Tests A & B
Anurseiscaringforaclientwhoreportspain.Whendocumentingthequalityoftheclient'spainonani
nitialpainassessment,thenurseshouldrecordwhichofthefollowingclientstatements?
"Iamhavingmildpain"
"Thepainislikeadullacheinmystomach"
"InoticethatthepaingetsworseafterIeat"
"Thepainmakesmefeelnauseous"-Correctanswer~"Thepainislikeadullacheinmystomach"
Aclientinnonambulatorynotifiesthenursethathistrashcanisonfire.Afterthenurseconfirmsthepr
esenceofthefire,whichofthefollowingactionsshouldthenursetakenext?
Activatetheemergencyfirealarm
Extinguishthefire
Evacuatetheclient
Confinethefire-Correctanswer~Evacuatetheclient
Anurseiscompletinganadmissionassessmentforaclientwhoreportsvomitinganddiarrheaforthe
past3days.Whichofthefollowingfindingsshouldthenurseexpect?
Neckveindistention
Urinespecificgravity1.010
RapidHeartrate
Bloodpressure144/82mmHg-Correctanswer~Rapidheartrate
,Anursehasacceptedaverbalprescriptionfor"theetenthsofamilligramoflevothyroxineIVstat"fora
clientwhohasmyxedemacoma.Howshouldthenursetranscribethedosageofthismedicationinth
eclient'smedicalrecord?
.3mg
0.3mg
0.30mg
3/10mg-Correctanswer~0.3mg
Anurseispreparingaheparininfusionforaclientwhowasadmittedtothefacilitywithdeepveinthro
mbosis.Theprescriptionreads:25,000unitsofheparinin0.9%sodiumchloride250mltoinfuseat80
0units/hour.Atwhatrateshouldthenursesettheinfusionpump?-Correctanswer~8ml/hour
Anurseiscaringforaclientwhohasaprescriptionforwoundirrigation.Whichofthefollowingactions
shouldthenursetake?
Wearsterilegloveswhenremovingtheolddressing
Warmtheirrigationsolutionto40.5C(105F)
Cleansethewoundfromthecenteroutward
Usea20mlsyringetoirrigatethewound-
Correctanswer~Cleansethewoundfromthecenteroutward
AnurseiscaringforaclientwhoisreceivingfluidthroughaperipheralIVcatheter.Whichofthefollowi
ngfindingsattheIVsiteshouldthenurseidentifyasindicatinginfiltration?
Purulentexudate
Warmth
Skinblanching
Bleeding-Correctanswer~Skinblanching
,Anurseisteachingaclientwhoseleftlegisinacastaboutusingcrutches.Whichofthefollowingstate
mentsshouldthenurseidentifyasanindicationthattheclientunderstandstheteaching?
"Whendescendingthestairs,Iwillfirstshiftmyweighttomyrightleg"
"Ishouldplacemycrutches12inchesinfrontandtothesideofeachfoot"
"AsIsitdown,Iwillholdonecrutchineachhand"
"Iwillmakesuretheshoulderrestsaresnugagainstmyarmpits"-
Correctanswer~"Whendescendingthestairs,Iwillfirstshiftmyweighttomyrightleg"
AnurseiscaringforaclientwhohasanNGtubeandisreceivingintermittentfeedingsthroughanopen
system.Whichofthefollowingactionsshouldthenursetakefirst?
Rinsethefeedingbackwithwaterbetweenfeedings
Telltheclienttokeeptheheadofthebedelevatedatleast30degrees
Makesuretheenteralformulaisatroomtemperature
Wipethetopoftheformulacanwithalcohol-
Correctanswer~Telltheclienttokeeptheheadofthebedelevatedatleast30degrees
Anurseisreviewingaclient'smedicationprescriptionthatreads,"digoxin0.25bymoutheveryday".
Whichofthefollowingcomponentsoftheprescriptionshouldthenurseverifywiththeprovider?
Medicationname
Routeofadministration
Medicationdose
Frequencyofadministration-Correctanswer~Medicationdose
Anurseiscaringforaclientwhohasrecentlystartedusingabehindtheearhearingaid.Whichofthefol
lowingstatementsshouldthenurseidentifyasanindicationthattheclientunderstandstheuseofthi
sassistivedevice?
"Thistypeofhearingaiddoesnotallowforfinetuningofvolume"
"Ishouldn'thavetroublekeepingthehearingaidinplaceduringexercise"
, "IexpecttohearawhistlingsoundwhenIfirstinsertthehearingaid"
"Iwillbesuretoremovemyhearingaidbeforetakingashower"-
Correctanswer~"Iwillbesuretoremovemyhearingaidbeforetakingashower"
Anurseentersaclient'sroomandfindsheronthefloor.Theclient'sroommatereportsthattheclient
wastryingtogetoutofbedandfelloverthesiderailontothefloor.Whichofthefollowingstatementss
houldthenursedocumentaboutthisincident?
"Incidentreportcompleted"
"Clientclimbedoverthesiderails"
"Clientfoundlyingonthefloor"
"Clientwastryingtogetoutofbed"-Correctanswer~"Clientfoundlyingonthefloor"
Anurseonamedicalunitispreparingtodischargeaclienttohome.Whichofthefollowingactionssho
uldthenursetakeaspartofthemedicationreconciliationprocess?
Sealunusedmedicationsfromthefacilityinaplasticbag
Evaluatetheclient'sabilitytoselfadministermedications
ReportanidentifieddiscrepancytoTheJointCommission
Compareprescriptionswithmedicationstheclientreceivedwhileatthefacility-
Correctanswer~Compareprescriptionswithmedicationstheclientreceivedwhileatthefacility
Anurseiscaringforaclientwhorequiresaninformedconsentforasurgicalprocedure.Whichofthefo
llowingactionsisthenurse'sresponsibility?
Describetheproceduretotheclient
Witnesstheclient'ssignatureontheconsentform
Informtheclientofalternativestotheprocedure
Telltheclientwhichteammemberswillassistwiththeprocedure-
Correctanswer~Witnesstheclient'ssignatureontheconsentform