front 1 A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take? Change the pt position every 4 hours Apply petroleum base ointment in the red area Assess the red area for blanching Use friction when cleansing the client's skin | back 1 Assess the red area for blanching |
front 2 A nurse is teaching a client who had an enucleation about care of an artifical eye. Which of the following information should the nurse include in the teaching? (select all that apply ) Store the artificial eye in the label container filled with 0.9 % sodium chloride irrigation Remove from the artificial eye by retracting the upper eyelid Apply pressure just below artificial eye to break the suction Clear the artificial eye with hydrogen peroxide before storing Retract the upper and lower lids to reinsert the artificial eye | back 2 Apply pressure just below artifical eye to break the suctioN Retract the upper and lower lids to reinsert the artifical eye |
front 3 A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? Determine areas of resonance across the abdomen using a systemic approach Expose the client's abdomen to look for changes in appearance Perform abdominal palpation by pressing gently with the finger pads Use the diaphragm of the stethoscope to listen for bowel sounds | back 3 Expose the client's abdoment to look for changes in appearance |
front 4 A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority? Determine the client's reading ability Review the use of an artifical larynx With the client schedule a support session For the client explain the techniques of esophageal speech | back 4 For the client explain the techniques of esophageal speech |
front 5 A home care 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) I will use the bars when getting in and out of the bath tub I need to check my medications for expiration dates I need to have a fire escape plan with my family I will apply tape over frayed areas of electrical cords I need to set my hot water heater to 140 degrees Fahrenheit | back 5 I will use the bars when getting in and out of bath tub I need to check my medications for expirations dates I need to have a fire escape plan with my family |
front 6 A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first? Offer pain medication Palpate the abdomen Auscultate bowel sounds Adminsiter an antiemetic | back 6 Ausculate bowel sounds |
front 7 A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressing? Dry Gauge Transparent Calcium alginate Hydrogel | back 7 Transparent |
front 8 A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching? I can apply lotion to soften the calluses as long as I don't put lotion between my toes I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly I should soak my feet in warm water daily to soften corns calluses I should use an over the counter liquid medication to remove corns | back 8 I can apply lotion to softne the calluses as long as I don't put lotion between my toes |
front 9 A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take? Tie the restraints to the side rail Secure restraints with a square knot Remove one restraint at a time Remove the restraints every 3 hours | back 9 Remove one restraint at a time |
front 10 A nurse is admitting a client who has a clostridium diff infection. Which of the following actions should the nurse take? Select all that apply Use an N95 respirator while providing client care Wear a gown and gloves when providing client care Assign the client to a private room with positive air flow Wash hands with soap and water after contact with the client Ensure the client does not receive fresh fruit | back 10 Wear a gown and gloves when providing client care Assign the client to a private room wiht positive air flow Wash hands with soap and water after contact with the contact |
front 11 A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care? Schedule the client as the first surgical procedure of the day Cleanse the stoppers with primidone iodine for withdrawing medication Remove the stop stocks from iv tubing Ensure the gloves in the surgical suite are powdered gloves | back 11 Schedule the client as the first surgical procedure of the day |
front 12 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 clients motivation to learn? The client's belief that his needs will be met through education The nurse explaining the need for education to the client The client seeking family apporval by agreeing to a teaching plan The nurse's empathy about the client having to self- inject | back 12 The client's belief that his needs will be met through education |
front 13 A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take? Heat the formula to 105 degrees Fahrenheit Flush the tubing with 10 ml of water every 2 hours Change the tubing every 72 hours Aspirate residual vilume every 4 hours ( every 4-8 hours is correct) | back 13 Aspirate residual volume every 4 hours |
front 14 A nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching? The client picks up the walker with each step The client stoops slightly forwars when moving the walker The client stands with her elbows slightly flexed while holding the walker The client moves the walker ahead 10 inches with each step | back 14 The slient stands with her elbows slightly flexed while holding the walker |
front 15 A nurse us caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her restraints. The nurse should identify that the AP is committing which of the following torts? Libel Defamation of character Assault Battery | back 15 Assault |
front 16 A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take? Stabilize the vein by applying traction above the insertion site Engorge the vein by placing the arm in the dependent position Use friction at the insertion site to increase venous distention Leave the tourniquet on for 30 to 60 seconds after initial insertion | back 16 Engorge the vein by placing the arm in the dependent position |
front 17 A nurse us planning care for a client who has a new prescription for parental nutrition in 20 % dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care? Prepare the client for central venous line Change the PN and fat emulsion separately Obtain a random blood glucose daily | back 17 Prepare the client for central venous line |
front 18 A nurse is caring for a client who is schedule while witnessing the client signature. While the client is saying I trust the doctor, but I dont understand what he meant when he said he'll reset my intestines. Which of the following actions should the nurse take? Provide broochures about the procedure Notify the provider Complete an incident report Describe the surgery to the client | back 18 Notify the provider |
front 19 A nurse is caring for a client who agitated and threating to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts? False imprisonment Invasion of privacy Assault Negligence | back 19 False Imprisonment |
front 20 An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest? Use the television to mask external noises Listen to soft music before lying down Exercise just pior to bedtime | back 20 Listen to soft music befire lying down |
front 21 A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take? | back 21 Place an activated tuning fork in the middle of the clients forehead |
front 22 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? Eat a light carbohydrate snack before bedtime Exercise 1 hour before bedtime Drink a cup of cocoa before bedtime Take a 30 min nap daily | back 22 Eat a light carbohdrate snack before bedtime |
front 23 A nurse is teaching in a group of newly licensed nurses about the braden scale. Which of the following responses by the newly licensed nurse indicates understanding in the teaching? Each elements has a range 1 to 5 points The higher the score the higher the pressure ulcer risk The clients age is part of the measurement The scale measures six elements | back 23 The scale measure six elements |
front 24 A nurse is planning care for a client who is schedule for an
intravenous pyelogram. Which of the following actions is appropriate
for the nurse to include? Administer 240 ml contrast before the procedure Monitor the client for pain in the suprapubic region assist the client with a bowel cleansing | back 24 Ensure the client is free of metal objects |
front 25 A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest. Which of the following should the nurse take to obtain the sample? The pad of the finger tip The lateral aspect of the finger The pinna of the ear The side of the wrist | back 25 The lateral aspect of the finger |
front 26 A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first? Provide the client with a contact number for a diabetes education specialist Make a copy of the medication record of the reconciliation for the client Determine whether the client can afford the insulin administration supplies Obtain printed information about self administration | back 26 Determine whether the client can afford the insulin administration supplies |
front 27 A nurse is teaching about home safety with a client. Which of the following insrtuctions should the nurse include? Use electrical tape to secure extension cords next to base boards on the floor Replace carpet floors with tiles Unplug electronics by grasping the cord To use fire extinguisher, aim high at the top of the flames | back 27 Use electrical tape to secure extension cords next to the base boards on the floor |
front 28 A nurse is caring for a client who has restraint to each extremity. Which of the following assessment should the nurse perform first? Elimination needs Comfort level Peripheral pulse Skin integerity | back 28 Peripheral Pulse |
front 29 A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take? Cotton tip applicator to clean the inside of the cannula Soak the outer cannula in warm soapy tap water Cleanse the skin around the stoma with normal saline Secure the tracheostomy ties to allow one finger to fit snuggly underneath | back 29 Secure the tracheostomy ties to allow one finger to fit snuggly underneath |
front 30 Nurse is providing teaching to a client who is self administer an ophtalmic solution. Which of the following statements by the client indicates understanding of the teaching? I will keep my eyes closed for 5 mins after inserting drops I will insert the drops in the center of the eye I will press the inner corner of my eyes after insert drops I will raise my eye lid up while looking down and insert drops | back 30 I will press the inner corner of my eye after insert drops |
front 31 A nurse in a long term care facility is planning care for 4 clients. Which of the following client's is at greatest risk of developing a pressure ulcer? A client who is incontinent of urine 1 to 2 times a day A client who is receiving enteral tube feedings Client who requires assistance to transfer from the bed to a chair Client who is unrepsonsive to pain stimuli | back 31 Client who is unresponsive to pain stimuli |
front 32 A nurse is assessing a client's bowel sounds. Which if the following actions should the nurse take? Listen to bowel sounds after performing abdominal palpation Place diaphragm of stethoscope over each quadrant Ask client to cough upon auscultating Auscultate for 2 mins to determine if bowel sounds are active | back 32 Place diaphragm of stethoscope over each quadrant |
front 33 Hyperosmolar Syndrome Symptoms | back 33 Dry Mouth |
front 34 Phlebitis Symptoms | back 34 Erythema is present following the route of the vein |
front 35 Finger pulse oximeter is not working Patient's normal 13.5 - 17.5 | back 35 Patient's Hemoglobin is 10 |