A nurse is using the I-SBAR communication tool to provide the client’s provider with information about the client. The nurse should convey the client’s pain status in which portion of the report?
- Assessment
- Backgr
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A nurse is using the I-SBAR communication tool to provide the client’s provider with information about the client. The nurse should convey the client’s pain status in which portion of the report?
- Assessment
- Background
- Situation
- Recommendation
2. 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?
- Sweeping the floor
- Shoveling snow
- Cleaning windows
- Washing dishes
3. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
- Warm, dry skin
- Increased urinary output
- Tachycardia
- Bradypnea
4. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?
- Inspection
- Auscultation
- Percussion
- Palpation
5. A nurse is responding to a parent’s question about his infant’s expected physical development during the first year of life. Which of the following information should the nurse include?
- A 2-month-old infant can turn from his abdomen to his back.
- A 10-month-old infant can pull up to a standing position.
- A 4-month-old infant can sit up without support.
- A 6-month-old infant can crawl on his hands and knees.
6. A client who reports shortness of breath requests her nurse’s help in changing positions. After repositioning the client, which of the following actions should the nurse take next?
- Encourage the client to take deep breaths.
- Observe the rate, depth, and character of the client’s respirations.
- Prepare to administer oxygen.
- Give the client a back rub to help her relax.
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7. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, “You are not putting that hose down my throat.” Which of the following statements should the nurse make?
- “I would try to get it over with because you won’t get better without this tube.”
- “You should talk to your provider about it.”
- “Why don’t you want the tube inserted?”
- “I can see that this is upsetting you.”
8. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
- The AP uses soap and water to clean the perineal area.
- The AP tapes the catheter to the client’s inner thigh.
- The AP hangs the collection bag at the level of the bladder.
- The AP ensures that there are no kinks in the drainage tubing.
9. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?
- A client who has a prescription for a transfusion of packed red blood cells
- A client who is being transported for radiography of the kidneys, ureters, and bladder
- A client who has a prescription for a tuberculin skin test
- A client who has a distended bladder and needs urinary catheterization
10. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?
- Limit total caloric intake to 25 kcal/kg of body weight.
- Provide an intake of 500 mg/day of vitamin E.
- Limit fluid intake to 20 mL/kg of body weight per day.
- Provide a protein intake of 1.5 g/kg of body weight per day.
11. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?
- Fasten the ties on the restraint to the side rails of the bed.
- Tie restraint with a quick-release knot.
- Allow one finger’s beneath between the restraint and the client’s chest.
- Place the restraint under the client’s clothing.
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12. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client’s balance?
- Two-point discrimination test
- Glasgow coma scale
- Babinski reflex
- Romberg test
13. A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?
- Carminative
- Hypertonic
- Oil retention
- Sodium polystyrene sulfate
14. 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?
- Daily weight
- Blood pressure
- Specific gravity
- Intake and output
15. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
- Blood loss
- NPO status after surgery
- Nasogastric tube suctioning
- Impaired peristalsis of the intestines
16. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?
- Blow into the spirometer to elevate the balls in the device.
- Cough deeply after each use.
- Clean the mouth piece with an alcohol swab after each use.
- Use the spirometer every 8 hr.
17. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?
- “Support the majority of your weight on the axillae.”
- “Keep your elbows extended.”
- “Bear weight on both of your legs.”
- “Move both crutches forward at the same time.”
18. A nurse iscalled away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?
- Autonomy
- Fidelity
- Nonmaleficence
- Justice
19. 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?
- Aim the hose at the base of the fire.
- Squeeze the handle of the extinguisher.
- Remove the safety pin from the extinguisher.
- Sweep the hose from side to side to dispense material.
20. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client’s urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?
- Hemolytic
- Febrile
- Circulatory overload
- Sepsis
21. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?
- Consult the medication reference book available on the unit.
- Ask a more experienced nurse for information about the medication.
- Call the client’s provider and verify the prescription.
- Ask the client if she takes this medication at home.
22. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client’s wound has eviscerated?
- Cover the incision with a moist sterile dressing.
- Have the client lie on his back with his knees flexed.
- Call the client’s surgeon.
- Reassure the client.
23. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?
- Insert the rectal tube 15.2 cm (6 in).
- Wear sterile gloves to insert the tubing.
- Position the client on his left side.
- Hold the solution bag 91 cm (36 in) above the client’s rectum.
24. 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?
- “A lot of clients who are cared for at home have the same problem.”
- “Don’t worry about it. He will get a bath, and that will take care of the odor.”
- “It must be difficult to care for someone who is confined to bed.”
- “When was the last time that he had a bath?”
25. 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?
- Place the client in Trendelenburg’s position
- Perform percussions directly over the client’s bare skin.
- Use a flattened hand to perform percussions.
- Remind the client that chest percussions can cause mild pain.
26. 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?
- Redness at the infusion site
- Edema at the infusion site
- Warmth at the infusion site
- Oozing of blood at the infusion site
27. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?
- Place a padded tongue blade in the client’s mouth.
- Lower the client to the floor and place a pad under the client’s head.
- Seek the help of a coworker and lift the client back into bed.
- Use an oropharyngeal airway to keep upper airway passages open.
28. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
- Vastus lateralis
- Dorsogluteal
- Deltoid
- Ventrogluteal
29. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?
- Sit at the bedside while feeding the client.
- Order pureed foods.
- Make sure feedings are at room temperature.
- Offer the client a drink of fluid after every bite.
30. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?
- Loss
- Trust
- Self-disclosure
- Risk-taking
31. 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?
- “People who practice the Islamic faith pray over the deceased for a period of 5 days before burial.”
- “People who practice the Hindu faith bury the deceased with their head facing north.”
- “People who practice Judaism stay with the body of the deceased until burial.”
- “People who are practicing the Buddhist faith have the female family members prepare the body following death.”
32. A nurse in a provider’s office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
- Constipation
- Gastric ulcers
- Respiratory depression
- Liver damage
33. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client’s death is imminent?
- Urinary retention
- Cold extremities
- Hypertension
- Tachycardia
34. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?
- BT for bedtime
- SC for subcutaneously
- PC for after meals
- HS for half-strength
35. A nurse is reviewing the laboratory values for a client who has a positive Chvostek’ssign. Which of the following laboratory findings should the nurse expect?
- Decreased calcium
- Decreased potassium
- Increased potassium
- Increased calcium
36. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
- Set the suction machine at 120 mm HG.
- Provide oral hygiene frequently.
- Measure the amount of drainage form the NG tube every shift.
- Secure the NG tube to the client’s gown.
- Apply petroleum jelly to the client’s nares.
37. A nurse in a provider’s office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?
- WBC 15,000 mm3
- Erythrocyte sedimentation rate (ESR) 15 mm/hr
- Urine pH 7.2
- Urine specific gravity 1.0063
38. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?
- Pain level
- Hydration status
- Airway
- Urinary output
39. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
- Repeat each joint motion five times during each session.
- Move the joint to the point of considerable resistance.
- Sit approximately 2 feet from the side of the bed closest to the joint being exercised.
- Exercise the smaller joints first.
40. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
- Wear gloves when changing the client’s gown.
- Use alcohol-based sanitizer to cleanse the hands.
- Wear a mask when assisting the client with his meal tray.
- Place the client on complete bed rest.
41. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
- Teaching clients to perform self-examinations of breasts and testicles
- Educating clients about the recommended immunization schedule for adults
- Teaching clients who have type 1 diabetes mellitus about care of the feet
- Recommending that clients over the age of 50 have a fecal occult blood test annually
42. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client’s understanding of the process within the psychomotor domain of learning?
- Ask the client if he wants to self-administer his insulin.
- Have the client list the steps of the procedure.
- Have the client demonstrates the procedure.
- Ask the client if he understands the purpose of insulin.
43. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
- Use battery-operated equipment for personal care.
- Apply mineral oil to protect the facial skin from irritation.
- Remove the television set from the client’s bedroom.
- Wear cotton clothing to avoid static electricity.
44. A nurse in a provider’s office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?
- Sunken eye balls
- Hypotension
- Poor skin turgor
- Bounding pulse
45. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states “All this equipment is making me nervous.” Which of the following responses should the nurse make?
- “You won’t need the equipment very long.”
- “All of this equipment can be frightening.”
- “Why does the equipment bother you?”
46. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?
- Place the client in a lateral position with the head turned to the side before beginning the procedure.
- Use the thumb and index finger to keep the client’s mouth open.
- Rinse the client’s mouth with an alcohol-based mouth wash following the procedure.
- Cleanse the client’s mucous membranes with lemon-glycerin sponges.
47. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
- “Don’t worry, teenagers often have friends who give them bad advice.”
- “I think you should stop seeing those friends since they discourage you from following your treatment plan.”
- “Tell me more about how your friends discourage you.”
- “Tell me where you met these friends.”
48. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?
- Leave the bag in place for 45 min.
- Fill the bag two-thirds full with ice.
- Place the ice bag uncovered on the client’s ankle.
- Tell the client that it is expected to feel numbness when the ice bag is in place.
49. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?
- Stand 3 feet from the client when assisting with lifting.
- Lock your knees when standing for long periods.
- Lift up to 22.6 kg (50 lbs) without the use of assistive devices.
- When lifting an object, spread your feet apart to provide a wide base of support.
50. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?
- Cream of rice
- Cottage cheese
- Gelatin
- Ice cream
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