1. A nurse is reaching a client and his family how to care for the client’s tracheostomy at home.

Which of the following should the nurse include in the teaching?

a. Use tracheostomy covers when outdoors

2. A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube

through which they receive intermittent feedings and medications. The client has recently

developed diarrhea. Which of the following findings should the nurse identify as a possible cause

of the diarrhea?

a. The client’s care giver washed out the feeding bag once every 24 hours with

warm water

3. A nurse is talking with an older adult client who is contemplating retirement. The client states, “I

keep thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the

following responses should the nurse make?

a. Let’s talk about how the change in your hob status will affect you.

4. A nurse is assessing a client who reports increased pain following pt. Which of the following

questions should t15he nurse ask hen assessing the quality of the client’s pain?

a. Sharp & dull

5. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer.

Which of the following actions should the nurse take?

a. Reassure the client that this is an expected response to grief.

6. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist

restraints. Which of the following actions should the nurse take?

a. Pad the client’s wrist before applying the restraints

7. A nurse is performing a home safety assessment for a client who is receiving supplemental

oxygen. Which of the following observations should the nurse identify as proper safety protocol?

a. The client uses no acetone nail polish remover.

8. Nurse caring for a client who has a respiratory infection. What technique should she use when

preforming nasotracheal suctioning?

a. Apply intermittentsuction when withdrawing the catheter.

9. Nurse is preparing for change of shift. Which document or tools should the nurse use to

communicate?

a. SBAR

10. Nurse is planning care for a client who had a stroke. What should be assigned to the assistive

personal? (SATA)

a. -Assist the client with a partial bed bath.

b. -Measure the client’s BP after the nurse administers antihypertensive

meds.

c. -Use a communication board to ask what the client wants for lunch.

11. Nurse caring for a client who has dementia. What interventions should be taken to minimize risk

for injury?

a. Use bed exit alarm system

12. Nurse performing a skin assessment for a client who expresses concern about skin cancer. What

findings should the nurse identify as a potential indication of a skin malignancy?

a. A mole with an asymmetrical appearance