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1. A nurse is caring for a client who reports pain. When
documenting the quality of the client's pain on an initial pain
assessment, the nurse should record which of the following?:
Answer "The pain is like a dull ache in my stomach"
2. A client who is non-ambulatory notifies the nurse that his trash
can is on fire. After the nurse confirms the presence of the fire,
which of the following actions should the nurse take next?:
Answer Evacuate the client
3. A nurse is completing an admission assessment for a client
who reports vomiting and diarrhea for the past 3 days. Which of
the following findings should the nurse expect?
Answer: Rapid heart rate
4. A nurse has accepted a verbal prescription for three tenths of a
milligram of levothyroxine IV stat for a client who has myxedema
coma. How should the nurse transcribe the dosage of this
medication in the client's medical record?
Answer: 0.3 mg
, 5. A nurse is preparing a heparin infusion for a client who was
admitted to the facility with DVT. The prescription reads: 25,000
units of heparin in 0.9% sodium chloride 250 mL to infuse at 800
units/hr. At what rate should the nurse set the infusion pump?
(Round to the nearest whole number)
Answer: 8 mL/hr
6. A nurse is caring for a client who has a prescription for wound
irrigation. Which of the following actions should the nurse take?
Answer: Cleanse the wound from the center outward.
7. A nurse is caring for a client who is receiving fluid through a
peripheral IV catheter. Which of the following findings at the IV site
should the nurse identify as indicating infiltration?
Answer: Skin blanching
8. A nurse is teaching a client whose left leg is in a cast about using
crutches. Which of the following statements should the nurse
identify as an indication that the client understands the teaching?
Answer: "When descending stairs, I will first shift my weight to my right
leg"
9. A nurse is caring for a client who has an NG tube and is
receiving intermit- tent feedings through and open system. Which
of following action should the nurse take first?
Answer: Tell the client to keep the head of the bed elevated at least 30
degrees
10. A nurse is reviewing a client's medication prescription that reads,
"digoxin
0.25 by mouth every day." Which of the following components of the
prescrip- tion should the nurse verify with the provider?
Answer: Medication dose
11. A nurse is caring for a client who has recently started using a be-