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UPDATE 2025
A nurse is caring for a client who is 4 hr postpartum and reports that she
cannot urinate. Whichof the following interventions should the nurse
implement?
a. Perform fundal massage ( massage if fundus is boggy)
b. Pour water from a squeeze bottle over the client’s
perineal area.
e. Insert an indwelling urinary catheter.
f. Apply cold therapy to the client’s perineal area.( warm)
A nurse is providing discharge teaching to a client who has cancer
and a prescription for afentanyl 25 mcg /hr transdermal patch. Which of the
following instructions should the nurse include in the teaching?
a Avoid hot tub while wearing the
. patch
e. Apply patch to your forearm
f. Avoid high-fiber foods while taking this medication
g. Remove the patch for 8 hours every day to reduce the risk for tolerance.
A nurse working on a surgical unit is developing a care plan for a client
who has paraplegia.The client has an area of non-blanchable erythema over
his ischium. Which of the following interventions should the nurse include in
the care plan?
a. Teach the client to shift his weight every 15 min while sitting (cannot do this because
he is paraplegic)
b. Place the client upright on a donut-shaped cushion
c. Assess pressure points every 24 hr.- must assess
d. Turn and reposition the client every 3 hrs. while in bed. - must be
, q 2 hours in bed, 1hour in chair.
A nurse is working with a client who has an anxiety disorder and is in
the orientation phaseof the therapeutic relationship. Which of the following
statements should the nurse make during this phase?
d. We should discuss resources to implement in your daily life
e. Let me show you simple relaxation exercises to manage stress.
f. Let’s talk about how you can change your response to stress
d. We should establish our roles in the initial
session.
, A nurse is providing discharge teaching to a client who has a new
prescription for phenelzine. The nurse should instruct the client that it is
safe to eat which of the following foodswhile taking this medication?
a. Avocados
b. Whole grain
bread
e. Pepperoni pizza
f. Smoked salmon
A nurse is caring for a client who is experiencing mild anxiety.
Which of the followingfindings should the nurse expect?
ab. H
Raepigidhtsepneeedchp-
. esrecveeprteual field
c. Feelings of dread
d. Purposeless activity
A nurse is caring for a client who has type 1 diabetes mellitus. The
client reports that she is not feeling well. Which of the following findings
should indicate to the nurse that the client ishypoglycemic? (Select all that
apply.)
ba.. T
Porelymdoiprssia = hyperglycemia
c. Acetone Breath odor = DKA
d. Diaphoresis
e. Inability to concentrate
A nurse is caring for an infant who has coarctation of the aorta.
Which of the followingshould the nurse identify as an expected finding?
a. Upper extremity hypotension
, b. Increased intracranial pressure
c. Frequent nosebleeds
d. Weak femoral
pulses
A community health nurse is planning primary prevention activities to
reduce the occurrenceof abuse. Which of the following strategies should the
nurse include in the plan?
a. Instruct healthcare professionals to identify abusive situations
(screening=secondaryprevention)
b. Locate financial support to open a shelter for abuse survivors (3rd)
c Teach parenting skills to families at risk for
. abuse
d. Connect abuse survivors with legal counsel (3rd)
A nurse and an assistive personnel (AP) are caring for a group
of clients. Which ofthe following tasks is appropriate for the nurse to
delegate to the AP?
a. Documenting the report of pain for a client who is postoperative
b. Administering oral fluids to a client who has dysphagia-
c Applying a condom catheter for a client who has a spinal
. cord injury