1. A community health nurse is evaluating eligibility for home assistance for a
client who isquadriplegic. Which of the following actions should the nurse
perform first?
a. Determine the client's living situation.
b. Problem solved with the client.
c. Offer community resources to the client.
d. Assist the client with decision-making.
2. A nurse is discussing care with a newly licensed nurse for a client who practices
Orthodox Judaism. Which of the following meals suggestions by the newly licensed
nurse indicates a needfor further teaching?
a. Chicken breast and boiled potatoes.
b. Carrot sticks and cottage cheese.
c. Grilled cheese an
Applesauce.d. Roast beef
and icecream.
3. A nurse is preparing to auscultate a client apical pulse at the point of maximal
impulse (PMI). thenurse should place the diaphragm of the stethoscope at
which of the followinglocations
a. Within the angle of Louis.
b. 5th intercostal space at the left midclavicular line.
c. Second intercostal space to the right of the sternum.
d. Over the xyphoid process.
4. A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hour
and develops ahemolytic reaction. Which of the following actions should the
nurse perform?
a. Infuse 0.9% sodium chloride IV.
b. Administer an anti-pyretic.
c. Decrease the infusion rate to 75 mL/hour.
d. Place the client in a left lateral position
5. A nurse is planning care for a client who is prescribed a cane for ambulation.
Whichof thefollowing nursing actions should the nurse include in the plan
of care?
a. Remind the client to place the cane on the unaffected side.
b. Adjust the length of the cane to equal the distance from the client's iliac
crest to thefloor.
c. Remove the rubber tip from the cane to enhance ambulation.
d. Place the King safely in the closet during naps and at bedtime.
6. Nurse is caring for a client who had a partial laryngectomy and is receiving
continuousenteralfeedings at 65 mL/hour through a gastrostomy tube.
Which of th
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