1
The nurse provides education to an adult client to facilitate bowel elimination. Which action should the nurse encourage?
1. Engaging in sedentary activity.
2. Increasing dietary bulk.
3. Decreasing fluid intake
4. Using oral laxatives.
Increasing dietary bulk
The nurse cares for an older adult client and provides education about dietary needs. Which information is included in the teaching?
1. As metabolism decreases, caloric need decreases.
2. The need for calcium in the diet decreases with age.
3. The client should decrease the intake of protein.
4. The client should decrease the fluid intake.
As metabolism decreases, caloric need decreases.
The nurse observes a staff member prepare to leave the room of a client on droplet precautions. The nurse intervenes if which action is observed
1. The staff member removes the first glove by grasping the cuff and pulling glove inside out over hand.
2. The staff member holds onto the outer surface of the face mask while pulling mask away from face.
3. The staff member unties the gown and removes it without touching the outside of the gown.
4. The staff member performs hand hygiene.
The staff member holds onto the outer surface of the face mask while pulling mask away from face.
The nurse helps a client cough and deep breathe after surgery. For coughing and deep breathing to be most effective, the nurse assists the client to assume which position?
1. Side- ying.
2. Prone.
3. Supine with one pillow.
4. High Fowler.
High Fowler
The nurse instructs a client how to successfully begin a regular exercise program. The nurse determines teaching is successful if the client makes which statement?
1. "I should start by running 5 miles every day."
2. "I will exercise for a few minutes twice a week."
3. "I should focus on aerobic exercise."
4. "I am making a commitment to exercise regularly."
"I am making a commitment to exercise regularly."
An older adult client is diagnosed with a fractured femur after a fall and is recovering at home with a walker. The home health nurse educates the client about fall prevention. Which nursing observation in the home indicates the client has an understanding the information provided?
1. There are small area rugs in the kitchen and bathroom.
2. The client ambulates wearing socks.
3. The bathroom is equipped with grab bars.
4. Books and papers are stacked against the wall in the hall.
The bathroom is equipped with grab bars.
The nurse identifies which diet best meets the needs of a client with multiple wounds?
1. High-protein, low-fat, high-iron diet.
2. High-vitamin C, high-protein, high-carbohydrate diet.
3. High-vitamin A, high-calcium, high-fat diet.
4. High-vitamin B,
high-protein, low-carbohydrate diet.
High-vitamin C, high-protein, high-carbohydrate diet.
The nurse cares for a client with an open, draining wound on the lower left leg. The client has a white blood cell count of 16,000/mm? (16 x 109L). Which intervention does the nurse anticipate in the client's plan of care?
1. Place the client on bleeding precautions
2. Administer an antibiotic by intramuscular injection
3. Obtain a culture of the wound and send to the laboratory.
4. Limit visitors and place the client on contact precautions
Obtain a culture of the wound and send to the laboratory.
A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. Which client statement indicates to the nurse a correct understanding of medical asepsis?
1. "I need to buy sterile gloves to redress this wound."
2. "I should wash my hands before redressing my wound."
3. "I need to keep the wound covered at all times."
4. "I will use an over-the-counter antimicrobial ointment."
"I should wash my hands before redressing my wound."
An adolescent client hospitalized for a leg fracture is reluctant to participate in physical therapy stating, "I'd rather just rest in bed and play video games." Which consequence of immobility does the nurse include when providing education to this client?
1. Delusions.
2. Diabetes mellitus.
3. Diplopia.
4. Deep vein thrombosis.
Deep vein thrombosis.
The nurse identifies which findings are characteristic of chronic pain?
1. Withdrawal and fatigue.
2. Tachycardia and restlessness.
3. Anxiety and memory loss
4. Urine retention and agitation.
Withdrawal and fatigue
The nurse provides care for a client following surgery to repair a broken femur. The client is restless, perspiring, and grimaces when trying to move in the bed. Which is the most appropriate intervention for the nurse to implement first?
1. Darken the room and encourage the client to rest.
2. Assess the client's pain level.
3. Assist the client to turn to the the unaffected side.
4. Administer the required PRN pain medication.
Assess the client's pain level.
In which situation does the nurse consider withholding morphine until further assessment is completed?
1. Client reports acute pain from deep partial thickness burns affecting the lower extremities.
2. Client's respirations are 28 and regular.
3. Client's level of consciousness fluctuates from drowsy to lethargic.
4. Client exhibits restlessness, anxiety, and cold, clammy skin.
Client's level of consciousness fluctuates from drowsy to lethargic.
A two day postoperative client reports pain, tenderness, and redness of the right calf. Which findings are most critical for the nurse to report to the health care provider?
1. Nausea and abdominal distention
2. Back pain and hematuria.
3. Chest pain and shortness of breath.
4. Mild redness around the surgical incision.
Chest pain and shortness of breath.
The nurse observes a staff member enter a client's room wearing a fit-tested N95 type respirator mask. The nurse questions this action if the staff member is caring for which client?
1. A client diagnosed with mumps.
2. A client diagnosed with varicella.
3. A client diagnosed with active tuberculosis
4. A client diagnosed with measles.
A client diagnosed with mumps.
The nurse provides care for a client on the medical surgical floor who is experiencing difficulty sleeping at night. Which nursing action is most appropriate to promote adequate sleep for the client?
1. Encourage frequent daytime naps.
2. Ensure the room is cool.
3. Provide the client with hot tea at bedtime.
4. Avoid unnecessary lights, noises, and interruptions ät night.
Avoid unnecessary lights, noises, and interruptions ät night.
A client returns from surgery with a drain sutured into the surgical wound. Which explanation is the purpose of the drain?
1. It decreases fluid accumulation within the tissues.
2. It prevents infection by providing a means for bacteria to escape.
3. It provides hemostasis.
4. It creates a space that will facilitate reconstructive surgery.
It decreases fluid accumulation within the tissues.
The nurse teaches a client how to maintain an adequate intake of protein. The nurse determines teaching is most effective if the client chooses which foods for breakfast?
1. Orange juice and white toast with jelly.
2. Biscuit and jelly.
3. Scrambled eggs and whole wheat bread.
4. Oatmeal and raisins
Scrambled eggs and whole wheat bread.
The nurse and the licensed practical nurse (LPN/LVN) provide care to clients on the medical floor. Which task can the nurse delegate to the LPN/LVN?
1. Teach the client colostomy care.
2. Add a nursing diagnosis to the nursing care plan.
3. Administer a tap-water enema.
4. Add potassium to an existing V infusion.
Administer a tap-water enema.
A client reports "coughing up bloody mucus" in the mornings. The nurse tries to determine the source of the bleeding. Which action does the nurse take first?
1. Sends a specimen to the laboratory for analysis.
2. Inspects oral cavity with a pen light.
3. Inspects the nose and mouth to assess for bleeding.
4. Listens to the client's lungs and breathing
Inspects oral cavity with a pen light.
A client is admitted to the medical unit with a temperature of 101°F (38.3°C) and a white blood cell (WBC) count of 3,000/mm% (3 X 109L). The nurse institutes which precautions?
1. Contact precautions.
2. Airborne precautions.
3. Droplet precautions.
4. Neutropenic precautions
Neutropenic precautions
A client asks the nurse to provide examples of foods rich in vitamin C. Which food is a good source of vitamin C?
1. Apple juice.
2. Oatmeal.
3. Lean chicken.
4. Tomatoes.
Tomatoes
A client requires a dressing change. The LPN/LVN assigned to care for the client reports never having performed the procedure before to the nurse. The nurse takes which action?
1. Tells the LPN/LVN to review the hospital's procedure manual prior to performing the dressing change.
2. Verbally reviews the steps of the dressing change with LP/LVN
3. Completes the dressing change while the LPN/LVN observes
4. Assigns a more experienced LP/LVN to the client.
Completes the dressing change while the LPN/LVN observes
The nurse knows which statement is an important fact about warfarin?
1. It has a prolonged action.
2. It is never given for prolonged periods of time.
3. It must be given several times a day to be effective.
4. It can only be given parenterally.
It has a prolonged action.
The nurse provides care for an older adult client with a diagnosis of advanced dementia who is mostly bed confined and develops a reddened area on the right hip. Which intervention is most appropriate for the nurse to implement?
1. Encourage the client to lie on the left side.
2. Use a draw sheet to turn the client every two hours.
3. Rub lotion on the reddened area four times per day.
4. Assess bony prominences once per shift.
Use a draw sheet to turn the client every two hours.