A nurse is preparing to mix short acting and intermediate acting insulin in one syringe to
administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse
should follow - ANSWER To mix insulin from two vials in the same syringe, the nurse
should first draw up a volume of air equal to the volume of insulin from the intermediate-
acting insulin vial. The nurse should then inject the volume of air equal to the amount of
insulin to withdraw from the intermediate-acting insulin vial, making sure the needle does
not touch the insulin. Next, the nurse should inject the volume of air equal to the insulin
dose from the short-acting insulin vial. Then, the nurse should withdraw the prescribed
amount of insulin from the short-acting insulin vial. Lastly, the nurse should withdraw the
prescribed amount of insulin from the intermediate-acting insulin vial. The insulins are now
mixed and ready to administer.
A nurse is providing discharge teaching to a client who has a new prescription for home
oxygen therapy utilizing a compressed oxygen system. Which of the following statements by
the client indicates an understanding of the teaching - ANSWER "I will store my oxygen
tanks in an upright position"
This statement by the client indicates an understanding of the teaching. The nurse should
instruct the client to store oxygen tanks in an upright position in a holder to prevent damage
to the tank and injury to the client and the client's family.
A nurse is evaluating preoperative teaching with a client who is to undergo surgery with
general anesthesia. Which of the following statements by the client indicates an
understanding of the teaching? - ANSWER "I should remove nail polish from my
fingers before surgery
The nurse should instruct the client to remove nail polish for accurate pulse oximetry
monitoring and for a clear view of the nail beds when assessing capillary refill.
1
,A nurse is providing teaching about cough etiquette to a client who has influenza. Which of
the following instructions should the nurse include in the teaching? - ANSWER "Cover
your mouth and nose with a tissue when coughing"
The nurse should instruct the client to cover their nose and mouth with a tissue when
coughing. The client should discard the tissue promptly in the nearest trash container
A nurse is planning care for a client who has a history of seizures. Which of the following
interventions should the nurse include in the plan of care? - ANSWER Ensure oral
suction equipment is at the bedside; to prevent aspiration of oral secretions during seizure
A nurse is assessing an older adult client who has become increasingly confused and
agitated in the last 48 hrs. Which of the following conditions should the nurse expect? -
ANSWER UTI
According to EBP, the RN should expect the client who has a UTI to become increasingly
confused and agitated. Confusion and agitation in older adult clients often result from a
systemic infection, such as a UTI or pneumonia
A nurse is assessing a client who has an NG tube and is receiving continuous enteral
feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the
feeding, which of the following actions should the nurse take next? - ANSWER Turn
client onto side
The greatest risk to this client is aspiration from possible dislodgment of the NG tube and
aspirated stomach contents into the respiratory tract.
A nurse is assessing a client for hearing acuity by performing the Rinne Test. Which of the
following actions should the nurse take? - ANSWER Move a vibrating tuning fork's
prongs in front of the client's left or right ear canal. The nurse should perform the Rinne test
by placing the handle of a vibrating tuning fork on the client's mastoid process and then
moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left or right ear
canal. The Rinne test compares bone conduction with air conduction. The client is expected
to hear sound conduction by air for twice as long as bone conduction.
A nurse is caring for a client who had a stroke and is immobile. Which of the following
actions should the nurse take to maintain the client's skin integrity? - ANSWER Apply
2
, an alcohol free barrier product; to keep the pt's skin dry and protect it from the collection of
moisture. This action will help to maintain the integrity of the pt's skin
A nurse is completing a preadmission interview for a client who is to undergo surgery the
following day. The client reports a latex allergy. Which of the following interventions should
the nurse include when planning care? (SATA) - ANSWER Notify ancillary departments
of the client's allergy
Label the surgical suite as latex-free
Ensure latex allergy cart is available
A nurse is preparing to transfer a pt who weighs 136 kg/300 lb from a bed to a stretcher with
the aid of an AP. Which of the following actions should the nurse take? - ANSWER Use
an air-assisted transfer device to move the client.
The nurse should place an air-assisted device under the client prior to transfers to prevent
injury. An air-assisted transfer device is an inflatable mattress that minimizes friction to
smoothly and efficiently move the client from the bed to the stretcher. In addition, at least
two caregivers should assist with the transfer of a client who weighs 136 kg (300 lb).
A home health nurse is performing a home assessment for an older adult client. which of the
following statements by the client should alert the nurse to suggesst additional safety
measures? - ANSWER ""I use space heaters to keep warm in the winter"
A common environmental hazard in the home is the use of space heaters, which can
increase the risk of fire.
A RN is caring for a client who has terminal illness. The client request a DNR order, but their
family opposes the decision. Which of the following actions should the nurse take first.? -
ANSWER Gather information to support the client's request for a DNR
Using the nursing process, the first action the nurse should take is to assess the situation by
gathering information to support the client's request for a DNR order. This information
should include the client's current clinical status, factors such as the client's spirituality,
culture, and family dynamics, and evidence from literature about the client's condition.
3
administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse
should follow - ANSWER To mix insulin from two vials in the same syringe, the nurse
should first draw up a volume of air equal to the volume of insulin from the intermediate-
acting insulin vial. The nurse should then inject the volume of air equal to the amount of
insulin to withdraw from the intermediate-acting insulin vial, making sure the needle does
not touch the insulin. Next, the nurse should inject the volume of air equal to the insulin
dose from the short-acting insulin vial. Then, the nurse should withdraw the prescribed
amount of insulin from the short-acting insulin vial. Lastly, the nurse should withdraw the
prescribed amount of insulin from the intermediate-acting insulin vial. The insulins are now
mixed and ready to administer.
A nurse is providing discharge teaching to a client who has a new prescription for home
oxygen therapy utilizing a compressed oxygen system. Which of the following statements by
the client indicates an understanding of the teaching - ANSWER "I will store my oxygen
tanks in an upright position"
This statement by the client indicates an understanding of the teaching. The nurse should
instruct the client to store oxygen tanks in an upright position in a holder to prevent damage
to the tank and injury to the client and the client's family.
A nurse is evaluating preoperative teaching with a client who is to undergo surgery with
general anesthesia. Which of the following statements by the client indicates an
understanding of the teaching? - ANSWER "I should remove nail polish from my
fingers before surgery
The nurse should instruct the client to remove nail polish for accurate pulse oximetry
monitoring and for a clear view of the nail beds when assessing capillary refill.
1
,A nurse is providing teaching about cough etiquette to a client who has influenza. Which of
the following instructions should the nurse include in the teaching? - ANSWER "Cover
your mouth and nose with a tissue when coughing"
The nurse should instruct the client to cover their nose and mouth with a tissue when
coughing. The client should discard the tissue promptly in the nearest trash container
A nurse is planning care for a client who has a history of seizures. Which of the following
interventions should the nurse include in the plan of care? - ANSWER Ensure oral
suction equipment is at the bedside; to prevent aspiration of oral secretions during seizure
A nurse is assessing an older adult client who has become increasingly confused and
agitated in the last 48 hrs. Which of the following conditions should the nurse expect? -
ANSWER UTI
According to EBP, the RN should expect the client who has a UTI to become increasingly
confused and agitated. Confusion and agitation in older adult clients often result from a
systemic infection, such as a UTI or pneumonia
A nurse is assessing a client who has an NG tube and is receiving continuous enteral
feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the
feeding, which of the following actions should the nurse take next? - ANSWER Turn
client onto side
The greatest risk to this client is aspiration from possible dislodgment of the NG tube and
aspirated stomach contents into the respiratory tract.
A nurse is assessing a client for hearing acuity by performing the Rinne Test. Which of the
following actions should the nurse take? - ANSWER Move a vibrating tuning fork's
prongs in front of the client's left or right ear canal. The nurse should perform the Rinne test
by placing the handle of a vibrating tuning fork on the client's mastoid process and then
moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left or right ear
canal. The Rinne test compares bone conduction with air conduction. The client is expected
to hear sound conduction by air for twice as long as bone conduction.
A nurse is caring for a client who had a stroke and is immobile. Which of the following
actions should the nurse take to maintain the client's skin integrity? - ANSWER Apply
2
, an alcohol free barrier product; to keep the pt's skin dry and protect it from the collection of
moisture. This action will help to maintain the integrity of the pt's skin
A nurse is completing a preadmission interview for a client who is to undergo surgery the
following day. The client reports a latex allergy. Which of the following interventions should
the nurse include when planning care? (SATA) - ANSWER Notify ancillary departments
of the client's allergy
Label the surgical suite as latex-free
Ensure latex allergy cart is available
A nurse is preparing to transfer a pt who weighs 136 kg/300 lb from a bed to a stretcher with
the aid of an AP. Which of the following actions should the nurse take? - ANSWER Use
an air-assisted transfer device to move the client.
The nurse should place an air-assisted device under the client prior to transfers to prevent
injury. An air-assisted transfer device is an inflatable mattress that minimizes friction to
smoothly and efficiently move the client from the bed to the stretcher. In addition, at least
two caregivers should assist with the transfer of a client who weighs 136 kg (300 lb).
A home health nurse is performing a home assessment for an older adult client. which of the
following statements by the client should alert the nurse to suggesst additional safety
measures? - ANSWER ""I use space heaters to keep warm in the winter"
A common environmental hazard in the home is the use of space heaters, which can
increase the risk of fire.
A RN is caring for a client who has terminal illness. The client request a DNR order, but their
family opposes the decision. Which of the following actions should the nurse take first.? -
ANSWER Gather information to support the client's request for a DNR
Using the nursing process, the first action the nurse should take is to assess the situation by
gathering information to support the client's request for a DNR order. This information
should include the client's current clinical status, factors such as the client's spirituality,
culture, and family dynamics, and evidence from literature about the client's condition.
3
