Practice Questions

a pt. has 1L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How may hrs. will it take for the liter to infuse?

8 hrs 1 L = 1,000 mL volume (mL)/ Time= X mL/hr

A nurse is teaching a client who is postoperative how to use a flow-oriented spirometer. Which of the following instructions should the nurse include? A.blow into the spirometer to elevate the balls in device B.cough deeply after each use C.clean the mouthpiece with an alcohol swab after each use D.use the spirometer every 8 hr

B.cough deeply after each use proper use of the incentive spirometer loosens secretions in the clients lungs. The client should cough deeply to facilitate the removal of secretions in his lungs.

a nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the meds, which of the following actions should the nurse take? A. instruct the client to blink several times after instilling the meds B.ask the client to look straight ahead during the instillation of the meds C. apply pressure to the puncta after instilling the meds D. place each drop of the medication onto the clients cornea

C. apply pressure to the puncta after instilling the meds instill the meds into the conjunctival sac and apply pressure to the puncta for 1-2 min. after to prevent systemic absorption of the medication

a nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. use a 10 ml syringe B. attach a 22 g catheter to syringe C. warm the irrigated solution to 37C D. admin. analgesic 10 min before irrigation

C. warm the irrigated solution to 37C the nurse should prepare about 200ml of irrigation solution and warm it to body temp to minimize discomfort and vascular constriction

a nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A.tenderness when touched B> pink, shiny tissue with a granular appearance C. serosangineus drainage D. halo of erythema on the surrounding skin

D. halo of erythema on the surrounding skin erythema (redness) might indicate underlying infection. This and any other manifestations of infection (purulent drainage, swelling, warmth, or strong odor) should be reported to provider

a nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy VS isolation occurs during which stage of development? A. middle adulthood B. Adolescence C. Childhood D. young adulthood

D. young adulthood

a nurse is teaching a group of older adults about expected age-related changes. Which of the following shows that the teaching has been effective? a. I should expect my heart rate to take longer to return to normal after exercise as I get older b. urinary incontinence is something I will have to live with as I get older c. I can expect to have less ear wax as I get older d. my stomach will empty more quickly after meals as I get older

a. I should expect my heart rate to take longer to return to normal after exercise as I get older older adults experience decreased cardiac output, which causes an increased pulse rate during exercise and the pulse also takes longer to return to normal.

a nurse is caring for a pt. who has DM1 and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? a. tell me what I can do to help you overcome your fear of giving yourself injections b. your provider will not be please that you refuse to give yourself the injections c. its ok, im sure your partner will be able to learn how to give you your injections d. you won't be able to go home unless you learn to give yourself the injections

a. tell me what I can do to help you overcome your fear of giving yourself injections -this response shows the therapeutic communication of clarifying and offering self. the rn should allow the pt to express feelings and fears and support the client in learning how to give injections

a nurse is teaching a pt who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following should the rn include in the teaching? a. exhale slowly to reach the goal volume b. hold the breath for 5 sec after goal volume is reached c. continue to breath deeply between each cycle d. limit the repeat patter of breathing to 5 breaths

b. hold the breath for 5 sec after goal volume is reached instruct the pt to hold the breath for 3-5 sec. after reaching maximal inspiratory volume. this decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia

a nurse is preparing to insert an NG tube for a client that requires enteral feedings. Which of the following instructions should the nurse give the client before beginning procedure? a. inhale forcefully during insertion b. raise your index finger if you need to pause during the insertion c. bear down during the insertion d. avoid making any swallowing motions during the insertion

b. raise your index finger if you need to pause during the insertion the nurse should advise the pt that procedure is uncomfortable and the gag reflex will be activated. the nurse should establish a communication technique so that pt. can indicate distress and the need to pause during process.

a nurse is assessing the pH of a clients gastric fluid to confirm the placement of an NG tube in stomach. Which of the following pH should be expected by the nurse? a.6 b.2 c.10 d.8

b.2 a pH of 2 is within the expected range of 0-4 for gastric secretions.

a nurse is caring for a client who is receiving TPN-total parenteral nutrition. which of the following actions should the nurse take? a. admin. 0.9% NaCl until TPN is available from pharmacy b.check client's capillary blood glucose q 4 hrs c. obtain the client's wt. each week d. change the IV tubing every 3 days

b.check client's capillary blood glucose q 4 hrs - due to risk of hyperglycemia while receiving TPN. The dextrose in TPN increases this risk

a nurse is preparing to administer an IM injection to a client that is overweight. Which of the following sites should the nurse select for the injection? a. lower medial quadrant of buttock near coccyx b.side hip beteween the iliac crest and anterior iliac spine c. tissue of the posterior upper arm d. lower inner thigh 4 finger widths above patella

b.side hip beteween the iliac crest and anterior iliac spine this site is preferred for an adult client. place a hand on the clients greater trochanter with the first 2 fingers touching the iliac crest and anterior superior iliac spine. V shape

A CNA is helping the nurse care for a female client who has an indwelling catheter. Which of the following actions would indicate the CNA needs further teaching? a. the CNA uses soap and H2O to clean the perineal area b.the CNA tapes the catheter to the client's inner thigh c. the CNA hangs the collection bag at the level of the bladder d. the CNA makes sure there are no kinks in drainage tubing

c. the CNA hangs the collection bag at the level of the bladder -the bag should be hung below to bladder to make sure gravity is assisting with drainage

a nurse is caring for a pt. who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? a. apply fecal collection system b. apply barrier cream c.cleanse and dry the area d. check the clients perineum

d. check the clients perineum -apply the nursing process priority setting framework to plan care and prioritize actions. first collect adequate data from the client and the assessing will provide the nurse the knowledge to make an appropriate decision

a nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? a. trauma b. severe infection c. fe-deficiency anemia d. chronic hypoxemia

d. chronic hypoxemia clubbing of the nails of the fingers and toes is the result of chronic hypoxemia like with COPD. It is a change in the angle between the nail and the nail base with enlargement of the fingertips

a nurse is leading an education session about disposing of biohazard materials. Which of the following instructions should the nurse include in the teaching? A. use alcohol to clean blood spills b. discard empty blood bags in bedside trash can c. break used needles before discarding d. place soiled linen in single linen bag

d. place soiled linen in single linen bag -should be placed in a single bag and tightly secured to reduce the risk of microorganism transmission