PRACTICE 153 REAL EXAM
QUESTIONS AND CORRECT
ANSWERS
A nurse is planning care for a client who is receiving heparin to treat a deep
vein thrombosis of the left lower leg. Which of the following interventions
should the nurse include in the plan of care?
Elevate the affected leg.
A nurse in a clinic receives a call from a guardian whose child has varicella.
The guardian asks when the child can return to school. Which of the
following responses should the nurse make?
"When crusts have formed on every lesion."
A home health nurse is caring for a group of older adult clients. The nurse
should initiate a referral to the Program of All-Inclusive Care for the Elderly
(PACE) for which of the following clients?
A client whose caregiver requests adult day care services
A nurse is caring for a client who is 12 hr postoperative, is receiving PCA for
pain control, and requires a blood pressure check in 10 min. Which of the
following staff members should the nurse assign to collect this information?
An assistive personnel (AP) who is assisting a client to return to bed
,A nurse manager is preparing a newly licensed nurse's performance
appraisal. Which of the following methods should the nurse manager use to
evaluate the nurse's time management skills?
Maintain regular notes about the nurse's time management skills.
A nurse is caring for four clients. Which of the following clients should the
nurse assign to an assistive personnel (AP) to assist with meals?
A client who has Alzheimer's disease and is demonstrating aphasia
A nurse is planning care for a client who has dementia. Which of the
following interventions should the nurse include?
Evaluate the client for a tendency to wander.
A nurse is providing teaching to a client about how to ambulate with a
standard nonwheeled walker. Which of the following statements by the client
indicates understanding?
"I should pick the walker up and move it forward."
A nurse is caring for a client who has thrombocytopenia and is scheduled to
receive IM injections of vitamin B12 and a pneumococcal vaccine. Which of
the following actions should the nurse plan to take?
Clarify the medications with the provider.
A nurse in an outpatient mental health clinic is working with a client who has
posttraumatic stress disorder (PTSD) and asks the nurse to recommend a
,nonpharmacological therapy to use to provide relief of the manifestations.
Which of the following complementary therapies should the nurse teach the
client to use to help alleviate the distress?
Guided imagery
A nurse in a prenatal clinic is teaching a client about foods to avoid during
pregnancy to decrease the risk of listeriosis. Which of the following images
identifies a food the nurse should include in the teaching?
salami and other luncheon meats can harbor the bacteria Listeria
A nurse is caring for a newly admitted client. The client tells the nurse, "I'm
afraid to go to sleep because I'm worried I will not wake up." Which of the
following responses should the nurse make?
"Would you like to talk about your concerns?"
A hospice nurse is consulting with a client and their family about receiving
home services. Which of the following statements should the nurse identify
as an indication that the family understands home hospice care?
We can expect the hospice nurse to provide support for us after our mother's
death."
A nurse is caring for four clients. Which of the following tasks should the
nurse delegate to an assistive personnel (AP)?
Arrange the lunch tray for a client who has a hip fracture.
, A nurse is caring for a client who has a pulmonary embolism. The client is
receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5
mg PO daily. The morning laboratory values for the client are aPTT 98
seconds (30 to 40 seconds) and INR 1.8 (0.8 to 1.1). Which of the following
actions should the nurse take?
Withhold the heparin infusion.
A nurse is facilitating a group family session for a client who has a substance
use disorder. One of the family members is remaining silent. Which of the
following statements should the nurse make?
"You have been affected by this situation, too. How does it make you feel?"
A nurse on an inpatient unit is caring for a client who has schizophrenia and
recently started taking risperidone. Which of the following actions should the
nurse take?
Implement fall precautions for the client.
A charge nurse is observing a newly licensed nurse administer enteral
feedings via nasogastric (NG) tube. Which of the following actions by the
newly licensed nurse indicates an understanding of the procedure?
Keeps the head of the bed elevated to a 45° angle after feeding is completed
A nurse is caring for a client who has schizophrenia and is exhibiting the
finding of associative looseness. Which of the following actions should the
nurse take?