VERSION 12
A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her
husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of
the following is an appropriate nursing intervention?”
Offer to speak to the client’s husband regarding his abuse behavior.
Help the client to recognize the signs of escalation of abuse behavior
Assist the client to identify personal behaviors that trigger abusive behavior
Assist the client to Reports abusive behavior to the proper authority
A client was having suicidalthoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which
of the following responses for the nurses appropriate?
Why do you think your life is not worth it anymore?
Do you have a plan to end your life?
I need to know what you mean my misery You
can trust me and tell me what you’re thinking
A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?
Decreased level consciousness
Unable to identify common objects
Poor problem solving ability
Preoccupation was somatic disturbances
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following action should
nurse take? There are 3 tabs that contain separate categories of data.
Position the client with the affected extremity lower than the heart
Administration of acetaminophen
Massage the affected extremity every 4 hrs.
Withhold heparin IV infusion
Is caring for clients was a new prescription for enoxaparin for the prevention of DVT. Which of the following is an appropriate
action by the nurse?
Expel air bubble at the top of the prefilled syringe
Massage the injection site to evenly distribute the medication
Inject the medication the lateral abdominal wall
Administer an NSAID for injection site discomfort
Nurses caring for four clients. Which of the following client data should the nurse report to the provider?
A client who has a pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
Client was a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hour following surgery
Client who is 4 hrs postoperative and has a heart rate of 98 per minute
The client was a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
Nurses caring for client was in end-stage osteoporosis and is reporting severe pain. Clients respiratory rate is 14 per minute.
Which of the following medications should the nurse expect to be the highest priority to administer to the client?
Promethazine
Hydromorphone
Ketorolac
Amitriptyline
, A nurse is caring for a client who has DVT. Which of the following instructions the nurse include in the plan of care?
Live with the clients fluid intake to 1500 mL per day
Massage place affected extremity to relieve pain
Apply cold packs of clients affected extremity
Elevate the client’s affected extremity when in bed
A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring
every 45 seconds with a nine seconds duration in the fetal heart rate is 170 to 180/minute. Which of the following actions
should nurse take?
Discontinue oxytocin infusion
Increased oxytocin infusion
Decreased oxytocin infusion
Maintain oxytocin infusion
A nurse is admitting a client who is in labor and at 38 wks of gestation to the maternal newborn unit. The client has a
history of herpes simplex virus 2. Which of the following questions is most appropriate for the nurse to ask the client?
Have your membranes ruptured?
How far apart are your contractions?
Do you have any active lesions? Are
you positive for beta strap?
Nurse is providing teaching for child prescribed ferroussulfate. Which of the following instructions should the nurse include?
Takewith meals
Take at bedtime
Take with a glass of milk
Take with a glass of orange juice
Four clients present to the emergency department. The nurse should plan to see which of the following clients first?
A 6 year old client whose left shoulder is dislocated
A 26 year old client for sickle cell disease and a severe joint pain
A 76 year old client was confused, febrile and has foul smelling urine - uti
A 50- year old client who has slurred speech, is disoriented, and reports a headache - stroke
A nurse is completing a dietary assessment for client who is Jewish and observes kosher dietary practices. Which of the
following behaviors should the nurse expect to find?
Leavened bread maybe eaten during Passover.
Shellfish is commonly consumed in the diet.
Meat and dairy products are eaten separately.
Fasting from meat occurs during Hanukkah.
A nurse is reviewing assessment data from several clients. For which of the following clients should
the nurse recommend referral to a dietitian?
An older adult client who has a BMI of 24(18.5-24.9)
A client who has a nonhealing leg ulcer (diet isn’t good)
An older adult client who has presbyopia (age related far-sightness)
A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4)
A nurse is providing discharge teaching to a client who has a chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching? Eat 1 g/kg of protein per day