1. A client who reports shortness of breath requests her nurse's help in changing positions. After
repositioning the client, which of the following actions should the nurse take next?
Observe the rate, depth, and character of the client's respirations.
2. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which
of the following actions should the nurse take?
Lower the client to the floor and place a pad under the client's head.
3. A home health nurse is planning to provide health promotion activities for a group of clients in
the community. Which of the following activities is an example of the nurse promoting primary
prevention?
Educating clients about the recommended immunization schedule for adults
4. A nurse is using the I-SBAR communication tool to provide the client's provider with
information about the client. The nurse should convey the client's pain status in which portion of
the report?
Assessment
5. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse
should identify that which of the following findings is an indication of infiltration?
Edema at the infusion site
6. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client?
Washing dishes
7. A nurse is caring for a client who has acute renal failure. Which of the following assessments
provides the most accurate measure of the client's fluid status?
Daily weight
8. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several
weeks. Which of the following methods of assessment should the nurse use first?
Inspection
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, 9. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse
should ensure that a written consent form has been signed by which of the following clients?
A client who has a prescription for a transfusion of packed red blood cells
10. A nurse in a long-term care facility is admitting a client who is incontinent and smells
strongly of urine. His partner, who has been caring for him at home, is embarrassed and
apologizes for the smell. Which of the following responses should the nurse make?
"It must be difficult to care for someone who is confined to bed."
11. A nurse in a provider's office is assessing a client who has heart failure. The client has gained
weight since her last visit and her ankles are edematous. Which of the following findings by the
nurse is another clinical manifestation of fluid volume excess?
Bounding pulse
12. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the
following actions should the nurse take first after discovering that the client's wound has
eviscerated?
Cover the incision with a moist sterile dressing.
13. A nurse in a provider's office is collecting information from an older adult client who reports
that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should
instruct the client that large doses of acetaminophen could cause which of the following adverse
effects?
Liver Damage
14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch
gait. Which of the following instructions should the nurse include in the teaching?
"Bear weight on both of your legs."
15. A nurse is planning to document care provided for a client. Which of the following
abbreviations should the nurse use?
PC for after meals
16. A nurse is responding to a parent's question about his infant's expected physical development
during the first year of life. Which of the following information should the nurse include?
A 10-month-old infant can pull up to a standing position.
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