Preview Extract
1. A nurse is reinforcing information with a client who wishes to complete their advance
directives. Which of the following statements should the nurse make?
a) “You must have advance directives in place in order to refuse recommended treatment.”
b) “An attorney is needed in order for you to name a designee in your health care proxy.”
c) “You can decline to have certain medical procedures performed in your living will.”
d) “A living will can be an oral statement that you agree upon with your provider.”
Answer: c) “You can decline to have certain medical procedures performed in your living will.”
2. A nurse is reinforcing teaching with a client who is premenopausal. Which of the following
statements by the client indicates in understanding of the teaching?
a) “I should stop receiving Papanicolaou tests once I reach menopause.”
b) “The best time to perform a breast self-examination is on the first day of my period.”
c) “I can expect to have regular periods until I am in menopause.”
d) “I might have headaches due to a decline in my estrogen levels.”
Answer: d) “I might have headaches due to a decline in my estrogen levels.”
3. A nurse in a provider’s office is calculating a client’s BMI. Which of the following pieces of
the client data should the nurse use as a part of the calculation?
a) Daily calorie intake
b) Height
c) Abdominal girth
d) Blood pressure
Answer: b) Height
4. A nurse is reinforcing teaching with a client about the use of a peak flow meter. Which of the
following actions should the nurse make first?
a) Determine the client’s knowledge of the use of the peak flow meter.
b) Show the client a video demonstration of peak flow meter use.
c) Observe the client using the peak flow meter.
d) Emphasize the importance of the daily use of the peak flow meter.
Answer: a) Determine the client’s knowledge of the use of the peak flow meter.
5. A nurse is collecting data about a client’s oral care. The client wears dentures and reports
having mouth sores. The nurse should identify which of the following oral care practices by the
client as a possible cause of the mouth sores?
a) Soaks dentures in water after removal.
b) Applies an adhesive to seal dentures in place.
c) Wears dentures while sleeping at night.
d) Rinses dentures after meals.
Answer: c) Wears dentures while sleeping at night.
6. A nurse is preparing to administer a medication from an ampule. Which of the following is an
appropriate action for the nurse to make?
a) Inject air into the ampule prior to drawing the medication into a syringe.
b) Add 0.5 mL of diluent to the medication.
c) Cleanse the tip of the ampule with an alcohol swab after opening.
d) Use a filter needle to aspirate the medication.
Answer: d) Use a filter needle to aspirate the medication.
7. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following
findings should the nurse identify as a safety hazard?
a) An assistive personnel places a weight-sensitive sensor mat on the mattress beneath the
client’s buttocks.
b) An assistive personnel raises all four side rails of a client’s bed before leaving the room.
c) A client who has bilateral wrist restraints has a capillary refill less than 2 seconds.
d) A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation
at the application site.
Answer: b) An assistive personnel raises all four side rails of a client’s bed before leaving the
room.
8. A nurse is caring for a client who is 2 days postoperative following a below-the-knee
amputation. Which of the following statements by the client should the nurse identify as
indicating an acceptance of the limb loss?
a) “I stay awake at night because I keep thinking about my leg.”
b) “I need to learn how to perform a dressing change on my leg.”
c) “I know my family means well, but I don’t want visitors seeing my leg right now.”
d) “I am going to have to find someone who can take care of my leg at home.”
Answer: b) “I need to learn how to perform a dressing change on my leg.”
9. A nurse on a medical-surgical unit is collecting data from a client who is postoperative
following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now
finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse
make?
a) Measure the client’s BP in the other arm.
b) Use a narrower cuff to repeat the BP measurement.
c) Deflate the cuff faster when repeating the bp measurement.
d) Request a prescription for an antihypertension medication.
Answer: a) Measure the client’s BP in the other arm.
10. A nurse is assisting with the admission of a client who has streptococcal pharyngitis.
Which of the following precautions should the nurse make?
a) Have the client’s visitors put on a gown before entering the room.
b) Escort the client to a room with a negative airglow.
c) Prohibit fresh flowers and plants in the client’s room.
d) Wear a surgical mask when giving the client direct care.
Answer: d) Wear a surgical mask when giving the client direct care.
11. A nurse is caring for a client who has dyspnea with an oxygen saturation of 88%. Which of
the following images indicates the type of face mask the nurse should use to deliver the client a
90% oxygen concentration?
a) Nasal cannula
b) Simple face mask
c) Non-rebreather mask
d) Venturi mask
Answer: c) Non-rebreather mask
12. A nurse working in a rehabilitation unit is caring for a client who has dysphagia and has
difficulty swallowing during meals. Which of the following actions should the nurse take to
prevent the client from aspiration while eating?
a) Add liquid to foods to thin consistency.
b) Tilt the clients head slightly backward.
c) Offer verbal support while the client is eating.
d) Encourage socialization with others during meals.
Answer: a) Add liquid to foods to thin consistency.
13. A nurse in a provider’s office performs a fecal occult blood test with a positive result on a
client. Which of the following clients may have a false positive result?
a) A client who has a venous stasis ulcer.
b) A client who takes an iron supplement.
c) A client who has peripheral hematomas.
d) A client who underwent a barium swallow study.
Answer: b) A client who takes an iron supplement.
14. A nurse is caring for a client who is flushed and has temperature of 38.7 C (101.7 F).
Which of the following actions should the nurse take?
a) Give the client an alcohol sponge bath.
b) Place cold packs on the client’s axillae.
c) Place a fan to blow air across the client.
d) Remove blankets from the client.
Answer: d) Remove blankets from the client.
15. A nurse is caring for a client who has a hip fracture and plans to administer a pain medication
prior to turning the client. Which of the following ethical principles is the nurse implementing?
a) Beneficence.
b) Fidelity.
c) Autonomy.
d) Veracity.
Answer: a) Beneficence.
16. A nurse is caring for a client who was recently admitted to hospice care and tells the nurse “I
am going to die, and my family is hoping for a cure. I am mad that they behave like everything
will be fine.” Which of the following responses should the nurse make?
a) “It sounds like you have given up and you want to stay mad at your family.”
b) “Why do you think they don’t know what’s happening?”
c) “You are feeling angry that your family continues to wish for a cure?”
d) “I think you and I need to talk about your anger with your family.”
Answer: c) “You are feeling angry that your family continues to wish for a cure?”
17. A nurse in a provider’s office is reviewing the medical record of an older adult who report’s
having nausea and vomiting for the last 48 hrs. Which of the following findings indicate fluid
volume deficit? (Select all that apply.)
a) Dry mucous membranes.
b) Decreased skin turgor.
c) Heart rate 72/min.
d) Distended neck veins.
e) Blood pressure 88/62 mm Hg.
Answer: a) Dry mucous membranes.
b) Decreased skin turgor.
e) Blood pressure 88/62 mm Hg.
18. A nurse is caring for a client who refuses a prescribed medical procedure. Which of the
following actions should the nurse take to act as the client’s advocate?
a) Evaluate the client’s concerns and communicate them to the provider.
b) Ask the client’s partner to find out why the client has refused the procedure.
c) Explain the necessity of the procedure to the client.
d) Contact the unit’s social worker to report the client’s refusal.
Answer: a) Evaluate the client’s concerns and communicate them to the provider.
19. A nurse is assisting with scoliosis screenings for students at a public school. Which of the
following findings should the nurse recognize as an indication of scoliosis?
a) Expansion of the upper intercostal spaces.
b) Increased convex curve of the cervical spine.
c) Increased concave curve of the thoracic spine.
d) Unequal height of the shoulders.
Answer: d) Unequal height of the shoulders.
20. A nurse is disinfecting the room of a client who has a Clostridium difficile infection.
Which of the following solutions should the nurse use?
a) Isopropyl alcohol.
b) Triclosan.
c) Chlorhexidine.
d) Chlorine bleach.
Answer: d) Chlorine bleach.
21. A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per day
to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/ 10 mL.
How many mL should the nurse administer per dose? (Round to the nearest whole number.)
______ mL
Answer: (80 x 35 ÷ 1 * 1000 x 10) / 4 = 7 mL
22. A nurse is reinforcing teaching with a client who follows a vegan diet and is interested in
ways to increase protein to promote healing after a recent surgery. Which of the following
suggestions is appropriate?
a) Scrambled eggs.
b) Baked eggs.
c) Grilled salmon.
d) Cottage cheese.
Answer: d) Cottage cheese.
23. A home health nurse is reinforcing teaching about dietary needs with the son of a client. The
son states, “I don’t know what to do because he’s not eating.” Which of the following responses
should the nurse make?
a) “I’m sure it’s nothing serious and his appetite will return soon.”
b) “Why do you think he is not eating?”
c) “He may need a feeding tube.”
d) “Tell me more about what happens at mealtime.”
Answer: d) “Tell me more about what happens at mealtime.”
24. A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of
the following tasks should the nurse assign to the AP?
a) Assess the pain level of a client who has received acetaminophen.
b) Measure the intake and output of a client who has received furosemide.
c) Check a client’s peripheral IV site for redness or swelling.
d) Reinforce teaching with a client about crutch-gait walking.
Answer: d) Reinforce teaching with a client about crutch-gait walking.
25. A nurse is preparing to insert an indwelling urinary catheter and is verifying the client’s
express consent for the procedure. Which of the following actions should the nurse take?
a) Witness the client’s signature on a consent form.
b) Check the medical record for the client’s signature on a previous consent form.
c) Have another nurse co-sign the client’s consent.
d) Obtain verbal consent from the client.
Answer: d) Obtain verbal consent from the client.
26. A nurse is planning to place a client into the Sims’ position. Which of the following actions
should the nurse plan to take?
a) Position the client’s arms at his side.
b) Raise the head of the client’s head to a 30-degree angle.
c) Place a pillow under the client’s flexed leg.
d) Evaluate the client’s feet with two pillows.
Answer: c) Place a pillow under the client’s flexed leg.
27. A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of
the following instructions should the nurse include?
a) Avoid placing the toilet tissue in the bedpan after defecation.
b) Urinate after the specimen collection.
c) Place 1.3 cm (0.5 in) of formed stool into a culture tube.
d) Keep the specimen in a warm area.
Answer: a) Avoid placing the toilet tissue in the bedpan after defecation.
28. A nurse is planning to apply a belt restraint to a client who is confused and at risk for falls.
Which of the following actions should the nurse make?
a) Apply the belt under the client’s gown.
b) Allow four finger widths between the restraint and the client.
c) Place the belt across the client’s chest.
d) Fasten the client’s restraint using a quick-release tie.
Answer: d) Fasten the client’s restraint using a quick-release tie.
29. A nurse is collecting data from a client following lumbar puncture. For which of the
following adverse effects of the procedure should the nurse monitor the client?
a) Headache.
b) Fluid overload.
c) Difficulty voiding.
d) Diarrhea.
Answer: a) Headache.
30. A nurse is collecting data from a client who is immobile and has a potential deep-vein
thrombosis. Which of the following findings should the nurse report to the provider?
a) Bradycardia.
b) Calf swelling.
c) Tortuous veins.
d) Clammy skin.
Answer: b) Calf swelling.
31. A nurse is caring for a client who is postoperative and is preparing to walk for the first time
in several days. Which of the following interventions should the nurse give the client to prevent
orthostatic hypotension?
a) “Perform regular isometric exercise.”
b) “Increase your intake of protein.”
c) “use your incentive spirometer.”
d) “dangle your legs over the side of the bed.”
Answer: d) “dangle your legs over the side of the bed.”
32. A nurse is caring for a client who speaks a different language than the nurse and is 6 hrs
postoperative. Which of the following actions should the nurse take to determine the client’s
level of pain?
a) Use a communication board to interact with the client.
b) Ask an assistive personnel who speaks the same language as the client to interpret.
c) Use the FACES pain scale to gauge the client’s level pf pain.
d) Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client’s pain
level.
Answer: a) Use a communication board to interact with the client.
33. A nurse is performing a wound irrigation for a client who has methicillin-resistant.
Staphylococcus aureus. When removing personal equipment, which of the following pieces
should the nurse remove first?
a) Goggles.
b) Mask.
c) Gown.
d) Gloves.
Answer: d) Gloves.
34. While performing hygiene care for a client, a nurse notices a frayed electrical cord on the
clients electronic BP monitor. Which of the following actions should the nurse take first?
a) Report the defective equipment.
b) Remove the device from the room.
c) Request a replacement deice.
d) Access the facility’s maintenance protocol.
Answer: b) Remove the device from the room.
35. A nurse is reinforcing teaching with a male client about collecting a mid-stream urine
specimen. Which of the following interactions should the nurse include?
a) Begin by urinating a small amount into the toilet, stop the stream of urine, and then urinate
into the cup.
b) Urinate a small amount into the cup, discard the urine, and then urinate into the cup for the
sample.
c) Begin by urinating into the cup and then finish urinating in the toilet.
d) Urinate into the toilet and then place the cup into the stream to collect urine.
Answer: d) Urinate into the toilet and then place the cup into the stream to collect urine.
36. A nurse is reinforcing teaching with a client who has a new ileostomy about nutrition therapy.
Which of the following food choices by the client demonstrates an understanding of the
teaching?
a) Mushrooms.
b) Popcorn.
c) Bananas.
d) Broccoli.
Answer: c) Bananas.
37. A nurse is collecting data regarding home safety from a client who is prone to falls. Which of
the following findings should the nurse recognize as placing the client at additional risk?
a) The client has removed the wheels from rolling chairs.
b) The client’s mattress is directly on the floor.
c) A stool riser is in place on the bathroom toilet.
d) Throw rugs over electrical cords on the floor.
Answer: d) Throw rugs over electrical cords on the floor.
38. A nurse is collecting data from a client who had a stroke and is unable to name common
items. The nurse should recognize that the client’s experiencing which of the following types of
aphasia?
a) Global aphasia.
b) Expressive aphasia.
c) Receptive aphasia.
d) Sensory aphasia.
Answer: b) Expressive aphasia.
39. A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for
2 days. Which of the following laboratory findings should the nurse expect?
a) Hyperkalemia.
b) Hypermagnesemia.
c) Hyponatremia.
d) Hypocalcemia.
Answer: c) Hyponatremia.
40. A nurse is collecting data from a client who has an NG tube in place for gastric
decompression. Which of the following findings should the nurse report to the provider?
a) Greenish-yellow drainage.
b) Report of hunger.
c) Gastric contents are present in the air vent.
d) Abdominal distention.
Answer: c) Gastric contents are present in the air vent.
41. A nurse observes an assistive personnel (AP) perform mouth care for a client who is
unconscious which of the following actions by the AP requires intervention by the nurses?
a) Using an oral care sponge swab moistened with cool water to clean the client’s mouth
b) Wearing clean gloves to perform mouth care for the client
c) Lowering the side rail on the side of the bed where they will stand to perform mouth care
d) Using two gloved fingers to open the client’s mouth for cleaning
Answer: d) Using two gloved fingers to open the client’s mouth for cleaning
42. A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute
unit. Which of the following actions should the nurse include in the plan?
a) Restrict the number of visitors for clients
b) Assign different nurses to provide care for clients each day
c) Turn on loud music in client care areas
d) Offer the clients many choices regarding care
Answer: a) Restrict the number of visitors for clients
43. A nurse is reinforcing teaching with a client who is learning to use a walker and his left leg
weakness. Which of the following instructions should the nurse include in the teaching?
a) “Move your right leg forward as you advance the walker”
b) “Keep your eyes on your feet when ambulating with the walker”
c) “Support yourself with the walker when rising from a chair”
d) “Maintain your arms in a slightly fixed position when using the walker”
Answer: a) “Move your right leg forward as you advance the walker”
44. A nurse is reinforcing teaching with a client about using guided imagery to manage chronic
pain. Which of the following statements by the client indicates an understanding of this
technique?
a) “I’ll think about my grandfather’s farm to reduce pain”
b) “I’ll use focused breathing to control my pain”
c) “I’ll learn to notice the sensation of muscle tension”
d) “I’ll listen to my favorite music to take my mind off the pain”
Answer: a) “I’ll think about my grandfather’s farm to reduce pain”
45. A nurse is assisting a client who is 4hr postoperative to get out of bed. The client states, “Do
not touch me! I can get up by myself.” Which of the following response should the nurse make?
a) “I will be next to you and will help if you need to”
b) “I think you need some pain medication before getting out of bed
c) “We can talk about this after you have gotten out of bed”
d) “Why don’t you want to be touched?”
Answer: a) “I will be next to you and will help if you need to”
46. A nurse is reinforcing teaching with a newly hired nurse about cultural sensitivity during
death and dying. Which of the following information should the nurse include?
a) Devout practitioners of Hinduism prefer to be buried after death and not cremated
b) Devout practitioners of Judaism prefer to be buried 5 days after death
c) Devout practitioners of Islam prefer to have their heads turned toward Mecca at death
d) Devout practitioners of Buddhism prefer a ritual bath prior to burial
Answer: c) Devout practitioners of Islam prefer to have their heads turned toward Mecca at
death
47. A nurse is reinforcing teaching about beginning an exercise program with an older adult
client who is at risk for osteoporosis. Which of the following activities should the nurse
recommend?
a) Passive range-of-motion exercise
b) Walking
c) Bowling
d) Jogging
Answer: b) Walking
48. A nurse is caring for a client who has hearing loss. Which of the following actions should the
nurse take to promote commutation?
a) Use short phrases
b) Speak in a loud voice
c) Decrease background noise
d) Talk at a rapid rate
Answer: c) Decrease background noise
49. A nurse is caring for a client who requires a sterile dressing change. The nurse should
recognize that the surgical field has been contaminated if which of the following actions occur?
a) The sterile solution is poured with the bottle held over the field
b) A pair of sterile forceps is allowed to rest in a container of sterile water on the field
c) The handle of a pair of sterile scissors is resting 5cm (2in) from the field’s edge
d) Unnecessary sterile items are place on the field
Answer: a) The sterile solution is poured with the bottle held over the field
50. A nurse is reinforcing teaching with the adult children of a client who is receiving palliative
care. Which of the following statements by one of the adult children indicates an understanding
of the teaching?
a) “We will receive emotional support during our mother’s illness”
b) “We won’t allow her spiritual advisor to visit during this time”
c) “We won’t discuss the illness in the presence of our mother”
d) “We will provide resuscitation to our mother if necessary”
Answer: a) “We will receive emotional support during our mother’s illness”
51. A nurse is inserting an indwelling urinary catheter for a female client. In which order should
the nurse perform the following steps?
1) Separate the labia with the nondominant hand
2) Clean around the urinary meatus from front to back
3) Insert the catheter into the urethral meatus
4) Inflate the catheter balloon
5) Secure the catheter to the client’s thigh
Answer: 1) Separate the labia with the nondominant hand
2) Clean around the urinary meatus from front to back
3) Insert the catheter into the urethral meatus
4) Inflate the catheter balloon
5) Secure the catheter to the client’s thigh
52. A nurse is assisting with the postmortem care of a client whose partner is at the bedside.
Which of the following actions should the nurse take?
a) Instruct the partner not to touch the client’s body
b) Place the client’s personal belongings in a safe location in the facility
c) Ask the partner about any rituals they would like to be performed
d) Direct the partner to leave and return once postmortem care is complete
Answer: c) Ask the partner about any rituals they would like to be performed
53. A nurse is reinforcing teaching plan regarding proper lifting with a client. Which of the
following strategies should the nurse include to prevent back injury when lifting an object?
a) Bend at the waist
b) Tighten the abdominal muscles
c) Keep legs straight
d) Hold object away from the body
Answer: b) Tighten the abdominal muscles
54. A nurse in a provider’s office receives a telephone call from a client’s sibling requesting
current information about the client’s condition. Which of the following actions should the nurse
take?
a) Provide the caller with a brief update about the client’s condition
b) Gather additional information from the caller to verify their identity
c) Ask the caller to contact the client directly for information
d) Request that the caller contact the client’s provider directly for information
Answer: c) Ask the caller to contact the client directly for information
55. A nurse is caring for a client who is experiencing fecal incontinence. Which of the following
actions should the nurse take?
a) Decrease the client’s fluid intake
b) Increase the client’s intake of raw fruits and vegetables
c) Cleanse the client’s perianal area with an alcohol-based solution
d) Apply barrier ointment to the client’s perianal area
Answer: b) Increase the client’s intake of raw fruits and vegetables
56. A nurse is caring for a client who has difficulty swallowing following a stroke. Which
following actions should nurse take when administering an oral medication to this client?
a) Instruct the client to use a straw to take liquid medications
b) Place the client in high-Fowler’s position
c) Tilt the client’s head backward while swallowing
d) Dissolve medications in water prior to administration
Answer: b) Place the client in high-Fowler’s position
57. A nurse is caring for a group of clients. For which of the following situations should the
nurse complete an incident report? (Select all that apply)
1) A client is unable to afford the physical therapy that the provider recommends
2) A client becomes disoriented and falls out of bed
3) A client reports being dissatisfied with the temperature of the meals provided
4) A client’s visitor becomes dizzy and faints in the client’s room
5) A client receives burns from a heating pad
Answer: 2) A client becomes disoriented and falls out of bed
4) A client’s visitor becomes dizzy and faints in the client’s room
5) A client receives burns from a heating pad
58. A nurse is caring for a young adult client who is postoperative and requires physical therapy,
pain management, and dietary advancement. The nurse enters the client’s room and finds them
dressing and stating that they are going home. Which of the following actions should the nurse
take?
a) Have the client sign an against medical advice form
b) Tell the client that the surgeon will prescribe restraints if they try to leave
c) Administer a sedative medication to the client
d) Explain to client that they cannot leave until the surgeon discharges them
Answer: a) Have the client sign an against medical advice form
59. A nurse is caring for a client who has experienced a cerebrovascular accident with resulting
dysphagia. Which of the following therapists assists clients to learn to eat with less risk of
aspiration?
a) Speech
b) Physical
c) Occupational
d) Respiratory
Answer: a) Speech
60. A nurse is caring for a client who is postpartum. Which of the following documentations
should the nurse include in the client’s health record?
a) Client drank adequate amounts of fluid with meals
b) Episiotomy approximated, 3 cm (1.18 in) in length
c) Client instructed on self-care needs
d) Oral temperature elevated at 0800
Answer: d) Oral temperature elevated at 0800
61. A nurse is in a long-term care facility is transcribing a prescription for a client. Which of the
following abbreviations is appropriate?
a) sub q
b) mcg
c) qhs
d) qod
Answer: b) mcg
62. A nurse is assisting with the admission of a client. Which of the following statements should
the nurse make to demonstrate the principle of advocacy?
a) “I will do my best to fulfill my promises to you”
b) “I will keep your personal information private”
c) “I will speak with your provider on your behalf”
d) “I will let you make decisions about your health care”
Answer: c) “I will speak with your provider on your behalf”
63. A nurse is reinforcing teaching with a client who has crutches regarding the use of the threepoint gait. Which of the following instructions should the nurse include?
a) Standing with the crutch tips against the feet
b) Bear weight on the unaffected leg
c) Keep the crutches at the level of the axillae
d) Hold the arms straight when walking
Answer: b) Bear weight on the unaffected leg
64. A nurse at a long-term care facility is caring for an older adult client who has dementia and is
at risk for malnutrition. Which of the following actions should the nurse take to promote an
increase in food intake?
a) Restrict visitors during meals
b) Provide the client with finger foods for meals
c) Limit snacks between meals
d) Provide the client with three large meals each day
Answer: a) Restrict visitors during meals
65. A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen
saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should
the nurse take?
a) Reposition the sensor probe
b) Apply a cooling blanket to the client
c) Ambulate the client
d) Place the client in a side-lying position
Answer: a) Reposition the sensor probe
66. A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to
promote wound healing. Which of the following foods should the nurse recommend as the best
source of vitamin C?
a) 1 small banana
b) 1 small pink grapefruit
c) 1 small apple with the skin
d) 1 medium fresh green pear
Answer: b) 1 small pink grapefruit
67. A nurse in an acute care center is caring for a client who just died. The client’s family
requests to perform the postmortem care. Which of the following is an appropriate response for
the nurse to make?
a) “You will have to sign a release form to perform the care yourself”
b) “I will assist you in any way I can during this process”
c) “A licensed health care worker must perform postmortem care.”
d) “This care takes place after the client leaves the facility”
Answer: b) “I will assist you in any way I can during this process”
68. A nurse is wearing sterile gloves in preparation for assisting with a client’s sterile procedure.
While waiting for the procedure to begin, how should the nurse position her hands?
a) Interlock her fingers and hold her hand away from her body above her waist
b) Keep her arms at the sides of her body with her hands in a relaxed position
c) Place one hand over the other against the part of the gown covering her upper body
d) Clasp her hands together in a relaxed position behind her body at her waist
Answer: a) Interlock her fingers and hold her hand away from her body above her waist
69. A nurse is assisting in the transfer of a client who has left-side weakness from a bed to chair.
Which of the following actions should the nurse take?
a) Flex hips and knees when assisting the client to a standing position
b) Pivot on the foot farthest from the bed when assisting the client into the chair
c) Raise the bed to waist level before moving the client
d) Stand on the client’s stronger side when moving the client into the chair
Answer: a) Flex hips and knees when assisting the client to a standing position
70. A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the
following statements by the newly licensed nurse indicates understanding of this assistive
device?
a) "I will use the lift to transfer a client from the bed to a chair."
b) "I will place the client's feet first when transferring them."
c) "I will position the lift's base close to the client's chair."
d) "I will use the lift without assistance to transfer a client."
Answer: A. "I will use the lift to transfer a client from the bed to a chair."
