NSG 230 Final Exam
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which
of the following interventions should the nurse implement to prevent infection?
a) Thread the IV catheter so that the hub rests at the insertion site
b) Shave excess hair from around the insertion site
c) Cleanse the site with hydrogen peroxide before IV catheter insertion
d) Palpate the site carefully just before inserting the IV catheter - ANS A
Inserting the catheter up to the hub reduces the risk of contaminating along the length of the catheter
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following
major abdominal surgery. Which of the following is the nurse's priority action?
a) Request that a respiratory therapist discuss the technique for incentive spirometry
b) Administer a pain medication to the client
c) Chart the client's refusal to participate in health restorative activities
d) Determine the reasons why the client is refusing the use the incentive spirometer - ANS D
A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After
the injection, which of the following is an appropriate action by the nurse?
a) Return the unused portion to the pharmacy
b) Have another nurse witness the disposal of the excess medication
c) Place the syringe with the unused portion in a locked medication drawer
d)Discard the unused medication in the sharps container - ANS B
,meperidine is a controlled substance
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
SATA
a) Place the client in a negative pressure room
b) wear gloves when assisting the client with oral care
c) limit each visitor to 2 hr increments
d) wear a surgical mask when providing care
e) Use antimicrobial sanitizer for hand hygiene - ANS A, B, E
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of
the following information should the nurse include in the teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-based hand sanitizer when leaving the clients room
c) clean contaminated surfaces in the clients room with a phenol solution
d) have family members wear a gown and gloves when visiting - ANS D
A nurse is providing teaching to a client about techniques to promote sleep. Which of the following
instructions should the nurse include in the teaching?
a) Consume a light snack of carbohydrates at bedtime
b) Drink warm tea at bedtime
c) watch TV in bed util drowsy
d) exercise 1 hr before bedtime - ANS A
, A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the
client has developed phlebitis and removes the IV catheter. Which of the following actions should the
nurse take next?
a) place a warm compress over the IV site
b) record the findings in the client's chart
c) notify the client's primary care provider
d) prepare to insert a new IV catheter - ANS A
The greatest risk to the client is further injury. The next action should take is to apply a warm compress
over the IV site to decrease edema and client discomfort.
A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates
to the charge nurse that the sterile field is contaminated?
a) Outer edges of the sterile field is touching a bottle
b) first fold is opened away from the body
c) sterile objects are held above the waist
d) sterile field is opened on a wet surface - ANS D
Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria
through the dressing
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse
take to minimize the risk for injury for this client?
a) use a bed exit alarm system
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which
of the following interventions should the nurse implement to prevent infection?
a) Thread the IV catheter so that the hub rests at the insertion site
b) Shave excess hair from around the insertion site
c) Cleanse the site with hydrogen peroxide before IV catheter insertion
d) Palpate the site carefully just before inserting the IV catheter - ANS A
Inserting the catheter up to the hub reduces the risk of contaminating along the length of the catheter
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following
major abdominal surgery. Which of the following is the nurse's priority action?
a) Request that a respiratory therapist discuss the technique for incentive spirometry
b) Administer a pain medication to the client
c) Chart the client's refusal to participate in health restorative activities
d) Determine the reasons why the client is refusing the use the incentive spirometer - ANS D
A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After
the injection, which of the following is an appropriate action by the nurse?
a) Return the unused portion to the pharmacy
b) Have another nurse witness the disposal of the excess medication
c) Place the syringe with the unused portion in a locked medication drawer
d)Discard the unused medication in the sharps container - ANS B
,meperidine is a controlled substance
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
SATA
a) Place the client in a negative pressure room
b) wear gloves when assisting the client with oral care
c) limit each visitor to 2 hr increments
d) wear a surgical mask when providing care
e) Use antimicrobial sanitizer for hand hygiene - ANS A, B, E
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of
the following information should the nurse include in the teaching?
a) Assign the client to a room with a negative air-flow system
b) Use alcohol-based hand sanitizer when leaving the clients room
c) clean contaminated surfaces in the clients room with a phenol solution
d) have family members wear a gown and gloves when visiting - ANS D
A nurse is providing teaching to a client about techniques to promote sleep. Which of the following
instructions should the nurse include in the teaching?
a) Consume a light snack of carbohydrates at bedtime
b) Drink warm tea at bedtime
c) watch TV in bed util drowsy
d) exercise 1 hr before bedtime - ANS A
, A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the
client has developed phlebitis and removes the IV catheter. Which of the following actions should the
nurse take next?
a) place a warm compress over the IV site
b) record the findings in the client's chart
c) notify the client's primary care provider
d) prepare to insert a new IV catheter - ANS A
The greatest risk to the client is further injury. The next action should take is to apply a warm compress
over the IV site to decrease edema and client discomfort.
A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates
to the charge nurse that the sterile field is contaminated?
a) Outer edges of the sterile field is touching a bottle
b) first fold is opened away from the body
c) sterile objects are held above the waist
d) sterile field is opened on a wet surface - ANS D
Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria
through the dressing
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse
take to minimize the risk for injury for this client?
a) use a bed exit alarm system
