1. A postoperative client has three different PRN analgesics prescribed for
different levels of pain. The nurse inadvertently administers a dose
that is not within the prescribed parameters. What action should the
nurse take first? C
A) Determine if the pain was relieved.
B) Complete a medication error report.
C) Assess for side effects of the medication.
D) Document the client’s responses.
2. The unlicensed assistive personnel (UAP) describes the appearance of
the bowel movements of several clients. Which descriptions warrant
additional follow-up by the nurse? (Select all that apply.) ABDE
A) Multiple hard pellets.
B) Brown liquid.
C) Formed but soft.
D) Solid with red streaks.
E) Tarry appearance.
3. An elderly woman comes to the clinic because of vaginal bleeding. The
healthcare provider finds a vaginal tear, which the client reports are
likely to have occurred during unprotected sexual intercourse. Which
content is most important for the nurse to include in this client’s
teaching plan? A
A) The importance of using vaginal lubricants.
B) Methods used to practice safe sex.
C) Information about alternative ways to express sexuality.
D) Intercourse positions that help prevent tears.
4. A male client has right-sided hemiplegia following a left
cerebrovascular accident (CVA). His sitting balance has improved, and
he is now able to sit in a wheelchair. To assist the client in transferring
from the bed to a wheelchair, what action should the nurse take?
A) Have the client put both arms around the nurse’s neck for
support.
B) Place the wheelchair on the client’s left side.
C) Instruct the client to look at his feet.
, D) Instruct the client total slow, deep breaths while transferring.
5. The nurse observes a newly admitted older adult female take short
steps and walk very slowly while pushing a walker in front of her. What
action should the nurse take in response to these observations? A
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at a faster pace.
C) Suggest that the client use a wheelchair instead of a walker.
D) Place the client on bed rest until the healthcare provider is
notified.
6. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for
postoperative pain. The available 2 ml vial is labeled, Toradol IM 30
mg/ml, How many should the nurse administer?
(Round to the nearest tenth.) 1.5mg
7. While suctioning a client’s nasopharynx, the nurse observes that the
client’s oxygen saturation remains at 94%, which is the same reading
obtained prior to starting the procedure. What action should the nurse
take in response to this finding? C
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above
95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client’s nose and mouth.
8. An older woman with end-stage heart disease is hospitalized for severe
heart failure. She is alert, oriented, and requests that no heroic
measures are implemented if her breathing stops. What action should
the nurse take first? A
A) Discuss with the client her meaning of heroic measures.
B) Obtain a “do not resuscitate” (DNR) prescription.
C) Set up a family conference to discuss the clients.
D) Consult the palliative care team about the client’s care.
9. A client diagnosed with primary open-angle glaucoma received a
prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What