1. A nurse is caring for a client who requires a 24-hr urine collection. Which of the
following statements indicates an understanding of the teaching?
a. I had a bowel movement, but I was able to save the urine – should be free of
feces
b. I have a specimen in the bathroom from about 30 minutes ago- Client should
place any urine in the container immediately and keep it on ice or in the fridge.
c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24
hr urine collection, the client should discard the first voiding and save all
subsequent voiding.
d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified
amount
2. A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has
developed thrombophlebitis?
a. Bladder distention – urinary retention which causes bladder distension is a
common complication of bed rest due to a loss of muscle tone in the bladder and
detrusor muscles
b. Decreased blood pressure – client on bed rest can develop postural hypotension.
Drop in BP when the client moves from a lying to a sitting position. Nurse should
assess for pulse rate and dizziness.
c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations
ofthrombophlebitis, a common complication of immobility
d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis.
Constipation is common complication of immobility.
3. A nurse manager is overseeing the care on a unit. Which of the following situations
should the nurse manager identify as a violation of HIPAA guidelines?
a. A nurse who is caring for a client reviews the client's medical chart with the
nursing student who is working with the nurse – any healthcare professional
directly caring for a client has access to the medical information.
b. A nurse asks a nurse from another unit to assist with her documentation –
onlyhealth care professionals directly caring for a client may access medical
information.
c. A nurse who is caring for a client returns a call to the client's durable power of
attorney for healthcare designee to discuss the client's care – The person the
durable power of attorney for health care designates has a legal right to
information about the client’s care.
d. A nurse discusses the client's status with the physical therapist that is caring for
the client at the client's bedside – any healthcare professional directly caring for
a client has access to the medical information.
4. A nurse is caring for a client who requires bed rest and has a prescription for anti-
embolic stockings. Which of the following actions should the nurse take?
a. Apply the stockings so the creases are on the front side of the leg – nurse should
assure that there are no creases or wrinkles in the stocked to prevent kind
irritation and promote venous return
, b. Apply the stockings while the client's legs are in a dependent position – nurse
should apply stockings in the morning before the client gets our o bed because
the legs are less edematous at that time
c. Remove the stockings at least once per shift – nurse should remove stocking
tocheck for CMS.
d. Remove the stockings while the client is sitting in a reclining chair – Client should
wear the stockings while sitting in the chair to promote venous return.
5. A nurse is administering IV fluid to an older adult client. The nurse should perform which
priority assessment to monitor for adverse effects?
a. Auscultate lung sounds – ABC approach. Auscultate lung sounds to monitor
for fluid volume excess, a complication of IV therapy. Manifested in moist
crackles heard in lung fields, dyspnea, and SOB
b. Measure urine output – The nurse should measure urine output to monitor the
renal function of an older client, however it is not the priority assessment
c. Monitor blood pressure readings - The nurse should monitor BP readings to
evaluate the hemodynamic stability of an older client, however it is not the
priority assessment
d. Monitor serum electrolyte levels - The nurse should monitor serum electrolyte
levels (esp Na) to guide the planning of interventions to correct any imbalances
in an older client, however it is not the priority assessment
6. A nurse is assessing a client's readiness to learn about insulin administration. Which of
the following statements should the nurse identify as an indication that the client is
ready to learn?
a. I can concentrate best in the morning – best indicates readiness to learn bc he
isverbalizing the best time frame for him to learn
b. It is difficult to read the instructions because my glasses are at home
c. I'm wondering why I need to learn this
d. You will have to talk to my wife about this
7. A nurse is performing a Romberg's test during the physical assessment of a client. Which
of the following techniques should the nurse use?
a. Touch the face with a cotton ball – tests CN 5 - trigeminal
b. Apply a vibrating tuning fork to the client's forehead – Weber test - sound
lateralization for hearing
c. Have the client stand with her arms at her side and her feet together –
Romberg’s test helps identify alterations in balance. The nurse should observe
forswaying and loss of balance
d. Perform direct percussion over the area of the kidneys – This evaluates for kidney
inflammation
8. A nurse is planning an education session for an older adult client who has just learned
that she has type 2 diabetes mellitus. Which of the following strategies should the nurse
plan to use with this client?
a. Allow extra time for the client to respond to questions – Older clients process
information at a slower rate than younger clients. The nurse should plan for
extratime to allow for questions and absorption of information
following statements indicates an understanding of the teaching?
a. I had a bowel movement, but I was able to save the urine – should be free of
feces
b. I have a specimen in the bathroom from about 30 minutes ago- Client should
place any urine in the container immediately and keep it on ice or in the fridge.
c. I flushed what I urinated at 7 AM and have saved all the urine since – for a 24
hr urine collection, the client should discard the first voiding and save all
subsequent voiding.
d. I drink a lot, so I will fill up the bottle and complete the test quickly – no specified
amount
2. A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has
developed thrombophlebitis?
a. Bladder distention – urinary retention which causes bladder distension is a
common complication of bed rest due to a loss of muscle tone in the bladder and
detrusor muscles
b. Decreased blood pressure – client on bed rest can develop postural hypotension.
Drop in BP when the client moves from a lying to a sitting position. Nurse should
assess for pulse rate and dizziness.
c. Calf swelling – Swelling, redness, and tenderness in a calf are manifestations
ofthrombophlebitis, a common complication of immobility
d. Diminished bowel sounds – decrease in bowel sounds reflects slowed peristalsis.
Constipation is common complication of immobility.
3. A nurse manager is overseeing the care on a unit. Which of the following situations
should the nurse manager identify as a violation of HIPAA guidelines?
a. A nurse who is caring for a client reviews the client's medical chart with the
nursing student who is working with the nurse – any healthcare professional
directly caring for a client has access to the medical information.
b. A nurse asks a nurse from another unit to assist with her documentation –
onlyhealth care professionals directly caring for a client may access medical
information.
c. A nurse who is caring for a client returns a call to the client's durable power of
attorney for healthcare designee to discuss the client's care – The person the
durable power of attorney for health care designates has a legal right to
information about the client’s care.
d. A nurse discusses the client's status with the physical therapist that is caring for
the client at the client's bedside – any healthcare professional directly caring for
a client has access to the medical information.
4. A nurse is caring for a client who requires bed rest and has a prescription for anti-
embolic stockings. Which of the following actions should the nurse take?
a. Apply the stockings so the creases are on the front side of the leg – nurse should
assure that there are no creases or wrinkles in the stocked to prevent kind
irritation and promote venous return
, b. Apply the stockings while the client's legs are in a dependent position – nurse
should apply stockings in the morning before the client gets our o bed because
the legs are less edematous at that time
c. Remove the stockings at least once per shift – nurse should remove stocking
tocheck for CMS.
d. Remove the stockings while the client is sitting in a reclining chair – Client should
wear the stockings while sitting in the chair to promote venous return.
5. A nurse is administering IV fluid to an older adult client. The nurse should perform which
priority assessment to monitor for adverse effects?
a. Auscultate lung sounds – ABC approach. Auscultate lung sounds to monitor
for fluid volume excess, a complication of IV therapy. Manifested in moist
crackles heard in lung fields, dyspnea, and SOB
b. Measure urine output – The nurse should measure urine output to monitor the
renal function of an older client, however it is not the priority assessment
c. Monitor blood pressure readings - The nurse should monitor BP readings to
evaluate the hemodynamic stability of an older client, however it is not the
priority assessment
d. Monitor serum electrolyte levels - The nurse should monitor serum electrolyte
levels (esp Na) to guide the planning of interventions to correct any imbalances
in an older client, however it is not the priority assessment
6. A nurse is assessing a client's readiness to learn about insulin administration. Which of
the following statements should the nurse identify as an indication that the client is
ready to learn?
a. I can concentrate best in the morning – best indicates readiness to learn bc he
isverbalizing the best time frame for him to learn
b. It is difficult to read the instructions because my glasses are at home
c. I'm wondering why I need to learn this
d. You will have to talk to my wife about this
7. A nurse is performing a Romberg's test during the physical assessment of a client. Which
of the following techniques should the nurse use?
a. Touch the face with a cotton ball – tests CN 5 - trigeminal
b. Apply a vibrating tuning fork to the client's forehead – Weber test - sound
lateralization for hearing
c. Have the client stand with her arms at her side and her feet together –
Romberg’s test helps identify alterations in balance. The nurse should observe
forswaying and loss of balance
d. Perform direct percussion over the area of the kidneys – This evaluates for kidney
inflammation
8. A nurse is planning an education session for an older adult client who has just learned
that she has type 2 diabetes mellitus. Which of the following strategies should the nurse
plan to use with this client?
a. Allow extra time for the client to respond to questions – Older clients process
information at a slower rate than younger clients. The nurse should plan for
extratime to allow for questions and absorption of information
