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& B QUESTIONS AND ANSWERS VALIDATED
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AND GRADED A+
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,A nurse is caring for a client who reports pain. When documenting the quality of the
client's pain on an initial pain assessment, the nurse should record which of the
following client statements?
"I am having mild pain"
"The pain is like a dull ache in my stomach"
"I notice that the pain gets worse after I eat"
"The pain makes me feel nauseous"
"The pain is like a dull ache in my stomach"
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A client in non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms
the presence of the fire, which of the following actions should the nurse take next?
Activate the emergency fire alarm
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Extinguish the fire
Evacuate the client
Confine the fire
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Evacuate the client
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A nurse is completing an admission assessment for a client who reports vomiting and diarrhea
for the past 3 days. Which of the following findings should the nurse expect?
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Neck vein distention
Urine specific gravity 1.010
Rapid Heart rate
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Blood pressure 144/82 mmHg
Rapid heart rate
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A nurse has accepted a verbal prescription for "thee tenths of a milligram of levothyroxine IV
stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this
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medication in the client's medical record?
.3 mg
0.3 mg
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0.30 mg
3/10 mg
0.3 mg
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep
vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 ml
to infuse at 800 units/hour. At what rate should the nurse set the infusion pump?
8 ml/hour
, A nurse is caring for a client who has a prescription for wound irrigation. Which of the following
actions should the nurse take?
Wear sterile gloves when removing the old dressing
Warm the irrigation solution to 40.5 C (105 F)
Cleanse the wound from the center outward
Use a 20 ml syringe to irrigate the wound
Cleanse the wound from the center outward
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A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the
following findings at the IV site should the nurse identify as indicating infiltration?
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Purulent exudate
Warmth
Skin blanching
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Bleeding
Skin blanching
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A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the
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following statements should the nurse identify as an indication that the client understands the
teaching?
"When descending the stairs, I will first shift my weight to my right leg"
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"I should place my crutches 12 inches in front and to the side of each foot"
"As I sit down, I will hold one crutch in each hand"
"I will make sure the shoulder rests are snug against my armpits"
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"When descending the stairs, I will first shift my weight to my right leg"
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A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through
an open system. Which of the following actions should the nurse take first?
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Rinse the feeding back with water between feedings
Tell the client to keep the head of the bed elevated at least 30 degrees
Make sure the enteral formula is at room temperature
Wipe the top of the formula can with alcohol
Tell the client to keep the head of the bed elevated at least 30 degrees