Ra onales Included | Newly Updated 2025/2026
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
con nuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes
ago, but feels fine now. What ac on is best for the nurse to take? - A!er clearing the tube with
30 ml of air, check the pH of fluid withdrawn from the tube.
A client is in the radiology department at 0900 when the prescrip on levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is
the best interven on for the nurse to implement? - Give the missed dose at 1300 and change
the schedule to administer daily at 1300.
A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which ac on should the nurse
implement? - Give an around-the-clock schedule for administra on of analgesics.
A!er comple ng an assessment and determining that a client has a problem, which ac on
should the nurse perform next? - determine the e ology of the problem
What is the most important reason for star ng intravenous infusions in the upper extremi es
rather than the lower extremi es of adults? - A decreased flow rate could result in the
forma on of a thrombosis.
The nurse no ces that the mother of a 9-year-old Vietnamese child always looks at the floor
when she talks to the nurse. What ac on should the nurse take? - Con nue asking the mother
ques ons about the child.
Which interven on is most important for the nurse to implement for a male client who is
experiencing urinary reten on? - Assess for bladder disten on.
, A client who is a Jehovah's Witness is admi7ed to the nursing unit. Which concern should the
nurse have for planning care in terms of the client's beliefs? - Blood transfusions are forbidden.
While instruc ng a male client's wife in the performance of passive range-of-mo on exercises
to his contracted shoulder, the nurse observes that she is holding his arm above and below the
elbow. What nursing ac on should the nurse implement? - Acknowledge that she is suppor ng
the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client posi on for
administra on of the bolus tube feedings? - Fowler's.
An adult male client with a history of hypertension tells the nurse that he is red of taking
an hypertensive medica ons and is going to try spiritual medita on instead. What should be
the nurse's first response? - It is important that you con nue your medica on while learning to
meditate.
A client is to receive cime dine (Tagamet) 300 mg q6h IVPB. The prepara on arrives from the
pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20
minutes. For how many ml/hr should the infusion pump be set to deliver the secondary
infusion? - 150
The nurse is comple ng a mental assessment for a client who is demonstra ng slow thought
processes, personality changes, and emo onal lability. Which area of the brain controls these
neuro-cogni ve func ons? - Frontal lobe
A client is receiving a cephalosporin an bio c IV and complains of pain and irrita on at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above
the IV access site. Which ac on should the nurse take at this me? - Ini ate an alternate site
for the IV infusion of the medica on.