswself-careswtoswoptimalswlevelswofswcapacity.
C)s w Clientswverbalizesswimportanceswofswhygienicswpracticesswinswtheswrecoveryswprocess.