EXAM QS &A/VERIFIED SOLUTIONS
• A nurse is assessing a client’s personal hygiene. Which of the following
findings indicates that the client might have difficulty with routinely bruising
their teeth?
• The clients mucosa is moist
• The client gums feel spongy
• The client has a missing tooth
• The Client’s tongue is a dull red color
• A nurse is planning to discharge a client who has diabetes mellitus and a
new prescription for insulin. Which of the following actions should the nurse
plan to complete first?
• Make a copy of the medication reconciliation form for the client
• Provide the client with the contact number for a diabetes education specialist
• Determine whether the client can afford the insulin administration supplies
• Obtain printed about insulin self administration
• A community health nurse is teaching a group of clients about kegel exercises
to prevent urinary incontinence. Which of the following instructions should the
nurse include?
• Contact your pelvic muscle when performing the exercises
• Expect improvement after 2 weeks of performing the exercises
• Hold your breath when performing the exercises
• Tighten your buttocks when performing the exercises
• A nurse is assessing the skin of a client who has worked outdoors for the past
20 years. Which of the following findings is the nurse's priority?
• Skin tags noted in the neck region
• A change in appearance of a mole on the shoulder
• A flat, nonpalpable, discovered area of skin on the trunk
• Atrophic wart on the left index finger
• A nurse is caring for a client who has a high fever. Which of the following
actions should the nurse take?
A cover the client with heavy blankets after shivering subsides
B place ice packs on the clients neck and behind the knees
C apply a bath blanket between the client and a cooling blanket
D give the client a sponge bath using alcohol water solution
• A nurse is caring for an infant who is to undergo surgery. The nurse should
identify which of the following individuals should sign the consent form?
• The infants 17 year old mother
• The infants provider
, • The infants grandmother
• The mother’s 21 year old sibling
• A nurse is assisting in the use of a fracture bedpan for a client who is immobile due
to a cast. Which of the following actions should the nurse use?
• Encourage the client to try to defecate for 20 min while on the fracture pan.
• Keep the bed flat while the client is on the fracture pan.
• Hyperextend the clients back while the fracture pan is in place. D. Place the
shallow end of the fracture pan under the clients buttocks. 8. A nurse is reviewing
the medical record of a client who asks about the use of a magnet therapy for pain
relief. The nurse should identify which of the following findings is a contraindication
for receiving this type of therapy?
• The client is allergic to penicillin
• The client has a prescription for metoprolol
• The client has a history of alcohol use disorder
• The client has an implanted defibrillator
• A nurse is caring for a client who requires airborne precautions. The nurse is
preparing to leave the clients room following a dressing change. Which of the
following pieces of personal protective equipment should the nurse remove first? A.
Gloves
B. Eyewear
C. Gown
D. Mask
• A nurse is teaching a newly licensed nurse about the care of a client who has
methicillin resistant staphylococcus aureus (MRSA) infection. Which of the
following statements by the newly licensed nurse indicates an understanding of
the teaching?
A. I will wear an N95 respirator mask when caring for the client
B. I will tell the clients visitors to wear a mask when they are within 3 feet of the
client.
C. I will place the client in a private room
D. I will remove my gown before my gloves after providing client care. 11. A
charge nurse in a long term care facility is preparing an educational program
about delirium for newly hired nurses. Which of the following statements should
the nurse plan to include?
A. Delirium has an abrupt onset
• A nurse is preparing to insert an IV catheter for an adult client. Which of
the following actions should the nurse take?
• choose the most proximal site on the extremity selected
• apply a cool compress for several minutes before insertion of the IV catheter
,• place the tourniquet below the proposed insertion site
• place the extremity in a dependent position
• A nurse is teaching a client who is about to undergo a bowel resection about
advance directives. Which of the following instructions should the nurse include in
the
teaching?
• Your partner must be present when you sign the advance directives
• You will receive written information about advance directives prior to signing
• You are required to sign advance directives prior to surgery
• Your provider must sign the advance directives before surgery
• A nurse is caring for a client who has wrist restraints after an episode
of violent behavior. Which of the following actions should the nurse take?
- Remove one restraint at a time
• A nurse is preparing to administer several medications via NG tube to a client who
is receiving a continuous tube feeding. Which of the following actions should the
nurse take?
• Dilute each crushed medication with sterile water
• Mix the medication together in a single syringe
• Flush the NG tube with 5 mL of sterile water prior to administration
• Combine the medication with the formula in the feeding bag
• A nurse is planning care for a client who has urinary incontinence. Which of
the following interventions should the nurse include in the client's plan of care?
A. Toilet the client every 4 hr while the client is awake
B. Apply a moisture barrier in a thick layer to vulnerable skin areas C. Cleanse
the skin with antibacterial soap and hot water after each incontinence episode
D. Reduce the clients daily fluid intake
• A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus.
The nurse administers a 500 mL IV bolus. Which of the following actions should the
nurse take first?
• Complete an incident report
• Obtain the client’s vital signs
• Document the fluid infusion in the client’s chart
• Report the incident in to the unit manager
• A home health nurse is teaching a client about home safety. Which of the
following statements by the client indicates an understanding of the teaching?
(SATA) - I need to check my medications for expiration dates
• I will use the grab bars when getting in and out of the bathtub
• I need to have a fire escape plan with my family
, • A nurse is caring for a client who is scheduled for surgery. While the nurse
is witnessing the client's signature, the client states, I trust my doctor, but I don't
understand what is meant by resecting my intestine. Which of the following
actions should the nurse take?
- Notify the provider
• A nurse is discussing the stages of general adaptation syndrome with a newly
licensed nurse. The nurse should identify that which of the following
manifestations occurs during the alarm reaction stage?
• Dilated pupils
• Physical exhaustion
• Bradycardia
• Depression
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• A nurse is preparing to administer IV fluids to a client. The nurse notes sparks
when plugging in the IV pump. Which of the following actions should the nurse take
first? - - -
• Unplug the pump
• obtain a replacement pump
• Notify the biomedical department to fix the pump
• Label the pump with a defective equipment sticker
• A nurse is caring for a client who is receiving a warm, moist compress to
relieve lower back pain. Which of the following findings should indicate to the
nurse that the compress has been effective?
• The client’s skin on the lower back is intact without redness
• The client’s laughing at a television show
• The client states that he is able to concentrate while eating
• The clients’s vital signs are within the expected reference range
• A nurse is preparing a sterile field to assist with suturing a clients laceration.
Which of the following actions should the nurse plan to take?
A. Pour the sterile solution with the bottle 20 cm (8 in) above the sterile bowl B.
Hold the bottle of sterile solution so that the label is facing the palm of the hand
C. Place the lid of the sterile solution bottle face down on the sterile drape D.
Apply sterile gloves before opening the bottle of sterile solution -
24 a nurse receives a new prescription over the telephone from a client’s provider.
Which of the following actions should the nurse take first?
• Ensure that the provider signs the prescription