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• Which of the instructions should a nurse include in the teaching for a pt. who had removal of a cataract
in the lefteye?
• "Forcefully cough and take deep breaths every two hours to keep your airway clear."
• "Perform the prescribed eye exercises each day to strengthen your eye muscles."
• "Rinse your eyes with saline each morning to prevent postoperative infection."
• "Take the prescribed stool softener to avoid increasing intraocular pressure."
• A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of
theseactions?
• Suction the nasogastric tube.
• Flush the tube with 30 mL of sterile water.
• Remove the nasogastric tube.
• Check the residual volume.
• Which of these actions best demonstrates cultural sensitivity by a nurse?
• The nurse talks in a slow-paced speech.
• The nurse asks clients about their beliefs and practices toward pregnancy.
• The nurse uses charts and diagrams when teaching pregnant clients.
• The nurse can speak several different languages.
• Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is
diagnosed with dehydration?
• Hyperreflexia.
• Tachycardia.
• Bradypnea.
• Agitation.
• When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential
entry portals, which include:
• the urinary meatus.
• vomitus.
• contaminated water.
• sexual intercourse.
• A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a
nurse take if the client is agitated?
• Encourage the client to verbalize feelings.
• Lock the client in a secluded room.
• Ask the other clients to give feedback regarding the client's behavior.
• Ignore the client's inappropriate behavior.
• Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell
crisisepisode?
• Monitoring for signs of bleeding.
• Providing pain relief.
• Administering cool sponge baths to reduce fevers.
• Offering a high calorie diet.
• Which of these instructions should a nurse include in the plan of care for a 32-week gestation client
who had an amniocentesis today?
• "Drink at least six glasses of fluids during the next six hours after the test."
• "Call the clinic if you experience any abdominal cramps."
• "Don't be concerned if you have some vaginal spotting in the next 12 hours."
,• "When you get home, stay on bed-rest for the next 48 hours."
• An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection
of which of these lunches by the client indicates a correct understanding of foods high in iron content?
• Peanut butter and jam sandwich.
• Chicken nuggets with rice.
• Tuna salad sandwich.
• Beefburger with cheese.
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• Elevated serum amylase level.
• Elevated serum sodium level.
, • Elevated serum creatinine level.
• Which of these manifestations, if assessed in a client who is two-hours postoperative after
abdominal surgery, should a nurse report immediately?
• Vomiting and a pulse rate of 106/minute.
• Respiratory rate of 12/minute and urine dribbling.
• Blood pressure of 100/60 mm Hg and wound discomfort.
• Urine output of 100 mL/hr and flushed skin.
• Which of these observations of a student nurse's behavior while interacting with a client who is crying
indicates a correct understanding of therapeutic communication?
• The student maintains continuous eye contact with the client.
• The student places one arm around the client's shoulder?
• The student sits quietly next to the client.
• The student leaves the room to provide privacy for the client.
• Which of these actions should a nurse take initially if a client who is diagnosed with diabetes
mellitus develops tremors and ataxia?
• Measure the client's blood sugar level.
• Administer a concentrated form glucose to the client.
• Administer a prn dose of insulin.
• Measure the client's urine for ketones.
• An elderly client is at increased risk of developing drug toxicity to prescribed medications due to
declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk?
• Increasing the time interval between medication doses.
• Limiting the client's oral fluid intake.
• Administering the medications with meals.
• Encouraging the client to void every three to four hours.
• A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these
measures should a nurse include in the client's care plan?
• Explaining that staff does not poison clients.
• Focusing on how the hospital staff helps clients.
• Allowing the client to eat food from sealed containers.
• Telling the client that not eating the food that is served will result in privilege restrictions.
• Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse
take in the operating room to prevent this complication from occurring?
• Gatch the knee of the bed.
• Administer anticoagulants preoperatively.
• Apply sequential compression devices.
• Maintain the legs in a dependent position.
• When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a
pregnant client who is at ideal body weight for her height is:
• at least 15 pounds.
• 15 to 20 pounds.
• 25 to 35 pounds.
• at least 45 pounds.
• Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis
of ruptured tubal pregnancy.
• Sharp unilateral abdominal pain.
• Uncontrollable vomiting.
• Marked abdominal distention.
• Profuse vaginal bleeding.