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NUR224
getting a headache. Which action should the nurse take first?
Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is present, what action should the nurse take
first?
Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health insurance through her
place of employment. Which agency should the client be referred to by the employee
health nurse for health insurance needs?
Medicare
13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
“I have a headache that gets worse when I sit up”
“I am having pain in my lower back when I move my legs”
“My throat hurts when I swallow”
“I feel sick to my stomach and am going to throw up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with incontinence. Which action should the nurse implement?
Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods
that are in keeping with the child’s dietary restrictions. Which foods are contraindicated
for this child?
Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for
this client. Which response should the circulating nurse provide?
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
18. Which breakfast selection indicates that the client understands the nurse’s instructions
about the dietary management of osteoporosis?
Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the beginning of the shift that less
than the optimal number of registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a
Foley catheter and soft wrist restrains applied
NUR224
getting a headache. Which action should the nurse take first?
Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is present, what action should the nurse take
first?
Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health insurance through her
place of employment. Which agency should the client be referred to by the employee
health nurse for health insurance needs?
Medicare
13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
“I have a headache that gets worse when I sit up”
“I am having pain in my lower back when I move my legs”
“My throat hurts when I swallow”
“I feel sick to my stomach and am going to throw up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with incontinence. Which action should the nurse implement?
Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods
that are in keeping with the child’s dietary restrictions. Which foods are contraindicated
for this child?
Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for
this client. Which response should the circulating nurse provide?
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
18. Which breakfast selection indicates that the client understands the nurse’s instructions
about the dietary management of osteoporosis?
Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the beginning of the shift that less
than the optimal number of registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a
Foley catheter and soft wrist restrains applied
