The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure
caused by a ruptured appendix. Which intervention is most important for the nurse to
include in the plan of care?
A. Assess warmth of extremities
B. Keep head of bed raised 45 degrees
C. Monitor blood glucose level
D. Maintain strict intake and output
Give this one a try later!
D. Maintain strict intake and output
The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3
year old son for wetting his pants. What initial action should the nurse take?
A. Provide disposable training pants while calming the mother
,B. Refer the mother to a community parent education program
C. Inform the mother that toilet training is slower for boys
D. Suggest that the mother consult a pediatric nephrologist
Give this one a try later!
C. Inform the mother that toilet training is slower for boys
An older adult male reporting abdominal pain is admitted to the hospital from a long-
term care facility. It has been 7 days since his last bowel movement, his abdomen is
distended, and he just vomited 150mL of dark brown emesis. In what order should the
nurse implement these interventions? (Highest to lowest priority)
Give this one a try later!
1. Send emesis sample to the lab
2. Elevate the head of the bed
3. Complete focused assessment
4. Offer PRN pain medication
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation
from a near-drowning incident. While providing care to the child, the nurse begins talking
with his preadolescent brother who rescued the child from the swimming pool and
initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked
about what happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
Give this one a try later!
, B. Ask the older brother how he felt during the incident
A male client tells the nurse that he is concerned that he may have a stomach ulcer,
because he is experiencing heartburn and a dull gnawing pain that is relieved when he
eats. Which is the best response by the nurse?
A. Instruct the client that these mild symptoms can generally be controlled with changes
in his diet
B. Advise the client that he needs to seek immediate medical evaluation and treatment of
these symptoms
C. Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer
D. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not
relieved with food
Give this one a try later!
C. Encourage the client to obtain a complete physical exam, since these
symptoms are consistent with an ulcer
The nurse leading a care team on a medical surgical unit is assigning client care to a
practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the
nurse delegate to the UAP?
A. Evaluate a client's mobility progress toward the plan of care
B. Assess for side effects of administered pain medications
C. Turn and reposition a client with a total hip replacement
D. Monitor an intravenous infusion rate on an established schedule
Give this one a try later!
, C. Turn and reposition a client with a total hip replacement
Two days prior to discharge from the rehabilitation facility, the nurse is teaching a client
who is recovering from Guillain-Barre syndrome about home care. Which actions should
the nurse include when providing discharge teaching to the client and spouse? (Select
all that apply)
A. Review safe transfer strategies
B. Develop a nutritional plan
C. Help identify community support
D. Initiate a rigorous exercise routine
E. Provide cooking instructions
Give this one a try later!
A. Review safe transfer strategies
B. Develop a nutritional plan
C. Help identify community support
An older client's daughter calls the home health nurse and reports that her mother has
become forgetful and is very confused at night. The daughter stated that her mother's
behavior changed suddenly a few days ago and is now getting worse. Which actions
should the nurse take?
A. Encourage increased intake of high protein foods
B. Instruct the daughter to check her mother's temperature
C. Review the client's current food and medication allergies
D. Ask if the mother is experiencing any pain with urination
E. Determine if the mother has recently experienced a fall.
Give this one a try later!
caused by a ruptured appendix. Which intervention is most important for the nurse to
include in the plan of care?
A. Assess warmth of extremities
B. Keep head of bed raised 45 degrees
C. Monitor blood glucose level
D. Maintain strict intake and output
Give this one a try later!
D. Maintain strict intake and output
The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3
year old son for wetting his pants. What initial action should the nurse take?
A. Provide disposable training pants while calming the mother
,B. Refer the mother to a community parent education program
C. Inform the mother that toilet training is slower for boys
D. Suggest that the mother consult a pediatric nephrologist
Give this one a try later!
C. Inform the mother that toilet training is slower for boys
An older adult male reporting abdominal pain is admitted to the hospital from a long-
term care facility. It has been 7 days since his last bowel movement, his abdomen is
distended, and he just vomited 150mL of dark brown emesis. In what order should the
nurse implement these interventions? (Highest to lowest priority)
Give this one a try later!
1. Send emesis sample to the lab
2. Elevate the head of the bed
3. Complete focused assessment
4. Offer PRN pain medication
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation
from a near-drowning incident. While providing care to the child, the nurse begins talking
with his preadolescent brother who rescued the child from the swimming pool and
initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked
about what happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
Give this one a try later!
, B. Ask the older brother how he felt during the incident
A male client tells the nurse that he is concerned that he may have a stomach ulcer,
because he is experiencing heartburn and a dull gnawing pain that is relieved when he
eats. Which is the best response by the nurse?
A. Instruct the client that these mild symptoms can generally be controlled with changes
in his diet
B. Advise the client that he needs to seek immediate medical evaluation and treatment of
these symptoms
C. Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer
D. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not
relieved with food
Give this one a try later!
C. Encourage the client to obtain a complete physical exam, since these
symptoms are consistent with an ulcer
The nurse leading a care team on a medical surgical unit is assigning client care to a
practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the
nurse delegate to the UAP?
A. Evaluate a client's mobility progress toward the plan of care
B. Assess for side effects of administered pain medications
C. Turn and reposition a client with a total hip replacement
D. Monitor an intravenous infusion rate on an established schedule
Give this one a try later!
, C. Turn and reposition a client with a total hip replacement
Two days prior to discharge from the rehabilitation facility, the nurse is teaching a client
who is recovering from Guillain-Barre syndrome about home care. Which actions should
the nurse include when providing discharge teaching to the client and spouse? (Select
all that apply)
A. Review safe transfer strategies
B. Develop a nutritional plan
C. Help identify community support
D. Initiate a rigorous exercise routine
E. Provide cooking instructions
Give this one a try later!
A. Review safe transfer strategies
B. Develop a nutritional plan
C. Help identify community support
An older client's daughter calls the home health nurse and reports that her mother has
become forgetful and is very confused at night. The daughter stated that her mother's
behavior changed suddenly a few days ago and is now getting worse. Which actions
should the nurse take?
A. Encourage increased intake of high protein foods
B. Instruct the daughter to check her mother's temperature
C. Review the client's current food and medication allergies
D. Ask if the mother is experiencing any pain with urination
E. Determine if the mother has recently experienced a fall.
Give this one a try later!
