and answers 2024
28. What to assess first for a client with cyanosis
A. Temperature
B. Heart rate
C. Blood pressure
D. Respiratory rate - Ans: D
29. What should the nurse implement when inserting an indwelling catheter to an
uncircumcised male.
A. Clean meatus before retracting the foreskin
B. Advance catheter before inflating balloon
C. Sterile field should be even between nurse's hips
D. Wipe the meatus back and forth - Ans: B
30. A nurse notices a fire in the bathroom of an empty room and reports the location of
the fire immediately. What should the nurse do next?
A. Close the door to all the client's rooms in the hallway
B. Evacuate clients in the rooms close to the fire
C. Shut the door to the bathroom and the empty room
D. Obtain fire extinguisher on the unit - Ans: C
31. HCP tells the nurse that he will be prescribing a placebo to a client. The nurse
should:
A. Inform the nurse supervisor and refuse to administer placebo
B. Administer the placebo to the client
C. Inform the patient that he will be receiving a placebo
D. Discuss ethical concerns with HCP - Ans: D
32. Proper method of wound care
A. Cleaning outwards to inward
B. Cleaning inward to outward
C. Cleaning back and forth
D. Wiping sterile cotton swab twice - Ans: B
33. A nurse walks into a client's room to see him coughing non-productively into his
upper sleeve. The nurse should:
A. Obtain face masks for all staff entering client's room
B. Teach client how to cough into his hands
C. Provide tissues for the client to cough into - Ans: C
, 34. A client has concerns and fears about his new temporary pacemaker. The nurse
should:
A. Encourage discussion about concerns and fears
B. Use simple terms how pacemaker functions
C. Offer reassurance that pacemaker his temporary
D. Reminds him that the pacemaker will be monitored at all times - Ans: A
35. A client with a new exercise regimen states that it still takes him an hour to fall
asleep. The nurse should:
A. Tell the client that it usually takes a few weeks for the body to regulate a new
exercise regimen
B. Ask client to describe his exercise regimen - Ans: B
36. Order: 1.2 Million units. Available: 600,000 units in 2 mL. Give how many mL?
1,200,000 U x 2 mL__ = 4 mL
600,000 U -
37. Order: 1200 mg divided in 3 doses. Available: 400 mg in a capsule. How many
capsules in one dose?
1200 mg x capsule = 1 capsule
3 doses 400 mg dose -
38. A confused elderly patient is having trouble sleeping and is often found wandering
the halls. The nurse should:
A. Administer PRN sedative
B. Have client's room door open slightly
C. Provide back rub before bed
D. Apply soft wrist restraints to prevent wandering - Ans: C
39. Intervention for skin turgor in aging client:
A. Bathe daily with mild soap and water
B. Apply lubricating lotion to skin - Ans: B
40. A mother requests to see her 18 year-old lab results. What is the nurse's best
response?
A. I will give you the results when it is back.
B. I can only give the results to your son. He is an adult.
C. The healthcare provider will give you the results. - Ans: B
41. What should the nurse do when interviewing a client about sexual and reproductive
matters? - Ans: Begin with less sensitive topic
42. What should be monitored when assessing for water intoxication?
A. Serum sodium levels
B. Serum potassium levels
C. Creatine - Ans: A