Q&A Hero

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.

Q: When delegating bed-making to unlicensed assistive personnel (UAP), on which items should the nurse instruct the UAP? Standard Text: Select all that apply. 1. Proper disposal of linens that contain drainage 2. What tubes or dressings the client might have 3. How to make hospital corners 4. Whom to inform if they notice anything unusual 5. Placing the call bell in a specific location for a client with mobility concerns

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

Q: The nurse prepares to delegate bathing a client to unlicensed assistive personnel (UAP). Which actions are appropriate prior to delegating this task to the UAP? Standard Text: Select all that apply. 1. Informing the UAP what type of bath is appropriate 2. Describing precautions specific to the needs of the client 3. Telling the UAP who to notify if there are any concerns 4. Informing the UAP to encourage the client to perform as much self-care as appropriate 5. Having the UAP document the bathing experience for the nurse to read later

Q: The nurse is caring for a healthy young adult client who was involved in a motor vehicle crash resulting in a fractured femur. The femur was pinned, and the client was placed in traction. Which type of bath should the nurse provide for this client? 1. Complete bath 2. Therapeutic bath 3. Partial bath 4. Commercial product bath

Q: The nurse is preparing a commercial cleansing system to bathe a client. Which action is the priority for the nurse? 1. Wetting the disposable washcloths 2. Drying the client after using a washcloth 3. Using one washcloth for the lower extremities 4. Warming the washcloth in the microwave

Q: The nurse is preparing a client for a morning bath. What should be assessed prior to providing personal hygienic care? Standard Text: Select all that apply. 1. Allergies 2. Culture 3. Ability to provide self-care 4. Social history 5. Diagnosis

Q: The nurse who is planning the day will perform morning care at which point? 1. When the client first awakens 2. Before breakfast 3. Before retiring for the night 4. Whenever the client requests it

Q: While emptying the urinal of a client with radioactive bladder implants several drops of urine splash on the nurse's upper arm. What should the nurse do first? 1. Pour the urine in the commode 2. Complete an occurrence report 3. Notify the radiation safety officer 4. Wash the arm with soap and water

Q: The nurse is completing a home safety assessment during the first care visit. What should be the focus when assessing the client's bedroom? Select all that apply. 1. Adequate space 2. Night light availability 3. Flooring in good repair 4. Handrails fastened to wall 5. Ease in getting into and out of bed

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

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."

Q: Which items are appropriate for the nurse to include when assessing a client for falls? Standard Text: Select all that apply. 1. Reviewing for a history of falls before admission 2. Talking with family about concerns 3. Assessing the overall physical condition 4. Assessing medication lists 5. Assessing mental status

Q: The nurse is instructing unlicensed assistive personnel (UAP) on fall prevention for the clients. Which statement made by the UAP warrants further instruction? 1. "I will ensure that the call light is within reach of the client." 2. "I will make sure to have at least one side rail up at all times." 3. "I don't have to worry about the clients who are bedridden, as they are moved by the staff." 4. "I will make sure that the bed is in the lowest position prior to leaving the room."

Q: The nurse is providing care to a client requiring restraints. How often should the nurse assess the client and document the assessment? 1. Once per shift 2. Once a day 3. Once every 4"6 hours 4. Once every 1"2 hours

Q: The nurse is caring for a client who has seizure precautions. Which actions by the nurse are appropriate for these precautions? Standard Text: Select all that apply. 1. Padding the bed around the head, foot, and side rails 2. Placing functional oral suction equipment in the room 3. Placing extremity restraints in the room for use if the client has a seizure 4. Keeping pillows handy to protect the client's head 5. Taping a bite block to the wall to protect the client from biting his or her tongue

Q: The nurse is providing care to a client who has an order for a jacket restraint. Which action by the nurse is appropriate when applying this restraint to the client? 1. Placing the vest with the opening on the side 2. Pulling the tie on the end of the vest flap across the chest and placing it through the slit on the same side of the chest 3. Using a slipknot to secure the tie around the solid leg of the bed frame 4. Using a half-bow knot to secure the tie around the movable bed frame

Q: Which action is required by the nurse prior to putting the bed or chair exit safety-monitoring device in place? 1. Obtaining a health care provider's order 2. Documenting the use of the alarm system 3. Testing the alarm 4. Applying the leg band or sensor pad

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

Q: The nurse is caring for a pediatric client who is focused on pulling out the IV line in the right arm. Which type of restraint is the most appropriate for this client? 1. Elbow restraint to the right arm 2. Elbow restraint to the left arm 3. Mitt restraint to the right hand 4. Wrist restraint to the left arm

Q: A client with paranoid schizophrenia is threatening the staff and believes the staff is trying to harm him. When the nurse enters the client's room, the client is agitated, and attempts to slap the nurse. The nurse gets assistance from other staff members and restrains the client. Which nursing action is the priority at this time? 1. Requesting a psychiatric referral 2. Notifying the health care provider of the need to see the client 3. Padding the side rails 4. Obtaining consent from the client for use of restraints

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

Q: Which action performed by the nurse will be the least effective to reduce the risk of client falls? 1. Orienting clients to the unit and explaining how the call bell system works 2. Encouraging clients to use call bells for assistance and ensuring that the call bell is within easy reach 3. Placing overbed and bedside tables out of the way 4. Using nonskid mats in the tub or shower

Q: The nurse is caring for a client who consistently pulls at the IV and urinary catheter. Restraints are applied that prevent the client from being able to grasp the tubing. Which term will the nurse use when documenting the restraints used for this client? 1. Jacket restraint 2. Limb restraint 3. Mitt restraint 4. Waist restraint

Q: The nurse administers an antianxiety (anxiolytic) medication to a client diagnosed with dementia who has been harming himself. When documenting the use of this medication as a restraint, which term is the most appropriate for the nurse to use? 1. Chemical restraint 2. Physical restraint 3. Medication restraint 4. Psychological restraint

Q: A client is instructed on the proper way to apply nitroglycerin ointment. What should the nurse use to evaluate the effectiveness of teaching provided? 1. Questionnaire 2. Verbal response 3. Teach back method 4. Paper and pencil test

Q: The charge nurse is reviewing a list of clients scheduled for discharge. Which client should have a referral for home care? 1. Client scheduled for outpatient radiation treatments 2. Client recovering from total knee replacement surgery 3. Client treated in the emergency department for a bee sting 4. Client admitted for 12 hours for fluids to treat dehydration

Q: Family has arrived to take a client home. What should the nurse provide to the client before leaving the healthcare organization? 1. Written instructions 2. Results of diagnostic testing 3. Names of health plan approved pharmacists 4. Telephone number of the healthcare provider

Q: The nurse reviews a client's teaching plan, activity level, and referral agencies contacted. What is the nurse most likely preparing? 1. Care plan 2. Critical pathway 3. Discharge summary 4. Admission assessment

Q: A client is being prepared to go home. For which reason should the nurse identify the client as being high-risk for discharge? 1. Adjustments made to medications 2. Recovering from open heart surgery 3. Removal of a cast for a fractured limb 4. Treatment provided to correct electrolyte imbalances

Q: During a home visit the nurse wants to evaluate the success of discharge teaching provided. What tool should the nurse use to evaluate the client's ability to measure pulse before taking medications? 1. Measure the client's heart rate 2. Provide a paper and pencil test 3. Ask the client to complete a questionnaire 4. Observe the client count the pulse for 1 minute

Q: The nurse is unsure if a teaching pamphlet would be appropriate for a client with an 8th grade reading level. What should the nurse do before providing the client with the pamphlet? 1. Use a readability formula 2. Read the material for comprehension 3. Contact the manufacturer and ask what the readability level is 4. Ask another staff member to read the material for comprehension

Q: The nurse determines that a teaching session scheduled with a client should be postponed for a few hours. What information caused the nurse to make this decision? 1. Family members visiting 2. Laboratory tests scheduled 3. Pain level 8 on a scale from 0 to 10 4. Healthcare provider making rounds

Q: A client from a non-English speaking country is admitted to a care area. Which nursing behavior exemplifies cultural competence? 1. Asks the family to wait in the visitor's lounge during the assessment 2. Realizes that teaching cannot be completed because of a language barrier 3. Contacts an interpreter to assist with data collection and goal identification 4. Documents "no response" when the client does not answer assessment questions

Q: A client needs to learn how to care for a new colostomy. Which teaching strategy should the nurse select for this instruction? 1. Role playing 2. Group process 3. Lecture-discussion 4. Demonstration"return demonstration

Q: The nurse is determining approaches to teach a client how to perform wound care. What should the nurse consider when determining appropriate strategies? Select all that apply. 1. Date of discharge 2. Available resources 3. Client reading level 4. Client attention span 5. Best time for teaching

Q: The nurse learns that a client will be discharged in 2 days. On what should the nurse focus when planning for this client's discharge? Select all that apply. 1. Needs 2. Goals of care 3. Measureable outcomes 4. Implementation strategies 5. Compliance with medical treatment

Q: The nurse provides information on self-administration of injectable medication to a client in 15 minute teaching increments. If equating this teaching with the nursing process in which phase is the nurse providing care? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

Q: The nurse is caring for a client. What action should the nurse take to determine this client's teaching needs? 1. Speak in plain language 2. Ask if the client understands 3. Select 5th grade reading material 4. Use questions beginning with "why"

Q: The nurse is preparing to teach an adult client about dietary changes required in the treatment of hypertension. What adult learning principles should the nurse utilize during this teaching? Select all that apply. 1. Reinforce positive behaviors 2. Progress from simple to complex topics 3. Invite family to participate in the teaching 4. Ask the client to verbally repeat instructed material 5. Assess what the client knows about the health issue

Q: A client who speaks English as a second language needs instruction on self-administration of injectable medications and wound care before being discharged the next day. What should the nurse identify as potential challenges when teaching this client? Select all that apply. 1. Lack of time 2. Lack of supplies 3. Various languages 4. Lack of support systems in the home 5. Lack of appropriate readable materials

Q: The nurse is preparing materials for client teaching. What should be the goal for this educational session? 1. Client desires to improve own health 2. Client understands follow-up appointment schedule 3. Client knows what actions to take to care for a health problem 4. Client learns to telephone the healthcare provider with questions

Q: The nurse is preparing to discharge a client with a new ileostomy. What should the nurse include when documenting discharge information about this client?1. Last weight calculated and BMI2. Most recent vital signs measurements3. Findings from the physical assessment4. Return demonstration on appliance care

Q: The nurse is concerned that a home care client is experiencing abuse. What information did the nurse use to make this clinical determination? 1. New bruises on various body parts 2. Client states oldest daughter moved home 3. Next door neighbor brought homemade soup 4. Bank phoned because social security check will be delayed one day

Q: An older client on Medicare has physical limitations and telephones a local home care agency to schedule a nurse to visit. What should the nurse do first before proceeding with this client's request? 1. Determine homebound status 2. Identify available staff to visit the client 3. Discuss the challenges the client is facing 4. Find out when the client was last hospitalized

Q: The nurse is visiting the home of a newly discharged client. What should the nurse plan to complete at the conclusion of the physical assessment? 1. List for teaching 2. List of supplies the client will need to purchase 3. Method the client intends to pay for home care services 4. Outcome and Assessment Information Set (OASIS) forms

Q: During morning rounds the nurse notes that a client is packing clothing and personal items in preparation for leaving the hospital. What should the nurse do with the signed against medical advice form? 1. Place it on the client's medical record 2. Fax it to the healthcare provider's office 3. Send it to the Risk Management department 4. Send a copy to the organization's legal department

Q: Family members arrive to take home a client desiring to leave against medical advice. What should the nurse do? 1. Begin medication teaching 2. Refer the client to home care 3. Prepare discharge instructions 4. Notify the healthcare provider

Q: The nurse is reviewing the status of assigned clients. Which observation should the nurse identify as appropriate for a client to be discharged?1. Client with heart disease understands the discharge process2. Client with multiple sclerosis wants to stay in the hospital "forever"3. Client with asthma wants to use a previous form of inhaled medication4. Client recovering from knee surgery is apprehensive about going home alone

Q: A client recovering from abdominal surgery is being discharged home. What should the nurse emphasize when providing this client with discharge instructions? 1. Wound care 2. Time family should arrive 3. Where family should park 4. Antibiotics received while hospitalized

Q: A client is being transferred from the neurologic intensive care unit to a general medical-surgical care area. What should the nurse do first when the client arrives to the new care are? 1. Update the care plan 2. Validate all nursingtle 2: Rationale 3: Rationale 4: Global Rationale: general medical-surgical care area. What should the n diagnoses 3. Complete a physical assessment 4. Check the healthcare provider's orders

Q: The nurse notes that a client being prepared for discharge is not to continue taking two medications at home. Where should the nurse find additional information about this change in medications? 1. Laboratory reports 2. Previous nurse's documentation 3. Healthcare provider's documentation 4. Summary of diagnostic testing completed

Q: A client is being transferred from a critical care area to the telemetry unit. What information should the nurse include when communicating this client's care needs? 1. Last doses of medication 2. Where the spouse is employed 3. Number of children the client has 4. Family members' opinions about the hospital

Q: A newly admitted client refuses to answer any assessment questions and is seen sitting in a chair near the window crying. What should the nurse do to help this client become acclimated to the hospital environment? Select all that apply. 1. Assess emotional needs 2. Consult the case manager 3. Talk with the organization's clergy 4. Ask the healthcare provider to prescribe a sedative 5. Suggest receiving health care in another environment

Q: The nurse is asking a client about lifestyle patterns and spiritual practices. For which admission document is this information needed? 1. Care plan 2. Health history 3. Demographics 4. Discharge needs

Q: The nurse is assessing a newly admitted client. What should the nurse include when discussing advanced directives with this client? Select all that apply. 1. It is the same for every state 2. It is sometimes called a living will 3. It includes preferences for health care 4. A copy is placed in the medical record 5. It specifies treatments desired at end of life

Q: A client wearing a diamond engagement and wedding band set does not want to send the rings home with the spouse. What should the nurse do? 1. Cover the rings with adhesive tape 2. Suggest the rings be placed in the night stand 3. Provide a "Release from Responsibility" form 4. Ask Security to explain the risk of losing the items

Q: The nurse is assessing a newly admitted client. What information should be documented about the client's current medications? Select all that apply. 1. Allergies to drugs 2. List of nutritional supplements 3. List of all prescribed medications 4. Pharmacy used to fill prescriptions 5. List of all over-the-counter medications

Q: A client arrives to the hospital the day before orthopedic surgery. What should be completed before the client is escorted to the care area? Select all that apply. 1. Orient to the hospital room 2. Receive an identification band 3. Assign a medical record number 4. Sign consent for treatment forms 5. Document demographic information

Q: The nurse notes that an older client is withdrawn and has lost weight over the last few weeks. What should the nurse suggest to help this client? 1. Setting firm limits 2. Maintaining a calm quiet approach 3. Talking about feelings of depression 4. Attending the bingo game in the dining room

Q: The nurse notes that a client is having difficulty deciding to have surgery, has a heart rate of 110 beats per minute and is diaphoretic. What should the nurse consider this client is demonstrating? 1. Verbal cues of anger 2. Physical cues of anxiety 3. Physical cues of depression 4. Emotional cues of depression

Q: A client says that the health care provider always seems to be in a hurry which causes confusion with care expectations. What should the nurse recommend to this client? 1. Write questions to ask when the health care provider makes rounds 2. Suggest telephoning the healthcare provider's office and speak to the staff 3. Volunteer to discuss the client's concerns with the provider later in the day 4. Remind that if the healthcare provider does not mention something it probably is not an issue

Q: During the orientation phase of a new relationship the nurse explains the activities that need to be accomplished before the client is discharged back to home. Why should the nurse do this at this time? 1. Identifies coping mechanisms 2. Establishes trust between the nurse and client 3. Prevents the client from being placed on the defensive 4. Promotes independence and increases sense of self-esteem

Q: The nurse is having difficulty maintaining rapport with a client. What should the nurse do to facilitate this relationship? 1. Establish mutual goals 2. Demonstrate consistent behavior 3. Use a warm, accepting manner during interactions 4. Accept client as having value and worth as an individual

Q: The nurse is engaged in a relationship with a client. Which action should the nurse take when in the continuation phase of this relationship? 1. Identify major problems 2. Anticipate issues once discharged 3. Teach how to self-administer insulin 4. Recognize barriers to communication

Q: The nurse is caring for a client newly diagnosed with heart failure. Which nursing statement encourages the client to express thoughts and feelings? 1. "Please tell me how I can help you learn to manage this health problem." 2. "Oftentimes heart failure can be prevented with proper diet and exercise." 3. "Many of my clients have your same health problem and they are doing very well." 4. "Would you mind holding any questions until I review your healthcare provider's care orders?"

Q: The nurse is preparing to meet a newly admitted client. What should the nurse do first? 1. Ask the client for feedback 2. Introduce herself to the client 3. Ask if the client has any questions 4. Check client ID with two forms of identification

Q: The nurse is completing a spiritual assessment as part of a health history with a newly admitted client. Which question should the nurse use to learn more about this client's spirituality? Select all that apply. 1. "Do you like your religion?" 2. "How often do you attend religious services?" 3. "Do you follow any particular religious practices?" 4. "Isn"t it difficult to have to go to church every Sunday?" 5. "How can I ensure that your religious practices are followed in the event of a health crisis?

Q: The nurse is preparing to assess a client who has lived in the United States for 6 months. What should the nurse include to ensure cultural sensitivity? Select all that apply. 1. Education 2. Nutrition practices 3. Family relationships 4. Cultural background 5. Access to a computer

Q: The nurse asks to attend a seminar on cultural diversity. What was the primary reason for the nurse making this request? 1. Improve ability to care for pediatric clients 2. Decide if a home care position should be accepted 3. Recognize the special needs of an aging population 4. Understand care issues of non-English speaking clients

Q: The nurse manager is observing a new graduate provide client care. Which statements should the manager identify as being barriers to communication? Select all that apply. 1. "What a beautiful day! I love bright sunshine!" 2. "If it were me I would take the new medication." 3. "You gave yourself the insulin injection very well." 4. "You shouldn"t worry so much about your surgery." 5. "I think it was right for you to delay having the surgery."

Q: The nurse is reviewing data collected during a health history. Which statement should the nurse use to clarify information? 1. "I hear what you"re saying." 2. "When you say that, it makes me feel uncomfortable." 3. "I don"t understand. Can you say it in a different way?" 4. "You were telling me how hard it is to talk to your spouse."

Q: During an assessment a client answers no questions and tells the nurse to talk with the spouse who is due to arrive later in the day. What can occur with this situation? 1. Noncompliance 2. Enhanced rapport 3. Situational awareness 4. Dysfunctional communication

Q: A visitor asks the nurse questions about a client's health status. What should the nurse respond to this individual? 1. "I can tell you that the client is not doing very well." 2. "That information cannot be shared without the client's permission." 3. "Please keep this to yourself. The client needs to go on hospice soon." 4. "Since you are a visitor I can tell you that the client will be here for a few more days."

Q: The nurse educator is preparing an inservice presentation about communication. What should the nurse emphasize during this training? 1. Communication is an optional task 2. Communication is a sense of self-pride 3. Communication is an essential part of nursing care 4. Communication ensures the provision of quality nursing care

Q: The nurse is caring for a group of clients. Which nursing behaviors exemplify communication about these clients' care? Select all that apply. 1. Making a check mark on a care tracking sheet 2. Initialing and dating an entry in the medical record 3. Volunteering to participate in an upcoming seminar 4. Reading the results of laboratory and diagnostic tests 5. Discussing a client's response to pain medication with the care provider

Q: The nurse is completing a tool to help coordinate care needed for several clients. What should the nurse identify as a task that must be completed at a specific time for a client? 1. Evaluating the amount of food a client ingested after lunch 2. Providing intravenous medication before a peak blood level is drawn 3. Measuring urine in a collection bag before attending afternoon report 4. Checking the results of laboratory tests before documenting end of shift care

Q: The nursing student is using a data collection tool while researching a client assignment before clinical the next day. In which category should the student document the client's use of oxygen? 1. Medications 2. Biographical data 3. Nursing interventions 4. Physical assessment findings

Q: After delegating an aspect of care to unlicensed assistive personnel (UAP) the nurse answers any questions and is available while the care is being provided. Which "right of delegation" is this nurse performing? 1. Person 2. Direction 3. Supervision 4. Circumstances

Q: The nurse is preparing to electronically enter data in a client's medical record. For which reason could a legal issue occur? 1. Obtains password taped under keyboard 2. Logs out of the record before leaving the terminal 3. Shreds laboratory reports after using them during report 4. Turns off the monitor when approached by a family member