An assistive personnel tells the charge nurse that her assignment is
too demanding. She angrily tells the nurse to reassign one of her
tasks to another AP. Which of the following actions should the nurse
take to resolve the conflict?
Ask the AP to discuss the issue in a private area
A nurse is supervising an assistive personnel (AP) obtain supplies
for a client who is on seizure precautions. Which of the following
materials should the AP place in the client's room?
Oral Suction Equipment
A charge nurse on a mental health unit is supervising a newly
licensed nurse. For which of the following actions by the newly
licensed nurse should the supervising nurse intervene?
Tells a client he will lose his phone privileges if he does not take
his medication
A nurse is caring for a client who follows a kosher diet. Which of
the following menu items should the nurse include in the meal tray?
Roasted Salmon
A nurse is reviewing information about advance directives with a
newly admitted client. Which of the following statements by the
client indicates an understanding of the information?
"Advance directives include a living will"
A nurse is collecting data from the caregiver of a client who has
Alzheimer's disease. The caregiver reports the client has difficulty
sleeping at night and wanders throughout the house. Which of the
following interventions should the nurse recommend?
Encourage the client to take frequent walks during the day
A nurse is assisting in the care of a client who is 8hr postpartum
and has uterine atony with increased bleeding. Which of the following
actions should the nurse take? (Select all that apply)
Assist the client to empty her bladder
A nurse is reinforcing teaching with the support person of a client
who is in the first stage of labor. Which of the following
instructions should the nurse include regarding effleurage?
"Gently stroke her abdomen during contractions"
A nurse is caring for an older adult client who is postoperative
following a total hip arthroplasty. The client is incontinent of
stool and urine. Which of the following actions should the nurse take
to prevent skin breakdown?
,Use a moisture barrier on the client's skin
A nurse is caring for a client who has terminal cancer. Which of the
following actions should the nurse take to promote the client's
autonomy?
Allow the client to choose treatment times
A nurse in a clinic is caring for a client who is at 40 weeks of
gestation and experiences a sudden gush of vaginal fluids. Which of
the following findings is evidence of an obstetric complication?
Appears greenish-brown in color
A nurse is assisting with the care of an adolescent client
immediately following a lumbar puncture. Which of the following
actions should the nurse take?
Inform the adolescent that he might experience a headache
A nurse is reinforcing teaching about advance directives with a
client who has end-stage heart failure. Which of the following
statements by the client indicates an understanding of the teaching?
"I should discuss this document with my family after I sign it"
A nurse is caring for a client who has continuous bladder irrigation
following a transurethral resection of the prostate. The nurse
notices clots and dark red blood in the catheter collection bag.
Which of the following actions should the nurse take?
Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride
A nurse is planning to obtain a 12-lead ECG for a client who has a
history of cardiac dysrhythmias. Which of the following actions
should the nurse plan to take?
Instruct the client to remain as still as possible during the
recording
A nurse is reinforcing teaching with a client who has genital herpes.
Which of the following information should the nurse include in the
teaching?
"You should increase fluid intake to relieve dysuria"
A nurse is preparing to empty a postoperative client's closed-wound
drainage system. Which of the following actions should the nurse plan
to take?
Compress the container before replacing the drainage plug
A nurse is reinforcing teaching with the parents of a toddler who has
a new diagnosis of asthma and a prescription for montelukast. Which
of the following instructions should the nurse include in the
teaching?
Administer the medication to the toddler each evening
A nurse in an acute mental health facility is caring for a newly
admitted client. Which of the following should occur during the
orientation phase of the nurse-client relationship?
, Defining responsibilities
A nurse is caring for a client who reports having a decrease in fetal
movement following an external cephalic version 6 hr ago. The nurse
identifies the fetus is in the right occiput anterior position. The
nurse should place the fetal heart monitor on which of the following
sites to auscultate the fetal heart rate?
Lower left
A charge nurse is observing a newly licensed nurse perform suctioning
for a client who has a tracheostomy. For which of the following
actions by the newly licensed nurse should the charge nurse intervene?
Suction for 30 seconds
A nurse is reviewing the medication administration record of a client
who takes atenolol PO and supplies a nitroglycerin transdermal patch
daily. Which of the following interactions should the nurse monitor
with this client?
Hypotension
A nurse in an acute care setting is preparing to administer
medications to a client. Which of the following actions should the
nurse verify the client's identity?
Verify the client's identity using a photograph
A nurse in a provider's office is collecting data from a client who
has psoriasis. Which of the following statements made by the client
should she report to the provider?
"I try not to look at the scales on my body"
A nurse is completing chart reviews in a long-term care facility in
response to an increase in falls. Which of the following responses in
the chart should the nurse use to determine the potential causes of
falls?
Medication record
A nurse is making client care assignments for an assistive personnel
(AP). Which of the following tasks should the nurse assign to the AP?
Complete post mortem care for a client who has died
A nurse is reinforcing teaching with a client who is taking
allopurinol about the risk for developing Stevens-Johnsons syndrome.
For which of the following manifestations should the nurse instruct
the client to monitor and report?
Skin rash with fever
A charge nurse in a long-term care facility is reinforcing teaching
with a group of nurses about fall precautions. Which of the following
statements made by the nurse indicates an understanding of the
teaching?
"I will instruct the client to sit when putting on a pair of pants"
too demanding. She angrily tells the nurse to reassign one of her
tasks to another AP. Which of the following actions should the nurse
take to resolve the conflict?
Ask the AP to discuss the issue in a private area
A nurse is supervising an assistive personnel (AP) obtain supplies
for a client who is on seizure precautions. Which of the following
materials should the AP place in the client's room?
Oral Suction Equipment
A charge nurse on a mental health unit is supervising a newly
licensed nurse. For which of the following actions by the newly
licensed nurse should the supervising nurse intervene?
Tells a client he will lose his phone privileges if he does not take
his medication
A nurse is caring for a client who follows a kosher diet. Which of
the following menu items should the nurse include in the meal tray?
Roasted Salmon
A nurse is reviewing information about advance directives with a
newly admitted client. Which of the following statements by the
client indicates an understanding of the information?
"Advance directives include a living will"
A nurse is collecting data from the caregiver of a client who has
Alzheimer's disease. The caregiver reports the client has difficulty
sleeping at night and wanders throughout the house. Which of the
following interventions should the nurse recommend?
Encourage the client to take frequent walks during the day
A nurse is assisting in the care of a client who is 8hr postpartum
and has uterine atony with increased bleeding. Which of the following
actions should the nurse take? (Select all that apply)
Assist the client to empty her bladder
A nurse is reinforcing teaching with the support person of a client
who is in the first stage of labor. Which of the following
instructions should the nurse include regarding effleurage?
"Gently stroke her abdomen during contractions"
A nurse is caring for an older adult client who is postoperative
following a total hip arthroplasty. The client is incontinent of
stool and urine. Which of the following actions should the nurse take
to prevent skin breakdown?
,Use a moisture barrier on the client's skin
A nurse is caring for a client who has terminal cancer. Which of the
following actions should the nurse take to promote the client's
autonomy?
Allow the client to choose treatment times
A nurse in a clinic is caring for a client who is at 40 weeks of
gestation and experiences a sudden gush of vaginal fluids. Which of
the following findings is evidence of an obstetric complication?
Appears greenish-brown in color
A nurse is assisting with the care of an adolescent client
immediately following a lumbar puncture. Which of the following
actions should the nurse take?
Inform the adolescent that he might experience a headache
A nurse is reinforcing teaching about advance directives with a
client who has end-stage heart failure. Which of the following
statements by the client indicates an understanding of the teaching?
"I should discuss this document with my family after I sign it"
A nurse is caring for a client who has continuous bladder irrigation
following a transurethral resection of the prostate. The nurse
notices clots and dark red blood in the catheter collection bag.
Which of the following actions should the nurse take?
Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride
A nurse is planning to obtain a 12-lead ECG for a client who has a
history of cardiac dysrhythmias. Which of the following actions
should the nurse plan to take?
Instruct the client to remain as still as possible during the
recording
A nurse is reinforcing teaching with a client who has genital herpes.
Which of the following information should the nurse include in the
teaching?
"You should increase fluid intake to relieve dysuria"
A nurse is preparing to empty a postoperative client's closed-wound
drainage system. Which of the following actions should the nurse plan
to take?
Compress the container before replacing the drainage plug
A nurse is reinforcing teaching with the parents of a toddler who has
a new diagnosis of asthma and a prescription for montelukast. Which
of the following instructions should the nurse include in the
teaching?
Administer the medication to the toddler each evening
A nurse in an acute mental health facility is caring for a newly
admitted client. Which of the following should occur during the
orientation phase of the nurse-client relationship?
, Defining responsibilities
A nurse is caring for a client who reports having a decrease in fetal
movement following an external cephalic version 6 hr ago. The nurse
identifies the fetus is in the right occiput anterior position. The
nurse should place the fetal heart monitor on which of the following
sites to auscultate the fetal heart rate?
Lower left
A charge nurse is observing a newly licensed nurse perform suctioning
for a client who has a tracheostomy. For which of the following
actions by the newly licensed nurse should the charge nurse intervene?
Suction for 30 seconds
A nurse is reviewing the medication administration record of a client
who takes atenolol PO and supplies a nitroglycerin transdermal patch
daily. Which of the following interactions should the nurse monitor
with this client?
Hypotension
A nurse in an acute care setting is preparing to administer
medications to a client. Which of the following actions should the
nurse verify the client's identity?
Verify the client's identity using a photograph
A nurse in a provider's office is collecting data from a client who
has psoriasis. Which of the following statements made by the client
should she report to the provider?
"I try not to look at the scales on my body"
A nurse is completing chart reviews in a long-term care facility in
response to an increase in falls. Which of the following responses in
the chart should the nurse use to determine the potential causes of
falls?
Medication record
A nurse is making client care assignments for an assistive personnel
(AP). Which of the following tasks should the nurse assign to the AP?
Complete post mortem care for a client who has died
A nurse is reinforcing teaching with a client who is taking
allopurinol about the risk for developing Stevens-Johnsons syndrome.
For which of the following manifestations should the nurse instruct
the client to monitor and report?
Skin rash with fever
A charge nurse in a long-term care facility is reinforcing teaching
with a group of nurses about fall precautions. Which of the following
statements made by the nurse indicates an understanding of the
teaching?
"I will instruct the client to sit when putting on a pair of pants"
