SATA

The nurse is collecting data from a client with an acute Myocardial infraction (MI) . Which of
the following findings would be consistent with an acute MI?

SATA

1) Nausea and vomiting

2) Diaphoresis
3) Dyspnea – shortness of breadth
4) Nailbed splinter hemorrhages
5) Petechiae
6) Dizziness and fatigue

A nurse is collecting data with COPD patient. Which of the following findings would be a priority to
report to the charge nurse ?

1. The client reports getting tired easily – normal

2. The client reports having increased sputum production in the morning – normal

3. The client's breathing is shallow

4. The clients sputum is yellow – most likely cause its infection

Yellow + Green = Infection

The nurse is preparing for a client for an emergency surgery to repair a depressed skull fracture.
Which of the following for actions are essential for the nurse to make ?

1. Determining the time that the client last ate – most likely = client should remain
NPO 8 hrs before surgery , no NSAIDS

2. Showing the client a picture of the postoperative would drainage system

3. Telling the client what will occur in the post anesthesia care unit (PACU)

4. Checking the client's corneal reflex

The nurse is assisting to admit a client with active pulmonary tuberculosis TB. Which of the
following actions should the nurse take prior to the client’s arrival?

1) Assign the client to room with client who has pertussis if a private room is not available

2) Have a particular respirator mask available for client transport

3) Have a particular respirator mask available for staff who care for the client

4) Post a sign outside the room restricting pregnant women from entering the room

- again post

The nurse is contributing to staff education conference about advance directives. Which of the
following information should the nurse recommend including ?

SATA

1) Advance directives support a client’s ethical right autonomy = Client wishes

2) A client’s may designate another person to make health care decisions for
the client

3) Health care facilities must ask clients if they have completed an advance directive

4) Advance directives indicates a client; s treatment wishes for acute diagnoses =

chronic ilness

5) A living will must be witnesses by a client’s attorney

Patient doesn’t have consult HCP for advance directives.

The nurse is talking with the parent of 3 month old client . The client expresses concern
that the infant in unable to roll over. Which of the following would be an appropriate
response for the nurse to make ?

1) We should inform your child’s primary health care provider about this delay
2) Most infants are able to roll over between ages 4 to 6 months
3) Does your infant smile in response to your smile ?
4) Is your infant able to pick up objects
The nurse is caring for client with pertussis . Which of the following infection control
precautions should the nurse implement ?

1) Place a stethoscope in the client’s room to be used for the client only
2) Wear gloves when checking the client’s pulse
3) Wear a protective gown when bathing the client
4) Wear a surgical mask when assisting the client to eat or giving medications

Pertussis = Droplet precation

The nurse in a long term facility is making client care assignments for UAP. Which of the
following statements by the nurse would provide a UAP directions for the assignment ?

1) Client’s who are unable to ambulate should be assisted to ambulate after meals
2) Notify me if any develops an abnormal temperature
3) Check the meal trays distributed to client’s with DM type 1
4) Obtain vital signs first for the client with Hypertension and report the results to me

Time and minutes are important

The nurse is caring for client who has active TB . Which of the following infection control
precautions should the nurse implement ?

1) Put on sterile gloves to administer prescribed medications to the client = No

need , just the clean gloves
2) Perform hand hygiene prior to checking the client’s vital signs
3) Wear a particular respirator mask when assisting the client’s to bathe or
giving meds to the patient
4) Wear a protective gown if clothing may be soiled = contact isolation
5) Close the door after entering client’s room
The nurse has reinforced teaching with a client who has an ileal conduit. Which of the following
statements by the client would indicate a correct understanding of the teaching ?

1) I will need to awaken several times at night to empty the pouch

2) I can expect mucus in my urine
3) The stoma should be a dark purple color
4) I will need to limit by fluid intake
The charge nurse in a long term care facility has completed client care assignments for UAP.
Which of the following statements by the change nurse provides best directions to UAP
regarding the assignment?

1) Record your assigned client’s vital sign before you take mid-morning break
2) Weigh your assigned client’s before breakfast with the scale used 1 day ago- could be
3) Help the clients who eat their meals in the dining room with breakfast
4) Measure the amount of your assigned client intake and output regularly = no time, no
min provided
The nurse is caring for client who is prescription of darbepoetin 0.45mcg/kg , subcutaneously.
The client weighs 190lb (86KG) . The nurse has 100 mcg.ml solution available. How many ML
should the nurse administer with each dose ?

0.4

0.45mcg kg 190 LB mL
Kg 2.2lb X 100MCG

0.38

= 0.4
The nurse is reinforcing teaching with the parents of a child who is scheduled for surgical repair
of hypospadias. The nurse should reinforce that intended outcomes of the procedure include.

1) Relief from pain

2) Relief from bladder obstruction- maybe
3) The ability to void while standing
4) The ability to achieve an erection

A condition in which the opening of the penis is on the underside rather than the tip.
The nurse is caring for client who has just returned from the radiology department after having
an upper gastrointestinal UGI series. Which of the following action should the nurse take first ?

1) Administer the prescribed enema

2) Give the prescribed multiple vitamin that was withheld prior to the procedure
3) Determine whether follow-up x-rays are to be taken
4) Verify the preliminary test results – most likely

Assess , check , collect data , Determine , verify = correct answers

The nurse is collecting data from a client who has hypovolemic shock . which findings are
consistent with hypovolemic shock?

SATA

1) Confusion
2) Hypertension
3) Decreased urine output
4) Elevated respiratory rate
5) Jugular vein distention

with increased circulating blood volume/CHF

1. Hyperention
2. Jugular vein distention
The nurse has reinforced dietary teaching with a client who has esophageal varices. Which of
the following food choices by the client would indicate a correct understanding of the teaching ?

1) 1 cup vanilla yogurt

2) 8oz of chicken broth- mostly likely clear liquid
3) 4 oz of pretzels- hard to chew
4) 1 fresh apple – hard to chew
 1. The charge nurse in a long-term care facility has been advised that the following Assign
clients with me it will be admitted during the shift the charge nurse should assign the only
available private room to which client ?

1. Pneumocystis pneumonia – droplet precautions

2.A positive vericella zoster titer ( Chicken pox ) – Airborne
3.Hepatitis C
4. A positive cytomegalovirus
A nurse has received the following information about a sign clients then there should first check the client?

1. Who has right sided heart failure at and is reporting frequent urination
2. With active pulmonary tuberculosis who is reporting expectorating blood tinged mucous
3. Who has a fractured femur and received a dose of pain medication intramuscular one hour Ago and
is reporting that the pain has not been relieved
4. With benign prostatic hyperplasia who is reporting having no bowel movement for the past three days and is
requesting a does of prescribed laxative

3 – compartment syndrome

Breathing and pain comes first .

A nurse is collecting data from a client with Guillian Barre . The client is experiencing paralysis and
paracentesis of the lower extremity and has a respiratory rate of 18 which of the following actions should the
nurse take?
1.Massage the clients legs every two hours
2. Monitor the clients respiratory rate frequently
3. Pad the side rails of the clients bed
4. Keep the head of the bed elevated at 30°

Paracentesis = Sitting up with legs dangling

Thoracentesis = Sitting up in the bed , leaning on the table
Lumber puncture = lateral position , knees flexed
After = lie flat
The nurse is caring for a client who has been diagnosed with a hookworm infestation.
The clients parent asks how can I prevent my other children from getting hookworm?
Which of the following would be appropriate response for the nurse to make?

1. Cook all the meet is thoroughly

2. Have your pets treated for the worms = its not worm related
3.  Encourage your children to wear shoes when outside
4. Wash all clothing in hot water – pediculosis ( LICE)
The nurse In an ambulatory care facility has been advised that several clients have arrived for
scheduled appointment the nurse should ask a client with which of the following concerns to come to
a private examination room first
1. A productive cough with night sweats = nagging cough means cancer
2. Diabetes mellitus with tingling in both feet = expected
3. Red eyes with moderate Tearing = the word moderate / mild used
4. Emphysema with clubbing of the fingernails
7. A nurse is caring for a client with pediculosis Which of the following infection control
precautions should the nurse implement?

1. Place a thermometer in the clients room to be use for the client only
2. Where is surgical mask when assisting the client to bathe – this is for droplet
precautions
3. Keep the door to the clients room closed = not necessary
4. Remove the gloves after leaving the clients room = before leaving the clients room

Pediculosis = Contact isolation

pediculosis =head lice infestation. Rationale= to prevent transfer to others

8. The nurse is assisting with the plan of care of a client with moderate Alzheimer’s
disease which of the following intervention should the nurse suggest including in the
clients plan of care?

Select all that apply

1.  Avoid the use of restraints

2. Avoid reminiscing about happy times in the clients life = why avoid
3. Use the distraction when the client becomes anxious or agitated
4. Provide the client with a wide selection of food choices at mealtime = patient is
confused no need
5. Speak slowly and use short simple sentences when providing the client with
information
6. Ride to family members with information about community support services for
respite care – maybe

No need to have open questions technique = Alzheimer’s

No need explaining the procedure = Alzheimer’s
9.The nurse is contributing to a staff development conference about confidentiality
which of the following information should the nurse suggest including?

1.Client must wait until after discharge to review their medical records
2. Nurses on a hospital unit must may review the medical records for all clients
on the unit
3. Certain information in the clients medical record may not be considered confidential
4. Clients must disclose all personal information order to receive care = no need
The nurse and unlicensed assistive personnel are caring for assigned clients which of
the following activities should be appropriate for the nurse to assign the UAP?

1. Obtain vital signs from the client with major depression

2. Provide medication teaching to the client with schizophrenia = RN
3. Monitor medication side effects of the client with bipolar disorder = RN
4.  Telephoning the primary care provider to report the intake and output information
from the client with anorexia nervosa = RN

Teaching , Monitoring , Telephoning , Evaluating , checking quality, Care plan

newly/first = RN
10. The charge nurse in a long-term care facility has made client care assistants for
Unlicensed assistive personnel which of the following statements by the charge nurse
would provide the best directions to the UAP about the assignments?

1.Your clients will need assistance to ambulate once in the morning and once in the
afternoon
2.Obtain vital signs for clients every four hours and report any abnormal
measurements
3.Assist clients who are on special diets to eat their meals
4. Turn clients who are on bed rest onto the left side for two hours/ 2 hrs and then
on to the right side for two hours until lunch is served

To prevent pressure ulcers

The nurse is contributing to a staff education conference about advance directive which
of the following information should the nurse recommend including?

select all that apply

1. Advance directive support a clients ethical ride to autonomy = client wishes

2. A client may designate another person to make healthcare decisions for the
client 
3. Healthcare facilities must ask clients if they have completed an advance directive
4. advanced directives indicate a clients treatment wishes for acute diagnosis
5. A living will must be witnessed by a clients attorney

The word must be / only are doughy

And nurses assisting to admit a client with active pulmonary tuberculosis. Which of the
following actions should the nurse take prior to the clients arrival?

1. Assign the client to room with a client who has pertussis if a private room is not
available
2. Have a particulate Respiratory mask available for a client transport
3.  Have particulate respiratory mask available for staff will care for the client
4.  Post a sign outside the room restricting Pregnant women from entering the room
The nurse is collecting data from a client with an acute myocardial infarction which of
the following findings would be consistent with an acute MI? Select all that apply

1. Nausea and vomiting 

2. Diaphoresis
3. Dyspnea = difficult breathing
4.  Nailbed splinter hemorrhages
5.  Petechiae

The nurse and unlicensed assistive personnel are caring for a sign clients which of the
following activities would be appropriate to assign to the new UAP?

1.Bathing the client who has an altered mental status = RN

2. assisting the client who uses a walker to ambulate
3. Check in the vital signs of a client who has a peripheral vascular access device
4. Adjusting the prescribed oxygen flow rate for the client based on oxygen saturation
levels = RN
5. Measuring the oral intake and urine output for a client who has an indwelling
urethral catheter = RN
The nurse is contributing to the plan of care for a client who had a stroke three days ago
and has right sided hemiplegia and dysphasia ( Difficulty swallowing).Which of the
following nutritional outcomes would be most appropriate for the nurse to recommend
including in the clients plan of care?

1. The client will eat 90% of each meal

2. The client will eat without episodes of coughing
3.  The client will drink for ounces of juice or water with each meal
4. The client will drink liquids without drooling
The charge nurse in a long-term care facility has made client care assignments for unlicensed assistive
personnel which of the following statements by the Charge nurse provide the best information to a UAP about
the assignments?

1. The client needs assistance to get out of bed = no time given

2.The client needs to have food cut into bite sized pieces – safety first
3.  The client needs range of motion exercises every four hours – time frame given
4. The client needs frequent perineal care = no time given
And the nurse is collecting data from a client who had a kidney transplant five days ago
which of the following findings would require immediate intervention?

2. Blood pressure 154/96- BP Should be low

3. 2.Blood urea nitrogen 20 MG/DL = Range 6 – 20

4. You’re in output of 120 ml in the past four hours - Normal as 30/hr

5. Incisional pain rated five on a scale of 0 (no pain) to 10 (severe pain) –

5 is Normal
The nurse is collecting data from a client with sickle cell anemia which of the following
statements by the client will it be essential to follow up?

1. I usually drink 4 L of water or juice daily

2. I am scheduled to receive the influenza vaccine
3. I may need to receive a prescribed anti-infective if I develop a fever
4. I have been applying ice/cold packs daily to help relieve the pain in my knees
The nurse is observing a coworker suctioning a client with a tracheostomy the Nurse
should intervene if the coworker - sterile technique

1. Appliance suction as the catheter is being withdrawn 

2.  Wears a face shield throughout the procedure
3. Applies suction for 10 seconds at each pass of the catheter
4. Wears clean non-sterile gloves throughout the procedure =

suctioning a client with a tracheostomy = sterile gloves technique

The nurse is talking with a client who has schizophrenia the client states I just returned
from Mars which of the following responses would be appropriate for the nurse to
make?

1. I need to tell you that you cannot talk about silly things here = never
2.  Why do you think you made that trip? = never asked why questions
3.  How does it feel to be back = also good response
4.  I am here to listen to your concerns
The nurse in a long-term care facility is making client care assignments for the
unlicensed assistive personnel which of the following statements by the nurse would
provide a UAP with the best directions about an assignment?

1. The client is weak on the Right side so please assist the client with
dressing and bathing
2. Please check the clients capillary blood glucose level and tell me the
results by 7 o’clock = time frame given
3. We need to document vitals signs for the client every four hours
today = time frame given
4. Please encourage the client to change positions frequently = no time
frame
The nurse is collecting data from an 85 or older male client which of the following
statements would be essential to follow up?

1.  I feel that it takes longer to to do task such as balancing my checkbook

2. I feel some stomach discomfort after eating a large meal
3. I have awakened from sleep Because of shortness of breath = Breathing 1 st
4. I have a problem starting a strong stream of urine = normal in old age
The nurse is collecting data from a client with a preliminary diagnosis of abdominal
aortic aneurysm which of the following findings would be consistent with an abdominal
aortic aneurysm?

1. Urinary retention
2.  Back pain
3. Neck vein distention
4. Dysphasia
A nurse is assisting to admit a client who has Streptococcal pharyngitis which of the
following actions should the nurse take?

1.  Wear a surgical mask when checking the clients vital signs – droplet
precautions
2. Ensure the assigned a room has the monitor negative air pressure = airborne
3. Obtain particulate respiratory mask for staff members to use one providing Client
care = airborne
4. Request The dietary department Provide disposable dishes and utensils for the
clients meals
The nurse has assisted with the orientation of new staff members to the care of
postpartum client which of the following statements by a staff member would indicate a
correct understanding of the orientation
1. I would encourage a client to wear gloves when the client applies a prescribed
medication cream to the hemorrhoids- rectum area
2. I would wear gloves to assist a client who is breast-feeding her newborn = never
3.  I would wear a mask when checking a clients lochia = never
4.  I would offer a clean gloves to wear doing formula feeding of the clients newborn
develops a fine white rash or the nose and chin
The nurse is contributing to a staff education program about caring for a client in active
pulmonary tuberculosis TB of the following information should the nurse suggest
including

1. It is mandatory to report a client positive TB test results to the public health

department
2. It is necessary to isolate a hospitalized client for 24 hours after initiating
Antitubercular Therapy
3. Antitubercular therapy is continued until the client provide three sputum cultures that
test negative for TB = maybe
4. Droplet precautions must be implemented as soon as a hospitalize client is
suspected of active TB = airborne precautions
The nurse is contributing to the Plan of care for a client with gestational hypertension
who is at 32 weeks gestation which of the following should the nurse recommend be
included in the plan of care

1.  Monitoring the client urinary output

2. Instructing the client to report any increase in fetal activity
3. Instructing the client to use relaxation techniques to relieve a headache
4. Minimizing the clients and dietary intake of high calcium foods
The nurse is reinforcing teaching with a client who is scheduled for a thoracentesis
which of the following information should the nurse reinforce ?

1.  You should be on the affected side for four hours after the procedure
2.  You will be placed in a sitting position with your arms resting on a bedside
table doing the procedure
3. You will be given a does of a prescribed Sedative/hypnotic before the procedure
4.  You should not have anything to eat or drink for 24 hours before the procedure

No need consent / NPO

The nurse is caring for a client who has Mycoplasma pneumonia. Which of the following
infection control precautions should the nurse Implement

1. Where a surgical mask when checking the clients breath sounds

2. Place a client in a private room with monitored negative air pressure = airborne
prections
3.Place a stethoscope in the clients room to be used for that client only
4. Remind Visitors to put on a productive gown before entering the clients room =
contact precautions  
The nurse is caring for assigned clients the nurse should recognize that the client at
highest of for developing peritonitis is a client who had

1) An appendectomy for ruptured appendix 12 hours ago

2) A nasal gastric tube inserted five hours ago for gastrointestinal
bleeding
3) An abdominal cholecystectomy 16 hours ago and has 300 ml of
greenish brown drainage in the drainage tube
4) A subtotal gastrectomy eight hours ago and is reporting pain rated
seven on a scale of 0 to 10
A nurse is talking with a client who has borderline personality disorder which of the
following statements Would the nurse expect the client to make? 

I often feel bored and empty

I hear voices others are unable to hear
I need to go to my room to wash my hands again
I am worried the food on the meal tray has been poisoned

The nurse is collecting data from a client with the right sided heart failure which of the
following findings would be consistent with right sided heart failure?

Edema 
Dyspnea
Dry cough
Weight gain
Jugular vein distention
The nurse is contributing to a staff development conference about clients who are
pregnant and rubella non Immune. Which of the following information should the nurse
suggest including?

Live VACNINES = MMR + Influenza nasal

1.Fetal a effects from the mothers exposure to rubella tend to be mild

2.Exposure to Rubella during pregnancy is only harmful in the first trimester 
3. Clients that are not immune to rubella should be vaccinated postpartum
4.  Antibiotics administered after exposure eliminate the risk of Rubella in the fetus
5. Pregnancy should be prevented for four weeks after receiving the rubella
vaccine

Take rubella 1 month/3 months prior to getting pregnant

The nurse is caring for a client with disseminated intravascular coagulation which of the
following statements by the client would be essential to follow up?

I prefer to receive my medication subcutaneously rather than intramuscularly

I have been taking one aspirin every day since I had an MI one year ago

No NSIADS with MI

I held pressure on the puncture site for five minutes after the nurse drew blood from my
arm

I have avoided blowing my nose today because I have had two episodes of
epistaxis(Nosebleeds)

Disseminated intravascular coagulation is a condition in which small blood clots

develop throughout the bloodstream, blocking small blood vessels
The nurse is in a rehabilitation facility caring for a client who had a right knee
arthroplasty eight days ago and has been diagnosed with pneumonia.  The client is
being transferred to an acute care facility it would be essential for the nurse to
communicate in the transfer report that ?

The discharge to home is anticipated for the client after one more week of physical
therapy

The client lives in a ranch home that requires climbing to stairs to get to the
house

The most recent focused data collection reveals bilateral crackles auscultated in the
clients lungs

The client spouse will be visiting the client at the hospital later today after leaving work

Bilateral crackles auscultated = Pneumonia

The nurse is caring for a client with moderate Alzheimer’s disease the nurse should
immediately intervene if a staff member is observed

Providing the client with a sandwich to eat while wandering in the hallway

Offer the client several ounces of fluid at regular intervals

Securing the client a shower chair before the shower begins

Letting the client to choose What sweater to wear = patient is confused

Securing is not restraining

The nurse is caring for assigned clients the nurse should recognize that the client at
highest of for developing peritonitis is a client who had

1) An appendectomy for ruptured appendix 12 hours ago = Mark k

2) A nasal gastric tube inserted five hours ago for gastrointestinal
bleeding
3) An abdominal cholecystectomy 16 hours ago and has 300 ml of
greenish brown drainage in the drainage tube
4) A subtotal gastrectomy eight hours ago and is reporting pain rated
seven on a scale of 0 to 10
A nurse is talking with a client who has borderline personality disorder which of the following
statements Would the nurse expect the client to make?
I often feel bored and empty
I hear voices others are unable to hear
I need to go to my room to wash my hands again
I am worried the food on the meal tray has been poisoned

1 BPD
2 is hallucination
3 is OC
4 is paranoia

A is BPD
B is Hallucination (Schizophrenia)
C is OCD
D is Paranoid (Schizophrenia)
1.  The nurse is reinforcing teaching about sleep and rest at home for a client who had a
vaginal delivery 24 hours ago which of the following information to the nurse reinforce?

1.  Take a nap when your baby is sleeping

2. Perform all of the household chores in the morning when you have more energy
3. Wake up and go to sleep at the same time every day
4. On the weekend plan and prepare all meals for the week to prevent fatigue
2. The nurse is talking with the spouse of a client who has Malignant melanoma and is
terminally ill on the following statements by the spouse would be essential to follow up?

1. I give my spouse the prescribed pain medication regularly even though the
medication causes my spouse to become drowsy

2. I feel as though there is so much happening now and I have been relying on my adult
children to help care for my spouse

3. I sometimes feel bad because I often have one or two glasses of wine to help me
relax and sleep at night

4. I tried to keep my spouse’s window open and the weather is nice because my spouse
and I was listening to birds
The nurse is caring for a client who had an abdominal paracentesis one hour ago which of the
following statements by the client would be priority to follow up
1. The urine in my drainage bag looks pink
2. I will avoid sleeping on my left side for two days = GOOD
3. I feel dizzy when I change positions in bed too quickly
4. It is easier for me to breathe when I’m sitting up in bed
The nurse is reinforcing teaching with a client who has iron efficiency and anemia which
of the following information should the nurse reinforce?

Continue to take your prescribed iron supplement after your symptoms resolve

Consult with a genetic counselor to establish inheritance patterns

Alternate periods of activity and rest throughout the day

Increase your dietary intake of food such as legumes 

Take the prescribed iron supplement with a glass of milk if you Experience
gastric upset

No Milk , No Calcium

SE: Black stools

The nurse is reinforcing teaching by the parents of a nine-year-old child who is receiving
prescribed methylphenidate which of the following information should the nurse
reinforce?

Give me child Methylphenidate no more than three hours before bedtime

Your child will need to visit the primary healthcare provider periodically

Check your child’s pulse daily before administering methylphenidate

Increase your child intake of foods that are high in iron and potassium
The nurse is caring for a 17-year-old client with Guillian Barre syndrome who is
beginning to have return of sensation and motor function the client states I’m going to
miss my senior dance it’s not fair which of the following responses would be appropriate
for the nurse to make?

1) You will be able to have your friends visit and tell you about the dance

2) You should be happy that you are getting some movement back

3) You will graduate from high school soon and they will be dances at the college
you plan to attend next time 

4) You are sad because you will miss something you have looked forward to
for a long time
6. The nurse has reinforced discharge teaching with a parent of a newborn which of the
following statements by the parent would require follow-up?

I will leave my babies diaper off when possible if the diaper area starts to become red

I will secure my baby in a rear facing infant seat in the front seat of the car since
there is an airbag there

I should give my baby a pacifier at bedtime to reduce the risk of sudden infant death
syndrome

I should squeeze the bulb syringe before inserting it into my baby’s mouth when I
suction access secretions 

Should be rear- facing seat in the back seat

 The nurse is caring for adolescence recently Diagnosed with diabetes Mellitus Type
one. The client states you don’t understand what it is Like to have to give yourself
injections every day which of the following responses would be appropriate for the nurse
to make?

I have cared for many clients who are the same age as you and they have adjusted

There are many athletes who have the same diagnoses and are very healthy

I can teach one of your parents how to give the injections 

 It must be difficult to self administer an injection every day

The nurse has reinforced teaching with a client who had a colostomy created five days
ago which of the following statements by the client indicates correct understanding of
the teaching?

I will begin an aerobic exercise program since I will not be able to go swimming

I should avoid emptying the pouch more than two times a day so that It do not loosen
the seal around the appliance

I will notify the primary healthcare provider if I develop a fever or redness around
the drainage from the incision

I can expect to experience a burning sensation around the stoma until the incision is
completely healed

Know labs, how to put on/off PPE, order of catheter, med classification, priorities, ABCs,
delegation just to name a few. Good Luck 🍀
A nurse who is pregnant as a sign to the care of a three-month-old client with
respiratory syncytial virus pneumonia. The client it is receiving ribavirin therapy
Which of the following actions would be most appropriate for the nurse to take?

1. Maintain strict isolation precautions while caring for the client

2. Discuss the assignments with the client’s physician 

3. Request a change of assignment from the charge nurse

4. Switch the client assignments with a coworker

3 RSV can be transmitted to the unborn baby

RSV = Contact precautions 1st
The nurse is preparing to administer prescribed regular insulin to a client the nurse
should understand that regular insulin is administered which of the following routes?

Select all that apply

1. Subcutaneous
2. Oral = NEVER
3. Intravenous ( IV)
4. Intermuscular –  vastus lateralis muscle = Baby
5. Intradermal = TB

RN = IV only

NPH = NO IV
The nurse is contributing to a staff education conference about the stages of grief in
client with a terminal illness. Which of the following information should the nurse
suggest including?

1. The nurse should confront the client in the denial phase and emphasize that the
client illness will indeed result in death

2. The nurse should leave the client alone as much as possible if feelings are
misdirected toward the nurse during the anger phase

3. The client may openly express feelings of sadness during the depression
phase or withdraw from friends and family members

4. The client avoid making plans during the acceptance face

The nurse has reinforced teaching with a client who had a colostomy created five days
ago which of the following statements for the client would indicate a correct
understanding of the teaching?

1. I will begin an aerobic exercise program since I will not be able to go swimming

2. I should avoid emptying the pouch more than two times a day so that I do not
loosen the seal around the appliance

3. I will notify my primary healthcare provider if I develop a fever or redness

and drainage from the incision

C - signs of infection

Redness, cough , fever

4. I can expect to experience a burning sensation around the stoma until the
incision is completely healed
The nurse is checking a client with disseminated Herpes Zoster who is in a private room
the nurse should understand the client maybe developing a sensory isolation if the client
reports the onset of

1. Photophobia
2. Headache
3. Anxiety
4. Tremors
The nurse has received the following information about assigned clients. The nurse
should first check the client who ?

1. Has gastroenteritis is reporting nausea and vomiting 100 ML of green liquid

2. Has a Long cast and is sitting in a chair with the casted leg elevated on a stool

3. Had a appendectomy one day ago and has a 2 cm area of serosanguinous

drainage on the incision dressing

4. Had a thyroidectomy two days ago and has muscle spasm and the wrist when
the blood pressure is taken
The nurse and UAP are caring for an assigned client which of the following activities
would be appropriate for the nurse to assign to a UAP?

1. Removing a condom catheter for the male  client who had a fractured
pelvis

2. Providing discharge teaching to the client with COPD

3. Evaluating the pain level for the client who had an abdominal hysterectomy
several hours ago

4. Determining the effectiveness of an anti-anxiety medication for a client with

moderate Alzheimer’s disease

Discharge teaching , Evaluating , Determining , instructing , first/newly , monitoring =

RN
The nurse is contributing to the plan of care for a client who sustained a spinal cord
injury at T1 five days ago. Which of the following interventions should the nurse
recommend including in the clients plan of care?

1. Limit new clients fluid intake to 1 L daily = never , 2/3 Litre always

2. Encouraged the client to increase the intake of foods high in carbohydrates

3. Request a prescription for a stool softener to be administered to the client

daily 

4. Perform a lower extremity passive range of motion exercises for the client once
daily
The nurse is caring for a client who had an abdominal paracentesis one hour ago which
of the following statements by the client would be priority to follow up

1. The urine in my drainage bag looks pink = Injury

2. I will avoid sleeping on my left side for two days

3. I feel dizzy when I change positions in bed too quickly

4. It is easier for me to breathe when I’m sitting up in bed

The nurse is talking with the spouse of a client with left-sided Hemiplegia.  The spouse
tell the nurse I scheduled the appointment because I noticed a sore had developed on
my spouses hip. I feel so guilty because I caused this to happen I do not know what to
do which of the following would be appropriate initial response for the nurse to make?

1. Have you been been offering your spouse fluid at regular time intervals?

2. How often do you change your spouses position?

3. The type of care that you have undertaken is not easy

4. We will make sure that you have help if this requires special dressings
A nurse who is pregnant as a sign to the care of a three-month-old client with respiratory syncytial
virus pneumonia. The client it is receiving ribavirin therapy Which of the following actions would be
most appropriate for the nurse to take?
1.Maintain strict isolation precautions while caring for the client
2.Discuss the assignments with the client’s physician
3.Request a change of assignment from the charge nurse
4.Switch the client assignments with a coworker
And the nurse is caring for a client who had an abdominal paracentesis one hour ago
which of the following statements by the client would be a priority to follow up?

1. The urine in my drainage bag looks pink = injury

2. I will avoid sleeping on my left side for two days
3. I feel dizzy when I change positions in bed too quickly
4. It is easier for me to breathe when I’m sitting up in bed
The nurses is talking with the spouse of a client with left-sided hemiplegia.The spouse
told the nurse I should scheduled the appointment because I notice a sore developed
on my spouses hip I feel so guilty because I caused it to happen. I don’t know what to
do which of the following would be an appropriate initial response for the nurse to
make?

1. Have you been offering your spouse fluids at regular time intervals
2. How often do you change your spouses position
3. The type of care that you have undertaken is not easy
4. We will make sure that you have help if this requires special dressings
The nurse is teaching with a client who has a vitamin D deficiency which of the following
dietary modifications to the nurse reinforce?

1) Increase the amount of green leafy vegetables in the diet

2) Increase the amount of calcium in the diet
3) Drink a glass of orange juice at breakfast
4) Use fortified milk with Cereal 

Calcium Will not be absorb properly if there is a Deficiency of Vitamin D

No calcium is absorb with the help of vitamin D
The nurse has received the following information about assigned clients the nurse
should first

1. Who has right sided heart failure and is reporting frequent urination 

2. With active pulmonary tuberculosis who is reporting expectorating black tinted

mucus

3. Who has a fractured femur and receiving a dose of pain medication

intramuscularly one hour ago and is reporting that the pain has not been
relieved

Acute over chronic , new admit

4. With benign prostatic hyperplasia who is reporting no bowel movement for the
past three days and is requesting a dose of prescribed laxative

The charge nurse in a long-term care facility has been advised that the following
assigned clients will be admitted during this shift the charge nurse should assign the
only available Private room to the client with 

1. cytosis pneumonia
2. A positive vericella zoster titer – airborne , needs a private room
3. Hepatitis C 
4. A positive cytomegalovirus titer
The nurse is reinforcing discharge instructions with client for taking prescribed
isosorbide dinitrate. The nurse should reinforce that the client should avoid

1. Exposure to sunlight
2. Sudden position changes –
3. Vigorous exercise
4. Taking antacids

HTN , Pyche meds = orthostatic hypotension

The nurse is caring for a client who has been diagnosed with hook worm infestation the
clients parent asks how can I prevent my other child getting hookworm which of the
following would be appropriate response by the nurse to make

1. Cook all meals thoroughly

2. Have your pets treated for worms
3. Encourage your children to wear shoes when outside
4. Wash all clothes in hot water

1 is for tapeworm, 2 is for round worms 3 is for hookworm.

The nurse is collecting data from a client with guillan barre the client is experiencing
paralysis and paresthesias of the lower extremity and has a respiratory rate of 18 which
the following actions should the nurse take

1. Massage the clients legs every two hours

2. Pad the side rails of the clients bed

3. Monitor the clients respiratory rate frequently

4. Keep the head of the clients bed elevated at 30°

The nurse is preparing a client for emergency surgery to repair a depressed skull
fracture which of the following actions would be essential for the nurse to take

1. Determining the time that the client last ate

2. Showing the client a picture Of the postoperative wound drainage system

3. Telling the client What will occur in the post anesthesia care unit

4. Check in the clients corneal reflex = assessment/ check with head injury

The nurse is assisting with the plan of care for a client who is scheduled to have a right
mastectomy which of the following would be most important for the nurse recommend to
be included to maintain the clients positive body image

1) Encourage the client to explore her feelings = If you can get the pt to express
their feelings more, you can understand and help them cope positively with their loss

2) Provide the client with a calm quiet environment – never leave alone

3) Discuss the types of prostheses available

4) Reinforce information on coping mechanism= no need to reinforce

The nurse and UAP are caring for assigned clients which of the following activities
would be appropriate for the nurse assign to a UAP

 Administer an enema to the client with a fractured right hip

Removing sutures from the client who had an abdominal hysterectomy

Instructing the client with irritable bowel syndrome about dietary restrictions

Conducting a home safety assessment for the client with moderate Alzheimer’s
disease
The nurse is contributing to a staff development conference about confidentiality which
of the following information should the nurse and suggest including

1. Client must wait until after discharge to review the medical records

2. Nurses on the hospital Unit may review the medical record for all clients on
the unit

3. Certain information in the clients medical records may not be considered

confidential

4. clients may disclose all information in order to receive care

The nurse is assisting with the plan of care for a client with moderate Alzheimer’s
disease which of the following interventions should the nurse suggest including in the
Clients plan of care

SATA

1. Avoid the use of restraints

2. Avoid reminiscing about happy times in the clients life- always do

3. Use a distraction when the client becomes anxious or agitated

4. Provide the client with a wide selection of food choices at meal times – never

5. Do not asked open ended questions as it will confused the client

6. Speak slowly and use short simple sentences and providing the client with
information

7. Provide family members with information about community support service

for respite care
The nurse is caring for a client with pediculosis Which of the following infection control
precautions Should the nurse implement?

1. Place a thermometer in the clients room to be used for the client only –
contact isolation

2. Wear a surgical mask when assisting the client to bathe

3. Keep the door to the client room closed – ebola

4. Remove the gloves after leaving the room - should always remove before
leaving the room

The nurse in an ambulatory Care facility has been advised that several clients have
arrived for scheduled appointment the nurse should ask a client with which of the
following concerns to come to a private examination room first

1. A productive cough with night sweats – infection

2. Diabetes Mellitus with tingling in both feet
3. Red eyes with moderate tearing
4. Emphysema with clubbing of the finger nails

A- to prevent the others from contracting in case it is TB

The nurse is caring for a client who has right sided Hemiplegia and is ambulating using
a walker it would indicate a correct understanding of how to use a walker if the client is
observed

1. Taking steps forward with the left leg and then advancing the right leg and the
walker

2. Moving the Walker forward 12 inches then swinging both legs forward together

3. Moving the walker and the right leg forward 6 inches and then move in the
left leg forward 

4. Placing the rear legs of the walker and the Right leg forward and then moving the
left leg forward
The nurse has reinforced discharge teaching with a parent of a newborn which of the following
statements by the parent would require follow-up?
I will leave my babies diaper off when possible if the diaper area starts to become red
I will secure my baby in a rear facing infant seat in the front seat of the car since there is an
airbag there – always back seat
I should give my baby a pacifier at bedtime to reduce the risk of sudden infant death syndrome
I should squeeze the bulb syringe before inserting it into my baby’s mouth when I suction access secretions

B (2) rear facing in the back not in front

The nurse is caring for a client who has a prescription to remove the NG tube which of
the following actions should the nurse take ?

1) With draw the tube steadily while the client takes shallow breaths

2) Have a client hyper extend the neck before withdrawing the tube- when inserting

3) Withdraw the tube quickly while the client holds a deep breath= bearing
down

4) Have the client flex the neck before withdrawing the tube
The nurse is reinforcing teaching with a client about performing a breast self
examination which of the following information to the nurse reinforced select all that
apply

1) You should use the palm of your hand to Feel for lumps – Finger pads
2) Perform the BSE after your menses when your breast are less tender
3) You should notify your primary healthcare provider if you observe dimpling
of the skin
4) Remain lying flat on your back and observe your breast for chain is using a Hand
mirror
5) You should notify your primary healthcare provider if you have discharge
from your nipples
Check

Was looking at the BSE question again, I think # 1 is also incorrect cos it should be the
finger pads and not the whole palm. So #1 & 4 are off.
The nurse is caring for a five-year-old client who sustained burns over 10% of the body
one week ago which of the following between meals snacks would be appropriate to
offer The client?

1) Slices of red Apple  - finger foods

2) cheese sticks
3) Strawberry gelatin
4) Frozen juice bar 
the nurses working in the emergency department received information that several clients Are being
transported by a radiologist emergency response team after exposure to radiation. When the clients
arrive at the ED which of the following actions should the nurse take first?
1. Bag and tag each client clothing and place the clothing in the appropriate BioHazard receptacle
2. Irrigate any wounds and cover each with a water resistant dressing
3. Have the client shower thoroughly with soap and water
4. Determine whether each client has been decontaminated
The nurse on the maternity unit is talking with a staff member from another unit.  The
staff member asks the nurse about a mutual friend who had a baby at the healthcare
facility which of the following would be an appropriate response for the nurse to make 

select all that apply

1. You should give her a call on the telephone to see how she is doing

2. I saw her this morning and she is going to be discharged home today

3. I understand the delivery went well and her spouse is with her

4. I cannot give you any information about her condition

5. I will take a look in the computer system to find out which room she is in so you
can visit
The nurse is contributing to a staff education conference about a Atenolol which of the
following information should the nurse recommend including in the conference

1) Atenolol block the vasoconstrictor and aldosterone producing affects of

angiotensin  II
2) Atenolol blocks the conversion of angiotensin l to angiotensin ll 

3) Atenolol blocks the stimulation of beta 1 adrenergic receptors

4) Atenolol blocks the post synaptic alpha 1 adrenergic receptors

The nurse is collecting data from a client who has hypovolemic shock which of the
following findings would be consistent with hypovolemic shock

1. Confusion

2. Hypertension – HYPOTENSION

3. Decreased urine output

4. Elevated respiratory rate

The nurse is caring for a client who has just returned from the radiology department
after having an upper gastrointestinal series which of the following actions should the
nurse take first ?

Administer the prescribed enema

Give the prescribed multiple vitamin that was withheld prior to the procedure

Determine whether follow up x-rays are to be taken

Verify the preliminary test result

The nurses is caring for a client who is scheduled to have an arterial blood gas sample
obtained the nurse should anticipate that which of the following tests would be
performed prior to the procedure

1) Coombes test
2) Schilling test
3) Ham test
4) Allen test = ABG
The nurse is measuring a client for crutches which of the following actions should the
nurse take

1. Measure the Client’s height and subtract 8 inches to obtain the correct crutch
length

2. Ask the client to stand upright and position the shoulder rest of the crutch 6 inch
below the axilla

3. Adjust the crutches so the clients elbows are at 30° angle while the clients
hands are resting on the handgrips

4. Measure  from the interior fold of the axillae to the toes of the clients feet and add
1 inch while the client is in a supine position
The nurse is contributing to the plan of care for a client Who sustained full thickness
burns on 30% of the body three days ago which of the following interventions to the
nurse suggest including in the clients plan of care ?

select all that apply

1. Discourage movement of the affected body parts

2. Offer the client prescribed opioids analgesics prior to providing wound care

3. Wear a hair covering and a surgical mask when the bum wounds are exposed

4. Are used ice and other cold therapy as an adjunct to pharmaceutical pain relief

5. Stress the importance of strict intake and output recording for the client with the
unlicensed assistive personnel
The nurse is caring for a client who has a prescription to remove the NG tube which of the following
actions should the nurse take ?
1)With draw the tube steadily while the client takes shallow breaths
2)Have a client hyper extend the neck before withdrawing the tube
3)Withdraw the tube quickly while the client holds a deep breath = CORRECT
4)Have the client flex the neck before withdrawing the tube
The nurse has reinforced teaching with a female client who will receive prescribed
oxytocin for induction of labor which of the following statements by the client would
indicate the correct understanding of the teaching? 

1. The breathing exercises that I learned will not help manage labor pain

2. I will have my blood pressure checked every 60 minutes

3. The oxytocin infusion can result in uterine hyperstimulation and fetal harm

4. I can expect to have a headache and vomiting because of the oxytocin infusion

3 uterine stimulation- no longer 90 sec closer to 2 mins

The nurse is caring for a client who had a thoracentesis one hour ago which of the
following findings would require immediate follow-up

1. Respiration of 24= MOSTLY

2. Tenderness of the puncture site

3. Temperature of 99.6°F

4. Small amount of bleeding at the puncture site

The nurse is caring for a client who has just been told that the cancer has metastasized
The nurse into the room and observed the client crying or the following response would
be appropriate for the nurse to make first

1. You seem upset may I sit with you for a while

2. I can telephone a family member to come and stay with you

3. Do you have a spiritual advisor that you would like me to notify

4. I will give you some time alone and will come back soon
The nurse is caring for a client who is experiencing new onset profuse epistaxis. which
of the following action should the nurse take ?

Select all that apply

1. Check the clients vital signs = No need

2. Apply a warm compress to the clients noes = Never

3. Assist the client to apply pressure to the Nares

4. Encourage the client to spit out blood instead of swallowing it

5. Play the client in an upright position with the head Tilted forward

6. Encourage the client to blow their nose periodically until the epistaxis resolves
The nurse has reinforced teaching with a client who is scheduled for Electro convulsive
therapy which of the following statement for the client would indicate a correct
understanding of the teaching?

1. I will experience a tonic clonic seizure for approximately 15 minutes during the
ECT procedure

2. ECT is commonly used to treat depression when several antidepressants

have not been effective

3. ECT is effective because it Decreases the level of Nero transmitters in the central
nervous system

4. Common side effects of ECT are diarrhea a low-grade fever and short term
memory loss
The nurse is caring for a client who sustained a closed head injury which of the
following findings would require immediate intervention?

1. Ecchymotic area or the left temple

2. Glasgow coma scale score of 13 = Normal …. <7

3. Blood pressure of 136/76

4. Headache that worsens with coughing

The nurse is preparing to administer prescribed regular insulin and NPH insulin to an
assigned client select in the correct order the steps the nurse should take.

Arrange in order

1. Aspirate a volume of air equal to the prescribed dose of NPH insulin and inject
the air into the vial

2. Withdraw the prescribed amount of regular insulin into the syringe

3. With draw the prescribed amount of NPH insulin into the syringe

4. Administer the injection to the client

5. Aspirate a volume of air equal to the prescribed dose of regular insulin and
inject the air into the vial

15234
The nurse on the maternity unit is talking with a staff member from another unit. The staff member
asks the nurse about a mutual friend who had a baby at the healthcare facility which of the following
would be an appropriate response for the nurse to make
select all that apply
1. You should give her a call on the telephone to see how she is doing
2. I saw her this morning and she is going to be discharged home today
3. I understand the delivery went well and her spouse is with her
4. I cannot give you any information about her condition
5. Take a look in the computer system to find out which room she is in so you can visit

1,4 you are not allowed to look in the computer system for anyone except your current patients not even
to follow up on your past patients condition it’s a HIPAA thing.
And the nurse is collecting data from a client who has hypovolemic shock which of the following
findings would be consistent with hypovolemic shock
1. Confusion
2. Hypertension
3. Decreased urine output
4. Elevated respiratory rate

In hypovolemic shock, one fifth or 20 % of the body's blood or

fluid is lost and is a life threatening

1) low systolic pressure,

2) narrow pulse pressure

3) tachycardia.

4) Cold or pale skin,

5) decreased level of consciousness and depressed mental

status.
The nurse is contributing to a staff development conference about client confidentiality
which of the following information should the nurse suggest including?

1. And the clients medical record is the clients property and the client may have
access to the record any time

2. Unneeded computer generated work sheets must be shredded at the end of the
shift to ensure client confidentiality

3. Personal computer passwords may not be shared with anyone including other
members of the clients healthcare team

4. Medical information about the client may be shared with a police officer who
brought the client into the emergency department

5. Keep your voice low when speaking with the client Because direct interaction
with clients must be kept as private as possible
The nurse is reinforcing teaching with a client about performing a breast self examination which of
the following information to the nurse reinforced select all that apply
1. You should use the palm of your hand to Feel for lumps – Finger
2. Perform the BSE after your menses when your breast are less tender
3. You should notify your primary healthcare provider if you observe dimpling of the skin
4. Remain lying flat on your back and observe your breast for chain is using a Hand mirror
5. You should notify your primary healthcare provider if you have discharge from your nipples
The nurse in an outpatient care facility has received the following telephone message
from the client who were previously seen at the facility the nurse should first telephone
the client who is reporting

1. No memory of the post procedure instructions following an EGD

2. A sore throat and cough following a bronchoscopy

3. shortness of breath following a bronchoscopy

4. Abdominal cramping following a colonoscopy

The nurse is assisting with the admission of a client who is scheduled for a colon
resection Which of the following statements made by the client would be most important
for the nurse to clarify

1. I take acetaminophen for occasional headache

2. I had successful cataract surgery two years ago

3. Are usually have a few glasses of wine in the in the evening- mostly

4. I have urinary incontinence when I sneeze

The  nurse and Unlicensed assistive personnel are caring for assigned clients which of
the following activities would be appropriate for the nurse to assign to a UAP?

1. Applying a condom catheter to the male client with a hip fracture who is in
continent – mostly

2. Applying pressure dressing to the right hand of the client who Has a stab wound

3. Inserting a NG tube for the client with anorexia nervosa

4. Obtaining vital signs from the client who is experiencing delirium Tremens
= delierum confusion
The nurse is contributing to a staff education conference about inform consent which of
the following information to the nurse suggest including?

Select all that apply

1. The nurse Witnessing the consent is Responsible for explaining the procedure
to the client - HCP is Explaining

2. Consent is implied for care required to treat the clients condition in a life-
threatening emergency situation

3. The client signature on the consent form is documentation that the client
has no question about the procedure counseling when the nurse signed
the consent form the nurse is confirming that the client appears competent
to give consent

4. When the client refuses to give consent for a procedure the nurse a
document refusal in the medical record
The nurse is reinforcing teaching with the parents of a child who is scheduled for
surgical repair of hypospadias. The nurse should reinforce that intended outcome of the
procedure includes

1. Relief from pain

2. Relief from bladder obstruction
3. The ability to void while standing – mostly
4. That ability to achieve an erection
The nurse is reinforcing teaching with the client with Lymphocytic leukemia Who is a
risk for developing thrombocytopenia (Bleeding disorder ) which of the following
information should the nurse reinforce is not further education

1. You should use a disposable razor rather than an electric razor when shaving

2. Frequent deep breathing exercises should be performed but avoid

coughing and blowing your nose

3. Frequent oral hygiene should be performed including flossing your teeth and
using alcohol-based mouthwashes

4. You may take over the counter ibuprofen for any discomfort but avoid using OTC
acetaminophen = No NSAIDS
The nurse is contributing to the plan of care for a client with multiple sclerosis which of
the following should the nurse recommend to be included?

1. Encouraging the client to perform aerobic exercises several times daily

2. Limiting the amount of time that the client spends in a hot environment
3. Offering the client between meals snacks that are high in vitamin C
4. Keeping the clients legs elevated when sitting upright in a chair

multiple sclerosis- NO Hot wheather heat intolerance

The nurse is caring for a client with a panic disorder. Which of the following findings
should the nurse expect to observe

1. Dry skin
2. Chest pain – mostly
3. Decrease bowls
4. Delusional thinking

Breathing , Hypoxia, restlesness , pain , SOB 1ST

The nurse is caring for a client with diabetes type two who has been disoriented to play
sometime and has a capillary blood glucose level of 60 mg/dL Before administering
oranges to the client it would be priority for the nurse to

1. Recheck the clients blood glucose levels using a different glucometer = no need
to recheck
2. Check the clients gag reflex – mostly
3. Determine the availability for a glucagon on the nursing unit 
4. Notify the primary healthcare provider

Normal is 70-110
The charge nurse in a long-term care facility has just completed client care assignments
for UAP. Which of the following statement by the charge nurse would provide the best
direction to a UAP about the assignments ?

1. The client with heart failure should be weighed and have vital signs checked
before breakfast is served

2. You will need to assist the client with mild Alzheimer’s disease with
activities of daily living

3. You need to follow proper infection control precaution assisting the client in
active pulmonary Tuberculosis

4. The client with paraplegia should have the monthly safety check completed in the
wheelchair
The client is admitted with severe pain In the left lower extremity the client is scheduled
for a complete blood count urinalysis, chest x Ray and X-ray of the lower extremitiesThe
client asked the nurse why do I have to have all these test the pain is in my leg which of
the following responses by the nurse will best help the client deal with feelings of
anxiety?

1. The test will not take long to complete

2. These tests are part of the admission procedure
3. It must be difficult not understanding what is happening to you = go with
the feeling
4. Perhaps this is something you need to discuss with your physician
The nurse is observing a newly hired nurse administrator. A clients transdermal patch
the nurse should intervene if the newly hired nurse is observed

1. Instructing the Client to avoid massaging the patch

2. Cleansing the client skin with soap and water after removing the old patch
3. Initialing the patch and writing the date and time the patch was applied on the
patch
4. Omitting (not) documentation about the location on the clients body where
the patch was applied
The nurse is reinforcing teaching with a client who has an ileal conduit, Which of the
following statements by the client indicates correct understanding of the teaching

1. I will need to awaken several times at night to empty the pouch – MOSTLY
2. I can expect to have mucus in my urine
3. The stoma should be a dark purple color
4. I will need to limit my fluid intake
The nurse is contributing to a staff development conference about electronic medical
records which of the following information should the nurse suggest including 

SATA

1. And advantage of using electronic medical records is improved legibility in

documentation

2. The nurse should log off the computer system before leaving a computer
terminal

3. And issue surrounding computerized documentation is access to secure

information – NOT SURE BUT YES

4. A nurse with experience documentation in 1 electronic medical record system

can use another system without training

5. And the nurse should Refrain from sharing security passwords for the
electronic medical record system

6. A disadvantage of the use of electronic medical record’s is that departments are

unable to interact with the system
The charge nurse in a long-term care facility has completed client care assignments for
Unlicensed assistive personnel which of the following statements by the charge nurse
would provide the best directions to a UAP regarding the assignments

1. Record your assigned clients vital signs before you take a midmorning break

2. Weigh your Assigned client before breakfast with scale used one day ago 

3. Help the clients who eat their meals in the dining room with the breakfast

4. Measure of the amount of your assigned client intake and output regularly

And the nurse is caring for a 6 Year old client who is receiving prescribed Skeletal
traction for the following would be priority for the nurse to monitor?

1. The distance between the clients knees 

2. The pull of the traction on the clients pins

3. The degree of flexion of the clients ankles

4. The position of the clients cervical spine on the bed

The nurse is contributing to the plan of care for a client Who sustained full thickness burns on 30%
of the body three days ago which of the following interventions to the nurse suggest including in the
clients plan of care ?
Select all that apply
1. Discourage movement of the affected body parts
2. Offer the client prescribed opioids analgesics prior to providing wound care
3. Wear a hair covering and a surgical mask when the bum wounds are exposed
4. Are used ice and other cold therapy as an adjunct to pharmaceutical pain relief
5. Stress the importance of strict intake and output recording for the client with the unlicensed assistive
personnel
The nurse in an outpatient care facility has received the following telephone message from the client
who were previously seen at the facility the nurse should first telephone the client who is reporting
1. No memory of the post procedure instructions following an EGD
2. A sore throat and cough following a bronchoscopy
3. shortness of breath following a bronchoscopy
4. Abdominal cramping following a colonoscopy
3, priority matters. ABCDEFG. AIRWAY/ BREATHING.

The nurse is caring for a client with a panic disorder. Which of the following findings should the nurse
expect to observe
1. Dry skin
2. Chest pain – mostly
3. Decrease bowls
4. Delusional thinking

The nurse is reinforcing teaching with a client who has an ileal conduit, Which of the following
statements by the client indicates correct understanding of the teaching
1. I will need to awaken several times at night to empty the pouch
2. I can expect to have mucus in my urine
3. The stoma should be a dark purple color
4. I will need to limit my fluid intake
An adolescent client is prescribed lispro (Humalog) and glargine (Lantus) insulins
for the treatment of diabetes mellitus. When reinforcing teaching with the client
about how to administer the insulins, the nurse should instruct the client to
adjust the glargine dose based on blood glucose readings.
administer the lispro 1 hr after breakfast.
give the glargine in three divided doses during the day.

draw up the lispro and glargine in separate syringes.

A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus.
The nurse should recognize that the client needs a referral for diabetic education
when the client
1) draws up Regular insulin before NPH when demonstrating injection
2) technique.
3) says that he will see a primary care provider to treat corns on his feet.
4) states that he will treat hypoglycemic reactions with 15 g of carbohydrates.
5) lists sweating, shaking, and palpitations as symptoms of hyperglycemia.
A client receives a new prescription for warfarin (Coumadin). Which of the
following should the nurse reinforce with this client?

1) Use a safety (manual) razor for shaving.

2) Avoid the use of salicylates, including aspirin.
3) Eat foods that are high in vitamin K content.
4) Do not take over-the-counter laxatives.
A nurse is reinforcing discharge instructions to the mother of a newborn. Which of
the following statements by the mother indicates an understanding of the teaching?

"I will notify my doctor if my baby sleeps more than 5 hr at a time." =they sleep 12-16 hrs
"I will check my baby when she cries."
"I will change my baby's diaper every 4 hr."
"I will limit my baby's feedings so she does not become overweight."
A nurse is reinforcing foot care instructions to a client with diabetes mellitus. Which
of the following client statements indicates proper understanding of the teaching?
"I should shake out my shoes before I put them on."
"I can remove my own calluses with a pumice stone."
"I should wear the same shoes all day."
"I should not use moisturizers on my feet."

A nurse is caring for an older adult client who was admitted with dehydration.
Which of the following is the nurse's priority for data collection?
1) Deep tendon reflexes
2) Skin turgor
3) Intake and output
4) Blood pressure and pulse
A nurse is reinforcing teaching with the parent of a child who has hypothyroidism and is to start taking
levothyroxine. Which of the following information should the nurse include?
1 )Administer a calcium supplement with this medication."
2) Expect your child to take this medication for his lifetime."
3) Your child will have permanent hair loss due to this medication."
4) Avoid giving this medication on an empty stomach."

A nurse at an urgent care clinic is caring for a child who hit her head on the playground
at school 30 min ago. Which of the following findings is the nurse's priority?

1)Nasal discharge negative for glucose

2)2 cm (0.8 in) scalp laceration

3) Asymmetric pupils

4) Negative Babinski reflex

A nurse is caring for an infant who has heart failure and a new prescription for digoxin.
Which of the following findings should the nurse report to the provider?

1. Vomiting twice in 4 hr
2. Respiratory rate 30/min
3. Heart rate 130/min
4. Weight loss 0.25 kg (0.55 lb)
The nurse is contributing to a staff education conference about fall prevention which of
the following information should the nurse recommend including in the conference?

1. Raise the side rails for a client with memory impairment

2. Encourage the client with impaired balance to avoid ambulation
3. Instructed client with orthostatic hypotension to ambulate slowly
4. Place a commode at the bedside of a client with urinary frequency – correct
The nurse is reinforcing teaching with client my preventing skin cancer which of the
following statements by client would indicate a correct understanding of the teaching? 

1. I can very wide brimmed hat rather than the sunscreen if I am a door for a short
period of time

2. I will gradually increase the amount of time I am exposed to the sun to put on
sunburn

3. I will wear sunscreen with the sun protection factor of at least 15 when
spending time in the sun

4. I do not need to wear sunscreen on cloudy days because clouds provide natural
protection = Still need to
The nurse is reinforcing teaching with a client who is receiving Prescribe insulin gargline
which of the following information should the nurse reinforce?

1. After administering the insulin gargline the same syringe can be used to
administer regular insulin

2. Extra Vials of insulin gargline that have not been open can be stored in the
freezer

3. Insulin gargline does not have a peak action time

4. Insulin gargline should be administered three times each day 15 minutes before
meals

The charge nurse in a long-term care facility has made client care assignments for
unlicensed assistive personnel which of the following statements by the charge nurse
would provide the best directions to a UAP about the assignment?

1. The client with a UTI should drink two pitchers of water this shift

2. The client with mild dementia need assistance with bathing 

3. The client who had a stroke needs to ambulate in the hallway

4. The client with peripheral neuropathy should receive good skin care
The nurse is caring for a client with the dysthymic disorder What are the following
behaviors without the nurse expect to observe?

1. Grandiose actions 
2. Reports of Auditory hallucinations
3. Expansive pressured speech
4. Inability to experience joy or pleasure in life
The nurse in a pediatric outpatient care facility receive telephone message from parents
the client who is previously seen at the facility. The nurse should first telephone the
parent of a client who has 

1. Acute otitis media and reports insomnia after taking prescribed amoxicillin six
hours ago

2. A fracture of the left tibia and has placed a crayon in the cast

3. A colostomy and reports skin irritation around the stoma

4. Epilepsy and has pink frothy sputum = pulmonary Edema

The nurse is contributing to a staff education program about caring for a client in active pulmonary
tuberculosis of the following information should the nurse suggest including
1. It is mandatory to report a client positive TB test results to the public health department
2. It is necessary to isolate a hospitalized client for 24 hours after initiating Antitubercular Therapy
3. Antitubercular therapy is continued until the client provide three sputum cultures that test negative
for TB
4. Droplet precautions must be implemented as soon as a hospitalize client is suspected of active TB
The nurse in a Rehabilitation facility is admitting a client who had a stroke the client has an
advance directive which of the following actions should the nurse take?

SATA

1. Obtain a do not resuscitate prescription for the client

2. Make the healthcare team aware of the advanced directive
3. Notify the client family that the emergency care will not be given 
4. Witnessed a client signature on the advanced directive and have it notarized
5. Document in the Medical record that the client has an advanced directive 
The charge nurse in a long-term care facility Has been advised of the following clients will be
admitted during the shift. The charge nurse should assign the only available private room to the
client with

1. Scabies – contact precaution, private room

2. Salmonellosis 
3. Hepatitis
4. Cytomegalovirus
The nurse is preparing to assist a client who has recently developed a visual impairment to
ambulate to ensure the client safety it would be appropriate for the nurse to

1. Hold the clients hand while walking next to the client

2. Place one hand on the clients shoulder and walk in front of the client

3. Apply a gait belt around the clients waist and walk at the client side

4. Instruct the client to hold onto the nurses upper arm while the nurse walks slightly
ahead of the client – most likely

The nurse has reinforced teaching with a client Who is receiving prescribed alendronate which
of the following statements about the client would indicate a correct understanding –
osteoporosis

1. I should take the medication with orange juice

2. I can take the medication at any time of the day
3. I will avoid taking over-the-counter vitamin D supplements
4. I must set up right for 30 minutes after taking the medication – dronates

 Fosamax -before breakfast and keep the client stay upright for 30 minutes.
The nurse has reinforced teaching about sexually transmitted infections with a group of
clients are the following statements about client indicated good understanding of the
teaching?

1. Gonorrhea and has no symptoms in female clients until the infection has entered
the pelvis

2. A Watery gray discharge from the penis is associated with gonorrhea

3. Frothy green vaginal discharge is an indication of an infection caused by

chlamydia trachomatis

4. A mail client with chlamydia trachomatis will have a faint rash on the testicles
The nurse is caring for a sign clients who have closed chest drainage system the nurse
should first check the client

1. Who reports thick drainage in the system tubing 

2. Who’s chest tube has become disconnected from the drainage system

3. Who reports pain at the incision site reading five on a scale of zero no pain to 10
severe pain

4. Who’s chest tube is clamped in accordance with a prescription from the primary
health care provider 
A client is scheduled to have a glucose tolerance test at 8 o’clock to ensure the
accuracy of the test results the nurse should make which of the following statements to
the client prior to the test?

1. Do not smoke during the test

2. Tell me if you get nauseated during the test

3. Discard your for your example after the blood test sample is taken

4. Let me know if you begin to feel hungry during the test

The nurse is collecting data from the client who is receiving continuous Ambulatory
peritoneal dialysis or the following statements by the client would be essential to follow
up

1. My abdomen feels very full after the fluid has infused

2. The drainage at the end of the dwell time is greater than the amount of fluid that
has infused

3. My food taste bland to me since I have been receiving CAPD

4. The drainage at the end of the dwell Time is cloudy

The nurse is collecting data from a client who sustained a fracture of the femur 24 hours
ago. Which of the following findings would be a priority to follow up?

1. Petechiae on the chest = 1. Can be Fat Embolism Syndrome.

2. Ecchymosis of the affected extremity

3. Pain rated five on a scale of zero no pain to 10 severe pain

4. Reports of muscle spasms in the affected extremity

The nurse is contributing to a staff development conference about using electronic
medical records which of the following information to the nurse suggest including? 

Select all that apply

1. Do not document sensitive information such as positive HIV status in the

electronic Medical record – maybe

2. You may view the electronic medical record for any client as long as you do not
Modify the record= never , only your own clien

3. Do not leave the computer unattended while you are logged in the
computer

4. Tell your password to your supervisor for use in case of emergencies = never
share passwords

5. Change your password frequently

A nurse is preparing to administer enoxaparin 1.5mg/kg subcutaneously to a client who has
pulmonary embolism. The client weighs 132 lbs. The amount available to enoxaparin solution for
injection 100mg /ml. How many should the nurse administer? Round the answer to the nearest
tenth. Use a leading zero if it applies .
0.9 ml
  Prioritization and delegation

o  · 3h

 Nesha Hamilton  Delegation and priority what can you delegate to UAP and what person to see first

o  · 3h

 Gihan Sinare I got a lot of prioritization and delegation questions and SATA as well.
 Monique Smith-Powell prioritization and delegation and I had a bunch

o  · 3h

 Kaitlin Watts  I had alot of priorty and delegation, which client needs a private room, alcohol and
substance withdrawal, what's expected in a certain age bracket of a child, and lab values.
 Kayla Morgan  My last test I have zero delegations 😩😩😩

Hide or report this

o Like

o  · Reply

o  · 3h

 Nigel Wilson  F

Hide or report this

o Like

o  · Reply

o  · 3h

 Merne Fortich Following

Hide or report this

o Like

o  · Reply

o  · 1h
 Dannie B. Nem Torts negligence practice act advance directives
The nurse and UAP are caring for assigned clients which of the following activities
would be appropriate for the nurse to assign to a UAP?

SATA

1. Performing pro pharyngeal suctioning for the client who has a newly created
tracheostomy

2. Measuring and documenting Intake and output for the client with diabetes
insipidus

3. Weighing the client with anorexia nervosa at the same time daily

4. Writing a back rub for a client was experiencing preterm labor

5. Check in the vital signs for the client with stable angina pectotis

The charge nurse in a long-term care Facility has been advised that the following clients
will be admitted during the shift.  The charge nurse should assign the only available
private room to the client with

1. Human immunodeficiency virus and bacterial pneumonia 

2. Hepatitis B and acute gastritis – DROPLET – private room

3. End stage renal disease and cellulitis of the left leg

4. Acute pulmonary tuberculosis and osteoarthritis- Airborne first

The nurse is contributing to a staff education conference about client confidentiality.
Which of the following information should the nurse suggest including?

1. Written consent is not needed to acknowledge the hospitalization of the client to

a visitor

2. Personal information will be revealed to the public from volunteers who

participate in research study

3. The client may see and copy the clients medical record and may have
amendments made to the document

4. Nurses may share a computer password with other team members who are
assigned to care for the same client

5. Clients medical records should not be displayed on a monitor where others

may see the medical record
The nurse assisting with the admission of a client with active pulmonary tuberculosis
which of the following actions should the nurse take?

SATA

1. Provide a supply of sterile gloves outside the clients room 

2. Keep the client in the room and the door to the clients room closed

3. Inform visitors that plants are restricted from the clients room 

4. Place the client in a private room with monitor negative air pressure

5. Place a surgical mask on the client when preparing the client for transport
to the radiology department
The nurse is caring for a client with schizophrenia which of the following clients
behaviors with the nurse expect to observe?

1. Disorganized speech

2. Hand tremors

3. Mood swings – depression

4. Binge eating
The nurse is collecting data from a client with A plural effusion Who had a thoracentesis
30 minutes ago which of the following findings will require immediate followed up?

1. Pulse 108
2. Decreased pain with inspiration
3. Temperature 100.4 (38 ) ….. Fever
4. Absence of drainage at the puncture site

The nurse is contributing to the plan of care for a client with peptic ulcer disease the
nurse should suggest monitoring for which of the following as part of the clients plan of
care?

1. Dysphagia
2. Heartburn after eating – not
3. Symptoms of Barrett’s syndrome
4. Hematemesis – RECHECK

4.specifically Gastric Ulcer.

Barett syndrome is too much xposure to stomach acid along esophagus seen in GERD.also,there’s pain
DURING🙃 MEALS.

4 vomiting blood, means severe symptom

The nurse in an obstetrics Clinic has attended a staff education conference about
Leopold’s maneuvers. It would indicate quick understanding of the conference if the
Nurse states that Leopold maneuvers help determine

1. The location of the Placenta

2. Whether the fetus moves with stimulation

3. The location of the presenting part

4. Whether cervical dilation has started

The nurse is collecting data from a client who had percutaneous transluminal coronary
angioplasty Via right femoral artery two hours ago. Which of the following findings would
require immediate intervention?

1. Diminish right dorsalis pedis pulse

2. Nausea after drinking a cup of  water

3. 2 cm area of serosanguinous drainage on the right groin dressing

4. Right groin pain rated three on the scale of zero no pain to 10 severe pain
The home health nurse has collected data from a client with diabetes Mellitus type one
recently diagnosed with retinopathy. The nurse should recognize that the client may We
had increased risk for injury if

1. Outdoor steps have a railing on only one side of the steps

2. Skid resistant rugs are covering the wood floor

3. Carbon monoxide detectors are battery-

operated

4. Prescribe medication have standard labels

The nurse is reinforcing teaching with a client with osteoarthritis which of the following
information should the nurse reinforce?

1. Balance Periods of exercise with periods of rest

2. Increase your intake of foods that are high in calcium

3. Isotonic exercises place less stress on your joints than isometric exercise

4. Limit your alcohol consumption to one drink per day while taking prescribed non-
steroidal anti-inflammatory drugs
the nurses working in the emergency department received information that several
clients Are being transported by a radiologist emergency response team after exposure
to radiation. When the clients arrive at the ED which of the following actions should the
nurse take first?

1. Bag and tag each client clothing and place the clothing in the appropriate
BioHazard receptacle

2. Irrigate any wounds and cover each with a water resistant dressing

3. Have the client shower thoroughly with soap and water

4. Determine whether each client has been decontaminated

The nurse is caring for a client who has Clostridium difficile. Which of the following
infection control precautions should the nurse implement?

SATA

1. Place a blood pressure cuff in the clients room to be used for the client
only

2. Wear a particulate respiratory mask when assisting the client with meals

3. Place the client in a private room with monitor negative air pressure

4. Limit visits by the clients family members to 30 minutes each day

5. Remove the gloves prior to leaving the Clients roommate

The nurses received a change of shift report about a client who had a left radical
mastectomy six hours ago The nurse has been advised that since surgery the client
has consumed 3 cups of ice chips has not been out of bed and Had a urinary output of
200 ML go to the following actions would be appropriate for the nurse to take in the next
two hours?

1. Check the clients urinary output

2. Show the client a 30 minute video tape about wound care
3. Assisted client to ambulate in the hallway for 20 minutes- mostly
4. Performed passive range of motion exercises with client left arm
The nurse is preparing to administer prescribed nasal drops to a client select in the
correct order of the steps the nurse should take all options must be used

1. Ask the client to blow her nose

2. Instill the prescribed number of drops

3. Encourage the client to breathe through the mouth

4. How the medication dropper 0.5 inches above the Nares

5. Assist the client to lilt the head back over the edge of the bed

6. Encourage the client to remain supine for five minutes

1,5,4,2,3,6
The charge nurse in a long-term care facility has completed client care assignments for
unlicensed assistive personnel which of the following statements by the charge nurse
would give a UAP the best directions about the assignments

1. The client with quadriplegia should receive a complete bed bath before the
client goes to the physical therapy at noon

2. All clients should have a vital signs taken and documented on the flowsheet let
me know if anything needs follow up

3. The client who had a stroke should perform exercises twice daily before the client
attended recreation therapy

4. All clients should be assisted with meals make a list of what they eat at each
meal
The nurse is contributing to a staff education program about impaired nurses and nurse
should recommend including the nurses who abuse substance typically

1. Deny that there is a problem with substances

2. Have been practicing nursing less than five years
3. Abstrain from using substances while at work
4. Do not hold a management position

The nurse has reinforced teaching on a client who is receiving prescribed NPH and
regular insulin which of the following statements by the client would indicate a correct
understanding of the teaching

1. I should increase the dose of NPH incident if I am planning to have dessert for
dinner

2. I should administer regular insulin into my arm if I am planning to exercise with in

one hour

3. I will withhold regular insulin if I’m vomiting but I will administer NPH  insulin as
prescribed

4. I will draw regular insulin into the syringe first and then draw npH into this
same syringe

The nurse is reinforcing teaching with a female client who is at 24 weeks gestation and
is scheduled for a glucose tolerance test which of the following information should the
nurse in reinforce 

1. Fasting is required for four hours prior to the test

2. A serum glucose level will be obtained 1 hour after the test

3. A written consent form is required before the test is perform

4. A second test will be performed if your serum  glucose level is below 140 MG/DL


The nurse is reinforcing teaching with a client who has Giardiasis.  Which of the
following statements by the Client would indicate a correct understanding of the
teaching?

1. I should drink only bottled water

2. I will avoid using Using a public washroom
3. I should keep my eating utensils separate from those of other family members
4. I will avoid drinking water from the streams or lakes while I’m camping

The nurse is changing the dressing over a clients infected wound.  The client tells the
nurse I would not need all of this care if someone in the staff here had taken care of Me
correctly.  Which of the following responses would be most appropriate for the nurse to
take

1. It sounds like you’re angry - mostly likely

2. I will arrange to have the wound care specialist busy

3. Let me see how the infection is responding to the treatment

4. Tell me what I can do to help you at the time

The nurse is caring for assigned clients the nurse should first evaluate the equipment of
a client who has

1. A patient controlled analgesia device and reports that the medication is not
received each time that the button on the pump is activated

2. A pulse oximeter sensor attached to the finger and reports that the numbers on
the pulse oximeter screen change every few seconds

3. A nasogastric tube connected to low intermittent section and reports that

Bubbles appear in the NG tube when the machine turned on

4. A sequential compression stocking and reports that the stockings have remained
inflated for the past several minutes

The nurse is assigned in developing a plan of care for an older adult client with visual
impairment which of the following modifications in the clients home environment would
be appropriate for the nurse to recommend

1. Encourage the client to place a bright light next to the chair the client uses while
reading magazines

2. Rearranging the clients furniture so that the bed faces is the window

3. Obtaining polish brass colored handles for the use on exit doors

4. Using contrasting colors like black and white to mark the edge of stairs

The nurse is talking with a parent of a four month old infant the parent is concerned that
the infant may have been exposed to measles the nurses response should be based on
the understanding that the infant

1. May have passive immunity for rubeola measles based on the mothers immune
status

2. Needs to be isolated from other children for 4 to 5 days

3. Needs to receive immunoglobin to prevent rubeola

4. May need to have blood test completed to determine whether exposure

occurred – mostly
The nurse is caring for a five-year-old client with pertussis which of the following
infection control precautions will the nurse implement

1. Place a surgical mask on the client during transport out of the clients room

2. Place a client in a private room with monitor negative air pressure – airborne

3. Restrict family members who are pregnant from Visiting the client – no need

4. Keep the doors of the clients room closed at all times – for Ebola patient

The nurses is preparing to change a sterile dressing select in the correct order the steps
the nurse should take all options must be used

1. Remove the old dressings

2. Secure dressing with tape
3. Put on sterile gloves
4. Apply sterile dressing
5. Clean the wound

1,3,5,4,2
The nurse is collecting data about a client sleep and rest patterns which of the following
statements by the client would be a priority to follow up?

1. I take a nap in the afternoon if I feel tired after work 

2. I watch television at night when I have difficulty falling asleep – maybe
3. I wake up feeling tired even though I sleep 7 to 8 hours each night
4. I often wake up once or twice during the night but fell back to sleep quickly
The nurses been to perform an EKG for assigned client which of the following actions
should the nurse take?

1. Assist the client in semi Fowler’s position

2. Applied a gel to the clients chest before applying the transducer 

3. Place electrodes to all four extremities and on the Clients chest 

4. Ensure the client had a patent Peripheral venous access device

The nurse is caring for a client who has been receiving nalbuphine, Which of the
following should the nurse plan to have available as an antagonist for the medication?

1. Sodium bicarbonate
2. Magnesium sulfate
3. Naloxone
4. Methadone 

The nurse is caring for assigned clients. the nurse should recognize that the client at
risk for developing hypothyroidism is a client who

1. Has a pituitary tumor

2. Has a parathyroidectomy 
3. has a small cell lung cancer
4. Has been receiving prolonged corticosteroid therapy

The nurse has received the following information about assign clients the nurse should
first check the client

1. With diverticulitis who has had four episodes of diarrhea in the past 12 hours

2. Who has a long leg cast and is reporting that the toes feel numb –

compartment syndrome

3. With right sided heart failure who has 3+ pitting Edema of the lower extremities

4. Who has pleurisy and is reporting right sided chest pain while deep breathing 
The nurse is preparing to administer an intramuscular injection to a client. The client ask
why the medication is being administered in the ventroglutral site Instead of the deltoid
site. The nurse’s response should be based on which understanding

1. The Ventrogluteal site provides a large muscle mass for injection- best
muscle as large tissue is there

2. Intramuscular injections are not painful when given in the ventrogluteal site

3. The deltoid muscle should be used only for immunizations

4. There is a risk for injuring the sciatic nerve when injecting the deltoid muscle
Diphenhydramine – treats rashes

Miconazole – maybe 1st

The nurse and unlicensed assistive personnel are caring for a sign clients which of the
following activities would be appropriate for the nurse to assign to a UAP select that
apply?

SATA

1. Providing telephone instructions to the client with posttraumatic stress disorder

who is experiencing a flashback – RN
2. Measuring and recording intake and output for the client with major
depression who has refused to eat for several days
3. Monitoring the client with moderate Alzheimer’s disease so the client will
not wander from the facility – monitoring is RN
4. Transporting the client with schizophrenia to receive electro convulsive
therapy
5. Taking a urine specimen to the laboratory for the client with anorexia
nervosa

6.
The nurse is preparing a newly admitted client with meningococcal meningitis for a
magnetic resonance imaging scan of the chest which of the following actions would be
appropriate for the nurse to take?

1. Cleanser clients test where they povidone iodine solution

2. Place a surgical mask over the clients Mouth and nose
3. Where a protective gown when assisting the client onto a stretcher

4. Put the clients dentures in a container with water

The nurse is reinforcing teaching about nutrition and preventing infection at home with a
client newly diagnosed with acquired immune deficiency disorder ( AIDS) which of the
following information should the nurse reinforce?

SATA

1. Consult with a registered dietitian

2. Monitored for weight loss or weight gain
3. Wash all produce thoroughly before eating
4. Use separate sets of dishes and utensils
5. Consume a diet high in calories and protein
6. Eat large meals when you are not feeling nauseated
The nurse has attended a staff education conference about reminiscence therapy For
clients with Alzheimer’s disease which of the following statements about Reminiscence
Therapy by the nurse would indicate correct understanding of the Conference?

1. The client is encouraged to listen to familiar tunes to Induce relaxation, alter

moods and improve social interaction

2. Reminiscence therapy elicits pleasant memories from the clients past

through the use of sensory stimulation such as pictures

3. The client is provided with a stable and coherent social organization to facilitate
individual treatment

4. Reminiscence therapy focuses the use of dolls or stuffed animals To provide

tactile stimulation and comfort
The nurse has reinforced teaching with a client with phenochromocytoma Who is
scheduled for adrenal arteriography. Which of the following statements by the client
would indicate a correct understanding of the teaching?

1. I may experience numbness or tingling in my legs during the procedure 

2. I may be a risk for severe hypertension during the procedure

3. I will need to remain flat in bed for 10 hours After the procedure

4. I will need to have coagulation studies prior to the procedure

The nurse is caring for a five-year-old client who sustained burns over 10% of the body
one week ago which of the following between meals snacks would be appropriate to
offer The client?

1. Slices a red Apple 

2. cheese sticks
3. Strawberry gelatin
4. Frozen juice bar 
There is caring for a client who has streptococcal Pharyngitis. Which of the following
infection control precautions should the nurse implement

1. Place a particulate respirator mask on the client during transport – surgical mask

2. Insert the client to cover the mouth with a reusable cotton cloth when coughing 

3. Ensure that the door to the client room remains closed at all times – Ebola

4. Where a surgical mask when administering medications to the client

The nurse is collecting data from a client with a major depression. The clientele the
nurse yesterday I felt like killing myself but today I feel better which the following
statements will be essential for the nurse to make

1. This information will help us to plan further treatment for you

2. Do you think your treatment has been effective

3. I’m glad you’re feeling better

4. Will you promise to contact someone if these feelings happen again

The nurse has reinforced teaching with the client about nonpharmacological pain
management techniques which of the following statements by the client would indicate a
correct understanding of the teaching?

Select all that apply

1. Massage can be performed to decrease pain intensity

2. I will read a book to distract my attention from the pain

3. Analgesics will not be necessary if I use non-pharmacological techniques

4. I will use a heating pad on Low temperature

5. The nurse should provide me with a topic if I use guided imagery

The nurse is contributing to a staff development conference about informed consent
which of the following information should the nurse suggest including?

select all that apply

1. The client may not withdraw consent once the informed consent form has been
signed

2. The student nurse assigned to the client may witness and sign and form consent
form if a staff nurse is not available

3. The nurses responsible for explaining the procedure to the client prior to asking
for the informed consent form to be signed 

4. The client who is minor and enlisted in the military is considered legally
capable of signing their own informed consent form

5. The nurses signature on informed consent form indicate that the client has
voluntary given consent for the treatment or procedure

The nurse is observing a client who has been receiving diphenoxylate hydrochloride
with atropine Sulfate which following would be the best indication that the medication is
effective?

1. The client no longer strains at stool

2. The client has an increase in flatulence

3. The client has an increase in bowl sounds

4. The client has more solidly formed stools = brown stools

The nurse is reinforcing teaching with a client who is receiving prescribed metronidazole
which of the following information to the nurse reinforced?

1. You may consume one glass of wine

2. You may experience metallic taste while taking the medication – Normal
side effects
3. Notify your primary healthcare provider if you’re in becomes dark in color 
4. Take the medication with food to increase the rate of absorption
The nurse is reinforcing teaching with a client about performing a breast self
examination which of the following information to the nurse reinforced select all that
apply

1. You should use the palm of your hand to Feel for lumps
2. Perform the BSE after your menses when your breast are less tender
3. You should notify your primary healthcare provider if you observe dimpling of the
skin
4. Remain lying flat on your back and observe your breast for chain is using a Hand
mirror
5. You should notify your primary healthcare provider if you have discharge from
your nipples

The nurse and UAP are caring for assigned clients which of the following activities
would be appropriate for the nurse assign to a UAP

1. Administer an enema to the client with a fractured right hip

2. Removing sutures from the client who had an abdominal hysterectomy

3. Instructing the client with irritable bowel syndrome about dietary restrictions

4. Conducting a home safety assessment for the client with moderate

Alzheimer’s disease

The nurse is assisting with the plan of care for a client who is scheduled to have a right
mastectomy which of the following would be most important for the nurse recommend to
be included to maintain the clients positive body image

1. Encourage the client to explore her feelings

2. Provide the client with a calm quiet environment 

3. Discuss the types of prostheses available

4. Reinforce information on coping mechanism

The nurse is assisting with a health screening at a community health fair the nurse
should recognize that which of the following clients are at risk for developing
malnutrition?

1. The six-year-old client who has missing front teeth

2. The 16-year-old client who has a history of kidney stones
3. The 45-year-old client who had a stroke and has right sided weakness
4. The 65-year-old client who had a stomach cancer
5. The 88-year-old client who has a history of alcohol abuse

The nurse is teaching with a client who has a vitamin D deficiency which of the following
dietary modifications to the nurse reinforce?

1. Increase the amount of green leafy vegetables in the diet

2. Increase the amount of calcium in the diet
3. Drink a glass of orange juice at breakfast
4. Use fortified milk with Cereal 

Milk has Vitamin D

The nurse has reinforced teaching with a client about healthy sleep patterns follow up is
required if the client reports doing which of the following before bed?

1. Perform aerobic exercise – mostly likely

2. Eating a carbohydrate containing snack 

3. Taking an over-the-counter lavender supplement – improves sleep quality

4. Listening to music
The nurse is reinforcing teaching with a client about performing a breast self examination which of
the following information to the nurse reinforced select all that apply
1. You should use the palm of your hand to Feel for lumps
2. Perform the BSE after your menses when your breast are less tender
3. You should notify your primary healthcare provider if you observe dimpling of the skin
4. Remain lying flat on your back and observe your breast for chain is using a Hand mirror
5. You should notify your primary healthcare provider if you have discharge from your nipples

1,4 ? finger pad should be used for assessment and you should be standing infront of a mirror so
you can inspect properly then lie down to palpate very well each breast??
The nurse is assisting with a health screening at a community health fair the nurse should recognize
that which of the following clients are at risk for developing malnutrition?
1. The six-year-old client who has missing front teeth
2. The 16-year-old client who has a history of kidney stones
3. The 45-year-old client who had a stroke and has right sided weakness
4. The 65-year-old client who had a stomach cancer
5. The 88-year-old client who has a history of alcohol abuse
The nurse has reinforced teaching with a client with phenochromocytoma Who is scheduled for
adrenal arteriography. Which of the following statements by the client would indicate a correct
understanding of the teaching?
1. I may experience numbness or tingling in my legs during the procedure
2. I may be a risk for severe hypertension during the procedure
3. I will need to remain flat in bed for 10 hours After the procedure
4. I will need to have coagulation studies prior to the procedure
The nurse is caring for a client who sustained a closed head injury which of the following findings
would require immediate intervention?
1. Ecchymotic area or the left temple = battle
2. Glasgow coma scale score of 13
3. Blood pressure of 136/76
4. Headache that worsens with coughing = ICP
The nurse and UAP are caring for assigned clients which of the following activities would be
appropriate for the nurse assign to a UAP
1. Administer an enema to the client with a fractured right hip
2. Removing sutures from the client who had an abdominal hysterectomy
3. Instructing the client with irritable bowel syndrome about dietary restrictions
4. Conducting a home safety assessment for the client with moderate Alzheimer’s disease
There is caring for a client who has streptococcal Pharyngitis. Which of the following infection
control precautions should the nurse implement
1. Place a particulate respirator mask on the client during transport
2. Insert the client to cover the mouth with a reusable cotton cloth when coughing
3. Ensure that the door to the client room remains closed at all times
4. Where a surgical mask when administering medications to the client = Droplet precation
 the nurses working in the emergency department received information that several clients Are
being transported by a radiologist emergency response team after exposure to radiation. When the clients
arrive at the ED which of the following actions should the nurse take first? 1. Bag and tag each client
clothing and place the clothing in the appropriate BioHazard receptacle 2. Irrigate any wounds and cover
each with a water resistant dressing 3. Have the client shower thoroughly with soap and water

5. Determine whether each client has been decontaminated = correct

The nurse at an outpatient care facility has received the following telephone message
from clients Who were previously seen at the facility then there should first telephone a
client who is at ?

1. 12 weeks gestation is experiencing nausea and vomiting = Normal

2. 36 weeks gestation is reporting the leakage of yellow fluid from the nipple =
Normal

3. 35 weeks station is reporting a gush of clear fluid from the vagina

4. 22 weeks gestation and has a burning sensation with your urination = UTI 2 nd
The nurse is obtaining a pole street for a client with dysrhythmia which of the following
actions should the nurse take

1. Count the apical rate for 15 seconds and multiply the total by four

2. Count the radial rate for 60

3. Count the apical rate for 60 seconds

4. Count on the radial and apical rate for 30 seconds and multiply the total by two
The nurse is contributing to a staff development conference about client confidentiality which of the
following information should the nurse suggest including?
1.And the clients medical record is the clients property and the client may have access to the record
any time
2.Unneeded computer generated work sheets must be shredded at the end of the shift to
ensure client confidentiality
3.Personal computer passwords may not be shared with anyone including other members of the clients
healthcare team
4.Medical information about the client may be shared with a police officer who brought the client into the
emergency department
5.Keep your voice low when speaking with the client Because direct interaction with clients must be kept
as private as possible
The nurse is contributing to the plan of care for a client Who sustained full thickness burns on 30%
of the body three days ago which of the following interventions to the nurse suggest including in the
clients plan of care ?
select all that apply
1. Discourage movement of the affected body parts
2. Offer the client prescribed opioids analgesics prior to providing wound care
3. Wear a hair covering and a surgical mask when the bum wounds are exposed
4. Are used ice and other cold therapy as an adjunct to pharmaceutical pain relief
5. Stress the importance of strict intake and output recording for the client with the unlicensed assistive
personnel
The nurse is talking with a client who is exhibiting defense mechanisms which of the
following statements by the client with exemplify projection?

1. I purchased a gift for the nurse because I was rude yesterday

2. I became angry at my spouse and threw a glass against the wall
3. I backed my car into a pole because my spouse was distracting me
4. I have been informed of my poor prognosis But I know I will live a long time =
denial
The charge nurse is talking with a coworker who has returned from a meal break five
minutes ago the charge nurse observes that the coworkers eyes appear glassy and the
speech is slurred which of the following actions should the charge nurse take

SATA

1. Send a coworker to the employee health department to have a urine

specimen obtained for a drug screen  = marginuna = glass eyes , not sure
about this answer

2. Suggest the coworker in the eyes with cold water and telephone the coworkers
Spouse to drive that coworker home

3. Re-assign the coworkers clients and ask a coworker to wait in the

conference room

4. Notified the facility security officer and ask the officer to question the coworker

5. Provide assistance to the impaired colleague by reporting the behavior to

the appropriate supervisor
The nurse has attended a staff development conference about the care of clients with a
neurological injury the following statements by the nurse would indicate a correct
understanding of the conference

1. Clients with closed head injury should be encouraged to drink 3 liters of fluid
each day to help prevent dehydration

2. A client who has a Neurosurgery is at risk for developing a DVT and may
have antiembolism stockings prescribed

“Anti Embolism Stockings” or “TED hose” are often given to patients who are
hospitalized and have had surgery. They put mild pressure on the legs to prevent blood
from clotting and can, to some degree, prevent blood clots in the legs (DVT).

3. Clients who develop slow respirations

4. following neurosurgery should be encouraged to deep breath and cough

5. A client who develops pinpoint pupils following a closed head injury should be
placed in supine position with the head of the bed flat
The nurse has reinforced teaching with a client who was placed in skeletal traction 24
hours ago for affected femur it would indicate a correct understanding of the following if
the client

1. Rolls from side to side for linen changes

2. Reports a change in the sensation on the leg = Yes paresthesia
3. Rest the feet against the end of the bed
4. Adjusts the length of the rope used for traction

Paresthesia (or paraesthesia) is an abnormal dermal sensation (e.g., a tingling, pricking,

chilling, burning, or numb sensation on the skin) with no apparent physical cause. The
manifestation of a paresthesia may be transient or chronic, and may have any of
dozens of possible underlying causes.
Yellow from a Nipple from pregnant women = Normal
Yellow execduce from circumcision = Normal
The nurse in the pediatric clinic is caring for a five week 1 months and 1 week old
infant which of the following behaviors is a nurse likely to observe in a healthy five-year-
old client 

1. Inspecting and playing with hands = No

2. Crying when a stranger approaches  = 6 months ,10 months , 18 months ,3 yrs.
3. Lifting the head when lying on the abdomen
4. Frequent drooling – 3 months -5 months
The nurse is caring for a client who practices Orthodox Judaism and is expected to die
during the shift which of the following with the nurse expect to observe after the client
dies 

1. One of the clients  family members will remain with the client

2. Several small drops of oil will be placed on the clients lips and forehead

3. The client spiritual advisor will fold the clients hands across the clients
chest 

4. The client spouse will request that staff members wrap the Client in a red cloth
The nurse is caring for a client with chronic pain who is requesting a dose of prescribed
opioid analgesic every 1 to 2 hours. Which of the following statements would be
appropriate for the nurse to make?

1. Using the medication to treat chronic pain may cause drug addiction

2. You are scheduled to receive a dose of the medication every four hours and you
may not receive additional doses

3. You don’t seem to be experiencing relief from the medication let’s talk with
your primary healthcare provider about a different medication

4. Additional problems may be causing you pain talk with your primary healthcare
provider about scheduling test to determine the source of pain
The nurse is caring for a couple who just experience a stillbirth the client’s spouse says
to the nurse I’m tired I need to go home I’ll probably take the babies bassinet back to
the store while I’m gone since we just started to buy furniture for the nursery. Which of
the following responses would be most appropriate for the nurse to make

1. Your wife need you here with her 

2. there will be plenty of time to return the bassinet = maybe
3. I can help you talk with your wife about the nursery
4. You need to get some rest instead of working
Nurse is caring for a five-year-old client with autism which of the following behaviors
would be consistent with the diagnosis

1. Frequently Trips or falls when ambulating

2. Blinks and twitches extremities uncontrollably
3. Tonic clonic muscle contractions
4. Speech and language delays
The nurse is talking with a dietitian who is preparing to consult with a client at 12 weeks
gestation during the first prenatal visit it would be essential to inform the dietitian of the
client

1. Is allergic to penicillin the client 

2. is experiencing Ptyalism

3. Have a history of diabetes mellitus

4. Has a  body mass index of 22 before pregnancy 

The nurse is cooking with multiparous client who was just admitted at term in early labor
stage which of the following statements by the client would be requiring immediate
Notification of the RN

1. My back is really hurting

2. It feels like there’s a water running down my legs
3. I feel the emesis basin right away 
4. My contractions make it feel like I need to have a bowl movement = baby is
coming = When contractions make you feel like having a bowel movement, the baby is in the
perineum. Remember they are multiparous clients. , Remember they're multiparous women.

2 (if there is watering running down her legs that means she had spontaneous rupture of membranes and
needs a vaginal examination to assess for progress of labour and cord prolapse)

2 bcz RN needs to monitor FHR and look for cord prolapse

The nurse is talking with a client who has a DVT and is receiving prescribed enoxaparin.
Which of the following statements about the client would require follow-up means
review

1. I am scheduled for a lumbar puncture in the morning and will have To be NPO
2. My primary healthcare provider said my serum aminotransferase AST and I
mean Aminotransferase ALT Levels are being monitored
3. I have been saving through specimen so the nurses can test them for blood
4. My primary health care provider said protamine selfie should be
administered in the event of an aspirin overdose
My primary health care provider said protamine selfie should be administered in the event of an
aspirin overdose

 Antidote for aspiring overdose is sodium bicarbonate therefore it can not be protamin sulfate. Cause protamin
sulfate antidote is for heparin.

The nurse is reinforcing teaching about safety with a group of parents do the following
information to the nurse reinforce?

1. School-age children are at greatest risk for ingesting toxic plants

2. Toddlers are at great risk for acetaminophen poisoning

3. Toddlers Who ingest honey are at greatest risk for botulism poisoning - its for infant
who ingest honey is risk for botulism

Preschool age children living in a home built after 1978 Are at greatest risk for lead
poisoning - .lead poisoning is greater in toddler 18 to 24 months
The nurse has reinforced teaching with a client who has depression and is taking it
prescribed monoamine oxidase inhibitor MAOI. Which of the following statements by the
client would indicate a great understanding of the teaching?

1. Every morning I will eat a banana with my cereal for breakfast = no BAR

Banana, avocado , raisin , yogurt , chocolate, caffeine ,alcohol , only cottage

cheese.

2. I should not eat any type of cheese while taking the medication

3. I should avoid eating chocolate while I am taking the medication

4. I can continue to drink one glass of wine with my evening meal = no

The nurse is reinforcing teaching with a female client but early detection of breast
cancer. Which of the following statements by a client would indicate a correct
understanding of the teaching?

1. Digital mammography is less painful than e-Ray mammography 

2. Digital mammography is better at detecting tumors in dense breast tissue

than X-ray mammography

3. Magnetic resonance imaging can be used to direct breast tumor instead of

mammography

The nurse reinforced teaching with a son of a female client who is being discharged
after the stroke the client will continue rehabilitation At the sons home. The nurse is
aware that one of the family members is a 10-month-old infant which of the following
statement by the son would indicate the correct understanding of the teaching ?

1. We need to schedule my mothers physical therapy during times that our baby
normally is taking a nap

2. We should make sure that our mothers bed is located close to the door of her
bedroom because of our baby.

3. We should remove my mothers raised toilet seat From the toilet after each use 

4. If we get a hospital bed for my mother we will need to look under the bed
Before we lower the height of the bed
The nurse is caring for a client recently diagnosed with terminal lung cancer,The clients
shouts I can’t believe how terrible the food is here are you trying to make me ill. Which
of the following responses should be appropriate for the nurse to make
 
1. You are not happy with the food you have been served is there anything
else you would like to discuss

2. Your behavior is unacceptable I will return when you are calm and rational

3. Please stop shouting at me I will be happy to help you plan your meals 

4. Is there a problem with your food I will ask the register dietitian to talk with you
The nurse is caring for a client who has a partial gastrectomy six hours ago the client
has the NG tube attached to low intermittent suction and the drainage tube bright red
blood. The nurse should first 

1. Check the clients vital signs = patient 1st

2. Irritate the clients NG tube as prescribed prn
3. Determine the setting on the suction device
4. Inform the Charge nurse about the observation = Passing bucket

A nurse is collecting data from a client with Bell’s palsy. Which of the following findings
would the nurse expect to observe?

1. Cold intolerance 
2. Positive Babinski reflex
3. tearing on the affected side
4. Nystagmus

The nurse has attended a staff education conference about reminiscence therapy For clients with
Alzheimer’s disease which of the following statements about Reminiscence Therapy by the nurse
would indicate correct understanding of the Conference?
1. The client is encouraged to listen to familiar tunes to Induce relaxation, alter moods and improve
social interaction
2. Reminiscence therapy elicits pleasant memories from the clients past through the use of
sensory stimulation such as pictures
3. The client is provided with a stable and coherent social organization to facilitate individual treatment
4. Reminiscence therapy focuses the use of dolls or stuffed animals To provide tactile stimulation and comfort
The nurse is caring for a client recently diagnosed with terminal lung cancer,The clients shouts I
can’t believe how terrible the food is here are you trying to make me ill. Which of the following
responses should be appropriate for the nurse to make
1.You are not happy with the food you have been served is there anything else you would like
to discuss = best
2.Your behavior is unacceptable I will return when you are calm and rational
3.Please stop shouting at me I will be happy to help you plan your meals
4.Is there a problem with your food I will ask the register dietitian to talk with you – maybe
The nurse is reinforcing discharge instructions with a client who has heart failure the
client has prescriptions for diuretic and a potassium supplement we do the following
statements for the client would indicate an understanding of the instructions?

1. I will take an extra diuretic pill with a glass of orange juice at night if I start gaining
weight

2. I will include canned soups and frozen vegetables in my diet because they’re
easy to prepare and a good source of potassium = NEVER

3. I will increase my activity gradually but if I get short of breath I will stop and
rest

4. I will not take my diuretic pill and I will call my doctor if my pulse is below 60

The nurse is collecting data from a client in labor who just had an amniotomy
performed. The fetal heart rate is 92. Which of the following would be consistent with
the findings

1. Polyhydramnios

2. Imminent delivery 

3. Fetal cardiac anomaly 

4. Prolapsed umbilical cord

The nurse has reinforced teaching with a client who is scheduled for a bronchoscopy
which of the following statements by the client would require follow-up?

1. I should remove my dentures prior to the procedure

2. I can eat and drink immediately after the procedure

Following the procedure, the client will need to be monitored for complications
such as bleeding

3. I will be given a local anesthetic during the procedure 

4. I will need to sign a consent prior to the procedure
The nurse Is collecting data from a client who is at 30 weeks gestation. The client tells
the nurse it seems like I have been in continent of urine for the last few days. The nurse
should make sure that which of the following is available in the clients examination room

1. Electronic fetal monitor

2. Sterile urine container
3. Nitrazine paper
4. Clean, cotton-tipped applicators
 The nurse is caring for a client with prostate cancer who is scheduled for an
orchiectomy.The client states I don’t understand why I need to have this surgery. The
nurse should reinforce the preoperative instructions with the client to indicate that the
surgery

1. Decreases male hormones that stimulate the prostate cancer growth

2. Eliminates the most common site of metastasis 
3. Minimizes a need for chemotherapy
4. Remove the source of the cancer

Orchiectomy (also named orchidectomy, and sometimes shortened as orchi) is a

surgical procedure in which one or both testicles are removed (bilateral orchiectomy)
The nurse is collecting data from a client with primary hypothyroidism which of the
following findings would the nurse expect?

1. Elevated serum thyroxine

2. Elevated serum thyroid stimulating hormone
3. Elevated serum triiodothyronine 
4. Elevated serum parathyroid hormone
The nurse is caring for a client who wants to leave the facility against medical advice
AMA which of the following actions should the nurse take?

1. Complete an incident report and forward it to the risk management department

2. Inform the client that the client can leave after the family member is notified
3. Do not allow the client to leave until the primary healthcare provider performs a
complete physical assessment
4. Permit the client to leave after the client sign the release form
The nurse is reinforcing teaching with a client who is scheduled for a radical neck
dissection and laryngectomy. Which of following statements by the client would indicate
a great understanding of the teaching

1. After surgery I look forward to spending time alone at home doing my hobbies

2. I will ask my friends to make a special board with pictures of food that I like
to eat – 1st

3. I need to renew my membership at the local swimming club so that I can go

swimming during the recovery.

4. After surgery I will probably feel more comfortable if I am wearing a shirt

that buttons around my neck
Nurse is contributing to a staff education conference about advanced directive and the
responsibilities of the nurse which of the following should the nurse suggest including

select all that apply

1. Encourage the client to complete advance directives

2. Answer the clients legal questions regarding advanced directive = never
3. You may serve as a witness for the clients adventure asked if asked = not HCP ,
Not listed , not nurse
4. Make sure a copy of the clients advance directive is in the medical record
5. Encourage the client to discuss healthcare preferences with family
members
6. You may reassure the client that advance directive can be change at
anytime
Isolation precautions

The nurse has attended a staff development conference about infection control
precautions which of the following statements by the nurse would indicate a good
understanding of the Conference

1. A gown and gloves should be worn when changing the bed linens of a
client with pediculosis capitis
2. Disposable towels should be used when bathing a client with bacterial
conjunctivitis
3. Gloves should be worn when giving a back rub to a client with systemic lupus
erythematosus
4. Goggles and a gown should be worn when obtaining a sputum specimen from a
client with active pulmonary tuberculosis 
Nclex Pharma

The nurse is reinforcing teaching with a client who is receiving prescribed methotrexate
which of the following information to the nurse reinforce?

1. Take over-the-counter aspirin if you have a headache

2. Apply sunscreen prior to participating in outdoor activities
3. Continue to take Saint johns wort for depression
4. Notify your primary healthcare provider if your experience a sore throat
5. Limit your intake of beverages that contain alcohol to one glass of red wine per
day
The nurse is caring for a client who is receiving prescribed oxygen a spiritual advisor is
performing a ritual in the clients room. Which of the following if used doing the ritual
would require the nurse to intervene ?

1. Special food and herbs

2. small candles
3. Religious books
4. Metals and threads
The nurse is caring for 5 year old client who has prescription for
acetaminophen 12mg/kg , every 4 hrs. The client weighs 43 lb ( 19.kg).
The nurse 160 mg/ 5ml of solution available. How many ML should the
nurse administer to the client with each dose ? One decimal places

12MG KG 43 5ML
KG 2.2 LB X 160MG

2580
352

7.3 ml
The nurse is caring for a client who has a prescription for tobramycin
3mg/kg/day. IM , divided doses every 8 hrs . The client weighs 115lb . The
nurse has tobramycin 40mg/ml of solution available. How many ML each does
? round answer to using one decimal place .

1.3
A nurse is contributing to a staff conference program about electroconvulsive therapy
which of the following information should the nurse recommend including

1. ECT is commonly used to treat depression prior to prescribing antidepressant

medications

2. ECT may be administered to clients on an outpatient basis 

3. Auditory hallucinations are common side effects of ECT

4. ECT lowers the level of norepinephrine in the central nervous system

The nurse is collecting data from a client who is receiving but he prescribed anti-
hypertensive medication which of the following would indicate a correct data collection
technique to identify Orthostatic hypotension

1. Measure the clients blood pressure in each arm while the client is seated and
compare the results

2. Ask the client to stand from a sitting position and then measure the clients blood
pressure while standing

3. Asked the client to walk for five minutes and then measure the client blood
pressure while seated

4. Measure the clients blood pressure in the supine sitting and standing
position 1 to 3 minutes apart 
The nurse is caring for a client who has been vomiting and has diarrhea for the past 24
hours which of the following actions would be priority for the nurse to take ?

1. Measure the clients weight

2. Obtain a 24 hour urine specimen
3. Monitor the client for changes in mental status
4. Check clients blood pressure in a supine and standing position
The nurse has reinforced teaching with a client who is receiving prescribe alprazolam
which of the following statements by the client would require follow-up

1. I will avoid drinking grapefruit juice while taking alprazolam

2. I can divide the total daily dose of alprazolam into more frequent intervals
3. I should Avoid Alcohol while taking Alprazolam
4. I will need to take alprazolam for the rest of my life – not for rest of live

Levothyroxine yes
The nurse is caring for a client who’s wearing antiembolism stockings. The nurse should
recognize that which of the following findings as likely to impede venous return

1. Sequential compression devices have been applied over the stockings

2. Powder was applied to the clients legs prior to application of the stockings
3. The top of the stockings have rolled down
4. The stockings are too large for the client
The Change Nurse in a long-term care facility has completed client care assignments
for unlicensed assistive personnel which of the following statements by the charge
nurse will provide a UAP with the best directions regarding the assignments

1. Assist the client with dementia to ambulate to the bathroom after eating
2. Offer between meals snacks to the client with diabetes Mellitus 
3. Help the client with microvalve prolapse prepare for a schedule dental
appointment today
4. Encourage the client with gastroenteritis to drink one cup of liquid every
two hours = time frame given

I think they all possible answer, UAP can help with ADL, routine procedures , measure I/O, measure v/s,
ambulating
And the nurse an unlicensed assistive personnel I can for assign clients which of the
following activities would be appropriate for the nurse to assign to a UAP

SATA

1. Weighing the client with heart failure

2. Providing oral hygiene to the client with severe Alzheimer’s disease
3. Palpating the pedal pulses of the client who had a cardiac Catherization two
hours ago = less than 12 hrs fresh operative
4. Obtaining and documenting vital signs from the client who had an
appendectomy  24 hours ago
5. Obtaining a pulse oximetry reading from the client with chronic obstructive
pulmonary disease
The nurse in a long-term care facility is making client care assignments for you a P
which of the following statements by the nurse would provide a UAP but the best
directions about the assignment?

1. The client is Risk for infection take the vital signs and report back to me if
the temperature is above 100.5 - task given , report back to me good
answer

2. The client has hemiplegia assist the client to eat breakfast

3. The client who had total knee replacements needs to begin physical therapy plan
of the client care around the therapy

4. All the clients who have been assigned to you will need to have vital signs
obtained an intake and output recorded
The nurse is reinforcing teaching with the parents of a three-year-old client about how to
administer prescribed eyedrops medication and a prescribed Eye ointment which of the
following should the nurse reinforced?

Select all that apply

1. It is best to administer the eye ointment soon after your child awakens in the
morning

2. Administer the eyedrops prior to the eye

3. Ointment 
4. You can ask your spouse to help immobilize your child head and arms
5. Clean each eye from the outer canthus to the inner canthus prior to administering
the medication

6. Apply the ointment In a thin strip along the conjunctival sac

The nurse is caring for an adult client admitted one day ago following a stroke which of
the following findings should be reported immediately

1. Negative Babinski reflex

2. Breast Pupillary response

3. Irregular respirations of 22

4. Capillary refill less than two seconds

The nurse is contributing to a staff education conference about informed consent which
of the following information to the nurse suggest including

1. A clients knowledge of the procedure include the name of the procedure length of
the hospital stay and medications prescribed

2. nurse should ask the client if there is anyone that they would like to have present
during the explanation of the procedure

3. A client could file a charge of assault if the consent is not signed before a
procedure is performed

4. A nurse Should avoid answering your clients questions about the procedure until
the consent is signed