Accurately Answered Updated 2025/2026
A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of
the following actions should the nurse take when performing tracheostomy care for the
client? - correct answer Soak the inner cannula of the tracheostomy tube in normal
saline.
A nurse is caring for a client who has a gastric ulcer. The nurse should explain that
prolonged exposure of the body to stress can also cause which of the following to
occur? - correct answer Hyperglycemia
A nurse manager is providing teaching to a group of newly licensed nurses about ways
that clients acquire healthcare associated infections (HAI's). Which of the following
routes of infection should the manager identify as an iatrogenic HAI? - correct answer
Infection acquired from a diagnostic procedure
A nurse is collecting data from a client who is postoperative. Which of the following
findings should the nurse identify as an indication that the client is experiencing pain? -
correct answer Grimacing
A nurse is monitoring a client's laboratory results. Which of the following results should
the nurse report to the provider? - correct answer Potassium 3.0 mEq/L (Potassium
normal levels is 3.5-5.3)
A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her
neck with both hands and appears frightened. Which of the following actions should the
nurse take first? - correct answer Determine whether the client is able to breathe
A nurse is reinforcing teaching with a client who is using a patient controlled analgesia
(PCA) pump to deliver morphine for pain management. Which of the following
statements should the nurse identify as an indication that the client understands the
instructions? - correct answer "I can still use my TENS unit even though I'm pushing
the PCA button."
,A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk
from a bed to a wheelchair. Which of the following techniques should the nurse use? -
correct answer Place the wheelchair at a 45 degree angle to the bed
A nurse is caring for a client who had a mastectomy and has a self-suction drainage
evacuator in place. Which of the following actions should the nurse take to ensure paper
operation of the device? - correct answer Collapse air from the device after emptying
A nurse is discussing fire safety with newly hired nurses. Which of the following actions
is the priority if a fire occurs in the healthcare facility? - correct answer Evacuate
clients from the unit
A nurse is teaching a client who has asthma about the proper use of an albuterol
inhaler. Which of the following client statements indicates an understanding of the
teaching? - correct answer "I will shake the inhaler well right before I use it."
A nurse is contributing to the plan of care for a client who has a wound infection
following abdominal surgery. To promote healing and fight infection, which of the
following vitamins and/or minerals should the nurse plan to increase in the client's diet?
- correct answer Vitamin C and Zinc
A nurse is preparing to instill a vaginal medication in suppository form to a client. Which
of the following actions should the nurse take during this procedure? - correct answer
Use the index finger to insert the suppository
A nurse is reinforcing teaching with a client about the use of a straight legged cane.
Which of the following client actions indicates an understanding of the teaching? -
correct answer The client holds the cane on the unaffected side.
A nurse is administering a controlled substance to a client who is postoperative. The IM
dosage requires the nurse to use only part of th amount of medication in the vial. Which
of the following actions should the nurse take? - correct answer Have another nurse
witness the disposal of the medication
, A nurse is administering medication to a client who asks the nurse to leave the
medication at the bedside so she can take it at a later time. Which of the following
responses should the nurse provide? - correct answer "Call me when you are ready,
and I will return with the medication."
A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve
stimulation (TENS) for pain management. The client asks the nurse how a TENS unit
help relieve pain. Which of the following responses should the nurse make? - correct
answer "It modulates the transmission of the pain impulse."
A nurse is assisting with the care of a client who is having difficulty with muscle
coordination following a head injury. The nurse should suspect an injury to which of the
following areas of the brain? - correct answer Cerebellum
A nurse is reinforcing teaching with a client who has hypertension and is starting
medication therapy for treatment. The provider has a recommend that, because of these
new medications, the client should increase her intake of potassium. Which of the
following foods should the nurse remind the client to include in her diet? - correct
answer Bananas
A nurse is preparing to collect data about the function of a client's trigeminal nerve or
cranial nerve (CN) V. Which of the following items should the nurse gather for the test? -
correct answer Cotton wisps
A nurse in a provider's office is reinforcing teaching with a client about foods that are
high in fiber. Which of the following food choices made by the client indicate an
understanding of the teaching? - correct answer Black beans, Whole-grain bread
A nurse is performing suctioning for a client who has a tracheostomy. Which of the
following actions should the nurse take? - correct answer Pull back the suction
catheter by 1cm (0.5in) if the client starts coughing
A nurse is caring for a client who is receiving continuous enteral feedings through an
NG tube and develops diarrhea. Which of the following actions should the nurse take? -
correct answer Request a prescription for an isotonic enteral nutrition formula