FINAL DOCUMENT 180 QUESTIONS AND ANSWERS
1. A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure
precautions. Which of the following materials should the AP place in the client’s room?
Oral suction equipment
2. A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the
following actions by the newly licensed nurse should the supervising nurse intervene?
Tells a client he will lose his phone privileges if he does not take his medication
3. A nurse is caring for a client who follows a kosher diet. Which of the following menu items
should the nurse include in the meal tray?
Roasted Salmon
4. A nurse is reviewing information about advance directives with a newly admitted client. Which
of the following statements by the client indicates an understanding of the information?
“Advance directives include a living will”
5. A nurse is collecting data from the caregiver of a client who has Alzheimer’s disease. The
caregiver reports the client has difficulty sleeping at night and wanders throughout the house.
Which of the following interventions should the nurse recommend?
Encourage the client to take frequent walks during the day
6. A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with
increased bleeding. Which of the following actions should the nurse take? (Select all that apply)
Assist the client to empty her bladder
,7. A nurse is reinforcing teaching with the support person of a client who is in the first stage of
labor. Which of the following instructions should the nurse include regarding effleurage?
“Gently stroke her abdomen during contractions.”
8. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty.
The client is incontinent of stool and urine. Which of the following actions should the nurse take
to prevent skin breakdown?
Use a moisture barrier on the client’s skin
9. A nurse is caring for a client who has terminal cancer. Which of the following actions should the
nurse take to promote the client’s autonomy?
Allow the client to choose treatment times
10. A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden
gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?
Appears greenish-brown in color
11. A nurse is assisting with the care of an adolescent client immediately following a lumbar
puncture. Which of the following actions should the nurse take?
Inform the adolescent that he might experience a headache
12. A nurse is reinforcing teaching about advance directives with a client who has end-stage heart
failure. Which of the following statements by the client indicates an understanding of the
teaching?
“I should discuss this document with my family after I sign it.”
13. A nurse is caring for a client who has continuous bladder irrigation following a transurethral
resection of the prostate. The nurse notices clots and dark red blood in the catheter collection
bag. Which of the following actions should the nurse take?
Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation
14. A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac
dysrhythmias. Which of the following actions should the nurse plan to take?
Instruct the client to remain as still as possible during the recording
, 15. A nurse is reinforcing teaching with a client who has genital herpes. Which of the following
information should the nurse include in the teaching?
“You should increase fluid intake to relieve dysuria.”
16. A nurse is preparing to empty a postoperative client’s closed-wound drainage system. Which of
the following actions should the nurse plan to take?
Compress the container before replacing the drainage plug
17. A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma
and a prescription for montelukast. Which of the following instructions should the nurse include
in the teaching?
Administer the medication to the toddler each evening
18. A nurse in an acute mental health facility is caring for a newly admitted client. Which of the
following should occur during the orientation phase of the nurse-client relationship?
Defining responsibilities
19. A nurse is caring for a client who reports having a decrease in fetal movement following an
external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior
position. The nurse should place the fetal heart monitor on which of the following sites to
auscultate the fetal heart rate?
Lower left
20. A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a
tracheostomy. For which of the following actions by the newly licensed nurse should the charge
nurse intervene?
Suctions for 30 seconds
21. A nurse is reviewing the medication administration record of a client who takes atenolol PO and
supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the
nurse monitor with this client?
Hypotension
22. A nurse in an acute care setting is preparing to administer medications to a client. Which of the
following actions should the nurse verify the client's identity?
1. A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure
precautions. Which of the following materials should the AP place in the client’s room?
Oral suction equipment
2. A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the
following actions by the newly licensed nurse should the supervising nurse intervene?
Tells a client he will lose his phone privileges if he does not take his medication
3. A nurse is caring for a client who follows a kosher diet. Which of the following menu items
should the nurse include in the meal tray?
Roasted Salmon
4. A nurse is reviewing information about advance directives with a newly admitted client. Which
of the following statements by the client indicates an understanding of the information?
“Advance directives include a living will”
5. A nurse is collecting data from the caregiver of a client who has Alzheimer’s disease. The
caregiver reports the client has difficulty sleeping at night and wanders throughout the house.
Which of the following interventions should the nurse recommend?
Encourage the client to take frequent walks during the day
6. A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with
increased bleeding. Which of the following actions should the nurse take? (Select all that apply)
Assist the client to empty her bladder
,7. A nurse is reinforcing teaching with the support person of a client who is in the first stage of
labor. Which of the following instructions should the nurse include regarding effleurage?
“Gently stroke her abdomen during contractions.”
8. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty.
The client is incontinent of stool and urine. Which of the following actions should the nurse take
to prevent skin breakdown?
Use a moisture barrier on the client’s skin
9. A nurse is caring for a client who has terminal cancer. Which of the following actions should the
nurse take to promote the client’s autonomy?
Allow the client to choose treatment times
10. A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden
gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication?
Appears greenish-brown in color
11. A nurse is assisting with the care of an adolescent client immediately following a lumbar
puncture. Which of the following actions should the nurse take?
Inform the adolescent that he might experience a headache
12. A nurse is reinforcing teaching about advance directives with a client who has end-stage heart
failure. Which of the following statements by the client indicates an understanding of the
teaching?
“I should discuss this document with my family after I sign it.”
13. A nurse is caring for a client who has continuous bladder irrigation following a transurethral
resection of the prostate. The nurse notices clots and dark red blood in the catheter collection
bag. Which of the following actions should the nurse take?
Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation
14. A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac
dysrhythmias. Which of the following actions should the nurse plan to take?
Instruct the client to remain as still as possible during the recording
, 15. A nurse is reinforcing teaching with a client who has genital herpes. Which of the following
information should the nurse include in the teaching?
“You should increase fluid intake to relieve dysuria.”
16. A nurse is preparing to empty a postoperative client’s closed-wound drainage system. Which of
the following actions should the nurse plan to take?
Compress the container before replacing the drainage plug
17. A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma
and a prescription for montelukast. Which of the following instructions should the nurse include
in the teaching?
Administer the medication to the toddler each evening
18. A nurse in an acute mental health facility is caring for a newly admitted client. Which of the
following should occur during the orientation phase of the nurse-client relationship?
Defining responsibilities
19. A nurse is caring for a client who reports having a decrease in fetal movement following an
external cephalic version 6 hr ago. The nurse identifies the fetus is in the right occiput anterior
position. The nurse should place the fetal heart monitor on which of the following sites to
auscultate the fetal heart rate?
Lower left
20. A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a
tracheostomy. For which of the following actions by the newly licensed nurse should the charge
nurse intervene?
Suctions for 30 seconds
21. A nurse is reviewing the medication administration record of a client who takes atenolol PO and
supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the
nurse monitor with this client?
Hypotension
22. A nurse in an acute care setting is preparing to administer medications to a client. Which of the
following actions should the nurse verify the client's identity?
