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1.
A nurse is reviewing a client's medication The dose
prescription, which reads, "digoxin 0.25 by
mouth every day." Which of the following
components of the prescription should the
nurse question?
2.
A client who reports shortness of breath re- Observe the rate, depth,
quests her nurse's help in changing posiand character of the client's
tions. After repositioning the client, which of respirations.
the following actions should the nurse take
next?
3.
A nurse is caring for a client who, while sit- Lower the client to the floor
ting in a chair, starts to experience a seizure. and place a pad under the
Which of the following actions should the client's head.
nurse take?
4.
A home health nurse is planning to provide Educating clients about the
health promotion activities for a group of
recommended immunizaclients in the community. Which of the fol- tion schedule for adults
lowing activities is an example of the nurse
promoting primary prevention?
5.
A nurse is using the I-SBAR communication Assessment
tool to provide the client's provider with information about the client. The nurse should
convey the client's pain status in which portion of the report?
6.
A nurse is caring for a client who is receiv- Edema at the infusion site
ing IV therapy via a peripheral catheter. The
nurse should identify that which of the following findings is an indication of infiltration?
7.
A nurse is providing discharge teaching to Washing dishes
a client who is recovering from lung cancer. The provider instructed the client that
he could resume lower-intensity activities of
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daily living. Which of the following activities
should the nurse recommend to the client?
8.
A nurse is caring for a client who has acute Daily weight
renal failure. Which of the following assessments provides the most accurate measure
of the client's fluid status?
9.
A nurse is planning to assess the abdomen Inspection
of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use
first?
10. A nurse is explaining the use of written con- A client who has a present forms to a newly-licensed nurse. The
scription for a transfusion of
nurse should ensure that a written consent packed red blood cells
form has been signed by which of the following clients?
11. A nurse in a long-term care facility is admit- "It must be difficult to care
ting a client who is incontinent and smells for someone who is constrongly of urine. His partner, who has been fined to bed."
caring for him at home, is embarrassed and
apologizes for the smell. Which of the following responses should the nurse make?
12. A nurse in a provider's office is assessing a Bounding pulse
client who has heart failure. The client has
gained weight since her last visit and her
ankles are edematous. Which of the following findings by the nurse is another clinical
manifestation of fluid volume excess?
13. A nurse is caring for a client who is postoper- Cover the incision with a
ative following abdominal surgery. Which of moist sterile dressing.
the following actions should the nurse take
first after discovering that the client's wound
has eviscerated?
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14. A nurse is teaching a client who has lower "Bear weight on both of your
extremity weakness how to use a four-point legs."
crutch gait. Which of the following instructions should the nurse include in the teaching?
15. A nurse in a provider's office is collectLiver Damage
ing information from an older adult client
who reports that he has been taking acetaminophen 500 mg/day for severe joint pain.
The nurse should instruct the client that
large doses of acetaminophen could cause
which of the following adverse effects?
16. A nurse is planning to document care provid- PC for after meals
ed for a client. Which of the following abbreviations should the nurse use?
17. A nurse is responding to a parent's question A 10-month-old infant can
about his infant's expected physical devel- pull up to a standing posiopment during the first year of life. Which of tion.
the following information should the nurse
include?
18. An assistive personnel (AP) is assisting a The AP hangs the collection
nurse with the care of a female client who bag at the level of the bladhas an indwelling urinary catheter. Which of der.
the following actions by the AP indicates a
need for further teaching?
19. A newly licensed nurse is preparing to ad- Consult the medication refminister medications to a client. The nurse erence book available on
notes that the provider has prescribed a
the unit.
medication that is unfamiliar to her. Which of
the following actions should the nurse take?
20. A nurse is providing oral care for a client
Place the client in a laterwho is unconscious. Which of the following al position with the head
actions should the nurse take?
turned to the side before beginning the procedure.
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21. A nurse is planning to perform passive
Repeat each joint motion
range-of-motion exercises for a client. Which five times during each sesof the following actions should the nurse
sion.
take?
22. A nurse is teaching a client who is postop- Cough deeply after each
erative how to use a flow-oriented incentive use.
spirometer. Which of the following instructions should the nurse include?
23. A nurse is teaching a client how to self-ad- Have the client demonminister insulin. Which of the following ac- strates the procedure.
tions should the nurse take to evaluate the
client's understanding of the process within
the pyschomotor domain of learning?
24. A nurse is providing teaching about food
Gelatin
choices to a client who has a prescription
for a clear liquid diet. Which of the following
selections by the client indicates an understanding of the teaching?
25. A nurse is performing a neurological assess- Romberg test
ment for a client. Which of the following examinations should the nurse use to check
the client's balance?
26. A nurse in a provider's office is reviewing the WBC 15,000 mm3
laboratory findings of a client who reports
chills and aching joints. The nurse should
identify which of the following findings as an
indication that the client has an infection?
27. A nurse is preparing to administer an intra- Ventrogluteal
muscular injection to a young adult client.
Which of the following injection sites is the
safest for this client?
28.
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A nurse is applying an ice bag to the ankle Fill the bag two-thirds full
of a client following a sports injury. Which of with ice.
the following actions should the nurse take?
29. A nurse is caring for a client who is 48 hr
Impaired peristalsis of the
postoperative following a small bowel resec- intestines
tion. The client reports gas pains in the periumbilical area. The nurse should plan care
based on which of the following factors contributing to this postoperative complication?
30. A client is being discharged home with oxy- Wear cotton clothing to
gen therapy via a nasal cannula. Which of
avoid static electricity.
the following instructions should the nurse
provide to the client and family?
31. A nurse is planning to insert a nasogastric "I can see that this is upsettube for a client after explaining the proce- ting you."
dure. The client states, "You are not putting
that hose down my throat." Which of the following statements should the nurse make?
32. A nurse is preparing to administer a cleans- Position the client on his left
ing enema to a client. Which of the following side.
actions should the nurse plan to take?
33. A nurse on a surgical unit is receiving a
Airway
client who had abdominal surgery from the
postanesthesia care unit. Which of the following assessments should the nurse make
first?
34. A nurse is caring for a client who has a pre- Tie the restraint with a
scription for a vest restraint. Which of the
quick-release knot.
following actions should the nurse take?
35. A nurse is cqaring for a client who has a
Oil retention
fecal impaction. Before digital removal of the
mass, which of the following types of ene5 / 37
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mas should the nurse plan to administer to
soften the feces?
36. A nurse is providing education about cultur- People who practice Jual and religious traditions and rituals relat- daism stay with the body of
ed to death for the assistive personnel on the deceased until burial.
the unit. Which of the following information
should the nurse include?
37. A nurse is reviewing the correct use of a
fire extinguisher with a client. Which of the
following actions should the nurse direct the
client to take first?
38. A nurse is preparing to provide chest phys- Place the client in Trendeiotherapy for a client who has left lower lobe lenburg's position.
atelectasis. Which of the following actions
should the nurse plan to take?
39. A nurse is planning care for a client who
Provide a protein intake of
is postoperative and has a history of poor 1.5 g/kg of body weight per
nutritional intake. Which of the following ac- day.
tions should the nurse include in the plan of
care to promote wound healing?
40. A nurse is caring for a client who has a ter- Cold extremities
minal illness. Which of the following findings
indicates that the client's death is imminent?
41. A nurse is caring for a client who is receiving Hemolytic
a blood transfusion. The client reports flank
pain and the nurse notes reddish-brown
urine in the client's urinary catheter bag. The
nurse recognizes these manifestations as
which of the following types of transfusion
reactions?
42. A nurse on a mental health unit is preparLoss
ing to terminate the nurse-client relationship
with a client who no longer requires care.
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Which of the following concepts should the
nurse and client discuss in the termination
phase of the relationship?
43. A nurse is caring for a client who has bilater- Sit at the bedside while
al casts on her hands. Which of the following feeding the client.
actions should the nurse take when assisting the client with feeding?
44. A nurse is caring for a client who has
Wear gloves when changClostridium difficile and is in contact isola- ing the client's gown.
tion. Which of the following actions should
the nurse take?
45. A nurse is planning care for a client who
has a single-lumen nasogastric (NG) tube for
gastric decompression. Which of the following actions should the nurse include in the
plan of care? (Select all that apply.)
-Provide oral hygiene frequently.
-Measure the amount of
drainage from the NG tube
every shift.
-Secure the NG tube to the
client's gown.
46. A nurse is called away for an emergency
while conversing with a client who is concerned about his medical diagnosis. The
nurse returns to the client promptly, as
promised. Which of the following ethical
principles is the nurse demonstrating?
Fidelity
47. A nurse in the emergency department is car- Tachycardia
ing for a client who has abdominal trauma.
Which of the following assessment findings
should the nurse identify as an indication of
hypovolemic shock?
48. A nurse is reviewing the laboratory values Decreased calcium
for a client who has a positive Chvostek's
sign. Which of the following laboratory findings should the nurse expect?
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49. An adolescent client in an outpatient mental "Tell me more about how
health facility tells the nurse that it is hard your friends discourage
to follow his treatment plans because his
you."
friends discourage him. Which of the following statements should the nurse make?
50. A nurse is reviewing measures to prevent
back injuries with assistive personnel (AP).
Which of the following instructions should
the nurse include?
When lifting an object,
spread your feet apart to
provide a wide base of support.
51. A nurse on a telemetry unit is caring for
"All of this equipment can
a client who had a myocardial infarction.
be frightening."
The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?
52. A nurse is caring for a client who reports
"The pain is like a dull ache
pain. When documenting the quality of the in my stomach."
client's pain on an initial pain assessment,
the nurse should record which of the following client statements?
53. A client who is nonambulatory notifies the evacuate the client
nurse that his trash can is on fire. After the
nurse confirms the fire, which of the following actions should the nurse take next?
54. A nurse is completing an admission assess- Rapid heart rate
ment for a client who reports vomiting and
diarrhea for the past 3 days. Which of the
following findings should the nurse expect?
55. A nurse has accepted a verbal prescription 0.3 mg
for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe
the dosage of this medication in the client's
medical record?
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56. A nurse is preparing a heparin solutionA
8 mL/hr
nurse is preparing a heparin infusion for a
client who was hospitalized with deep-vein
thrombosis. The order reads: 25,000 units of
heparin in 250 mL of 0.9% sodium chloride
to infuse at 800 units/hr. At what rate should
the nurse set the infusion pump? (Round the
answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing
zero.)
57. A nurse is caring for a client who has a pre- Cleanse the wound from the
scription for wound irrigation. Which of the center outward
following actions should the nurse take?
58. The nurse is caring for a client who is receiv- Skin blanching
ing fluid through a peripheral IV catheter..
Which of the following findings at the IV site
should the nurse identify as indicating infiltration?
59. A nurse is teaching a client whose left leg
is in a cast about using crutches. Which of
the following statements should the nurse
identify as an indication that the client understands the teaching?
"When descending stairs, I
will first shift my weight to
my right leg."
60. A nurse is caring for a client who has an NG Tell the client to keep the
tube and is receiving intermittent feedings head of the bed elevated at
through an open system. Which of the follow- least 30 degrees
ing actions should the nurse take first?
61. A nurse is reviewing a client's medication Medication dose
prescription that reads "digoxin 0.25 by
mouth everyday." Which of the following
components of the prescription should the
nurse verify with the provider?
62. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid.
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Which of the following statements should "I will be sure to remove my
the nurse identify as an indication that the hearing aid before taking a
client understands the use of this assistive shower"
device?
63. A nurse enters a client's room and finds her "Client found lying on floor"
on the floor. The client's roommate reports
that the client was trying to get out of bed
and fell over the side rail onto the floor.
Which of the following statements should
the nurse document about this incident?
64. A nurse on a medical unit is preparing to
Compare prescriptions with
discharge a client to home. Which of the fol- medications the client relowing actions should the nurse take as part ceived while at the facility.
of the medication reconciliation process.
65. A nurse is caring for a client who requires an Witness the client's signainformed consent for a surgical procedure. ture on the consent form.
Which of the following actions is the nurse's
responsibility?
66. A nurse is planning an educational program "You should receive a
for a group of older adults at a senior living pneumococcal immunizacenter. Which of the following recommenda- tion every 10 years."
tions should the nurse include?
67. A nurse is caring for a client who is refusing Withhold the blood transfua blood transfusion for religious reasons.
sion
The client's partner wants the client to have
the blood transfusion. Which of the following
actions should the nurse take?
68. A nurse is admitting a client who has rubella. Droplet
Which of the following types of transmission-based precautions should the nurse initiate?
69. A middle adult client tells the nurse, "I feel so "People in middle adulthood
useless now that my children do not need me often find satisfaction in nur10 / 37
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anymore." which of the following responses turing and guiding young
should the nurse make?
people."
70. A nurse is providing discharge teaching to a
client who has a new prescription for a home
oxygen concentrator. Which of the following
instructions should the nurse provide to the
client and his family? (Select all that apply)
Check the cord routinely for
frays or tearing
Consider purchasing a generator for power backup
Observe for signs of hypoxia
71. The nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the
following actions should the nurse take?
Instruct the family to refrain from pushing the button for the client while she is
asleep.
72. A nurse is admitting a client who has been Wrap blankets around all
having frequent tonic-clonic seizures. Which four sides of the bed
of the following actions should the nurse add
to the client's plan of care?
73. A nurse manager is overseeing the care ac- A nurse asks a nurse from
tivities on a unit. For which of the following another unit to assist with
situations should the nurse manager inter- documentation for a client
vene due to a violation of HIPAA guidelines?
74. A nurse is caring for a client who has limited Have the client use a
mobility in his lower extremities. Which of trapeze bar when changing
the following actions should the nurse take position.
to prevent skin breakdown?
75. a nurse is preparing to delegate client care Ambulating a client who is
tasks to an assistive personnel (ap). which postoperative
of the following tasks should the nurse delegate?
76. a nurse in an acute care facility is preparing a current medications
discharge summary for a client who is transferring to a long-term care facility. Which
of the following documentation should the
nurse include?
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77. A nurse is caring for a client who has termi- "What could I have done to
nal liver cancer. Which of the following state- deserve this illness?"
ments should the nurse identify as an indication that the client is experiencing spiritual
distress?
78. A nurse is calculating a client's fluid intake 8 oz of ice chips
over the past 8 hour. Which of the following
items should the nurse plan to document
on the client's intake and output record as
120ml of fluid?
79. A nurse is planning teaching for a group of practice sessions
adolescents who each recently had surgical
placement of an ostomy. Which of the following methods should the nurse use as a
psychomotor approach to learning?
80. a nurse is preparing to obtain a lower exadd 30 mm Hg
tremity blood pressure from a client and no
longer palpates the popliteal pulse after 92
mm Hg. Which of the following images displays the measurement in mm Hg to which
the nurse should inflate the cuff when obtaining the blood pressure
81. a nurse is caring for a client who has a termi- we can talk about advanced
nal diagnosis and whos health is declining. directives brochures
Advanced directives.
82. A nurse is reviewing practice guidelines with Initiate an enteral feeding
a group of newly licensed nurses. Which of through a gastrostomy tube.
the following interventions should the nurse
include that is within the RN scope of practice?
83. a nurse is assessing a client who received an distended neck veins
IV fluid bolus for dehydration. Which of the
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following findings should the nurse identify
as an indication of fluid volume excess?
84. A nurse in a surgical suite notes documenta- Wrap monitoring cords with
tion on a client's medical record that he has stockinette and tape them in
a latex allergy. In preparation for the client's place.
procedure, which of the following precautions should the nurse take?
85. A home health nurse who has attended a
A client who has asthma.
training session for the therapeutic use of
aromatherapy with essential oil is planning
to use this modality with some of her clients.
For which of the following clients should the
nurse consult the provider before using this
complementary therapy?
86. A nurse is planning care for a client who has N95 respirator
tuberculosis. The nurse should use which
of the following pieces of personal protective equipment when providing care for the
client?
87. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10
units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move
the steps into the box on the right, placing
them in the order of performance. Use all the
steps.)
3) Inject 10 units of air into
the bottle of NPH insulin1)
Inject 5 units of air into the
bottle of regular insulin4)
Withdraw the correct dose
of regular insulin from the
bottle2) Withdraw the correct dose of NPH insulin
from the bottle
88. A charge nurse is observing a newly licensed nurse prepare a sterile field for a
dressing change. Which of the following actions by the newly licensed nurse requires
intervention by the charge nurse?
The newly licensed nurse
places the cap of a bottle of
sterile saline solution on the
sterile field.
89.
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A nurse in a clinic is caring for a middle
"You should have a fecal ocadult client who states, "The doctor says
cult blood test every year."
that, since I am at an average risk for colon
cancer, I should have a routine screening.
What does that involve?" Which of the following responses should the nurse make?
90. A nurse is discussing the use of herbal sup- "I can take echinacea to implements for health promotion with a client. prove my immune system."
Which of the following client statements indicates an understanding of herbal supplement use?
91. indwelling urinary catheter
bladder scan
92. a nurse is giving a change of shift report
breath sounds
about a client admitted earlier who has pneumonia
93. a home health nurse is completing an adthe caregiver insists on remission assessment of an older adult client maining in the room
who has their caregiver present. which of the
following findings should the nurse identify
as a potential indication of elder abuse
94. A nurse is performing a peripheral vascular Narrowed arterial lumen
assessment for a client. When placing the
bell of the stethoscope on the client's neck,
she hears the following sound. This sound
indicates which of the following?
95. ethical principle of veracity
nurse tells client she has
cancer
96. a community health nurse is checking BP a client who smokes one
for a group of clients at a community health pack of cigarettes each day
screening. which of the following clients is at
an increased risk for hypertension?
97.
an x-ray
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a nurse has just inserted an NG tube for
a client. Which of the dollowing findings
should the nurse expect to confirm correct
tube placement?
98. A nurse is performing a Romberg's test
Have the client stand with
during the physical assessment of a client. her arms at her side and her
Which of the following techniques should feet together.
the nurse use?
99. A nurse is teaching an older adult client who Walking briskly
is at risk for osteoporosis about beginning
a program of regular physical activity. Which
of the following types of activity should the
nurse recommend?
100. a nurse is caring for a client who has deapply an ankle-foot orthotic
creased mobility. which of the following ac- device to the client's feet
tions should the nurse take to decrease the
client's risk of developing plantar flexion
contractures?
101. A nurse is preparing to administer multiple Flush the tube with 15 mL of
medications to a client who has an enteral sterile water.
feeding tube. Which of the following actions
should the nurse plan to take?
102. A nurse is preparing to transfer a client who Assess the client for orthocan bear weight on one leg from the bed to static hypotension.
a chair. After securing a safe environment,
which of the following actions should the
nurse take next?
103. A nurse is administering an otic medication Press gently on the tragus
to an older adult client. Which of the follow- of the client's ear.
ing actions should the nurse take to ensure
that the medication reaches the inner ear?
104.
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A nurse is providing care to four clients.
Which of the following situations requires
the nurse to complete an incident report?
105. A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
Reassure the client that this
is an expected response to
grief.
106. A nurse is lifting a bedside cabinet to move Stand close to the cabinet
it closer to a client who is sitting in a chair. when lifting it.
To prevent self-injury, which of the following
actions should the nurse take when lifting
this object?
107. A nurse is reviewing a client's fluid and elec- Potassium 5.4 mEq/L
trolyte status. Which of the following findings should the nurse report to the provider?
108. A nurse is evaluating a client's use of a cane. The client holds the cane
Which of the following actions should the on the stronger side of her
nurse identify as an indication of correct
body.
use?
109. A nurse is assisting a client who is postoper- Semi-Fowler's
ative with the use of an incentive spirometer.
Into which of the following positions should
the nurse place the client?
110. A charge nurse is discussing the responsi- Have family members wear
bility of nurses caring for clients who have a gown and gloves when
a Clostridium difficile infection. Which of the visiting.
following information should the nurse include in the teaching?
111. A nurse is preparing to administer an injec- Ask another nurse to
tion of an opioid medication to a client. The observe the medication
nurse draws out 1 mL of the medication from wastage.
a 2 mL vial. Which of the following actions
should the nurse take?
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112. A nurse is performing a peripheral vascular Narrowed arterial lumen
assessment for a client. When placing the
bell of the stethoscope on the client's neck, (Bruit)
she hears the following sound. This sound
indicates which of the following? (Click on
the audio button to listen to the clip.)
113. A nurse is using an open irrigation techSubtract the amount of irrinique to irrigate a client's indwelling urigant used from the client's
nary catheter. Which of the following actions urine output.
should the nurse take?
114. A nurse is assessing an older adult client's B) Pupil clarity
risk for falls. Which of the following assess- D) Visual fields
ments should the nurse use to identify the E) Visual acuity
client's safety needs? (Select all that apply.)
115. A nurse is caring for a client receiving fluid Skin blanching
through a peripheral IV catheter. Which of the
following findings at the IV site should the
nurse identify as infiltration?
116. A nurse is preparing to administer 0.5 mL of Gently shake the container
oral single-dose liquid medication to a client. of medication prior to adWhich of the following actions should the ministration.
nurse take?
117. A nurse is administering IV fluid to an older Auscultate lung sounds.
adult client. The nurse should perform which
priority assessment to monitor for adverse
effects?
118. A nurse is planning care to improve
Use a clock pattern to deself-feeding for a client who has vision loss. scribe food on the client's
Which of the following interventions should plate.
the nurse include in the plan of care?
119. A nurse is assessing an adult client who
has been immobile for the past 3 weeks.
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The nurse should identify that which of the
following findings requires further intervention?
120. A nurse is reviewing protocol in preparation Select a suction catheter
for suctioning secretions from a client who that is half the size of the
has a new tracheostomy. Which of the follow- lumen.
ing actions should the nurse plan to take?
121. A nurse is admitting a client who has varicel- Airborne
la. Which of the following types of transmission precautions should the nurse initiate?
122. A nurse is caring for a client who is reporting Use progressive relaxation
difficulty falling asleep. Which of the follow- techniques at bedtime.
ing measures should the nurse recommend?
123. A nurse is responding to a call light and finds Check the client for injuries.
a client lying on the bathroom floor. Which of
the following actions should the nurse take
first?
124. A nurse is caring for a client who has had his Eggs
diet prescription changed to a mechanical
soft diet. Which of the following food items
should the nurse remove from the client's
breakfast tray?
125. A nurse in a long-term care facility is plan- "Are you able to help with
ning to perform hygiene care for a new res- your hygiene care?"
ident. Which of the following assessment
questions is the nurse's priority before beginning this procedure?
126. A nurse is giving discharge instructions to
a client who will require oxygen therapy
at home. Which of the following statements
should the nurse identify as an indication
that the client understands how to manage
this therapy at home?
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127. A nurse is assessing a client who has been Calf swelling
on bed rest for the past month. Which of the
following findings should the nurse identify
as an indication that the client has developed
thrombophlebitis?
128. A nurse is completing an admission assess- Rapid heart rate
ment for a client who reports vomiting and
diarrhea for the past 3 days. Which of the
following assessment findings should the
nurse expect?
129. A nurse is planning an education session for Allow extra time for the
an older adult client who has just learned
client to respond to questhat she has type 2 diabetes mellitus. Which tions.
of the following strategies should the nurse
plan to use with this client?
130. A nurse is admitting a client who has an ab- Contact precautions
dominal wound with a large amount of purulent drainage. Which of the following types of
transmission precautions should the nurse
initiate?
131. A nurse manager is overseeing the care
A nurse asks a nurse from
on a unit. Which of the following situations another unit to assist with
should the nurse manager identify as a vio- her documentation.
lation of HIPAA guidelines?
132. A nurse is caring for a client who requires a "I flushed what I urinated at
24-hr urine collection. Which of the following 7:00 a.m. and have saved
statements by the client indicates an under- all urine since."
standing of the teaching?
133. A nurse is preparing a heparin infusion for a 8 mL/hr
client who was hospitalized with deep-vein
thrombosis. The order reads: 25,000 units of
heparin in 250 mL of 0.9% sodium chloride
to infuse at 800 units/hr. At what rate should
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the nurse set the infusion pump? (Round the
answer to the nearest whole number. Use a
leading zero if it applies. Do not use a trailing
zero.)
134. A nurse is caring for a client who requires an
NG tube for stomach decompression. Which
of the following actions should the nurse
take when inserting the NG tube?
Have the client take sips
of water to promote insertion of the NG tube into the
esophagus.
135. A nurse is caring for a client who is postDetermine the reasons why
operative and refuses to use an incenthe client is refusing to use
tive spirometer following major abdominal the incentive spirometer.
surgery. Which of the following is the nurse's
priority action?
136. A nurse is planning to insert a peripheral IV Place the client's arm in a
catheter for an older adult client. Which of dependent position.
the following actions should the nurse plan
to take?
137. A nurse manager is preparing to review med- "Use the complete name of
ication documentation with a group of new- the medication magnesium
ly licensed nurses. Which of the following
sulfate."
statements should the nurse manager plan
to include in the teaching?
138. A nurse is caring for a client who requires Remove the stockings at
bed rest and has a prescription for antiem- least once per shift.
bolic stockings. Which of the following actions should the nurse take?
139. A nurse is talking with the partner of an old- Role overload
er adult male client who has dementia. The
client's partner expresses frustration about
finding time to manage household responsibilities while caring for his partner. The nurse
should identify that he is going through
which of the following types of role-performance stress?
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140. A nurse is preparing to transfer a client who
has right-sided weakness from the bed to a
chair. In what order should the nurse take the
following actions to assist the client? (Move
the steps into the box on the right, placing
them in the order of performance. Use all the
steps.)
1) Ask the client if he can
bear weight
3) Position the chair on the
left side of the bed
4) Have the client sit and
dangle his feet at the bedside
2) Use the stand-and-pivot
technique to move the client
to the chair
141. A nurse is preparing a change-of-shift reSituation, background, asport. Which of the following tools or docu- sessment, and recommenments should the nurse use to communicate dation (SBAR)
continuity of care?
142. A nurse is assessing a client's readiness to "I can concentrate best in
learn about insulin administration. Which of the morning."
the following statements should the nurse
identify as an indication that the client is
ready to learn?
143. A nurse is caring for a client who has herpes Acupuncture
zoster and asks the nurse about the use of
complementary and alternative therapies for
pain control. The nurse should inform the
client that his condition is a contraindication
for which of the following therapies?
144. A nurse is caring for a client who is havAssist the client to an uping difficulty breathing. The client is lying in right position.
bed with a nasal cannula delivering oxygen.
Which of the following interventions should
the nurse take first?
145. A nurse is caring for a client who has tuA) Place the client in a room
berculosis. Which of the following actions with negative-pressure airshould the nurse take? (Select all that apply.) flow.
B) Wear gloves when as21 / 37
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sisting the client with oral
care.
E) Use antimicrobial sanitizer for hand hygiene.
146. A nurse is caring for a client who asks about
the purpose of advance directives. Which of
the following statements should the nurse
make?
"They indicate the form of
treatment a client is willing
to accept in the event of a
serious illness."
147. A nurse is caring for a client who is termi- "This is a difficult time, but
nally ill. Which of the following statements we are helping each other
should the nurse identify as an indication
through this."
that the client's family member is coping effectively with the situation?
148. A nurse at an extended-care facility is in"When the client moves, he
structing a class of AP's about the use of
should move the cane forassistive devices during ambulation. Which ward first."
of the following should the nurse give the
AP's about the clients' use of a cane?
149. A nurse is admitting a client who has acA room with air exhaust ditive TB to a room on a medical-surgical unit. rectly to the outdoor enviWhich of the following room assignments ronment
should the nurse make for this client?
150. A nurse is assessing a client who is reHyperglycemia
ceiving TPN. Which of the following findings
should the nurse recognize as a complication to this therapy?
151. A nurse is assessing four clients on a med- A client who has a cast
ical-surgical unit. Which of the following
and reports numbness and
clients should the nurse care for first?
paresthesia
152. A nurse is assisting with transferring a client Lock the wheels of the bed
from the bed to a wheelchair. Which of the and wheelchair
following actions should the nurse take?
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153. A nurse is caring for a client who has a hip surgeon
fracture that requires surgical repair. Which
of the following health care professionals is
responsible for obtaining informed consent?
154. A nurse is caring for a client who has dia- 14 + 28 = 42 units.
betes and a new prescriptions for 14 units of
regular insulin and 28 units of NPH insulin
to be given subcutaneous at breakfast daily.
What is the total number of units of insulin
that the nurse should prepare in the syringe?
155. A nurse is caring for a client who has fall- "The provider was notified."
en while getting out of bed and states, "I'm
okay! I guess I should have called for help
to the bathroom. After assessing, the nurse
notifies the provider. What documentation
should the nurse use?
156. A nurse is caring for a client who is having Remain with the client
difficulty sleeping and is pacing the floor.
The client's head is down, and he is wringing
his hands. Which of the following actions
should the nurse take?
157. A nurse is discussing indications for urinary
catheterization with a newly licensed nurse.
Which of the following indications should
the nurse include?
-relief of urinary retention
-measurement of residual
urine after urination
-presence of an open perineal wound
158. A nurse is planning care for a client who has Instruct client to actively
terminal cancer and a prescription for mor- cough to prevent buildup of
phine. Which intervention should the nurse secretions in airway.
include in the plan of care?
159. A nurse is preparing to administer
40 / 10 = 4 mL
furosemide 40 mg IV. Available is furosemide
10 mg/ 1 mL. How many mL should the nurse
administer per dose?
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160. A nurse is preparing to move a client who is Two nurses using a friconly partially able to assist up in bed. Which tion-reducing device
of the following methods should the nurse
plan to use?
161. A nurse is providing teaching to a client
blurred vision / tachycardia /
who has a new diagnosis of type 2 diabetes moist clammy skin
mellitus. The nurse should recognize that
the client understands the teaching when
he identifies which manifestations of Hypoglycemia
162. A nurse is removing PPE after giving direct Gloves
care to a client who requires isolation. Which
of the following PPE items should the nurse
remove first?
163. A nurse is reviewing a clients ABG lab results. Which of the following should the
nurse report to the provider?
Sodium 126 mEq/L
164. A nurse is reviewing the ABG's for a client. Respiratory acidosis
The pH is 7.32, PaCO2 48 mm Hg and the
HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the
following acid base balances?
165. A nurse is teaching a client who has asthma The client holds his breath
about how to use an albuterol inhaler. Which for 10 seconds after inhalof the following actions by the client indiing the medication
cates an understanding of the teaching?
166. Which of the following clients should the
a client who has a protein
nurse identify as being at risk for the devel- calorie malnutrition
opment of pressure ulcers?
a client who has right-sided
heart failure and 4+ edema
to lower extremities
a client who has post operative delirium
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167. The nurse overhears two AP's from the med- Quietly tell the AP's that that
ical surgical unit discussing a hospitalized this is inappropriate
patient while in the cafeteria. Which of the
following is the priority nursing action?
168. A client who is non-ambulatory notifies the Evacuate the client
nurse that his trash can is on fire. After the
nurse confirms the fire, which of the following actions should the nurse take next?
169. Diaphragm of stethoscope?
Used for high-pitched
sounds (heart sounds,
bowel sounds, breath
sounds)---placed firmly on
the body
170. Bell of stethoscope?
Used for low-pitched
sounds (abnormal heart
sounds, bruits)---placed
lightly on the body
171. Tympanic temperature--adults? children?
Adult--pull ear up and back;
Children younger than 3 pull
down and back
172. Rectal temperature?
Sims position---inserted
3.5cm or 11/2 in for adults
173. Pulse strength scale?
0-4+---0=absent- 4+= full or
bounding
174. how to take apical pulse?
5th intercostal space at
left midclavicular line--place
stethoscope on chest
and always count for 1
minute----used to assess
HR of infant, rapid rates >
100, irregular rhythms, and
prior to cardiac meds
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175. s/s of tachycardia?
pain, anxiety, restlessness,
fatigue, low BP, and low O2
sat
176. s/s of bradycardia?
hypotension, chest pain,
syncope, diaphoresis, dyspnea, altered mental status
177. Assessment of respirations?
Rate, Depth (deep or shallow), and Rhythm (regular)
178. Assessment of pulse?
Rate, Rhythm (regular),
Strength (amplitude 0-4),
Equality (symmetrical)
179. Normal pulse oximetry?
95%-100%---<85% is abnormal
180. Men respirations? Women respirations?
Men--diaphragmatic
breathers, abdominal
movements more
noticeable--Womenthoracic muscles, and
chest movements more
pronounced
181. Hypoxemia?
SaO2 < 90%--s/s
tachypnea, tachycardia, restlessness, anxiety, cyanosis----place in
semi-Fowlers or Fowlers
position
182. Circadian rhythms?
BP usually lowest in the early morning and peaking during later part of afternoon
183. Sphygmomanometer?
BP measurement---Width
should be 40% of arm
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circumference--Bladder (inside cuff) should surround
80% of arm circumference
of adult and whole arm for
child
184. Palpate radial pulse for BP then?
inflate cuff another
30mmHg to hear BP systolic number
185. Rinne test?
Tuning fork against mastoid
bone AC > BC 2-1 ratio
186. Weber Test
Tuning fork on top of client's
head---sound heard equally
in both ears---Negative Weber test
187. Tonsils grading scale?
1+ barely visible 2+ halfway
to uvula 3+ touching uvula
4+ touching each other or
midline
188. 20/20?
1st # is distance pt is standing from Snellen chart--2nd
# is distance a normal sighted person can read the line
189. Palpation of the thorax and lungs?
Chest excursion: thumbs
move outward 5cm and Vocal (Tactile) Fremitus: client
says 99 each time--vibration symmetrical
190. Percussion of thorax and lungs?
Normal= resonance---Dullness= fluid or solid tissue,
pneumonia or tumor---Hyperresonance= presence of
air, pneumothorax or emphysema
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191. signs of dysphagia?
coughing, choking, gagging, and drooling of food
192. high risk for aspiration?
instruct client to tuck chin
when swallowing
193. body's preferred energy source?
Carbohydrates
194. Cane instructions?
2 points of support on ground at all
times---Keep cane on
stronger side---Move cane
6-10 in, then move weaker
leg then stronger leg
195. Crutch instructions?
Position crutches on unaffected side when sitting or
rising from chair---support
body weight at the hand
grips with elbows flexed 30
degrees
196. Discontinue hot or cold applications?
usually 15-20 minutes
197. how often to remove TED hose?
remove and reapply at least
twice a day
198. Insert catheter how?
Using the sterile hand
199. Advance catheter until?
Urine returns then continue to advance it another
2.5-5cm
200. Change IV site?
according to facility policy
(usually 72 hours)
201. Fluids should not hang more than?
24 hours unless closed system
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202. selecting vein for IV insertion?
distal veins first on nondominant hand--soft and bouncy
feeling when palpated
203. Insert catheter?
bevel up at angle of
10-30 degrees----flash back
of blood---lower hub of
catheter close to skin to prepare for threading into vein
1/4 in---advance catheter
into vein until hub rests
against the insertion site
204. when to flush IVs?
every 8-12 hours when not
in use
205. Infiltration?
pallor, local swelling, dec
skin temp, damp dressing,
slowed infusion----Treat:
stop infusion and remove
IV, elevate extremity, warm
compress
206. Phlebitis/thrombophlebitis?
edema, throbbing, burning, or pain at site, inc
temp, erythema, red line
up arm with palpable band
at vein site, slowed infusion----Treat: D/C infusion
and remove IV, elevate extremity, warm compress
207. Hematoma?
Ecchymosis at site---Treat:
No alcohol, apply pressure
after IV removal, war compress and elevation after
bleeding stops
208. Cellulitis?
pain, warmth, edema,
induration, red streak29 / 37
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ing, fever, chills, and
malaise-----Treat: D/C and
remove IV, elevate extremity, warm compress, culture
209. Fluid Overload?
distended neck veins, increased BP, tachycardia,
SOB, crackles and edema----Treat: Stop infusion,
raise HOB, VS, adjust rate,
Diuretics if prescribed
210. Catheter embolus?
missing catheter tip when
D/C, severe pain at
site----Treat: tourniquet high
on extremity to limit venous
return, X-ray
211. Nasal Cannula?
24-44% at flow rate
of 1-6L/min----Humidification for flow rate 4L or >
212. Simple Face Mask?
40-60% at flow rate of
5-8L/min
213. Partial rebreather mask?
60-75% at flow rate of
6-11L/min---reservoir bag
attached with no valve
which allows client to rebreathe up to 1/3 of exhaled
air
214. Nonrebreather mask?
80-95% at flow rate of
10-15L/min to keep reservoir bag 2/3 full during I and
E----one way valve allows
client to inhale max O2 from
reservoir bag
215. Venturi Mask?
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24-55% at flow rate of
2-10L/min via different
size adaptors---most precise O2 concentration--humidification not required
216. Oxygen-induced hypoventilation?
develop in clients with
COPD bc high levels of O2
can decrease or eliminate
their respiratory drive
217. Wear what clothing while on oxygen?
Cotton b/c synthetic or wool
fabrics can generate static
electricity
218. Chest physiotherapy (CPT)?
involves chest percussion,
vibration, and postural
drainage to assist client to
mobilize secretions---treatments 1hr before meals or
2hr after meals and at bedtime
219. Postural drainage?
client assumes one or more
positions (total of 9) to allow gravity to assist with
removal of secretions from
specific areas of the lung
220. Percussion on chest?
use cupped hand to clap
rhythmically on chest to
break up secretions
221. Vibration on chest?
move heel of hands to create vibrations as the client
exhales---cough after each
set of vibrations
222. Position for suctioning?
high-Fowlers or Fowlers position
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223. Prior to suctioning?
hyperoxygenate with FiO2
of 100%, obtain baseline
vitals of O2 and breath
sounds
224. lubricate the distal 6-8 cm of suction catheter nasopharyngeal and nasowith a water-soluble lubricant for?
tracheal suctioning
225. surgical asepsis for what suctioning?
all but suctioning of the
mouth
226. Suction pressure?
no higher than 120mmHg
227. Limit suction attempt to no longer than?
10-15 sec and 2-3 attempts
with 20-30 sec for recovery
between sessions
228. Tracheal cuff pressure?
between 14-20 mmHg
229. emergency if decannulation occurs?
in the 1st 72 hours
230. how often providing tacheostomy care?
every 8 hours
231. what solutions used to clean trach?
hydrogen peroxide of normal saline
232. Minimum degrees of bed while on enteral
feeding?
30 degrees
233. aspirate for residual volume?
intestinal should be less
than 10mL and gastric should be less than
100mL---every 4-8 hours
234. Intermittent feeding?
60mL syringe---formula instilled via gravity until done
followed with 60-100mL tap
water
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235. monitoring tube replacement?
checking gastric contents
for pH 0-4
236. with continous-drip feeding, what must be
done every 4-6 hours?
flush enteral tubing with
30-60mL of irrigant (tap water) and check tube placement
237. Blood glucose check on enteral feedings?
every 6 hours until max administration rate is reached
and maintained for 24 hours
238. Unused formula after 24 hours?
discarded
239. short term < 4 weeks enteral feeding?
nasogastric of nasointestinal tubes
240. when gastric residual exceeds 100mL?
withhold feeding and
notify provider---maintain
semi-Fowler's position
241. Serous drainage?
portion of the blood (serum)
that is watery and clear or
slightly yellow
242. Sanguineous drainage?
contains serum and
RBCs---thick and appears
reddish
243. Serosanguineous drainage?
contains both serum and
blood---watery and appears blood-streaks or
blood-tinged
244. Purulent drainage?
result of infection---thick
and contains WBCs, tissue
debris, and bacteria
245. Albumin levels < 3.5?
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lack of protein puts client at
risk for delayed wound healing and infection
246. Dehiscence?
partial or total rupture of sutured wound
247. Evisceration?
dehiscence that involves
the protrusion of visceral
organs through a wound
opening
248. Evisceration and Dehiscence requires?
Emergency treatment---cover wound and
protruding organs with
sterile towels soaked in
sterile normal saline---DO
NOT attempt to reinsert organs---position client
supine with hips and knees
bent
249. Risk tools for Staging Pressure Ulcers?
Braden Scale <18---at risk;
Norton Scale 15-16---indicator of risk
250. Beneficence?
agreement that the care given is in the best interest of
the client---positive actions
251. Nonmaleficence?
avoidance of harm or pain
as much as possible when
giving treatments
252. Fidelity?
agreement to keep one's
promise to the client about
care that was offered
253. Airborne precautions?
Protect against droplet
infections smaller than
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5mcg----Measles, varicella,
pulmonary or laryngeal TB
254. Airborne precaution equipment?
Private room, N95 or HEPA
respirator for TB, Negative
pressure airflow exchange
255. Droplet precautions?
protect against droplets
larger than 5mcg---streptococcal pharyngitis or
pneumonia, scarlet fever,
rubella, pertussis, mumps,
mycoplasma pneumonia,
meningococcal pneumonia/sepsis, pneumonic
plague
256. Droplet precaution equipment?
Private room OR room with
same disease client, masks
for providers and visitors
257. Contact Precaution?
protect visitors and caregivers against direct
client/environment contact
infections---respiratory syncytial virus, shigella, enteric
diseases caused by micros, wound infections, herpes simplex, scabies, multidrug-resistant organisms
258. Contact precaution equipment?
Private room OR room with
same disease client, gloves
and gowns by caregivers
and visitors, disposal of infectious dressing material
into single nonporous bag
259. Neurosensory checks and ROM in restraints?
every 2 hours
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260. Client in restraints assessed for food, fluids, every 15-30 minutes
comfort, and safety?
261. SaO2 < 90%?
Hypoxemia---Early: tachypnea, tachycardia, restlessness, pale skin, elevated
BP---Late: confusion, cyanotic, bradypnea, bradycardia, hypotension, dysrhythmias
262. delivers most precise oxygen concentration?
Venturi Mask: 24-55%
at flow rates
of 2-10L/min---Humidification not required
263. Highest O2 concentration possible?
Nonrebreather mask:
80-95% at flow rates of
10-15L/min
264. high humidification with O2 delivery?
Aerosol mask, face tent,
and tracheostomy collar:
24-100% at flow rates of
10L/min or more
265. Tracheostomy client permitted to eat?
position upright and tip chin
to chest to enable swallowing
266. Hyperglycemia? Hypoglycemia?
greater than
250mg/dL---Less than
70mg/dL
267. Positive test for ketones in urine?
uncontrolled blood glucose
268. Parenteral site for infants and children < 2
years of age?
vastus lateralis site recommended
269.
ventral gluteal
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After age 2, what site can be used for parenteral injections?
270. position for suppositories?
left lateral position
271. MDI administration?
hold inhaler 1-2 inches
away from mouth
272. Instillation of drops?
above conjunctival sac 1-2
cm, drop med into center of
sac and hold pressure on
nasolacrimal duct
273. Risk for infection at what injection site?
subcut and IM
274. what is used to cleanse peristomal area?
mild soap and water
275. _____ color is positive for blood in fecal oc- Blue color
cult blood testing (guaiac test)?
276. Causes concern with UO < ___mL/hr?
< 30 mL/hr for more than 2
hours
277. Apical pulse?
5th intercostal space at left
midclavicular line
278. Glasgow Coma scale?
15= awake and
alert----3=coma
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