1. A nurse is assisting with the plan of care for a client following a
transurethral resection of the prostate. Which of the following
interventions should the nurse include in the plan of care?
…Answer>> The nurse should irrigate the bladder using strict sterile
technique and maintain closed catheter drainage system to minimize the
rick of infection.
2. A nurse is reviewing a client's electronic medical record and finds
,Page 2 of 45
that an assistive per sonnel recorder the client's temperature as 35.3
degrees Celsius (95.5 degrees F) 2 hrs earlier. Which of the following
actions should the nurse take first?
…Answer>> check the clients temp
3. A nurse is receiving change of shift report for four clients. Which of
the following clients should the nurse see first?
…Answer>> A client whose urinary output was 100mL for the past 12
hrs
4. A nurse in reinforcing teaching about weight loss with a female
older adult client who is overweight. Which of the following
statements should the nurse include in teaching?
…Answer>> keep fat intake to no more that 30% of daily caloric
intake.
5. A nurse is collecting data from a client who has iron deficiency
anemia. Which of the following findings should the nurse expect?
…Answer>> difficulty concentrating
,Page 3 of 45
6. A Nurse is collecting data from an older adult client who is 48 hr
post- operative following abdominal surgery. The provider writes a
prescription to advance the client to a re gular Diet. For which of the
following findings should the nurse notify the provider?
…Answer>> The client has absent bowel sounds
7. A parent brings her adolescent son to an urgent care center and
states. "He is high on something and needs help" The client is
exhibiting agitation and paranoia and reports visual hallucinations.
The nurse should suspect intoxication with which of the following
substances?
…Answer>> Methamphetamines
8. A nurse notices an assistive personnel taking a nap in the break
room during he meal t ime. The AP appears drowsy while
performing routine tasks. Which of the following a ctions should the
nurse take?
…Answer>> Report the observations about the ap to the unit's nurse
manager.
, Page 4 of 45
9. A nurse is reinforcing teaching with a client who has a fluid
volume deficit about selec ting foods that have a high water content.
The nurse should include that which of the following raw foods
contains the highest amount of water per 1 cup serving?
…Answer>> cherry tomatoes
10. The nurse is position a client who is scheduled for a lumbar
puncture. The nurse should assist the client into which of the
following positions?
…Answer>> lateral recumbent
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