1. What should a nurse do first for a toddler with poor dietary intake?: Encourage the
family to be with the child during mealtimes.
2. What instruction should a postpartum nurse include about the MMR vaccine?-
: Avoid pregnancy for at least 28 days after receiving the vaccine.
3. What technique should a nurse use for a wet-to-dry dressing change?: Clean the
wound from the center to the outer edges.
4. What indicates a client understands contraception teaching?: My partner will use
condoms with spermicides.
5. What defense mechanism is a client with bipolar disorder using when yelling at the
nurse?: Displacement.
6. What is a possible source of infection for an immunocompromised client?: -
Soiled linens are placed on the floor.
7. What should a nurse ensure before an esophagogastroduodenoscopy?: Ensure that
the client gave informed consent.
8. What intervention should a nurse implement for a client who has been assaulted?:
Maintain a safe and private environment for the client.
9. What should a nurse provide to a client who has been assaulted and is seeking
support?: Provide resources for local support services.
10. What is an appropriate action for a nurse caring for a client with leukemia
experiencing chronic fatigue?: Contribute to the plan of care that addresses energy
conservation.
11. What should a nurse do regarding a client who has been sexually assaulted?-
: Request a consult for case management.
12. What should a nurse do if a client is immunocompromised and has uncapped
sharps?: Identify it as a possible source of infection.
13. What should a nurse inform a client about the duration of an
esophagogastroduodenoscopy?: The procedure will take approximately 60 minutes.
14. What should a nurse do when a client yells during medication changes?: Identify
that the client is using displacement as a defense mechanism.
15. What should a postpartum nurse tell a client about the MMR vaccine and
breastfeeding?: Avoid breastfeeding for 3 days after receiving the vaccine.
,16. What should a nurse do regarding a client's dietary history?: Obtain the child's
dietary history if they have poor dietary intake.
17 What is a safe practice for a nurse when changing a dressing on an infected wound?:
Wear sterile gloves to remove the dressing.
18. What should a nurse advise a client about using petroleum jelly with latex
condoms?: It should not be used as it can weaken the condom.
19. What should a nurse do if a client reports a history of depression after an assault?:
Provide resources for local support services.
20. What should a nurse do for a client who has been drinking socially and reports an
assault?: Provide resources to the client for the local Alcoholics Anonymous chapter.
21. What should a nurse do if soiled linens are found on the floor in an
immunocompromised client's room?: Identify this as a potential source of infection.
22. What should a nurse do to support a client with chronic fatigue due to leukemia?:
Encourage rest and energy conservation strategies.
23. What intervention should a nurse include in the care plan for a client with leukemia
experiencing chronic fatigue?: Encourage strength-training exercise.
24. What finding should a nurse expect when collecting data from a client with placenta
previa?: Bright red vaginal bleeding.
25. What are the responsibilities of a nurse regarding a client's advance direc-
tives?: 1. Provide written information about advance directives. 2. Instruct that it is a legal
document that must be honored. 3. Communicate advance directives status via medical
record and shift report. 4. Document discussions about do-not-resuscitate status.
26. Which action is an example of protecting client confidentiality?: Giving change-of-
shift report to a nurse outside the client's room.
27. What should a nurse do when assisting with postmortem care for a client who was
a devout follower of Islam?: Position the client's head toward Mecca.
28. What statement by a mother indicates understanding of breastfeeding
teaching for her 5-day-old newborn?: I should have my baby latch on to my nipple and
areola during feeding.
29. What intervention should a nurse implement for a client with varicella zoster?:
Assign the client to a negative pressure airflow room.
, 30. What instruction should a nurse give to prepare a client for testing the plantar
Babinski reflex?: Lie down and I will stroke the bottom of your foot.
31 What resource should a nurse recommend to a family caring for an older adult client
with early onset dementia?: Adult day care facility.
32. What should a nurse instruct a client who experiences syncope after starting
enalapril?: C. Rise slowly from a sitting position to a standing position.
33. Which food should a nurse recommend for a client with irritable bowel syndrome?:
A. Yogurt.
34. What important information should a nurse teach guardians of a child with cystic
fibrosis?: C. Have your child wear a medical identification wristband.
35. What action should a nurse take when a client requests a tub bath?: A. Check on
the client every 10 min during the bath.
36. What indicates a client's understanding of actions to take when experiencing chest
pain with stable angina?: C. 'I will stop what I am doing and lie down.'
37. What supply should a nurse ensure a client has upon discharge if oxygen is
prescribed at 1 to 2 L/min?: A. Nasal cannula.
38. What is the first action a charge nurse should take upon noticing the smell of alcohol
on a nurse's breath?: C. Remove the nurse from the client care area.
39. What is the priority action for a nurse caring for a cyanotic client with a respiratory
rate of 8/min?: A. Establish a patent airway for the client.
40. What reading level should a community health nurse use when developing a
brochure about hypertension?: A. Write the information at an 8th-grade reading level.
41. What should a nurse teach parents of an infant with a Pavlik harness?: C. The
harness can promote hip joint development.
42. What is an important instruction for changing an ostomy appliance for a
client with a sigmoid colostomy?: C. Empty the client's ostomy pouch before removing the
skin barrier.
43. What should a nurse advise regarding dietary potassium for a client on enalapril?:
D. Increase dietary potassium.
44. What should a nurse tell a client about taking nitroglycerin for chest pain?: A.
'I will call the provider after taking one dose of nitroglycerin.'