Fundamental Skills - Safety

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Author:
nursedaisy98
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256728
Filename:
Fundamental Skills - Safety
Updated:
2014-04-19 23:52:51
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NCLEX RN
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Fundamental Skills
Description:
Safety
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  1. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
    1. Reassess the client.
    2. Conduct a staff meeting to describe the fall.
    3. Document in the nurse's notes that an incident report was completed.
    4. Contact the nursing supervisor to update information regarding the fall.
    1. Reassess the client.
  2. A client is being weaned from parenteral nutrition (PN), also known as total parenteral nutrition, and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?
    1. Discontinue the PN.
    2. Decrease PN rate to 50 mL/hour.
    3. Start 0.9% normal saline at 25 mL/hour.
    4. Continue current infusion rate prescriptions for PN.
    2. Decrease PN rate to 50 mL/hour.
  3. The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change?
    1. Breathe normally.
    2. Turn the head to the right.
    3. Exhale slowly and evenly.
    4. Take a deep breath, hold it, and bear down.
    4. Take a deep breath, hold it, and bear down.
  4. The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action?
    1. Rolls the bottle of solution gently
    2. Obtains a different bottle of solution
    3. Shakes the bottle of solution vigorously
    4. Runs the bottle of solution under warm water
    2. Obtains a different bottle of solution
  5. The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?
    1. Initiate the intravenous line without the use of a pump.
    2. Contact the electrical maintenance department for assistance.
    3. Plug in the pump cord in the available plug above the room sink.
    4. Use an extension cord from the nurses' lounge for the pump plug.
    2. Contact the electrical maintenance department for assistance.
  6. The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP?
    1. Placing a safety knot in the safety device straps
    2. Safely securing the safety device straps to the side rails
    3. Applying safety device straps that do not tighten when force is applied against them
    4. Securing so that two fingers can slide easily between the safety device and the client's skin
    2. Safely securing the safety device straps to the side rails
  7. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan?
    1. Wearing gloves when emptying the client's bedpan
    2. Keeping all linens in the room until the implant is removed
    3. Wearing a lead apron when providing direct care to the client
    4. Placing the client in a semiprivate room at the end of the hallway
    4. Placing the client in a semiprivate room at the end of the hallway
  8. The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?
    1. Call for help.
    2. Extinguish the fire.
    3. Activate the fire alarm.
    4. Confine the fire by closing the room door.
    3. Activate the fire alarm.
  9. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?
    1. Induce vomiting.
    2. Call an ambulance.
    3. Call the Poison Control Center.
    4. Bring the child to the emergency department.
    3. Call the Poison Control Center.
  10. The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. The nurse should take which initial action?
    1. Prepare the triage rooms.
    2. Activate the emergency response plan.
    3. Obtain additional supplies from the central supply department.
    4. Obtain additional nursing staff to assist in treating the casualties.
    2. Activate the emergency response plan.
  11. The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client?

    1. Semi-Fowler's
    2. Trendelenburg's
    3. Reverse Trendelenburg's
    4. Flat
    1. Semi-Fowler's
  12. The nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?
    1. Out-of-bed activities as desired
    2. Bed rest with the affected extremity kept flat
    3. Bed rest with elevation of the affected extremity
    4. Bed rest with the affected extremity in a dependent position
    3. Bed rest with elevation of the affected extremity
  13. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
    1. Side-lying on the operative side
    2. On the nonoperative side with the legs abducted
    3. Side-lying with the affected leg internally rotated
    4. Side-lying with the affected leg externally rotated
    2. On the nonoperative side with the legs abducted
  14. The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?
    1. "I should not sleep on my left side."
    2. "I should not sleep on my right side."
    3. "I should not sleep with my head elevated."
    4. "I should not wear my glasses at any time."
    2. "I should not sleep on my right side."
  15. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?
    1. Left Sims position
    2. Right Sims position
    3. On the left side of the body, with the head of the bed elevated 45 degrees
    4. On the right side of the body, with the head of the bed elevated 45 degrees
    1. Left Sims position
  16. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?
    1. Prone
    2. Reverse Trendelenburg's
    3. Supine, with the amputated limb flat on the bed
    4. Supine, with the amputated limb supported with pillows
    4. Supine, with the amputated limb supported with pillows
  17. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan?
    1. Maintain the client in a prone position.
    2. Elevate and immobilize the grafted extremity.
    3. Maintain the grafted extremity in a flat position.
    4. Keep the grafted extremity covered with a blanket.
    2. Elevate and immobilize the grafted extremity.
  18. The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?
    1. Right side
    2. Low Fowler's
    3. High Fowler's
    4. Supine with the head flat
    3. High Fowler's
  19. The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply.
    1. Check the residual volume.
    2. Aspirate the stomach contents.
    3. Turn off the suction to the nasogastric tube.
    4. Remove the tube and place it in the other nostril.
    5. Check the stomach contents for a pH of less than 3.5.
    • 1. Check the residual volume.
    • 2. Aspirate the stomach contents.
    • 3. Turn off the suction to the nasogastric tube.
    • 5. Check the stomach contents for a pH of less than 3.5.
  20. The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action?
    1. Position the client supine to assist in medication absorption.
    2. Aspirate the nasogastric tube after medication administration to maintain patency.
    3. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.
    4. Change the suction setting to low intermittent suction for 30 minutes after medication administration.
    3. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.
  21. The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted?
    1. 3.5
    2. 7.0
    3. 7.35
    4. 7.5
    1. 3.5
  22. The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?
    1. Mark the tube at 10 inches.
    2. Mark the tube at 32 inches.
    3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
    4. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.
    3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
  23. The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take?
    1. Hold the feeding.
    2. Reinstill the amount and continue with administering the feeding.
    3. Elevate the client's head at least 45 degrees and administer the feeding.
    4. Discard the residual amount and proceed with administering the feeding.
    1. Hold the feeding.
  24. The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action?
    1. Quickly insert the tube.
    2. Notify the health care provider immediately.
    3. Remove the tube and reinsert when the respiratory distress subsides.
    4. Pull back on the tube and wait until the respiratory distress subsides.
    4. Pull back on the tube and wait until the respiratory distress subsides.
  25. The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse?
    1. A 75-year-old man who has moderate hypertension
    2. A 68-year-old man who has newly diagnosed cataracts
    3. A 90-year-old woman who has advanced Parkinson's disease
    4. A 70-year-old woman who has early diagnosed Lyme disease
    3. A 90-year-old woman who has advanced Parkinson's disease
  26. The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?
    1. Check for medication interactions.
    2. Determine whether there are medication duplications.
    3. Call the prescribing health care provider (HCP) and report polypharmacy.
    4. Determine whether a family member supervises medication administration.
    2. Determine whether there are medication duplications.
  27. When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply.
    1. Limiting the time with the client to 1 hour per shift.
    2. Keeping pregnant women out of the client's room.
    3. Placing the client in a private room with a private bath.
    4. Wearing a lead shield when providing direct client care.
    5. Removing the dosimeter film badge when entering the client's room.
    6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client.
    2. Keeping pregnant women out of the client's room.3. Placing the client in a private room with a private bath.4. Wearing a lead shield when providing direct client care.
  28. While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?
    1. Call the health care provider (HCP).
    2. Reinsert the implant into the vagina.
    3. Pick up the implant with gloved hands and flush it down the toilet.
    4. Pick up the implant with long-handled forceps and place it in a lead container.
    4. Pick up the implant with long-handled forceps and place it in a lead container.
  29. The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
    1. Restrict all visitors.
    2. Restrict fluid intake.
    3. Teach the client and family about the need for hand hygiene.
    4. Insert an indwelling urinary catheter to prevent skin breakdown.
    3. Teach the client and family about the need for hand hygiene.
  30. The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?
    1. A clotting time of 10 minutes
    2. An ammonia level of 20 mcg/dL
    3. A platelet count of 50,000 cells/mm3
    4. A white blood cell count of 5000 cells/mm3
    4. A white blood cell count of 5000 cells/mm3
  31. The nurse is caring for an 18-month-old child who has been vomiting. Which is the most appropriate position for this child while sleeping?
    1. Supine
    2. Side-lying position
    3. Prone with the head elevated
    4. Prone with the face turned to the side
    2. Side-lying position
  32. The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention?
    1. Unsecured scatter rugs
    2. Clear exit passageways
    3. An operable smoke detector
    4. A prefilled medication cassette
    1. Unsecured scatter rugs
  33. The nurse provides instructions to the parents of an infant regarding car travel and safety seats. Which is the most appropriate information related to the safety of the infant?
    1. Restrain in a car seat in the back seat in a semireclined, rear-facing position
    2. Restrain in a car seat in the front seat in a semireclined, rear-facing position
    3. Restrain in a car seat in the back seat in a semireclined, forward-facing position
    4. Restrain in a car seat in the front seat in a semireclined, forward-facing position
    1. Restrain in a car seat in the back seat in a semireclined, rear-facing position
  34. The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action?
    1. Aspirate the fluid, remove the catheter, and insert a new catheter.
    2. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
    3. Remove the syringe from the balloon; discomfort is normal and temporary.
    4. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
    2. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
  35. 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. What action should the nurse take next?
    1. Immediately inflate the balloon.
    2. Insert the catheter 2.5 cm to 5 cm and inflate the balloon.
    3. Withdraw the catheter about 1 inch and inflate the balloon.
    4. Insert the catheter until resistance is met and inflate the balloon.
    2. Insert the catheter 2.5 cm to 5 cm and inflate the balloon.
  36. The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times?
    1. An obturator
    2. A Kelly clamp
    3. An irrigation set
    4. A pair of scissors
    4. A pair of scissors
  37. The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what should the nurse consider?
    1. Aspiration is a concern with an NG tube feeding.
    2. The client needs to be maintained in a supine position.
    3. The NG tube needs to be changed with every other feeding.
    4. The rate of the feeding needs to be increased if the infusion rate falls behind schedule.
    1. Aspiration is a concern with an NG tube feeding.
  38. The nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. Which assistive device should the nurse suggest that the client use to provide the best stability for ambulating?
    1. Walker
    2. Quad cane
    3. Crutches
    4. Single straight-legged cane
    2. Quad cane
  39. The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction should the nurse provide to the client?
    1. Hold the cane on the affected (weak) side.
    2. Hold the cane on the unaffected (strong) side.
    3. Move the cane forward first along with the unaffected (strong) leg.
    4. Move the cane and the unaffected (strong) leg down first when going down stairs.
    2. Hold the cane on the unaffected (strong) side.
  40. The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made?
    1. The handle of the cane is even with the client's waist.
    2. The client's elbow is straight when ambulating with the cane.
    3. The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane.
    4. The client's elbow is flexed at a 50- to 75-degree angle when ambulating with the cane.
    3. The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane.
  41. The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the UAP is observed taking which action?
    1. Turning the client's head to one side
    2. Using small volumes of fluid to rinse the mouth
    3. Using a gloved finger to open the client's mouth
    4. Placing an emesis basin under the client's mouth
    3. Using a gloved finger to open the client's mouth
  42. The mother of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The mother also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition?
    1. "Does your child chew on pencils or crayons?"
    2. "Do you live in a house that is more than 25 years old?"
    3. "Have you noticed a sweet and fruity odor on the child's breath?"
    4. "Has your child been breathing very fast or sweating profusely?"
    2. "Do you live in a house that is more than 25 years old?"
  43. The community health nurse is performing a safety assessment in the home of a mother with two children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children?
    1. Small dog as a house pet
    2. Hot water heater set above 120° F
    3. Gate placed at the stairs of the second floor
    4. Toys with small loose parts in the playroom
    4. Toys with small loose parts in the playroom
  44. The home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the client, indicates a need for further instruction?
    1. "I need to be sure that no one smokes in my home."
    2. "I need to be sure that I stay at least 10 feet away from any burning candles."
    3. "It is all right to use an electric razor for shaving only if I leave it plugged in for a short time."
    4. "I need to be sure that there is space between the oxygen concentrator and the wall in the room."
    3. "It is all right to use an electric razor for shaving only if I leave it plugged in for a short time."
  45. The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for arrival of the client?
    1. Prepare a private room at the end of the hallway.
    2. Assign one primary nurse to care for the client during the hospital stay.
    3. Place a sign on the door that indicates that visitors are limited to 60-minute visits.
    4. Place a linen bag outside of the client's room for discarding linens after morning care.
    1. Prepare a private room at the end of the hallway.
  46. The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do?
    1. Use a ⅝-inch needle for the injection.
    2. Apply prolonged pressure to the IM site after the injection.
    3. Apply a 4 × 4 pressure dressing at the IM site after the injection.
    4. Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.
    2. Apply prolonged pressure to the IM site after the injection.
  47. The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk?
    1. Encourage early ambulation.
    2. Discuss the resumption of home care and other activities with the client.
    3. Review hand washing techniques and pericare procedures with the client.
    4. Instruct the client in proper positioning of the newborn to facilitate breast-feeding.
    3. Review hand washing techniques and pericare procedures with the client.
  48. An unconscious client has an impaired corneal reflex on one side. The nurse should demonstrate the best understanding of how to protect the client's eye by performing which action?
    1. Placing an eye patch
    2. Taping the eye shut during the day
    3. Using sterile saline drops every few hours to keep the eye moist
    4. Wiping inside the lower eyelid with a cotton-tipped applicator three times a day
    3. Using sterile saline drops every few hours to keep the eye moist
  49. A client with right leg hemiplegia has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family?
    1. Applying a premolded splint
    2. Active range of motion to the affected leg
    3. Passive range of motion to the affected leg
    4. Encouraging the client to stand unassisted on the leg
    4. Encouraging the client to stand unassisted on the leg
  50. The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture?
    1. The client's temperature
    2. The client's blood pressure
    3. The client's electrolyte values
    4.  The IV solution for particles or contamination
    4.  The IV solution for particles or contamination
  51. The health care provider (HCP) prescribes fat emulsion (Intralipids), given intravenously, for a client. The nurse should consult with the HCP before administering the fat emulsion solution if which is noted in the client's record?
    1. The client has an allergy to iodine.
    2. The client has an allergy to egg yolks.
    3. The client has a blood glucose level of 120 mg/dL.
    4. The client is receiving total parenteral nutrition (TPN).
    2. The client has an allergy to egg yolks.
  52. The nurse is providing instructions to an unlicensed assistive personnel (UAP) who is assigned to care for a client with hemiparesis of the right arm and leg. Where should the nurse instruct the UAP to place personal articles for morning care?
    1. Within the client's reach on the left side
    2. Within the client's reach on the right side
    3. Just out of the client's reach on the left side
    4. Just out of the client's reach on the right side
    1. Within the client's reach on the left side
  53. A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse should take which priority action in the care of this client?
    1. Encourage the family to visit.
    2. Assign the client to a private room.
    3. Place the client on protective isolation.
    4. Encourage the client to take frequent rest periods.
    2. Assign the client to a private room.
  54. A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard?
    1. Void into a bedpan and then empty the urine into the toilet.
    2. Disinfect the toilet with bleach after voiding for 6 hours after a treatment.
    3. Purchase extra bottles of scented disinfectant for daily bathroom cleansing.
    4. Have one bathroom strictly set aside for the client's use for the next 2 months.
    2. Disinfect the toilet with bleach after voiding for 6 hours after a treatment.
  55. A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse administers an intramuscular opioid analgesic in the left arm to relieve the pain. The nurse should plan to take which action next?
    1. Ensure client safety.
    2. Dim the lights in the room.
    3. Check the name bracelet of the client.
    4. Perform range-of-motion exercises to the left arm to promote medication absorption.
    1. Ensure client safety.
  56. A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method?
    1. Anterolateral thigh using an air lock
    2. Deltoid muscle using a 1-inch needle
    3. Gluteal muscle using Z-track technique
    4. Subcutaneous tissue of the abdomen using a 1-inch needle
    3. Gluteal muscle using Z-track technique
  57. The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What should the nurse's first action be?
    1. Activate the fire alarm.
    2. Quickly pour the coffee on the fire.
    3. Open the bottle of water and throw it on the fire.
    4. Grab a fire extinguisher and attempt to put out the fire.
    1. Activate the fire alarm.
  58. The nurse is providing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with hand restraints. The nurse asks the UAP to repeat the instructions to ensure that the UAP understands the care. Which statement, if made by the UAP, indicates an understanding of the care for this client?
    1. "I need to remove the restraints every 4 hours."
    2. "I need to make sure that the restraints are securely tied to the side rails."
    3. "If the family comes in to visit, I can tell them to take the restraints off if they want to."
    4. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."
    4. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."
  59. A nurse is developing a plan of care for a client with a diagnosis of early-stage Alzheimer's disease. The plan of care should include nursing interventions that address which early characteristic of Alzheimer's disease?
    1. Confusion is common.
    2. The client may wander.
    3. The client may be easily frustrated.
    4. Forgetfulness interferes with the daily routine.
    4. Forgetfulness interferes with the daily routine.
  60. A client has a prescription for an injection to be administered by the intradermal route. The nurse should avoid which action when administering this medication?
    1. Injecting the medication slowly
    2. Massaging the area after removing the needle
    3. Inserting the needle at a 10- to 15-degree angle
    4. Making a circular mark around the injection site
    2. Massaging the area after removing the needle
  61. The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure?
    1. Turning the head to one side
    2. Using oral suction equipment
    3. Rinsing with a large volume of fluid
    4. Using a bite stick or padded tongue blade
    3. Rinsing with a large volume of fluid
  62. The nurse has instructed a client with a continuous passive motion (CPM) device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question?
    1. How to use the "stop-go" button
    2. About reporting discomfort in the knee to the nurse
    3. How to reset the degrees of flexion or extension according to comfort
    4. Whether the knee should stay aligned with the hinged joint on the machine
    3. How to reset the degrees of flexion or extension according to comfort
  63. The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education?
    1. Paint chips
    2. Vinyl blinds
    3. Properly glazed pottery
    4. Solder used in plumbing
    3. Properly glazed pottery
  64. The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by one of the parents should the nurse identify as something that requires the need for reinforcement of the instructions?
    1. Refers to medication as "candy for when you are sick"
    2. Says he or she will store medications in child-proof containers
    3. Keeps the Poison Control Center telephone number readily available
    4. States the intention to label all toxic substances and place them in a locked area
    1. Refers to medication as "candy for when you are sick"
  65. The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction?
    1. "I'm going to take a painting class."
    2. "I've learned to knit and sew my own clothes."
    3. "When I'm feeling better, I'm returning to the soccer team."
    4. "I'm using a schedule to maintain my increased fluid intake."
    3. "When I'm feeling better, I'm returning to the soccer team."
  66. The nursing student develops a plan of care for a client with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the plan, the co-assigned licensed nurse identifies which action as an incorrect intervention?
    1. Using prescribed muscle relaxants as needed
    2. Using padded restraints to immobilize the limb
    3. Performing range-of-motion exercises to the affected limbs
    4. Removing potentially harmful objects near the spastic limbs
    2. Using padded restraints to immobilize the limb
  67. The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration?
    1. Low Fowler's
    2. On the left side
    3. Upright in a chair
    4. On the right side
    3. Upright in a chair
  68. A nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action should the nurse take to meet this client's need?
    1. Assist the client onto a bedpan.
    2. Assist the client to the bathroom.
    3. Contact the health care provider and request a prescription for a Foley catheter.
    4. Tell the client that preoperative medications cause the urge to void, and check the bladder for distention.
    1. Assist the client onto a bedpan.
  69. The nurse is assessing a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse increases the safety of the client?
    1. Eyeglasses left at home
    2. Unfamiliar hospital setting
    3. Stress induced by the fracture
    4. Hearing aid available and in working order
    4. Hearing aid available and in working order
  70. The nurse is caring for an older client who had a hip pinned after being fractured. Which should the nurse do to prevent further injury?
    1. Respond to the call light within 10 minutes.
    2. Use a night light in the hospital room and the bathroom.
    3. Medicate the client with a sleeping pill to encourage him or her to sleep through the night.
    4. Keep all four side rails in the up position, preventing the client from getting out of bed.
    2. Use a night light in the hospital room and the bathroom.
  71. A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. The nurse determines that further teaching is required if the client performs which action?
    1. Holds the walker using the hand grips
    2. Advances the walker with reciprocal motion
    3. Leans forward slightly when advancing the walker
    4.Supports body weight on the hands while advancing the weaker leg
    2. Advances the walker with reciprocal motion
  72. The nurse has administered diazepam (Valium) 5 mg by the intravenous (IV) route to a client. The nurse should plan to maintain the client on bed rest for at least how long?
    1. 1 hour
    2. 3 hours
    3. 12 hours
    4. 30 minutes
    2. 3 hours
  73. The nurse is providing instructions to a client regarding the use of a walker. Which statement by the client would indicate the need for further instruction?
    1. "I need to inspect the rubber tips daily."
    2. "I need to wear shoes when ambulating."
    3. "I need to pick up the walker and move it forward, and then walk into the walker, one step at a time."
    4. "The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe."
    4. "The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe."
  74. The nurse is preparing to administer an intramuscular (IM) injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected?
    1. 0.5 mL
    2. 1.0 mL
    3. 1.5 mL
    4. 2.0 mL
    3. 1.5 mL
  75. The nurse is administering an acetaminophen (Tylenol) suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters?
    1. 0.5
    2. 1
    3. 2
    4. 2.5
    3. 2
  76. The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse should perform which action?
    1. Pulls the pinna of the ear back and up
    2. Pulls the pinna of the ear back and down
    3. Places the child in a prone position with the ear to receive the drop facing downward
    4. Places the child in a side-lying position with the ear to receive the drop facing downward
    2. Pulls the pinna of the ear back and down
  77. The home health nurse performs an assessment on a client who had cardiac surgery 10 days ago. The client states, "I get dizzy in the shower." On the basis of the client's statement, which option should the nurse assess first?
    1. The bathroom environment in the home
    2. The temperature of the water of the client's shower
    3. The client's insurance plan for reimbursement of medical equipment
    4. The client's insurance plan regarding coverage for home health assistive personnel care
    2. The temperature of the water of the client's shower
  78. The nurse develops a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan?
    1. Restrict all visitors.
    2. Place a lead shield at the bedside.
    3. Keep the client's room door open.
    4. Place the client in a semi-private room.
    2. Place a lead shield at the bedside.
  79. The nurse is instructing a client to perform a two-point gait for crutch walking. The nurse should tell the client to perform which action?
    1. Advance the right foot and then the left foot, followed by both crutches.
    2. Advance both crutches forward, followed by the left foot and then the right foot.
    3. Move the left foot and then the left crutch forward, followed by the right crutch and then the right foot.
    4. Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward.
    4. Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward.
  80. The community health nurse is conducting an education session for community members regarding measures to prevent skin cancer and is providing instructions for use of sunscreen protection. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time?
    1. Immediately after swimming
    2. One hour before exposure to the sun
    3. Immediately before exposure to the sun
    4. Five minutes before exposure to the sun
    2. One hour before exposure to the sun
  81. A community health nurse is preparing to administer a tuberculin skin test. The nurse should select which syringe to administer the medication?

    1. A
    2. B
    3. C
    4. D
    2. B
  82. The nurse is transcribing a health care provider's prescription and notes that the client is to receive a medication at 1:00 pm. Using the military time clock, the nurse documents which military time in the medication record for administration of the medication?

    1. A
    2. B
    3. C
    4. D
    1. A
  83. An adolescent is admitted to the hospital after an accidental gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury?
    1. Explore the client's knowledge of gun safety.
    2. Assess the client for a history of risk-taking behaviors.
    3. Refer the client to a firearm safety class sponsored by the hospital.
    4. Have the client watch a video on the tragedies of improper firearm use.
    1. Explore the client's knowledge of gun safety.
  84. A client has an impairment of cranial nerve II. To maintain safety in the home, the nurse should teach the spouse to implement which measure?
    1. Speak to the client in a loud voice.
    2. Serve food that is not too hot or too cold.
    3. Keep traveled paths in the home free of clutter.
    4. Lower the temperature setting of the hot water heater.
    3. Keep traveled paths in the home free of clutter.
  85. A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client?
    1. Walker
    2. Slider board
    3. Raised toilet seat
    4. Adaptive eating utensils
    1. Walker
  86. A nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority?
    1. Risk for injury
    2. Social isolation behaviors
    3. Role performance alterations
    4. Inability to communicate verbally
    1. Risk for injury
  87. A nurse is preparing to infuse (piggyback) a 50-mL dose of a compatible medication through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag?
    1. Hanging the medication bag level with the primary IV bag
    2. Hanging the medication bag lower than the primary IV bag
    3. Hanging the medication bag higher than the primary IV bag
    4. Disconnecting the primary IV solution and plugging in the medication
    3. Hanging the medication bag higher than the primary IV bag
  88. A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often should the nurse plan to check the IV infusions and IV sites of these clients?
    1. Every 1 hour
    2. Every 2 hours
    3. Every 3 hours
    4. Every 4 hours
    1. Every 1 hour
  89. A nurse has a prescription to administer phenytoin (Dilantin) by intravenous push (IVP) through an IV line infusing 1000 mL of 0.9% sodium chloride. Arrange the actions in the order that they should be performed. All options much be used.
    1. Check the client's identification (ID) bracelet.
    2. Pinch off the IV tubing above the injection port.
    3. Draw up the medication in a 3-mL syringe.
    4. Check the compatibility of phenytoin with the IV solution.
    5. Inject the medication.
    6. Document that the medication was administered.
    • 4. Check the compatibility of phenytoin with the IV solution.
    • 3. Draw up the medication in a 3-mL syringe.
    • 1. Check the client's identification (ID) bracelet.
    • 2. Pinch off the IV tubing above the injection port.
    • 5. Inject the medication.
    • 6. Document that the medication was administered.
  90. A nurse is making a note in the care plan for a client who has a multilumen central venous catheter. The nurse should write to change the injection caps on the lumens at which times?
    1. Once a week
    2. At the change of each shift
    3. After administration of each medication
    4. Whenever blood is drawn from the lumen
    4. Whenever blood is drawn from the lumen
  91. A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home?
    1. Conduct pill counts on each home visit.
    2. Demonstrate the proper procedure to take prescribed medications.
    3. Instruct the client to double up on medications if a dose has been missed.
    4. Observe the client verbalize and demonstrate the correct administration procedures.
    4. Observe the client verbalize and demonstrate the correct administration procedures.
  92. The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the most appropriate nursing action in this situation?
    1. Obtain a dust pan and mop to sweep up the syringe.
    2. Call the housekeeping department to pick up the syringe.
    3. Carefully pick up the syringe from the floor and gently recap the needle.
    4. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
    4. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
  93. A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse providing care for the client administers an opioid analgesic to relieve the pain, as prescribed. What is the next nursing action for this client?
    1. Dim the lights in the room.
    2. Check the name bracelet of the client.
    3. Ensure the call bell is within the client's reach. 
    4. Tell the client to perform range of motion (ROM) of the injection site.
    3. Ensure the call bell is within the client's reach.
  94. The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan? 
    1. Turn the head slowly when spoken to. 
    2. Remove throw rugs and clutter in the home. 
    3. Go to the bedroom and lie down when vertigo is experienced. 
    4. Drive only when feelings of dizziness have not been experienced for several hours.
    2. Remove throw rugs and clutter in the home.
  95. A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective? 
    1. "I will avoid getting the cast wet." 
    2. "I will use my fingertips to lift and move the leg." 
    3. "I can use a padded coat hanger end to scratch under the cast." 
    4. "I need to cover the casted leg with warm blankets for the next few days."
    1. "I will avoid getting the cast wet."
  96. A health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. At 11:00 PM, the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action? 
    1. The restraints were applied tightly. 
    2. A safety knot was used to secure the restraints. 
    3. The call light was placed within reach of the client. 
    4. The client's record indicates that the restraints will be released every 2 hours.
    1. The restraints were applied tightly.
  97. When administering an intramuscular (IM) injection in the gluteal muscle, how should the nurse position the client to best relax the muscle? 
    1. Sims with a toe-in position 
    2. Prone with a toe-in position 
    3. On the side with the knee of the uppermost leg flexed 
    4. On the side with the knee of the lowermost leg flexed
    2. Prone with a toe-in position
  98. The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication? 
    1. Start a new IV line for the medication. 
    2. Flush the tubing after the medication with sterile water. 
    3. Flush the tubing before and after the medication with normal saline. 
    4. Call the health care provider for a prescription to change the route of the medication.
    3. Flush the tubing before and after the medication with normal saline.
  99. The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation? 
    1. Wait until the client's agitation has subsided before approaching the client. 
    2. Speak and move slowly toward the client while assessing the client's needs. 
    3. Speak to the client at the entrance of the room to avoid any episodes of agitation. 
    4. Walk up behind the client and gently put a hand on the client's shoulder while speaking.
    2. Speak and move slowly toward the client while assessing the client's needs.
  100. The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure? 
    1. Half-inch tape 
    2. Oil-soluble lubricant 
    3. A 50-mL catheter tip syringe 
    4. A glass of tap water with a straw
    2. Oil-soluble lubricant
  101. A home care nurse performs a home safety assessment and discovers that a client is using a space heater in the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater? 
    1. A space heater should not be used in an apartment. 
    2. The space heater should be placed in the hallway at night. 
    3. The space heater should be kept at a low setting at all times. 
    4. The space heater needs to be placed at least 3 feet from anything that can burn.
    4. The space heater needs to be placed at least 3 feet from anything that can burn.
  102. The nurse is preparing to administer an oral medication to an infant. Which position should the nurse place the infant?
    1. Prone
    2. Semi-Fowler's
    3. Trendelenburg's
    4. Dorsal recumbent
    2. Semi-Fowler's
  103. The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention?
    1. Apply restraints to the client.
    2. Place a mattress sensor pad on the bed.
    3. Collaborate with the health care provider (HCP) for a prescription for a sedative.
    4. Have the unlicensed assistive personnel (UAP) check the client every half hour.
    2. Place a mattress sensor pad on the bed.
  104. The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Which medication prescription should the nurse question?
    1. Furosemide (Lasix) 20 mg via PEG tube daily
    2. Digoxin (Lanoxin) 0.25 mg via PEG tube daily
    3. Isosorbide mononitrate (Imdur) 30 mg via PEG tube daily
    4. Acetaminophen (Tylenol) elixir 650 mg via PEG every 4 hours as needed for temperature >101° F
    3. Isosorbide mononitrate (Imdur) 30 mg via PEG tube daily
  105. The health care provider (HCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the HCP's prescription and address the needs of the client? 
    1. Progressively ambulate the client in the hall three times daily. 
    2. Ambulate the client in the room for short distances frequently. 
    3. Ambulate the client to the bathroom in his or her room three times daily. 
    4. Assist with range-of-motion exercises three times daily to increase strength.
    1. Progressively ambulate the client in the hall three times daily.
  106. The nurse is preparing to discontinue a client's nasogastric (NG) tube. The client is positioned properly and the tube has been flushed with 15 mL of air to clear secretions. Which statement should the nurse make to the client before removing the tube? 
    1. "Take a deep breath when I tell you, and hold it while I remove the tube." 
    2. "Take a deep breath when I tell you, and bear down while I remove the tube." 
    3. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." 
    4. "Take a deep breath when I tell you, and breathe normally while I remove the tube."
    1. "Take a deep breath when I tell you, and hold it while I remove the tube."
  107. The nurse is caring for a client with a nasogastric (NG) tube connected to continuous suction. During assessment the nurse observes that the client is mouth-breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which intervention would be most appropriate to maintain the integrity of this client's oral mucosa? 
    1. Offer small sips of water frequently. 
    2. Encourage the client to suck on sour, hard candy. 
    3. Use lemon glycerin swabs to provide oral hygiene. 
    4. Brush the teeth frequently; use mouthwash and water.
    4. Brush the teeth frequently; use mouthwash and water.
  108. The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will bestfacilitate easy insertion of the tube? 
    1. Placing the NG tube in warm water 
    2. Hyperextending the head to insert the tube 
    3. Removing the tube if any resistance to insertion is met 
    4. Asking the client to swallow as the tube is being advanced
    4. Asking the client to swallow as the tube is being advanced
  109. The health care provider prescribes 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt) per mL. The nurse sets the flow rate at how many drops per minute?
    21 gtt/min
  110. The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply. 
    1. The right dose 
    2. The right route 
    3. The right time 
    4. The right client 
    5. The right staff member 
    6. The right documentation
    • 1. The right dose 
    • 2. The right route 
    • 3. The right time 
    • 4. The right client
    • 6. The right documentation
  111. A client is in the bathroom when the nurse arrives at his room with his scheduled medications. The client calls to the nurse, "Just leave my medication on the bedside table like the rest of the nurses, and I will take it when I get finished." What is the nurse's best action? 
    1. Tell the client you will be back when he is finished. 
    2. Leave the medication at the bedside as the client requested. 
    3. Let another nurse who is not busy give the client his medication when he is finished. 
    4. Tell the unlicensed assistive personnel (UAP) to give it to the client when he is finished.
    1. Tell the client you will be back when he is finished.
  112. The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing?
    1. Basic level 
    2. Primary level 
    3. Secondary level 
    4. Tertiary level
    4. Tertiary level
  113. The nurse is preparing to administer an intramuscular injection of pain medication to a new postoperative client. When the nurse walks into the client's room, the client asks why he is receiving an intramuscular form of the medication instead of the oral form. What is the nurse's best response with regard to the absorption of the medication? 
    1. "Your health care provider wants you to have it this way." 
    2. "Are you saying that you are not going to take this medication?" 
    3. "Medications given this way have fewer side effects than those given orally." 
    4. "Medications given this way are absorbed more quickly than by other routes."
    4. "Medications given this way are absorbed more quickly than by other routes."
  114. The nurse is preparing medications when a pill pops out of the medication container and falls onto the countertop. What action should the nurse take? 
    1. Promptly pick up the pill and put it into the medicine cup. 
    2. Promptly pick up the pill, blow off the dust, and then put it into the medicine cup. 
    3. Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. 
    4. Promptly pick up the pill, use an alcohol swab to clean it off, and put it into the medicine cup.
    3. Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy.
  115. The nurse is preparing to administer an intradermal medication. Which action should the nurse take before administering the medication? 
    1. Cleanse the site of injection with an alcohol swab and fan the alcohol dry. 
    2. Cleanse the site of injection with an alcohol swab and pat it dry with tissue. 
    3. Cleanse the site of injection with an alcohol swab and blow the alcohol dry. 
    4. Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry.
    4. Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry.
  116. A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period?
    1. In 24 hours 
    2. In 48 hours 
    3. In about 8 hours 
    4. Within 20 to 30 minutes of application
    4. Within 20 to 30 minutes of application
  117. The nurse has given a client with a leg cast instructions on cast care at home. The nurse determines that the client needs further instruction if the client makes which statement? 
    1. "I should avoid walking on wet, slippery floors." 
    2. "I'm not supposed to scratch the skin underneath the cast." 
    3. "It's okay to wipe dirt off the top of the cast with a damp cloth." 
    4. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."
    4. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."
  118. A nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis (DVT) and pulmonary emboli. Which nursing action is most helpful to prevent these disorders from developing?
    1. Restricting fluids 
    2. Placing a pillow under the knees 
    3. Encouraging active range-of-motion exercises 
    4. Applying a heating pad to the lower extremities
    3. Encouraging active range-of-motion exercises
  119. A client has a prescription to receive purified protein derivative (PPD), 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines? 
    1. 20-gauge, 1-inch needle inserted at a 30-degree angle, with the bevel side down 
    2. 26-gauge, 5/8-inch needle inserted at a 45-degree angle, with the bevel side down
    3. 20-gauge, 1-inch needle inserted almost parallel to the skin, with the bevel side up 
    4. 26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up
    4. 26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up
  120. The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. Sutilains is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse? 
    1. The nurse cleans the wound with a sterile solution. 
    2. The nurse places the sutilains in the refrigerator after use. 
    3. The nurse moistens the wound with sterile normal saline and then applies the sutilains. 
    4. The nurse washes and dries the wound and covers the sutilains application with a dry sterile dressing.
    4. The nurse washes and dries the wound and covers the sutilains application with a dry sterile dressing.
  121. The nurse is assessing the intravenous (IV) dressing of a client with a peripheral IV infusion running. The date on the dressing is 7/25 (July 25). The nurse documents on the client's record that the dressing should be changed on which date? 
    1. 7/26 
    2. 7/28 
    3. 7/30 
    4. 8/1
    2. 7/28
  122. The nurse is preparing the morning medications to be administered to her assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question? 
    1. Lanoxin (Digoxin) 0.25 mg orally daily 
    2. Hydrochlorothiazide (HCTZ) orally twice daily 
    3. Docusate sodium (Colace) 100 mg orally twice daily 
    4. Enoxaparin sodium (Lovenox) 20 mg subcutaneously daily
    2. Hydrochlorothiazide (HCTZ) orally twice daily
  123. The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply. 
    1. Confusion because of homelessness 
    2. Risk for unsafe conditions because of homelessness 
    3. Anxiety when consciousness is regained because of the unfamiliar surroundings 
    4. Lack of knowledge regarding hygiene because of the client's unkempt condition 
    5. Risk for infection because of his unkempt condition, various scratches, and homelessness
    • 2. Risk for unsafe conditions because of homelessness 
    • 3. Anxiety when consciousness is regained because of the unfamiliar surroundings 
    • 5. Risk for infection because of his unkempt condition, various scratches, and homelessness
  124. The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply. 
    1. Keep leads on the child at all times. 
    2. Place the monitor inside the child's crib. 
    3. Adjust the monitor to eliminate false alarms. 
    4. Sleep in the same bed as the monitored infant. 
    5. Keep pets and children away from the monitor. 
    6. Keep emergency rescue numbers near the telephone.
    • 5. Keep pets and children away from the monitor. 
    • 6. Keep emergency rescue numbers near the telephone.
  125. A male nurse is working in the hospital when he hears a client call out that there is a fire in his hospital room. What actions should the nurse take? Arrange the actions in the order that they should be performed. All options must be used.
    1. Extinguish the fire.
    2. Activate the fire alarm.
    3. Protect the client from injury.
    4. Pull the pin on the fire extinguisher.
    5. Close the doors to the other clients' rooms.
    • 3. Protect the client from injury.
    • 2. Activate the fire alarm.
    • 5. Close the doors to the other clients' rooms.
    • 4. Pull the pin on the fire extinguisher.
    • 1. Extinguish the fire.
  126. The nurse is completing medication reconciliation with a client just before his or her discharge to home. The client asks, "Why are you going over this list? They did that when I was admitted!" Which statement by the nurse is the best response? 
    1. "Medication reconciliation is required before you can go home." 
    2. "Your insurance company requires a list of medications that you will be taking." 
    3. "We are checking to see what medications can be discontinued before you go home." 
    4. "We do this to make sure you will be receiving the correct medications once you are at home."
    4. "We do this to make sure you will be receiving the correct medications once you are at home."
  127. The nurse is giving a change-of-shift report. What is the primary purpose of a change-of-shift report? 
    1. Assess the client's status. 
    2. Plan care for the next shift. 
    3. Ensure continuity of care for the client. 
    4. Document the client's care for that shift.
    3. Ensure continuity of care for the client.
  128. A client is being transferred from the intensive care unit to a step-down unit. The nurse is performing a final assessment of the client before moving the client to the new unit. The priority components of this final assessment should include which parameters? Select all that apply. 
    1. The client's weight 
    2. The client's vital signs 
    3. The client's dietary orders 
    4. The client's level of consciousness 
    5. The patency of intravenous (IV) lines
    • 2. The client's vital signs 
    • 4. The client's level of consciousness 
    • 5. The patency of intravenous (IV) lines
  129. A nurse has called a client's primary health care provider to clarify a medication prescription. The health care provider gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time? 
    1. Ensure that the prescription is written neatly. 
    2. Double-check the prescription with another registered nurse. 
    3. Call the pharmacy to verify the accuracy of the prescribed medication. 
    4. Read the prescription back to the health care provider after writing it on the prescription sheet.
    4. Read the prescription back to the health care provider after writing it on the prescription sheet.
  130. A nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What should the nurse do next? 
    1. Notify the prescriber. 
    2. Stop the IV infusion. 
    3. Obtain a prescription for a chest x-ray. 
    4. Apply cold compresses to the insertion site.
    2. Stop the IV infusion.
  131. A nurse is preparing to administer 1 mg of hydromorphone (Dilaudid), a Schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action by the nurse is correct? 
    1. Return the unused portion of the medication to the pharmacy. 
    2. Ask a second nurse to witness disposal of the unused portion. 
    3. Administer the 1-mg dose and save the remainder for the next dose. 
    4. Administer the 1-mg dose and discard the unused portion of medication.
    2. Ask a second nurse to witness disposal of the unused portion.
  132. A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased and the client is still shivering. What should the nurse do next? 
    1. Apply a smaller heating pad to the client's axillae and neck areas. 
    2. Wait 10 more minutes and then check the client's temperature again. 
    3. Remove the hypothermia blanket and notify the client's health care provider (HCP). 
    4. Increase the blanket's temperature again and recheck the client's temperature in 15 minutes.
    3. Remove the hypothermia blanket and notify the client's health care provider (HCP).
  133. A nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which assessment finding, if present, is of greatest concern? 
    1. The client is able to wiggle the fingers. 
    2. The restraint is secured to the bed's frame. 
    3. The skin of the hand feels cool to the touch and is pale. 
    4. The nurse is able to insert two fingers under the restraints between the restraint and the client's skin.
    3. The skin of the hand feels cool to the touch and is pale.
  134. A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care? 
    1. Encourage the client to drink only thin liquids. 
    2. Teach the client to examine his oral mucosa monthly. 
    3. Teach the client to speak slowly and enunciate clearly.
    4. Encourage the client to use artificial saliva to manage dryness.
    4. Encourage the client to use artificial saliva to manage dryness.
  135. A nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place and takes which action next?
    1. Extinguishes the fire 
    2. Activates the fire alarm
    3. Pulls the pin on the fire extinguisher 
    4. Closes the doors to the other clients' rooms
    2. Activates the fire alarm
  136. A nursing student is caring for a client with a stroke (brain attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit? 
    1. Telling the client to scan the environment 
    2. Placing the bedside articles on the affected side 
    3. Approaching the client from the unaffected side 
    4. Moving the commode and chair to the affected side
    3. Approaching the client from the unaffected side
  137. The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 
    1. Adhering to the mandatory abuse reporting laws 
    2. Notifying the case worker of the family situation 
    3. Removing the client from any immediate danger 
    4. Obtaining treatment for the abusing family member
    3. Removing the client from any immediate danger
  138. The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next?
    1. Performs mouth care 
    2. Starts feeding the client 
    3. Adds thickener to the food 
    4. Places the client in a semi-Fowler's position
    4. Places the client in a semi-Fowler's position
  139. The nurse is preparing to apply a mitten restraint to the client's hand. The nurse should take which action to ensure that the restraint is applied correctly?
    1. Applies the restraint loosely 
    2. Makes sure that two fingers can be inserted under the restraint 
    3. Secures the restraint straps to the side rail using a quick-release tie
    4. Makes sure that the sheepskin is on the outside rather than against the client's skin
    2. Makes sure that two fingers can be inserted under the restraint
  140. A registered nurse (RN) asks a licensed practical nurse (LPN) to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe? 
    1. Restraints 
    2. Nasal cannula 
    3. Suction catheter 
    4. Padding for side rails
    1. Restraints
  141. A nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair? 
    1. Arrange for a transfer board to be used. 
    2. Perform the transfer using a hydraulic lift only. 
    3. Put the client's shoes on so that the client will not slip on the floor during the transfer. 
    4. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
    4. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
  142. The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety? 
    1. Maintain the client in a supine position. 
    2. Change the NG tube with every other feeding. 
    3. Increase the rate of the feeding if the infusion falls behind schedule. 
    4. Check for tube placement and residual amount at least every 4 hours.
    4. Check for tube placement and residual amount at least every 4 hours.
  143. A client is scheduled for insertion of a peripherally inserted central catheter (PICC) and the nurse explains the advantages of this catheter. Which statement by the client indicates a need for follow-up? 
    1. "It is reasonable in cost." 
    2. "This type of catheter is very reliable."
    3. "It is specifically designed for short-term use." 
    4. "I should not have pain or discomfort with this catheter."
    3. "It is specifically designed for short-term use."
  144. A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. At which frequency should the nurse plan to check the IV sites of these clients? 
    1. Every hour 
    2. Every 2 hours 
    3. Every 3 hours 
    4. Every 4 hours
    1. Every hour
  145. A 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 should document in the medical record that which occurred? 
    1. Phlebitis of the vein 
    2. Infiltration of the IV line 
    3. Hypersensitivity to the IV solution 
    4. Allergic reaction to the IV catheter
    1. Phlebitis of the vein
  146. A nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? 
    1. Band-Aid 
    2. Alcohol swab 
    3. Betadine swab 
    4. Sterile 2 × 2 gauze
    4. Sterile 2 × 2 gauze
  147. A 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 health care provider has prescribed a dose that is twice the amount that the client has reported taking before admission. What is the most appropriate nursing action?
    1. Contact the health care provider directly. 
    2. Administer the medication as prescribed. 
    3. Question the client if the reported dosage is accurate. 
    4. Call the hospital pharmacy to clarify the prescription.
    1. Contact the health care provider directly.
  148. A nurse 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? 
    1. Extinguish the fire. 
    2. Activate the fire alarm. 
    3. Confine the fire and then call 911. 
    4. Remove the client from the waiting room.
    4. Remove the client from the waiting room.
  149. The health care provider writes a prescription to apply a heating pad to a client's back. Which intervention is contraindicated and is unsafe? 
    1. Setting the heating pad on a low setting 
    2. Assessing the skin frequently for burns 
    3. Placing the heating pad under the client 
    4. Using tape to hold heating pad in place
    3. Placing the heating pad under the client
  150. A nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What should the nurse instruct the client to do? 
    1. Avoid the use of commercially prepared ice bags. 
    2. Keep the ice pack on the eye continuously for 24 hours. 
    3. Place the ice pack directly on the eye and cover with gauze. 
    4. Cover the ice pack with a pillowcase and place it on the eye.
    4. Cover the ice pack with a pillowcase and place it on the eye.
  151. A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel (UAP) to clean up the blood spill is incorrect? 
    1. Uses tongs to collect any broken glass 
    2. Wears gloves for the cleaning procedure 
    3. Blots up the spill with a face cloth or cloth towel 
    4. Disinfects the area of the blood spill with a dilute bleach solution
    3. Blots up the spill with a face cloth or cloth towel
  152. 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 should include taking which action first if an accidental poisoning occurs? 
    1. Induce vomiting. 
    2. Call an ambulance. 
    3. Bring the child to urgent care. 
    4. Call the poison control center.
    4. Call the poison control center.
  153. The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse should plan to place the right-sided arm in which position? 
    1. Elevated above shoulder level 
    2. Elevated on one or two pillows 
    3. Level with the right-sided atrium 
    4. Dependent to the right-sided atrium
    2. Elevated on one or two pillows
  154. The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action? 
    1. Remove the tube, and notify the health care provider. 
    2. Instruct the client to hold their breath and insert the NG tube. 
    3. Remove the tube, and reinsert when the client fully recovers. 
    4. Pull back on the tube, and wait until the client is breathing easily.
    4. Pull back on the tube, and wait until the client is breathing easily.
  155. The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action? 
    1. Assess tube placement. 
    2. Flush with 30 mL of sterile saline. 
    3. Aspirate to determine residual volume. 
    4. Administer the antacid by gravity flow.
    1. Assess tube placement.
  156. Treatment for a client with bleeding esophageal varices has been unsuccessful and the health care provider decides to insert a Sengstaken-Blakemore tube. What is the priority nursing action? 
    1. Request an obturator. 
    2. Obtain a Kelly clamp. 
    3. Place a pair of scissors at client's bedside. 
    4.Pour sterile water in the irrigation set basins.
    3. Place a pair of scissors at client's bedside.
  157. The nurse is performing discharge teaching for a client with a peripherally inserted central catheter (PICC). Which instructions should the nurse include? Select all that apply. 
    1. Wear a Medic-Alert tag or bracelet. 
    2. Report redness or swelling at the catheter insertion site. 
    3. Have a repair kit available in the home for use if needed. 
    4. Keep activity level to a minimum while this catheter is in place. 
    5. Cover the PICC dressing with plastic when in the shower or bath.
    • 1. Wear a Medic-Alert tag or bracelet. 
    • 2. Report redness or swelling at the catheter insertion site. 
    • 3. Have a repair kit available in the home for use if needed.
    • 5. Cover the PICC dressing with plastic when in the shower or bath.

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