1. What action should a nurse take first for a toddler with poor dietary intake?-
: Obtain the child's dietary history.
2. What instruction should a nurse include about the MMR vaccine for a postpartum
client?: Avoid pregnancy for at least 28 days after receiving the vaccine.
3. What technique should a nurse use when performing a wet-to-dry dressing
change?: Clean the wound from the center to the outer edges.
4. Which statement indicates understanding of contraception teaching by a female
client?: My partner will use condoms with spermicides.
5. What defense mechanism is a client with bipolar disorder using when yelling at the
nurse during medication changes?: Displacement.
6. What should a nurse identify as a possible source of infection for an
immunocompromised client?: Soiled linens are placed on the floor.
7. What action should a nurse take prior to an esophagogastroduodenoscopy for a
client with peptic ulcer disease?: Ensure that the client gave informed consent.
8. What intervention should a nurse implement for a client who has been as-
saulted? (Select all that apply): Maintain a safe and private environment for the client;
Provide resources for local support services; Request a consult for case management.
9. What is a key consideration for a nurse caring for a client with leukemia
experiencing chronic fatigue?: Assess the client's energy levels and provide appropriate
rest periods.
10. What intervention should a nurse include in the care plan for a client with leukemia
experiencing chronic fatigue?: Increase protein in the diet.
11. What is a common finding in a client with placenta previa?: Bright red vaginal
bleeding.
12. What are the responsibilities of a nurse regarding a client's advance direc-
tives?: 1. Provide written information about advance directives. 2. Instruct the client that
an advance directive is a legal document that must be honored. 3. Communicate advance
directives status via the medical record and shift report.
4. Document discussions about do-not-resuscitate status.
13. Which action is an example of protecting client confidentiality?: Giving change-of-
shift report to a nurse outside the client's room.
,14. What should a nurse do when assisting with postmortem care for a Muslim client?:
Allow a family member to stay with the client's body until burial.
15 What indicates understanding of breastfeeding teaching in a mother of a
5-day-old newborn?: I should have my baby latch on to my nipple and areola during
feeding.
16. What intervention should a nurse implement for a client with varicella zoster?:
Assign the client to a negative pressure airflow room.
17. How should a nurse prepare a client for testing the plantar Babinski reflex?-
: Lie down and I will stroke the bottom of your foot.
18. What resource should a nurse recommend for a family caring for an older adult
client with early onset dementia?: Adult day care facility.
19. What is the expected intervention for a client experiencing chronic fatigue due to
leukemia?: Encourage strength-training exercise.
20. What should a nurse expect to find in a client with placenta previa?: Bright red
vaginal bleeding.
21. What is the nurse's role regarding advance directives?: Communicate advance
directives status via the medical record.
22. What is an appropriate action to maintain client confidentiality?: Discarding
worksheets containing client information in a secure manner.
23. What should a nurse do to respect the beliefs of a devout Muslim client after death?:
Position the client's head toward Mecca.
24. What breastfeeding practice should a mother follow for her newborn?: My baby
should breastfeed 5 to 10 minutes on each breast.
25. What is the correct nursing intervention for a client with varicella zoster?: Initiate
contact precautions for the client.
26. What is the correct instruction for testing the plantar Babinski reflex?: Place your
foot in my hand and I will tap the back of your heel.
27. What is a key responsibility of a nurse regarding advance directives?: Instruct the
client that an advance directive is a legal document.
28. What should a nurse document regarding do-not-resuscitate status?: Document
that the provider discussed do-not-resuscitate status with the client.
, 29. What is an appropriate recommendation for a family caring for an older adult with
dementia?: Suggest adult day care facility for support.
30. What should a nurse avoid when discussing client information?: Discussing a client's
prognosis with assistive personnel who is not involved in their care.
31 What is the appropriate action for a nurse regarding a client's advance directives?:
Provide the client with written information about advance directives.
32. What should a nurse instruct a client to do if they experience syncope after starting
enalapril?: Rise slowly from a sitting position to a standing position.
33. Which food should a nurse recommend to a client with irritable bowel syndrome?:
Yogurt.
34. What important information should a nurse include when teaching
guardians of a child with cystic fibrosis?: Have your child wear a medical identification
wristband.
35. What action should a nurse take when a client requests to take a tub bath?-
: Check on the client every 10 min during the bath.
36. What indicates a client's understanding of what to do when experiencing chest pain
with stable angina pectoris?: I will stop what I am doing and lie down.
37. What supplies should a nurse ensure a client has upon discharge when prescribed
oxygen at 1 to 2 L/min?: Nasal cannula.
38. What is the first action a charge nurse should take upon noticing the smell of alcohol
on a nurse's breath?: 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?: Establish a patent airway for the client.
40. What should a community health nurse consider when developing a brochure
about hypertension?: Write the information at an 8th-grade reading level.
41. What statement should a nurse include when teaching parents of an infant with a
Pavlik harness?: 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?: Empty the client's ostomy pouch before removing the
skin barrier.
43. What should a nurse advise a client regarding fluid intake after experiencing
syncope?: Do not decrease daily fluid intake.