Complete Questions and Guide Answers
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1. A nurse is assisting with the plan of care for a client following a transurethral
resection of the prostate. Which of the following interventions should the nurse
include in the plan of care?
Answer: The nurse should irrigate the bladder using strict sterile technique and maintain closed catheter
drainage system to minimize the rick of infection.
2. A nurse is reviewing a client's electronic medical record and finds that an
assistive per sonnel recorder the client's temperature as 35.3 degrees Celsius
(95.5 degrees F) 2 hrs earlier. Which of the following actions should the nurse
take firsT?
Answer: check the clients temp
3. A nurse is receiving change-of-
shift report for four clients. Which of the following clients should the nurse
,see first?
Answer: A client whose urinary output was 100mL for the past 12 hrs
4. A nurse in reinforcing teaching about weight loss with a female older adult client
who is overweight. Which of the following statements should the nurse include in
teaching?
Answer: keep fat intake to no more that 30% of daily caloric intake.
5. A nurse is collecting data from a client who has iron deficiency anemia.
Which of the following findings should the nurse expect?
Answer: diflculty concentrating
6. A Nurse is collecting data from an older adult client who is 48 hr postop-
erative following abdominal surgery. The provider writes a prescription to
advance the client to a re gular Diet. For which of the following findings should
the nurse notify the provider?
Answer: The client has absent bowel sounds
7. A parent brings her adolescent son to an urgent care center and states. "He
is high on something and needs help" The client is
exhibiting agitation and paranoia and reports visual hallucinations. The nurse
should suspect intoxication with which of the following substances?
Answer: Metham-phetamines
,8. A nurse notices an assistive personnel taking a nap in the break room during he
meal t ime. The AP appears drowsy while performing routine tasks. Which of
the following a ctions should the nurse take?
Answer: Report the observations about the ap to the unit's nurse manager.
9. A nurse is reinforcing teaching with a client who has a fluid volume deficit
about selec ting foods that have a high water content. The nurse should
include that which of the following raw foods contains the highest amount of
water per 1 cup serving?
Answer: cherry tomatoes
10. The nurse is position a client who is scheduled for a lumbar puncture.
The nurse should assist the client into which of the following positions?
Answer: lateral recumbent
11. A nurse is talking with a client whose son died in a motor- vehicle crash 2
weeks ago. The client states "I really thought I'd be back to my usual routines
by now, but I can't think of anythingelse except my son is gone" Which of the
following responses should the nurse make?
Answer: Grieving for your son is hard work. It will take as much time as you need to come to terms
with your loss.
12. A nurse is assisting with monitoring a client who is at 40 weeks of gestation
, and is in active labor. The nurse recognizes late deceleration on the fetal
monitor tracing. Whichof the following actions should the nurse take?
Answer: Place the client in the lateral position.
13. A nurse manager is providing an in-
service on hand hygiene to assistive personnel. which of the following infor-
mation should the nurse manager include in the in-service?
Answer: Remove rings when washing hands with soap and water
14. A nurse is reinforcing home safety instructions with the parent of a new-
born. Which of the following statements should the nurse include in the
instructions?
Answer: Place your baby's crib away from heat vents.
15. A nurse is preparing to administer a client's morning medications. Which
of the follow ing actions should the nurse take to verify the client's identity?
Answer: Scan the facility identification board.
16. A nurse is caring for a client following a bronchoscopy procedure. Which of
the following actions should the nurse perform first?
Answer: check for a gag reflex
17. While administering a medication to a client, a nurse notices a trayed elec-
trical cord connecting the client's continuous passive motion machine to the