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1. A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? 2. A ... nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? 3. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following actions should the nurse perform first after discovering the client’s wound has eviscerated? 4. A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? 5. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? 6. A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (round to nearest whole number) 7. A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client’s body? 8. A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? 9. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client’s fluid status? 10. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? 11. A nurse is caring for a client who has bilateral cats on her hands. Which of the following actions should the nurse take when assisting the client with feeding? 12. A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? 13. A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? 14. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? 15. A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? 16. A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? 17. A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? 18. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? 19. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? 20. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? 21. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client’s skin turgor? 22. A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? 23. A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? 24. A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? 25. A nurse is preparing to administer a unit of packed RBC’s to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? 26. A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? 27. A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? 28. A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during 12-hour night shift? (round to the nearest whole number) 29. A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? 30. A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? 31. While in the hospital, a client who has a terminal illness tells the nurse, “I can’t believe I’m dying. A lot of bad people in the world are healthy and here I am dying!” Which of the following responses should the nurse provide? 32. A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? 33. A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? 34. A nurse in a provider’s office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (SATA) 35. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? 36. A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson’s developmental task for this age group? 37. A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client’s urine is 1.035. Which of the following actions should the nurse take? 38. A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? 39. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? 40. A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? 41. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. Which of the following actions should the nurse take? 42. A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson’s developmental task for her age group? -incorrect: This statement relates to Erikson’s developmental task for young adults, which is intimacy vs. isolation. 43. A nurse is inserting an NG tube into a client who begins to gag and cough. Which of the following actions should the nurse take? 44. An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? 45. A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? 46. A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (nearest tenth) 47. A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? 48. A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client’s commitment to a long-term goal of weight loss? 49. A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? 50. A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? 51. A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? 52. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? 53. A new resident provider asks the charge nurse for an access code to review clients’ online records. The resident is not scheduled to attend the facility’s orientation computer class until next week. Which of the following actions should the nurse take? 54. A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? 55. A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? 56. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? 57. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? 58. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? 59. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (SATA) 60. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client’s room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? Download to view full exam [Show More]

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