Download NCLEX RN NCSBN ON-LINE Examtestbank-with 100% verified solutions2024-2025 GUARANTEED PAS and more Exams Nursing in PDF only on Docsity! NCLEX RN NCSBN ON-LINE Exam- testbank-with 100% verified solutions- 2024-2025 GUARANTEED PASS NCSBN ON-LINE REVIEW 1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client comfort will be improvedas well. 2. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A) Clean the meatus, begin voiding, then catch urine stream B) Void a little, clean the meatus, then collect specimen C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to obtain and requires cleardirections. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteriafrom contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it’s best tojust slip the container into the stream. Other responses do not reflect correct technique 3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hours ago D) 75 year-old who is in skin traction prior to planned hip pinning surgery. C: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hoursago is at risk for life threatening hemorrhage and should be seen first. The 16 year- old should be seen next because it is still thefirst post-op day. The 75 year-old is potentially vulnerable to age-related physical and cognitive consequences in skin tractionshould be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury. 10. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with familymembers. Which of these interventions would be most helpful at this time? A) leave a book about relaxation techniques B) write out a daily exercise routine for them to assist the client to do C) list actions to improve the client's daily nutritional intake D) suggest communication strategies D: suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly challenges caregivers. The nursecan be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.By use of select verbal and nonverbal communication strategies the family can best support the client’s strengths and cope withany aberrant behavior. 11. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100 to180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse reportimmediately to the provider? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse A: Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intracranial bleeding orextension of the stroke. Further diagnostic testing may be indicated. 12. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parentindicates that teaching has been inadequate? A) "I will keep the cast uncovered for the next day to prevent burning of the skin." B) "I can apply an ice pack over the area to relieve itching inside the cast." C) "The cast should be propped on at least 2 pillows when my child is lying down." 9D) "I think I remember that my child should not stand until after 72 hours." D: "I think I remember that my child should not stand until after 72 hours.". Synthetic casts will typically set up in 30 minutesand dry in a few hours. Thus, the client may stand within the initial 24 hours. With plaster casts, the set up and drying time,especially in a long leg cast whichisthickerthananarmcast,cantake up to 72 hours. Both types of castsgiveoffalotofheawhendryinganditis preferable to keep the cast uncovered for the first 24 hours. Clients may complain of a chill from the wetcast and therefore can simply be covered lightly with a sheet or blanket. Applying ice is a safe method of relieving the itching. 13. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79%2 C: HCT of 60. This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis.Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation. In the absenceof insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energyketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3), which would be the secondconcern for this client. The potassium and PaO2 levels are near normal. 14. The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the followingwould be necessary for preparing the client for this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anti-coagulant therapy prior to the test D) No special preparation is necessary D: No special preparation is necessary. This is a non-invasive procedure and does not require preparation other than clienteducation. 15. A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition? A) dyspnea B) heart murmur C) macular rash D) HemorrhageB: heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off,causing emboli and leaving ulcerations onthevalveleaflets.Theseemboli produce findings ofcardiacmurmurfever,anorexia,malaiseandneurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney,coronary artery, brain and lungs, and obstruct blood flow. 16. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." C: my thigh.". Autografts are done with tissue transplanted from the client''s own skin. 17.A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would beexpected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills A: Diffuse expiratory wheezing. In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results. 18. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursinginterventions should receive priority? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed B: Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess neurovascularstatus. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and earlyintervention may prevent permanent limb damage. 19. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions aboutthis condition. What area is a priority for the nurse to discuss at this time? B: Continue with the regular diet and include oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. 25. The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) formula or breast milk B) broth and tea C) rice cereal and apple juice D) gelatin and ginger ale A: formula or breast milk. The usual diet for a young infant should be followed. 26. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) call for emergency transport to the hospital B) immobilize the limb and joints above and below the injury C) assess the child and the extent of the injury D) apply cold compresses to the injured area C: assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The "5 Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). 27. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings B: Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load. 4 28. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced one at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle A: Solid foods are introduced one at a time beginning with cereal. Solid foods should be added one at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food. 29. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise B: Client controlled analgesia. Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. 30. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in detail B: Use minimal physical contact. The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action. 31. What finding signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgment that "stealing is wrong" D) Reasons that homework is time-consuming yet necessary C: Makes the moral judgment that "stealing is wrong". The stage of concrete operations is depicted by logical thinking and moral judgments. 32. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." A: "Folic acid should be taken before and after conception.". The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects. 38. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) once each day B) 3 times daily after meals C) with each meal or snack D) each time carbohydrates are eaten C: Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten. 39. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula C: Let tap water run for 2 minutes before adding to concentrate. Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used in sealing water pipes. Letting tap water run for several minutes will diminish the lead contamination. 40. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair D: Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits. 41. When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor? A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus A: Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. 42. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying? 6 A) DTaP B) Hepatitis B C) Polio D) H. Influenza A: DTaP. The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization. 43. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? A) "I think you or your partner needs to stay with the child while in the hospital." B) "Oh, that behavior will stop in a few days." C) "Keep in mind that for the age this is a normal response to being in the hospital." D) "You might want to "sneak out" of the room once the child falls asleep." C: The protest phase of separation anxiety is a normal response for a child this age. In toddlers, ages 1 to 3, separation anxiety is at its peak 44. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? A) To discuss feelings with each other and use support persons B) To focus on the other healthy children and move through the loss C) To seek causes for the fetal death and come to some safe conclusion D) To plan for another pregnancy within 2 years and maintain physical health A: To discuss feelings with each other and use support persons. To communicate in a therapeutic manner, the nurse''s goal is to help the couple begin the grief process by suggesting they talk to each other, seek family, friends and support groups to listen to their feelings. 45. The nurse is performing a pre-kindergarten physical on a 5 year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A) vastus intermedius observation of hourly urinary output is necessary for early detection of this condition. 50. A client is admitted to the rehabilitation unit following a cerebral vascular accident (CVA) and mild dysphagia. The most appropriate intervention for this client is to A) position client in upright position while eating B) place client on a clear liquid diet C) tilt head back to facilitate swallowing reflex D) offer finger foods such as crackers or pretzels A: position client in upright position while eating. An upright position facilitates proper chewing and swallowing. 51. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device C: Assessing the client''s ability to participate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. 52. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered B: Administer epinephrine 1:1000 as ordered. All the answers are correct given the circumstances, but the priority is to administer the epinephrine, then maintain the airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normotensive, administering the epinephrine is first, and applying the oxygen, and watching for hypotension and shock, are later responses. The prevention of a severe crisis is maintained by using diphenhydramine. 53. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. The physiological basis for this instruction is that the medication A) retards pepsin production B) stimulates hydrochloric acid production C) slows stomach emptying time D) decreases production of hydrochloric acid B: stimulates hydrochloric acid production. Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers. 54. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? A) Dystonia B) Akathisia C) Brady dyskinesia D) Tardive dyskinesia D: Tardive dyskinesia. Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. These findings are often described as Parkinsonian. 55. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema 8 C: Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics. 56. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least 5 years after the diagnosis B: Begin treatment with acyclovir at the onset of symptoms of recurrence. When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease; they simply decrease the level of symptoms. 57. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? A) Hypothermia C: Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risks for infection. 9 63. While interviewing a new admission, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to A) ask the client what she is feeling B) assess the client for auditory hallucination C) recognize the behavior as a side effect of medication D) re-focus the discussion on a less anxiety provoking topic A: ask the client what she is feeling. The initial step in anxiety intervention is observing, identifying, and assessing anxiety. The nurse should seek client validation of the accuracy of nursing assessments and avoid drawing conclusions based on limited data. In the situation above, the client may simply need to use the restroom but be reluctant to communicate her need! 64. A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront the client’s delusion D) Contact the government agency A: Listen quietly without comment. The client''s comments demonstrate grandiose ideas. The most therapeutic response is to listen but avoid being incorporated into the client’s delusional system. 65. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention C: Decreased potassium. In bulimia, loss of electrolytes can occur in addition to other findings of starvation and dehydration. 66. A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond? A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him." B) "Go to an AA meeting when you feel the urge to drink." C) "It is important to exercise daily and get involved in activities that will cause you not to think about drug use." D) "Let’s talk about possible options you have when you recognize relapse triggers in yourself." D: This option encourages the process of self evaluation and problem solving, while avoiding telling the client what to do. Encouraging the client to brainstorm about response options validates the nurse’s belief in the client’s personal competency and reinforces a coping strategy that will be needed when the nurse may not be available to offer solutions. 67. Therapeutic nurse-client interaction occurs when the nurse A) assists the client to clarify the meaning of what the client has said B) interprets the client’s covert communication C) praises the client for appropriate feelings and behavior D) advises the client on ways to resolve problems A: assists the client to clarify the meaning of what the client has said. Clarification is a facilitating/therapeutic communication strategy. Interpretation, changing the focus/subject, giving approval, and advising are non- therapeutic/barriers to communication. 68. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with 1 person B) Provide the client with frequent opportunities to interact with other clients C) Assist the client to analyze the meaning of the withdrawn behavior D) Discuss with the client the focus that other clients have similar problems A: Offer the client frequent opportunities to interact with 1 person. The withdrawn client is uncomfortable in social interaction. The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships. 69. An important goal in the development of a therapeutic inpatient milieu is to A) provide a businesslike atmosphere where clients can work on individual goals B) provide a group forum in which clients decide on unit rules, regulations, and policies C) provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) discourage expressions of anger because they can be disruptive to other clients C: provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. 10 70. A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you’re so perfect and pure and good." An appropriate response for the nurse is vital signs. 76. Which intervention best demonstrates the nurse's sensitivity to a 16 year-old’s appropriate need for autonomy? A) Alertness for feelings regarding body image B) Allows young siblings to visit C) Provides opportunity to discuss concerns without presence of parents D) Explores his feelings of resentment to identify causes C: Provides opportunity to discuss concerns without presence of parents. This intervention provides the teen with the opportunity to have control and encourages decision making. 77. The nurse's primary intervention for a client who is experiencing a panic attack is to A) develop a trusting relationship B) assist the client to describe his experience in detail 11 C) maintain safety for the client D) teach the client to control his or her own behavior C: maintain safety for the client. Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others. 78. A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects A) Respiratory distress, dyspnea B) Bacterial gastrointestinal infections, overhydration C) Metabolic acidosis, constricted colon D) Dental erosion, parotid gland enlargement D: Dental erosion, parotid gland enlargement. Dental erosion and parotid gland enlargement due to purging are common complications of binge eating followed by self-induced vomiting. 79. Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7 to 14 days after initiation of antidepressant medication and psychotherapy C) Following an angry outburst with family D) When the client is remov0ed from the security room B: 7 to 14 days after initiation of antidepressant medication and psychotherapy. As the depression lessens, the depressed client acquires energy to follow the plan. 80. A client is admitted to a psychiatric unit with delusions. What findings could the nurse observe that would be consistent with delusional thought patterns? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints B: Suspiciousness and resistance to therapy. Clinical features of paranoid delusional disorder include extreme suspiciousness, jealousy, distrust, and a belief that others intend to invoke harm. 81. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness." C: "Clothes are becoming tighter across her abdomen.". One of the most common signs of neuroblastoma is increased abdominal girth. The parents'' report that clothing is tight is significant, and should be responded to with additional assessments. 82. Parents call the emergency room to report that a toddler has swallowed drain cleaner. The triage nurse instructs them to call for emergency transport to the hospital. The nurse would also suggest that the parents give the toddler sips of while waiting for an ambulance. A) Tea B) Water C) Milk D) Soda B: Water. Small amounts of water will dilute the corrosive substance prior to gastric lavage. 83. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) Ask the teenager to wait until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the partner C) Refer the teenager to a community pediatric hospital emergency department D) Proceed with the triage process in the same manner as any adult client D: Proceed with the triage process in the same manner as any adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. 84. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is C) plan nursing care around lengthy rest periods D) promote a diet rich in iron C: plan nursing care around lengthy rest periods. The initial priority for this client is rest due to the inability of red blood cells to carry oxygen. 89. The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours C: Assess movement and sensation of extremities. Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities. 90. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? A) Call the Poison Control Center once the situation is identified B) Empty the child's mouth in any case of possible poisoning C) Keep the child as quiet as possible if a toxic substance was inhaled D) Do not induce vomiting if the poison is a hydrocarbon B: Empty the child''s mouth in any case of possible poisoning. Emptying the mouth of poison prevents further ingestion and should be done first to limit damage from the substance. Note that all of the actions are correct, but option B is the priority. 91. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) Lethargy 13 B) Irritability C) Negative Moro D) Depressed fontanel B: Irritability. Signs of increased intracranial pressure (IICP) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, e.g., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular. 92. The nurse is caring for a 4 year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness D: Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. 93. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of 4 hours D) Assess vital signs every 15 minutes throughout the entire infusion C: Limit the infusion time of each of the unit to a maximum of 4 hours. Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time, the blood should be divided into appropriately sized quantities. 94. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A) Prothrombin Time (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes (AST and ALT) D: Liver enzymes (AST and ALT). Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver enzymes are released into the blood stream and serum levels of those enzymes rise. Other lab values are reviewed as well. 95. A nurse admits a premature infant who has respiratory distress syndrome (RDS). In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to A) stabilize thermoregulation B) maintain alveolar surface tension C) begin normal pulmonary blood flow D) regulate intracardiac pressure B: maintain alveolar surface tension. RDS is primarily a disease related to a developmental delay in lung maturation. Although many factors may lead to the development of the problem, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development since the infant is premature. 96. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) assess for abdominal distention A: when it is 1/3 to 1/2 full. If the pouch becomes more than half full it may separate from the flange. 101. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be the client’s A) response to stimuli B) bladder control C) respiratory function D) muscle weakness C: respiratory function. Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority. 102. A client has been admitted to the coronary care unit with a myocardial infarction. Which nursing diagnosis should have priority? A) pain related to ischemia B) risk for altered elimination: constipation C) risk for complication: dysrhythmias D) anxiety related to pain A: pain related to ischemia. Pain is related to ischemia of the heart muscle, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands. 103. The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is A) orientation to time, place and person B) pulse oximetry C) circulation to casted extremity D) blood pressure B: pulse oximetry. Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. The nurse needs to confirm hypoxia first. 104. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soak C) Leaving the area open to dry D) Applying a hydrocolloid or foam dressing D: Applying a hydrocolloid or foam dressing. While the previously accepted treatment was a transparent cover, evidence now indicates that the foam (DuoDerm) dressings work best. 15 105.A client is recovering from a thyroidectomy. While monitoring the client's initial post-operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness C) Irritability and insomnia D) Headache and nausea A: Tetany and paresthesia. Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. 106. A client is scheduled for an intravenous pyelogram (IVP). Which of the following data from the client’s history indicate a potential hazard for this test? A) Reflex incontinence B) Allergy to shellfish C) Claustrophobia D) Hypertension B: Allergy to shellfish. It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may have an allergic reaction to the IVP contrast dye injected during the procedure. 107. A client enters the emergency department unconscious via ambulance. What document should be given priority to guide the direction of care for this client? A) The statement of client rights and the client self determination act B) Orders written by the provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department C: A notarized original of advance directives brought in by the partner. This document specifies the client''s wishes. 108. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from Central America a few weeks ago. B) I had the best raw oysters last week. C) I have many different sex partners. D) I had a blood transfusion 15 years ago. D: I had a blood transfusion 15 years ago.. The client who was transfused prior to blood screening for hepatitis C may show findings many years later. Options B and C are associated with risk of hepatitis B. D) History of hepatitis A: Estrogen replacement therapy. Estrogen increases the hypercoagulability of the blood and increased the risk for development of thrombophlebitis. 115. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? A) "Mongolian spots are a normal finding in dark-skinned children." B) "Port wine stains are often associated with other malformations." C) "Telangiectatic nevi are normal and will disappear as the baby grows." D) "The child is too young for consideration of surgical removal of these at this time." C: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years. 116. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies C: Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible by persons with celiac disease.: F.A. Davis Company. 117. A nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcement of the manipulative behavior C) Confront the client about the negative effects of behaviors on other clients and staff D) Develop a behavior modification plan that will promote more functional behavior A: Discuss the feeling of reluctance with an objective peer or supervisor. The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship. 118. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) may result in charges of unlawful seclusion and restraint B) leaves the nurse vulnerable for charges of assault and battery C) was appropriate in view of a client history of violence D) was necessary to maintain the therapeutic milieu of the unit A: may result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate threat of violence or threatening behavior toward the staff, the other clients, or the client himself. 119. The provisions of the law for the Americans with Disabilities Act require nurse managers to A) Maintain an environment free from associated hazards B) Provide reasonable accommodations for disabled individuals 17 C) Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities B: Provide reasonable accommodations for disabled individuals. The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant’s ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations." 120. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary B: Give information about advance directives. For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client’s choice to sign it. In option 1 just recording the information is not sufficient. In option 3 the nurse should not assume that the client has been informed of choices for emergency care. In option 4 this represents an inappropriate delegation approach. 121.A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care? A) Airborne precautions B) Droplet precautions C) Contact precautions D) Compromised host precautions C: Contact precautions. The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions remove throw rugs, and eliminate other environmental hazards. 127. An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk C: Chicken strips, corn on the cob, milk. This menu is lowest in sodium. Ideally, low fat milk would be available. 128. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) maintain previous calorie intake B) keep a candy bar available at all times C) reduce carbohydrates intake to 25% of total calories D) keep a regular schedule of meals and snacks D: keep a regular schedule of meals and snacks. Currently, calorie-controlled diets with strict meal plans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided. 129. A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the best response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" C) "Did you tell that to your family?" D) "Think of the many positive things in life." B: "Have you thought about hurting yourself?". It is appropriate and necessary to determine if someone who has voiced thoughts about death is considering a suicidal act. This response is most therapeutic in the circumstances. Options A and D deny the validity of the client’s statement, and the purpose of option C is unclear and it lacks client focus. 130. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis? A) Repeatedly checking that the door is locked B) Verbalized suspicions about thefts C) Preference for consistent caregivers D) Repetitive, involuntary movements A: Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduced feelings of anxiety, often interfere with normal function and employment. 131.A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." The nurse's best response would be which of these statements? A) "I hear you saying that you have a fear for the loss of love." B) "You sound concerned that your partner will reject you." C) "Are you wondering about the effects on your sexuality?" D) "Are you worried that the surgery will lead to changes?" D: "Are you worried that the surgery will lead to changes?". This is a general lead in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem. 132. A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse ? A) Provide negative room ventilation B) Wear a face mask with shield C) Wear a particulate respirator mask D) Institute airborne precautions 19 C: Wear a particulate respirator mask. Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety. 133. The charge nurse has a health care team that consists of 1 practical nurse (PN), 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN B) Client who had a major stroke 6 days ago - PN nursing student C) A child with burns who has packed cells and albumin IV running - charge nurse D) An elderly client who had a myocardial infarction a week ago – UAP A: An admission at the change of shifts with atrial fibrillation and heart failure - PN. The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP. 134. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to 138. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do?” B) Stop. Tell me why aspiration is needed. C) Loudly state: “You forgot to aspirate.” 20 D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”. This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream. Option 4 protects the client and is the most professional. 139. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) ensure an open airway D: ensure an open airway. According to the ABCs of CPR the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed, after breathing is evaluated. The need for abdominal thrusts is determined by inability to achieve chest rise when ventilation is attempted. 140. A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse? A) Telfa dressing with antibiotic ointment B) Moist sterile nonadherent dressing C) Dry sterile dressing that is occlusive D) Sterile occlusive pressure dressing B: Moist sterile nonadherent dressing. Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist. 141. A parent brings her 3 month-old into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) increased temperature and lethargy B) restlessness and increased mucus production C) increased sleeping and listlessness D) diarrhea and poor skin turgor B: restlessness and increased mucus production. This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended. 142. The nurse manager hears a provider loudly criticize one of the staff nurses within the hearing range of others. The nurse manager's next action should be to A) Walk up to the provider and quietly state: "Stop this unacceptable behavior." B) Allow the staff nurse to handle this situation without interference C) Notify the of the other administrative persons of a breech of professional conduct D) Request an immediate private meeting with the provider and staff nurse D: Request an immediate private meeting with the provider and staff nurse. Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee. 143. The charge nurse is planning assignments on a medical unit. The client with should be assigned to the unlicensed assistive personnel (UAP). A) d ifficulty swallowing after a mild stroke B) an order of enemas until clear prior to colonoscopy C) an order for a post-op abdominal dressing change D) transfer orders to a long term facility B: an order of enemas until clear prior to colonoscopy. The UAP can be assigned routine tasks which have predictable outcomes. 144. The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will A) Improve the quality of care B) Decrease staff turnover C) Minimize the amount of overtime payouts D) Improve team morale D: Improve team morale. Nurses are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule when self- scheduling exists. 145. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days 150. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform? A) Take a history on a newly admitted client B) Adjust the rate of a gastric tube feeding C) Check the blood pressure of a 2 hours post operative client D) Check on a client receiving chemotherapy C: Check the blood pressure of a 2 hours post operative client. UAPs must be assigned tasks that require no nursing judgment or decision making situations. Vital signs on stable clients are commonly assigned to unlicensed staff. 22 Management of Care 1. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) has had a change in respiratory rate by an increase of 2 breaths B) has had a change in heart rate by an increase of 10 beats C) was minimally responsive to voice and touch D) has had a blood pressure change by a drop in 8 mmHg systolic C: was minimally responsive to voice and touch. A change in level of consciousness indicates delirium related to acute illness. This would require the assessment of a nurse. The other changes could occur within the range of normal fluctuations. 2. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) "I must document and report any information." B) "I can’t make such a promise." C) "That depends on what you tell me." D) "I must report everything to the treatment team." B: "I can’t make such a promise." Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality. 3. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Test blood sugar every 2 hours by Accu-Check B) Review with family and client signs of hyperglycemia C) Monitor for mental status changes D) Check skin condition of lower extremities A: Test blood sugar every 2 hours by Accu-Check. The UAP can do standard, unchanging procedures. 4. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) a Dopamine drip IV with vital signs monitored every 5 minutes B) a myocardial infarction that is free from pain and dysrhythmias C) a tracheotomy of 24 hours in some respiratory distress D) a pacemaker inserted this morning with intermittent capture B: A myocardial infarction that is free from pain and dysrhythmias. This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client. 5. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch D: Apply and care for a client''s rectal pouch. The RN may delegate the application and care of rectal pouches to a UAP. This is an uncomplicated, routine task. 6. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? 23 A) Encourage oral fluids to prevent dehydration B) Recheck temperature 15 minutes after removing hot liquids from the bedside C) Ask the client to drink only cold water and juices D) Chart this temperature elevation on the flow sheet B: Recheck temperature 15 minutes after removing hot liquids from the bedside. Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading. Avoid premature assumptions about explanations for findings. The other options are incorrect. 7. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage B) Monitor the client for nausea or other complications C) Irrigate the nasogastric tube with the ordered irrigant B: Assign 1 of the nursing staff to visit the client regularly. Regular, frequent, planned contact by 1 staff member provides continuity of care and communicates to the client that care will be available when needed. 24 13. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that A) a referral is needed to the psychiatrist who is to provide the client with answers B) the client has a right to know about the prescribed medications C) such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects B: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies. 14. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube system C) Irrigate and redress a leg wound D) Admit a client from the emergency room C: Irrigate and redress a leg wound. The PN is a licensed provider and can perform this complex task. Options A and B could be delegated to an unlicensed assistive personnel (UAP), and option D requires an RN. 15. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) "How long have you been a UAP and what units you have worked on?" B) "What type of care do you give on the surgical unit and what ages of clients?" C) "What is your comfort level in caring for children and at what ages?" D) "Have you reviewed the list of expected skills you might need on this unit?" D: "Have you reviewed the list of expected skills you might need on this unit?". The UAP must be competent to accept the delegated task. Review of skills needed versus level of performance is the most efficient and effective way to determine this. 16. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) "I am sorry. Referral information can only be provided by the client’s providers" B) "I can never give any information out by telephone. How do I know who you are?" C) "Since this is a referral, I can give you this information" D) "I need to get the client’s written consent before I release any information to you" D: In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared. 17. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to A) ask to not be assigned to this client or to work on another unit B) tell the client that such behavior is inappropriate C) inform the client that hospital policy prohibits staff to date clients D) discuss the boundaries of the therapeutic relationship with the client D: Discuss the boundaries of the therapeutic relationship with the client. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust. 18. Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) "If the client is dizzy on standing, ask him to take some deep breaths." C) "Assist the client to the bathroom at least twice on this shift." D) "After you assist him to the chair, let me know how he feels." A: Give clear information to the UAP about what is expected for client safety. 19. After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He may be scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day." C: "He may be scared and taking it out on you. Let''s talk to figure out what to do." This response explains the client''s behavior without belittling the UAP’s feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem. 20. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? A) A client admitted with multiple trauma with a history of a newly implanted pacemaker B) A new admission with left-sided weakness from a stroke and mild confusion C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident 26 D: A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident. This client is the most stable with a predictable outcome. 6. The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most immediately accurate? A) The RN has no accountability for this situation B) The RN did not delegate appropriately C) The UAP is covered by the RN’s license D) The UAP is responsible for following instructions D: The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated especially if given verbally and in writing. 7. As the RN responsible for a client in isolation, which can be delegated to the practical nurse (PN)? A) Reinforcement of isolation precautions B) Assessment of the client's attitude about infection control C) Evaluation of staffs' compliance with control measures D) Observation of the client's total environment for risks A: PNs and UAPs can reinforce information that was originally given by the RN. 8. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client? A) Unlicensed assistive personnel (UAP) B) Senior nursing student C) PN D) RN D: RN. The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to the others listed. 9. The charge nurse on a cardiac step-down unit makes assignments for the team consisting of a registered nurse (RN), a practical nurse (PN), and an unlicensed assistive personnel (UAP). Which client should be assigned to the PN? A) A 49 year-old with new onset atrial fibrillation with a rapid ventricular response B) A 58 year-old hypertensive with possible angina C) A 35 year-old scheduled for cardiac catheterization D) A 65 year-old for discharge after angioplasty and stent placement B: A 58 year-old hypertensive with possible angina. This is the most stable client. The clients in options C and D require initial teaching. The client in option A is considered unstable since the dysrhythmia is a new onset. 10. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? A) Practical nurse (PN) B) Registered Nurse (RN) C) Unlicensed assistive personnel (UAP) D) Volunteer C: Unlicensed assistive personnel (UAP). The measurement and recording of vital signs may be delegated to UAP. This falls under the umbrella of routine task with stable clients. Other considerations for delegation of care to UAP would be: Who is capable and is the least expensive worker to do each task? 11. Which of these clients would be appropriate to assign to a practical nurse (PN)? A) A trauma victim with multiple lacerations and requires complex dressings B) An elderly client with cystitis and an indwelling urethral catheter C) A confused client whose family complains about the nursing care 2 days after surgery D) A client admitted for possible transient ischemic attack with unstable neurological signs B: This is a stable client, with predictable outcome and care and minimal risk for complications. 12. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? A) Assist with plans for any clients discharged B) Provide basic hygiene care to all clients on the unit C) Assess a client after an acute myocardial infarction D) Gather the vital signs of all clients on the unit B: Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients. 13. A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? 27 A) "What degree of supervision for basic care do you think you need?" B) "Let’s review your skills check-list for type and level of skill" C) "Are you comfortable working independently?" D) "What client care tasks or assignments do you prefer?" B: The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills. 20. A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor? A) Provide decubitus ulcer care and apply a dry dressing B) Bathe and feed a client on bed rest C) Oral suctioning of an unresponsive elderly client D) Teaching a family intermittent (bolus) feedings via G-tube before discharge 28 D: Teaching a family intermittent (bolus) feedings via G-tube before discharge. Initial teaching can not be delegated to a UAP or a PN and must be done by RNs. 21. Which of these clients would be most appropriate to assign to a practical nurse (PN)? A) A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection B) A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia C) A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation D) A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure C: A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability. 22. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? A) Report signs of redness overlying a joint B) Monitor the client's response to ambulatory activity C) Encouragement for the independence in self-care D) Assist the client to transfer from a bed to a chair B: Monitor the client''s response to ambulatory activity. Monitoring the client’s response to interventions requires assessment, a task to be performed by an RN. 23. When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? A) "If we work together we can get all of the client care completed." B) "Since I am late for lunch, would you do this one client's glucose test?" C) "This client seems confused, we need to watch monitor closely." D) "I’ll come back and make the bed after I go to the lab." B: Only the RN and PN can delegate to UAPs. One UAP can not delegate a task to another UAP. The RN or PN is legally accountable for the nursing care. 24. A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? A) Ask the client the degree of relief and document the client’s response B) Decrease the set rate on the pump by 2 ml/minute C) Check the IV site for drainage and loose tape D) Assist the client with ambulation and a gown change with supervision D: When directing the UAP, communicate clearly and specifically what the task is and what should be reported to the nurse. Implementation of routine tasks should be delegated since they do not require independent judgment. 25. Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items? A) "The client has complaints of not sleeping well for the past week" B) "The family wants to discontinue the home meal service, meals on wheels" C) "The urine in the urinary catheter bag is of a deeper amber, almost brown color" D) "The partner says the client has slower days every other day" C: Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation. 29 Priority 1. The nurse must know that the most accurate oxygen delivery system available is A) the Venturi mask B) nasal cannula C) partial non-rebreather mask D) simple face mask A: the Venturi mask. The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with following is appropriate reinforcement of information by the nurse? A) "Drink at least 8 glasses of water a day." B) "Be sure to take the medication with food." C) "It is safe to take with oral contraceptives." D) "Stop the medication after 5 days." A: "Drink at least 8 glasses of water a day." Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim. 8. A client calls the evening health clinic to state “I know I have a severely low sugar since the Lantus insulin was given 3 hours ago and it peaks in 2 hours.” What should be the nurse’s initial response to the client? A) What else do you know about this type of insulin? B) What are you feeling at this moment? C) Have you eaten anything today? D) Are you taking any other insulin or medication? B: What are you feeling at this moment? When a client has changed from stable to unstable, the nurse’s initial response should be to do further assessment of the client. 9. The nurse is caring for a client who is receiving total parenteral nutrition (TPN) (hyperalimentation and lipids). What is the priority nursing action on every 8 hour shift? A) Monitor blood pressure, temperature and weight B) Change the tubing under sterile conditions C) Check urine glucose, acetone and specific gravity D) Adjust the infusion rate to provide for total volume C: Check urine glucose, acetone and specific gravity. Because of the high dextrose and protein content in parenteral nutrition, the nurse should assess the urine at least every 8 hours. 10. The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman following the birth of an Rh positive baby. Which assessment is a priority before the nurse gives the injection? A) Newborn's blood type B) Coombs' test results C) Previous RhoGAM history D) Gravida and parity B: Coombs'' test results. Rh (D) immune globulin (RhoGAM) is given only if antibody formation has not occurred. A negative Coombs'' test confirms this. 11. A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse? A) foul smelling urine B) burning on urination C) elevated temperature D) nausea and anorexia C: elevated temperature. Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented. Options A and B are expected with cystitis. Option D may be related to the antibiotics as a side effect and should also be reported to the provider. 12. The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism following treatment for chronic renal disease. Which of the following lab data should receive priority attention? A) Calcium and phosphorus levels B) Blood sugar C) Urine specific gravity 31 D) Blood urea nitrogen A: Calcium and phosphorus levels. Calcium and phosphorous levels will be elevated until the client is stabilized. 13. When caring for a client with urinary incontinence, which content should be reinforced by the nurse? A) hold the urine to increase bladder capacity B) avoid eating foods high in sodium C) restrict fluid to prevent elimination accidents D) avoid taking antihistamines D: avoid taking antihistamines. Antihistamines can aggravate urinary incontinence and should be avoided by these clients. Holding the urine, avoiding sodium, and restricting fluids have not been shown to reduce urinary incontinence. 14. A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to A) maintain fluid and electrolyte balance B) manage post-operative pain C) ambulate the client within 1 hour of surgery D) control bladder spasms B: manage post-operative pain. Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery. 15. A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and D: elevated temperature. It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature. The other findings should be reported to the provider as well. 21. The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings requires priority follow-up? A) Gum bleeding B) Lung sounds C) Homan's sign D) Generalized weakness A: Gum bleeding. The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments remain important for post-CVA clients. 22. The registered nurse (RN) is making decisions regarding client room assignments on a pediatric unit. Which possible roommate would be most appropriate for a 3 year-old child with minimal change nephrotic syndrome? A) 2 year-old with respiratory infection B) 3 year-old fracture whose sibling has chickenpox C) 4 year-old with bilateral inguinal hernia repair D) 6 year-old with a sickle cell anemia crisis C: 4 year-old with bilateral inguinal hernia repair. The nurse must know that children with nephrotic syndrome are at high risk for development of infections as a result of the standard use of immunosuppressant therapy, as well as from the accumulation of fluid (edema). Therefore, these children must be protected from sources of possible infection. D is incorrect because the sickle cell crisis is potentially due to an infectious process. 23. The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first? A) Administer calcium gluconate B) Call the provider immediately C) Discontinue the magnesium sulfate D) Perform additional assessments C: Discontinue the magnesium sulfate. The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client. 24. A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first? A) Repeat glycohemoglobin in 24 hours B) Document Accu-checks, intake and output every 4 hours C) Humulin N 20 units IV push D) IV fluids of 0.9% normal saline at 125 ml per hour C: Humulin N 20 units IV push. Regular insulin is the only insulin that can be given by the intravenous route. This is the initial order to question. Option A should also be questioned, although it is not a priority since the client would not be harmed by this action. This lab test gives the average glucose on the hemoglobin molecule for the past 2 to 3 months. There would be no need to repeat it at this time. A fasting glucose in the morning would be a more appropriate assessment. The other orders are within expected actions in this situation. 25. The nurse performs an assessment during a fluid exchange for the client who is 48 hours post- insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately? A) slight pink-tinged drainage B) abdominal discomfort C) muscle weakness D) cloudy drainage D: cloudy drainage. Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis. 33 Safety and Infection Control 1. After an explosion at a factory one of the employees approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness C: Palpate pulses. The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first. 2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client? A) Reverse lavage or for activated charcoal administration. 6. The parents of a toddler who is being treated for pesticide poisoning ask: “Why is activated charcoal used? What does it do?” What is the nurse's best response? A) "Activated charcoal decreases the body’s absorption of the poison from the stomach." B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) "This substance helps to get the poison out of the body through the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by children and adults." B: "The charcoal absorbs the poison and forms a compound that doesn''t hurt your child." All of the options are correct responses. However, option B is most accurate information to answer the parents’ questions about the use and action of activated charcoal. The language is appropriate for a parent''s understanding. 7. Which of these nursing diagnoses, appropriate for elderly clients, would indicate the client is at greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia D: Altered patterns of urinary elimination related to nocturia. Nocturia is especially problematic because many elders fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling, and then they may fall over furniture or carpets. 8. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h C: Place in respiratory/secretion precautions Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial meningitis includes respiratory/secretions precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital signs, instituting seizure precautions and lastly maintaining optimum hydration. The first action for nurses to take is initiate any necessary precautions to protect themselves and others from possible infection. Viral meningitis usually does not require protective measures of isolation. 9. Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative (PPD) test with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptysis B: A positive purified protein derivative (PPD) test with an abnormal chest x-ray. The client who must be placed in airborne precautions is the client with these findings that suggest a suspicious tuberculin lesion. A sputum smear for acid fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. Good handwashing is recommended for CMV. When signs and symptoms do occur, they are often similar to those of mononucleosis, including sore throat, fever, muscle aches and fatigue. 10. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include in client teaching is which of these statements? A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation." B) "Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice." C) "Your family can use the same bathroom that you use without any special precautions." 35 D) "Drink plenty of water and empty your bladder often during the initial 3 days of therapy." A: "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation." The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours. The client should drink 3 to 4 liters of fluid a day for the initial 48 hours to help remove the ( 131I) from the body. Staff should limit contact with hospitalized clients to 30 minutes per day per person. 11. The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice? A) Verify the order for the medication. Prior to giving the medication the nurse should say, "Please state your name." B) Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. C) As the room is entered say "What is your name?" then check the client's name band. D: place the hands or a folded blanket under the head of the child. The priority during seizure activity is to protect the person from physical injury. Place a pillow, folded blanket or your hands under the child''s head to prevent concussion or other head trauma. The other body parts are at less risk for injury, consequently the prioritized sequence of the actions above would be options D, A, B, and C. 16. A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims: “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.” Which of these comments would be the best tool for the nurse to determine if the child has swallowed a corrosive substance? A) "Ask the child if the mouth is burning or throat pain is present." B) "Take the child’s pulse at the wrist and see if the child is has trouble breathing lying flat." C) "What color is the child’s lips and nails and has the child voided today?" 36 D) "Has the child had vomiting, diarrhea or stomach cramps?" A: "Ask the child if the mouth is burning or throat pain is present." Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the child’s overall condition, however the question concerns evaluation for ingesting a caustic substance. 17. Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility? A) An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits. B) A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen D: A young adult in the second day of treatment for an overdose of acetometaphen. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time . A strong risk of liver failure exists immediately following Tylenol overdose. 18. When an infant car seat is properly installed, the infant should face A) forward, so child may look out window B) backward, so child faces the seat C) the side window, to increase sensory stimulation D) upward, as child lies on back with seat installed sideways B: backward, so child faces the seat. Nurses are now responsible for promoting the continued safety of infants and children outside of the hospital. Emergency Department and Women’s Services staff are trained in child seat placement. Growth and development data indicate that infants still require support of the head. Therefore, they should be positioned reclining and facing the rear until their leg muscles are strong enough to kick away from the backseat (about 10-12 months- old) for the greatest protection. 19. Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear. Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time. Options A and D may need contact isolation precautions. Option C -- findings may indicate the initial stage of autoimmune deficiency syndrome (AIDS). 20. Which of these actions is the primary nursing intervention designed to limit transmission of a client’s Salmonella infection? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens A: Wash hands thoroughly before and after client contact. Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Two million new cases appear each year. Thorough handwashing can prevent the spread of salmonella. Note that all of the options are appropriate activities, but handwashing is primary. 37 Health Promotion and Maintenance 1. The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning? A) Performance on written tests B) Responses to verbal questions C) Completion of a mailed survey D) Reported behavioral changes