Question: A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?
Answer Options:
A 2-year-old child who has diarrhea and reports abdominal pain
A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL
A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions
A 3-year-old child who has an atrial septal defect and a heart rate of 120/min
Answer: A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions
Question: A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?
Answer Options:
Cleanse the client’s meatus with antiseptic solution
Lubricate the catheter with water-soluble gel
Attach a prefilled syringe to the catheter inflation hub
Position the sterile drape leaving the perineum exposed
Answer: Position the sterile drape leaving the perineum exposed
Question: A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?
Answer Options:
Ketonuria
Tachypnea
Nervousness
Warm skin
Answer: Nervousness
Question: A nurse observes two assistive personnel (AP) discussing a client’s information in the facility cafeteria. Which of the following actions should the nurse take?
Answer Options:
File an incident report with the risk management department
Notify the client of the breach of confidentiality
Notify the ethics committee of the breach of confidentiality
Remind the AP about maintaining client confidentiality
Answer: Remind the AP about maintaining client confidentiality
Question: A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?
Answer Options:
A client who had a right hemisphere stroke
A client who has a right peripherally inserted central catheter
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm
A client who had blood drawn from the right antecubital area 1 hr ago
Answer: A client who has a right peripherally inserted central catheter
Question: A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?
Answer Options:
Monitor the client’s temperature every 4 hr
Use clean technique for invasive procedures
Make sure the client’s room is cleaned every 2 days
Allow healthy children to visit
Answer: Monitor the client’s temperature every 4 hr
Question: A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client’s bedside?
Answer Options:
Padded clamp
Tracheostomy tray
Montgomery straps
Wire cutters
Answer: Padded clamp
Question: A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
Answer Options:
Transfer a client to physical therapy
Obtain a client’s vital signs every 4 hr
Instruct a client on the use of an incentive spirometer
Insert an NG tube for a client who requires enteral feedings
Record a client’s intake after each meal
Answer: Transfer a client to physical therapy
Obtain a client’s vital signs every 4 hr
Record a client’s intake after each meal
Question: A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client’s plan of care?
Answer Options:
Strain the client’s urine
Attach a dosimeter to the client’s gown
Limit each of the client’s visitors to 2 hr per day
Instruct visitors to stay 1 m (3.3 feet) away from the client
Answer: Strain the client’s urine
Question: A school nurse is using the Weber’s test to check a child’s hearing acuity. Which of the following actions should the nurse take?
Answer Options:
Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child’s ears
Measure the amount of time the child can hear the sound
Obtain a tympanogram reading prior to initiating the test
Place a vibrating tuning fork on the top of the child’s head
Answer: Place a vibrating tuning fork on the top of the child’s head
Question: A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?
Answer Options:
“Plan for your son to meet his sister for the first time at home.”
“Give your son a little gift from his new sister.”
“Give your son plenty of ‘alone time’ with his sister.”
“Hold your daughter when your son first meets her.”
Answer: “Give your son a little gift from his new sister.”
Question: A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client’s risk for acquiring a UTI?
Answer Options:
Loop the tubing so that it is lower than the collection bag
Obtain urinary samples by disconnecting the tubing connections
Keep the urinary bag at bladder level when ambulating
Secure the catheter to the client’s thigh
Answer: Secure the catheter to the client’s thigh
Question: A nurse is assessing a client who has Alzheimer’s disease and has been taking donepezil. Which of the following information is the priority for the nurse to report to the provider?
Answer Options:
Loss of weight since previous visit
Heart rate 54/min
BP 120/78 mm Hg
New onset of incontinence
Answer: Heart rate 54/min
Question: A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take?
Answer Options:
Withdraw the NPH insulin before the regular insulin
Administer the mixture within 5 min of preparing it
Shake both insulin vials for 2 min before withdrawing the doses
Inject air into the regular insulin vial before injecting air into the NPH vial
Answer: Administer the mixture within 5 min of preparing it
Question: A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?
Answer Options:
Abdominal cramping
Breathlessness
Heartburn
Constipation
Answer: Heartburn
Question: A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?
Answer Options:
Instruct the client to use an overbed trapeze to move around in bed
Place the client on an air mattress
Turn the client every 4 hr while in bed
Rewrap the bandage every 8 hr in a circular pattern
Answer: Instruct the client to use an overbed trapeze to move around in bed
Question: A nurse is preparing assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? (Select all that apply.)
Answer Options:
Transfer a client to physical therapy
Obtain a client’s vital signs every 4 hr
Instruct a client on the use of an incentive spirometer
Insert an NG tube for a client who requires enteral feedings
Record a client’s intake after each meal
Answer: Transfer a client to physical therapy
Obtain a client’s vital signs every 4 hr
Record a client’s intake after each meal
Question: A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client’s plan of care?
Answer Options:
Strain the client’s urine
Attach a dosimeter to the client’s gown
Limit each of the client’s visitors to 2 hr per day
Instruct visitors to stay 1 m (3.3 feet) away from the client
Answer: Strain the client’s urine