A nurse is teaching an assistive personnel about a upper body
mechanics to prevent injury. Which of the following actions by the
AP demonstrate an understanding of the teaching? - The AP keeps
the object he is lifting close to his body
. a nurse is assessing a client who is immobile and notices a red area
over the client's coccyx. Which of the following actions should the
nurse take? - Assess the red area for blanching
. a nurse is preparing to insert an iv catheter for a client following a
right mastectomy. Which of the following veins should the nurse
select when initiating an IV therapy? - The cephalic vein in the left
distal forearm
a nurse is preparing to administer a medication into a client by the
intradermal route after applying gloves and cleaning the site with an
antiseptic swab. In what order should the nurse take the steps to
administer the medication? (move steps into box 1- 4 priority) -
. a nurse is providing teaching to a client about colorectal cancer
prevention guidelines. Which of the following recommendations
should the nurse include? - Reduce intake of red meats
a nurse is planning care to prevent skin breakdown for a client who is
immobile and is urinary incontinent. Which of the following actions
should the nurse include in the plan of care? - Request a prescription
for an indwelling urinary catheter
a nurse is preparing to apply a condom catheter for a client who is
uncircumcised which of the following actions should the nurse plan
to take? - Place adhesive tape directly on the penis
a nurse is teaching a client who had an enucleation about care of an
artificial eye. Which of the following information should the include
in the teaching? (select all that apply) - -Apply pressure just below
artificial eye to break the suction
-Retract the upper and lower lids to reinsert the artificial eye
9. a nurse is reviewing client confidentiality with a newly licensed
,nurse. The nurse should identify which of the following examples
as a violation of HIPPA? - Discussing the clients transfer to a long-
term care facility with a nurse from another unit
10. anurse is caring for a client who is 2 days postoperative
following bowel resection and reports sudden severe abdominal
pain. Which of the following actions should the nurse take first? -
Expose the clients abdomen to look for changes in appearance
11. anurse is providing care for a client who is to undergo a total
laryngectomy. Which of the following interventions is the nurses
priority? - For the client explain the techniques of esophageal speech
12. ahome care nurse is teaching a client about home safety. Which
of the following statements by the client indicates an understanding
of the teaching? (select all that apply) - -I will use the bars when
getting in and out of the bathtub
-I need to check my medications for expiration dates
-I need to have a fire escape plan with my family
13. anurse is assessing a client's cranial nerve VII. Which of the
following responses should the nurse expect? - The client has a
symmetrical smile
14. anurse in an emergency department is assessing a client who
reports a right lower quadrant pain, nausea and vomiting for the
past 48 hours? Which of the following actions should the nurse
take first? - Auscultate bowel sounds
15. anurse is caring for a client who recently received a diagnosis of
terminal cancer. Which of the following statements by the clients
partner indicates maladaptive coping? - I am going to ask my
daughter to come and stay for a week
16. a
nurse is planning care for a client who has a stage 1 pressure
ulcer on the right heel. The nurse should anticipate application of
which of the following dressings? - Transparent
17. anurse is caring for a client who has brain cancer and is
transferring to hospice care. The client's son tells the nurse "I don't
know what to tell my dad if he asks how he is going to die". Which
,of the following is an appropriate response from the nurse? - I think
you should discuss this with the hospice nurse
18. anurse is teaching an older adult client who has type 2 diabetes
mellitus about how to care for corns and calluses toes. Which of
the following statements by the client indicates understanding of
the teaching? -
19. anurse is caring for a client who has wrists restraints after an
episode of violent behavior. Which of the following actions should
the nurse take? - Tie the restraints to the side rale
20. anurse is admitting a client who has a clostridium difficile
infection. Which of the following actions should the nurse take?
Select all that apply - -Wear a gown and gloves when providing
client care
-Wash hands with soap and water after contact with the client
21. anurse is planning care for a client who has latex allergy and is
scheduled for surgery. Which of the following actions is appropriate
to include in the clients plan of care? - Remove the stop stocks from
iv tubing
22. anurse is providing discharge teaching to a client who does not
speak the same language as the nurse. Which of the following actions
should the nurse take? - Direct verbal discharge instructions to the
interpreter
23. anurse is teaching a client how to self-administer daily low dose
heparin injections. Which of the following factors is most likely to
increase the clients motivation to learn? - The nurse explaining the
need for education to the client
24. a nurse is preparing to teach a female client about osteoporosis
prevention. Which of the following recommendations should the
nurse make for this client? - Walk for 30 mins 3 to 5 times a week
25. a nurse is caring for a client who is receiving continuous enteral
feedings through gastrostomy tubes. Which of the following actions
should the nurse take? - Flush the tubing with 10 ml of water every 2
hours
, 26. anurse is caring for a client who has an incisional wound and a
prescription for wound care. Which of the following images indicates
the proper method of cleaning a wound site? -
27. anurse is caring for a client who reports a pain level of 5 on a
scale of 0- 10. The client informs the nurse that pain medications is
not an option for managing pain. Which of the following is an
appropriate response by the nurse? - Why do you think pain
medication is not going to help you
28. anurse is teaching a client who requires maximum support about
how to use a two wheeled walker. Which of the following actions
by the client indicates an understanding of teaching? - The client
moves the walker ahead 10 inches with each step
29. a nurse is caring for a client who refuses to follow the providers
prescription for bed rest. The nurse over hears an assistive personnel
tell the client that if she does not remain in bed he will place her in
restraints. The nurse should identify that the AP is committing which
of the following torts? - Assault
30. anurse is preparing to insert an IV catheter for an older adult
client who has fragile skin. Which of the following actions should
the nurse take? - Engorge the vein by placing the arm in the
dependent position
31. anurse is planning care for a client who has a new prescription for
parental nutrition in 20% dextrose and fat emulsion. Which of the
following is the appropriate action to indicate in the plan of care? -
Prepare the client for a central venous line
32. a
nurse is caring for a client who is schedule for surgery while
witnessing the client signature. While the client is saying I trust my
doctor, but I don't understand what he meant when he said he'll reset
my intestines. Which of the following actions should the nurse take? -
Notify the provider
33. anurse is caring for a client who is agitated and threatening to
harm others. The nurse places the client in restraints but does not
notify the provider or obtain a prescription for the restraints. The
situation respects which of the following torts? - False imprisonment