2. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should

include that which of the following situations requires the competition of an incident report. (b)

A client’s prescribed laboratory testing was not obtained

3. A nurse is teaching a client about repositioning into the sims position. Which of the following

information should the nurse include in the teaching? (d). You will be turned to one side with

your leg with your legs fixed

4. A nurse is communicating with a client who has aphasia following a stroke. The client is

having difficulty choosing the correct words during their conversation. Which of the following

responses should the nurse make (c) Take as much time as you need to communicate.

5. A nurse receives a telephone prescription from a provider for a client who is experiencing

pain. Which of the following responses should the nurse make?

(b) Let me clarify that you want the medication given QID, correct?

6. A nurse is collecting a sputum specimen for culture from a client who has a respiratory

infection. Which of the following actions should the nurse take?

(d) Collect 1 ML of sputum

7. A nurse is planning care for a client who reports having a latex allergy. Which of the following

interventions should the nurse include in the plan?

(c) Apply adhesive tape when securing an IV insertion site,

8. A nurse obtain a prescription for wrist restraints for a client who is trying to pull out his NG

tube. Which of the following actions should the nurse take?

(a) Attach the restraints securely to the side rails of the client’s bed.

9. A nurse is teaching a client about fire safety at home. Which of the following information

should the nurse include in the teaching?

(c) Cover the nose and mouth with a damp cloth before exiting a smoke-filled area.

10. A nurse is caring for a client who has terminal illness. The client states, I don’t know which

treatments I want to continue and which treatment I should avoid. Which of the following

response should the nurse make?

 (d) Would you like to talk about the different treatment options?

11. A nurse is caring for a client who has pneumonia. The nurse should recognize that which of

the following should be discarded in a biohazard bag?

(d) An emesis basin filled with blood from sever coughing

12. A nurse is caring for a client who reports a pain level of 5 on a scale from 0 to 10. The client

informs the nurse th at pain med option for managing pain. Which of the following is an

appropriate response by the nurse?

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(b) Why do you think pain medication is not going to help you

13. A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a

prescription for ondansetron 4 mg IV bolus every 6-hour PRN for nausea and vomiting. Identify

the sequence of steps the nurse should follow to administer the medication. (Move the steps into

the box on the right. Placing them in the order of performance. Use all the steps.

(A) Perform hand hygiene (b) Select the injection port of the IV tubing closest to the client (c)

Cleanse the injection port with an antiseptic swab (d) Aspirate for a blood return (e) Inject the

medication.

14. A charge nurse in a long-term care facility is preparing an educational program about

delirium for newly hired nurses. Which of the following statements should the nurse plan to

include? (a) Delirium has an abrupt onset (b) Delirium has a slow progression (c) Delirium

does not affect a client’s sleep cycle (d) Delirium does not affect a client’s perception of her

environment

15. A nurse is caring for a client who has dysphagia following a stroke. Which of the following

interventions should the nurse use when feeding the client? ANS Instruct the client to tilt her

head forward while eating

16. A nurse is preparing a client who has terminal cancer for discharge. Which of the following

questions should the nurse ask when assessing the client’s psychosocial history?

(a) What medications are you currently taking? (b) Are you experiencing any pain (c) What

techniques do you use to cope with stress (d) Have any of your relatives been diagnosed with

cancer?

17. A nurse is conducting a health assessment for a client who takes herbal supplements. Which

of the following statements by the clients indicates an understanding of the use of the

supplements?

 (a) I use garlic for my menopausal symptoms (b) I take echinacea to control my cholesterol (c) I

take ginkgo biloba for a headache (d) I use ginger when I get car sick

18. When documenting the care of a client, the nurse is aware of the need to use abbreviations

conscientiously and safely. This includes (a) SQ for subcutaneous (b) SS for sliding scale (c)

BRP for bathroom privileges (d) OJ for orange juice

19. A nurse is teaching a client who has diabetes mellitus about mixing regular insulin and NPH

insulin. Which of the following statements by the client indicates an understanding of the

teaching? (a) I should wait 3 minutes after mixing the insulin to inject it (b) I should inject air

into the vial of regular insulin first. (c) I should roll the vial of NPH insulin between my hands

before drawing it up (d) I should draw up the NPH insulin before the regular insulin.

20. A nurse is caring for a client who is receiving enteral feedings via NG tube. Which of the

following actions should the nurse take prior to administering the formula.?

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 (a) Check for gastric residual volume. (b) Encourage the client to breath deeply and cough (c)

Flush the tube with sterile 0.9% sodium chloride irrigation (d) Encourage the client to take sips

of water.

21. A nurse is assessing the body temperature of an adult client using a temporal artery

thermometer. Which of the following actions should the nurse take? (Select all that apply).

(b) Hold the client’s hair aside while performing the procedure (c) Move the probe in a

circular motion to obtain the reading (d)Document the client’s temperature with “AX” next to the

value (e) Slide the probe across the client’s forehead

22. A nurse is assessing a client who receives morphine for severe pain 30 minutes ago. Which of

the following findings is the nurse’s priority (a) Distended bladder (b) Last bowel movement was

3 days ago (c) Reports pain of 8 on a scale from 0to 10 (d) Respiratory rate 7/min

23. A nurse is teaching a client about the use of an overhead trapeze bar while in bed. Which of

the following information should the nurse include in the teaching?

(a) The bar will reduce your chance of injury from friction while repositioning (b) You

should use the bar when you turn from side to side in bed (c) A nurse must be present whenever

you use the bar to move in bed (d)The bar is intended to increase your lower-body strength.

24. A nurse is preparing to transfer a client who is partially weight-bearing from the the bed to a

chair. Which of the following actions should the nurse take? (a) Have the client bear weight on

her stronger leg. (b) Keeps his knee straight when moving the client (c) Stand with his feet

together when lifting the client (d) Position the chair next to the bed at a 90-degree angle.

25. A nurse is caring for a client who has brain cancer and is transferring to hospice care. The

client’s son tells the nurse “I don’t know what to tell my dad if he asks how he is going to die”

Which of the following is an appropriate response by the nurse. (a) Let’s talk more about your

dad’s condition (b) I think that you should discuss this with the hospice nurse (c) The social

worker will help you answer those questions (d) Try to help your dad enjoy this time as much as

he can.

26. A nurse is admitting a client who has tuberculosis. Which of the following types of

transmission precaution should the nurse plan to initiate (a) Contact (b) Protective environment

(c) Airborne (d) Droplets

27 A nurse is collaborating with a risk management team about potential legal issues involving

client care. The nurse should identify that which of the following situations is an example of

negligence. (a) An Assistive personnel prevent a client from leaving the facility (b) An Assistive

personnel discusses client care in the facility cafeteria with visitors present. (c) A nurse

administers a medication without first identifying the client. (d) A nurse begins a blood

transfusion without obtaining consent from a client.

28. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse

perform a straight catheterization on a client. In which of the following roles is the nurse

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