When cleansing a female patient prior to catherization, the nurse performs the following actions: “Select All that Apply.” a. Cleanse in a circular motion.b. Cleanse the area from the clitoris toward the anus.c. Cleanse the area directly over the urethra first, then both sides adjacent to the urethra.d. Cleanse the entire perineal area with betadine.e. Inform the client about the procedure.  

The development of a pressure ulcer must be avoided at all cost.  The nurse understands that the following steps are taken to avoid development of a pressure ulcer:   “Select All that Apply.” a. Avoid shearing forces when moving a patient.b. Keep the area moist to avoid drying the area.c. Turn the patient every 2 hours to avoid collapse of blood vessels to the area.d. Limit friction when helping a patient move up in bed by the use of a draw sheet.e. Limit large meals to underweight patients to decrease pressure to the area.

A patient comes into the emergency department with crepitus to the right knee.  During assessment, the nurse knows that feeling the knee can best be described as: a. Auscultationb. Percussionc. Palpationd. Inspection 

Sodium is the most abundant electrolyte in the body. The location of electrolytes is important for maintaining homeostasis.  Sodium is the major electrolyte in which fluid compartment? a. Extracellularb. Intracellularc. Interstitiald. Intravascular

With whom should a nurse should share her password for access to the facility’s computer system? a. No oneb. The nurse managerc. The facility’s information system representatived. The unit clerk

A patient  was just diagnosed with cancer.  The patient is tearful, and starts to verbalize something, but stops in mid-sentence.  The nurse knows that the best action would be: a. To state, “I know you just got the diagnosis.  You have to be strong at a time like this!”b. Remain silent and stay with the patient.c. To state, “If I were you, I would get a second opinion.  It might help you feel better.”d. To state, “It’s good that you are crying right now.  That is exactly what you need.”  

A nurse is completing an incident report after finding a client lying on the floor. Which following information is appropriate for the nurse to include? a. The client attempted to climb over the side rails and fell.b. The client was lying on the floor next to his bed.c. The client was restless and trying to get out of bed all evening.d. The presence of a bed alarm could have prevented the client from falling.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take? a. Put on sterile gloves.b. Assist the client to the left Sims’ position.c. Hang the enema container 61 cm (24 in) above the anus.d. Insert the tubing about 15 cm (6 in) into the anus.

The nurse recognizes that a patient that is ordered a bulk-forming cathartic drug may have an order for the following: a. Metamucilb. Lomotilc. Milk of Magnesiad. Colace

A nursing student is doing her clinical rotation at a Long-Term Care Facility. When doing her AM care, she recalls her lecture and demonstrations of oral care. The frequency of oral hygiene is determined by the:    a. Physician’s orderb. Presence of teethc. Nurse assessment of client’s needsd. Institutional policy regarding oral hygiene