NSG 100 practice test

A nurse is preparing to administer lorazepam 1 mg PO at bedtime. The amount available is lorazepam 2 mg tablets. How many tablets should the nurse administer per dose?

0.5 tablet(s)

A nurse is preparing to administer amoxicillin 320 mg PO every 12 hr to an infant. The amount available is amoxicillin suspension 400 mg/5 mL/. How many mL should the nurse administer per dose?

4 mL

A nurse is caring for a client following a total laryngectomy. Which of the following is a priority observation in the client's care? A. patency of the IV line B. level of pain C. integrity of the dressing D. need for suctioning

D. Using the airway, breathing, circulation (ABC) priority-setting framework, confirming a patent airway is the priority observation for a postoperative client after a total laryngectomy.

A nurse is preparing to administer vancomycin 15 mg/kg/day divided equally every 12 hr. The client weighs 198 lb. How many mg should the nurse administer with each dose?

675 mg

A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (select all that apply) A. teach balance and strength exercises B. provide information about home safety checks C. lock beds and wheelchairs when not providing care D. place the bedside table within client's reach E. administer a sedative at bedtime

A, B, C, & D. Teach balance and strengthening exercises is correct. There is a strong correlation between exercise and fall risk reduction, especially when combined with balance training. Provide information about home safety checks is correct. The nurse should provide information about home safety checks, including removing loose rugs, the use of nightlights, and installing non-slip bath mats. Lock beds and wheelchairs when not providing care is correct. Locking beds and wheelchairs when not providing care allows the client to move in and out of bed easily. Place the bedside table within the client's reach is correct. Placing the bedside table within the client's reach keeps the client from overreaching and potentially losing her balance. Administer a sedative at bedtime is incorrect. Administering a sedative at bedtime can increase the client's risk for falls due to the effects of the medication.

A home health nurse is assessing an older adult client who reports falling a couple of times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls? A. the client takes alprazolam B. the client has a non-slip bath mat in his shower C. the client uses a raised toilet seat D. the client wears fitted slippers

A. Alprazolam is a CNS depressant that can cause dizziness and orthostatic hypotension, which can cause the client to lose his balance and fall

A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first? A. ask what she will be assigned to do B. determine if she has the skills to complete the assignment C. identify her options D. notify the nurse manager about her concerns for client safety

A. Before accepting the assignment, the nurse should clarify the complexity of the assignment, such as how many clients she will be assigned to care for, what skills are needed, and what resources are available to her.

A nurse is preparing an older adult client for physical examination the provider is about to perform. Which of the following actions should the nurse take? A. explain to the client what is about to happen B. make sure the room temperature is cool C. provide music as an environmental distraction D. inform the client that the provider will examine sensitive areas first

A. Explaining assessment techniques can decrease stress and anxiety. It also increases trust and promotes a therapeutic nurse-client relationship.

The nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? A. "It is a good idea to use handrails in the bathroom." B. "I should use chairs without armrests." C. "I should place a throw rug over electrical cords." D. "I should get a longer cord for my telephone."

A. Handrails or grab bars in the bathroom can help prevent falls. Clients should use them for added stability when changing positions.

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? A. pain B. hearing loss C. the client's culture D. motor impairment

A. If the client reports pain, the nurse should address managing the client's pain and postpone the learning session until the client reports pain relief.

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client? A. client concerns B. family information C. medical history D. progress note

A. Information the nurse obtains directly from the client is generally the most accurate and provides the best information available. The client is a primary source of information.

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 the client's full name and date of birth B. verify client's room number C. check the client's name on the medication administer record (MAR) D. ask a family member to verify client's identity

A. The nurse must use two identifiers before administering medications. Acceptable identifiers include the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge.

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following should the nurse use when helping the client ambulate? A. gait belt B. jacket harness C. four-wheel walker D. cane

A. The nurse should use a gait belt to help support the client during ambulation. A gait belt helps keep the client's center of gravity stable and helps maintain balance and prevent falls.

A nurse at an extended-care facility is instructing a class of AP about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the client's use of a cane? A. "When the client moves, he should move the can forward first." B. "The client should hold the cane on the weak side of the body." C. "The grip should be level with the client's waist." D. "The client should first move the strong leg, then the weak one."

A. When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? A. call the family and ask them to stay with the client B. move the client to a room closer to the nurses' station C. apply wrist and leg restraints to the client D. administer medication to sedate the client

B. This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.

A nurse is preparing an in-service about fire safety. Place the steps in the order in which they need to be performed. A. pull the fire alarm B. rescue the clients C. extinguish the fire D. confine the fire

B, A, D, C. Following the RACE mnemonic the nurse should first rescue all clients by moving them to a safe area out of immediate danger. Next the nurse should pull the alarm fire and then, if possible, call the agencies emergency extension to report the location and details of the fire. The next step the nurse should take is to close all of the room doors and fire doors at the entrance to the unit to confine the fire. Lastly, the nurse should attempt to extinguish the fire with the appropriate fire extinguisher. If unable to do so, the nurse should evacuate the area.

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply) A. keep the client's room dark at night B. teach the client to use the call light C. keep the client's bed in the lowest position D. place a fall-risk identification band on the client's wrist E. assess the client every 4 hours

B, C, D. Keep the client's room dark at night is incorrect. The client's room should have night lights or low lighting to improve visibility and help prevent falls. Teach the client to use the call light is correct. Clients need an easy, accessible way to summon assistance, especially those who are at risk for falls. Keep the client's bed in the lowest position is correct. With the bed in the lowest position and the wheels locked, the client is less likely to fall when getting out of bed. Place a fall-risk identification band on the client's wrist is correct. Fall-risk bands, usually yellow, help staff identify clients at risk and take precautions to prevent falls. Assess the client every 4 hr is incorrect. Nurses should do hourly rounding at night for clients at risk for falls and every 2 hr during daytime hours.

A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? A. determining the client's length of stay B. assigning tasks to AP C. providing anticipatory guidance to a client in crisis D. establishing the client's secondary medical diagnoses

B. Delegation of nursing care to an AP is considered indirect care. To meet the clients' needs, activities of daily living such as ambulation, bathing and vital signs may be assigned to an AP, but the nurse is responsible for verifying that the tasks have been completed according to standards of care.

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include? A. make sure a family member is present to interpret for the staff B. determine the client's level of fluency in his primary language C. speak directly to the interpreter when teaching the client D. encourage the client to nod to indicate understanding

B. It is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand.

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? A. call the client's provider B. assess the client C. notify the nurse manager D. complete an incident report

B. The first action the nurse should take using the nursing process is to assess the client. The nurse must first determine whether or not the error has caused the client any harm and also provide any relevant interventions.

A nurse is assisting with transferring a client from bed to wheelchair. Which of the following actions should the nurse take? A. place the wheelchair at a 90 degree angle B. lock the wheels of the bed and wheelchair C. acquire the help of several people to lift the client D. elevate the bed toa. position of comfort for the nurse

B. The nurse should keep the wheels of the bed and wheelchair locked to prevent them from moving when transferring client

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? A. critically analyze client data to determine priorities B. collect and organize data C. set client-centered, measureable, and realistic goals D. determine effectiveness of interventions.

B. The steps in the nursing process include assessment, analysis/diagnosis, planning, implementation and evaluation. The nurse should first collect client data, and then critically analyze the data to determine the client's' priorities. This is followed by the nurse planning client-centered, measurable and realistic goals. The nurse implements care, which involves putting the plan into action, followed by evaluation to determine the effectiveness of the interventions.

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? A. planning B. evaluation C. assessment D. implementation

C. The assessment phase includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? A. recommend that the partner the client in a long-term care facility B. suggest that the partner see a counselor to help him cope with his exhaustion C. ask the partner to talk about his difficulties in caring for the client D. tell the partner to call a family meeting to get help

C. The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife.

When caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? A. complete an incident report B. request the risk manager obtain consent for HIV testing from the client C. wash the site of injury with soap and water D. consent to postexposure treatment with antiretroviral medications

C. The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.

A nurse on a medical unit is teaching a group of AP about handling clients' bed linens safely. Which of the following instructions should the nurse include? A. return fresh linen not used for the client in the linen supply area B. use double bagging to remove soiled linen from client's room C. tie the linen bags securely at the top D. fill the linen bags with as much soiled linen as possible

C. This action secures the linen inside the bag, keeping any soiled linen from contaminating surfaces or the hands of whoever has to pick it up and bag it again.

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. limit the client's fluid intake in the evening B. obtain a bedside commode for the client's use C. leave a nightlight on in the client's room D. put the side rails up and tell the client to call the nurse before voiding

C. This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.

A home health nurse drives up to the house of her client, who has schizophrenia and manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take? A. Honk the horn to get the client's attention B. calmly speak the client's name out of the car window C. keep driving in a path that is going away from the client's house D. stop the car in the client's driveway and call the authorities

C. This is an appropriate action for the nurse to take as it removes her from immediate danger.

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make? A. "I'll provide more stimulation in his environment." B. "I will call the doctor and get the prescription." C. "I will cover the catheter so he cannot see it." D. "Let's wait until tonight to see if he continues this behavior."

C. Using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter.

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply) A. bathtub with rails B. Electric cords behind the furniture C. raised toilet seats D. water heater temperature 130F E. throw rugs

D & E. Bathtub with rails is incorrect. Rails and grab bars promote safety at home, especially in bathrooms, where floors and other surfaces are often slippery. Electric cords behind the furniture is incorrect. The nurse should make sure all electrical cords are secure against the walls or baseboards or under or behind furniture so that the client does not trip over them. Raised toilet seats is incorrect. Raised toilets seats make it easier for older adults to sit down on and get up from the toilet. Water heater temperature 54.4°C (130° F) is correct. The nurse should recommend setting the water heater's temperature no higher than 49°C (120° F). Throw rugs is correct. The nurse should recommend removing or securing any rugs or mats that could move and cause the client to slip, slide, or trip.

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will keep my walker at the end of my bed." B. "I will keep the fluorescent ceiling light on in my room at night." C. "I will place an area rug at the entry of my bathroom." D. "I will place a bath seat in my shower to use when I bathe."

D. A bath seat can help reducing slipping and falling in the bathtub or shower.

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal x-ray and is awaiting transport B. a client who has a prescription for discharge C. a client who received oral pain medication 30 mins ago D. a client who told AP he is SOB

D. A client who has shortness of breath is unstable; therefore, this is the client the nurse should plan to see first.

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include? A. emphasize four important points at each session B. use a passive voice to explain the information C. refer to the client in the third person during the session D. have short teaching lessons

D. Longer sessions might overwhelm the client. Multiple, short sessions, that emphasize one key point per session can enhance understanding.

A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution? A. 1500 B. 1600 C. 1700 D. 1800

D. The IV will infuse at 125 mL/hr. The next bag of IV solution will need to be administered at 1800.

A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene? A. verifies medication against prescription and medication label B. scans the barcode on the medication administration record and the client's arm band C. checks the provider's orders and confirmed dosage in a medication reference guide D. documents medication administration prior to administering it

D. The nurse should document administering medications after they are given to reduce the risk of error.