1. A nurse on a medical surgical unit is receiving a change-of-shift report for four clients.
Which of the following clients should the nurse see first?
a) A client who has new onset of dyspnea 24 hr after a total hip arthroplasty0 can mean dvt
b) A client who has acute abdominal pain of 4 on a scale from 0 to 10
c) A client who has a UTI and low-grade fever
d) A client who has pneumonia and an oxygen saturation of 96%
<always look for new onset of anything, other findings are normal also.>
2. A nurse is caring for a client who is nauseated and unable to eat after taking her antibiotic.
Identify the steps the nurse should take to address the nausea.
a) Identify possible nursing interventions that address the client‟s nausea
b) Review the potential benefits and consequences of each intervention
c) Select an intervention that provides the greatest benefit and least risk
d) Determine the probability of intervention-related complications (3)
<I am sure, it goes (a) to (b),(c), then (d)
3. A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern
about his future. Which of the following is therapeutic response by the nurse?
a) You‟re concerned about what will happen when you leave the hospital?”
b) “If you work hard on your physical therapy, you won‟t need to worry”
c) “You shouldn‟t worry about the future so you can concentrate on getting well”
d) “Why are you concerned even though everyone is here to help you?”
4. A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions
should the nurse take?
a) Follow a systematic pattern from side-to-side moving down the client‟s chest
b) Ask the client to breathe in deeply through his nose
c) Instruct the client to sit erect with his head tilted slightly backward
d) Place the bell of the stethoscope on the client‟s chest
5. A nurse is teaching a client who requires maximal support about how to use a two wheeled walker.
Which of the following actions by the client indicates an understanding of teaching.
a) The client moves the walker ahead 25.4cm with each step
b) The client picks up the walker with each step
c) The client stands with her elbow slightly while holding the walker
, d) The client stoops slightly forward when moving the walker
6. A nurse in a provider‟s office is caring for a client who states “I always have trouble sleeping”. Which of
the following actions should the nurse take first?
a) Teach the client stress reduction techniques
b) Recommend that the client avoid caffeine intake in the evening
c) Identify the client typical bedtime routine
d) Encourage the client to exercise regularly during day time hours.
7. A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the
nurse include when developing the plan of care?
a) The hispanic culture views late adulthood as a negative time in the client‟s life
b) The hispanic culture identifies the eldest female family member as the decision maker
c) The Hispanic culture expects individuals to make their own decisions when death is imminent.
d) The hispanic culture expects adult children to care for older adult parents.
8. A nurse is providing teaching to a client who has a new med prescription. Which of the following
manifestations of a mild allergic reaction should the nurse include?
a) Ptosis
b) Hematuria
c) Urticaria
d) Nausea
9. A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood
glucose test. Which of hte following instructions should the nurse include in the teaching?
a) Don sterile gloves prior to puncturing the site
b) Puncture site after cleansing and before antiseptic dries.
c) Gently squeeze the puncture site until a large droplet of blood forms
d) Hold the finger to puncture above the level of the heart
10. A nurse is providing teaching to a client about reducing the adverse effects of immobility.
Which of the following statements by the client indicates an understanding of the teaching?
,a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures .
b. I will hold my breath when rising from a sitting position
c. I will remove my antiembolic stockings while I am in bed
d. I will have my partner help me change positions every 4 hours
11. A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left
forearm. Which of the following findings indicates that the client has developed phelbitisat the IV site?
a. Erythema along the path of the vein
b. Pitting edema at the insertion site- infiltration since water is probably displaced.
c. Coolness of the client‟s left forearm - infiltration
d. Pallor of the client‟s left forearm
12. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse
perform shortly before bedtime?
a. Provide a late supper
b. Offer a wet washcloth for the client to wash her face
c. Perform range of motion excercise
d. Prepare a hot cocoa or tea for the client
13. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the
following statements by the newly licensed nurse indicates an understanding of teaching?
a. I will place the client in a private room
b. I will tell the client‟s visitors to wear a mask when they are within 3 feet of the client
c. I will remove my gown after leaving the client‟s room
d. I will wear an N95 respirator mask when caring for the client
14. A nurse is teaching about home safety with a client. Which of the following instructions should the nurse include?
a. Unplug electronics by grasping the cord
b. Use electrical tape to secure extension cords next to baseboards on the floor
c. To use a fire extinguisher, aim high at the top of the flames.
d. Replace carpeted floors with tile
15. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the
following actions should the nurse take?
, a.) Perform deep palpation at the end of the admission assessment
b.) Auscultate the client‟s abdomen before palpation
c.) Begin palpation of the abdomen at the site of pain
d.) Assess the client‟s bowel sounds using the bell of the stethoscope
<inspect - auscultate - palpate - percuss>
16. A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty
voiding. Which of the following actions should the nurse take? a.) Allow the client to hear running water
while attempting to void
b.) Provide the client a bedpan while lying supine
c.) Insert an indwelling urinary catheter and connect it to gravity drainage
d.) Encourage fluid intake up to 1,000 mL daily
<least invasive first, bedpan doesn‟t promote independence, fluid intake more than 2L>
17. 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? (select ALL)
a.) “I need to set my hot water heater to 140 degrees Fahrenheit”
b.) “I will use the grab bars when getting in and out of the bathtub”
c.) “I will apply tape over frayed areas of electrical cords”
d.) “I need to have a fire escape plan with my family”
e.) “I need to check my medications for expiration dates”
18. A nurse is caring for a client preoperatively who has given informed consent for an appendectomy. Which of the
following statements by the client should the nurse address first?
a.) “I am afraid to walk if it hurts too much”
b.) “I don‟t understand why I need this surgery”
c.) “I don‟t want my family helping me after the surgery”
d.) “I am afraid the scar will make me look disfigured”
Which of the following clients should the nurse see first?
a) A client who has new onset of dyspnea 24 hr after a total hip arthroplasty0 can mean dvt
b) A client who has acute abdominal pain of 4 on a scale from 0 to 10
c) A client who has a UTI and low-grade fever
d) A client who has pneumonia and an oxygen saturation of 96%
<always look for new onset of anything, other findings are normal also.>
2. A nurse is caring for a client who is nauseated and unable to eat after taking her antibiotic.
Identify the steps the nurse should take to address the nausea.
a) Identify possible nursing interventions that address the client‟s nausea
b) Review the potential benefits and consequences of each intervention
c) Select an intervention that provides the greatest benefit and least risk
d) Determine the probability of intervention-related complications (3)
<I am sure, it goes (a) to (b),(c), then (d)
3. A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern
about his future. Which of the following is therapeutic response by the nurse?
a) You‟re concerned about what will happen when you leave the hospital?”
b) “If you work hard on your physical therapy, you won‟t need to worry”
c) “You shouldn‟t worry about the future so you can concentrate on getting well”
d) “Why are you concerned even though everyone is here to help you?”
4. A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions
should the nurse take?
a) Follow a systematic pattern from side-to-side moving down the client‟s chest
b) Ask the client to breathe in deeply through his nose
c) Instruct the client to sit erect with his head tilted slightly backward
d) Place the bell of the stethoscope on the client‟s chest
5. A nurse is teaching a client who requires maximal support about how to use a two wheeled walker.
Which of the following actions by the client indicates an understanding of teaching.
a) The client moves the walker ahead 25.4cm with each step
b) The client picks up the walker with each step
c) The client stands with her elbow slightly while holding the walker
, d) The client stoops slightly forward when moving the walker
6. A nurse in a provider‟s office is caring for a client who states “I always have trouble sleeping”. Which of
the following actions should the nurse take first?
a) Teach the client stress reduction techniques
b) Recommend that the client avoid caffeine intake in the evening
c) Identify the client typical bedtime routine
d) Encourage the client to exercise regularly during day time hours.
7. A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the
nurse include when developing the plan of care?
a) The hispanic culture views late adulthood as a negative time in the client‟s life
b) The hispanic culture identifies the eldest female family member as the decision maker
c) The Hispanic culture expects individuals to make their own decisions when death is imminent.
d) The hispanic culture expects adult children to care for older adult parents.
8. A nurse is providing teaching to a client who has a new med prescription. Which of the following
manifestations of a mild allergic reaction should the nurse include?
a) Ptosis
b) Hematuria
c) Urticaria
d) Nausea
9. A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood
glucose test. Which of hte following instructions should the nurse include in the teaching?
a) Don sterile gloves prior to puncturing the site
b) Puncture site after cleansing and before antiseptic dries.
c) Gently squeeze the puncture site until a large droplet of blood forms
d) Hold the finger to puncture above the level of the heart
10. A nurse is providing teaching to a client about reducing the adverse effects of immobility.
Which of the following statements by the client indicates an understanding of the teaching?
,a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures .
b. I will hold my breath when rising from a sitting position
c. I will remove my antiembolic stockings while I am in bed
d. I will have my partner help me change positions every 4 hours
11. A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left
forearm. Which of the following findings indicates that the client has developed phelbitisat the IV site?
a. Erythema along the path of the vein
b. Pitting edema at the insertion site- infiltration since water is probably displaced.
c. Coolness of the client‟s left forearm - infiltration
d. Pallor of the client‟s left forearm
12. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse
perform shortly before bedtime?
a. Provide a late supper
b. Offer a wet washcloth for the client to wash her face
c. Perform range of motion excercise
d. Prepare a hot cocoa or tea for the client
13. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the
following statements by the newly licensed nurse indicates an understanding of teaching?
a. I will place the client in a private room
b. I will tell the client‟s visitors to wear a mask when they are within 3 feet of the client
c. I will remove my gown after leaving the client‟s room
d. I will wear an N95 respirator mask when caring for the client
14. A nurse is teaching about home safety with a client. Which of the following instructions should the nurse include?
a. Unplug electronics by grasping the cord
b. Use electrical tape to secure extension cords next to baseboards on the floor
c. To use a fire extinguisher, aim high at the top of the flames.
d. Replace carpeted floors with tile
15. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the
following actions should the nurse take?
, a.) Perform deep palpation at the end of the admission assessment
b.) Auscultate the client‟s abdomen before palpation
c.) Begin palpation of the abdomen at the site of pain
d.) Assess the client‟s bowel sounds using the bell of the stethoscope
<inspect - auscultate - palpate - percuss>
16. A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty
voiding. Which of the following actions should the nurse take? a.) Allow the client to hear running water
while attempting to void
b.) Provide the client a bedpan while lying supine
c.) Insert an indwelling urinary catheter and connect it to gravity drainage
d.) Encourage fluid intake up to 1,000 mL daily
<least invasive first, bedpan doesn‟t promote independence, fluid intake more than 2L>
17. 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? (select ALL)
a.) “I need to set my hot water heater to 140 degrees Fahrenheit”
b.) “I will use the grab bars when getting in and out of the bathtub”
c.) “I will apply tape over frayed areas of electrical cords”
d.) “I need to have a fire escape plan with my family”
e.) “I need to check my medications for expiration dates”
18. A nurse is caring for a client preoperatively who has given informed consent for an appendectomy. Which of the
following statements by the client should the nurse address first?
a.) “I am afraid to walk if it hurts too much”
b.) “I don‟t understand why I need this surgery”
c.) “I don‟t want my family helping me after the surgery”
d.) “I am afraid the scar will make me look disfigured”
