mobility
safety
wounds
hygeine
comfort/rest
100
• List the principles of positioning a nurse should follow.
o Raise the height of the bed to the caregiver’s elbows, remove pillows prior to positioning, and change the client’s position every 2 hours.
100
• A nurse is caring for an elderly and disoriented client who is restrained. Upon reassessment, the nurse finds that the client improved. However, the restraint is still ordered for two hours. What is the appropriate action?
o Remove the restraints for a trial period.
100
• The nurse is using a spica turn technique to bandage a client. What body part is the nurse bandaging?
o The trunk or chest.
100
• The nurse is providing AM care for a client. The client refuses a partial bath and requests a shower. The nurse’s priority nursing intervention is?
o Assess client for ability to shower and use a nonskid floor mat.
100
• Nurse caring for a client with leg ulcers has noted edema upon assessment. What intervention is appropriate to reduce the swelling?
o Elevate the legs on pillows.
200
• The nurse is caring for a client with dyspnea, the nursing priority is?
o Place the bed in Fowler’s position. 
200
• Client with accidental poisoning resulting from a consumption of a sedative medication is brought to the healthcare facility. What is your nursing priority?
o Assess breathing and cardiac function.
200
• When healing occurs when the wound edges are widely separated that leads to a compelled reparative process is called?
o Healing by second intention.
200
• The nurse is caring for a diabetic client with thick discolored nails. What is the priority intervention?
o Consult a podiatrist.
200
• A client who is taking diuretics reports decreased sleep due to frequency of urination. The nurse’s priority intervention is what?
o Give diuretics in the AM.
if the order states BID give second dose of diuretics before 6pm.
300
• The nurse is caring for a client with diabetes. Which exercise is recommended?
walking
300
• The nurse requests a restraint alternative order for a client. Which alternatives would be appropriate?
o Tilt wedges, seat belts with Velcro, and a harness with buckles.
300
• The nurse is caring for a wound with a closed drain. What is the priority nursing intervention?
o Assess and measure the drainage.
300
• The nurse is providing oral care to a comatose client. What is the priority intervention?
o Use oral swabs for oral care.
300
• The client reports having difficulty falling asleep. Which food items should the nurse tell the client to avoid before bed?
o Coffee, cocoa, and chocolate.
nicotine should also be avoided
400
• The nurse is caring for a client who has undergone a mastectomy. Which exercises should the nurse recommend for strengthening?
o Squeeze a softball, comb hair, and finger climbing
400
• The nurse is planning discharge planning for an elderly client. Which teaching points should the nurse include to prevent falls at home?
o Remove throw rugs.
400
• Define the technique that is used to treat extensive necrotic tissue within a wound.
o Debridement
400
• The nurse is caring for a client with a high fever. What type of bath is best for this client?
o Sponge bath
400
• The nurse is preparing discharge instructions for a client with narcolepsy. Which information is important to put in the discharge planning?
o Avoid driving a motor vehicle.
500
• List aspects a nurse should keep in mind when performing ROM exercises on a client.
o Raise the level of the bed to elbow or waist height, avoid forceful movement of the joints, move the client closer to the edge of the bed.
500
• Upon entering a client’s room, the nurse notices smoke and flames coming from the electrical outlet. What is your priority action?
o Evacuate the client.
500
• During the assessment of the client’s skin, the nurse notes redness and blistering on the buttocks. How will the nurse document this assessment?
o Stage II Wound
500
• What type of bath should the nurse provide for a client with acute arthritis?
o Partial bath
500
• The nurse is assessing the mastectomy site in a female client. Which intervention should be implemented to maintain dignity?
o Pull the privacy curtain.