1. A nurse is assessing a client who has diabetes mellitus prior to performing a
blood glucose test. Which of the following finding should indicate to the nurse that
the client has hyperglycemia?
a.cool skin
b. confusion
c. shakiness
d. thirst
2. A nurse is providing teaching to a client who is at risk for thrombus formation.
Which of the following statements made by the client indicates an understanding
of the teaching?
a. “I should limit the time that I spend sitting in a chair.”
b. “I will keep my legs crossed while sitting”
c. “I should massage my legs when they hurt.”
d. “I will perform leg exercises once every 4 hours while I am awake.”
4. A nurse working on a medical-surgical unit is making client assignments for an
upcoming shift. Which of the
following tasks should the nurse assign to an assistive personnel?
a. Showing a client how to use an incentive spirometer prior to surgery
b. Irrigating a client's infected surgical wound
Inserting a glycerin suppository for a client who is constipated
d. Assisting with ambulation for a client who has a pulmonary infection
5. A nurse is preparing to insert an IV catheter for an adult client. Which of the
following actions should the nurse
take?
a. Apply a cool compress for several minutes before insertion of the IV catheter
b. Place the extremity in a dependent position
c. Choose the most proximal site on the extremity selected
,d. Place the tourniquet below the proposed insertion site
6. A nurse is teaching a newly licensed nurse about the care of a client who has a
methicillin-resistant (MRSA) infection. Which of the following statements by the
newly licensed nurse
indicates understanding of the teaching.
a."I will tell the client's visitors to wear a mask when they are within 3 feet of the
client"
b.I will remove my gown before my gloves after providing client care"
c. I will wear an N95 respirator mask when caring for the client
d. I will place client in a private room
7. A nurse is preparing a medication from a vial for a subcutaneous injection for a
client. Which of the following
actions should the nurse take?
a. Hold the vial with the top facing upward while injecting air into the vial
b. Hold the syringe so that bubbles collect at the level of the plunger
c. Inject air into the vial with the eye of the needle immersed in the fluid
d. Hold the syringe at a 45 angle to verify dosage
8. A community health nurse is teaching a group of clients about Kegel exercises to
prevent urinary incontinence. Which of the following should the nurse include?
a. "Hold your breath when performing the exercises"
b. "Expect improvement after 2 weeks of performing exercises"
c. "Tighten your buttocks when performing the exercises"
d. "Contract your pelvic muscle when performing the exercises
9. A nurse is assessing a client who has diabetes mellitus prior to performing a
blood glucose test. Which of the
following finds the nurse that the client has hyperglycemia?
a. Confusion - hypoglycemia
, b. Thirst
c. Shakiness -hypo
d. Cool skin -hypo
10. A nurse is documenting a dressing change for a client who has a pressure
injury.
Which of the following entries by the nurse demonstrates correct documentation?
a. No changes noted to the wound from previous nursing notes
b. New dressing applied as prescribed, no drainage on old dressing
c. Client premedicated with MSO4 subq prior to dressing change
d. The wound seems clean and does not appear to be infected
11. A nurse is teaching a client how to self-administer daily low-dose heparin
injections. Which of the following
factors is most likely to increase the client's motivation to learn?
a. The client's belief that his needs will be met through education
b. The nurse's empathy about the client having to self-inject
c. The client seeking family approval by agreeing to a teaching plan
d. The nurse explaining the need for education to the client
12. A nurse is planning care for a client who has a new prescription for parenteral
nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an
appropriate action to include in the plan of care?
a. Change the PN infusion bag every 48 hr
b. Prepare the client for a central venous line
c. Obtain a random blood glucose daily
d. Administer the PN and fat emulsion separately
13. A nurse is teaching a group of newly licensed nurses about the Braden scale.
Which of the following responses by a newly licensed nurse indicates an
understanding of the teaching?
blood glucose test. Which of the following finding should indicate to the nurse that
the client has hyperglycemia?
a.cool skin
b. confusion
c. shakiness
d. thirst
2. A nurse is providing teaching to a client who is at risk for thrombus formation.
Which of the following statements made by the client indicates an understanding
of the teaching?
a. “I should limit the time that I spend sitting in a chair.”
b. “I will keep my legs crossed while sitting”
c. “I should massage my legs when they hurt.”
d. “I will perform leg exercises once every 4 hours while I am awake.”
4. A nurse working on a medical-surgical unit is making client assignments for an
upcoming shift. Which of the
following tasks should the nurse assign to an assistive personnel?
a. Showing a client how to use an incentive spirometer prior to surgery
b. Irrigating a client's infected surgical wound
Inserting a glycerin suppository for a client who is constipated
d. Assisting with ambulation for a client who has a pulmonary infection
5. A nurse is preparing to insert an IV catheter for an adult client. Which of the
following actions should the nurse
take?
a. Apply a cool compress for several minutes before insertion of the IV catheter
b. Place the extremity in a dependent position
c. Choose the most proximal site on the extremity selected
,d. Place the tourniquet below the proposed insertion site
6. A nurse is teaching a newly licensed nurse about the care of a client who has a
methicillin-resistant (MRSA) infection. Which of the following statements by the
newly licensed nurse
indicates understanding of the teaching.
a."I will tell the client's visitors to wear a mask when they are within 3 feet of the
client"
b.I will remove my gown before my gloves after providing client care"
c. I will wear an N95 respirator mask when caring for the client
d. I will place client in a private room
7. A nurse is preparing a medication from a vial for a subcutaneous injection for a
client. Which of the following
actions should the nurse take?
a. Hold the vial with the top facing upward while injecting air into the vial
b. Hold the syringe so that bubbles collect at the level of the plunger
c. Inject air into the vial with the eye of the needle immersed in the fluid
d. Hold the syringe at a 45 angle to verify dosage
8. A community health nurse is teaching a group of clients about Kegel exercises to
prevent urinary incontinence. Which of the following should the nurse include?
a. "Hold your breath when performing the exercises"
b. "Expect improvement after 2 weeks of performing exercises"
c. "Tighten your buttocks when performing the exercises"
d. "Contract your pelvic muscle when performing the exercises
9. A nurse is assessing a client who has diabetes mellitus prior to performing a
blood glucose test. Which of the
following finds the nurse that the client has hyperglycemia?
a. Confusion - hypoglycemia
, b. Thirst
c. Shakiness -hypo
d. Cool skin -hypo
10. A nurse is documenting a dressing change for a client who has a pressure
injury.
Which of the following entries by the nurse demonstrates correct documentation?
a. No changes noted to the wound from previous nursing notes
b. New dressing applied as prescribed, no drainage on old dressing
c. Client premedicated with MSO4 subq prior to dressing change
d. The wound seems clean and does not appear to be infected
11. A nurse is teaching a client how to self-administer daily low-dose heparin
injections. Which of the following
factors is most likely to increase the client's motivation to learn?
a. The client's belief that his needs will be met through education
b. The nurse's empathy about the client having to self-inject
c. The client seeking family approval by agreeing to a teaching plan
d. The nurse explaining the need for education to the client
12. A nurse is planning care for a client who has a new prescription for parenteral
nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an
appropriate action to include in the plan of care?
a. Change the PN infusion bag every 48 hr
b. Prepare the client for a central venous line
c. Obtain a random blood glucose daily
d. Administer the PN and fat emulsion separately
13. A nurse is teaching a group of newly licensed nurses about the Braden scale.
Which of the following responses by a newly licensed nurse indicates an
understanding of the teaching?
