Q&A Hero

Q: The nurse caring for several clients could safely delegate which task to unlicensed assistive personnel (UAP)? 1. Initial application of the continuous positive motion (CPM) device to the postoperative client 2. Assessment of client's tolerance for passive range of motion 3. Documentation of joint improvement resulting from active range of motion 4. Performance of passive range of motion to client experiencing a CVA 2 weeks ago

Q: Which joint would the nurse pronate when performing range of motion on the hospitalized client? 1. Neck 2. Knee 3. Elbow 4. Finger

Q: Which joint will the nurse circumduct when performing range of motion on the hospitalized client? 1. Neck 2. Shoulder 3. Foot 4. Knee

Q: The nurse is concerned that a client is experiencing urinary effects of immobility. What did the nurse assess to make this clinical determination? 1. Urine retention 2. Bladder distention 3. Shortness of breath 4. Urinary tract infection

Q: The manager is identifying staff who would qualify to be a member of a lift team. What information does the manager need before finalizing this decision? 1. Date of last back injury 2. Reports of spinal x-rays 3. Evidence of daily back exercises being done 4. Staff signature relinquishing organization liability

Q: The nurse is preparing to lift a client from the bed to a chair using a sling. Which action should the nurse perform to ensure for the client's safety? 1. Raise the bed to waist level 2. Unhook the sling from lift arm 3. Move the lift away from the bed 4. Keep the client's arms inside of the sling

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

Q: A client is experiencing respiratory distress. In which position should the nurse place this client? 1. High Fowlers 2. Semi-Fowlers 3. Trendelenburg 4. Reverse Trendelenburg

Q: The charge nurse on a neurologic care area is assigning clients. What should be a priority when making staff assignments? 1. Limit number of allowed lifts per worker per day 2. Identify a team of staff who are responsible for all lifts 3. Ask staff to volunteer to participate when lifting clients 4. Assign the clients requiring to be lifted evenly among all staff

Q: The nurse is performing passive range of motion on the client and notes that the client's ankle is red, edematous, and painful to the touch. Which action by the nurse is the most appropriate? 1. Perform range of motion very gently to the ankle. 2. Perform normal range of motion to the ankle. 3. Skip range of motion in this joint and move on to the next joints. 4. Notify the health care provider before performing range of motion to this joint.

Q: The nurse transfers an assigned client from the wheelchair to the hospital bed. Which items will the nurse include when documenting the client's response to the transfer? Standard Text: Select all that apply. 1. Number of assistants needed 2. Type of equipment used 3. Pulse rate before and after the procedure 4. Blood pressure before and after the procedure 5. Safety precautions taken

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

Q: Which assistive devices would be appropriate for the nurse to use when assisting an unconscious client from the bed to the stretcher? Standard Text: Select all that apply. 1. Transfer belt 2. Transfer board 3. Hydraulic lift 4. Low-friction sheet 5. Egg crate mattress

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

Q: The nurse is transferring the client who is able to provide minimal assistance from the bed to the wheelchair. Which nursing action will provide for the safest transfer for this client? 1. Raising the bed height to waist height 2. Placing the wheelchair on the client's strong side 3. Placing the wheelchair with the feet pointing toward the side of the bed 4. Locking the wheels of the wheelchair and lowering the footplate

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

Q: The nurse is caring for a postoperative client, who is on strict bed rest, after having a rod placed for scoliosis. The client is currently supine. Which action by the nurse is necessary prior to logrolling this client? 1. Moving the client closer to the side of the bed that the client will be turned toward 2. Placing a pillow under the client's head 3. Placing one or two pillows between the client's legs 4. Having the client fold the arms on the chest

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.

Q: The nurse is preparing to lift a client up in bed. What should the nurse do prior to beginning this task in order to maintain safety? Standard Text: Select all that apply. 1. Plan the move 2. Face the head of the bed 3. Raise the bed to waist level 4. Stand close to the bed with the legs close together 5. Straighten the knees

Q: A person maintains balance as long as the line of gravity passes through which item? 1. The base of support 2. The center of gravity 3. The center of gravity and base of support 4. The moving body part

Q: The nurse is preparing to conduct a mental health assessment with a client. What should be included in this assessment? Select all that apply. 1. Past medical history 2. General motor activity 3. Past and present memory 4. Coherency, logic, and relevance 5. General appearance, manner, and attitude

Q: The Apgar score for a newborn is 4 and 5 minutes, 5 at 10 minutes, and 6 at 15 and 20 minutes. What should the nurse prepare when caring for this client? 1. Radiant heat 2. Intravenous fluids 3. Vitamin K injection 4. Emergency intubation equipment

Q: The nurse is preparing to assess a pregnant client's abdomen. In which order should the nurse complete this assessment? 1. Locate the fetal back 2. Locate the fetal head 3. Determine engagement 4. Identify the fetal part in the fundus

Q: The nurse is explaining to student nurses the different heart sounds that are assessed during the cardiac assessment. Which statement made by a student indicates understanding of the expected normal heart sounds? 1. "If I hear the S1 as lub and S2 as dub, then that is normal and means that the valves are working." 2. " If I hear a "˜lub-dub-ee" it means the client has a ventricular gallop." 3. "If I hear "˜dee-lub-dub" then the client may have an atrial gallop. This occurs near the very end of diastole just before S1 and creates the sound." 4. "If I hear the "˜dee-lub-dub" sound in an older adult, then I should know that is considered normal for the older client."

Q: The nurse is observing a student nurse performing a respiratory assessment on a client. Which statement indicates that the student nurse is performing the assessment correctly? 1. The student nurse has the client in either a sitting or lying position. 2. The client is placed in a sitting position and uncovered to the waist. 3. The client is placed in a sitting position with gown and blanket. 4. The client is placed in the semi-Fowler's position with gown removed.

Q: The nurse is going to perform light palpation. Which statement regarding light palpation is true? 1. It is a gentle downward movement of the hand in a circular fashion. 2. It is done by using two hands to apply pressure. 3. It is only done by the health care provider. 4. It should cause the client pain.

Q: The nurse is explaining to the client the need to do an assessment at the beginning of the shift. This type of assessment involves obtaining which type of information? 1. Information regarding the client's overall assessment 2. Information of a specific medical condition 3. Information specific to the client's current condition 4. Information regarding past medical history

Q: The nurse is explaining to the client the role of inspection during an assessment. Which client statement indicates understanding about this assessment technique? 1. "So, you are going to listen to my heart." 2. "So, you will be touching my abdomen." 3. "So, you will be looking at my skin." 4. "So, you are going tap my abdomen."

Q: The nurse is performing a head-to-toe assessment. Organize the areas that need to be assessed into the order in which the nurse would examine them. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Ears and eyes Response 2. General appearance Response 3. Respiratory and cardiac systems Response 4. Neurologic status Response 5. Abdomen and GI system

Q: When examining an older adult client's sense of smell, which finding would the nurse anticipate? 1. Heightened sense of smell 2. Normal sense of smell 3. Diminished sense of smell 4. Development does not impact the sense of smell

Q: The nurse is assessing the client's cardiorespiratory system. Which tool will the nurse require to perform these examinations? 1. Stethoscope 2. Percussion hammer 3. Nasal speculum 4. Lubricant

Q: The nurse is performing an assessment of the skin. Which statements regarding this assessment are correct? Standard Text: Select all that apply. 1. Assessment of the skin involves inspection, palpation, and auscultation. 2. Assessment of the skin involves using the sense of smell. 3. The nurse assesses the client for edema. 4. The nurse may assess the client's nails and hair while assessing the skin. 5. When assessing the skin, the nurse recognizes the effect of developmental stage on findings.

Q: The nurse is assigned to accept a new admission expected from the emergency department. As the client is wheeled off the elevator, which action by the nurse is the most appropriate? 1. Waiting for the client to be placed in bed, then orienting the client to the unit 2. Accompanying the client and making introductions while assessing the client's mental status and appearance 3. Entering the client's room as soon as possible to obtain data for admission history 4. Asking the unlicensed assistive personnel to assist the client into bed

Q: The nurse needs to assess a client's abdomen. In which order should the nurse complete this assessment? 1. Inspection and auscultation 2. Inspection, auscultation, and palpation 3. Inspection, auscultation, palpation, and percussion 4. Auscultation, percussion, and inspection

Q: The nurse is helping a student understand the techniques used when completing a physical assessment. Which definitions should the nurse use to define these techniques? 1. Palpation is visualizing, inspection is feeling or touching, percussion is hearing, and auscultation is tapping and listening. 2. Palpation is touching, inspection is feeling, percussion is tapping and listening, and auscultation is listening. 3. Palpation is touching, inspection is looking, percussion is tapping, and auscultation is listening. 4. Palpation is tapping and listening, inspection is listening, percussion is touching, and auscultation is smelling.

Q: During a health history a client relates a history of drug abuse. Where should the nurse document this information? 1. Health History 2. Biographic information 3. Psychosocial Factors 4. Lifestyle

Q: The nurse is completing a health history with a client. Which information is least likely to be the focus of this assessment? 1. Health promotion 2. Biographic data 3. Chief complaint 4. Family history

Q: The nurse notes that a client's blood pressure reading was unusually elevated. For what should the nurse assess to determine the reason for this reading? 1. Presence of pain 2. Cuff inflation was too slow 3. Blood pressure cuff too wide 4. Arm placed above the heart level

Q: The nurse is palpating a client's systolic blood pressure. What should the nurse identify as being the systolic reading? 1. The last palpated beat 2. The first palpated beat 3. The pressure when the arterial pulse is obliterated 4. The pressure where the client says the fingers are numb

Q: Which respiratory finding would indicate the need for further assessment by the nurse? 1. Regular 2. Quiet 3. Deep 4. Rate of 12"20 per minute

Q: The nurse demonstrating proper placement of the stethoscope when assessing the apical pulse. Where should the diaphragm be placed? 1. The brachial site 2. The apex of the heart 3. The carotid site 4. The radial site

Q: A newborn is admitted to the nursery after delivery. Which site should the nurse use to measure this infant's temperature? 1. Axillae 2. Temporal artery 3. Tympanic membrane 4. Oral cavity

Q: The nurse is unable to palpate a client's pedal pulse even though the foot is pink and warm. Which action by the nurse is the most appropriate? 1. Apply a warm soak to the foot. 2. Notify the health care provider that the client has lost circulation to the foot. 3. Elevate the foot. 4. Auscultate the pulse using an ultrasound Doppler.

Q: The nurse is assessing a client's peripheral pulses. For what should the nurse assess for? Standard Text: Select all that apply. 1. Bilaterality 2. Regularity 3. Strength 4. Rate 5. Arrhythmia

Q: A client who plays professional football reports having no symptoms and has the following vital signs: 98.6F; 48; 10; 88/54. Which action by the nurse is the priority? 1. Notify the health care provider. 2. Encourage fluids. 3. Document the client's vital signs and continue the history. 4. Place client in the Trendelenburg position.

Q: The nurse is reviewing a client's vital signs from birth to age 10. Which changes should the nurse expect to find? 1. Reduction in temperature, increase in heart rate, decrease in respiratory rate, and increase in blood pressure 2. Reduction in oxygen saturation, decreased heart and respiratory rate, and decreased blood pressure 3. Reduced heart and respiratory rate and increased blood pressure 4. Decreased temperature, reduced heart and respiratory rate, and increased blood pressure

Q: A client's blood pressure us144/82 which is higher than the usual baseline which has been normal. For what factors should the nurse assess the client based on the current blood pressure reading? Standard Text: Select all that apply. 1. Diet 2. Medication history 3. Activity 4. History of recent symptoms of hypertension 5. Recent stress factors the client has experienced

Q: The nurse is caring for a client with a fever of 101.8F oral. Which other vital signs should the nurse anticipate would be affected? Standard Text: Select all that apply. 1. Pulse rate 2. Respiratory rate 3. Diastolic blood pressure 4. Systolic blood pressure 5. Oxygen saturation

Q: The nurse is preparing to measure a client's temperature. Which factors could influence this measurement? Standard Text: Select all that apply. 1. Smoking 2. Eating or drinking 3. Exercise 4. Perfusion 5. Time of day

Q: The nurse delegates the measurement of vital signs on three clients to unlicensed assistive personnel (UAP). The nurse evaluates the UAP's performance and notes that blood pressure is measured on a client by having the client hold the arm hanging over the side of the bed. Which is the priority action by the nurse? 1. Commend the UAP for following the proper procedure. 2. Inform the charge nurse that the UAP does not know how to measure blood pressures. 3. Yell at the UAP and tell her she is incompetent. 4. Instruct the UAP that blood pressure should be measured with the artery at or above the level of the heart, and demonstrate correct technique.

Q: When the nurse delegates measurement of vital signs to unlicensed assistive personnel (UAP), which are the nurse's responsibilities? Standard Text: Select all that apply. 1. Assessment of vital sign readings obtained by UAP 2. Assessment of the UAP's skills in measuring vital signs 3. Determination that the vital signs were obtained correctly 4. Follow up on vital sign measurements that are abnormal or unexpected 5. Observe the UAP as vital signs are being measured

Q: The nurse is informed during shift report that a client has a wide pulse pressure, is hypertensive, and has a pulse deficit. When the nurse enters the client's room, which assessments should the nurse perform in order to confirm this report? 1. Blood pressure and apical pulse assessments 2. Blood pressure and radial pulse assessment 3. Blood pressure and respiratory rate assessment 4. Blood pressure and radial-apical pulse assessment

Q: A client in respiratory distress and has see-saw respirations with the chest and abdomen alternately rising, blue discoloration of the fingertips, and noisy difficult respirations. How should the nurse describe the client's condition when calling the health care provider? 1. Client is tachypneic with costal breathing and cyanosis. 2. Client is bradycardic with diaphragmatic breathing and cyanosis. 3. Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic. 4. Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds.

Q: A client has an elevated temperature. Which statement is the most clinically appropriate for the nurse to use when documenting this finding in the medical record? 1. The client is fever. 2. The client is febrile. 3. The client is hyperpyrexia. 4. The client is hyperthermia.

Q: A client who wears soft contact lenses is experiencing eye pain and excessive tearing. What should the nurse suspect is occurring with this client? 1. Corneal ulcers 3. Dry contact lenses 4. Corneal abrasions 2. Lacrimal duct infection

Q: The family of a client who is comatose asks why there are eye patches over the client's eyes. What should the nurse respond to the family? 1. "They prevent the eyes from drying out." 2. "They reduce the glare caused by the room lights." 3. "They reduce the amount of stimulation the client receives." 4. "They are used to keep eye medication in contact with the eyes."

Q: The nurse is providing perineal care to a male client. Which action ensures that cross-contamination does not occur? 1. Wring washcloth out 2. Use a clean washcloth for each motion 3. Cleanse from the shaft to the tip of the penis 4. Begin cleansing from the scrotum to the shaft

Q: A client who has difficulty raising the hips needs to urinate. What should the nurse do? 1. Use a fracture pan 2. Raise the head of the bed 3. Ambulate to the bathroom 4. Call for a bedside commode

Q: A client treated for head lice a week ago continues to complain of scalp itching. There is evidence of nits along the shafts of the hair. What should the nurse do first? 1. Wash the client's comb and brush 2. Obtain an order for medicated shampoo 3. Vigorously brush the client's hair over a sink 4. Washing the client's hair and apply conditioner

Q: While applying a treatment for head lice the client complains that the scalp is stinging. What should the nurse do first? 1. Comb the hair 2. Wrap the head with a towel 3. Stop applying the medication 4. Contact the Poison Control Center

Q: A male client asks if someone can help him shave. What should the nurse do first before preparing to help this client? 1. Wash hands 2. Obtain a shaving kit 3. Apply a gown and gloves 4. Check prescribed medications

Q: The nurse is preparing to cleanse a client's denture. Which action should the nurse take to prevent damaging the dentures? 1. Using hot water 2. Placing a towel in the sink 3. Cleansing them at the bedside 4. Rinsing them with mouthwash

Q: The nurse is helping a client with teeth flossing. What should the nurse instruct the client to do with the dental floss? 1. Wrap the length of dental floss around the wrist 2. Make a knot at the end of a length of dental floss 3. Weave the dental floss between the upper row of teeth 4. Wrap one length of floss loosely around index fingers of both hands

Q: A client asks for help with combing the hair. In which order should the nurse assist this client? Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Brush or comb client's hair from scalp to hair ends, using gentle, even strokes. Response 2. Place all hair care items within reach. Response 3. Place towel over client's shoulders. Response 4. Replace hair care items in appropriate place and clean items as needed. Response 5. Style hair in a manner suitable to client.

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.

Q: The nurse is caring for a client who is unconscious. In which order should the nurse provide oral care to this client? Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Prepare the client by positioning in a side-lying position with the head of the bed lowered. Response 2. Clean the teeth and rinse the mouth. Brush the teeth gently to prevent irritating the gums. Response 3. Ensure client comfort and document procedure per policy. Response 4. Perform hand hygiene and observe other appropriate infection control procedures. Response 5. Place a towel under the client's chin. Place the curved basin against the client's chin and lower cheek to collect fluid.

Q: What would the nurse document after providing hair care to the client? 1. Number of times the hair was combed or brushed throughout the shift 2. Type of brush used to provide hair care 3. Abnormal assessment findings 4. Routine nursing interventions

Q: The nurse is using a disposable system to wash a client's hair. What should the nurse do before using the system? 1. Heat the package in the microwave 2. Apply gloves 3. Place cap on the client's head 4. Rinse the hair with water

Q: The nurse is caring for a female client. In which order should the nurse complete perineal-genital care? Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Apply gloves. Response 2. Wipe from the pubis to the rectum. Response 3. Place a towel under the client's hips. Response 4. Clean the labia minora. Response 5. Position and drape the client.

Q: The nurse is caring for a client who feels like something is crawling through the hair. The client also has small, white dandruff-like particles along the hairline. Which term should the nurse use when documenting this client's health problem? 1. Alopecia 2. Hirsutism 3. Pediculosis 4. Scabies

Q: The nurse is preparing to brush a client's teeth. Which technique should the nurse use? 1. Gum line 2. Xerostomia 3. Gingivitis 4. Pyorrhea

Q: The nurse decides to use tapotement when providing a client with an evening back rub. What should the nurse keep in mind when using this massage stroke? 1. Avoid the kidney area 2. Use a continuous motion 3. Maintain constant skin contact 4. Focus on the shoulders and along back

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

Q: A critically ill client needs to be repositioned in bed. Which action will help prevent tearing this client's skin? 1. Sliding with a lift sheet 2. Raising the foot of the bed 3. Pulling to one side of the bed 4. Pulling up from the head of the bed

Q: The nurse notes that a client has extremely dry skin. How should the nurse document this finding? 1. Pallor 2. Cyanosis 3. Xeroderma 4. Poor skin turgor

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

Q: The nurse is preparing to bathe clients assigned for the shift. Which client should the nurse wear gloves to bathe? 1. The client diagnosed with HIV/AIDS 2. The newborn just admitted from the delivery room 3. The client with psoriasis 4. The postoperative client

Q: The nurse delegates the making of an occupied bed to unlicensed assistive personnel (UAP). Which statement made by the UAP indicates the need for further instruction prior to this assignment? 1. "I will be sure to inform you of any wound drainage." 2. "I will inform you if any of the client's tubes are loose." 3. "I will assess the client's IV tubing." 4. "I will inform you of any problems."

Q: Routine hygienic care has been provided to 1 client, with no abnormal findings assessed. What should the nurse document in the medical record? 1. Foot care 2. Hair care 3. Removal or insertion of a hearing aid 4. Type of bath provided and client's ability to provide self-care

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.