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1. A nurse is reinforcing teaching with a postpartum client. Which of the follow-
ing should the nurse explain as the most important reason for staff to wear
identification?: Reducing the risk of newborn abduction
2. A nurse is reinforcing teaching with a client who plans to bottle feed her
newborn. Which of the following statements indicates an understanding of
the instructions?: I will feed my baby six to eight times a day
3. A nurse is reinforcing teaching with a client diagnosed with osteoarthritis
who reports joint pain,swelling, and stiffness. Which of the following client
statements indicates understanding of the teaching?: I will exercise my joints as much as
i can when they are inflamed
4. A nurse is reinforcing teaching with a client who is scheduled for a mam-
mogram. Which of the following instructions should the nurse include in the
teaching?: Refrain from using deodorant on the morning of the test
5. A nurse is preparing a clients insulin regimen. Which of the following in-
sulin's can be mixed?: Insulin aspart, regular insulin, insulin lispro
6. A nurse is reinforcing discharge teaching with a client who is postoperative
following laser surgery for open-angle glaucoma. Which of the following
statements by the client indicates an understanding of the instructions?: I will
take a stool softener to prevent constipation
7. A nurse is caring for a client who had a stroke and is having difficulty
swallowing. The nurse should recommend a referral to which of the following
members of the interprofessional team?: Speech therapist
8. A nurse is reinforcing teaching with a client who is 12 hr postpartum and
has an episiotomy. Which of the following instructions should the nurse
include?: Change the perineal pad with each void
9. A nurse is collecting data from a child who has acute Glomerulonephritis.
Which of the following findings should the nurse expect?: Periorbital edema
10. A nurse is preparing to administer a liquid medication to a 6-month-old
infant who is crying. Which of the following actions should the nurse take to
reduce the risk of aspiration?: Administer using a needless syringe in the buccal cavity
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11. A nurse is reinforcing teaching with a client who has peptic ulcer disease.
Which of the following statements by the client indicates an understanding of
the teaching?: I will plan to have my meals at regular intervals
12. A nurse in long-term care facility has received change-of-shift report about
four clients. Which of the following clients should the nurse attend to first?: A
client who has COPD and dementia and was agitated during the night shift
13. A nurse is collecting data from a client who has substance use disorder and
reports recently taking opioids. Which of the following findings should the
nurse identify as a manifestation of opioid intoxication?: Pinpoint pupils
14. A nurse in a urgent care clinic is collecting data from a client who reports
having diarrhea for the past 3 days. Which of the following findings indicates
hypokalemia?: Muscle weakness
15. A nurse is contributing to the discharge plans for four clients. The nurse
should identify that which of the following clients requires an interdisciplinary
care conference?: A client who has hemiparesis and lives alone
16. A nurse is reinforcing teaching with an adolescent who has a new prescrip-
tion for cefazolin. For which of the following findings should the nurse instruct
the adolescent to monitor and report to the provider?: Depression
17. A nurse is reinforcing teaching with a group of expectant parents regarding
the proper use of a car seat. Which of the following statements by a parent
indicates an understanding of the teaching?: I can place a rolled towel on each side of my
newborns head until he can hold his head up
18. A nurse is caring for a school-age child who has epistaxis. Which of them
following actions should the nurse take?: Apply pressure at the bridge of the child's nose
19. A nurse is caring for four clients. Which of the following clients statements
should the nurse attend to first?: My heartburn pain is going into my jaw now
20. A nurse in a providers office is talking on the phone with the parent of a
school-age child who has varicella.: All vesicles have crusted over
21. A nurse is collecting data from a client who hgb is 8.8 mg/dL. Which of the
following statements should the nurse expect?: I feel tired all the time
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22. A nurse is administering a cleansing enema to a client who reports mild
cramping during instillation of the solution. Which of the following actions
should the nurse take?: Slow the rate of instillation
23. A nurse receives report on four clients. The nurse should first collect data
about the client who has which of the following?: A decreased level of consciousness and
vomiting
24. A nurse is setting up a sterile field prior to performing a dressing change.
Which of the following actions should the nurse take?: Open the outermost flap of the
wrapper toward the body
25. A nurse is caring for a client who has bipolar disorder and is experiencing
mania. Which of the following actions should the nurse take?: Frequently remind the
client of the expectations for her behavior
26. A nurse is caring for a client who has viral pneumonia. Which of the follow-
ing actions should the nurse take?: Administer Azithromycin
27. A nurse who orienting to a medical-surgical unit is having difficulty finishing
client care tasks during his shift. Which of the following suggestions should
the nurse's preceptor make to help the nurse with time management?: Try to
complete a task before moving on to the next.
28. A nurse is caring for an older adult client who is postoperative following a
total hip arthroplasty. The nurse is preparing to change the client's dressing.
Which of the following actions should the nurse take to demonstrate sensitiv-
ity to age-related changes?: Use paper tape for securing the new dressing.
29. A nurse working in an inpatient mental health facility is assisting with the
plan of care for a client who has anorexia nervosa. Which of the following
should the nurse recommend to include in the plan of care?: Maintain continuity of
staff members.
30. A nurse is assisting with an admission interview for a client who has schizo-
phrenia. He tells the nurse that he is receiving special audible messages from
the Central Intelligence Agency that no one else is able to hear. The nurse
should identify that the client is having which of the following alterations in
perception?: Hallucination