QUESTIONS WITH SIMPLIFIED
ANSWERS
A nurse at a rehabilitation facility is assisting with the admission of a client who has left hemiplegia
following a stroke. Which of the following actions should the nurse take first? - correct answer-
Determine the client's mental status
A nurse is planning care for a client who practices Judaism. Which of the following questions should the
nurse ask the client to better understand how he practices Judaism? - correct answer-"Do you observe
the Sabbath?"
A nurse is caring for a client who has a visual impairment. When setting up the client's meal tray, the
nurse should take which of the following actions? - correct answer-Describe food placement using the
numbers on the face of a clock
A nurse is reinforcing teaching with a male client about clean intermittent self-catheterization. Which of
the following instructions should the nurse include? - correct answer-Wash the catheter with soap and
water after use
A nurse is caring for a client who has a terminal illness. Which of the following is an expected response
by a family member during the anger stage of grieving? - correct answer-The family member criticizes
care provided by the nurse
A nurse is assisting with the plan of care for a client who is dying. Which of the following interventions
should the nurse include in the plan of care? - correct answer-Allow family to assist the client with
personal hygiene
A nurse is preparing to collect blood samples from an older adult client. Which of the following actions
should the nurse take when performing venipuncture? - correct answer-Apply the tourniquet over the
client's sleeve
A nurse is collecting data from a client who is receiving a continuous IV infusion of lactated Ringer's for
dehydration. Which of the following findings indicates infiltration of the solution into the subcutaneous
area? - correct answer-The area around the infusion site is cool to the touch
A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which of the
following client statements indicates an understanding of the teaching? - correct answer-I will secure all
of my electrical cords to the baseboard
A nurse is reinforcing teaching about sleep promotion with a client who reports having difficulty
sleeping. Which of the following client statements indicates an understanding of the teaching? - correct
answer-I should play music that relaxes me before I go to bed
A nurse is reinforcing teaching with the partner of a client who has left-sided weakness about how to
safely move the client from a bed to a chair at home. which of the following statements by the partner
, indicates an understanding of the teaching? - correct answer-I'll bend at the knees when lifting to get
better leverage
A nurse is reinforcing teaching about health promotion with an older adult client. Which of the following
instructions to the client is an example of secondary prevention? - correct answer-Participate in
screenings for tuberculosis
A nurse is monitoring an assistive personnel (AP) who is measuring a client's oxygen saturation using a
pulse oximeter. Which of the following observations by the nurse indicates that the AP is correctly
performing the task? - correct answer-The AP chooses a site with a capillary refill of less than 2 seconds.
A nurse is reviewing the laboratory results of a client who has malnutrition and has been receiving total
parenteral nutrition (TPN). The nurse should identify that which of the following laboratory values
indicates the treatment has been effective? - correct answer-Prealbumin 28 mg/dL
A nurse is preparing to perform wound irrigation for a client who has a stage IV pressure ulcer. Which of
the following images indicates the appropriate supply the nurse should plan to use? - correct answer-
Nurse should select a 30 to 60 mL syringe and use an 18 to 19 gauge needle to irrigate the client's
wound.
A nurse is caring for a client who has vancomycin-resistant enterococci (VRE) in a wound. Which of the
following actions should the nurse take to control the transmission of this infection? - correct answer-
Wear a gown when assisting the client with hygiene care
A nurse is contributing to the plan of care for a client who follows a kosher diet. Which of the following
dietary interventions should the nurse expect to include in the plan? - correct answer-Withhold foods
that contain both meat and dairy products
A nurse is caring for a client who states that he is concerned that his neighbor, who works as an assistive
personnel (AP) on another inpatient unit, will access his records and share his information with others.
Which of the following is an appropriate response by the nurse? - correct answer-"only those who are
involved with some aspect of your care may access your health care information"
A nurse is preparing to administer a medication intramuscularly to an adult client. Which of the following
is the preferred site for administering the medication to this client? - correct answer-Ventrogluteal
A nurse is reinforcing discharge teaching about preventing thrombophlebitis with a client who is
postoperative. Which of the following statements by the client indicates an understanding of the
teaching? - correct answer-"I will do leg exercises every 1 to 2 hours while I am awake"
A nurse is reinforcing teaching about health promotion with a client. Which of the following actions
should the nurse take first to promote effective learning? - correct answer-Identify areas of concern
A nurse is providing change-of-shift report for a client who had a stroke 48 hr ago. Which of the following
information should the nurse include in the report? - correct answer-The client's Glasgow coma scale
score
A nurse is caring for a client who has cancer and is asking about hospice care. Which of the following
responses should the nurse make? - correct answer-The hospice staff's focus is to relieve your pain and
distress