lab exam

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first? ◦A. Gown ◦B. Gloves ◦C. Face shield ◦D. Mask

b

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? ◦A. Administer oxygen at 2 L/min. ◦B. Administer prescribed analgesic medication. ◦C. Encourage coughing and deep breathing. ◦D. Raise the head of the bed.

d

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? ◦A. To confirm the placement of the NG tube ◦B. To remove gastric acid that might cause dyspepsia ◦C. To determine the client's electrolyte balance ◦D. To identify delayed gastric emptying

d

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? ◦A. Wraps the blood pressure cuff snugly around the client's arm ◦B. Places the client's arm above the level of the client's heart ◦C. Checks the instrument gauge to ensure the reading starts at zero ◦D. Centers the cuff bladder over the client's brachial artery

b

A nurse is orienting a new unlicensed assistive personnel (UAP) to the unit. For which of the following actions should the nurse intervene? ◦A. Wears a gown when entering the room of a client who requires contact precautions ◦B. Dons gloves to empty a urinary drainage device ◦C. Washes and rinses her hands for 10 seconds ◦D. Wears a respirator mask when entering the room of a client who requires airborne precautions

c

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take? ◦A. Use the tablet's packaging to pick it up from the counter. ◦B. Wash the tablet off with alcohol and place it in a clean medication cup. ◦C. Discard the tablet and obtain another dose of medication. ◦D. Place the tablet directly into a medication cup.

c

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take? ◦A. Instill the drops into the inner canthus. ◦B. Approach the client's eye from below it. ◦C. Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac. ◦D. Ask the client to look down when instilling the solution.

c

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? ◦A. Use a stiff toothbrush to clean the client's teeth. ◦B. Use the thumb and index finger to keep the client's mouth open. ◦C. Turn the client on his side before starting oral care. ◦D. Apply petroleum jelly to the client's lips after oral care.

c

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? ◦A. "They protect your legs and heels from skin breakdown." ◦B. "They help keep you warm after your surgery." ◦C. "They improve your circulation to keep blood from pooling in your legs."

c

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? ◦A. Secure the restraints using a quick-release tie. ◦B. Ensure four fingers fit under the restraints to prevent constriction. ◦C. Secure the restraints to the lowest bar of the side rail. ◦D. Anticipate removing the restraints every 4 hr.

a

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? ◦A. Gait belt ◦B. Jacket harness ◦C. Four-wheel walker ◦D. Cane

a

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take? ◦A. Remove the IV saline lock. ◦B. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency. ◦C. Apply a warm compress to the IV site. ◦D. Inject the solution more slowly while flushing the IV saline lock.

a

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? ◦A. Attach a humidifier bottle to the base of the flow meter. ◦B. Remove the nasal cannula while the client eats. ◦C. Secure the oxygen tubing to the bed sheet near the client's head. ◦D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

a

A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration? ◦A. 28% ◦B. 36% ◦C. 50% ◦D. 70%

a

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take? ◦A. Check that the client lifts the walker and then places it down in front of her. ◦B. Walk in front of the client to guide her in moving the walker. ◦C. Have the client move one leg forward with the walker. ◦D. Make sure that the upper bar of the walker is level with the client's waist.

a

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take? ◦A. Wait 30 min and return to measure the oral temperature ◦B. Provide the client a sip of warm water, wait 5 min, and measure the temperature. ◦C. Document that the nurse was unable to measure the client's temperature. ◦D. Proceed to measure the oral temperature.

a

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check? ◦A. At the client's bedside before administration ◦B. In the area where the nurse obtained the medication ◦C. At the time of documentation ◦D. At the nurses' station while reviewing the provider's prescription

a

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first? ◦A. Determine if the client can bear weight. ◦B. Place a transfer belt on the client. ◦C. Position the bed at an appropriate height. ◦D. Assist the client to a seated position.

a

A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? ◦A. Shake the inhaler for 3 to 5 seconds. ◦B. Rinse the mouth with mouthwash after inhaling the medication. ◦C. Wait 2 min between inhalations. ◦D. Press down twice on the MDI canister.

a

A nurse is providing teaching to a group of unlicensed assistive personnel (UAP) about hand hygiene. Which of the following statements by one of the UAPs indicates a need for further teaching? ◦A. "As long as I change gloves between clients, it is not necessary to wash my hands." ◦B. "I should wash my hands before I provide client care." ◦C. "I will not wear artificial nails when providing client care." ◦D. "It is acceptable to use alcohol-based hand products after most client contact."

a

An unlicensed assistive personnel (UAP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? ◦A. BP ◦B. Respiratory rate ◦C. Pulse rate ◦D. Temperature

a

Before entering the room of a patient on isolation where all protective barriers are required, the nurse first puts on the: A. Gown B. Gloves C. Eyewear D. Mask/respirator

a

How should the nurse identify a patient before obtaining a laboratory specimen? A. Use at least two patient identifiers. B. Look at the chart before entering the room. C. Ask the patient his name. D. Check the patient's armband twice.

a

In caring for a patient who has a pouch for a urinary diversion, which nursing intervention is essential? ◦A. Empty the pouch when it is one-third to one-half full. ◦B. Remove the ureteral stents after 2 days. ◦C. Pouch the stoma with the patient sitting up. ◦D. Dispose of used pouches in the toilet.

a

The nurse explains to the patient that the incentive spirometer is used to promote which of the following outcomes? ◦A. Lung expansion ◦B. Reduced likelihood of vascular complications ◦C. Incisional healing ◦D. Expectoration of mucus

a

The nurse is checking gastric residual on a patient who has a continuously running tube feeding and finds that the patient has a 600-mL gastric residual volume (GRV). How should the nurse respond? ◦A. Stop the tube feeding. ◦B. Slow the tube feeding. ◦C. Continue the tube feeding at the same rate. D. Increase the rate of the tube feeding

a

The nurse is preparing an injection of 0.45 mL of medication for a pediatric patient. Which syringe is most appropriate? ◦A. 1-mL ◦B. Insulin syringe ◦C. 3-mL syringe ◦D. 10-mL syringe

a

The nurse is preparing oral medications for administration. Which action by the nurse is appropriate? ◦A. Using a cutting device to cut scored tablets ◦B. Unwrapping all of the medications to be given and placing them together in a cup ◦C. Crushing capsules and enteric-coated medication for easier swallowing ◦D. Holding the medication cup at eye level to pour a liquid dosage

a

The patient has been hospitalized for several days and has received multiple intravenous antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea. The nurse should institute: A. contact precautions. B. standard precautions only. C. Airborne precautions D. Droplet precautions

a

The patient has been sleeping and has been lying on his right side. The nurse is ready to take his temperature using a tympanic thermometer. She needs to insert the thermometer into his __ ear. ◦A. left ◦B. right ◦C. either D.neither

a

When planning care for a patient who has a colostomy, which intervention is important for the nurse to perform when pouching the colostomy? ◦A. Leave an intact skin barrier in place for 3 to 7 days. ◦B. Use soap and water to cleanse the peristomal skin. ◦C. Empty the pouch when it is two-thirds full. D. Use tape to secure pouches that have minor leaks

a

When providing care for a patient with a colostomy or an ileostomy, the nurse recognizes that which is an expected assessment finding? ◦A. A moist, reddish-pink stoma ◦B. A dry, purplish stoma ◦C. Erythema on the skin around the stoma ◦D. No drainage noted from the stoma when washed

a

he patient is to receive a medication via the sublingual route. Which action by the nurse is appropriate? A.Placing the medication under the tongue B.Crushing the medication before administration C.Offering the patient a glass of orange juice after administration D.Using sterile technique to administer the medication

a

when assessing a patient, a nurse notes that the skin distal to a restraint is pale and cool to the touch. Which of the following interventions will the nurse perform first? A.Remove the restraint. B.Loosen the restraint. C.Obtain a larger restraint Reapply the restraint with more padding

a

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? ◦A. Discard the dressing in the bedside trash receptacle ◦B. Dispose of the dressing in a biohazardous waste container. ◦C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. ◦D. Double-bag the dressing in clear bags and label it "biohazard".

b

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first? ◦A. Mask ◦B. Gloves ◦C. Gown ◦D. Goggles

b

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take? ◦A. Assume a narrow base of support. ◦B. Lower the client to the floor. ◦C. Lean the client toward the wall. ◦D. Provide support by holding the client's arm.

b

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? ◦A. Apply a heat lamp twice a day. ◦B. Reposition the client at least every 2 hr. ◦C. Clean the wound with hydrogen peroxide solution. ◦D. Massage reddened areas with dressing changes.

b

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? ◦A. Observe client's respiratory status. ◦B. Elevate the head of the client's bed 30° to 45° ◦C. Monitor intake and output every 8 hr. ◦D. Check residual volume every 4 to 6 hr.

b

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? ◦A. Finger ◦B. Earlobe ◦C. Toe ◦D. Skin fold

b

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? ◦A. Adjust the water temperature to feel hot. ◦B. Apply 4 to 5 mL of liquid soap to the hands. ◦C. Hold the hands higher than the elbows. ◦D. Rub hands and arms to dry.

b

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take? ◦A. Raise the client's bed to the nurse's waist level. ◦B. Use a gait belt to stand and pivot the client. ◦C. Instruct the client to place his hands around the nurse's neck during the transfer. ◦D. Place the chair on the client's weak side.

b

A nurse is providing teaching to a new nurse about caring for clients with restraints. Which of the following statements by the new nurse indicates an understanding of the teaching? ◦A. "I will tie restraints in double knots." ◦B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." ◦C. "I will ensure that restraints fit tightly against the client." ◦D. "I will put four side rails up if a client is confused."

b

A nurse is teaching a new group of unlicensed assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? ◦A. "If you wear gloves, you do not have to wash your hands." ◦B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." ◦C. "Use an alcohol rub when your hands are visibly soiled." ◦D. "If you don't have an infection, your hands won't infect others."

b

A nurse is teaching an unlicensed assistive personnel (UAP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the UAP understands the instructions? ◦A. "I will wear gloves whenever I am in contact with clients." ◦B. "I will wear gloves and a gown when bathing a client who has open skin lesions." ◦C. "I will wear gloves to minimize the number of times I have to wash my hands." ◦D. "I will wear gloves when measuring a client's blood pressure."

b

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? ◦A. "The infusion rate has stopped but the tubing is not kinked." ◦B. "The area surrounding the insertion site feels warm to the touch." ◦C. "There is fluid leaking around the insertion site." ◦D. "There is no blood return when the tubing is aspirated."

b

A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate intervention for the nurse to implement in maintaining sterile asepsis is to: A. put sterile gloves on before opening sterile packages. B. discard items that may have been in contact with the area below waist level. C. place the povidone-iodine bottle well within the sterile field. D. place sterile items on the very edge of the sterile drape.

b

The nurse enters the patient's room to give medications. Which action is most appropriate to identify the "right patient"? A.Ask the patient to state his name. B.Ask the patient to state his name and birth date. C.Ask the primary nurse to identify the patient. D.Say the patient's name and date of birth and request patient validation.

b

The nurse is applying for a job at a local hospital. She wants to look her best for the interview and decides to wear artificial nails. She does this knowing that artificial nails: A.are appropriate in the ICU setting as long as the nurse washes her hands frequently. B.can lead to fungal growth under the nail. C.can actually lower the bacterial count on the hands because they cover the natural nail. D.are banned only in areas where patients are critically ill.

b

The nurse is preparing an intramuscular injection for a thin elderly patient. The nurse is aware that the maximum volume most likely tolerated by this patient is which amount? ◦A. 1 mL ◦B. 2 mL ◦C. 3 mL ◦C. 5 mL

b

The nurse is preparing to administer medication to a patient who is alert and oriented. When medications are reviewed with the patient, the patient states that he does not take metoprolol. Which action by the nurse is most appropriate? A.Ignore the patient's statement and give the medication. B.Withhold the medication. C.Convince the patient that the doctor ordered it, and he should take it. Give the medication and check the order afterward

b

The nurse is preparing to provide a complete bed bath to a patient who has a running IV. She places a bath blanket over the patient and: A.removes the gown from the arm with the IV first B.removes the gown from the arm without the IV first. C.removes the gown after the bath to keep the patient warm. D.readjusts the IV rate before removing the gown.

b

The nurse is teaching a patient how to use a metered-dose inhaler without a spacer. Which action by the patient demonstrates correct use of the device? A.Being careful not to shake the canister B.Positioning the mouthpiece in front of the mouth while not touching the lips C.Depressing the canister fully, waiting 3 to 5 seconds, then inhaling slowly and deeply D.Taking another puff of the medication within 10 seconds

b

The nurse takes the patient's temperature using a tympanic electronic thermometer. The temperature reading is 36.5° C (97.7° F). The nurse knows that this correlates with: ◦A. 37.0° C (98.6° F) rectally. ◦B. 37.0° C (98.6° F) orally. ◦C. 36.0° C (97.7° F) axillary. ◦D. 36.0° C (97.7° F) orally.

b

The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize? A. This patient should be turned onto his back for meals. B. This patient may have to be turned more frequently than every 2 hours. C. This patient may be allowed to remain in his favorite position as long as he doesn't complain of discomfort. D. Skin breakdown is not an issue for this patient.

b

To assist the patient to a sitting position on the side of the bed, what should the nurse do first? A. Raise the height of the bed. B. Raise the head of the bed 30 degrees. C. Turn the patient onto the side facing away from the nurse. D. Move the patient's legs over the side of the bed.

b

What should the nurse do before starting a patient's bed bath? A.Lower the bed. B.Offer the bedpan or urinal. C.Partially undress the patient. Place the head of the bed in high-Fowler's position

b

When caring for a patient who has been restrained, how often will the nurse perform an assessment? A.Every 15 minutes B.Every 30 minutes C.Every hour D.Every 2 hours

b

Which of the following is an appropriate technique for the nurse to use when performing sterile gloving? A.Put the glove on the nondominant hand first. B.Interlock the hands after both gloves are applied. C.Pull the cuffs down on both gloves after gloving. D.Grasp the outside cuff of the other glove with the gloved hand.

b

A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make? ◦A. "Sometimes the same pill comes in a different color." ◦B. "Let me explain the purpose of the medication." ◦C. "I will check your medication order again." ◦D. "This is the medication that your doctor wants you to take."

c

A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration? ◦A. Blood in the IV tubing ◦B. Absence of blanching at the insertion site ◦C. Edema in the palm of the hand ◦D. Warmth around the insertion site

c

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? ◦A. Request a prescription for a medication to ease the client's anxiety. ◦B. Irrigate the NG tube with 100 mL of sterile water. ◦C. Check to see if the suction equipment is working. ◦D. Remove and reinsert the NG tube.

c

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection? ◦A. Changing the client's bed linens each day ◦B. Encouraging the client to consume a high-protein diet ◦C. Performing hand hygiene before, during, and after direct contact with the client ◦D. Placing the client in a room with positive-pressure airflow

c

A nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? ◦A. Apply the stockings while the client is sitting in a chair. ◦B. Remove the stockings once each day. ◦C. Check the stockings for wrinkles. ◦D. Measure the size of the client's foot.

c

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? ◦A. Delivers a constant rate of a specific concentration of oxygen ◦B. Delivers a high concentration of oxygen ◦C. Delivers a low concentration of oxygen ◦D. Restricts the client's ability to eat, speak, or drink

c

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching? ◦A. "I will remove the old patch and apply a new one in the same location." ◦B. "I will press the patch securely in place on my forearm." ◦C. "I will clean and dry the area before applying the patch." ◦D. "I will use lotion on irritated skin before applying a new patch in that area."

c

A nurse on a medical unit is teaching a group of unlicensed assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include? ◦A. Return any fresh linen not used for a client to the linen supply area. ◦B. Use double bagging to remove soiled linen from the client's room. ◦C. Tie linen bags securely at the top. ◦D. Fill linen bags with as much soiled linen as possible.

c

A patient is concerned because her first guaiac test is positive. What information should the nurse share with the patient? A. The patient probably has colorectal cancer. B. The test needs to be repeated after she eats some red meat. C. The test needs to be repeated at least 3 times. D. The patient needs a low-residue diet to reduce intestinal abrasions.

c

A patient is planning to perform incentive spirometry after abdominal surgery. The nurse should encourage the patient to do which of the following? ◦A. Get comfortable in a semi-reclined position. ◦B. Inhale as deeply as possible and then exhale into the incentive spirometry device. ◦C. Hold the breath for at least 3 seconds before exhaling ◦D. Exhale as quickly as possible.

c

A patient is well known to the hospital staff from previous admissions and is prone to wandering at night. For patient safety, the physician writes an order for "belt restraint prn." What should the nurse do upon reviewing this order? A.Apply a belt restraint on the patient as needed. B.Have the patient sign an "informed consent" form. C.Inform the physician that "prn" restraint orders are unacceptable. D.Obtain a signed "informed consent" from a family member.

c

An appropriate principle of surgical asepsis is that: A. the entirety of a sterile package is sterile once it is opened. B. all of the draped table, top to bottom, is considered sterile. C. an object held below the waist is considered contaminated. D. if the sterile barrier field becomes wet, the dry areas are still sterile.

c

During his initial screening, the patient's blood pressure was noted to be elevated. Two months after the first assessment, he was noted to have a blood pressure of 150/92 and 166/96 at different times during the visit. It is now a month and a half later, and the nurse is concerned because the patient's initial blood pressure on this visit was 154/94. She is preparing to take a second blood pressure, understanding that another reading in this range could lead to a diagnosis of: ◦A. hypotension. ◦B. prehypertension. ◦C. hypertension. D. orthostatic hypotension.

c

Handwashing with soap and water is: A. the most effective way to reduce the number of bacteria on the nurse's hands. B. more effective than alcohol-based products for washing hands. C. necessary for hand hygiene if hands are visibly soiled. D. not necessary if the nurse wears artificial nails.

c

The home health nurse evaluates the provision of intermittent tube feedings by the patient's family member. The nurse notes that additional teaching is required when she notices that the family member: ◦A. keeps the formula refrigerated between feedings. ◦B. keeps the feeding tube capped between feedings. ◦C. begins the feeding before checking tube placement. ◦D. irrigates the tube with 30 to 60 mL of water before and after feedings.

c

The nurse is caring for a patient with an ostomy. The nurse notes that the ostomy is putting out watery effluent. The nurse recognizes that this is indicative of which location? ◦A. Descending colon ◦B. Sigmoid colon ◦C. Ileal portion of the small-intestine ◦D. Transverse colon

c

The nurse is preparing a liquid medication. Which action is most appropriate? A.Pour the liquid medication toward the label. B.Draw the liquid quickly into a syringe. C.Place the medication cup on a flat surface at eye level. Measure the poured liquid to the top of the meniscus

c

The nurse is teaching a family member of an obese patient how to administer a subcutaneous insulin injection to the patient. Which instruction should be included in the teaching plan? ◦A. Carefully massage the site after the injection to aid absorption. ◦B. Draw the medication into a tuberculin syringe with a 27-gauge needle. ◦C. Insert the needle quickly and firmly at a 90-degree angle. ◦D. Rotate injection sites between the abdomen, thighs, and upper arms.

c

The nurse is teaching a patient how to use a flow-oriented incentive spirometer (IS) the night before abdominal surgery. Which statement by the patient indicates an understanding of the procedure? ◦A. "I need to get the balls to the top as quickly as possible." ◦B. "Quick rapid breaths are the most effective when the incentive spirometer is used." ◦C. "I need to keep the balls elevated as long as possible." ◦D. "The balls must be elevated to be effective."

c

The patient has eyedrops ordered daily to both eyes. Which action by the nurse is appropriate when administering the medication? ◦A. Carefully place the drop on the cornea. ◦B. Wipe the eye with a tissue after placing the eyedrop. ◦C. Hold the eyedropper about 1 to 2 cm above the eye. ◦D. Instruct the patient to squeeze the eye shut after instillation.

c

The patient is an elderly gentleman who has been on bed rest for the past several days. When getting the patient up, the nurse should: A.tell the patient not to move his legs when dangling. B.tell the patient to hold his breath while dangling. C.raise the head of the bed and allow a few minutes before dangling. D.have the patient stand without dangling.

c

The patient is an elderly man who has just been admitted for a probable stroke. The patient is nonverbal and does not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: A.allow the patient to lie on his right side continuously because he seems comfortable. B.prevent the patient from lying on his right side until he no longer wishes to lie on that side. C.frequently assess the patient and turn him more frequently D.allow the patient to lie on his right side until a pressure ulcer develops and he can no longer lie on that side.

c

What should the nurse do once she recognizes that the patient has phlebitis at his intravenous (IV) catheter site? ◦A. Reduce the IV flow rate. ◦B. Elevate the affected extremity. ◦C. Place a moist warm compress over the site. ◦D. Adjust the additive in the current IV.

c

When discussing the collection of a clean-voided urine specimen, it is important for the nurse to instruct the patient to: ◦A. use a clean specimen cup. ◦B. collect 100 to 150 mL of urine for testing. ◦C. void some urine first and then collect the sample. ◦D. wash the perineal area with soap and water immediately before voiding.

c

When inserting a rectal thermometer, the nurse encounters resistance. The nurse should: ◦A. apply mild pressure to advance. ◦B. ask the patient to take deep breaths. ◦C. remove the thermometer immediately. D. remove the thermometer and reinsert it gently

c

When teaching about the procedure for capillary puncture, the nurse instructs a patient to: ◦A. hold the finger upright. ◦B. use the central tip of the finger. ◦C. allow the antiseptic to dry completely. ◦D. vigorously squeeze the end of the finger

c

Which site is used to auscultate blood pressure?◦A. Radial ◦B. Ulnar ◦C. Brachial D. Temporal

c

While giving the patient a bed bath, the nurse notices a reddened area on the patient's coccyx. The nurse should: A.decrease the temperature of the bath water. B.massage the reddened area to decrease the redness. C.apply topical moisturizing agents to the area. D.ignore the redness because it will return to normal soon.

c

While washing the patient's face, the nurse should A.wash the eyes using soap and warm water. B.wash the eyes from outer canthus to inner canthus. C.wash the eyes with plain warm water. D.use the same portion of the washcloth.

c

n appropriate procedure for the nurse to use when applying an elastic stocking is to: A.remove the stockings every 24 hours. B.keep the tops of the stockings rolled down slightly. C.turn the stocking inside out to apply from the toes up. D.wash stockings daily and dry in a dryer.

c

the nurse is teaching a patient how to measure medication dosages at home. The prescription is written for 30 mL of the medication. Which household measurement will the nurse teach the patient to use? A.Drops B.Teaspoon C.Tablespoon D.Cup

c

when moving a patient out of bed to a chair with a mechanical lift is to: A.Lower the height of the bed B.Lower the head of the bed C.Place the sling from shoulders to knees D.Keep the check valve open when the patient is seated in the chair

c

while ambulating, the patient becomes light-headed and starts to fall. What should the nurse do first? A.Call for help. B.Try to reach for a chair. C.Ease the patient down to the floor. D.Push the patient back toward the bed.

c

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? ◦A. The nurse initiates the feeding after aspirating 50 mL of gastric residual. ◦B. The nurse irrigates the NG tube with tap water after feeding. ◦C. The nurse administers the feeding through a syringe barrel by gravity. ◦D. The nurse allows the client to rest in a supine position during feeding.

d

A nurse in a long-term care facility is observing an unlicensed assistant personnel (UAP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the UAP understands the principles of infection control? ◦A. Shakes the soiled linen to remove any toilet paper remnants ◦B. Places the soiled linen on the floor before bagging it ◦C. Holds the soiled linen against her body while carrying it to the linen bag ◦D. Places clean linen that touched the floor in the soiled linen bag

d

A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? ◦A. Recap the needle. ◦B. Place the cap on the bedside table and slide the needle into the cap. ◦C. Wrap the needle with gauze. ◦D. Dispose of the needle uncapped.

d

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint? ◦A. The client has a capillary refill of less than 2 seconds. ◦B. The client has full range of motion in her wrist. ◦C. The client is attempting to remove the restraint. ◦D. The client's hand is cool and pale.

d

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? ◦A. Assess the pedal pulses for a full minute. ◦B. Assess the pedal pulses with a Doppler device. ◦C. Assess the apical pulse with a Doppler device. ◦D. Assess the apical pulse for a full minute.

d

A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? ◦A. Glasgow results ◦B. Intracranial pressure readings ◦C. Code status ◦D. Plan of care changes for upcoming shift

d

A nurse is observing an unlicensed assistive personnel (UAP) changing the linens on the bed of a client who is immobile. Which of the following actions by the UAP should the nurse identify as an indication of the need to intervene? ◦A. Raises the bed to waist level ◦B. Rolls the client to one side of the bed ◦C. Lowers the side rail on the side of the bed closest to the AP ◦D. Reaches over the bed to straighten the fitted sheet

d

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? ◦A. The provider must renew a restraint prescription every 8 hr. ◦B. The client must understand the need for the restraints. ◦C. The restraints should promote the client's safety and prevent injuries. ◦D. The nurse has already considered alternatives to restraints.

d

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle? ◦A. 45° ◦B. 60° ◦C. 75° ◦D. 90°

d

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle? ◦A. Locate the center of the arm between the elbow and the shoulder. ◦B. Find the center of the anterior aspect of the thigh. ◦C. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. ◦D. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

d

A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?◦A. Mix the three medications together prior to administering. ◦B. Dilute each medication with 10 mL of tap water. ◦C. Reattach the suction directly after administering the medication. ◦D. Pinch the tube prior to attaching the medication syringe.

d

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? ◦A. One nurse lifting as the client pushes with his feet ◦B. Two nurses lifting the client under the shoulders ◦C. One nurse lifting the client's legs as the client uses a trapeze bar ◦D. Two nurses using a friction-reducing device

d

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? ◦A. "I will allow him to be in the position where he is most comfortable during the feeding." ◦B. "I will elevate the head of the bed 10 degrees during the feeding." ◦C. "I will turn him on his left side during the feeding." ◦D. "I will have him sit in his chair during the feeding."

d

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take? ◦A. Request a prescription for an oral formulation of the medication. ◦B. Administer the crushed medication through the NG tube. ◦C. Dissolve the medication in water and give it through the NG tube. ◦D. Administer the medication under the client's tongue.

d

An appropriate method of assessing a patient's respirations is for the nurse to: ◦A. place the bed flat ◦B. remove all supplemental oxygen sources from documentation. ◦C. explain to the patient that respirations are being assessed. ◦D. gently place the patient's hand in a relaxed position over the upper abdomen.

d

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use? ◦A. Ask a family member to verify the client's identity. ◦B. Check the client's name on the medication administration record (MAR). ◦C. Verify the client's room number. ◦D. Ask the client's full name and date of birth.

d

The nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the nurse do to definitely ascertain that the tube is in the stomach or in the intestine? ◦A. Test the pH of the contents. ◦B. Use a carbon dioxide sensor. ◦C. Lower the head of the bed to 15 degrees. ◦D. Obtain an order for a chest xray.

d

The nurse is caring for a patient who has an ostomy. The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool. The nurse recognizes that this is indicative of which location? ◦A. Descending colon ◦B. Ileal portion of the small-intestine ◦C. Sigmoid colon ◦D. Transverse or ascending colon

d

The nurse is to administer several medications to a patient via a nasogastric (NG) tube. What should the nurse do first? ◦A. Add the medications to the tube feeding being given. ◦B. Crush all tablets and capsules before administration. ◦C. Administer all of the medications mixed together. ◦D. Check for placement of the NG tube.

d

What should the nurse do when discontinuing a peripheral intravenous (IV) catheter? ◦Withdraw the catheter quickly. ◦Keep the hub perpendicular to the skin. ◦Apply pressure to the site for 1 minute. Inspect the catheter for intactness after removal

d

When caring for a patient who has an arm or leg restraint in place, how often will the nurse remove the restraint? A.Every 15 minutes B.Every 30 minutes C.Every hour D.Every 2 hours

d

When medications are administered, which action by the nurse is appropriate? A.Administering medications prepared by another nurse B.Using sterile technique for nonparenteral medications C.Leaving medication at the bedside when the patient is in the bathroom D.Documenting the reason for medication refusal

d

he nurse is teaching a patient how to inject low-molecular-weight heparin. What instruction should be included in the teaching plan? a◦. The injection can be given in the abdomen or the upper thighs. ◦B. Before injecting the medication, be sure to expel the air bubble in the syringe. ◦C. After inserting the needle, pull back on the plunger of the syringe before injecting the medication. ◦D. After injecting the medication, apply gentle pressure to the injection site for 30 to 60 seconds.

d