EXAM QUESTIONS COMPLETE WITH 100% CORRECT
ANSWERS
1. A nurse is caring for a client who has a prescription for a continuous
enteral feeding. Which of the following actions should the nurse take
to prevent aspiration?
A) Position the client supine during feeding
B) Check gastric residual volume every 4 hours
C) Administer the feeding at a cold temperature
D) Flush the tube with 50 mL of water after feeding
Correct Answer: B. Checking gastric residual volume every 4 hours
helps identify delayed gastric emptying, which increases aspiration risk.
The client should be positioned with the head of bed elevated 30-45
degrees, not supine. Feedings should be at room temperature, and
flushing is done before and after feedings but does not prevent
aspiration.
,2. A nurse is preparing to administer a subcutaneous injection of
heparin. Which of the following actions is appropriate?
A) Massage the site after injection
B) Aspirate before injecting the medication
C) Insert the needle at a 90-degree angle
D) Use the same site for each injection
Correct Answer: C. Heparin is administered subcutaneously using a 90-
degree angle if using a ⅝-inch needle or 45-degree angle if using a ½-
inch needle. Massaging can cause bruising, aspiration is not
recommended for subcutaneous injections, and sites should be rotated
to prevent hematoma formation.
3. A nurse is assessing a client who has diabetes mellitus and is
experiencing hypoglycemia. Which of the following findings should
the nurse expect?
A) Deep rapid respirations
B) Fruity breath odor
C) Cool, clammy skin
D) Polyuria
Correct Answer: C. Cool, clammy skin is a classic sign of hypoglycemia
along with diaphoresis, tremors, and confusion. Deep rapid respirations
,and fruity breath odor indicate diabetic ketoacidosis (hyperglycemia).
Polyuria is associated with hyperglycemia.
4. A nurse is caring for a client who has an indwelling urinary catheter.
Which of the following actions should the nurse take to prevent
infection?
A) Keep the drainage bag on the bed
B) Empty the drainage bag when it is completely full
C) Secure the catheter to the client's thigh
D) Irrigate the catheter daily with sterile saline
Correct Answer: C. Securing the catheter to the client's thigh prevents
traction and urethral trauma, reducing infection risk. The drainage bag
should hang below the level of the bladder, never on the bed. Empty
the bag when it is half full to prevent backflow. Routine irrigation is not
recommended unless prescribed.
5. A nurse is providing teaching to a client who has hypertension.
Which of the following dietary modifications should the nurse
recommend?
A) Increase intake of processed meats
B) Limit sodium intake to 2,300 mg per day
, C) Increase consumption of canned vegetables
D) Limit potassium-rich foods
Correct Answer: B. The Dietary Approaches to Stop Hypertension
(DASH) diet recommends limiting sodium to 2,300 mg per day (or 1,500
mg for certain populations). Processed meats and canned vegetables
are high in sodium. Potassium-rich foods should be encouraged, not
limited, unless contraindicated.
6. A nurse is assessing a client who has chronic obstructive pulmonary
disease (COPD). Which of the following findings should the nurse
expect?
A) Prolonged expiratory phase
B) Decreased anterior-posterior chest diameter
C) Increased breath sounds
D) Hypertension
Correct Answer: A. COPD is characterized by airway obstruction leading
to a prolonged expiratory phase. The anterior-posterior chest diameter
is increased (barrel chest). Breath sounds are diminished, and
hypertension is not a typical finding.