The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client
will not swallow and is not gagging. What action should the nurse implement to facilitate the
NGT passage into the esophagus?
a. Push the NGT beyond the oropharynx gently yet swiftly.
b. Offer the client sips of water or ice and coax to swallow
c. Elevate the bed 90 degree and hyperextend the head.
d. Flex the client's head with chin to the chest and insert.
d. Flex the client's head with chin to the chest and insert.
The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which
intervention should the nurse implement to ensure that measurement of the client's weight is
accurate?
a. Ask the client to remove shoes before stepping on the scale
b. Ensure that the scale is calibrated before a weight is obtained.
c. Slide the balancing weights until the scale is at zero.
d. Compare client's weight at various time of the day.
b. Ensure that the scale is calibrated before a weight is obtained
The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick
to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the
procedure and tell the client that it is painless. What action should the nurse take?
a. Allow the UAP to complete the procedure, then discuss the painless comment privately with
the UAP.
b. Stop the UAP before the procedure and explain to the client that some discomfort may be felt
c. Interject that while the procedure is not extremely painful, the client will feel a prick on the
finger.
,d. Report the incident to the education director and request additional instruction for the UAP.
a. Allow the UAP to complete the procedure, then discuss the painless comment privately with
the UAP.
After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand
together, what action should the nurse do next?
a. Vigorous rub both hands together under running water
b. Path both hands dry keeping the fingers lower that the arm
c. Place one hand on top of the other and interlace the fingers
d. Hold both hand with the fingers pointing upward until dry.
c. Place one hand on top of the other and interlace the fingers
When attempting to establish risk reduction strategies in a community, the nurse notes that
regional studies indicate a high number of persons with growth stunting and irreversible mental
deficiencies (cretinism) caused by hypothyroidism. The nurse should seek funding to implement
which screening measure?
A) T4 levels in newborns.
B) TSH levels in women over 45.
C) T3 levels in school-aged children
D) Iodine levels in all persons over 60.
a. T4 levels in newborns
A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with
congenital heart defect. Which intervention should the nurse implement?
a. Feed the infant when he cries
,b. Allow the infant to rest before feeding
c. Weigh before and after feeding.
d. Insert a nasogastric feeding tube.
b. Allow the infant to rest before feeding
While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with
the needle. After washing the puncture site with soap & water, which action should the nurse
take?
a. Complete a usual incident report
b. Start prophylactic treatment
c. Seek psychological resources
d. Notify the employee health nurse.
d. Notify the employee health nurse.
A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD).
The nurse does morning rounds and reaches the client while he is repeatedly washing the top of
the same table. What intervention should the nurse implement?
a. Encourage the client to be calm and relax for a little while
b. Assist the client to identify stimuli that precipitates the activity.
c. Allow time for the behavior and then redirect the client to other activities.
d. Teach the client thought stopping techniques and ways to refocus.
c. Allow time for the behavior and then redirect the client to other activities
The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client
becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon
auscultation. What action should the nurse take first?
, a. Place client in Trendelenburg position on the left side.
b. Administer precordial thump
c. Monitor the client with a 12-lead electrocardiogram
d. Request a STAT portable chest x-ray.
a. Place client in Trendelenburg position on the left side
The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-yearol client
with infected pseudomonas aeruginosa. Which assessment data warrants further intervention
by the nurse?
a- Peak and trough levels have not been drawn since the tobramycin was started
b- Today labs report indicates a white blood cell count of 13,000 cell/mm3 or 13 x 10777/L (S1)
c- A serum creatinine level of 1.0 mg/dl or 88 mcmol/L (S1) is documented on yesterday
flowsheet.
d- The culture growth form the burn areas is sensitive to aminoglycosides.
a. Peak and trough levels have not been drawn since the tobramycin was started
A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3
sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus
bradycardia with ST elevation. In what order should the nurse implement the nursing actions?
(Arrange first to last)
Correct Order:
1. Call the rapid response team to assist
2. Move the crash cart to the client room
3. Notify the client's healthcare provider
4. Inform the family of the critical situation
will not swallow and is not gagging. What action should the nurse implement to facilitate the
NGT passage into the esophagus?
a. Push the NGT beyond the oropharynx gently yet swiftly.
b. Offer the client sips of water or ice and coax to swallow
c. Elevate the bed 90 degree and hyperextend the head.
d. Flex the client's head with chin to the chest and insert.
d. Flex the client's head with chin to the chest and insert.
The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which
intervention should the nurse implement to ensure that measurement of the client's weight is
accurate?
a. Ask the client to remove shoes before stepping on the scale
b. Ensure that the scale is calibrated before a weight is obtained.
c. Slide the balancing weights until the scale is at zero.
d. Compare client's weight at various time of the day.
b. Ensure that the scale is calibrated before a weight is obtained
The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick
to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the
procedure and tell the client that it is painless. What action should the nurse take?
a. Allow the UAP to complete the procedure, then discuss the painless comment privately with
the UAP.
b. Stop the UAP before the procedure and explain to the client that some discomfort may be felt
c. Interject that while the procedure is not extremely painful, the client will feel a prick on the
finger.
,d. Report the incident to the education director and request additional instruction for the UAP.
a. Allow the UAP to complete the procedure, then discuss the painless comment privately with
the UAP.
After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand
together, what action should the nurse do next?
a. Vigorous rub both hands together under running water
b. Path both hands dry keeping the fingers lower that the arm
c. Place one hand on top of the other and interlace the fingers
d. Hold both hand with the fingers pointing upward until dry.
c. Place one hand on top of the other and interlace the fingers
When attempting to establish risk reduction strategies in a community, the nurse notes that
regional studies indicate a high number of persons with growth stunting and irreversible mental
deficiencies (cretinism) caused by hypothyroidism. The nurse should seek funding to implement
which screening measure?
A) T4 levels in newborns.
B) TSH levels in women over 45.
C) T3 levels in school-aged children
D) Iodine levels in all persons over 60.
a. T4 levels in newborns
A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with
congenital heart defect. Which intervention should the nurse implement?
a. Feed the infant when he cries
,b. Allow the infant to rest before feeding
c. Weigh before and after feeding.
d. Insert a nasogastric feeding tube.
b. Allow the infant to rest before feeding
While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with
the needle. After washing the puncture site with soap & water, which action should the nurse
take?
a. Complete a usual incident report
b. Start prophylactic treatment
c. Seek psychological resources
d. Notify the employee health nurse.
d. Notify the employee health nurse.
A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD).
The nurse does morning rounds and reaches the client while he is repeatedly washing the top of
the same table. What intervention should the nurse implement?
a. Encourage the client to be calm and relax for a little while
b. Assist the client to identify stimuli that precipitates the activity.
c. Allow time for the behavior and then redirect the client to other activities.
d. Teach the client thought stopping techniques and ways to refocus.
c. Allow time for the behavior and then redirect the client to other activities
The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client
becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon
auscultation. What action should the nurse take first?
, a. Place client in Trendelenburg position on the left side.
b. Administer precordial thump
c. Monitor the client with a 12-lead electrocardiogram
d. Request a STAT portable chest x-ray.
a. Place client in Trendelenburg position on the left side
The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-yearol client
with infected pseudomonas aeruginosa. Which assessment data warrants further intervention
by the nurse?
a- Peak and trough levels have not been drawn since the tobramycin was started
b- Today labs report indicates a white blood cell count of 13,000 cell/mm3 or 13 x 10777/L (S1)
c- A serum creatinine level of 1.0 mg/dl or 88 mcmol/L (S1) is documented on yesterday
flowsheet.
d- The culture growth form the burn areas is sensitive to aminoglycosides.
a. Peak and trough levels have not been drawn since the tobramycin was started
A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3
sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus
bradycardia with ST elevation. In what order should the nurse implement the nursing actions?
(Arrange first to last)
Correct Order:
1. Call the rapid response team to assist
2. Move the crash cart to the client room
3. Notify the client's healthcare provider
4. Inform the family of the critical situation
