Preview Extract
Maternal Newborn
1. A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of
the following statements indicates an understanding of the instructions?
Answer: I will feed my baby six to eight times a day
2. A nurse is reinforcing discharge teaching with a client who is postoperative following laser
surgery for open-angle glaucoma. Which of the following statements by the client indicates an
understanding of the instructions?
Answer: I will take a stool softener to prevent constipation
3. A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying.
Which of the following actions should the nurse take to reduce the risk of aspiration?
Answer: Administer using a needless syringe in the buccal cavity
4. A nurse is reinforcing teaching with a client who has peptic ulcer disease. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: I will plan to have my meals at regular intervals
5. A nurse in a urgent care clinic is collecting data from a client who reports having diarrhea for
the past 3 days. Which of the following findings indicates hypokalemia?
Answer: Muscle weakness
6. A nurse is collecting data from a client who hgb is 8.8 mg/dL. Which of the following
statements should the nurse expect?
Answer: I feel tired all the time
7. A nurse is assisting with an admission interview for a client who has schizophrenia. He tells
the nurse that he is receiving special audible messages from the Central Intelligence Agency that
no one else is able to hear. The nurse should identify that the client is having which of the
following alterations in perception?
Answer: Hallucination
8. A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which
of the following client statements indicates to the nurse a need for further teaching?
Answer: "I will be sure to wear cotton socks."
9. A nurse is assisting with triaging clients in a mass casualty situation. The nurse should
recommend that which of the following clients receive care first?
Answer: A client who has diminished breath sounds and paradoxical chest movement
10. A nurse is caring for a child who has terminal cancer. Which of the following responses by
the child's siblings should the nurse expect?
Answer: The school-age sister is concerned about the impact of her sibling's death on herself
11. A home health nurse is reinforcing teaching with a client about kitchen safety. Which of the
following instructions should the nurse reinforce about using a fire extinguisher?
Answer: Sweep the extinguisher from side to side to put out the fire.
12. A nurse is reinforcing teaching with a client who has a new prescription for lithium
carbonate. Which of the following client statements indicates an understanding of the teaching?
Answer: "I will notify my provider if I develop a tremor."
13. A nurse is caring for a client who is 5 days postoperative following abdominal surgery. The
client tells the nurse that he was coughing and "felt a pop" at the incision site. The nurse
examines the incision and finds wound dehiscence and evisceration. Which of the following
actions should the nurse take?
Answer: Place the client in a side-lying position.
14. A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%.
Which of the following interventions should the nurse take first?
Answer: Repeat the test on another finger.
15. A nurse is observing the mother of a 12-hr-old newborn. Which of the following actions by
the mother requires intervention by the nurse?
Answer: The mother places the newborn in prone position.
16. After receiving change-of-shift report, which of the following clients should the nurse collect
data from first?
Answer: A client who has heart failure and reports severe dyspnea
17. A nurse is assisting with the admission of a client who has Hodgkin's disease and is receiving
chemotherapy. Because a private room is not available, the nurse should recommend that the
client share a room with a client who has which of the following diagnoses?
Answer: Community-acquired pneumonia
18. A nurse is evaluating a client who just attended a breastfeeding class. Which of the following
statements by the client demonstrates that she has understood the teaching?
Answer: "I will feed my baby each time he cries."
19. A nurse is reinforcing teaching about self-administration of nasal drops with a client. Which
of the following positions should the nurse recommend for instillation of the drops?
Answer: Supine
20. A nurse is receiving change-of-shift report on a group of clients. Which of the following
clients should the nurse see first?
Answer: A client who is exhibiting flight of ideas
21. A nurse in the newborn nursery is collecting data about a newborn's Moro reflex. Which of
the following actions should the nurse take to elicit this reflex?
Answer: Strike the crib surface on which the newborn is lying.
22. A nurse is caring for a school-age child who is scheduled for a bone marrow aspiration
biopsy. The child asks the nurse, "Will this be painful?" Which of the following is an appropriate
response by the nurse?
Answer: "There will be some pain, but I can give you medicine to make you more comfortable."
23. A nurse is assisting with the admission of a client who attempted suicide. When the nurse
processes the client's belongings, which of the following items should the nurse remove from the
client's suitcase?
Answer: Perfume
24. A nurse is caring for a client who is experiencing chest pain. The client states, "I am really
afraid because my brother died a year ago of a heart attack." Which of the following responses is
appropriate?
Answer: "This must be a frightening experience for you."
25. A nurse is collecting data from a client who is 1 day postoperative following a total hip
arthroplasty and has deep-vein thrombosis. Which of the following findings should the nurse
expect in the affected extremity?
Answer: Dull, aching pain
26. A nurse is contributing to the plan of care for a client who has bipolar disorder and is
experiencing mania. Which of the following actions should the nurse include in the plan of care?
Answer: Decrease the level of environmental stimuli.
27. A nurse is caring for a client who is receiving morphine 2 mg subcutaneously every 4 hr for
pain. The medication is available in a vial containing 10 mg/mL. How many ml should the nurse
administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a
trailing zero.)
Answer: 0.2 ML
28. A nurse is preparing to administer cefaclor to a preschooler who weighs 20 kg. The child is to
receive cefaclor 30 mg/kg/day to divide equally every 8 hr. Available is cefaclor suspension 125
mg/5 mL. How many ml should the nurse administer for one dose? (Round to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)
Answer: 8
29. A nurse is caring for a school-age child whose family adheres to a vegan diet in the home.
The nurse should recognize the child is at risk for deficiency of which of the following?
Answer: Vitamin D
30. A nurse is preparing to catheterize a client's bladder to check for residual urine. The nurse
should schedule this procedure at which of the following times?
Answer: Right after the client voids
31. A nurse is collecting data from a client who has diabetes mellitus. Which of the following
findings indicates the client might be experiencing diabetic ketoacidosis?
Answer: Anuria
32. A nurse is reinforcing teaching with a postpartum client. Which of the following should the
nurse explain as the most important reason for staff to wear identification?
Answer: Reducing the risk of newborn abduction
33. A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint
pain, swelling, and stiffness. Which of the following client statements indicates understanding of
the teaching?
Answer: I will exercise my joints as much as i can when they are inflamed
34. A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of
the following instructions should the nurse include in the teaching?
Answer: Refrain from using deodorant on the morning of the test
35. A nurse is preparing a clients insulin regimen. Which of the following insulin's can be
mixed?
Answer: Insulin aspart, regular insulin, insulin lispro
36. A nurse is caring for a client who had a stroke and is having difficulty swallowing. The nurse
should recommend a referral to which of the following members of the interprofessional team?
Answer: Speech therapist
37. A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy.
Which of the following instructions should the nurse include?
Answer: Change the perineal pad with each void
38. A nurse is collecting data from a child who has acute Glomerulonephritis. Which of the
following findings should the nurse expect?
Answer: Periorbital edema
39. A nurse in long-term care facility has received change-of-shift report about four clients.
Which of the following clients should the nurse attend to first?
Answer: A client who has COPD and dementia and was agitated during the night shift
40. A nurse is collecting data from a client who has substance use disorder and reports recently
taking opioids. Which of the following findings should the nurse identify as a manifestation of
opioid intoxication?
Answer: Pinpoint pupils
41. A nurse is contributing to the discharge plans for four clients. The nurse should identify that
which of the following clients requires an interdisciplinary care conference?
Answer: A client who has hemiparesis and lives alone
42. A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin.
For which of the following findings should the nurse instruct the adolescent to monitor and
report to the provider?
Answer: Depression
43. A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of
a car seat. Which of the following statements by a parent indicates an understanding of the
teaching?
Answer: I can place a rolled towel on each side of my newborns head until he can hold his head
up
44. A nurse is caring for a school-age child who has epistaxis. Which of them following actions
should the nurse take?
Answer: Apply pressure at the bridge of the child's nose
45. A nurse is caring for four clients. Which of the following clients statements should the nurse
attend to first?
Answer: My heartburn pain is going into my jaw now
46. A nurse in a providers office is talking on the phone with the parent of a school-age child
who has varicella.
Answer: All vesicles have crusted over
47. A nurse is administering a cleansing enema to a client who reports mild cramping during
instillation of the solution. Which of the following actions should the nurse take?
Answer: Slow the rate of instillation
48. A nurse receives report on four clients. The nurse should first collect data about the client
who has which of the following?
Answer: A decreased level of consciousness and vomiting
49. A nurse is setting up a sterile field prior to performing a dressing change. Which of the
following actions should the nurse take?
Answer: Open the outermost flap of the wrapper toward the body
50. A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of
the following actions should the nurse take?
Answer: Frequently remind the client of the expectations for her behavior
51. A nurse is caring for a client who has viral pneumonia. Which of the following actions
should the nurse take?
Answer: Administer Azithromycin
52. A nurse who orienting to a medical-surgical unit is having difficulty finishing client care
tasks during his shift. Which of the following suggestions should the nurse's preceptor make to
help the nurse with time management?
Answer: Try to complete a task before moving on to the next.
53. A nurse is caring for an older adult client who is postoperative following a total hip
arthroplasty. The nurse is preparing to change the client's dressing. Which of the following
actions should the nurse take to demonstrate sensitivity to age-related changes?
Answer: Use paper tape for securing the new dressing.
54. A nurse working in an inpatient mental health facility is assisting with the plan of care for a
client who has anorexia nervosa. Which of the following should the nurse recommend to include
in the plan of care?
Answer: Maintain continuity of staff members.
55. A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which
of the following statements should the nurse include?
Answer: "Wash your newborn's head under a stream of running water."
56. A nurse is caring for a client who has heart failure and reports difficulty limiting sodium in
his diet. Which of the following recommendations should the nurse provide?
Answer: Replace bottled salad dressing with homemade vinegar and oil dressing.
57. A nurse is reinforcing teaching about nonpharmacological pain relief with a client who is 6 hr
postpartum following a vaginal delivery. The client has an episiotomy and swelling of the labia.
Which of the following instructions should the nurse include?
Answer: Sit on soft pillows throughout the day.
58. A nurse is caring for a client who has a new colostomy. He voices a reluctance about
resuming sexual relations. Which of the following is an appropriate response by the nurse?
Answer: "I'm available if you'd like to talk about your concerns."
59. A nurse is reinforcing discharge teaching about transmission precautions with a client who
has hepatitis C. Which of the following information should the nurse include?
Answer: Avoid sharing razors with other family members.
60. A nurse is contributing to the plan of care for a client who has bulimia nervosa. Which of the
following interventions should the nurse recommend?
Answer: Observe the client for 1 hr after meals.
61. A nurse is assisting with the discharge planning for a client following a myocardial
infarction. Which of the following is an appropriate referral for this client?
Answer: Respiratory therapist for breathing exercises
62. A nurse is contributing to the discharge plan of an older adult client who had a total hip
arthroplasty. The client is unable to ambulate independently and lives alone. Which of the
following care settings should the nurse recommend for this client?
Answer: Skilled nursing facility
63. A nurse is reinforcing teaching with the parents of a preschool-age child who has a new
diagnosis of celiac disease. Which of the following foods should the nurse recommend?
Answer: Corn tortillas with black beans
64. A nurse is assisting with the admission of a client who has mononucleosis. Which of the
following isolation precautions should the nurse initiate?
Answer: Droplet
65. A nurse is speaking to a client who called the provider's office to report chest pain and
requests clarification on how to take his sublingual nitroglycerin tablets. Which of the following
instructions should the nurse give the client?
Answer: Wait 5 min between doses.
66. A nurse is caring for a client and begins to suspect he is experiencing transference. Which of
the following client statements should the nurse identify as an indicator of transference?
Answer: "I feel really close to you because you remind me of my ex-boyfriend."
67. A nurse is caring for a client who has been placed in restraints. Which of the following is
appropriate?
Answer: Monitor the client's skin integrity on a regular schedule.
68. A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse
should recognize that the client needs a referral for diabetic education when the client does
which of the following?
Answer: States that he will treat hypoglycemic reactions with 15 g of carbohydrates
69. A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about
the safety of a large sum of money in his wallet. Which of the following actions is appropriate
for the nurse to take?
Answer: Contact security personnel to place the money in the facility safe.
70. A nurse on a medical-surgical unit is planning care for a group of clients. Which of the
following tasks is appropriate to delegate to an assistive personnel?
Answer: Administer a large-volume enema to a client.
71. A nurse is reviewing the medical record of a client who has sustained a full-thickness burn
and is in the emergent phase of the burn. Which of the following findings should the nurse
expect?
Answer: Hypercalcemia
72. A nurse is collecting data from an 18-month-old toddler at a well-child visit. Which of the
following findings should the nurse report to the provider?
Answer: The toddler can say four words.
73. A nurse delegates a task to an assistive personnel (AP) and the AP refuses the assigned task.
Which of the following actions should the nurse take first?
Answer: Perform the task.
74. A nurse on a medical unit is observing an assistive personnel (AP) delivering food trays.
Which of the following actions by the AP requires intervention?
Answer: Providing a ham and cheese sandwich to a client who follows a kosher diet
75. A nurse is reinforcing teaching with a client who has a vitamin C deficiency. Which of the
following foods should the nurse include as having the highest vitamin C content?
Answer: 1 cup raw broccoli
76. A nurse is working in an urgent care clinic when a client who does not speak the same
language arrives with a laceration that will require suturing. Which of the following actions
appropriate for the nurse to take?
Answer: Ask an assistive personnel who speaks the same language as the client to assist in
obtaining informed consent.
77. A nurse is collecting data from a client who has dehydration and is receiving continuous IV
therapy. Which of the following findings indicates effectiveness of the IV therapy?
Answer: BUN 16 mg/dL
78. A nurse is caring for a client who attempted suicide. Which of the following actions should
the nurse take?
Answer: Serve meals with plastic utensils.
79. A nurse is removing a female client's indwelling urinary catheter. Which of the following
actions should the nurse take?
Answer: Withdraw the fluid from the catheter's balloon.
80. A nurse is collecting data from a parent of a preschooler at a well-child visit. Which of the
following findings is a contraindication to a measles, mumps, and rubella (MMR)
immunization?
Answer: Long-term use of immunosuppressants
81. A nurse is caring for a client who is asking about the technique of effleurage and its use in
labor and delivery. Which of the following responses should the nurse make regarding this
technique?
Answer: "It is a light stroking of the skin during a uterine contraction."
82. A nurse is preparing to administer required immunizations to a toddler during a well-child
visit. The parent asks the nurse how many baby aspirins he should administer if the toddler
develops a fever. Which of the following responses should the nurse make?
Answer: "You should follow the label directions based on your child's weight."
83. A nurse is caring for a client who is in mechanical restraints after becoming violent with a
staff member. Which of the following actions should the nurse take?
Answer: Request that the provider write an as-needed prescription for restraints.
84. A nurse is reinforcing teaching with an older adult client who has a new prescription for
digoxin for heart failure. Which of the following effects should the nurse include as an expected
outcome of this medication?
Answer: Increased heart rate
85. A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of
the following actions should the nurse recommend for the plan of care?
Answer: Give directions using simple phrases.
86. A nurse is caring for a client in a provider's office. The client asks about the purpose of a
living will. Which of the following is the appropriate response by the nurse?
Answer: "It expresses your wishes regarding health care when you can no longer communicate."
87. A nurse is planning to administer an ophthalmic medication to a client. Which of the
following actions will minimize systemic absorption of the medication?
Answer: Wait 5 min after instillation before instilling the drops in the other eye.
88. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA)
infection. Which of the following actions should the nurse plan to take?
Answer: Don a gown and gloves when providing perineal care.
89. A nurse is reviewing the medical record of a client who is requesting an oral contraceptive.
Which of the following findings should the nurse identify as a contraindication to the use of oral
contraceptives?
Answer: History of renal calculi
90. A nurse is caring for a client who is undergoing evaluation for a thoracic aortic aneurysm.
Which of the following findings should make the nurse suspect an impending rupture of the
aneurysm?
Answer: Cough with hemoptysis
91. A nurse collecting data from a client who is receiving a continuous IV infusion of 0.9%
sodium chloride. The nurse discovers the IV infusion pump was set incorrectly and the client
received 200 mL more than prescribed. Data collection reveals that the client is stable. The nurse
recognizes that this incident is not considered malpractice for which of the following reasons?
Answer: The client was not harmed as a result of the incident.
92. A nurse is escorting a client to his car following discharge from an acute mental health
facility. The client states intentions to harm a friend when he leaves the facility. Which of the
following actions should the nurse take?
Answer: Prevent the client from leaving the facility.
93. A nurse is planning to reinforce teaching with a preschooler who is about to undergo an
incision and drainage for cellulitis on the left arm. Which of the following techniques should the
nurse use?
Answer: Take the child on a tour of the surgery and recovery areas.
94. A nurse receives a verbal order for a client to receive a stat dose of meperidine 100 mg PO.
She administers the medication, charts the administration, and then realizes she has administered
phenytoin 100 mg PO. Which of the following actions should the nurse take first?
Answer: Check the client's vital signs.
95. A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a
client who has type 1 diabetes mellitus. Which of the following actions should the nurse take
first?
Answer: withdraw 5 units of regular insulin from the vial.
96. A nurse in a mental health facility is reviewing the laboratory reports for four clients. Which
of the following results should the nurse report to the provider immediately?
Answer: Sodium level of 130 mEg/L for a client who has bipolar disorder and takes lithium
97. A nurse is reinforcing teaching with a client who is about to undergo an upper
gastrointestinal series with fluoroscopy. Which of the following information should the nurse
provide?
Answer: "You will receive an injection of contrast dye during the test."
98. A nurse is preparing morning medications for a client who has a potassium level of 3.2
mEq/L. For which of the following medications should the nurse withhold administration and
notify the provider?
Answer: Furosemide
99. A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For
which of the following results should the nurse notify the provider?
Answer: Ketones positive
100. A nurse is admitting a client who has active tuberculosis. Which of the following nursing
interventions is appropriate?
Answer: Place the client in a room that is ventilated to the outside.
101. A nurse is caring for a client who was recently admitted to an inpatient mental health unit.
The client tells the nurse that he is not coming out of his room anymore because other clients on
the unit make fun of him. Which of the following responses by the nurse is appropriate?
Answer: "You feel upset by the responses of others."
102. A nurse is caring for a client who is receiving total parenteral nutrition. Which of the
following laboratory results indicates a possible complication of this therapy?
Answer: Serum calcium 12.5 mg/dL
103. A nurse in the newborn nursery is planning to obtain blood from a newborn by a heel stick.
Which of the following actions should the nurse plan to take?
Answer: Apply a heat pack 5 to 10 min prior to the procedure.
104. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the
appropriate assignment for the nurse to accept?
Answer: A client who had a cesarean delivery 24 hr ago
105. A client who is participating in an anger management session explains that his recent
behaviors are related to his job loss. Which of the following defense mechanisms is the client
using?
Answer: Rationalization
106. A nurse working at a crisis hotline call center receives a call from a client who states, "I
cannot take it. My life is over." Which of the following is the priority response by the nurse?
Answer: Are you thinking of harming yourself?"
107. A nurse is reinforcing teaching with the parents of a newborn who had a circumcision.
Which of the following client statements indicates understanding of the teaching?
Answer: "I will apply petroleum jelly to the penis with each diaper change."
108. A client's daughter calls the nurse requesting information about her mother's condition. The
client's chart does not specify that information can be released to the daughter. Which of the
following is an appropriate response by the nurse?
Answer: "You will need to contact your mother directly about her condition."
109. A nurse is caring for a 17-year-old client who admitted for an emergency appendectomy.
Which of the following is an appropriate action by the nurse in obtaining informed consent?
Answer: Delay the procedure if the provider cannot contact the parents.
110. A nurse is reinforcing teaching about home care with the parents of a child who has a
seizure disorder. Which of the following instructions should the nurse include?
Answer: Call EMS if a seizure lasts 5 min or more.
111. A nurse in a mental health unit asks a client who has schizophrenia, "How are you?" Which
of the following responses should the nurse identify as the speech alteration of echolalia?
Answer: "How are you?"
112. A nurse is reinforcing teaching with the family of a client who is receiving palliative care
for terminal cancer. Which of the following guidelines should the nurse emphasize about
appropriate pain control measures?
Answer: Administer pain medication on a regular schedule.
113. A nurse in an acute mental health facility observes a client having a panic attack. Which of
the following interventions should the nurse implement first?
Answer: Instruct the client to use abdominal breathing.
114. A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a
cleft palate repair. Which of the following pain rating tools should the nurse use?
Answer: FLACC scale
115. A nurse is caring for a client who has a new prescription for furosemide. The client asks the
nurse about the purpose of the medication. The nurse tells the client, "This medication is a
diuretic, and you should monitor your weight while taking it." Which of the following ethical
concepts is the nurse exhibiting?
Answer: Veracity
116. A nurse is expressing concern about his assignment with the charge nurse. The nurse states
that he has more work to do than anyone else. Which of the following statements by the charge
nurse demonstrates the conflict resolution strategy of competing?
Answer: "We will take a look at the assignments together and attempt to modify the workload
you are concerned about."
117. A nurse working on a mental health unit is meeting with a client who has been on the unit
for 2 days. The nurse greets the client and asks, "What has been happening with you today?"
Which of the following therapeutic techniques is the nurse using?
Answer: Focusing
118. A nurse discovers a fire in a trash can in a client's room. Which of the following actions
should the nurse take first?
Answer: Walk the client to the waiting room.
119. A nurse is caring for a client who is postoperative following a femoral cardiac
catheterization. Which of the following actions should the nurse take during the first 30 min?
Answer: Compare the bilateral peripheral pulses.
120. A client who has inoperable cancer tells the nurse that she does not want to pursue the
recommended treatment. She asks if the provider can force her to have the treatment. Which of
the following is an appropriate response by the nurse?
Answer: "You have the right to refuse the recommended treatment plan."
121. A nurse is reinforcing teaching with a client who is about to undergo a thoracentesis. Which
of the following statements by the client indicates an understanding of the information?
Answer: "I will have a chest x-ray following the procedure."
122. A nurse is reinforcing teaching with a client who has a permanent pacemaker in place.
Which of the following statements by the client indicates an understanding of the teaching?
Answer: "I will remove my microwave oven from my home."
123. A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis
(MG) and a prescription for neostigmine. Which of the following information should the nurse
include about the action of the medication?
Answer: Improves muscle strength
124. A nurse is assisting with the admission of an older adult client who has impaired mobility
and is at risk for falls. Which of the following actions should the nurse plan to perform first?
Answer: Check the client's ability to use the call light.
125. A nurse is assisting with the admission of an older adult client. Which of the following
subjective findings suggests that the client may have cataracts?
Answer: Cloudy vision
126. A nurse is caring for a client who was diagnosed with hyperemesis gravidarum. Which of
the following findings should the nurse anticipate?
Answer: Poor skin turgor
127. A nurse is reinforcing discharge teaching with an older adult client who has osteoarthritis.
Which of the following statements by the client indicates an understanding of the teaching?
Answer: "I will limit purine intake in my diet."
128. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse
should include that which of the following situations requires completion of an incident report?
Answer: A nurse collects data from a client who reports severe pain and finds a dose of
hydromorphone in the client's bed.
129. A nurse is reinforcing teaching with a client who has rheumatoid arthritis and is using a
straight-legged cane for ambulation. Which of the following instructions should the nurse
include?
Answer: "Keep the cane on the stronger side of the body."
130. A nurse is participating in a performance improvement process to decrease the rate of health
care- associated infections within the facility. The nurse should recognize that which of the
following is an appropriate performance improvement outcome indicator?
Answer: Client data indicates a decreased rate of infection.
131. A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease
and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend
to include in the plan of care?
Answer: Perform passive range-of-motion exercises.
132. A nurse is collecting data from a client who has hepatitis A. Which of the following findings
should the nurse expect?
Answer: Abdominal pain
133. A nurse is collecting data from a client who has preeclampsia and is receiving magnesium
sulfate via a continuous IV infusion. Which of the following findings should the nurse report to
the provider?
Answer: Urine output 20 mL/hr
134. A nurse is orienting a newly licensed nurse to a medical-surgical unit. Which of the
following actions should the nurse take to verify that the newly licensed nurse understands the
procedure for measuring a client's blood glucose level?
Answer: Have the nurse perform a return demonstration.
135. A nurse is caring for a client who has a new prescription for a protective safety restraint.
Which of the following actions should the nurse take?
Answer: Secure the restraint with an easy-to-release tie.
136. A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic
relationship should the nurse help the client develop problem-solving skills?
Answer: Working phase
137. A nurse is monitoring a client who is receiving a blood transfusion. Which of the following
findings indicates the client is experiencing an allergic reaction?
Answer: Urticaria
138. A nurse is assisting in the care of a client who is experiencing a postpartum hemorrhage.
Which of the following medications should the nurse plan to administer?
Answer: Methylergonovine
139. A nurse is caring for an older adult client who has pneumonia. When reinforcing teaching
about the diagnosis and age-related changes with the client's family, which of the following
alterations should the nurse include?
Answer: Increased elasticity of the thoracic cage
140. A nurse is collecting data from the guardian of a toddler during a well-child visit. The
guardian expresses concern to the nurse because his child has a poor appetite, but drinks a quart
of milk each day. The nurse should identify that this practice places the toddler at risk for which
of the following conditions?
Answer: Lactose intolerance
141. A nurse is applying a condom catheter to a male client who is incontinent. Which of the
following is an appropriate technique to use?
Answer: Leave space between the tip of the penis and the end of the condom catheter.
142. A nurse is assisting in the preparation of an in-service for a group of unit nurses about
ethical principles. Which of the following nursing actions should the nurse include as an
example of fidelity?
Answer: A nurse keeps a promise made to a client.
143. A nurse is assisting with a group therapy session in which a client begins to monopolize the
group's time. Which of the following interventions is appropriate?
Answer: Schedule one-on-one discussion time with the client.
144. A nurse is caring for a client who is 3 days postoperative following abdominal surgery and
has a Penrose drain. Which of the following actions should the nurse take?
Answer: Reposition the sterile safety pin when the surgeon advances the drain.
145. A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hr postoperative
following a tonsillectomy. Which of the following findings is a sign of hemorrhage?
Answer: Frequent swallowing
146. A nurse in a long-term care facility is observing an assistive personnel (AP) who is
performing hand hygiene. Which of the following actions by the AP requires intervention?
Answer: Holding his hands up and elbows down while washing his hands
147. A nurse is establishing a baseline postoperative assessment for a client who is recovering
from a right femoropopliteal bypass graft. Which of the following findings in the assessment of
the client's right leg should be of the most concern to the nurse?
Answer: The client's pedal pulse in the right foot is not palpable.
148. A nurse is reviewing standard precautions with an assistive personnel (AP) who is new to
the newborn nursery. For which of the following newborn care procedures should the nurse
remind the AP to wear clean gloves?
Answer: Applying an identification bracelet
149. A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60
mm Hg. Which of the following actions should the nurse take?
Answer: Instruct the client to stand up slowly.
150. A nurse is checking the home environment of a client for safety hazards. Which of the
following items require intervention by the nurse?
Answer: The television set is turned to a loud volume.
151. A nurse is reinforcing teaching with a client about the importance of a low-sodium diet.
Which of the following foods should the nurse recommend as the best choice to include in a
low-sodium diet?
Answer: 1 medium baked potato
152. A nurse in a prenatal clinic is reinforcing teaching with a client about a nonstress test.
Which of the following statements should the nurse include?
Answer: "You will be asked to press a button when you feel your baby move."
153. A nurse is preparing to instill an otic suspension into an adult client's ear. Which of the
following methods should the nurse plan to use?
Answer: Pull the auricle upward and backward.
154. A nurse is reinforcing teaching about colostomy care with a client. Which of the following
client statements indicates an understanding of how to care for the colostomy?
Answer: "I will empty the colostomy bag when it is one-half full,"
155. A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the
following is the best indication that the client needs PRN pain medication?
Answer: The client reports pain.
156. A charge nurse in a long-term care unit is planning care for a group of clients. Which of the
following care tasks should the nurse plan to delegate to an assistive personnel?
Answer: Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract
infection
157. A nurse in a provider's office is reinforcing teaching with the parents of a school-age child
who has an active case of Pediculosis humanus capitis. Which of the following should the nurse
include in the teaching?
Answer: Wash the bed linens in hot water.
158. A nurse in an inpatient mental health facility is caring for a client who has bipolar disorder
and is in an acute manic episode. Which of the following activities should the nurse suggest for
the client?
Answer: Take a walk with a staff member,
159. A nurse is reinforcing healthy eating habits for an older adult client to ensure adequate
dietary intake. Which of the following is an appropriate recommendation?
Answer: Snack between meals.
160. A nurse is preparing to administer an IM injection to a client. To reduce the risk of a
needlestick injury, the nurse should take which of the following actions?
Answer: Dispose of the used needle immediately in a puncture-proof sharps container.
161. A nurse is reviewing the laboratory results for a client who is at 32 weeks of gestation. For
which following results should the nurse notify the provider?
Answer: Platelet count 90,000/mm3
162. A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine.
Which of the following statements indicates understanding of the instructions?
Answer: "I need to take this medication for the rest of my life."
163. A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse
should use which of the following routes?
Answer: Intradermal
164. A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a
combination contraceptive transdermal patch. Which of the following should the nurse include in
the teaching?
Answer: Apply the patch to the lower abdomen,"
165. A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which
of the following foods should the nurse include?
Answer: Graham crackers
166. A nurse is caring for a client who has COPD. The client tells the nurse, "I get short of breath
during meals. It is too much trouble to eat." Which of the following instructions should the nurse
suggest?
Answer: "Have several small meals during the day."
167. A nurse working in a long-term care facility is assisting with the plan of care for a client
who has Alzheimer's disease. The nurse notes that the client wanders the halls at night and says
she is looking for the bathroom. Which of the following interventions should the nurse
recommend to include in the plan of care?
Answer: Label the client's bathroom door.
168. A nurse is reinforcing discharge teaching with an older adult client's family about safety
precautions when administering a tap water enema to the client. Which of the following should
the nurse include in the instructions?
Answer: Instruct the client to bear down during rectal tube insertion.
169. A client who is prescribed metoprolol for hypertension tells the nurse, "I don't want to take
this medication because makes me tired all the time." Which of the following is the appropriate
response?
Answer: "Let's talk with your doctor about other options."
170. A nurse on a mental health unit is discussing client rights with a group of coworkers. Which
of the following statements should the nurse include?
Answer: "A client must withdraw consent for treatment in writing if he is competent to do so."
171. A nurse is reinforcing teaching with the parent of a toddler who has difficulty falling asleep.
Which of the following instructions should the nurse include?
Answer: Establish a bedtime routine.
172. A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the
following laboratory values should the nurse check prior to administering the medication?
(Select all that apply.)
Answer: PT Serum potassium INR Serum sodium BUN
173. A nurse is caring for a client who has urolithiasis. Which of the following actions should the
nurse take?
Answer: Strain the client's urine.
174. A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain
medication. After the nurse administers the medication, which of the following tasks should the
nurse assign to the AP?
Answer: Document the client's respiratory rate in 1 hr.
175. A nurse in a provider's office is collecting data from a client who was discharged from the
hospital 7 days ago following treatment for deep-vein thrombosis. Which of the following
findings is the nurse's priority? (Click on the "Exhibit" button for additional information about
the client. There are three tabs that contain separate categories of data.)
Answer: The client takes ibuprofen daily to treat musculoskeletal pain.
