1. A nurse is planning to collect a stool specimen for ova and
parasites from a client who has diarrhea. Which of the following
actions should the nurse take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a
bedpan or a container for stool collection. The toilet water can
dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean
container using a tongue depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen
immediately to the laboratory after labeling the specimen properly to
prevent contamination with microorganisms and keep the specimen
from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a
biohazard bag with the client label on the container and the bag for
easy identification. This will also prevent contamination with
microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires
suctioning. Which of the following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper
oxygenate the client for several minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases
the risk of damage to the tracheal mucosa and removes oxygen
from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
,3. A nurse is providing teaching to a client regarding protein intake.
Which of the following foods should the nurse include as an
example of an incomplete protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential
amino acids necessary for the synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential
amino acids necessary for the synthesis of protein in the body.
,C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino
acids necessary for the synthesis of protein in the body. Examples
of incomplete proteins include lentils, vegetables, grains, nuts, and
seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential
amino acids necessary for the synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care
facility for rehabilitation after a total hip arthroplasty. At which of the
following times should the nurse begin discharge planning?
A. One week prior to the client‟s discharge
-incorrect: Beginning to plan for the client‟s discharge a week prior to
the event might not allow sufficient time for planning. The nurse
should begin discharge planning at the time of admission. B. Upon the
client‟s admission to the care facility
-The nurse should begin discharge planning at the time that the client is
admitted to the facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client‟s discharge once the
discharge date is identified might not allow sufficient time for planning.
The nurse should begin discharge planning at the time of admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client‟s discharge once the
discharge date is identified might not allow sufficient time for planning.
The nurse should begin discharge planning at the time of admission.
5. A nurse is preparing to administer a cleansing enema to a
client. Which of the following actions should the nurse plan to
take?
A. Insert the rectal tube 15.2 cm (6 in)
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent
contamination.
C. Position the client on his left side
-Positioning is an important aspect of administering an enema.
Having the client lie on his left side facilitates the flow of the enema
solution into the sigmoid and descending colon.
D. Hold the solution bag 91 cm (36 inch) above the client‟s rectum
-incorrect: The nurse should hold the solution bag 30 cm (12 in)
above the client‟s rectum for a low enema and 45 cm (18 in) for a high
, enema. If the nurse holds the solution bag too high, the solution
might run in too fast, causing discomfort and spasms that make
retaining the enema more difficult.
5. A nurse is caring for a client who has bilateral cats on her
hands. Which of the following actions should the nurse take when
assisting the client with feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the
bedside provides the client with the nurse‟s full attention during the
feeding
parasites from a client who has diarrhea. Which of the following
actions should the nurse take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a
bedpan or a container for stool collection. The toilet water can
dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean
container using a tongue depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen
immediately to the laboratory after labeling the specimen properly to
prevent contamination with microorganisms and keep the specimen
from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a
biohazard bag with the client label on the container and the bag for
easy identification. This will also prevent contamination with
microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires
suctioning. Which of the following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper
oxygenate the client for several minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases
the risk of damage to the tracheal mucosa and removes oxygen
from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
,3. A nurse is providing teaching to a client regarding protein intake.
Which of the following foods should the nurse include as an
example of an incomplete protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential
amino acids necessary for the synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential
amino acids necessary for the synthesis of protein in the body.
,C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino
acids necessary for the synthesis of protein in the body. Examples
of incomplete proteins include lentils, vegetables, grains, nuts, and
seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential
amino acids necessary for the synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care
facility for rehabilitation after a total hip arthroplasty. At which of the
following times should the nurse begin discharge planning?
A. One week prior to the client‟s discharge
-incorrect: Beginning to plan for the client‟s discharge a week prior to
the event might not allow sufficient time for planning. The nurse
should begin discharge planning at the time of admission. B. Upon the
client‟s admission to the care facility
-The nurse should begin discharge planning at the time that the client is
admitted to the facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client‟s discharge once the
discharge date is identified might not allow sufficient time for planning.
The nurse should begin discharge planning at the time of admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client‟s discharge once the
discharge date is identified might not allow sufficient time for planning.
The nurse should begin discharge planning at the time of admission.
5. A nurse is preparing to administer a cleansing enema to a
client. Which of the following actions should the nurse plan to
take?
A. Insert the rectal tube 15.2 cm (6 in)
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent
contamination.
C. Position the client on his left side
-Positioning is an important aspect of administering an enema.
Having the client lie on his left side facilitates the flow of the enema
solution into the sigmoid and descending colon.
D. Hold the solution bag 91 cm (36 inch) above the client‟s rectum
-incorrect: The nurse should hold the solution bag 30 cm (12 in)
above the client‟s rectum for a low enema and 45 cm (18 in) for a high
, enema. If the nurse holds the solution bag too high, the solution
might run in too fast, causing discomfort and spasms that make
retaining the enema more difficult.
5. A nurse is caring for a client who has bilateral cats on her
hands. Which of the following actions should the nurse take when
assisting the client with feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the
bedside provides the client with the nurse‟s full attention during the
feeding
