nt sit upright for 1 hr. following meals. c) Administer liquids to the client using a syringe. d) Allow the client to rest for 10 min prior to eating. 2. A nurse is assessing the IV infusion site of a client who report pain at the site. The site is red and there is warmth along the course of the vein. Which of the following actions should the nurse take? a) Initiate a new IV line below the original insertion site. b) Discontinue the infusion c) Raise the head of the bed d) Obtain a culture from the area of the insertion site. 3. A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take? a) Document shiny, taut skin as an expected finding. b) Perform palpitation after auscultation. c) Listen for 1 min before documenting absent bowel sounds d) Perform auscultation immediately after the client has consumed a meal. 4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as a part of the which of the following types of immunity? a) Passive immunity b) Active immunity c) Cellular immunity d) Acquired immunity 5. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify that which of the following is a risk factor that places older clients at an increased risk for developing infections? a) Overproduction of lymphocytes b) Elevated albumin levels c) Lowered immune system function d) Increased body fat 6. A nurse is teaching a client who has asthma the use of a metered dose inhaler. Which of the following instructions should the nurse include in the teaching? a) Hold your breath for 6 seconds after inhaling the medication. b) Inhale the medication deeply for 5 seconds. c) Do not shake the medication in the inhaler d) Hold the inhaler 3 inches away from your mouth. 7. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect? a) Pulse oximetry reading of 95 % b) Decreased depth of respirations c) Flaring of the nostrils d) Respiratory rate of 16/min 8. A nurse is teaching a client about the correct use of a cane. Which of the following instruction should the nurse include in the teaching? (Selected all that apply) a) Ensure the cane has a rubber cap. b) Hold the cane on the weaker side. c) Flex the elbow slightly when using the cane. d) Move the cane and stronger leg forward simultaneously e) Use a quad cane for increased support. 9. A nurse is teaching a group of assistive personnel about the expected integumentary changes in older adult clients. Which of the following findings should the nurse include in the teaching? a) Increase in subcutaneous tissue b) Decrease in pigmentation c) Increase in moisture levels d) Decrease in elasticity 16. A nurse s providing teaching about measures to promote sleep with a client who has insomnia. Which of the following client statements indicates an understanding of the teaching? a) “I can exercise as late as 2 hours before bedtime.” b) “I should reduce my fluid intake 2 hours before bedtime “ c) “I should take a 1 hours nap each day” d) “I can eat a large meal as late as 1 hours before bedtime” 17. A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use? a) Numerical pain scale b) Verbal description c) Faces pain scale d) Behavioral indicators 18. A nurse in an emergency department is monitoring the hydration status of a client who is receiving oral rehydration. Which of the following findings should the nurse identify as requiring further interventions? a) Heart rate 120/min b) BP 121/74 mm Hg c) Temperature 37.78 C (100 F) d) Urine specific gravity 1.020 19. A nurse in a provider’s office is assessing the motor skill development of a 15 month old toddler during a well child visit. Which of the following gross motor skills should the nurse expect? a) Takes several steps on tip toes b) Walks without assistance using a wide stance c) Has an accentuated cervical curvature when standing d) Stands with the feet turned slightly inward. 20. A nurse is teaching a group of parents and guardians about safety risks for adolescents. Which of the following statements should the nurse include in the teaching? a) “Exploring the environment commonly leads to injuries for this age group.” b) “Most injuries sustained during this time of life are caused by developing motor skills.” c) “At this age, peer influence to participate in high -risk behaviors can lead to injury” d) The risk for injuries sustained during this age are often a result of a changes in cognitive function” 21. A nurse is caring for a client who expresses anxiety about an upcoming surgery. Which of the following actions should the nurse take? a) Ask the client to describe their feelings b) Discuss the competency of the surgeon with the client c) Inform the client that others have had the procedure without problems.