Multiple Choice
Identify the choice that best completes the statement or answers the question.

 

 

 1. 

The nurse has a prescription to give ear drops to a 2-year-old child. The nurse positions the child’s ear properly by pulling the pinna of the ear:

a.	Upward and outward
b.	Downward and outward
c.	Downward and backward
d.	Upward and backward

 

 

 2. 

A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. When the client expresses concern about his or her ability to perform this procedure at home, the nurse would best respond with which of the following?

a.	“Tell me more about your concerns about going home.”
b.	“Do you want to stay in the hospital a few more days?”
c.	“Maybe a friend will do the feeding for you.”
d.	“Have you discussed your feelings with your family and doctor?”

 

 

 3. 

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should do which of the following when caring for this client to maintain client safety?

a.	Keep the client in a supine position.
b.	Change the NG tube with every other feeding.
c.	Check for tube placement and residual amount at least every 4 hours.
d.	Increase the rate of the feeding if the infusion falls behind schedule.

 

 

 4. 

The client with pancreatitis is being weaned from parenteral nutrition (PN). The client asks the nurse why the PN cannot just be stopped. The nurse includes in a response to the client that which of the following complications could occur with sudden termination of PN formula?

a.	Dehydration
b.	Hypokalemia
c.	Hypernatremia
d.	Rebound hypoglycemia

 

 

 5. 

The nurse hears in intershift report that a client receiving parenteral nutrition (PN) at 100 mL/hr has bilateral crackles and 1+ pedal edema. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lb in 2 days. Which of the following nursing actions should the nurse take first?

a.	Encourage the client to cough and deep-breathe.
b.	Compare the intake and output records of the last 2 days.
c.	Slow the PN infusion rate to 50 mL/hr per infusion pump.
d.	Administer the prescribed daily diuretic, and check the client in 2 hours.

 

 

 6. 

The nurse is caring for a client receiving parenteral nutrition (PN) via a central line. The nurse should monitor which of the following to detect the development of the mostcommon complication of PN?

a.	Temperature
b.	Daily weight
c.	Intake and output (I&O)
d.	Serum blood urea nitrogen (BUN) level

 

 

 7. 

The nurse is providing care to a client with continuous tube feedings through a nasogastric (NG) tube. The nurse should avoid doing which of the following, which is not part of the standard care for a client receiving enteral nutrition?

a.	Check the residual every 4 hours.
b.	Check for placement every 4 hours.
c.	Hang a new feeding bag every 72 hours.
d.	Check for placement prior to administering medications through the tube.

 

 

 8. 

The nurse is monitoring the nutritional status of the client receiving enteral nutrition. The nurse monitors which of the following to determine the effectiveness of the tube feedings for this client?

a.	Daily weight
b.	Calorie count
c.	Serum protein level
d.	Daily intake and output

 

 

 9. 

A client is scheduled for insertion of a peripherally inserted central catheter (PICC) and the nurse explains the advantages of this catheter. The nurse determines that the client needs additional information about the catheter if the client makes which statement?

a.	“It is reasonable in cost.”
b.	“There is less pain and discomfort than other types of catheters.”
c.	“This type of catheter is very reliable.”
d.	“It is specifically designed for short-term use.”

 

 

 10. 

A nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse interprets that which of the following complications has been experienced by the client?

a.	Phlebitis
b.	Infection
c.	Infiltration
d.	Thrombosis

 

 

 11. 

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which of the following frequencies?

a.	Every hour
b.	Every 2 hours
c.	Every 3 hours
d.	Every 4 hours

 

 

 12. 

The client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first?

a.	Shut off the infusion.
b.	Sit the client up in bed.
c.	Remove the angiocatheter and IV.
d.	Place the client in Trendelenburg’s position.

 

 

 13. 

The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced:

a.	Phlebitis of the vein
b.	Infiltration of the IV line
c.	Hypersensitivity to the IV solution
d.	Allergic reaction to the IV catheter material

 

 

 14. 

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which of the following supplies from the unit supply area for use in applying pressure to the site after removing the IV catheter?

a.	Band-Aid
b.	Alcohol swab
c.	Betadine swab
d.	Sterile 2  2 gauze

 

 

 15. 

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?

a.	Change the IV tubing.
b.	Attach a new needleless device.
c.	Wipe the tubing port with Betadine.
d.	Scrub the needleless device with an alcohol swab.

 

 

 16. 

The nurse is collecting data from an African-American client scheduled for surgery. Which of the following questions would be of least priority for the nurse to ask on initial assessment?

a.	“Do you ever experience chest pain?”
b.	“Do you have any difficulty breathing?”
c.	“Do you have a close family relationship?”
d.	“Do you frequently have episodes of headache?”

 

 

 17. 

The nurse is providing discharge instructions to an Asian-American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which of the following nursing actions is most appropriate?

a.	Continue with the instructions verifying client understanding.
b.	Walk around to the client so that you continuously face the client.
c.	Identify the importance of the instructions for the maintenance of health care.
d.	Give the client a dietary booklet, and return later to continue with the instructions.

 

 

 18. 

The nurse is planning to instruct the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware that this ethnic group:

a.	Primarily eats raw fish
b.	Enjoys eating red meat
c.	Views food as a primary form of socialization
d.	Eats bland food and food that lacks color, flavor, and texture

 

 

 19. 

The nurse is preparing to assist a Jewish-American client with eating lunch. A kosher meal is delivered to the client. Which of the following nursing actions is most appropriate in assisting the client with the meal?

a.	Unwrap the eating utensils for the client.
b.	Replace the plastic utensils with metal eating utensils.
c.	Carefully place the food from the paper plates to glass plates.
d.	Ask the client to unwrap the eating utensils, and allow the client to prepare the meal for eating.

 

 

 20. 

The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. When meeting the client, the nurse should plan to do which of the following?

a.	Avoid touching the client.
b.	Greet the client with a handshake.
c.	Smile and use humor throughout the entire admission process.
d.	Avoid any affirmative nods during the conversations with the client.

 

 

 21. 

The nurse is assisting in developing a postoperative plan of care for a 40-year-old male Filipino-American client scheduled for an appendectomy. The nurse includes which of the following in the plan of care?

a.	Offer pain medication on a regular basis as prescribed.
b.	Offer pain medication when nonverbal signs of discomfort are identified.
c.	Inform the client that he will need to ask for pain medication when needed.
d.	Allow the client to maintain control and request pain medication on his own.

 

 

 22. 

The nurse is planning the menu for a Chinese-American client with the hospital dietitian. On collaboration with the dietitian, the meal plan is designed to include which of the following foods generally included in the diet of this cultural group?

a.	Milk
b.	Vegetables
c.	Rice pudding
d.	Fruit and yogurt

 

 

 23. 

The nurse is preparing to assist in examining a Hispanic-American child who was brought to the clinic by the mother. During assessment of the child, the nurse would avoid which of the following?

a.	Admiring the child
b.	Taking the child’s temperature
c.	Obtaining an interpreter if necessary
d.	Asking the mother questions about the child

 

 

 24. 

The nurse plans to do dietary teaching with an African-American client. The nurse understands that foods preferred by individuals of this culture are which of the following?

a.	Rice
b.	Fruits
c.	Red meat
d.	Fried foods

 

 

 25. 

The registered nurse (RN) gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The RN notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the:

a.	Error will result in suspension.
b.	Incident will be reported to the board of nursing.
c.	Incident will be documented in the personnel file.
d.	Incident report is a method of promoting quality care and risk management.

 

 

 26. 

The registered nurse (RN) has been caring for a terminally ill client. The RN has developed a close relationship with the family of the client. Which of the following nursing interventions will the RN avoid in dealing with the family during this difficult time?

a.	Making decisions for the family
b.	Encouraging family discussion of feelings
c.	Accepting the family’s expressions of anger
d.	Facilitating the use of spiritual practices identified by the family

 

 

 27. 

A registered nurse (RN) who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The most appropriate initial action by the RN is which of the following?

a.	Call security.
b.	Call the police.
c.	Call the nursing supervisor.
d.	Lock the co-worker in the medication room until help is obtained.

 

 

 28. 

A hospitalized client tells the registered nurse (RN) that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the RN for assistance in obtaining a witness to the will. The most appropriate response to the client is which of the following?

a.	“I will sign as a witness to your signature.”
b.	“You will need to find a witness on your own.”
c.	“Whoever is available at the time will sign as a witness for you.”
d.	“I will call the nursing supervisor to seek assistance regarding your request.”

 

 

 29. 

The nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the physician has prescribed a medication dose that is twice the amount that the client has reported taking prior to admission. The most appropriate nursing action is to:

a.	Contact the physician directly.
b.	Administer the medication as prescribed.
c.	Question the client regarding the accuracy of the reported dosage.
d.	Ask the physician about the prescription the next time the physician makes rounds.

 

 

 30. 

The registered nurse (RN) is caring for a client with severe cardiac disease. While caring for the client, the client states, “If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me.” The most appropriate nursing action is to:

a.	Tell the client that the family must agree with the request.
b.	Plan a client conference with the nursing staff to share the client’s request.
c.	Tell the client that it is necessary to notify the physician of the client’s request.
d.	Tell the client that this procedure cannot legally be refused by a client if the physician believes that it is necessary to save the client’s life.

 

 

 31. 

The registered nurse (RN) has made an error in documenting an assessment finding on a client in the client’s record and obtains the record to correct the error. The RN corrects the error by:

a.	Documenting a late entry into the client’s record
b.	Trying to erase the error to make space for writing in the correct data
c.	Using white correction fluid to delete the error and writing in the correct data
d.	Drawing one line through the error, initialing and dating the line, and then providing the correct information

 

 

 32. 

The registered nurse (RN) hears a client calling out for help. The RN hurries down the hallway to the client’s room and finds the client lying on the floor. The RN performs a thorough assessment and assists the client back to bed. The physician is notified of the incident, and the nurse completes an incident report. Which of the following would the RN document on the incident report?

a.	The client fell out of bed.
b.	The client climbed over the side rails.
c.	The client was found lying on the floor.
d.	The client became restless and tried to get out of bed.

 

 

 33. 

An adult client is brought to the emergency department by emergency medical services after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which of the following is the best initial action?

a.	Obtain a court order for the surgical procedure.
b.	Transport the victim to the operating room for surgery.
c.	Call the police to identify the client and locate the family.
d.	Ask the emergency medical services team to sign the informed consent.

 

 

 34. 

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the physician that the client had terminal cancer. The emergency department physician examines the client and asks the registered nurse (RN) to contact the medical examiner regarding an autopsy. The family of the client tells the RN that they do not want an autopsy performed. Which of the following responses to the family is most appropriate?

a.	“An autopsy is mandatory for any client who is DOA.”
b.	“The decision is made by the medical examiner.”
c.	“I will contact the medical examiner regarding your request.”
d.	“It is required by federal law. Why don’t we talk about it, and why don’t you tell me how you feel?”

 

 

 35. 

The nurse is caring for a client whose physician prescribes airborne precautions. The nurse notes that the client is scheduled for magnetic resonance imaging (MRI). Which of the following nursing actions is most appropriate in preparing the client for the test?

a.	Place the client in gown, gloves, and mask.
b.	Request that the MRI technicians wear masks.
c.	Delay the test until airborne precautions are discontinued.
d.	Place a surgical mask on the client for transport and for contact with other individuals.

 

 

 36. 

The nurse employed in the ambulatory care department hears a client in the waiting room call out, “Help, fire!” The nurse rushes to the waiting room and finds the wastebasket on fire. Which action should the nurse take first?

a.	Confine the fire.
b.	Extinguish the fire.
c.	Activate the fire alarm.
d.	Remove the clients from the waiting room.

 

 

 37. 

The physician writes a prescription to apply a heating pad to a client’s back. The nurse implements the prescription and avoids which of the following?

a.	Setting the heating pad on a low setting
b.	Placing the heating pad under the client
c.	Assessing the heating pad periodically for proper electrical function
d.	Assessing the skin integrity frequently for signs of burns

 

 

 38. 

The nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to:

a.	Place the ice pack directly on the eye.
b.	Avoid the use of commercially prepared ice bags.
c.	Keep the ice pack on the eye continuously for 24 hours.
d.	Wrap a plastic bag filled with ice with a pillowcase, and place it on the eye.

 

 

 39. 

A filled blood specimen tube was dropped and broken in the client’s room. Which of the following actions by the nursing assistant is incorrect?

a.	Uses tongs to collect any broken glass
b.	Wears gloves for the cleaning procedure
c.	Blots up the spill with a face cloth or cloth towel
d.	Disinfects the area of the blood spill with a dilute bleach solution

 

 

 40. 

The nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning to care for the client, which of the following actions is the priority? The nurse:

a.	Speaks slowly to the client
b.	Moves slowly when approaching the client
c.	Bargains with the client to prevent the violent episodes
d.	Projects an attitude of calmness when caring for the client

 

 

 41. 

A community health nurse is providing an educational session on childhood poisoning at a local school. The topic of the discussion is preventive measures to avoid accidental poisoning. The nurse includes instructions that if an accidental poisoning occurs to immediately:

a.	Call an ambulance.
b.	Call the poison control center.
c.	Induce vomiting.
d.	Bring the child to the emergency department.

 

 

 42. 

A nurse is conducting a basic life support (BLS) recertification class and is discussing automated external defibrillation (AED) when a member of the class asks the nurse to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The nurse correctly responds with:

a.	Bilaterally, under the right-sided and left-sided clavicles
b.	Parallel, between the umbilicus and the left-sided nipple
c.	Centered on the upper and lower halves of the sternum
d.	Under the right-sided clavicle and to the left of the nipple in the midaxillary line

 

 

 43. 

The nurse is initiating one-rescuer cardiopulmonary resuscitation (CPR) on an adult client. After ventilating the client, the nurse places the hands in which of the following positions to begin chest compressions?

a.	On the lower half of the sternum
b.	On the lower third of the sternum
c.	On the upper third of the sternum
d.	On the upper half of the sternum

 

 

 44. 

A nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. The nurse then opens the victim’s airway by using the:

a.	Head tilt–chin lift
b.	Head tilt–jaw thrust
c.	Jaw thrust maneuver
d.	Chin lift position

 

 

 45. 

The nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which of the following landmarks to do the abdominal thrust maneuver?

a.	The umbilicus and the groin
b.	The lower abdomen and chest
c.	The umbilicus and xiphoid process
d.	The groin and the xiphoid process

 

 

 46. 

The nurse employed in the pediatric unit working on the 11 PM to 7 AM shift finds an infant unresponsive and without respirations or a pulse. After opening the airway and initiating ventilation, the nurse delivers chest compressions at a minimum rate of:

a.	140 times/min
b.	100 times/min
c.	80 times/min
d.	60 times/min

 

 

 47. 

A nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the most appropriate pulse point to use when determining pulselessness on an infant. The nurse undergoing recertification replies that the correct pulse point is:

a.	Radial
b.	Carotid
c.	Brachial
d.	Popliteal

 

 

 48. 

An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which of the following actions next?

a.	Performs cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating
b.	Administers rescue breathing during the defibrillation
c.	Charges the machine and immediately pushes the discharge buttons on the console
d.	Orders personnel away from the client, charges the machine, and depresses the discharge buttons

 

 

 49. 

The client has been defibrillated unsuccessfully three times using an automatic external defibrillator (AED). The nurse determines that which of the following actions should be taken next?

a.	Defibrillate one more time, and then terminate the resuscitation effort.
b.	Perform cardiopulmonary resuscitation (CPR) for 5 minutes, and then defibrillate three more times.
c.	Administer sodium bicarbonate intravenously, and resume defibrillation attempts.
d.	Perform cardiopulmonary resuscitation (CPR) for 1 minute, assess, and then defibrillate up to three more times.

 

 

 50. 

The nurse has completed four cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the nurse should:

a.	Stop CPR.
b.	Continue CPR.
c.	Prepare for defibrillation.
d.	Prepare for the administration of bicarbonate.

 

 

 51. 

The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of lay persons. Which of the following behaviors by one of the participants would indicate the need for further review?

a.	Letting the fingers rest on the chest
b.	Keeping the shoulders directly over the hands
c.	Straightening the arms and locking the elbows
d.	Placing the heel of the hand over the lower half of the sternum

 

 

 52. 

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse takes which priority action?

a.	Obtains a court order for the surgery
b.	Sends the client to surgery without the consent form being signed
c.	Has the hospital chaplain sign the informed consent immediately
d.	Obtains a telephone consent from the family member witnessed by two persons

 

 

 53. 

The preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following statements by the nurse is most likely to stimulate further discussion between the client and the nurse?

a.	“If it’s any help, everyone is nervous before surgery.”
b.	“I will be happy to explain the entire surgical procedure to you.”
c.	“Can you share with me what you’ve been told about your surgery?”
d.	“Let me tell you about the care you’ll receive after surgery and the amount of pain you can anticipate.”

 

 

 54. 

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions first?

a.	Ensure that the client has voided.
b.	Administer all the daily medications.
c.	Practice postoperative breathing exercises.
d.	Verify that the client has not eaten for the last 24 hours.

 

 

 55. 

The nurse is assigned to assist in caring for a client who recently returned from the operating room (OR). On data collection, the nurse notes that the client’s vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which of the following actions should the nurse plan to take first?

a.	Shake the client gently to arouse.
b.	Call the surgeon immediately.
c.	Cover the client with a warm blanket.
d.	Recheck the vital signs in 15 minutes.

 

 

 56. 

The nurse has just reassessed the condition of the postoperative client who was admitted 1 hour ago to the surgical unit. The nurse monitors which of the following parameters during the next hour most carefully?

a.	Urinary output of 20 mL/hr
b.	Temperature of 37.6° C (99.6° F)
c.	Blood pressure of 116/78 mm Hg
d.	Serous drainage on the surgical dressing

 

 

 57. 

The client is admitted to the surgical unit postoperatively with a wound drain (Jackson-Pratt) in place. Which of the following correctly describes the primary purpose of a Jackson-Pratt?

a.	It decreases the risk of infection.
b.	It decreases the risk of evisceration and dehiscence.
c.	It provides an accurate measurement of wound drainage.
d.	It assists in the evacuation of fluid and blood from the surgical wound.

 

 

 58. 

When performing a surgical dressing change of a client’s abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The priority nursing action at this time is to:

a.	Apply a povidone-iodine (Betadine)–soaked sterile dressing.
b.	Leave the incision exposed to the air to dry the area.
c.	Apply a sterile dressing soaked with normal saline.
d.	Irrigate the wound, and apply a dry sterile dressing.

 

 

 59. 

The nurse is reviewing the physician’s prescription sheet for the preoperative client, which states that the client must be NPO after midnight. The nurse should clarify which of the following medications should be given to the client and not withheld?

a.	Ferrous sulfate
b.	Atenolol (Tenormin)
c.	Cyclobenzaprine (Flexeril)
d.	Conjugated estrogen (Premarin)

 

 

 60. 

The client who underwent preadmission testing prior to a surgical procedure had serum laboratory studies drawn, including complete blood count, electrolytes, coagulation studies, and creatinine. Which of the following laboratory results should be reported to the surgeon immediately?

a.	Platelet count, 210,000/mm3
b.	Serum sodium (Na) level, 141 mEq/L
c.	Hemoglobin (Hgb) level, 8.9 g/dL
d.	Serum creatinine level, 0.8 mg/dL

 

 

 61. 

The client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. The nurse should position the client:

a.	In a semi-Fowler’s position
b.	With the head of the bed elevated 45 degrees
c.	With the head of the bed elevated no more than 15 degrees
d.	With the foot of the bed elevated as much as tolerated by the client

 

 

 62. 

The nurse is assisting the physician with a bedside liver biopsy. When the procedure is complete, the nurse assists the client into which of the following positions?

a.	Left side-lying, with the right-sided arm elevated above the head
b.	Right side-lying, with the left-sided arm elevated above the head
c.	Left side-lying, with a small pillow or towel under the puncture site
d.	Right side-lying, with a small pillow or towel under the puncture site

 

 

 63. 

The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse assists the client into which of the following positions?

a.	Left-sided lateral Sims position
b.	Right-sided lateral Sims position
c.	Left side-lying, with the head of the bed elevated 45 degrees
d.	Right side-lying, with the head of the bed elevated 45 degrees

 

 

 64. 

The client with right-sided pleural effusion by chest x-ray is being prepared for a thoracentesis. The nurse assists the client to which of the following positions for the procedure?

a.	Sims position, with the head of the bed flat
b.	Left side-lying position, with the head of the bed elevated 45 degrees
c.	Prone, with the head turned to the side supported by a pillow
d.	Right side-lying position, with the head of the bed elevated 45 degrees

 

 

 65. 

The client is about to undergo a lumbar puncture (LP). The nurse tells the client that which of the following positions will be used during the procedure?

a.	Side-lying position, with a pillow under the hip
b.	Prone, with a pillow under the abdomen
c.	Prone, in a slight Trendelenburg’s position
d.	Side-lying position, with legs pulled up and head bent down onto chest

 

 

 66. 

The client has had surgery to repair a fractured left-sided hip. The nurse will use which of the following important items when repositioning the client from side to side in bed?

a.	Bed pillow
b.	Abductor splint
c.	Adductor splint
d.	Overhead trapeze

 

 

 67. 

The nurse has admitted a client to the clinical nursing unit following right-sided mastectomy. The nurse plans to place the right-sided arm in which of the following positions?

a.	Level with the right-sided atrium
b.	Elevated above shoulder level
c.	Elevated on one or two pillows
d.	Dependent to the right-sided atrium

 

 

 68. 

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. The nurse notes the urine beginning to flow and next:

a.	Immediately inflates the balloon
b.	Inserts the catheter 2.5 to 5 cm farther, then inflates the balloon
c.	Inserts the catheter until resistance is met, then inflates the balloon
d.	Withdraws the catheter approximately 1 inch, then inflates the balloon

 

 

 69. 

The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse takes which immediate action?

a.	Has the client hold a breath
b.	Places the client in a prone position
c.	Immerses the end of the tube in sterile saline
d.	Places a sterile dressing over the end of the chest tube

 

 

 70. 

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client’s closed-chest drainage system. The nurse determines that which of the following is occurring?

a.	The pneumothorax is resolving.
b.	The drainage chamber is full.
c.	The suction to the system is shut off.
d.	There is an air leak somewhere in the system.

 

 

 71. 

A nurse is inserting a nasogastric (NG) tube for an adult client. During the procedure, the client begins to cough and have difficulty breathing. The priority action at this time is which of the following?

a.	Quickly insert the NG tube.
b.	Remove the tube, and notify the physician.
c.	Remove the tube, and reinsert when the client fully recovers.
d.	Pull back on the tube, and wait until the client is breathing easily.

 

 

 72. 

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which of the following is a priority nursing action?

a.	Assess tube placement.
b.	Administer the antacid by gravity flow.
c.	Aspirate to determine residual volume.
d.	Follow medication administration with 30 mL of sterile saline.

 

 

 73. 

Treatment for a client with bleeding esophageal varices has been unsuccessful and the physician decides to insert a Sengstaken-Blakemore tube. The nurse brings which of the following items to the bedside so that it is available at all times?

a.	An obturator
b.	A Kelly clamp
c.	An irrigation set
d.	A pair of scissors

 

 

 74. 

The male client complains of pain as the nurse is inflating the balloon following insertion of a Foley catheter. The nurse takes which of the following actions immediately?

a.	Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
b.	Remove the catheter, and reinsert a new one that is one size smaller.
c.	Finish inflating the balloon; the discomfort is normal and temporary.
d.	Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

 

 

 75. 

The unit manager is reviewing documentation describing a client’s progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control for the prior 48 hours. The manager’s first activity after making the observation of deviation from the path is to contact the client’s:

a.	Family to determine what is wrong
b.	Assigned nurse to increase client care interventions
c.	Physician to determine measures to discharge the client
d.	Case manager to determine whether the predicted variance has been negotiated with the health insurer

 

 

 76. 

The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. The nurse managers anticipate that the channel of communication and authority will be characterized by an organizational chart that is:

a.	Flat
b.	Vertical
c.	Circular
d.	Horizontal

 

 

 77. 

Which client would the emergency department triage nurse classify as emergent?

a.	A client with a displaced fracture
b.	A client with a temperature of 101° F
c.	A client with a simple laceration and soft tissue injury
d.	A client with crushing substernal pain who is short of breath

 

 

 78. 

The graduate nurse is interviewed by the manager of a unit that has three vacancies and is told that the manager’s leadership style is one of letting the staff nurses make the decisions about the unit’s operations. When the interviewee meets with the day nursing staff, the graduate nurse hears examples of unit issues indicating that the manager’s approach is laissez-faire. Which of the following questions should the graduate nurse ask to confirm her suspicions?

a.	“Does the manager facilitate decision making by the group?”
b.	“Does the manager maintain control and make all decisions?”
c.	“Does the manager assume a passive, nondirective approach?”
d.	“Does the manager change style according to the needs of the group?”

 

 

 79. 

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which of the following statements, if made by the nurse manager, would reflect the manager’s use of legitimate power?

a.	“The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors.”
b.	“If you don’t follow the new policy and procedure, I’ll have no choice but to give you a notice about poor performance—which could lead to termination of your employment.”
c.	“Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization’s effort to continue to improve quality care.”
d.	“You’re just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way.”

 

 

 80. 

For which of the following client situations would a consultation with a rapid response team (RRT) be most appropriate?

a.	45-year-old, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4° F, heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg
b.	72-year-old, 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion), temperature 97.8° F, heart rate 92 beats/min, respirations 28 breaths/min, blood pressure 136/86 mm Hg, anxious about going home
c.	56-year-old, fourth hospital day after coronary artery bypass procedure, sore chest, pain with walking, temperature 97° F, heart rate 84 beats/min, respirations 22 breaths/min, blood pressure 122/78 mm Hg, bored with hospitalization
d.	86-year-old, 48 hours after operative repair of fractured hip (nail inserted), alert, oriented, using patient-controlled analgesia (PCA) pump, temperature 96.8° F, heart rate 60 beats/min, respirations 16 breaths/min, blood pressure 120/82 mm Hg, talking with daughter

 

 

 81. 

The nurse assigned to four clients reviews client data at the beginning of the shift. Which information is assessed as the highest priority?

a.	Hemoglobin, 12.2 g/dL
b.	Potassium level, 3.6 mEq/L
c.	Pulse oximetry reading, 89%
d.	Urine output, 240 mL/8 hr

 

 

Multiple Response
Identify one or more choices that best complete the statement or answer the question.

 

 

 1. 

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client? Select all that apply.

a.	Sit leaning forward.
b.	Inhale deeply and quickly.
c.	Sit upright or lean slightly back.
d.	Hold the mouthpiece tightly with the teeth.
e.	Keep a tight seal between the lips and the mouthpiece.
f.	After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

 

 

 2. 

From the following list of nursing activities, select those that the registered nurse (RN) can delegate to the licensed practical nurse or licensed vocational nurse (LPN/LVN).Select all that apply.

a.	Assessment
b.	Urinary catheterization
c.	Endotracheal suctioning
d.	Intravenous push medication administration
e.	Intramuscular medication administration
f.	Subcutaneous medication administration

 

 

 3. 

Of the following list of responsibilities for disaster preparedness in the United States, identify those that are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA). Select all that apply.

a.	Provide monetary relief.
b.	Provide crisis counseling.
c.	Identify and train personnel.
d.	Deploy National Guard troops.
e.	Handle inquiries from families.
f.	Issue presidential declarations.

 

 

 4. 

The community health nurse is preparing to teach “personal and family preparedness for disasters” to a group of parents of school-age children. From the following list of items to be kept ready, identify the appropriate items that should be identified by the nurse. Select all that apply.

a.	Flashlight
b.	Supply of batteries
c.	Battery-operated radio
d.	Extra pair of eyeglasses
e.	Three-week supply of nonperishable food
f.	Three-week supply of water (1 gallon per person per day)

 

 

 5. 

The nurse is providing instructions to the client being discharged to home with a peripherally inserted central catheter (PICC). The nurse provides which instructions to the client? Select all that apply.

a.	Wear a Medic-Alert tag or bracelet.
b.	Report redness or swelling at the catheter insertion site.
c.	Have a repair kit available in the home for use if needed.
d.	Keep activity level to a minimum while this catheter is in place.
e.	Cover the PICC dressing with plastic when in the shower or bath.