Nursing Prioritization and Client Teaching | Exams Nursing

KAPLAN NCLEX COMPREHENSIVE TEST # 1

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1. The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see

FIRST?

1.A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worthlessness.

2.A patient indicates an intent to kill himself and says he has access to a gun.

3. A patient had a miscarriage last evening and is experiencing anger and resentment.

4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.

2. The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is

in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has

been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second

stage of labor. It is MOST important for the nurse to take which of the following actions?

1. Time the frequency of the contractions.

2. Assess the type of vaginal discharge.

3. Monitor the strength of the contractions.

4. Observe the perineum.

3. The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15

minutes by ambulance. Which of the following actions should the nurse take FIRST?

1. Contact the nursing supervisor.

2. Tell the emergency management team they will have to re-route 25 victims.

3. Activate the hospital’s disaster plan.

4. Inform the emergency department nurses they must work overtime.

4. As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse deter-

mines that further teaching is necessary if the client states which of the following?"

1. "This medication helps me with my depression."

2. "I will notify my physician if I show signs of hyperactivity and mania."

3. "I will see improvement in my symptoms in 1 to 4 weeks."

4. "If I experience a fever I will take Tylenol."

5. The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST?

1. A client diagnosed with COPD with an PaO 2 of 70%.

2. A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured.

3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement.

4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back.

6. The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The

nurse determines that teaching is effective if the mother selects which menu for her child?

1. Guacamole with pita bread, lettuce, tomato juice.

2. Poached halibut, brown rice, carrots, peach cobbler.

3. Scrambled eggs, whole wheat toast, grapes, skim milk.

4. Baked chicken leg, mashed potatoes, spinach, milkshake.

7. The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculo-

sis screening on which of the following children?

1. A child just returned from a 2-week trip to Europe.

2. A child recently moved to an apartment because the family lost their home.

3. A child with a new nanny who just emigrated from Latin America.

4. A child who weighed 4 lb, 10 oz at birth.

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KAPLAN NCLEX COMPREHENSIVE TEST # 1

The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST? 1.A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worthlessness. 2.A patient indicates an intent to kill himself and says he has access to a gun.
A patient had a miscarriage last evening and is experiencing anger and resentment.
A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.
The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions?
Time the frequency of the contractions.
Assess the type of vaginal discharge.
Monitor the strength of the contractions. 4. Observe the perineum.
The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST? 1. Contact the nursing supervisor. 2. Tell the emergency management team they will have to re-route 25 victims. 3. Activate the hospital’s disaster plan. 4. Inform the emergency department nurses they must work overtime.
As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse deter- mines that further teaching is necessary if the client states which of the following?"
"This medication helps me with my depression."
"I will notify my physician if I show signs of hyperactivity and mania."
"I will see improvement in my symptoms in 1 to 4 weeks." 4. "If I experience a fever I will take Tylenol."
The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST?
A client diagnosed with COPD with an PaO 2 of 70%.
A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured.
A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement. 4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back.
The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child?
Guacamole with pita bread, lettuce, tomato juice.
Poached halibut, brown rice, carrots, peach cobbler.
Scrambled eggs, whole wheat toast, grapes, skim milk. 4. Baked chicken leg, mashed potatoes, spinach, milkshake.
The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculo- sis screening on which of the following children?
A child just returned from a 2-week trip to Europe.
A child recently moved to an apartment because the family lost their home. 3. A child with a new nanny who just emigrated from Latin America.
A child who weighed 4 lb, 10 oz at birth.

The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the nurse to take which of the following actions?
Obtain vital signs. 2. Identify the source of the bleeding.
Elevate the head of the bed 30°.
Administer 0.9% NaCl IV.
During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse's excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate?
"I want to see both of you in my office right away." 2. "Would you please lower your voices and finish the report."
"I want the two of you to stop yelling and work this problem out."
"Both of you are good nurses and are under a lot of stress right now."
A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following?
Slowed pulse and reduced blood pressure.
Constipation and decreased bowel sounds. 3. Palpitations and nervousness.
Difficulty voiding and oliguria.
The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The nurse identifies that which of the following BEST measures the overall therapeutic response to management of the dia- betes? 1. Glycosylated hemoglobin (HbA 1 c) 5% of total Hb. 2. Fasting blood sugar 128 mg/dL. 3. Blood pressure 130/82. 4. Serum amylase 100 Somogyi U/dL.
The nurse cares for a client in labor. The client's examination reveals that the cervix is 5 cm dilated and 100% effaced and the fetal head is at -1. The membranes rupture and the nurse notes clear fluid. Which of the following actions should the nurse take FIRST?
Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes.
Prepare for delivery and notify the care provider.
Apply an electronic fetal monitor and start an IV. 4. Encourage the client to void every 1-2 hours and take her temperature every hour.
The nurse cares for a client receiving a heparin drip via an infusion pump. The physician orders warfarin (Coumadin) 5 mg PO. Which of the following actions should the nurse take NEXT? 1. Administer medication as ordered. 2. Notify the physician. 3. Check the most recent serum partial prothrombin levels. 4. Assess client for signs/symptoms of bleeding.
The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia nervosa. The nurse identifies that which of the following activities is MOST appropriate for this client? 1. Making jewelry with the occupational therapist. 2. Exercising in the physical therapy department. 3. Assisting the dietician to plan the week's menus. 4. Reading teen magazines with other patients her age Strategy: Determine the outcome of each answer.

The nurse evaluates assignments on the unit. The nurse determines that assignments are appropriate if the LPN/LVN is assigned to which client?
A client with type 1 diabetes scheduled for discharge.
A client newly admitted to the unit with chest pain.
A client receiving chemotherapy. 4. A client diagnosed with myasthenia gravis.
An elderly client is brought to the emergency department complaining of acute back pain. The client denies any chronic illness, allergies, or previous hospitalizations. Which of the following is the BEST initial response for the nurse to make to this client?
"We'll get this pain under control in no time."
"Are you sure you've never been in the hospital?"
"Did you fall, lift something heavy, or turn the wrong way?" 4. "On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing."
A nurse observes a student nurse administer carvedilol (Coreg) to an elderly patient. The patient refuses medication, saying, "Go away. It makes me dizzy." The nurse should intervene if the student nurse states which of the following? 1. "If you don't take this medication, you will be restrained." 2. "This medication will help control your blood pressure." 3. "Side effects of this medication make some patients feel uncomfortable." 4. "When do you notice the dizziness?"
The nurse cares for clients in the emergency department (ED). An 82-year-old client comes to the ED complaining of muscle weakness and drowsiness. The nurse notes decreased deep tendon reflexes and hypotension. Which of the follow- ing actions should the nurse take FIRST?
Escort the client to an emergency room unit. 2. Ask the client if he has been taking antacids.
Assess for Chvostek's sign.
Measure client's intake and output
A tornado has just leveled a large housing division near the hospital, and a disaster alarm has been declared at the hos- pital. The nurse caring for clients on the maternal-child unit considers which of the following clients appropriate for dis- charge within the next hour? SELECT ALL THAT APPLY 1. A multipara client who delivered over an intact perineum 12 hours ago. 2. A postpartum client with an infection who has been on antibiotics for the past 24 hours. 3. A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting. 4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL. 5. A client at 34 weeks' gestation diagnosed with generalized edema and complaints of epigastric pain. 6. A 2-day-old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-strepto- coccus (GBS).
The nurse cares for a client following a scleral buckling. Which of the following nursing actions is MOST important?
Remove all reading material. 2. Assess for nausea.
Assess drainage from affected eye.
Irrigate affected eye every 3 hours.
The nurse supervises care for a patient admitted to the psychiatric unit with a diagnosis of bipolar disorder: manic phase. A student nurse plans activities for the patient. The nurse should intervene if the student nurse chooses which of the following activities? 1. Volleyball. 2. Painting. 3. Walking. 4. Dancing.

The nurse on the medical/surgical unit is approached by an LPN/LVN from a different team. The LPN/LVN expresses concern because one of her patients is diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at 2 L/min. Which of the following statements by the nurse is MOST appropriate?
"I will assess the patient for oxygen toxicity."
"Are you concerned about the oxygen or the new graduate's competency?" 3. "Please tell me more about your concerns."
"Leave the oxygen in place."
The nurse cares for an infant diagnosed with congenital heart disease. The nurse notes that the infant becomes easily fatigued during feedings and the infant's pulse and respirations increase. The nurse should take which action? 1. Feed the infant soon after awakening. 2. Change the infant's diaper before feeding. 3. Increase the caloric content of the feeding to 30 kcal/oz. 4. Mix rice cereal in the formula.
The nurse instructs a client who is scheduled for a 24-hour creatinine clearance test. Which statement, if made by the client to the nurse, indicates further teaching is required? 1. "I will eat a high-protein meal before the test begins." 2. "I will use the specimen collection time to catch up on my reading." 3. "I will drink as much fluid as I want before and during the test." 4. "I will save all of my urine during the 24 hours and keep it in the refrigerator."
The nurse prepares to admit a 6-month-old diagnosed with rotavirus, severe diarrhea, and dehydration. The nurse should place the infant in which of the following rooms?
In a semiprivate room with a 2-year-old in traction due to a fracture.
In a semiprivate room with a 9-month-old admitted for a shunt revision. 3. In a private room that is close to the nurse's station.
In any private room that is available.
A patient returns from surgery for a total replacement of the right hip with a large surgical dressing and a Jackson-Pratt drain. Which of the following, if observed by the nurse 2 hours after surgery, necessitates calling the physician?
There is a small amount of bloody drainage on the surgical dressing. 2. The patient complains of increased hip pain.
A harsh, hollow sound is auscultated over the trachea.
The patient's blood pressure is 136/86.
An older client is placed in balanced suspension traction for a compound fracture of the femur. The client reports, "My hands, feet, and nose feel cold. Which action should the nurse take FIRST?
Provide the client with more blankets. 2. Assess for dependent edema.
Assess that client is exhaling when moving in bed.
Increase the temperature of the room.
The nurse cares for a client at term in labor. The client's blood pressure is 182/88 and fetal heart rate (FHR) is 132- with minimal beat-to-beat variability. Her bloody show is dark red and there is more bleeding than anticipated. Her ab- domen is firm between contractions and she complains of back pain. The nurse understands that the client is at risk for which of the following?
Placenta previa. 2. Abruptio placenta.
Miscarriage.
Imminent delivery.

Ask the client if he is worried about something. 4. Place the client in a sitting position.
The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago. 2. A client diagnosed with right-sided heart failure and glaucoma. 3. A client diagnosed with chronic obstructive pulmonary disease and psoriasis. 4. A client diagnosed with rheumatoid arthritis and malnutrition.
The nurse cares for a 4-year-old on the pediatric unit. The child is unable to go to sleep while in the hospital. It is MOST important for the nurse to take which of the following actions?
Turn out the light and close the door.
Encourage the child to exercise during the evening. 3. Identify the child's home bedtime ritual.
Ask the child's siblings to visit during the evening.
The nurse prepares an elderly client newly diagnosed with type 1 diabetes for discharge. The client is alert and ori- ented and lives alone in her home. It is MOST important for the nurse to assess for which of the following? 1. Client's vision and manual dexterity. 2. Client's understanding of diabetes. 3. Client's need for visits from the home care nurse. 4. Client's ability to perform blood glucose monitoring.
The nursing assistive personnel inform the nurse that the elderly client admitted following a hemorrhagic stroke ate half of the food on the tray. The food left on the tray looked as if someone had drawn a straight line down the center of the plate and eaten the food only to one side of the line. Which instruction by the nurse is MOST important? 1. "Rotate the plate so that the food is on the other side." 2. "Offer him a snack later in the day." 3. "Ask the client's family to assist him with the next meal." 4. "Which foods did he omit?"
The nurse evaluates care for a client who demonstrates manipulative behavior. The nurse should intervene if which of the following is observed?
The staff discusses with the client the consequences of his manipulative behavior.
The staff establishes limits on the client's manipulative behavior.
The staff clarifies the consequences of the client's manipulative behavior. 4. The staff decreases the demands on the client.
The nurse in the pediatric clinic performs a well-child assessment on a 20-month-old. The child's mother tells the nurse that she is earning extra money by growing houseplants in her home. Which of the following responses by the nurse is MOST appropriate?
"How did you get into that business?"
"What a great opportunity."
"You should not have plants in your home." 4. "Where do you keep the plants?"
The nurse performs discharge teaching for a client diagnosed with gastroesophageal reflux disease (GERD). The nurse determines that teaching is successful if the client selects which of the following menus?
Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello, and cola.
Cheddar cheese omelet, spinach salad, chocolate brownie, and milk. 3. Broiled chicken, cream of broccoli soup, rice pudding, and apple juice.
Baked salmon with lemon butter, baked potato, mint chocolate chip ice cream, and lemonade.

KAPLAN NCLEX COMPREHENSIVE TEST # 2

The nurse supervises the transfer of an elderly client with left-sided weakness from the bed to the chair. After assisting the client to a sitting position, which of the following actions should the nurse take NEXT? 1. Place nonskid shoes on the client's feet. 2. Instruct the client that she will be moving toward her left side. 3. Ask the client to pivot on her right foot. 4. Support the left leg with the nurse's knee.
A 16-year-old girl is brought to the emergency room by her parents for evaluation of an eating disorder. When the nurse approaches the client to draw a blood sample, the client cries out, "I hate having my blood drawn. Go away!" Which of the following responses by the nurse is BEST?
"What's the matter? Are you afraid of what we are going to find?" 2. "What is it about having your blood drawn that upsets you?"
"Take a deep breath. It will be over before you know it."
"I'll be back in 15 minutes so we can discuss your concern."
The nurse cares for clients in the prenatal clinic. A client comes to the clinic for a prenatal visit on June 6. Her last men- strual period was December 10. The nurse expects the client's fundal height to measure
24 cm. 2. 26 cm.
28 cm.
30 cm.
Recently several staff members on the unit have complained of back strain. The nurse determines that the staff is not consistently using correct body mechanics when transferring patients. Which of the following suggestions should the nurse make FIRST?
"Encourage your patients to assist as much as possible."
"Use your arms and legs when moving a client." 3. "Determine if help is required to transfer a patient."
"Position yourself close to the patient."
A client is receiving packed red blood cells. Several minutes after the infusion is started, the client complains of nausea and low back pain. It is MOST important for the nurse to take which of the following actions? 1. Obtain a urine specimen. 2. Start an IV of D 5 W. 3. Discard the blood container in a biohazard container. 4. Decrease the rate of the transfusion.
A 75-year-old client is brought by his wife to the outpatient clinic. The nurse notes that the client has a 10-year history of chronic renal failure and has been taking cimetidine (Tagamet) for two weeks. It is MOST important for the nurse to in- vestigate which of the following statements made by the client's wife?
My husband has been complaining that his bowel movements are hard to pass.
My husband takes his Tagamet just before he eats his meals. 3. My husband seems to be having more trouble with his memory lately.
My husband sometimes has a headache after reading the newspaper.
The nurse cares for an older woman with frequent bladder incontinence following a cerebrovascular accident (CVA). Which of the following actions by the nurse is MOST appropriate?
Perform intermittent catheterizations using sterile technique
Teach the patient how to perform Valsalva maneuver.
Instruct the patient how to perform the Cred é maneuver. 4. Toilet the patient when she awakens in the morning and before and after meals.

A patient with blunt trauma to the abdomen that caused bruising. 3. A patient complaining of chest pain with asymmetrical chest movement noted.
A patient who is confused and restless with no visible injuries.
A man hospitalized for alcohol abuse comes to the nurses' station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the patient becomes verbally abusive. Which of the following actions by the nurse is MOST appropriate?
Tell the patient to lower his voice.
Ask the patient what he wants from the cafeteria. 3. Calmly but firmly escort the patient to his room.
Assign a nursing attendant to accompany the patient to the cafeteria.
The nurse prepares a client for a skin biopsy. Which of the following statements, if made by the client, should the nurse report to the physician? 1. "I have been taking aspirin for my aching joints." 2. "I applied lotion to my skin after my shower last night." 3. "I laid out in the sun yesterday." 4. "I had coffee and a sweet roll for breakfast this morning.”
The nurse counsels a client diagnosed with degenerative joint disease. It is MOST important for the nurse to include which of the following instructions?
"Place your joints in the position of comfort."
"Place your joints in a flexed position."
"Place your joints in full extension." 4. "Place your joints in their functional position."
The nurse is making staff assignments on the medical/surgical unit. The nurse should assign a nursing assistant to care for which of the following clients? 1. A client diagnosed with a CVA 2 weeks ago requiring assistance ambulating. 2. A client diagnosed with COPD who is in acute distress requiring assistance bathing. 3. A client receiving total parenteral nutrition through a PICC line requiring a dressing change. 4. A client diagnosed with type 1 diabetes on mechanical ventilation requiring a bath.
The home care nurse visits a client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns the client operates a horse ranch. It is MOST important for the nurse to include which of the following instructions?
Ride with a companion and wear an identification bracelet. 2. Carry a cell phone and dressings and tape.
Provide significant others with a written itinerary for the day.
Temporarily change to activities that are safer for client
The nurse cares for clients in the outpatient clinic. A client with a pacemaker calls to report that he just had an episode of dizziness and shortness of breath. Which of the following responses by the nurse is MOST important? 1. "What is your pulse?" 2. "What were you doing before the episode?" 3. "Have you experienced this before?" 4. "Is the area over the pacemaker painful or red?"
A client is admitted to the labor and unit in a sickle-cell crisis. Which of the following nursing actions should the nurse take FIRST?
Administer oxygen.
Turn client to right side. 3. Begin an IV with normal saline.
Administer antibiotics.

The nurse cares for a laboring patient. The patient requests something for pain and says to the nurse, "I'm really scared of shots." Which of the following responses by the nurse is BEST?
"A shot is your only option, because labor slows the GI tract."
"I can give you a pill now, but it will not last as long as an injection." 3. "What was your previous experience with shots?"
"What are you afraid of?"
The nurse on the medical/surgical unit admits an elderly client after the patient has undergone a below-the-knee ampu- tation. The nurse obtains vitals signs and assesses that the client is able to be aroused but is sleepy. When the client awak- ens and realizes that the amputation was performed, the client begins to scream. Which of the following statements by the nurse is MOST appropriate?
"The physician informed you that the amputation was required."
"I'll get you some medication so that you can rest."
"Your family is waiting in the lobby to come see you." 4. "Since you seem upset, I'll stay with you.”
The nurse determines that which of the following clients is MOST at risk to develop gastroesophageal reflux disease (GERD)?
A 16-year-old African American male who had an NG tube for 3 days after surgery for a ruptured appendix.
A 30-year-old Hispanic female with a diagnosis of cholelithiasis and a t-tube in place. 3. A 52-year-old Caucasian female who is 5'5" tall and weighs 185 pounds.
A 65-year-old Caucasian male with a laryngectomy for laryngeal cancer.
The nurse cares for clients in the emergency department after an earthquake. Which of the following clients should the nurse see FIRST?
A client at 7 months' gestation complaining of cramping and blood-streaked discharge.
A client with a displaced fracture of the right radius with blood seeping from the wound. 3. A client complaining of lightheadedness; nurse notes client is clammy, pulse 112, respirations 28.
A client with type 1 diabetes who took insulin immediately before the earthquake and is complaining of lightheaded- ness.
The nurse on the medical unit is called to the room of an elderly client. The nurse finds the client sitting up in bed re- porting pressure in the chest and jaw. Vital signs are: BP 160/94, P 112, R 20, T 99.5°F (38°C). The client has a history of hypertension and is receiving IV antibiotics for a diagnosis of pneumonia. Which action should the nurse take first? 1. Administer oxygen at 4 L/min via nasal canula. 2. Place the client on a cardiac monitor and obtain a 12-lead ECG. 3. Obtain blood for CK-MB, troponin, and myoglobin levels. 4. Assess patency of the client's IV line.
The nurse administers meperidine (Demerol) 75 mg IM to a postoperative patient. Thirty minutes later, it is MOST im- portant for the nurse to take which of the following actions?
Reposition the patient.
Elevate the patient's head and place a pillow under the shoulders. 3. Observe the patient for restlessness and distress.
Ambulate the patient.
The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It is MOST important for the nurse to clarify which of the following orders by the physician?
Furosemide (Lasix) 20 mg IV every 12 hours.
2 g/day sodium diet 3. Normal saline at 125 ml/hour IV.
Oxygen at 2 L per nasal cannula.

2. Obtain the client's vital signs.

Determine how many times the client has voided.
Ask the client if she has experienced abdominal cramping. Strategy: Assess before implementing.
The nurse in the outpatient clinic performs an assessment of an elderly woman. The client states that her husband had a CVA 7 months ago, and she cared for him for 3 months. Four months ago she had to place her husband in a long-term care facility because she was no longer able to care for him. Since that time the client reports she has lost 40 pounds, she is afraid to live alone, and she sorely misses her husband. The nurse notices that the client is extremely hard of hearing. Which of the following suggestions should the nurse make FIRST?
"I think you should move to the nursing home with your husband."
"Have you considered installing a security system in your home?" 3. "I'm going to refer you to Meals on Wheels."
"Perhaps you should find a hobby or join a club for seniors.”
The nurse cares for a client diagnosed with chronic obstructive pulmonary disease (COPD) receiving oxygen per nasal canula at 2 L/min. The nurse observes that the client has shortness of breath and chest pain. The nurse notifies the as- signed physician, and the physician makes no changes in the amount of oxygen the client is receiving. Which of the fol- lowing responses by the nurse is MOST appropriate?
Report concerns to the supervisor.
Contact the physician a second time.
Inform the family members that the physician has not changed the client's orders. 4. Continue to monitor the respiratory status of the client.
The community health nurse visits the home of a client with four school-aged children. The client is diagnosed with severely disabling migraine headaches. Which of the following instructions by the nurse is MOST appropriate?
"Hire someone to help with your children."
"Report excessive menstrual flow."
"Avoid stressful situations." 4. "Go to bed at the same time every night."
In early October, a home health nurse makes a home visit to an older client diagnosed with cataracts who is scheduled to have cataract removal with a lens implant in mid-November. Which of the following recommendations by the nurse is MOST important?
"Notify a trusted neighbor that you will be gone overnight." 2. "Get a flu shot as soon as possible"
"Read this information about surgical removal of cataracts."
"Check with your insurance company regarding co-payment and services."
A patient is to be discharged after a right total hip replacement. Which of the following statements, if made by the pa- tient to the nurse, indicates that teaching has been effective?
"I can't sit in my favorite recliner with my legs up." 2. "I should ask my wife to put on my socks and shoes."
"I should clean the incision with a mixture of hydrogen peroxide and water before applying a sterile dressing."
"I don't need to continue to do the leg exercises I learned in the hospital."
The mother of an 8-month-old boy is concerned because her son has started to scream and refuses to eat when left with the child-care provider. Which of the following statements by the nurse is BEST?
"Start looking for a different child-care provider."
"Check your son for bruises and other injuries."
"Remember that this is just a phase your son is going through." 4. "Hand your child his blanket as you say goodbye."

The mother of a 4-year-old tells the nurse she is worried because her daughter has begun to stutter. The mother asks the nurse what actions can be taken to stop the stuttering. Which of the following responses by the nurse is BEST?
"What has been happening in your child's life?"
"Reward your child when she speaks fluently."
"Instruct your child to start over and speak more slowly." 4. "Slow down your own speech and talk to your daughter calmly."
While sitting at the front desk completing an assessment sheet, a new graduate nurse asks the nursing assistant to per- form a finger stick blood sugar for the assigned client. The nursing assistant responds, "Why can't you do it?" Which of the following responses by the nurse is BEST? 1. "Please page me when you have completed the task." 2. "It is important that the blood sugar be completed now." 3. "Why did you ask that?" 4. "If you don't have time, I will ask someone else to do it.”
The nurse cares for clients on the neurological unit. After receiving report, which of the following clients should the nurse see FIRST?
A client who is non-responsive with intermittent limb movement. 2. A client whose muscle tone of all four limbs is flaccid.
The client who is non-responsive but follows the staff with his eyes.
The client who immediately withdrawals from painful stimuli.
The home care nurse visits a client receiving levothyroxine (Synthroid) 75 mcg OD. The client tells the nurse that he has been experiencing insomnia the last couple of weeks. Which of the following responses by the nurse is MOST appro- priate?
"The physician may have to decrease the dose of medication."
"Tell me about your bedtime routine." 3. "When do you take the medication?"
"Take a warm bath before going to bed."
The nurse cares for a client diagnosed with hypertension and type 1 diabetes mellitus. The client complains to the nurse that the physician wants the client to discontinue taking verapamil (Calan) 80 mg PO tid and begin taking captopril (Capoten) 50 mg PO tid. The client states, "It took a long time to find a medication that controls my blood pressure with minimal side effects, and I do not want to go through that again." Which of the following responses by the nurse is BEST?
"How many different antihypertensives did you try?" 2. "Captopril is the best drug for preventing or slowing down the destruction of your kidneys."
"Your physician is a specialist in this area and feels you need to change."
"Why not give it a try?"
The nurse cares for client diagnosed in stage I chronic renal failure. During the nursing assessment, the nurse expects the client to state which of the following?
"I don't seem to urinate as much as I used to."
"I seem to have more swelling in my feet and ankles." 3. "I urinate more at night."
"The doctor told me I need dialysis."
The nurse in the pediatric clinic performs a well-child assessment on a 15-month-old. The child's mother tells the nurse that she is very excited because her mother is visiting. The grandmother rarely visits, and the child's mother is pleased that grandmother and grandchild will spend time together. Which of the following responses by the nurse is MOST important?
"Your toddler may be fearful when left alone with her grandmother."
"How long is your mother staying?" 3. "Does your mother take any medication?"
"I'm sure your mother will enjoy her grandchild."

Nursing Prioritization and Client Teaching, Exams of Nursing

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