An unlicensed assistive personnel (UAP) is asked to answer the call light for a client with streptococcal pharyngitis for whom droplet precautions have been implemented. The UAP refuses, informing the nurse of not being fitted for an N95 respirator mask. Which action should the nurse take?

The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client is lethargic and very weak. Before providing mouth care, the nurse plans to assess the client’s gag reflex. Which action should the nurse include?

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

When identifying the goals to be included in a client’s plan of care, the nurse should take which action?

The nurse enters the room of a client with a Clostridium difficile infection to administer an IV antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client’s buttocks and reports the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. Which action should the nurse implement first?

The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

After a client voids, 150 ml of residual urine is noted. Which nursing problem should be included in the client’s plan of care?

After reviewing the admission assessment of a client, which intervention(s) should the nurse include in this client’s plan of care? (Select all that apply)

Which intervention should the nurse implement for a client?

The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which description(s) warrant additional follow-up by the nurse? (Select all that apply)

An older adult woman with end-stage heart disease is hospitalized for severe heart failure (HF). She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. Which action should the nurse take first?

An unlicensed assistive personnel (UAP) is caring for a client who is confused and at risk for falls. Which action should the nurse instruct the UAP to implement?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

An older adult man comes to the clinic with a painful rash over his left abdomen. He tells the nurse that he has tried a variety of creams and ointments, but none of them have relieved his symptoms. Which action is most important for the nurse to take?

The nurse is caring for a client who wears bilateral hearing aids. Which action should the nurse take when communicating with the client?

A prescription for bilateral soft wrist restraints is obtained for an older adult client who has repeatedly removed the nasogastric tube (NGT) and IV sites. After applying the restraints, which action is most important for the nurse to take?

The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

A client arrives to a clinic appointment reporting sexual dysfunction for the past three months. Which condition should the nurse expect to see in the client’s medical record?

The nurse wants to use role-playing as a teaching technique. Which group is most likely to benefit from this teaching method?

The nurse manager observes a staff member crying and expresses concern. The staff member confides to the nurse manager about personal issues, feeling emotional and overwhelmed. The nurse manager provides suggestions about support systems that may be helpful. Which principle is the nurse manager encouraging?