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A client has ill-fitting dentures and limited intake of high-fiber foods. Based on this information, which of these potential problems may the patient experience?
Constipation.
Inadequate caloric intake.
Malabsorption of nutrients.
Dehydration.
2. When evaluating the effects of heat application on a body part, which of these outcome criteria should a nurse expect the heat to accomplish?
Increased venous congestion on the area of application.
Reduction of blood flow to tissues around the affected area.
Construction of peripheral blood vessels surrounding the area.
Increase supply of oxygen and nutrition to the area.
3. When turning a client to the side-lying position, which actions should a nurse take?
Put a footboard against the bottom of the client’s feet.
Place a small pillow under the client’s lumbar spine.
Place a rolled pillow parallel to the client’s back.
Put a small pillow under the client’s ankles.
4. A nurse is caring for a client with vaso-occlusive sickle cell crisis. What is the major purpose of administering intravenous fluids to patients with this condition?
To prevent atrophic changes in the spleen.
To prevent hemolysis of the sickled red blood cells.
To promote intravascular hemodilution.
To hydrate the sickled red blood cells.
5. What is the purpose of the placement of a nasogastric tube for a client who is in the immediate postoperative phase following an appendectomy?
To prevent paralytic ileus.
To monitor the amount of the client’s gastric secretions.
To monitor the pH of the client’s gastric secretions.
To prevent abdominal distention.
6. The nurse is to record the intake and output of a 2-year-old client. The client is not toilet trained. Which measure would be most appropriate to include in the patient’s plan of care?
Obtaining an order to have an indwelling urinary catheter inserted.
Sitting the client on the bedpan at least every two hours.
Applying a pediatric urine collection device over the patient’s urinary meatus
Weighing the client’s wet diapers prior to discarding them 7. The nurse reviews the medical prescription for preparation of a client for cesarean delivery. Which medical order should the nurse question?
Do an abdominal shave and prep.
Catheterize client with a straight catheter.
Obtain a blood type and cross match.
Initiate intravenous infusion using an 18-gauge catheter.
8. A woman has determined that she would like to bottle feed her infant. The nurse should provide which of the following instructions regarding this feeding method?
Expect a 2-week-old newborn to drink approximately 90-150 mL of formula at each feeding time.
Microwave refrigerated formula for about 2 minutes before feeding the newborn.
Water must be sterilized by boiling, then cooled and mixed with formula powder or concentrate.
Check the nipple before feeding to ensure that it allows passage of formula in a slow stream.
9. Which statement made by a client with a gastric ulcer demonstrates a need for further dietary instructions?
“I can eat pretzels for a snack.”
“I can have yogurt between meals.”
“I can eat bran cereal for breakfast with toast and jelly.”
“I can drink coffee with meals and between meals.”
10. Which measure should the nurse include while caring for a client who has been diaphoretic for the past six hours?
Changing the bed linens frequently.
Providing oral care every four hours.
Keeping an emesis basin near the bedside.
Offering the client a bedpan every six hours.
11. Which assignment, delegated to unlicensed assistive personnel (UAP) by a nurse, is appropriate?
The UAP is assigned to assess a client’s lung sounds
The UAP is assigned to measure a client’s intake and output.
The UAP is assigned to teach a client about diet restrictions
The UAP is assigned to change a client’s postoperative wound dressing
12. Each of these clients has impaired mobility related to knee surgery. Which clients should a nurse assess first?
A 70-year-old who has bilateral cataracts.
A 20-year-old who has a sports-related injury.
A 59-year-old who has a history of hypertension.
A 37-year-old who reports limited mobility.
13. Which factor should a nurse consider when delegating tasks to unlicensed assistive personnel (UAP)?
The UAP’s willingness to perform tasks.
The UAP’s duration of employment on the unit.
The UAP’s previous experiences on the unit.
The UAP’s relationship with clients.
14. The nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened to a client at 9:00 A.M. that was not charted. Which action would the nurse take?
Draw a line through the previous charting with “error” and then re-record everything, including the new information.
Puth the information in the margin and indicate the accurate time placement by drawing an arrow.
Include the 9:00 A.M. scenario in the shift report.
Enter the scenario after the original 2:00 P.M. charting and mark it as a “late entry.”
15. Which statement by the client would the nurse recognize as suggestive of hypothyroidism?
“I feel cold and tired all the time.”
“My hands shake whenever I reach for anything.”
“I sweat whenever I walk more than one block.”
“My head aches each evening.”
16. Which action would the nurse include to enhance the effectiveness of client teaching sessions?
Include all clients on the unit in the sessions.
Initially demonstrate and explain the procedure to the client.
Avoid repetition of content.
Include all content in one session so as not to overwhelm the patient.
17. Which task should the licensed practical nurse (LPN) delegate to the nursing assistant?
Measuring the pulse oximetry level for a client that has status asthmaticus.
Ambulating a client that had hip replacement surgery three days ago.
Changing the dressing for a client that had would debridement last week.
Checking the A.M. blood sugar for a client that has ketoacidosis.
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18. All of the following tasks need to be accomplished. Considering client safety, which task should be delegated to the nurse rather than delegating it to unlicensed personnel?
“Re-positioning a client that had a stroke one week ago.”
“Using an electric razor to shave a client that is on anticoagulant therapy.”
“Emptying all of the unit urinary collection bags and tabulating shift outputs.”
“Feeding a client who has dysphagia.”
19. Which of these nursing actions is an example of malpractice?
Injuring a back muscle while lifting a client up in bed.
Incorrectly informing a family member that they need to wear a mask when visiting a client.
Yelling at a client who has been ringing the call bell constantly for two hours.
Neglecting to report a decrease in blood pressure in a client who then develops shock.
20. The nurse administers a client’s morning dose of furosemide at 8 PM. The client gets up several times during the night to urine. The nurse’s action is an example of?
Negligence, since the nurse was careless when reading the order.
Allowable nursing practice, since the medication was administered on the correct day.
Malpractice, since the client’s sleep was disturbed.
A medication error, since the medication was administered at the wrong time.
21. Which of these employees demonstrates the competency of commitment to work ethic as expected by employers?
An employee who documents relevant data observations of clients.
An employee who applies theory into clinical practice.
An employee who volunteers to work overtime frequently.
An employee who arrives on time and takes only the allowed breaks.
22. Which of these actions, if taken by the nurse, indicates a correct application of the principles of delegation to unlicensed assistive personnel?
The nurse assigns the task of taking vital signs for all clients in the ICU.
The nurse delegates the task of interpreting data to the unlicensed assistive personnel.
The nurse delegates the task of evaluating treatment effectiveness.
The nurse assesses each client prior to delegating tasks to the unlicensed assistive personnel.
23. Which of these topics should the nurse include in the teaching plan for the parents of a child who has asthma?
The use of the stethoscope to monitor the child’s breath sounds.
The identification of the early symptoms of an asthmatic attack.
The importance of activity restrictions to prevent attacks.
The accurate counting of the respirations per minute.
24. The nurse gives instructions to a client that is receiving high dose of nonsteroidal anti-inflammatory drugs. Which of these statements, if made by the client, would indicate to the nurse that the client understands the instruction?
“I should call my doctor when I have frequent urination.”
“I’ll stop the medication if I get loose stools.”
“I will expect the medicine to give ne constipation.”
“I’ll notify the doctor if I experience epigastric pain.”
25. Which of the following actions would the nurse recognize as potential risk for causing a medication error?
Questioning the doctor about a dosage that is greater than usual.
Administering the medication and looking up information about the medication afterward.
Checking with the pharmacist when multiple tablets are needed for a single dose.
Removing the unit dose wrapper from the medication at the medication room.
26. Which of these clients is at risk for osteoporosis due to inadequate calcium intake?
A nursing mother who eats yogurt with each meal.
An elderly female who eats cottage cheese for breakfast and lunch
A thin female who limits dairy products because of lactose intolerance
An obese adolescent who eats ice cream daily after exercising.
28 When assessing a client’s abdomen, the nurse should perform which of these techniques first?
Percussion
Inspection
Auscultation
Palpation

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