WITH ACTUAL EXAM QUESTIONS
AND ANSWERS
A nurse is planning to administer medication to a client who has a Clostridium difficile infect
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ion. Which of the following actions should the nurse plan to take to prevent the transmissio
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n of this infection to others?
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Clean hands with an alcohol-based hand rub immediately after removing gloves.
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Remove the cover gown in the client's room after providing care. Place the client in a room
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with negative-pressure airflow
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Wear a mask when administering oral medications to the client. - ans-
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Remove the cover gown in the client's room after providing care.
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A nurse is caring for a client who has a prescription for a high-protein diet to
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promote wound healing following surgery. The client's religion prohibits eating
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meat on particular days. Which of the following actions should the nurse take?
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a. encourage the client to eat meat during this time to promote healing
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b. advise the client to eat everything on the tray except the meat
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c. suggest the client receive high-protein enteral feedings
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d. ask the dietitian to recommend alternative food choices for the client - ans-
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ask the dietitian to recommend alternative food choices for the client
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A nurse is caring for a client who has prescription for a high-
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protein diet to promote wound healing following surgery. The client's religion prohibits eatin
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g meat on particular days. Which of the following actions should the nurse take?
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Encourage the client to eat meat during this time to promote healing
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Advise the client to eat everything on the tray except the meat
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Suggest the client receive high-protein enteral feedings
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Ask the dietitian to recommend alternative food choices for the clie - ans-
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Ask the dietitian to recommend alternative food choices for the client
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A nurse is collecting data from a client who is 2 days postoperative following a
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colostomy. Which of the following findings should the nurse report to the
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provider?
a purple-colored stoma
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, protrusion of the stoma qa qa qa
a small amount of bleeding from the stoma
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intestinal gas in the pouch - ans-a purple-colored stoma qa qa qa qa qa qaqa qa qa
A nurse is reinforcing teaching with a client about self-administration of
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ophthalmic drops. Which of the following instructions should the nurse include? qa qa qa qa qa qa qa qa qa qa
"You will need to look to the side when you put the drops in your eye."
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"You should put the drops directly in the center of your eyeball."
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"You should cleanse your eye from the inner to the outer edge prior to putting in
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the drops." qa
"You should avoid pressing on your tear duct after putting the drops in your eye." -
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ans-"You should cleanse your eye from the inner to the outer edge prior to putting in
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the drops." qa
A nurse is reinforcing teaching about carbohydrate counting with a client who has
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a new diagnosis of diabetes mellitus. Which of the following actions should the
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nurse take first? qa qa
a. use pictures of different food groups to help the client plan a daily menu
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b. ask the client what he already knows about meal planning
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c. give the client a brochure with sample menus for all meals
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d. involve the family in the discussion of the client's meal plan - ans-
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ask the client what he already knows about meal planning
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A nurse is assisting with the admission of an adult client to a medical-
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surgical unit. Which of the following findings should the nurse identify as an indication that t
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he client is malnourished?
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heart rate 89/min qa qa
pink mucous membranes qa qa
pale, scaly skin qa qa
body mass index 23 - ans-pale, scaly skin
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A nurse is reinforcing teaching about advance directives with a client who has end-
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stage renal disease. Which of the following client statements indicates an
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understanding of the teaching? qa qa qa
a. "I know that i can change my advance directives if I need to in the future."
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b. "My health care proxy will make my health care decisions as soon as I have
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signed the power of attorney." qa qa qa qa
c. "My family can overrule the decisions made by my health care proxy."
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d. "Advance directives from one state are valid in any other state." -
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ans-"I know that i can change my advance directives if I need to in the future."
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A nurse is preparing a client for a Romberg test. Which of the following statements should t
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he nurse make? qa qa