Question: A nurse is teaching a client how to perform personal ileostomy care prior to discharge. The client says “I don’t think that I am going to be able to take care of this myself.” Which is the most appropriate response from the nurse?
Question: The adult child of a client who has had a colon resection will be caring for their parent at home. The client’s son tells the nurse “I don’t know how I am going to care for my mom now”. Which is the bestnursing response?
Question: A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from PACU. The float nurse is most qualified to care for which client?
Question: A client asks the nurse what causes constipation. Choose the bestresponse by the nurse.
Question: The nurse caring for a post-operative client performs an abdominal assessment. The nurse does not hear any bowel sounds over the left lower quadrant of the abdomen. What is the mostlikely reason for this?
Question: The nurse admits a client who is to undergo a colonoscopy. The nurse understands that this will be required in preparation for the procedure.
Question: A nurse is teaching a client about colorectal cancer testing. The nurse expects the provider to firstperform this test for colorectal screening.
Question: A nurse is caring for a client with a newly placed colostomy. The nurse teaches the client they may have formed stool after the bowel has healed because the surgeon placed the stoma where?
Question: The nurse is administering a tap water enema to a client in preparation for bowel surgery. The nurse correctly positions the enema bag containing the fluid where?
Question: The nurse correctly positions a client for a fleets enema by placing them in this position:
Question: The nurse is preparing a new ostomy flange for the client’s abdomen. Choose the correct action by the nurse.
Question: The nurse would plan to perform more frequent perineal care to prevent skin breakdown for this client.
Question: A female nurse is upset because a male client has requested only a male nurse help them with personal care. What is the bestresponse from the charge nurse?
Question: Select the priority nursing intervention for performing a complete bed bath on a client.
Question: Choose the adjunct therapy that can help improve circulation and assist in debridement of wounds.
Question: A nurse is providing oral care for a client who is immobile. Choose the correct nursing action for this client.
Question: The nurse caring for a client with C. Difficile must use which personal protective equipment?
Question: The nurse is providing enteric feeding to a client. A priority action on the part of the nurse to prevent infection is this:
Question: Choose the correct statement regarding sterile gloves.
Question: A student nurse notices a family member walking into a room under contact isolation. The student stops the visitor and instructs them how to don the appropriate protective equipment. The student is practicing this:
Question: A nurse is caring for a client who has a Clostridium difficile infection. Which cleansing agent should the nurse use for hand hygiene?
Question: The nurse is teaching a nursing assistant on correct use of personal protective equipment (PPE). The nurse knows the teaching was understood when the NA demonstrates this:
Question: The nurse is teaching students the importance of hand hygiene. Choose the mostcorrect statement.
Question: The nurse is preparing to exit the room of a client who has been placed on contact precautions. Identify the sequence to be followed when removing the personal protective equipment (PPE).
Question: The nurse uses medical asepsis when caring for clients when they do this.
Question: A nurse is teaching a group of new mothers on infant care. The nurse includes which information on teaching about infection prevention.
Question: An older client tells the nurse that they never get a flu shot because at their age, they’ve had every kind of flu there is. Choose the bestresponse from the nurse.
Question: The nurse is caring for an older adult who complains they don’t eat as much as they used to. Their overall physical and mental condition is good. Choose the best response from the nurse.
Question: A nurse is assessing a young woman diagnosed with anorexia nervosa. The nurse suspects the client is not eating all of the food on their prescribed diet when they observe this:
Question: The nurse caring for a new mother is teaching about proper nutrition for the infant. Choose the beststatement regarding infant nutrition.
Question: The nurse is performing a mini-nutritional assessment for a newly admitted client from a nursing home. The bestdescription of this type of assessment is what?
Question: The nurse is assessing a client’s peripheral circulation. Choose where the nurse will palpate a popliteal pulse.
Question: The nursing assistant reports these vital signs to a nurse: tympanic temperature 98.8ºF, pulse 92 bpm, respiratory rate 18 breaths/min, blood pressure 98/58. What does the nurse do next?
Question: A nurse instructs a group of new mothers to make sure the infant is covered up whenever in an air-conditioned space. Choose the bestrationale for this action.
Question: The nurse is caring for a client with an irregular radial pulse. What action should the nurse take next?
Question: A client is prescribed a medication that has adrenergic effects. Choose the effect on the vital signs that this drug can have.
Question: A nurse is preparing to administer a medication prescribed to treat the client’s tachycardia. The nurse should perform this action before giving the medication.
Question: A nurse assigns the nursing assistant the task of collecting vital signs on several clients. Select the client for whom the nurse should assess vital signs.
Question: A group of student nurses is learning about adrenergic cardiovascular effects. Choose the chemicals most likely to cause these effects.
Question: A nurse caring for an older client who has been a smoker for several years can expect to assess this abnormal vital sign.
Question: A young teen is injured playing football when he is shoved into a goalpost and suffers a head injury. The nurse is concerned that this part of the brain may have suffered damage that can impact respirations.
Question: A nursing assistant has just taken a client’s blood pressure and suspects the reading is not accurate. Choose a valid reason for blood pressure error.
Question: A nurse caring for a client who is short of breath places the client in this position to facilitate lung expansion.
Question: A nurse is caring for a client who is on fall precautions. An appropriatealternate solution to the use of restraints would be what?
Question: A nurse is teaching other healthcare workers about the acronym for fire safety: R.A.C.E. The nurse explains that the letter “E” stand for what?
Question: A nurse witnesses a client having a seizure. What is the nurse’s priorityaction?
Question: The nurse prepares to help a client with crutch-walking. The nurse correctly places the crutches in this position:
Question: The nurse is caring for a client with a deep, infected wound. The provider has prescribed wound irrigations be performed with each dressing change. Choose the best nursing action.
Question: A nurse is preparing to discharge a client who has been hospitalized to treat a Stage IV decubitus ulcer. Select the beststatement from the nurse regarding the client’s wound.
Question: A nurse caring for a client with a Stage III pressure ulcer notes a foul odor coming from the room. What does the nurse do next?
Question: The nurse is preparing to teach a client how to do their own wound care once discharged home. Choose the beststatement regarding wound packing.
Question: A nurse is discharging a client following surgical removal of the gall bladder. The nurse defines this type of wound healing as what?
Question: A nurse has admitted a client to the hospital from home. During assessment the nurse notes a reddened, warm spot on the client’s coccyx. Choose an appropriate nursing action to address this finding.
Question: A clinic nurse is assessing a client who complains of a large blister on their left heel following participation in a 5K race. Choose the bestnursing action to treat this wound.
Question: A nurse is caring for a client with a Stage III pressure ulcer. The nurse will measure and record what data in the client’s medical record?
Question: A client asks the nurse about bilevel positive airway pressure (BiPap) devices as the provider just prescribed one for them. Choose the bestexplanation from the nurse.
Question: The nurse is preparing to perform tracheal suctioning on a client. Select the bestposition in which to place this client.
Question: The nurse is suctioning a client when the oxygen saturation drops below 90%. Select the action the nurse should perform next.
Question: The nurse assesses a client having an anxiety attack who complains of numbness around the lips and tingling in the fingers. The nurse correctly recognizes these as signs of what?
Question: A nurse is teaching a group of post-operative clients how to correctly use the incentive spirometer. What does the nurse include in the teaching?
Question: The nurse is preparing to discharge a client home who will be using an oxygen concentrator. The nurse teaches the client to do what to maintain safety while using oxygen?
Question: A nurse admits a client with bacterial pneumonia. The nurse recognizes the client is most at risk for this:
Question: The nurse is caring for several clients in the urgent care clinic. The nurse understands that this group is most likely to suffer oxygenation problems.
Question: The nursing student is developing a plan of care for a client whose diagnosis is ineffective airway clearance related to retained pulmonary secretions as evidenced by the production of thick, yellow sputum. An appropriate nursing action for this client is what?
Question: The nurse teaching a group of students explains the purpose of postural drainage for a client with oxygenation problems. The bestexplanation for the use of postural drainage is what?
Question: The nurse is caring for a client who is able to cough productively, but unable to expectorate or swallow the sputum. Choose the appropriate nursing intervention and device.
Question: The nurse must select a prescribed oxygen delivery device that provides low flow oxygen at 60%. Select the correct device.
Question: A nurse in a long-term care facility instructs nurses about using an assistive device during ambulation. Choose the correct way to instruct ambulating with a cane.
Question: A nurse is preparing to move a client who is only partially able to assist up in bed. Which method should the nurse plan to use?
Question: Plantar flexion contractures can bestbe prevented through the use of this device.
Question: A nurse who is applying a gait belt before ambulating a client will correctly place the belt in this position:
Question: A nurse is helping to ambulate a client who frequently loses balance while walking. Choose the best device to aid in safety for this client.
Question: A client frequently attemps to remove his intravenous catheter. A family member asks the nurse to apply restraints. Choose the mostappropriate response from the nurse.
Question: A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which action should the nurse take first?
Question: The nurse is preparing a client for a diagnostic testing of urinary function. The nurse must make sure a consent form is on the client’s chart for this test:ou Answered
Question: The nurse receives intake and output reports on several clients from the nursing assistant. Select the output which the nurse should report to the provider.
Question: A client reports to the nurse that they feel the need to urinate but can’t. Select the priority nursing intervention for this client.
Question: The nurse is assigning care to a nursing assistant (NA) for a client with an indwelling urinary catheter. The nurse instructs the NA to do this in order to bestprevent catheter associated urinary tract infection:
Question: A client with this type of urinary diversion requires the nurse to instruct them how to self-catheterize.
Question: The nurse can delegate this intervention to the nursing assistant.
Question: While caring for a post-procedure client who underwent a cystoscopy a few hours ago, the nurse notes pink-tinged urine in the client’s urinal. Select the prioritynursing action.
Question: A nurse caring for an older adult male client understands that this is an expected physiological change.
Question: The nurse is teaching a group of home care providers about caring for the older adult with urine incontinence. The nurse includes this statement in the teaching:
Question: A nurse is doing preoperative teaching for a client about to undergo abdominal surgery. The nurse will insert a foley catheter prior to taking the client to the preoperative area. The bestrationale for this intervention is what?
Question: The nurse is caring for a female client who requires the insertion of an indwelling urinary catheter. The nurse will place the client in this position to bestfacilitate catheter insertion.
Question: The nurse is caring for a post-operative client and notes a moderate amount of serous drainage on the dressing 24 hours after surgery. What is an appropriate nursing action?
Question: The nurse is assessing a wound that is 75% covered with eschar. What treatment does the nurse expect to be ordered?
Question: The nurse is preparing to administer enteric feeding through a nasogastric tube. What does the nurse do after checking the placement of the tube?
Question: The nurse is inserting a nasogastric tube when the client begins to gag. What does the nurse do next after stopping the insertion?
Question: The nurse is preparing to insert a straight catheter into a male client. Which action is appropriate?
Question: The nurse is teaching teen-age girls about nutrition. Which nutrient do teen girls need more of that teen boys do not?
Question: The nurse is assessing an older client for dysphagia. What sign indicates the client may have dysphagia?
Question: The nursing assistant is feeding a client with dysphagia. What can the nurse teach the assistant to help prevent choking during feeding?
Question: A client tells the nurse they are still constipated despite increasing fiber in their diet. What is an appropriate question to ask the client?
Question: The nurse is providing a bath for a client who is bedbound. The nurse understands these care benefits from good hygiene: {Select all that apply}
Question: The nurse is teaching a group of home care workers about pressure ulcer formation. Choose the condition(s) that place a client at risk for pressure ulcer formation. {Select all that apply}
Question: A nurse is caring for a group of clients. Choose the client mostlikely to suffer from inadequate oxygenation {Select all that apply}
Question: A client suddenly starts to slide down to the floor while ambulating. Choose the correct actions by the nurse to prevent injury to both themselves and the client. {Select all that apply}
Question: The nurse is preparing to collect a sterile urine specimen from a client’s foley catheter. Choose the correct actions the nurse will perform. {Select all that apply}
Question: The nurse is helping a client select items for lunch from a clear liquid diet menu. Which items are allowed on this diet? {Select all that apply}
