RETAKE GUIDE GRADED ALATEST VERSION 180
QUESTIONS AND ANSWERS
• A nurse in a long term care facility notices a client who has alzheimers disease standing at the
exit doors at the end of the hallway. The clients appears to be anxious and agitated. Which of the
followingactions should the nurse take?
Escort the client to a quiet area on the nursing unit
• A nurse is assisting with the plan of care for a client who has a continent urinary division. Which of
thefollowing interventions should the nurse plan to implement to facilitate urinary elimination?
Use intermittent urinary catheterization for a client at regular intervals
• A nurse is assisting with a educational program about car restraint safety for a group of parents.
Whichof the following statements by a parent indicates an understanding of the instructions?
My 12 year old child should place the shoulder lap belt low across his hips
• A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD.
Whichof the following instructions should the nurse include in the teaching?
Drink high protein and high calorie nutritional supplements
• A nurse is supervising an assistive personnel who is preparing to remove her personal protective
equipment after providing direct care to a client who requires airborne and contact precautions. The
nurse should recognize that the AP understands the procedure when she removes which of the
followingPPE first?
Gloves
• A nurse is caring for a client who is crying and states that his provider informed him that he has
atumor and will need a biopsy. Which of the following responses should the nurse make?
What have you done in the past to help yourself get through stressful situations before?
• A nurse is inspecting the skin of a newborn. Which of the following findings should the nurse report
tothe provider
Generalized petechiae
• A nurse is contributing to a teaching plan for a group of male adolescents about the adverse effects
ofanabolic steroid use. Which of the following manifestations should the nurse include
,Reduced height potential
• A nurse is reinforcing teaching with an older adult client who has a severe left sided heart
failure.Which of the following statements should the nurse make
Rest 15 minutes between activities
• A nurse in a long term care facility is documenting the care of an older client. Which of the
followinginformation should the nurse include in the weekly nursing care summary
Hydration status
• A nurse is caring for a client who has a head injury. Using the gasgow coma scale collection data,
thenurse should obtain which of the following information
Motor response
• A home health nurse is reinforcing teaching with a client about the use of elastic stockings
todecrease peripheral edema. Which of the following instructions should the nurse include?
Apply stockings in the morning
• A nurse in a providers office is obtaining a health history from a client who is scheduled to undergo
acardiac catheterization in 2 days. Which of the following questions is the
Do you know if your allergic to iodine
• A nurse is planning to administer nystatin oral suspension to a client who has oral candiasis. Which
ofthe following instructions should the nurse give to the client
Hold the medication in your mouth for several minutes prior to swallowing
• A nurse is preparing to care for the assigned clients on her upcoming shift. Which of the
followingtime management strategies should the nurse plan to use?
Prepare a priority list of client needs for the shift
• A nurse is preparing to witness a client who is scheduled for surgery sign a informed consent.
Whichof the following actions should the nurse take?
Ask the client if he understands the procedure
• A nurse in an inpatient mental health clinic is caring for a newly admitted client who has alcohol
use disorder. During a therapy session, the client asks about alcoholics anonymous. Which of the
followingresponses should the nurse make?
What is your current understanding about the purpose of AA
, • A nurse is assisting with the care of a client who is 2 days postop following a total knee
arthroplasty.Which of the following tasks should the nurse assign to an assistive personnel?
Reapply antiembolic stockings to the client following a shower
• A client in a mental health facility unjustly accuses a nurse of stealing money from his room. Which
ofthe following therapeutic responses should the nurse make?
Tell me how you decided who took your money
• A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the
larynx. Which of the following statements made by the client indicates understanding of the
teaching?
I will wear a soft scarf around my neck when I am outside
• A nurse is using the FLACC scale to determine the level of pain for an 11 month old infant who
ispostop. Which of the following factors should the nurse consider when using this pain scale
Level of activity
• A nurse is reviewing the techniques for transferring a client from bed to chair with a group
ofassistive personnel. Which of the following instructions should the nurse include
Use lower body strength
• A nurse is reinforcing taching with a client who is to self administer epoetin alfa. Which of
thefollowing instructions should the nurse include
Administer the medication subcutaneously
• A nurse is collecting data from a 5 year old child at a well child visit. The parents reports that
the child is having frequent nightmares. Which of the following statements by the parent indicates
to thenurse that the child is experiencing sleep terrors rather than nightmares
My child goes back to sleep right away
• A nurse assisting with the care of a school age child immediately following surgery. The child
weighs 21.8kg and has a chest tube applied to suction. Which of the following findings should the
nurse reportto the provider
250ml of sanguineous drainage over the last 3hr
• A nurse is reinforcing teaching about advanced directives with a client. Which of the
followingstatements by the client indicates an understanding of the teaching
I can change my health care decisions even if I have advanced directives