RN Comprehensive Online Practice 2013 B

1. A nurse is caring for a client who is immediately Postop. Delegate to AP.

Measure drainage from the t tube collection bag
2. A nurse should recognize noncompliance with clients advance directives in
which of the following client scenarios?
Administration of eternal tube
feedings to a client who has end-stage Alzheimers disease whose family
desires to withhold fluids and nutrition and whose advance directive state,
comfort measures only
3. Charge nurse is teaching a newly licensed nurse how to identify true labor.
Which of the following should the nurse include in the teaching? Cervix
transitions to an anterior position
4. A nurse is planning care for a client who is 3 days Postop following an abovethe-knee amputation. Which of the following should the nurse include in the
plan of care?
Assist the client to the prone position every 4 hr.
5. A nurse is caring for four clients. Which of the following clients is appropriate
to assign to an AP to assist with meals?
A client who has Alzheimers
disease and is demonstrating aphasia.
6. A nurse is planning morning care for a client who has heart disease and type
2 DM. upon review of the clients medical record, which of the follow actions
should the nurse take.
Administer daily medications.
7. A nurse is providing instruction to a client with cancer who is receiving
chemo. Which of the following statements by the client indicates a need for
further teaching regarding precautions against developing a infection?
Fresh fruit and vegetables will help to boost my immune system.
8. A nurse is teaching a client who is being treated wit radiation therapy for
prostate cancer about expected side effects. Which of the following client
statements indicates an understanding of the teaching? I can wash the
irradiated area with mild soap and water.
9. A nurse is preparing a sterile field in order to insert an indwelling urinary
catheter into a male client. Which of the following tech should be used to
maintain aseptic tech?
Set the catheter tray on the overbed table at
waist height.
10.A nurse is providing discharge teaching to a client who is prescribed home
O@ therapy. Which of the following should the nurse include in the teaching?
Wear cotton fabrics while O2 is in use
11.A client reports taking her meds with a glass of grapefruit juice every
morning. The nurse notes that the client takes verapamil (Calan) daily. Which
of the following assessment findings indicates a possible med-food
interaction?
Hypotension.
12.A nurse is assessing a newborn following delivery. Which of the following
findings should the nurse report to the provider?
Nasal flaring
13.A nurse enters the room of a client who is receiving O2 and finds that a fire
has started in the wiring of the clients bedside lamp. After removing the
client from the room, which of the following actions should the nurse take
next? Activate the fire alarm.

14.A nurse manager is planning to make changes to the current scheduling

system. To facilitate the staffs acceptance of this change, which of the
following actions should the nurse manager take first?
Provide info about
scheduling issues to the staff.
15.A nurse is providing teaching to a client who has gestational diabetes. Which
of the following should the nurse include in the teaching?
At birth,
your baby will be at risk for hypoglycemia.
16.A client is receiving lorazepam (Ativan) IV for panic attack and develops a
respiratory rate of 6/min and blood pressure of 90/40 mmHg. Which of the
following medication should the nurse anticipate administering? Flumazenil
(Romazicon)
17.A nurse is caring fir a client who has gestational hypertension. Which of the
following findings should the nurse expect/
Blurred vision, facial
edema, proteinuria
18.A nurse manager is assisting with the orientation of a newly hired nurse.
Which of the following actions by the nurse requires the nurse manager to
intervene? Tells the hospital Chaplin the clients diagnosis.
19.A nurse manager is reviewing clients rights and informed consent with the
nurses on the unit. The nurse manager should tell the nurses that informed
consent is based on which of the following ethical principles?
Autonomy.
20.A nurse is providing teaching to the client who has hepatitis A. Which of the
following instructions should the nurse include?
Use a 1:100 chlorine
solution to clean kitchen surface.
21.A nurse is providing discharge teaching to a client who has new diagnosis of
tuberculosis. Which of the following statements by the client indicates an
understanding of the teaching? I will remain on my medications for at least 6
months
22.A nurse is administering meds to several clients and has to discard a portion
of the med dose. For which of the following meds should the nurse ask a
second nurse to observe and cosign disposal of a portion of the dose?
Fentanyl (Sublimaze)
23.A nurse in the emergency department is caring for a client who is
unconscious following an injury at work and requires emergency medical
procedures. The nurse is unable to locate members of the clients family to
obtain consent. Which of the following actions is appropriate?
Proceed in provision of medical care.
24.A nurse administers neb albuterol (Porventil) to a client for treatment of an
acute exacerbation of asthma. Which of the following findings indicates that
treatment has been effective?
Peak expiratory flow rate is 85% of
personal best.
25.A nurse is caring for a client who has a closed head injury and is receiving
mechanical ventilation. The nurse should prepare the administer which of the
following meds to reduce intracranial pressure?
Mannitol (Osmitrol)

26.A nurse is planning care for a client following a CVA. For which of the
following findings should the nurse initiate a referral for occupational
therapy?
Difficulty performing personal hygiene
27.Which of the following is the final step a nurse should perform when providing
tracheostomy care?
Change the trach ties
28.A nurse is caring for a client who has rheumatoid arthritis and has moderate
to severe pain in multiple joints. Which of the following should the nurse
implement to provide comfort to this client?
Allow for frequent rest
periods throughout the day.
29.A nurse is preparing to administer cefazolin (Ancef) 25mg/kg IV bolus to
school age child who weighs 55lbs. 330mg/ml available. How many ml should
the nurse administer per dose?
55lbs = 25kg
25kg x 25mg= 625mg IV bolus (625mg/300mg) x ml=
1.9ml per dose
30.A nurse is caring for a client in the hospital who is to undergo a surgical
procedure. Which of the following indicates to the nurse that the client should
sign the informed consent form?
The client is able to accurately
describe the upcoming procedure.
31.Following an educational program regarding child safety measures, which of
the following statements made by a patient demonstrates to the nurse and
need for further education?
My child needs to wear a helmet while riding a bike until he is 14 years old
32. The nurse is caring for a client who has fecal impaction. Which of the
following is correct procedure when digital evacuating the stool?
Insert the lubricated gloved finger and advance along the rectal wall.
33. The nurses reviewing urinalysis findings for a client who has acute
glomerulonephritis. When assessing the urine, which of the following is
expected finding?
Protein
34. And nurses providing dietary teaching to the parents of the seventh
month old infant. Which of the following instruction should the nurse include?
Introduce new foods one at a time over 4 to 7 days
35. The client has not waited for more than eight hours. Abdomen is
distended and she is restless. The nurse receives an order to insert and going
catheter. Four which of the following should the nurse assessed the client for
prior to insertion?
latex allergy
36. And nurses providing discharge instructions to the parents of a newborn
who is prescribed happy and monitoring at home. Which of the following

should the nurse include in the teaching?

Remove the leads with a newborn is not attach the monitor, ensure the alarm
can be heard throughout the house, avoid co-sleeping with a newborn
37. The nurses providing teaching to a client who is to undergo ECT. And
there should inform the client that side effects to treatment may include
which of the following?
Short-term memory loss
38. The nurses assessing a client who has bipolar disorder. Which of the
following alterations in speech is the client using?
Flight of ideas
39. The nurses assessing the client hospitalized with schizophrenia. Which of
the following questions by the nurse assesses the clients judgment and
problem-solving ability?
What should you do if you were alone in the room and the fire alarm began to
ring
40. The nurses providing teaching to the appearance of a newborn. Which of
the following instructions should the nurse include? Apply zinc oxide to your
baby's diaper area if it becomes red
41 and nurses providing teaching to a client who has just been prescribed
clozapine (Clozaril). The nurse should instruct the client that which of the
following is a common side effect of this medication?
Weight gain
42. And nurses assisting with an elective cardioversion for a client who has a
chill fibrillation. When the clients cardiac rhythm changes to ventricle
fibrillation, which of the following actions should the nurse take first? Switch
the defibrillator to the asynchronous mode
43. And nurses assessing a client who has returned to the clinical unit
following an intravenous pyelogram IVP. Which of the following assessment
findings indicates that the client is experiencing an abnormal response to the
procedure? Itching
44. And nurses teaching a client who is newly diagnosed with diabetes
mellitus type one to monitor for hypoglycemia. The nurse should instruct the
client to watch for which of the following?
Irritability
45. I nurse in the pediatric unit has received a change of shift report for four

children. Which of the following children should the nurse assessed first?
It's 10-year-old child who is awaiting surgery for an appendectomy and
experience sudden relief from pain
46. A four-month-old infant is admitted to an acute care facility with a
medical diagnosis of failure to thrive. The nurse provides education to the
mother about the infants psychosocial development. Which of the following
behaviors indicates to the nurse that teaching was effective? The mother
smiles at the infant when the infant smiles that her
47. The nurse is assessing a newborn who was just admitted to the nursery
and is sleeping. Which of the following findings should the nurse intervene?
Axillary temperature of 36.2C or 97.2F
48. An RN is planning care for a group of clients and is working with a LPN
and AAP. Which of the following tasks should the RN delegate to the LPN?
Insertion of NG tube
49. And nurses caring for a client who is recovering from a CVA and is
preparing for discharge home. During discharge planning for the client, the
nurse should anticipate doing which of the following actions? Identify
community resources available for the client, initiate contact with the home
health care agency, verify that arrangements have been made for medical
equipment needed in the home, coordinate occupational services
50. The nurses caring for a client who has gastrointestinal bleeding and an
NG tube. While performing gastric lavage, which of the following actions
should the nurse take? Ask the client to lie on the left side.
51. A nurse is planning teaching on allowable foods for a client who has a
history of uric acid-based urinary calculi formation. Which of the following
foods should the nurse recommended that the client include in his diet?
Oranges
52. Which of the following interventions for a newborn should the nurse
implement to prevent heat loss via conduction? Pad a scale with paper prior
to weighing the infant
53. The nurses observing and AP provide care for a toddler admitted with
infectious gastroenteritis. Which of the following requires intervention by the
nurse? Ensuring that the child is eating a BRAT diet
54. The nurses monitoring visit between the client who has a history of
aggressive behavior and his wife. Which of the following client behaviors

requires the nurses intervention to prevent escalation of the clients anger?

The client is observed pacing around the chair in which his wife is sitting
55. The nurses discharging a client who is newly diagnosed with type one
diabetes mellitus. Which of the following actions is the highest parity to assist
the client in managing the diseased? Ensure that the client understands the
medication regimen
56. The nurses teaching a client who has a new prescription of TPN. Which of
the following should the nurse include in the teaching? I will frequently
monitor your blood glucose
57. The nurses evaluating a clients ABG results. Which of the following
findings requires an action by the nurse? PCO2 of 33 mmHG
58. The nurses caring for a client who has active pulmonary tuberculosis.
Which of the following is an appropriate action for the nurse to make? Assign
the client to private room with negative air pressure
59. The nurses working in the emergency department is triaging for clients.
Which of the following clients should the nurse recommend for treatment
first? An adult client who has unstable vital signs
60. Provider prescribes codeine 30 mg PO Q 4 H PRN for pain for a client who
is being discharged from the hospital. The nurse provides discharge teaching
regarding prior administration of codeine . Which of the following statements
by the client indicates a need for further teaching?
I may experience urinary frequency while taking this medication
61. The nurses caring for a client in crisis. The nurse should expect to take
the following actions in what sequence in order to assist the client to cope?
1. Provide for client safety
2. Develop a therapeutic nurse client relationship
3. Assist the client with the development of an action plan
4. Coordinate with support agencies and other resources.
5. Plan and provide for follow-up care.
62. A nurses caring for a client who has end-stage Alzheimer's disease. The
daughter of the client says to the nurse I do not know why I bother to visit
my mother anymore. Which of the following responses by the nurses
therapeutic? It seems like you feel your visits are a waste of time.
63. The nurses caring for a client who is admitted following a miscarriage.
The nurse enters the clients room and finds her crying. Which of the following

responses should the nurse make? This must be very difficult for you
64. The nurses teaching a client about the use of a diaphragm for
contraception. Which of the following statements by the client indicates a
need for further teaching? I will remove the diaphragm right after intercourse
65. Vitamin D health nurse receives funding to develop an educational
program for the local community. Which of the following actions should the
nurse take first? Identify existing health programs
66. Nurse case manager is caring for a group of clients who has mental
health disorders. Which of the following actions is appropriate for this role?
Arranging for transportation to healthcare appointments
67. A nurses providing homecare instructions to a client who has a newly
implanted permanent pacemaker. Which of the following client statements
indicates an understanding of the teaching? I will be able to take baths or
showers
68. And nurses caring for a client who has a pulmonary embolism. The client
is receiving a heparin IV infusion at 1200 units per hour and warfarin
Coumadin 5 mg PO daily. Good morning laboratory values for the client are a
PTT 98 seconds and INR 1.8 which of the following nursing interventions is
appropriate?
Hold the heparin infusion
69. The nurses caring for a client with an implanted venous access device.
Which of the following actions should the nurse take first when accessing the
port.
Palpate skin to locate the body septum of the port
70. The nurses caring for a client who has skeletal traction for a fractured
femur. Which of the following assessment findings is the highest Priority?
Upper chest petechiae
71. The nurses caring for a client who is receiving hemodialysis within AV
fistula in the right arm. Which of the following should the nurse include in the
clients plan of care? Auscultate the affected extremity for a bruit
72. A nurses providing teaching regarding snacks to the parent of a toddler.
Which of the following foods should the nurse recommend? Seems carrots
73. The client is receiving IV fluids at 1:50 milliliters per hour. Which of the
following findings indicates that the client is experiencing fluid overload?

Dyspnea
74. The nurses caring for the child who has hemoglobin level of 7.8 g/dL.
Which of the following should the nurse include in the plan of care? Observed
for dyspnea on exertion
75. A nurse performing preoperative teaching for a client who is scheduled to
have a right modified radical mastectomy. Which of the following should the
nurse include in the post operative plan of care? Presence of one or more
surgical drains
76. Nurses admitting a client to the emergency department who is
experiencing cardiac tapenade. Which of the following assessment findings
should the nurse expect to find? Pulsus paradoxus
77. And nurses monitoring a client who is prescribed fluoxetine (Prozac) for
treatment of premenstrual dysmorphic syndrome. The nurse should recognize
which of the following as an adverse effect? Headache
78. The nurse is assessing an infant who has cystic fibrosis and has been
receiving oxygen therapy for the past 36 hours. Which of the following
findings should the nurse recognize is an indication of oxygen toxicity?
Bradypnea
79. The nurses caring for a client who is being discharged following heart
failure. The client is taking the Digoxin Lanoxin and furosemide Lasix. Which
of the following information should the nurse include in the clients home care
education?
Methods for measuring fluid intake, how to monitor pulse rate before taking
to Digoxin, need to report muscle weakness to the provider, importance of
obtaining daily weight
80. A nurse is caring for a female client who is prescribed misoprostol
(Cytotec) and is taking NSAIDs for arthritis. Then there should provide the
client with which of the following information? Have a serum pregnancy test
completed before beginning medication
81. A nurses providing care for an older adult client who is at high risk for
pressure ulcer formation. Which of the following nursing interventions is
appropriate? Position the quiet in the 30 lateral position while in bed
82. The nurses caring for a client who has acute blood loss and refuses a
blood transfusion that may potentially save her life. What's the following
actions should the nurse take first? Explore the clients reason for refusing

the treatment
83. The nurses caring for a client in the transition phase of labor. Which of the
following breathing techniques should the nurse recommended at this time?
Pattern paced breathing
84. The nurse manager discovers the client falls occur most frequently during
the hours of 0530 and 0730. Which of the following and interventions should
the nurse include when performing a root cause analysis? Investigate
environmental factors that may be contributing to a client injury during these
hours
85. Nurses providing dietary teaching to a client who has celiac disease.
Which of the following menu choices chosen by the client indicates
understanding of the teaching? Baked chicken and wild rice
86. The nurses caring for a client who has seen around magnesium level of
2.5 mEq per liter. Which of the following interventions should the nurse plan
to take? Initiate continuous cardiac monitoring
87. The nurses caring for a client who has a new prescription of clonidine
(Catapres). The nurse should inform the client that which of the following is
an adverse effect of this medication? Dry mouth
88. The nurses assessing an older client who has pneumonia. Which of the
following findings should the nurse expect? Acute confusion
89. The nurses caring for a child who has sickle cell anemia and is being
admitted for a vaso occlusive crisis. Which of the following intervention
should the nurse implement first? Start IV fluids
90. The nurse is preparing to perform an intermittent urinary catheterization
for a client who has urinary retention. Which of the following images indicates
the catheter the nurse should use?
C. Straight Cath
91. The nurses caring for a client who has a new P ICC line. Prior to starting
the initial infusion, which of the following actions should the nurse perform?
Review the chest x-ray report
92. A nurse is assigned to care for four clients at the beginning of the shift.
After hearing change of shift report, which of the following client should the
nurse attend to first? A client who is confused and has been attempting to get
out of bed

93. The client with COPD becomes extremely short of breath. Which of the
following interventions by the nurse requires completion of an incident
report? Increased oxygen via nasal cannula to 6 L per min
94. A nurse is preparing to administer an IM injection to a client who is obese.
Which of the following actions should the nurse plan to take? Use the
ventrogluteal site
95. The nurses caring for a client who has diabetes mellitus and has a
prescription for capillary blood glucose monitoring before meals and at
bedtime. Which of the following actions is appropriate for the nurse to take?
Was the clients hands with soap and warm water
96. A nurse is teaching the parent of a preschool age child how to collect a
specimen for the tape test for pinworms. Which of the following should the
nurse including the teaching? Please the specimen in a plastic bag
97. The client is prescribed propranolol (Inderal). Which of the following client
reports should indicate to the nurse that this client is experiencing an
adverse reaction? Coughing at night
98. The nurse is preparing to administer lactated ringers LR 1500 mL to
infuse at 50 mL per hour. The drop factor of the manual IV tubing is 15 drops
per ml. The nurse should set the manual IV infusion to deliver how many
drops per minute.
(50ml /60 min) x 15gtt
= 13 gtt/min
99. The nurse and an medical surgical unit is caring for a client who has a
new diagnosis of a terminal illness. The client tells the nearest that he thinks
about going home to be with loved ones. Which of the following is an
appropriate intervention by the nurse make a referral for social services
100. It charge nurses notified the clients 0900 medications are not available.
Medication availability has been an ongoing problem, and the charge nurse
has previously discussed this issue with the pharmacy staff. Which of the
following actions to the charge nurse take first? Informed the nurse manager
of the issue
101. The nurses providing teaching to the patient of a child with autism.
Which of the following should the nurse including the teaching? Manage
behavioral outbursts by limiting external stimuli and using a calming
approach

Hundred two. The AP and the nurse is turning a client on her right side. The
following actions by the AP requires the nearest intervene? Places a pillow
underneath the clients right arm
103. I nurses receiving report for four assigned clients. Which of the following
clients should the nurse assessed for a potential food and medication
interaction? A client receiving and MAOI who requests a cheeseburger for
dinner
104. A nurse is preparing to begin a transfusion of packed red blood cells to a
client. The nurses preceptor is double checking to see if the proper procedure
was followed. Which of the following indicates that the nurse needs to make a
correction? Y tubing with an in-line filter was attached to 500 mL of D5W.
105. A home health nurse is assessing a two week old newborn who has been
breast-feeding. Which of the following signs indicates effective breastfeeding? I newborn has 6 to 8 wet diapers per day
106. The client has a fracture of the right fibula. Shortly cast is applied, and
the client is non-weight bearing for six weeks. Which of the following
shouldn't be included in the clients teaching? Use a three-point gate
107 and nurse manager on the medical surgical unit has been informed that
there has been an explosion in the nearby chemical plant. The nurse
manager must make room for incoming clients. Which of the following clients
should the nurse recommend for discharge? A client who has admitted for
dehydration and has a urinary output of 680 mL in the last 12 hours
108. During the handoff report, a night shift nurse informs the date charge
nurse that a newly admitted to client was disoriented and combative during
the night. Which of the following actions should the nurse take? Move the
client to a room just outside the nurses station

109. The nurses caring for a client who has cancer and is deciding between
two different human plans. The client asked the nurse for assistance in
making a decision. Which of the following responses by the nurse is
appropriate? Tell me more about your understanding of the options
110. The nurses observing a student nurse perform a physical assessment on
the client. Which of the following actions by than nursing student indicates
the need for further intervention? And this writes detailed notes while
performing a head to toe assessment

111. The charge nurse here's two nurses in the Holly discussing the
nutritional status of a client who has anorexia nervosa. Which of the following
actions should the charge nurse take? To the nurses to stop the discussion
112. The nurses caring for a client who had a CVA six hours ago. Which of the
following interventions is appropriate to lower the risk of increased
intracranial pressure? Place the patient in a quiet environment
113. A nurse is presenting a program on cataracts for a group of older adult
clients at a local community center. The nurse should instruct the client to
monitor for which of the following?
Cloudiness of the lens with blurred
vision.
114. a nurse is caring for a school-age child who is experiencing status
epileptic. Which of the following medications should the nurse administer?
Diazepam (Valium)
115. A charge nurse is informed that one of the nurses on her shift frequently
violates unit policies by taking an extended amount of time for break. Which
of the following statements by the charge nurse is appropriate to address this
conflict?
I need to talk to you about the unit policies regarding
break time.
116. a nurse who is planning to finalize preparations for surgery enters a
clients room. the client is fully dressed and states I am going home.
Identify the sequence of actions that the nurse should take.
1. Clarify the clients concerns
2. Notify the surgeon
3. Have the client sign the against medical advice AMA form
4. Document the occurrence in the medical record.
117. a nurse is caring for a client who has renal failure and received
hemodialysis the day before. Which of the following lab values should the
nurse report to the provider?
Sodium 148 mEq/L
118. a nurse is caring for a school age child who type and report feeling
shaky, nervous, and sweaty. The childs blood glucose is 55 mg/dL. Identify
the sequence of steps the nurse should take.
1. Give the client 4 oz of orange juice
2. wait 15 mins
3. recheck the blood glucose
4. provide cheese and crackers

119. a nurse is caring for a client who reports feeling palpitations. The cardiac
fhythm strip reveals narrow QRS complexes occurring irregularly at a rate of
170/min with no visible P waves. The nurse should recognize this as which of
the following arrhythmias?
A Fib
120. a nurse is caring for an older adult client. Which of the following is a
physiological change associated with aging?
Decreased lung
expansion
121. a nurse is teaching a health education class at a community center on
the prevention of skin cancer. Which of the following statements made by a
participant indicates to the nurse that further education is needed?
I should select a sunscreen with minimum SPF of 10
122. a nurse in the ED is admitting a client who has DKA. Which of the
following actions should the nurse take first?
Obtain the clients vital
signs
123. a nurse is caring for a client who undergoes a diagnostic procedure that
reveals lung cancer. The client asks the nurse do I have cancer? Which of
the following is an appropriate response by the nurse?
The
provider will be here to talk with you later
124. A nurse manager is planning to use a democratic leadership style with
the nurse on the unit. Which of the following actions by the nurse manager
demonstrates a democratic leadership style?
Seeks input from
the other nurses.
125. a nurse is caring for a newborn who has HSV. Which of the following
precautions should the nurse initiate?
Contact
126. a nurse is caring for a client who has bipolar disorder. The nurse
observes that the client is becoming increasingly restless. She is pacing the
unit and speaking rapidly, using frequent profanities and sexual references.
Which of the following is the priority nursing intervention?
Move the client to a quiet place away from others.
127. a nurse is caring for several clients who have recently been diagnosed
with a chronic illness. Which of the following clients is effectively using a
defense mechanism to cope?
A client who engages in a hobby to
compensate for a lack of physical energy.
128. a nurse is caring for a client who is in the manic phase of bipolar. Which
of the following clinical manifestations should the nurse expect to find?
Gransiose thoughts.

129. a nurse is caring for a client who has a deficit with cranial nerve. (CN) II.
Based on implications of this deficit, the nurse should plan to
Clear
objects form the clients walking area
130. when caring for a child, a nurse plans to non-pharm interventions to
enhance the effectiveness of pain meds. Which of the following strategies
incorporates visualization techniques to help decrease the childs discomfort?
Blowing bubbles with liquid soap to blow the hurt away
131. a nurse is caring for a client who has hyperthyroidism. Which of the
following findings the nurse expect?
Tremors
132. a nurse is caring for a client who was recently battered in a domestic
violence incident. The client states if I would only be a better wife, keep the
house neat, and serve meals on time, this never would have happened.
Which of the following statements by the nurse is appropriate?
It
sounds as though you are feeling responsible for the violence that occurred
last night.
133. A nurse is caring for a female client in the emergency department who
report nausea and vomiting for the past 2 days. Which of the following
findings should the nurse expect?
Urine specific gravity 1.052
134. a nurse manager is explain in the use of incident reports to a newly
licensed nurse. Which of the following statements by the nurse indicates the
need for further teaching about incident reports?
I will document
that an incident report was completed in the clients medical record.
135. a nurse is preparing to suction a clients secretion through his
tracheostomy tube. Which of the following actions should the nurse plan to
take?
Hyperoxygenate with 100% oxygen before suctioning
136. a nurse is completing a home health visit with a client who has
hemianopsia. Which of the following information should the nurse review with
the client to promote safety in the home?
Use scanning technique
when ambulating.
137. a nurse is providing care for a client who has a colostomy. Which of the
following actions should the nurse take?
Place the skin barrier
over the stoma and hold for 30seconds.
138. a nurse is caring for client who is to start taking captopril (Capoten) for a
new diagnosis of hypertension. Which of the following tasks should the nurse
delegate to an AP?
Obtain blood pressure before an after medication
administration

139. a client has been diagnosed with peptic ulcer disease and has been
prescribed omprazole (Prilosec) and metronidazole (Flagyl). The client asks
the nurse why both medications are needed. Which of the following is the
appropriate response?
The omprazole will minimize the acid in your
stomach and metronidazole will treat the H. pylori infection
140. The nurses providing teaching for a client about his right to
confidentiality. Which of the following nursing statements is appropriate?
you can provide a list of family members who can receive information about
your diagnosis
141. The nurses providing discharge instructions to an older adult client
following a total hip arthroplasty. Which of the following instructions should
the nurse include in the teaching?
Install a raised toilet seat at home
142. And nurses caring for an older adult client in the PACU falling general
anesthesia. Which of the following findings should the nurse report to the
provider? Auditory stridor
143. A nurse is preparing to administer enoxaparin Lovenox to a client.
Identify the area dinner should use to administer the injection.
The nurse should administer Lovenox by deep subcutaneous injection into
the abdomen at least 2 inches from the umbilicus
144. The nurses providing information to the client and her family. The client
has progressive cardiomyopathy, is no longer responding to treatment, and
will be discharged hospice. Which of the following comments but the family
indicates a need for further teaching regarding the clients discharged to
hospice care? The hospice nurse will provide the same care you provided in
the hospital; however, now it will be my mothers home
145. The charge nurse is observing a newly licensed nurse to administer an
enteral tube feeding for an infant who has cerebral palsy. The infant is
receiving 130 mL of fluid every 4 hours. Which of the following observations
require the charge nurse to intervene? Allows feeding to run in via gravity
over eight minute period
146. And nurses calculating the clients intake and output. For dinner the
client had 4 ounce of gelatin, one cup of juice and half cup of milk. What is
the clients total intake in milliliters?
120 + 240 + 120 = 480 ml
147. The charge nurses evaluating a units policy and procedure for

medication administration, which include the following steps:

one. Check drug reference to ensure dose is within usual range when
calculating the dose.
Two. Select the correct preparation for the ordered bro. Have a second nurse
check the dose of high alert medications.
Three. Read the medication label three times when the container is
selected, when removing the dose from the counter, and when replacing the
container; and leave the unit dose medications and packaging until
administration.
Four. Check the clients identification band prior to administering medication.
Five. Administer medication within the timeframe of half hour before or half
hour after that scheduled time. Six. Document all medications given at the
end of the shift.
The charge nurse determines which of the following concerning this policy?
There is a significant risk of administering medication to frequently.
148. A client who is 24 hours post operative falling abdominal surgery refuses
to ambulate. Which of the following actions should the nurse take first? The
client to rate his pain level
149. The client is 24 weeks of gestation scheduled for three hour oral glucose
tolerance test. Which of the following instructions should the nurse provide to
the client? You should fast the night before the test
150. A client with a head injury is admitted to the critical care unit. The client
is agitated, confused, and attempting to pull out his IV line. Which of the
following is an appropriate nursing intervention? Put minutes on the clients
hands and maintain close observation