Guide. LATEST UPDATED VERSION 2025
A nurse is assisting with the care of a client who has a femur fracture and is in
skeletal traction. Which of the following actions should the nurse take - answer-
Ensure the client's weights are hanging freely from the bed.
A nurse in a provider's office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include? - answer-Take this medication between
meals
A nurse in a provider's office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include? - answer-Take this medication between
meals.
A nurse is reviewing the plan of care for a client who has cellulitis of the leg.
Which of the following interventions should the nurse recommend? - answer-
Wash daily with an antibacterial soap.
A nurse is reinforcing teaching with a client who is postoperative after having an
ileostomy established. Which of the following instructions should the nurse
include in the teaching? - answer-Avoid medications in capsule or enteric form.
,A nurse is caring for a client who is in the oliguric phase of acute kidney injury.
Which of the following actions should the nurse take? - answer-Monitor intake
and output hourly
A nurse is reinforcing teaching about an esophagogastroduodenoscopy with a
client who has upper gastric pain. Which of the following statements should the
nurse include in the teaching? - answer-"You will remain NPO for 8 hours before
the procedure."
A nurse is caring for a client who is difficult to arouse and very sleepy for several
hours following a generalized tonic-clonic seizure. Which of the following
descriptions should the nurse use when documenting this finding in the medical
record? - answer-Postictal phase
A nurse is reinforcing teaching with a client who reports right shoulder pain
following a laparoscopic cholecystectomy. Which of the following statements
should the nurse make? - answer-"The pain will dissipate if you ambulate
frequently."
A nurse is checking the suction control chamber of a client's chest tube and notes
that there is no bubbling in the suction control chamber. Which of the following
actions should the nurse take? - answer-Verify that the suction regulator is on.
A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that
apply.) - answer-Encourage fluid intake. 2) Monitor the puncture site for
hematoma.
A nurse is assisting with the care of a client who is postoperative following
surgical repair of a fractured mandible. The client's jaw is wired shut to repair and
, stabilize the fracture. The nurse should recognize which of the following is the
priority action? - answer-Prevent aspiration.
A nurse is collecting data from a client who has scleroderma. Which of the
following findings should the nurse expect? - answer-Hardened skin
A nurse is caring for an older adult client who has dysphagia and left-sided
weakness following a stroke. Which of the following actions should the nurse
take? - answer-Add thickener to fluids.
A nurse is caring for a client who has partial-thickness and full-thickness burns of
his head, neck, and chest. The nurse should recognize which of the following is
the priority risk to the client? - answer-Airway obstruction
A nurse is reinforcing teaching with a client who is newly diagnosed with
myasthenia gravis and is to start taking neostigmine. Which of the following
instructions should the nurse include in the teaching? - answer-1) Take the
medication 45 minutes before eating.
A nurse is caring for a client who is 12 hours postoperative following a
transurethral resection of the prostate (TURP) and has a 3-way urinary catheter
with continuous irrigation. The nurse notes there has not been any urinary output
in the last hour. Which of the following actions should the nurse perform first? -
answer-Notify the provider.. Determine the patency of the tubing.
A nurse is caring for a client scheduled for a bone marrow biopsy. The client
expresses fear about the procedure and asks the nurse if the biopsy will hurt.
Which of the following responses should the nurse make? - answer-"The biopsy
can be uncomfortable, but we will try to keep you as comfortable as possible."