upright. Which action should the nurse take first?
A. Encourage fluids
B. Place the client flat
C. Administer acetaminophen
D. Notify the provider
2. A client with a Foley catheter has had 20 mL of urine output in the last hour. What is the nurse’s
priority action?
A. Document as normal
B. Increase oral fluids
C. Assess catheter patency and tubing
D. Notify the provider immediately
3. A client scheduled for IV pyelography reports a shellfish allergy. What is the nurse’s priority
action?
A. Proceed with test
B. Premedicate with antihistamine
C. Notify the provider
D. Encourage fluids
4. Which client is at highest risk for fecal impaction?
A. Ambulatory adult with high fiber intake
B. Postoperative client on opioids and bedrest
C. Teenager with diarrhea
D. Adult with high activity level
5. A client’s urine specific gravity is 1.004. What does this finding suggest?
A. Dehydration
B. Normal hydration
C. Overhydration
D. Kidney failure
6. After a thoracentesis, which finding requires immediate intervention?
A. Mild discomfort at site
B. Respiratory rate 28 and dyspnea
C. Slight cough
D. BP 120/80
7. Which statement indicates correct understanding of 24-hour urine collection?
A. “I will save my first morning void.”
B. “I will discard the first void and collect the rest.”
, C. “I can stop collecting at bedtime.”
D. “I don’t need to refrigerate the sample.”
8. A client with urinary retention would most likely exhibit which finding?
A. Polyuria
B. Dribbling with bladder distention
C. Clear concentrated urine
D. No urge to void
9. A client receiving contrast dye develops wheezing and hives. What is the nurse’s priority?
A. Document reaction
B. Encourage fluids
C. Stop procedure and initiate emergency response
D. Elevate legs
10. Which route has the fastest onset of action?
A. Oral
B. IM
C. Subcutaneous
D. IV
11. A client has black tarry stools. What should the nurse suspect?
A. Lower GI bleed
B. Upper GI bleed
C. Iron supplement reaction
D. Bile duct obstruction
12. Which action prevents medication leakage during IM injection of irritating medication?
A. Aspirating
B. Using 45-degree angle
C. Z-track method
D. Massaging site
13. A client’s BUN is 42 mg/dL. Which assessment finding supports this lab value?
A. Edema
B. Dry mucous membranes
C. Clear urine
D. Bradycardia
14. A client has not voided 7 hours after catheter removal. What should the nurse do first?
A. Insert a Foley
B. Notify provider