A nurse is assigned to care for a client who
has returned to the nursing unit following
left nephrectomy.
The nurse places highest priority on obtaining
which of the following asessments ?
1 Tolerance for sips of clear liquids
2 Temperature
3 Hourly urine output
4 Ability to turn side to side
A child has just returned from surgery and
has a hip spica cast.
A priority nursing action at this time is to:
1 Elevate the head of bed
2 Abduct the hips using pillows
3 Assess circulatory status
4 Turn the child on the right side
A nurse is assessing the casted extremity of
a client for signs of infection.
Which of the following findings is indicative of
infection ?
1 Coolness and pallor of the skin
2 Presence of a "hot spot" on the cast
3 Diminished distal pulse
4 Dependent edema
A nurse obtains a fingerstick glucose reading of
425 mg/dl on a client who was recently started
on total parenteral nutrition (TPN).
What nursing action is most appropriate at this time ?
1 Stop the TPN
2 Decrease the flow rate of the TPN
3 Administer insulin
4 Notify the physician
A nurse is assessing a client who is diagnosed
with cystitis.
Which assesment finding is inconsistent with
the typical clinical manifestations noted in this
disorder ?
1 Urinary retention
2 Burning on urination
3 Low back pain
4 Hematuria
A nurse has given instructions on site care to
a hemodialysis client who had an implantation
of an arteriovenous (AV) fistula in the right arm.
The nurse determines that the client needs futher
instructions if the client states to :
1 Avoid carrying heavy objects on the right arm
2 Sleep on the right side
3 Report an increased temperature, redness, or
drainage at the site
4 Perform range of motion exercises routinely on
the right arm
A nurse is planning to do preoperative teaching
with a client scheduled for a transurethral
resection of the prostate (TURP).
The nurse plans to include in the discussion
that the most frequent cause of postoprerative
pain will be :
1 The lower abdominal incision
2 Bleeding within the bladder
3 Bladder spasms
4 Tension on the Foley catheter
A nurse is assisting in participating in a
prostate screening clinic for men.
The nurse questions each client about
which sign of prostatism ?
1 Excessive force in urinary stream
2 Hesitancy when initiating urinary stream
3 Ability to stop voiding quickly
4 Absence of post-void dribbling
A client request pain medication and the nurse
administers an intramuscular injestion.
After administration of the injection, the nurse
does which of following first ?
1 Massages the injection site
2 Removes the gloves
3 Washes the hands
4 Places the syringe in the puncture-
resistant needle box container
A nurse is planning care for a client with
acute glomerulonephritis.
The nurse instructs the nursing assistant to
do which of the following in the care of the
client?
1 Monitor the temperature every 2 hours
2 Remove the water pitcher from the bedside
3 Ambulate the client frequently
4 Encourage a diet that is high in protein
A client with urolithiasis is scheduled for
extracorporeal shock wave lithotripsy.
The nurse ensure that the client understands
the procedure and tells the client that:
1 The procedure involves breaking up the stone
by a vibrating needle that is inserted into the
urinary tract
2 He will be anesthetized and placed in a water bath
3 There is no pain at all involved with this procedure
4 There are no side effects or complications
associated with this procedure
A client admitted to the hospital with a
diagnosis of cirrhosis has massive ascites
and difficulty breathing.
The nurse performs which intervention as a
priority measure to assist the client with breathing?
1 Auscultates the lung fields every 4 hours
2 Repositions side to side every 2 hours
3 Encourages deep breathing execises every 2 hours
4 Elevates the head of the bed 60 degrees
A nurse is caring for a client with Buck's traction
and is monitoring the client for complications of
the traction. Which assessment finding indicate a
coｍplication?
1 Weak pedal pulses
2 Draiage at the pin site
3 Warm toes
4 Complaints of discomfort
A nurse is caring for a client who had an orthopedic
injury of the leg requiring surgery.
Postoperatively, which nursing assesmnt is of hightest
priority?
1 checking for bladder distention.
2 assessing for Homans' sign.
3 monitoring for extremity shortening.
4 monitoring for heel breakdown.