Fundamentals for the NCLEX®

An older adult client who has been diagnosed with lymphoma does not have a living will in place, but has filled out a values history. Which of the following is associated with this type of directive? Select all that apply.

In the event that a client becomes incompetent to make his or her own decisions, the healthcare power of attorney can authorize which of the following?

A nurse is admitting a client to the long-term care facility. During the admission process, the nurse asks the client if they have an advance directive and the client says no. How should the nurse respond?

The nurse is caring for a client who just arrived on the unit from PACU after a craniotomy for tumor debulking. After completing the initial assessment, the nurse administers morphine for pain. The client is groggy, but oriented and compliant. The client’s daughter is outside of the room and asks, “Can you just knock him out? He is agitated and getting on my nerves. He’s probably in pain and just needs to sleep off the rest of the day. I’m his health care power of attorney as you can see in the chart.” What is the most appropriate response?

A client is admitted to the hospital for surgery and the nurse discovers that the client has a living will. In addition to placing a copy of the document on the client’s chart, what would be a priority action for the nurse?

Which of the following best describes a healthcare proxy as part of an advance directive?

A nurse is performing postmortem care on a client who has just died. Which of the following actions should be included as part of postmortem care? Select all that apply.

Which of the following is a role of the registered nurse when working with older adults regarding advance directives? Select all that apply.

The nurse is caring for a 70-year-old client diagnosed with pneumonia. The treatment plan includes antibiotics, breathing treatments, and incentive spirometer use. The client is alert and oriented to person, place, time, and situation. They are on 2L nasal cannula without any signs or symptoms of distress. The client states, “I do not want to have any antibiotics, I just want this to run its course.” The nurse knows this client has a durable power of attorney. Which of the following should the nurse do?

A nurse is working with a client who wants to have an advance directive in place to direct their care. Select which aspects should be discussed with the client when formulating an advance directive for their care. Select all that apply.

Which of the following are examples of nursing malpractice? Select all that apply.

A nurse is being accused of defamation against a client’s family member. Which of the following is a true statement regarding defamation in the healthcare environment? Select all that apply.

A nurse is assisting a provider with obtaining informed consent about a medical procedure. Which of the following best describes the nurse’s role in obtaining informed consent?

A 12-year-old client needs to have treatment that involves a surgical procedure that will save the child’s life. The parents refuse to give consent for the procedure based on their personal convictions. Which of the following is allowable for the healthcare team in response?

A client is upset about the treatment received while in the hospital, and wants to leave AMA. The nurse should inform the client that it is within the client’s right to leave the hospital but should also include what information when care is refused? Select all that apply.

A nurse made a mistake with administering a medication, which caused her client to become ill and to stay in the hospital an extra day. The nurse is considering telling the client that it was the nurse’s mistake that caused the complications. Which implications should the nurse consider when disclosing this information to the client?

Which example best describes whistleblowing within nursing?

Which of the following best describes the concept of a compact state for nursing licensure?

A nurse who works in the emergency department has been caring for a client who is angry and complains about the care given. Before leaving the room, the client tells the nurse, “I’m going to sue this hospital. This has been terrible!” What actions could the nurse take that would best prevent litigation? Select all that apply

A nurse is taking care of a client at the beginning of a shift. Upon walking into the room, the nurse finds the client and the wife very upset. The wife says, “That last nurse was terrible! She reprimanded my husband for not taking his medication on time!” The client wants to leave against medical advice (AMA). Which response from the nurse best demonstrates conflict resolution between the client and the organization?

Which of the following individuals has an automatic right to view a client’s medical record without the consent of the patient?

The charge nurse on a healthcare unit walks into the conference room and finds another nurse looking up private health information on the computer for a client that the nurse is not assigned to. The charge nurse knows that protecting health information, according to HIPAA, is designed for which of the following?

Which best explains the difference between confidentiality and privacy?

A nurse was upset about a client’s behavior and feels very angry. The nurse wants to discuss it with someone but doesn’t know what to do. Which of the following potential responses from the nurse constitutes a HIPAA violation? Select all that apply.

Which of the following is not part of HIPAA provision for protection of confidentiality?

The nurse is caring for a male client with several supportive family members. The client’s sister from out of state calls the unit to ask how he fared overnight. Which of the following responses by the nurse is appropriate?

A client is being admitted to the hospital for medical care and upon admission, he signs a general release of medical information. Which of the following entities can receive client information from signing this release?

Despite HIPAA regulations regarding confidentiality, there are some situations in which confidentiality can be breached and information reported to other entities. This includes which of the following? Select all that apply.

A nurse wants to ensure that a breach the client’s privacy and confidentiality does not occur. Which situation of disclosure of protected health information is allowed under HIPAA? Select all that apply.

A nurse is caring for a client who recently had blood testing for HIV. The results of the test came back as HIV positive. According to standards set by HIPAA, which of the actions of the nurse is most appropriate?

Select the location on the client’s body where the second AED pad should be placed.

The nurse is on a rapid response team that has responded to a code blue. The victim is a visitor who has fallen down a flight of stairs and is unresponsive. A cervical spine injury is suspected. In order to perform CPR safely, what is the best initial intervention?

The care team must initiate cardiopulmonary resuscitation on a client who is on a ventilator. The nurse knows to set the ventilator at which of the following breathing rates?

The nurse is helping a conscious 9-month old client with an upper airway obstruction. What techniques will the nurse implement to help this client? Select all that apply.

A client has gone into ventricular fibrillation. Two nurses run into the room and one nurse tries unsuccessfully to find a pulse. The other nurse immediately begins CPR while the first nurse calls a code and grabs the ambu bag. What is the most important aspect of this attempted resuscitation?

The nurse is caring for a client who verbally expresses his wish to not be resuscitated. Later in the nurses shift the client codes. The nurse looks at the chart and notes that the client is listed as full code. What should the nurse do?

Which of the following are components of effective cardio-pulmonary resuscitation (CPR)? Select all that apply.

The nurse is performing CPR on a client’s family member who collapsed on the floor of the hospital. The nurse finishes a 2-minute cycle of chest compressions, and the AED has analyzed the rhythm and shows “shock advised”. Which of the following is should the nurse do next?

A client is in the hospital after having cardiac surgery. The client’s family tells the nurse that the client does not want CPR if the client’s heart were to stop. During recovery from surgery, the client goes into cardiac arrest. Which action of the nurse is most appropriate?

A nurse calls the charge nurse and asks for a vial of Epinephrine 1:10,000 to be brought to a client’s room STAT. The charge nurse knows that what situation is likely occurring in the client’s room?

A school nurse participates in monthly fire drills in which all students are to file out of the building. What best describes the nurse’s role during a fire drill?

The nurse is caring for a medically stable client who states that he is extremely busy at work. The client has multiple electronic devices in the room. What is the nurse’s priority?

A nurse is caring for clients during the day shift when the fire alarm goes off. The nurse remembers the RACE acronym for fires, and does which of the following actions for E in RACE in the event there is a small fire?

A fire breaks out in a long-term care facility and a nurse is in a client’s room. The nurse and the client cannot get out. Which of the following actions should the nurse perform to keep the two of them as safe as possible?

A nurse walks into a client’s room and realizes that there is a fire in the bathroom. Which actions should the nurse do in response? Select all that apply.

The nurse is working on a busy hospital unit. A small fire has started in a trashcan in the nurse’s break room, away from clients, and a colleague has pulled the fire alarm. What is the next priority action?

Using bones and muscles to maintain proper alignment and body posture while performing a task is known as which of the following?

A nurse walks into the dirty utility area of the unit and finds a small fire burning in the corner. The nurse is able to quickly put it out with a nearby fire extinguisher before it activates the fire alarm. Which of the following should be the next step of the nurse?

The risk management nurse at a long-term care facility is reviewing the facility’s data related to recent client falls. The nurse should consider which of the following as a risk factor for client falls? Select all that apply.

The emergency room has four clients that have had a fall. Which of the following types of falls is the priority for the nurse to see first?

A client who is exhibiting behavioral and psychological symptoms should be medically cleared to rule out which of the following?

A nurse is working in the surgical unit and is assigned the following clients. Client A, a 78-year-old male client who recently had a hip fracture and who suffers from Parkinson’s disease. Client B, a 60-year-old client who is visually impaired and who is post-op day three after hernia surgery. Client C, a 56-year-old client who has a prescription for ketorolac and who had shoulder surgery. In which order would the nurse categorize these patients’ fall risk from greatest risk to least risk?

While admitting a client, the nurse has determined the client is a fall risk. What is a priority nursing intervention?

A nurse is caring for a 9-year-old client who is considered a fall risk because of a history of seizures. Which of the following interventions should be implemented to prevent falls in a pediatric client? Select all that apply.

A nurse is filling out a fall risk assessment on a client who is considered to be at high risk of injury due to falls. Which of the following information is documented as part of the fall risk assessment?

A client is being discharged home after being evaluated for a fall. Which of the following should the nurse include in discharge instructions for the client? Select all that apply.

A 50-year-old client with measles has been admitted to the hospital and is in isolation. The client’s daughter asks the nurse, “How can I keep from catching this myself if I have been vaccinated?” Which answer from the nurse is most appropriate?

The nurse is caring for a client with watery diarrhea following a course of clindamycin. The nurse suspects clostridium dificile. Which of the following isolation precautions are necessary for this client? Select all that apply.

Which of the following principles of using personal protective equipment (PPE) is correct?

A 60-year-old client has been admitted to the hospital with Creutzfeldt-Jakob disease. Which type of isolation precautions must the nurse use while caring for this client?

A 31-year-old client has developed meningococcal meningitis after recently traveling out of the United States. Which type of precautions would the nurse most likely implement in this situation?

A client presents for care at a primary care facility. The client is coughing and has a fever of 102 F. Which statement from the nurse regarding protective equipment is most appropriate in preventing the potential spread of this client’s infection?

The nurse is caring for a client diagnosed with influenza. Which of the following personal protective equipment (PPE) MUST the nurse wear when entering this client’s room?

The nurse is going over discharge paperwork with a client. While educating the client on decreasing risks of falls such as removing rugs and keeping walkways clear of clutter, the client starts to cry. The nurse discovers that the client is homeless. Which of the following should the nurse do for the client?

What is the highest order of Maslow’s Hierarchy of needs?

What is an example of a self-esteem need found within Maslow’s hierarchy?

The nurse is assigned to a group of 4 clients. Which of the following clients should the nurse see first?

A nurse is starting a shift at the hospital and is considering which clients are highest priority to see first. Which of the following clients would be considered first priority? Select all that apply.

A nurse is caring for a client who has been diagnosed with lung cancer. The client tells the nurse that she has not spoken with her mother in 8 years and really wants to reconnect with her. The nurse recognizes that this need falls under which category of Maslow’s Hierarchy of Needs?

A nurse is caring for a client who was admitted to the hospital and is experiencing nausea. The nurse suspects that the client has not been getting enough sleep while staying in the hospital. Which actions describe how the nurse could help improve the client’s sleep? Select all that apply.

A nurse is caring for a client in the ICU who has been severely burned. According to Maslow’s hierarchy of needs, which of the following actions demonstrates that the nurse is meeting the client’s highest priority needs? Select all that apply.

Which is an example of a first-order priority need when providing client care?

The nurse is caring for a client who begins to push the call light multiple times. When the nurse enters the room, the client cannot recall why she has called for the nurse. Which of the following should the nurse do to ensure this client’s safety?

A 16-year-old client needs to get up to ambulate after having knee surgery. A nurse assigns a nursing assistant to ambulate the client. Which of the following should the nurse consider when delegating this task to the nursing assistant?

The nursing assistant in the busy emergency room is helping with tasks. Which of the following task is appropriate?

The nursing staff on a critical care unit must routinely check the crash cart each shift to ensure that all supplies are in place. The RN wants to delegate the task of checking the crash cart to a nursing assistant who is working with her. Which of the following is true regarding this action?

A nurse works as part of an interdisciplinary team that discusses care for a client who is being admitted from a long-term care facility. Which task is not appropriate for the nurse to delegate to the LPN that is part of the team?

A registered nurse is working on a busy medical-surgical unit. She decides to delegate the task of collecting vital signs of a recent post-op client to the LPN who is working with her. This situation is the best example of what type of right according to the five rights of delegation?

The nurse has completed hourly rounding and all clients are stable. The nurse has a list of tasks to complete. Which task is most strategic for the nurse to complete rather than delegating it to the nursing assistant?

A nurse is getting a new admission from the emergency room and has other clients that need assistance. Which of the following tasks can be delegated to the nursing assistant?

Which of the following tasks should the nurse delegate to the nursing assistant?

A nurse works in a labor and delivery unit and has two unlicensed assistive personnel helping with tasks. Which of the following tasks is not appropriate for the nurse to delegate to unlicensed assistive personnel?

The nurse is caring for a client who is having chest pain. Which of the following interventions can be appropriately delegated to the certified nursing assistant? Select all that apply.

A nurse in the emergency room has 4 clients that all have shortness of breath. Which of the following additional symptoms are the most concerning and should be the priority?

The nurse receives a client with altered mental status from the ambulance. What is the first thing the nurse will obtain?

A nurse working in a busy emergency room knows that a client with which of the following is the priority to see first?

Four pediatric clients have just come into the emergency room. The nurse should see the client with which of the following first?

Which of the following elements must the nurse consider when prioritizing care? Select all that apply.

The nurse is prioritizing tasks at the beginning of the shift. The client with which of the following should be the priority?

The night shift nurse gives report to the charge nurse. After reviewing the diagnosis and symptoms the charge nurse should see which of the following clients first?

There are four clients in the emergency room with different lacerations. The nurse knows that which of the following is the priority?

A student nurse is practicing how to effectively prioritize clients and client needs. Which of the following clients should the student nurse see first?

A nurse has arrived for work and is reviewing four assigned clients. Which client should the nurse see first?

A client is brought to the trauma bay after being stabbed in the upper abdomen with a sword at a costume event and is displaying signs and symptoms of a ruptured diaphragm. Which of the following situations is a priority for the nurse to monitor?

The following four clients are brought to the emergency room by ambulance. The triage nurse is assigning clients to a room and should prioritize which of the following symptoms?

A nurse is triaging clients at a disaster scene. Which of the following clients would be given a red tag?

A nurse is floated to the emergency room to help. The charge nurse gives the float nurse a list of clients that have not been seen. The client with which of the following should be seen first?

A nurse is working in an emergency department to conduct triage for several clients who have arrived at once. Which of the following vital sign results seen in some adult clients would be considered abnormal? Select all that apply.

There are 4 pediatric clients sitting in the waiting room of the emergency department. A bed becomes available and the triage nurse knows to take back the client with which of the following first?

There has been a bombing at the convention center downtown. The nurse is working in the emergency department and has been notified that approximately 58 clients are on the way to the hospital facility. Which clients will be given the highest priority?

Four clients arrive to the emergency room at the same time. The nurse is triaging them and knows that the client with which of the following should be brought back to be evaluated by a provider first?

There are four clients that the nurse is prioritizing in order of importance. Of the following clients, which client should the nurse see first?

After receiving report on four clients the emergency room nurse should see the client with which of the following diagnosis first?

A nurse is not sure if the provider should be contacted about a client’s condition. What elements of the problem-solving method should the nurse consider that would help with this decision? Select all that apply.

A client with lung cancer tells the nurse about how difficult it has been to go through cancer treatment. Which response from the nurse best demonstrates therapeutic communication?

A client and her spouse are seen at the primary care clinic for assessment for infertility. The client becomes tearful as she tells the nurse that she has been trying to become pregnant for over a year without success. The client says, “I do not think I could handle it if I knew I could never start a family.” Which intervention by the nurse best demonstrates therapeutic communication to assist the client with coping with her situation?

A nurse is caring for a client who is experiencing severe stress associated with her family. The nurse knows that which form of non-verbal communication would most likely indicate interest in what the client is trying to say?

A 39-year-old client is talking with a nurse about the client’s sexual relationship with a committed partner. Which describes how the nurse should discuss an awkward topic with a client?

Which of the following is a true statement regarding communication between the nurse and the client?

After a successful return demonstration, the nurse says to the client, “You are confidently using that inhaler!” This is an example of which type of therapeutic communication?

A nurse is performing an intake interview on a client who has come to the hospital for abdominal pain. Which action demonstrates that the nurse is actively listening during the client interview?

Which is an example of a qualitative open-ended question that the nurse may use in therapeutic communication with the client?

While talking to a patient about how she lost her job, the nurse utilizes clarifying techniques as therapeutic communication. Which of the following are examples of clarifying during the conversation? Select all that apply.

A school nurse suspects a 12-year-old student is a victim of child abuse. The nurse contacts child protective services and then the police. Following the incident, the child’s parent approaches the nurse and says, “Why did you call child protective services? Now I’ll be suspended from my job!” Which response from the nurse is most appropriate?

A client who delivered a baby 6 weeks ago is a victim of intimate partner violence. Which of the following psychological conditions is also associated with victims of domestic abuse?

The nurse is caring for a 90-year-old client with a potential fracture of the radius. The client was brought in by the caregiver, is wearing a brief that is soiled with urine and feces, and there is a pattern of multiple finger-sized bruises on the client’s body. Which of the following are appropriate actions by the nurse? Select all that apply.

A nurse is caring for a 79-year-old client whom she suspects is being abused by his daughter. Which of the following situations are risk factors for elder abuse?

Explain the difference between environmental and individual risk factors in a perpetrator of sexual abuse.

A 3-year-old client is being seen in the healthcare clinic for a fractured arm. The nurse suspects that the child is being neglected. Which of the following signs indicates potential child neglect? Select all that apply.

A nurse is caring for a client who may be in a domestic violence situation. What actions can the nurse perform that would uphold this client’s privacy? Select all that apply.

A nurse is caring for a client who has been physically abused and threatened by her partner. Which statement describes the tension stage of abuse?

A nurse is caring for a 35-year-old client who has been diagnosed with hypovolemic shock as a result of severe hemorrhage. In which position should the nurse place this client to promote optimal circulation?

A client just returned from the OR after a gastrectomy. What position would be most appropriate for the client after this particular surgery?

A nurse is caring for a client that is healing from an Achilles tendon surgery. While practicing active range of motion with the client, the nurse notes that the client is still unable to point the toes up toward the ceiling. The nurse should chart this as the client being unable to do which of the following?

A nurse has positioned a client in the high Fowler’s position for an intervention. For which intervention is this position useful? Select all that apply.

The nurse is caring for a client who is being hospitalized for illness. The nurse is repositioning the client into the Trendelenburg position. This position is best used for a client with which condition?

A client who underwent neurosurgery must remain prone in bed for the next 24 hours. Which of the following principles should the nurse adhere to when positioning this client in bed? Select all that apply.

A nurse is positioning a client on the table in the operating suite while preparing him for surgery. Which of the following principles would the nurse follow when properly positioning this patient? Select all that apply.

The nurse is caring for a client who has just had a bronchoscopy. In which of the following positions should the nurse position this client?

The nurse is receiving report on an elderly client who has developed a pressure ulcer from long periods of immobility. The outgoing nurse states the wound is a stage I pressure ulcer. Which of the following findings would the nurse expect to see with a stage I pressure ulcer?

A client has suffered a skin tear on the elbow from being assisted in bed for repositioning. Which best describes how the nurse can prevent this injury in the future??

A nurse is assisting a bedridden client with moving up in bed and repositioning. Which of the following interventions would most likely prevent friction against this client’s skin while transferring? Select all that apply.

A bedridden client requires cradle boots bilaterally to prevent foot drop while in bed. Which of the following describes how to apply cradle boots? Select all that apply.

A nurse is caring for a client who had knee surgery and is morbidly obese. The client has difficulties with mobility and needs two-person assistance when getting out of bed. Which of the following best describes appropriately education about preventing skin breakdown?

A nurse in a long-term care facility has many clients who have difficulties with urinary incontinence and immobility. Which methods could the nurse implement that would most likely reduce moisture content on the skin of these clients? Select all that apply.

A 78-year-old client is recovering from coronary artery bypass graft (CABG) surgery. Because of the client’s health status and level of immobility, he is at risk of skin breakdown. Which of the following factors is considered an intrinsic factor in the development of post-operative pressure ulcers? Select all that apply.

An immobile client is at risk of aspiration because of difficulty with chewing and swallowing food. Which of the following nursing interventions is most appropriate?

A nurse is using the Banner Mobility Assessment Tool (BMAT) to determine a client’s level of mobility while in the long-term care center. Which of the following is an element of assessment during this portion of the exam? Select all that apply.

The nurse is working in the intensive care unit and is taking report on a client who is septic in the emergency department. The ED nurse reports the client is immobile with a stage II pressure ulcer on the coccyx. Which is the priority question for the nurse to ask for further clarification?

A nurse is performing continuous bladder irrigation on a client. The bag from the pharmacy contained 400 mLs of fluid. The order is for 20 mLs every hour. The nurse notes that 4 hours ago, the bag had 200 mLs in it. What is the total amount of fluid that has been irrigated?

A client has urinary incontinence diagnosed because of instability of the detrusor muscle. Which of the following describes a form of management of this type of incontinence? Select all that apply.

A client has been diagnosed with stress incontinence and has frequent episodes of leaking urine. Which of the following nursing interventions are most appropriate in this situation? Select all that apply.

A 67-year-old client has been given a nursing diagnosis of Altered Patterns of Urinary Elimination related to stress incontinence. Which of the following most accurately explains this condition?

A 10-year-old child is going to be sent home from the hospital with an indwelling urinary catheter. Which of the following information should the nurse give to the parents about caring for the catheter and the tubing?

A nurse is performing a continuous bladder irrigation on a client. A 650 mL bag of fluid irrigation was started at the prescribed rate of 30 mL/hour six hours ago. What is the total amount of fluid instilled for irrigation?

A client in a long-term care facility is having elimination problems and suffers from incontinence. Which nursing intervention would most likely help to prevent skin breakdown in this client?

A nurse is assessing a client that arrived to the emergency department after being hit in the abdomen with a bat. The nurse knows that which of the following organs are most likely to sustain a rupture?

Which of the following changes in elimination would most likely occur in a client who is unable to get out of bed and is immobile? Select all that apply.

As part of preparing a 10-year-old client for surgery, the nurse needs to insert an indwelling urinary catheter. Which best describes the point at which the nurse should insert the catheter?

A client with a feeding tube has developed constipation as a result of inactivity. Which nursing intervention would most likely help to resolve this complication?

Your patient had an ileostomy placed 2 weeks ago. Which bowel pattern would be expected for this patient?

A 78 year-old client reports constipation for three days. What action should the nurse take next?

The nurse is caring for a client with an ileostomy. During assessment of the client, the nurse notes that the pouch opening is 1/2 inch larger than the stoma site. Which of the following poses a risk for this client?

The nurse is caring for a client who suffers from chronic constipation. The nurse asks questions to evaluate whether the client uses laxatives to manage this condition. Which of the following best describes the rationale for this action?

A client with chronic pain as a result of multiple sclerosis has requested music therapy for help with pain management. Which of the following describes music therapy for pain control? Select all that apply.

A client in the hospital complains of a headache and asks for pain medication. The nurse may give either an opioid or non-opioid analgesic. Which of the following drugs are examples of non-opioid analgesics for mild to moderate pain? Select all that apply.

A nurse has been ordered to give a patient an intravenous (IV) dose of an opioid pain medication following surgery. Which of the following should alert the nurse to question administering the IV opiate medication? Select all that apply.

A mind-body technique that a patient may use for complementary therapy and that involves focusing the mind on a relaxed and calming subject is best known as which of the following?

A client has come to the healthcare clinic complaining of pain in his left arm after an injury. Which describes the characteristics of nociceptive pain? Select all that apply.

A nurse prepares a dose of medication that is a controlled substance to give to a client for pain. When the nurse takes the medication into the room, the client refuses it. What action of the nurse is most appropriate?

A nurse is caring for a client who uses a morphine PCA for pain control. The client calls the nurse and says that the PCA does not seem to be working because he is still having significant pain. Which response from the nurse is most appropriate?

A client has been injured in an accident and needs treatment for an arm fracture. The client has a history of substance abuse and requests only acetaminophen for pain. The provider orders the nurse to administer narcotics for pain due to the fracture. Which best describes the first step of the nurse in managing this situation?

A 50-year-old patient is recovering from abdominal surgery. He complains of pain that has been continuously rated at a 6 on a 0-10 scale despite the intervention of giving morphine Q4H PRN. Which implication must the nurse consider when controlling this patient’s pain?

A nurse is caring for a client who has returned from the recovery room following surgery. The client arrived on the floor with a PCA pump in place and orders for pain control. Which step would the nurse perform first?

A nurse is caring for an older adult client with dentures. The client needs assistance to brush his dentures and put them back in his mouth. Which action indicates that the nurse is performing this appropriately? Select all that apply.

A nurse is getting ready to perform oral hygiene for an unconscious client. Which of the following principles should the nurse apply? Select all that apply.

A nurse is helping a client with his oral hygiene after eating breakfast in the morning. The nurse assesses the client’s ability to brush teeth and knows that lack of oral hygiene affects the client’s health. Which of the following situations is a risk for a client with poor oral hygiene?

A nurse is providing a complete bed bath for a client who is in the hospital. Which of the following steps would be included as part of a complete bed bath? Select all that apply.

A client with insulinoma is suffering from mental confusion and cognitive impairment. Which action of the nurse best demonstrates respecting the client’s dignity?

A nurse overhears two employees talking about a client’s poor hygiene in a derogatory way. Which of the following actions should the nurse take first?

A public health nurse is teaching a seminar about hygiene promotion. Which best describes the difference between health education and health promotion?

While caring for a client in a rehabilitation center who has self-care deficit related to bathing and hygiene, the nurse assists the client by finding loose clothing to wear that snaps easily in the front. Which of the following best describes the rationale for this?

A client with a paralytic ileus has an order for a nasogastric tube set to low-intermittent suction. Which steps would be included in this procedure? Select all that apply.

A nurse is assessing a diabetic client at the healthcare clinic who has a log of glucose levels and insulin dosages for the past month. The nurse notes that the client has had high levels of blood glucose every morning, requiring increased dosages of insulin first thing in the morning when compared to other times of day. Which of the following suggestions would most likely assist the client to have better readings of morning blood glucose levels?

A client is being seen in the emergency department for anxiety, confusion, and behavioral changes. The client’s heart rate is elevated and the blood glucose is 48 g/dL. The nurse administers a dose of glucagon and a continuous infusion of IV dextrose. Which of the following interventions should the nurse perform next?

A nurse is assessing a client with a history of diabetes. The client tells the nurse that she does not feel well. The nurse checks her blood glucose levels and gets a result of 51 mg/dL. What signs or symptoms would the nurse expect to see with this blood glucose level? Select all that apply.

A client uses Novolin R, a short-acting insulin, to control his blood glucose levels. The client is reviewing the principles of glucose control with the nurse and asks about when he should take his insulin in relation to meals. Which response from the nurse is most accurate?

A client who is in the hospital requires total parenteral nutrition for management of malnutrition. After two days on the TPN solution, the nurse checks the clients blood glucose levels and the result is 181 mg/dL. Which action of the nurse is most appropriate?

A 41-year-old client has been diagnosed with type 2 diabetes. The nurse is teaching the client about how to perform self-monitoring of blood glucose (SMBG) at home. The nurse instructs the client about how to use a lancet to obtain a blood sample. Which technique would the nurse most likely include?

A 65-year-old client is in the hospital for surgery for a colon resection. The client requires total parenteral nutrition, which is administered through a central venous catheter. The nurse notes that the client has a red area of induration around the catheter exit site. The client’s latest blood glucose result is 176 mg/dL and a current temperature of 38 degrees celsius. Which of the following conditions should the nurse suspect?

A 44-year-old diabetic client is undergoing surgery for a hysterectomy. The client is a type 1 diabetic who requires regular monitoring of blood glucose levels and insulin administration on a sliding scale. Which information should be given to the client about controlling blood glucose levels throughout surgery?

The nurse is admitting a diabetic client. The nurse asks questions about diet and discovers that the client avoids sugary foods, but eats rolls and bread at every meal. Which of the following responses by the nurse is correct?

What information should the nurse gather about a client’s diet during the nutrition screening? Select all that apply.

The nurse is caring for a client on a diabetic diet. This means the client needs to monitor intake of which of the following?

The nurse is caring for a client at risk for atherosclerosis. Which of the following dietary considerations is appropriate for this client?

A client who has lost weight because of cancer has asked the nurse about what foods to eat to help increase calorie intake and gain weight. Which suggestions could the nurse make that would best help promote weight gain in this client? Select all that apply.

A client with celiac disease is on a gluten-free diet while in the hospital. The nurse checks the tray before serving the client dinner. Which of the following foods would need to be removed before serving this client? Select all that apply.

A nurse is teaching an 82 year-old about proper nutrition. Which nursing interventions would be most important? Select all that apply.

A nurse is caring for a client who is Catholic and is NPO after abdominal surgery. The client’s priest visits to offer communion. Which action of the nurse is most appropriate?

A 36-year-old client with a history of short bowel syndrome has had a colostomy placed. The nurse is educating the client on dietary management of the syndrome. Which of the following instructions should the nurse include for this client?

A client who has leukemia has asked the nurse about what type of foods to eat to help boost the immune system. Which of the following supplements could the nurse suggest that would help to boost this client’s immune system? Select all that apply.

A 71-year-old client in the rehabilitation facility has dysphagia and must have food consistencies altered before eating. He is on the dysphagia diet, at level 1: dysphagia pureed. Which of the following foods would it be most appropriate for the nurse to serve to him?

When assessing the client’s abdomen, what is the first thing the nurse will do?

A nurse is caring for a client in the hospital and notes these nodes on the client’s joints (see image). Based on this finding, which diagnosis would the nurse expect to find in the client’s medical history?

A nurse is performing a cardinal gaze eye assessment. The nurse knows that this tests which of the following cranial nerves? Select all that apply.

A nurse is treating a client in the emergency department who was severely injured after a fall. The nurse begins the primary survey to assess for airway, breathing, and circulation. The client is crying and complaining of pain. Based on this information, what step must the nurse perform next to manage the client’s airway?

A client with a history of malnutrition has skin breakdown in several areas of the body with bony prominences. The nurse first determines the client’s age in the initial assessment. Which best describes the rationale for this measure?

The nurse is performing an assessment of a client’s abdomen. Upon palpation, the nurse feels an abnormal lump in the left upper quadrant that is extremely painful for the client. The nurse is likely palpating which of the following?

A client is brought to the emergency department after being involved in a motor vehicle collision. The client was the restrained passenger and is conscious and alert. Vitals are as follows: HR 115, BP 100/60, RR 26. The client has a visible seat belt sign across the lower abdomen and is complaining of pain in the left shoulder. The primary nurse suspects the client might have an injury to which of the following?

A nurse is performing an intake assessment on a client who has been transferred from the long-term care facility to the hospital. The nurse knows that the client has a history of skin breakdown and performs a skin check as part of the initial assessment. Which best describes the rationale for including this type of assessment during the admission process?

A client is brought in to the emergency department with multiple stab wounds and is at risk for hemorrhagic shock. The nurse knows that it is best to check blood circulation through which of the following pulse assessments?

A nurse is preparing to perform a physical assessment on a client. One of the pieces of equipment the nurse gathers is a sterile safety pin. Which best describes how the nurse would use this piece of equipment?