A charge nurse is delegating tasks to nursing Assigning the most efficient AP to

personnel on a 10-bed medical-surgical nursing unit.

Which o the following assignments is an example of perform glucometer monitoring for
overdelegation? each client

A charge nurse is reviewing guidelines for initiating

airborne precautions. Which of the following clients
should the nurse identify as requiring airborne A client who has measles
precautions?

A client is planning to perform nasotracheal suction

for a client who has COPD and an artificial airway. Preoxygenate the client with
Which of the following actions should the nurse
take? 100% oxygen for up to 3min

A client smoking in his bathroom has dropped a

cigarette butt into a wastepaper basket, which begins Move any clients in the
to smolder. Which of the following actions is the
nurse's priority? immediate vicinity

A home health nurse is conducting a home safety Water heater temp. 54.4 degree celcius
assessment for an adult client. Which of the
following findings should the nurse identify as a (130 degree fahrenheit)
safety risk for the client? Throw rugs

A nurse arrives for her shift and is preparing to count Verify the amounts of each medication
the controlled substances in the secure cabinet.
Which of the following actions should the nurse she counts match the amounts on the
take? inventory record

A nurse at an extended-care facility is instructing a class of

assistive personnel about client use of assistive devices during When the client moves, he should
ambulation. Which of the following instructions should the nurse
give the APs about the clients' use of a cane? move the can forward first

A nurse checks with the assistive personnel on the

unit throughout the shift to determine if they are
completing tasks. The nurse is demonstrating which Right supervision
of the following rights of delegation?

A nurse has completed care procedures for a client

who requires airborne precautions. Which of the
following items of PPE should the nurse remove Gloves
first?

A nurse id caring for a client who is 12hr postop and

has a chest tube to a disposable water-seal drainage Continuous bubbling in the
system with suction. The nurse should intervene for
which of the following observations? water-seal chamber
A nurse in a cardiac care unit is caring for a
client with acute right-sided heart failure. Which Elevated central venous
of the following findings should the nurse
expect?
pressure (CVP)

A nurse is admitting a client who requires

droplet precautions due to influenza. Which of
Wear a mask when providing
the following actions should the nurse take? care for the client

A nurse is assessing a client's ability to ambulate with

crutches using a three-point gait. Which of the The client places partial
following actions should the nurse identify as a risk
to the client's safety?
weight on the affected leg

A nurse is assessing a client who has a urine output

of 250ml in a 24-hr period. Which of the following
descriptive terms should the nurse place in the Oliguria
client's electrrnic record

A nurse is assessing a client who has COPD.

The nurse should expect the client's chest to Barrel
be which of the following shapes

A nurse is assessing a client who has left-

sided heart failure. Which of the following Hacking cough
findings should the nurse expect?

A nurse is assessing a client who has right

ventricular failure. Which of the following Hepatomegaly
findings should the nurse expect?

A nurse is assisting a newly licensed nurse with "Delegation permits a designated

delegating tasks to an assistive personnel on the unit.
Which of the following statements by the nurse individual to meet a goal on your
explains the purpose of delegation? behalf."

A nurse is assisting with transferring a client

Lock the wheels of the bed
from the bed to a wheelchair. Which of the
following actions should the nurse take? and the wheelchair

A nurse is bathing a toddler and notices that

Ask the parents what caused
she has several bruises. Which of the
following actions should the nurse take first? the bruises
A nurse is caring for a child who has tracheostomy.
After suctioning the trach, the nurse should use
which of the following findings to determine that the Clear breath sounds
procedure was effective?

A nurse is caring for a client who has a hip fracture

that requires surgical repair. Which of the following
health care professionals is responsible for obtaining Surgeon
informed consent from the client for the procedure?

A nurse is caring for a client who has a history of dementia. The

client is alert and oriented to person, place, and has advance
directives. The client is scheduled for a procedure that requires
informed consent. Which of the following persons should sign
The client
the informed consent

A nurse is caring for a client who has a stage 3

pressure ulcer. The nurse should recognize that
which of the following lab findings will affect wound Serum albumin 3.2g/dL
healing?

A nurse is caring for a client who has C. diff

infection. Which of the following cleansing Nonantimicrobial soap
agents should the nurse use for hand hygiene?

A nurse is caring for a client who has COPD. The client tells the
nurse, "I can feel the congestion in my lungs, and i certainly
cough a lot, but I can't seem to bring anything up." Which of the
Encouraging the client to drink
following actions should the nurse take to help this client with
tenacious bronchial secretions?
2 to 3 L of water daily
A nurse is caring for a client who has DVT and has been on
heparin continuous infusion for 5 days. The provider prescribes
"Warfarin takes several days to work, so
warfarin PO without discontinuing the heparin. The client asks the IV heparin will be used until the
the nurse why both anticoagulants are necessary. Which of the
following statements should the nurse make? warfarin reaches a therapeutic level"

A nurse is caring for a client who has heart failure

and a new prescription for furosemide. Which of the
following laboratory values should the nurse review Potassium
before administering furosemide?

A nurse is caring for a client who has impaired

mobility. Which of the following support devices
should the nurse plan to use to prevent the client Footboard
from developing plantar flexion contractures?

"I have to choose a family

A nurse is caring for a client who has named a person to serve
as his health care proxy. The client states he needs clarification

member as my health proxy"

about his type of advance directive. Which of the following
statements by the client indicates a need for clarification?
A nurse is caring for a client who has returned to the
unit following a surgical procedure. The client's
oxygen saturation is 85%. Which of the following Raise the head of the bed
actions should the nurse take first?

A nurse is caring for a client who has valvular heart disease and

Breathlessness
is at risk for developing left-sided heart failure. Which of the
following manifestations should alert the nurse that the client is
developing this condition?

A nurse is caring for a client who is 2 days postop following Cover the area with a sterile dressing,
abdominal surgery and observes the the client's wound has
eviscerated. After calling for help, which of the following actions moistened with 0.9% sodium chloride
should the nurse take first? irrigation

A nurse is caring for a client who is dying. The nurse Withholding a dose of narcotic pain
should incorporate the principle of nonmaleficence
into practice by taking which of the following medication when the client has
actions? respiratory depression

A nurse is caring for a client who is Loosen restrictive clothing

experiencing a seizure. Which of the Place a pillow under the client's
following actions should the nurse take? head
A nurse is caring for a client who is postop following
vascular surgery. Which of the following signs
should indicate to the nurse that the client has Dull, aching calf pain
developed a thrombus?

A nurse is caring for a client who is scheduled

Determining the client's level of
for surgery. The nurse's role in regard to
informed consent is which of the following? understanding about the procedure

A nurse is caring for a client who receives intermittent

enteral feedings through an NG tube. Before To identify delayed gastric
administering a feeding, the nurse should measure the
gastric residual for which of the following purposes? emptying

Inform the provider that the

A nurse is caring for a client whose informed consent form has
been signed in preparation for a procedure. The client states, "I

client is withdrawing consent

have decided not to have the procedure." Which of the following
actions should the nurse take?

A nurse is caring for a client with a trach. The client's

partner has been taught to perform suctioning. Which of Performing the procedure
the following actions by the partner should indicate to
the nurse a readiness for the client's discharge? independently
A nurse is caring for a group of clients. The
nurse demonstrates adherence to ethical Keeping an appointment with
principle of fidelity by doing which of the
following?
a client

A nurse is caring for a postop client who has a chest

tube connected to the suction and a water seal Fluctuation of the fluid level
drainage system. Which of the following indicates to
the nurse that the chest tube is functioning properly?
within the water seal chamber

Peripherally inserted central

A nurse is completing discharge planning for a client who has
bacterial endocarditis. The client will need to receive 12 weeks of

catheter
antibiotic therapy. Which of the following venous access devices
should the nurse identify as appropriate for the client?

A nurse is creating a discharge plan. Which of the

following nursing statements indicates the nurse "I will begin upon the client's
understands when discharge planning should be
implemented admission to the facility."

A nurse is documenting information in a

computerized health record. Which of the following
Sharing computer passwords
nursing actions jeopardizes client confidentiality? with coworkers

A nurse is educating a group of older adults in a

community center on weight management using the BMI A client with a weight of 150lb
scale. Using the client's height and weight to calculate
BMI, which of the following clients has a healthy BMI? and height of 68in

A nurse is giving a presentation about client

confidentiality to a group of newly licensed nurses. Reporting laboratory findings to
Which of the following actions is an example of a
violation of confidentiality?
a member of the client's family

A nurse is helping an older adult client ambulate in the hallway

for the first time since admission. The client has brought her
standard walker from home. To ensure proper use of the walker
Check that the client lifts the walker
and the safety of the client, which of the following actions and the places it down in front of her
should the nurse take?

A nurse is in a client's room when the client

begins having a tonic-clonic seizure. Which of
Turn the client's head to the
the following actions should the nurse take first? side

A nurse is measuring a client for knee-high anti-

embolic stockings to help prevent venous stasis. Measure from the heel to the
Which of the following actions should the nurse
take? popliteal space
A nurse is monitoring a client who has a chest tube in
place connected to wall suction due to a right-sided
pneumothorax. The client complains of chest burning. Reposition the client
Which of the following actions should the nurse take?

A nurse is obtaining informed consent Validate the signature is authentic

from a client who is postop. Which of the Verify the client understands the surgical procedure
Confirm that the consent is voluntary
following actions should the nurse take?

A nurse is performing a mental status examination on Grooming

a client who has a new diagnosis of dementia. Which
of the following components should the nurse Long-term memory
include? Affect

A nurse is planning care for a 4-year-old child who

requires airborne precautions. Which of the following
Putting a large-piece puzzle
activities should the nurse plan for the child? together

A nurse is planning care for a client who has

dementia. Which of the following interventions
Limit the client's choices for
should the nurse include in the plan of care? daily activities

A nurse is planning care for a client who has

manifestations of C. diff infection. Which of the
Place the client on contact
following actions should the nurse plan to take? precautions

A nurse is preparing to discharge a client who has an

abdominal wound that is healing by secondary Schedule a follow-up visit by a home
intention. Which of the following actions is the nurse's health nurse for dressing changes
priority?

A nurse is preparing to measure a client's level of

oxygen saturation and observes edema of both hands
and thickened toe nails. The nurse should apply a pulse Earlobe
oximeter probe to which of the following locations?

A nurse is preparing to witness informed consent for a

client who is preoperative. The client asks the nurse, "Have you discussed other
"Are there other options besides surgery?" Which of the
following responses should the nurse make?
treatments with your provider?"

A nurse is providing dietary teaching for a client who

takes furosemide. The nurse should recommend
which of the following foods as the best source of Bananas
potassium?
A nurse is providing discharge teaching to a client
who has a new diagnosis of heart failure. Which of Exercise at least three times
the following instructions should the nurse include in
the teaching? per week

A nurse is providing discharge teaching to a client

who was recently diagnosed with a latex allergy.
Which of the following client statements indicates an "I will use ink pens for writing"
understanding of the teaching?

A nurse is providing home safety information for an "You should advance your weak leg
older adult client who uses a cane. Which of the
following statements should the nurse include in the forward to the cane, then move your
teaching? strong leg"

A nurse is providing oral care for a

Turn the client on his side
client who is immobile. Which of the
follow actions should the nurse take? before starting oral care
A nurse is providing preop teaching for a client who will
undergo surgery. The nurse explains that the client will wear "They improve your circulation to keep
antiembolism stockings during and after the procedue. When the
client asks what the stockings do, which of the following blood from pooling in your legs"
responses should the nurse make?

A nurse is teaching a class on torts. The A nurse identifies the absence of peripheral pulsation
nurse should include which of the following in a casted extremity in the early morning and reports
situations is an example of negligence? it to the provider in the early afternoon

A nurse is teaching a client who has a history of falls

about home safety. Which of the following "I will place a bath seat in my
statements should the nurse identify as an indication
that the client understands the instructions?
shower to use when I bathe"

A nurse is teaching an older adult client who has

left-sided weakness about cane use. Which of the
"When walking, move your left
following instructions should the nurse include? foot forward first"

Serve food in small, non-circular pieces

A nurse is teaching the parents of a 10-month-old
Tie plastic bags in knots before discarding them
infant about home safety. Which os the following
Fit the mattress so that it is snug against the sides of
information should the nurse include in the teaching?
the crib

A nurse manager is preparing to take disciplinary

action for a staff nurse's substance use disorder. The
manager should identify which of the following as State Board of Nursing
having the authority to revoke a nurse's license?
A nurse manager is providing an inservice program "The nurse should consider the APs
about delegation to an AP with staff nurses on the
unit. Which of the following statements by a staff level of experience when making
nurse indicates an understanding of the teaching? delegation decisions"
A nurse plans to leaver her scheduled shift an hour
early without permissions or notification of the charge
nurse. The clients in the nurse's assignment are stable. Negligence
Which of the following legal torts applies to this
situation?

A nurse should teach which of the A client who has a right femur fracture
following clients requiring crutches with no weight bearing on the affected
about how to use a three-point gait? leg

A nurse us assisting a client who has received crutches

in an urgent care center following a foot injury. Which of "I have a set of my brother's crutches
the following statements should the nurse identify as an
indication that the client needs further teaching?
in my basement I can also use"

When planning delegation of tasks to an AP, a nurse

considers the five rights of delegation. Which of the The AP has the knowledge
following should the nurse consider when using one
of the five rights of delegation?
and skill to perform the task