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Questions and Answers
A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?
A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological Interventions should the nurse include in the plan?
A nurse is caring for a client who has a terminal illness.The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make?
A nurse is caring for a client who has a terminal illness.The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make?
A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?
A nurse is planning care for a client who is scheduled for an intravenous pyelogram.Which of the following actions is appropriate for the nurse to include?
A nurse is planning care for a client who is scheduled for an intravenous pyelogram.Which of the following actions is appropriate for the nurse to include?
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A nurse is performing an eye assessment for a newly admitted client.Which of the following findings should the nurse expect?
A nurse is performing an eye assessment for a newly admitted client.Which of the following findings should the nurse expect?
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A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
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A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?
A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?
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A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure.Which of the following actions should the nurse take first?
A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure.Which of the following actions should the nurse take first?
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A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)
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A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
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A nurse is planning to change a client's tracheostomy ties.Which of the following actions should the nurse take?
A nurse is planning to change a client's tracheostomy ties.Which of the following actions should the nurse take?
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A nurse is caring for a client who had a stroke and coughs frequently when swallowing.The nurse should request a referral to which of the following members of the interdisciplinary team?
A nurse is caring for a client who had a stroke and coughs frequently when swallowing.The nurse should request a referral to which of the following members of the interdisciplinary team?
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A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr.Which of the following actions should the nurse take first?
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr.Which of the following actions should the nurse take first?
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A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level.Which of the following actions should the nurse take prior to the start of the infusion?
A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level.Which of the following actions should the nurse take prior to the start of the infusion?
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A nurse manager overhears a nurse telling a client. "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?
A nurse manager overhears a nurse telling a client. "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?
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A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?
A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?
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A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication.The client tells the nurse. "I want to die now that my partner is gone." Which of the following responses should the nurse make?
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication.The client tells the nurse. "I want to die now that my partner is gone." Which of the following responses should the nurse make?
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A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?
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A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?
A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?
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A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child.Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?
A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child.Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?
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A nurse is caring for a client who has dysphagia and is receiving oral medications.Which of the following actions should the nurse take?
A nurse is caring for a client who has dysphagia and is receiving oral medications.Which of the following actions should the nurse take?
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A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?
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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
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A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?
A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?
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A nurse is preparing to provide postmortem care for a client.Which of the following actions should the nurse plan to take?
A nurse is preparing to provide postmortem care for a client.Which of the following actions should the nurse plan to take?
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A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?
A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?
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A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?
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A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?
A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?
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A nurse is planning care for a client who is immobile.Which of the following actions should the nurse include in the plan of care?
A nurse is planning care for a client who is immobile.Which of the following actions should the nurse include in the plan of care?
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A nurse is caring for a client who reports that she has insomnia.Which of the following interventions is appropriate for the nurse to recommend?
A nurse is caring for a client who reports that she has insomnia.Which of the following interventions is appropriate for the nurse to recommend?
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A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
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A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?
A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?
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To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?
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A nurse is caring for a client who is anxious about being admitted to a
health care facility for the first time.Which of the following statements should
the nurse make?
A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time.Which of the following statements should the nurse make?
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A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
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A nurse is conducting theWeber's test on a client.Which of the following is an appropriate action for the nurse to take?
A nurse is conducting theWeber's test on a client.Which of the following is an appropriate action for the nurse to take?
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A nurse is assessing a client who has left-sided weakness following a stroke.Which of the following findings is the nurse's priority?
A nurse is assessing a client who has left-sided weakness following a stroke.Which of the following findings is the nurse's priority?
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A nurse is teaching an older adult client about reducing the risk for osteoporosis.Which of the following statements by the client indicates an understanding of the teaching?
A nurse is teaching an older adult client about reducing the risk for osteoporosis.Which of the following statements by the client indicates an understanding of the teaching?
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A nurse is preparing to administer several medications via an NG tube to a client who is receiving a continuous tube feeding.Which of the following actions should the nurse take?
A nurse is preparing to administer several medications via an NG tube to a client who is receiving a continuous tube feeding.Which of the following actions should the nurse take?
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A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?
A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?
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A nurse is preparing to set up a sterile field.Which of the following actions should the nurse take?
A nurse is preparing to set up a sterile field.Which of the following actions should the nurse take?
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A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)
A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)
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A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?
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A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?
A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?
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A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?
A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?
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A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?
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A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair.The nurse determines that the client's BP is 158/66 mm Hg. Which of the following actions should the nurse take?
A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair.The nurse determines that the client's BP is 158/66 mm Hg. Which of the following actions should the nurse take?
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A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
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A nurse is preparing to teach a female client about osteoporosis preven- tion. Which of the following recommendations should the nurse make for this client?
A nurse is preparing to teach a female client about osteoporosis preven- tion. Which of the following recommendations should the nurse make for this client?
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A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
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Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.
Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.
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A nurse in a provider's office is caring for a client.
Diagnostic Results Initial visit:
Calcium 8.G mg/dL (G to 10.5 mg/dL)
Phosphorus 3.4 mg/dL (3 to 4.5
mg/dL)
Total 25-hydroxy D (vitamin Dg) 24 ng/dL (25 to 80 ng/dL)
6-month follow-up:
Calcium 8.8 mg/dL (G to 10.5 mg/dL)
Phosphorus 3.2 mg/dL (3 to 4.5 mg/dL)
Total 25-hydroxy D (vitamin Dg) 15 ng/dL (25 to 80 ng/dL)
The nurse is reviewing the client's medical record.Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)
A nurse in a provider's office is caring for a client. Diagnostic Results Initial visit: Calcium 8.G mg/dL (G to 10.5 mg/dL) Phosphorus 3.4 mg/dL (3 to 4.5 mg/dL) Total 25-hydroxy D (vitamin Dg) 24 ng/dL (25 to 80 ng/dL) 6-month follow-up: Calcium 8.8 mg/dL (G to 10.5 mg/dL) Phosphorus 3.2 mg/dL (3 to 4.5 mg/dL) Total 25-hydroxy D (vitamin Dg) 15 ng/dL (25 to 80 ng/dL) The nurse is reviewing the client's medical record.Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)
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A nurse is caring for a client. Nurses' Notes
Heart rate
0800:
Antibiotics administered as prescribed. Bilateral breath sounds clear and present throughout.
0830:
The client reports itching over the chest area and has urticaria over the chest and trunk. The client states tongue feels swollen. Bilateral breath sounds with scattered wheezing upon auscultation.
Select the 4 findings that require immediate follow-up.
A nurse is caring for a client. Nurses' Notes Heart rate 0800: Antibiotics administered as prescribed. Bilateral breath sounds clear and present throughout. 0830: The client reports itching over the chest area and has urticaria over the chest and trunk. The client states tongue feels swollen. Bilateral breath sounds with scattered wheezing upon auscultation. Select the 4 findings that require immediate follow-up.
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A nurse is caring for a client. Medical History
0800
Client has a history of hyperlipidemia, rheumatoid arthritis, and hypertension. Client has a BMI of 32
Client has a family history of colon cancer. The nurse is reviewing the client's medical record.Which of the following findings places the client at risk for heart disease? (Select all that apply)
A nurse is caring for a client. Medical History 0800 Client has a history of hyperlipidemia, rheumatoid arthritis, and hypertension. Client has a BMI of 32 Client has a family history of colon cancer. The nurse is reviewing the client's medical record.Which of the following findings places the client at risk for heart disease? (Select all that apply)
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History of hypertension A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?
BUN 18 mg/dL.
History of hypertension A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? BUN 18 mg/dL.
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A nurse is planning care for a group of clients.The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?
A nurse is planning care for a group of clients.The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?
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A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?
A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?
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A nurse is caring for a client who has chronic pain.The nurse recommends that the client concentrate on a memory of a pleasurable experience.Which of the following complementary therapies is the nurse suggesting?
A nurse is caring for a client who has chronic pain.The nurse recommends that the client concentrate on a memory of a pleasurable experience.Which of the following complementary therapies is the nurse suggesting?
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A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
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A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?
A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?
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A nurse is caring for a client who has a new diagnosis of cancer.Which of the following actions by the nurse maintains the client's confidentiality?
A nurse is caring for a client who has a new diagnosis of cancer.Which of the following actions by the nurse maintains the client's confidentiality?
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A nurse and an assistive personnel (AP) are providing postmortem care for a decease client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse?
A nurse and an assistive personnel (AP) are providing postmortem care for a decease client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse?
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A nurse reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?
A nurse reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?
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A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child.Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?
A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child.Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role?
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A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?
A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?
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A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
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A nurse is planning to change a client's tracheostomy ties.Which of the following actions should the nurse take?
A nurse is planning to change a client's tracheostomy ties.Which of the following actions should the nurse take?
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A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
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A nurse is caring for a client who reports that she has insomnia.Which of the following interventions is appropriate for the nurse to recommend?
A nurse is caring for a client who reports that she has insomnia.Which of the following interventions is appropriate for the nurse to recommend?
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A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
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