Answers Updated 2023
A nurse is caring for a client who requires a 24-hr urine collection. Which of the following
statements by the client indicates an understanding of the teaching?
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
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?
Calf Swelling
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 nurse asks a nurse from another unit to assist with her documentation.
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic
stockings. Which of the following actions should the nurse take?
Remove the stockings at least once per shift.
A nurse is administering IV fluid to an older adult client. The nurse should perform which
priority assessment to monitor for adverse effects?
Auscultate Lung Sounds
A nurse is teaching an older client who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the
nurse recommend?
Walking Briskly
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse
should identify that which of the following findings requires further intervention?
, Erythema on pressure points
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which
of the following actions should the nurse take first?
Check the client for injuries
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that,
since I am at an average risk for colon cancer, I should have routine screening. What does
that involve?" Which of the following responses should the nurse make?
"You should have a fecal occult blood test every year."
A nurse manager is preparing to review medication documentation with a group of newly
licensed nurses. Which of the following statements should the nurse manager plan to
include in the teaching?
"Use the complete name of the medication magnesium sulfate."
A nurse is caring for a client who has tuberculosis. Which of the following actions should
the nurse take?
Place the client in a room with negative-pressure airflow.
Wear gloves when assisting the client with oral care.
Use antimicrobial sanitizer for hand hygiene.
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10
units of NPH insulin to mix together and administer subcutaneously. Determine the correct
order of steps for this procedure.
Air into NPH
Air into Regular
Draw up Regular
Draw up NPH
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of
the following interventions should the nurse include that is within the RN scope of
practice?