1. A nurse is performing tracheostomy care for a client who is
postop following a laryngectomy. Which of the following
actions take when suctioning the client’s airway?
ANS>Apply suction for 10 seconds
2. A nurse is preparing to administer a long acting insulin to a client
who has DM.
Which of the following actions should the nurse take first?
ANS>Check the correct dose with another licensed nurse
3. A nurse is caring for an older adult client in the PACU following gen
anesthesia. Which of the following should the nurse report to the
provider?
ANS>Audible stridor
4. A nurse is planning an educational session for staff nurses about
working with parents whose terminally ill children are candidates for
donating their organs. Which of the following information should the
nurse plan to include?
ANS>The family can have the child in an open casket without fearing
that the
organ donation might disfigure the child’s body.
5. Math ANS>0.6mL
,6. A nurse manager is planning to make changes to the current
scheduling system on the unit. To facilitate the staff’s acceptance
of this change, which of the following actions should the nurse
manager take first?
ANS>Provide information about scheduling issues to the staff
7. A nurse is assessing a client who is receiving a blood transfusion.
Which of the following findings should indicate to the nurse that
the client is having a hemolytic transfusion reaction?
ANS>Low back pain
8. A nurse is assessing a client who has macular degeneration.
Which of the following findings should the nurse expect?
ANS>Decreased central vision
9. A nurse who is working in a long-term care facility is assessing
an adult client. Which of the following findings places the client at
risk for development of a pressure injury?
ANS>Recent weight loss
10. A nurse is teaching about TPN and IV lipid emulsion with a client
who has an extensive burn injury. Which of the following information
should the nurse include?
ANS> “you will receive finger sticks for blood glucose testing.”
, 11. A nurse is caring for a client who has dehydration secondary to
nausea and vomiting. The nurse should identify which of the
following findings as an indication of fluid volume deficit?
ANS>Orthostatic hypotension
12. A nurse is caring for a client who is in labor at 39 weeks of
gestation. During the second stage of labor, the nurse observes
early decelerations on the monitor tracing. Which of the following
actions should the nurse take?
ANS>Continue observing the fetal heart rate
13. A nurse is caring for a client who requires physical therapy
following discharge. Which of the following actions should the
nurse take?
ANS>Involve the client in the selection of a physical therapy provider
14. A nurse is assessing a client who has sickle cell anemia. The
nurse should identify which of the following findings as a
manifestation of vaso- occlusive crisis?
ANS>Hematuria
15. A nurse is teaching a group of guardians about child safety
measures. Which of the following statements by a guardian
indicates an understanding of the teaching?
ANS>I should have my child avoid sun exposure between 10am and
2pm
16. A nurse is caring for four clients at the beginning of a shift. After
receiving change of shift report, which of the following clients
should the nurse attend to first?
ANS>A client who is confused and has been attempting to get out of
bed.
17. A nurse is assessing a client who has been taking lithium
carbonate for the past month to treat bipolar disorder. Which of the
following assessment findings should the nurse identify as the
priority?
ANS>Confusion
18. A nurse manager is on a planning committee to develop an