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Q: The nurse is caring for a client with a hearing aid. In which order should the nurse care for this hearing device? Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Perform hand hygiene and wear appropriate personal protective equipment. Response 2. Wipe the casing with dry cloth. Response 3. Check the batteries. Response 4. Cleanse the outer ear gently with a cotton-tipped applicator. Response 5. Determine ability of client to perform all or part of cleaning procedure. Response 6. Insert ear mold and turn the switch to ON.

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Q: The nurse is completing evening care for a client. What should the nurse do before documenting that this care has been completed? 1. Straighten top linens 2. Raise upper side rails 3. Remove any unnecessary equipment 4. Fluff pillow and turn cool side next to client

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Q: The nurse is reviewing bed making with newly hired unlicensed assistive personnel (UAP). What should the nurse explain as the reason for mitering the corners of the bed linen? 1. Keeps the bed linens tight 2. Helps the client stay in bed 3. Makes raising the side rails easier 4. Prevents the mattress from moving

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Q: Which explanation is the most accurate when describing PM care to a client? 1. Providing for elimination needs, washing face and hands, giving oral care, and possibly a back massage. 2. Providing care when the client awakens to include providing urinal or bedpan, washing of face and hands, and giving oral care 3. Providing care that includes elimination needs, a bath or shower, perineal care, and oral, nail, and hair care. 4. Providing care required by the client such as changing of linen and clothes when they become soiled.

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Q: The nurse is making beds on the medical"surgical unit. What should the nurse do differently when making a surgical bed versus an open unoccupied bed? Standard Text: Select all that apply. 1. Strip the bed. 2. Do not tuck, miter, or toe-pleat the top covers. 3. Fold top sheets into a triangle at the side of the bed. 4. Place pillows on the chair beside the bed. 5. Raise the bed to a comfortable working height.

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Q: The nurse is caring for a client who is on bed rest with bathroom privileges. While the client is in the bathroom, the nurse changes the client's bed and should make the bed in what way? 1. Unoccupied open bed 2. Occupied open bed 3. Unoccupied closed bed 4. Surgical bed

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Q: When putting a client in restraints, the nurse will need to assess the client per policy. Which items will the nurse include when assessing this client? Standard Text: Select all that apply. 1. The client's range of motion 2. That the client's restraint is tied in a knot 3. The client's vital signs 4. The client's circulation 5. The client's hydration

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Q: The nurse is delegating supportive care to unlicensed assistive personnel (UAP) for several clients on a medical"surgical unit. Which statement made by the UAP warrants the need for more information? 1. "I can untie the restraint when giving the client a bath." 2. "I will make sure to tie the restraint in a slip-knot." 3. "I will inform you of any changes to the skin." 4. "I will assist the client with hygiene."

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Q: The nurse completes yearly training regarding the use of restraints. Which situation should the nurse categorize as a restraint? 1. A safety belt applied across the client's waist when sitting in a geri chair with a quick release button demonstrated to the client 2. The use of the top side rail to provide something for the client to hold on to when getting out of bed 3. A safety belt around the infant when placing the child in a swing 4. The use of all four side rails on the bed after administering preoperative sedation

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Q: The nurse is preparing to ambulate a client in the hall. Which action by the nurse is a strategy to reduce the client's risk of falls? 1. Encouraging client to wear nonskid footwear 2. Cautioning the client about cords or clutter on the floor 3. Encouraging the client to continue walking after complaints of feeling tired 4. Acting as the client's means of support instead of using a walker to provide additional support

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Q: A client with gastric ulcers has been taking licorice root. Which finding should suggest to the nurse that the client should stop taking this herbal preparation? 1. Diarrhea 2. Insomnia 3. Dry mouth 4. Elevated blood pressure

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Q: The family of a client undergoing treatment for cancer is concerned about the client's unwillingness to spend time or talk with any family members. Which category of stress is this client demonstrating? Select all that apply. 1. Behavioral 2. Physiologic 3. Interpersonal 4. Psychological 5. Developmental

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Q: During an assessment the nurse considers that a client's new onset of symptoms is because of an increased amount of stress. What did the nurse assess to make this clinical determination? Select all that apply. 1. Sweating 2. Warm dry skin 3. Rapid heart rate 4. Elevated blood pressure 5. Increased depth of respirations

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Q: A client is observed in the clinic waiting room bouncing both legs and snapping the fingers. After a short while the client stands and begins to pace. On what should the nurse focus when assessing this client? 1. Level of pain 2. Reason for the anxiety 3. Fear of health problems 4. Frustration with waiting

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Q: The nurse suspects that a client is experiencing stress. Which observation indicates that the client's manifestations fit Hans Selye's definition of this disorder? Select all that apply. 1. Weight gain 2. Loss of appetite 3. Inability to sleep 4. Planning a vacation 5. Increased blood glucose level

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Q: The nurse is caring for a client who is experiencing acute pain. Which action by the client, noted by the nurse during the assessment, is considered an associated symptom of pain? 1. Changing position 2. Crying 3. Grimacing 4. Vomiting

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Q: The nurse is working on the orthopedic unit, and is caring for a client who complains of back pain. Which responses by the nurse would be appropriate when caring for this client? Standard Text: Select all that apply. 1. "I'm sorry you're hurting. I want to make you feel better." 2. "People with back pain experience very different symptoms. Tell me more about your back." 3. "You had medication for your pain at 4 p.m., so I can't give you any more until 8 p.m., because the health care provider ordered it every 4 hours." 4. "Does anything other than your back hurt?" 5. "Why don't you try another position to make it feel better until it's time for more pain medication?"

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Q: The nurse is working on a surgical unit, and overhears another nurse say, "That client is asking for pain medication again. He is constantly on the call bell, always reporting how severe his pain is, and I think he's just drug-seeking. I'm going to make him wait the full 4 hours before I give this medication again." Which action by the nurse is the most appropriate in this situation? 1. Ignoring the situation because the client in question is not this nurse's responsibility 2. Entering the nurses' station, reprimanding the nurse, and completing an incident or variance report 3. Pulling the second nurse aside and providing a reminder that the sensation of pain is subjective, and that professionals have a duty to believe clients' reports of their symptoms 4. Informing the charge nurse of what was overheard

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Q: The nurse is teaching the client how to walk with crutches. Which gait requires considerable skill, strength, and coordination? 1. Three-point gait 2. Swing-to gait 3. Swing-through gait 4. Two-point alternate gait

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Q: The client is recovering from a fractured left femur, and has just had the cast removed. Which technique is the most appropriate for the nurse to use when assisting this client to ambulate? 1. Standing on the client's left side 2. Standing on the client's right side 3. Standing behind the client and holding the client's belt 4. Standing in front of the client and having the client lean on the nurse's shoulders

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Q: A comatose client is being positioned supine. What should be done to maintain the functional alignment of this client's hands? 1. Externally rotate the arms 2. Cross the arms over the chest 3. Elevate the upper arms on pillows 4. Place a rolled washcloth in each hand

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Q: The nurse is caring for an unconscious client who has foot drop. Which items would be useful in properly aligning the client's foot? 1. Pillows 2. Footboard 3. Trochanter roll 4. Foot boot

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Q: The nurse positions the client on the sling, wheels the lift into position, and connects the sling to the lift. Which are priority safety measures prior to lifting the client? Standard Text: Select all that apply. 1. Locking the wheels of the lift 2. Opening the base to the widest position 3. Lowering the side rails 4. Checking that the hooks are correctly placed and that matching chains are of equal length 5. Facing the hooks toward the client

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Q: The nurse is caring for a client who has been on complete bed rest for the past week. As the nurse assists the client to sit in the chair, the client becomes dizzy when the legs are dangled over the side of the bed. Which action by the nurse is the priority? 1. Returning the client to bed in the Trendelenburg position 2. Calling for help 3. Measuring the client's blood pressure 4. Having the client sit on the edge of the bed for several minutes, and encourage a few deep, slow breaths

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Q: Two nurses are preparing to transfer a client from the stretcher to the bed. Which is a safe and efficient action to complete this task? 1. The nurse pulling the client onto the bed enlarges the base of support by moving the feet apart laterally. 2. The nurse pushing the object moves one foot forward. 3. The nurse pushing faces the head of the bed. 4. The nurse pulling faces the foot of the bed.

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Q: A client is nearing death and begins to cry. What should the nurse do to provide emotional care to this client? 1. Stay physically close 2. Offer the client privacy 3. Remove all noxious odors 4. Move the bed near the window

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Q: After learning of having cancer a client begins to demonstrate psychological symptoms of grief. What did the nurse most likely assess in this client? 1. Crying 2. Insomnia 3. Anorexia 4. Gastrointestinal disturbances

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Q: A client is recovering from hip arthroplasty using the anterolateral approach. What should the nurse ensure to maintain the integrity of the joint? 1. Place needed items on operative side 2. Keep needed items on the non-operative side 3. Instruct to avoid bending at the waist to put on shoes 4. Instruct to avoid crossing the operative leg past the body's midline

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Q: A client's x-ray report shows a fractured leg where one part of fractured bone is driven into another. How should the nurse document this client's fracture? 1. Impacted 2. Greenstick 3. Comminuted 4. Compression

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Q: The nurse caring for a client in traction inspects the apparatus and determines all is well when noting which finding? 1. The weight is sitting on the floor. 2. The rope is on the side of the pulley. 3. The knots are positioned 5 inches from the pulley. 4. All ropes are intact and connected with slipknots, and short ends are taped.

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