RN Comprehensive Online Practice 2019 A
A charge nurse is observing a newly licensed nurse administer eternal feedings via
NG tube. Which of the following actions by the newly licensed nurse indicates an
understanding of the procedure?
Instills 100 mL of air into the NG tube after checking for
residual Flushes the NG tube with 0.9% sodium chloride
irrigation every 2 hr Adds 20 mL of blue dye to each
feeding to help detect aspiration
Keeps the head of the bed elevated to 45° for 1 hr after feedings - ANSKeeps the
head of the bed elevated to 45° for 1 hr after feedings
The nurse should keep the client's head elevated to 30° to 45° for 1 to 2 hr after
feedings to decrease the risk for aspiration.
A) The nurse should inject 10 to 30 mL of air into the NG tube before checking for
residual to clear the tube of any feeding. Instilling excessive air into the tube can
cause abdominal distention and discomfort.
B) The nurse should use 20 mL of tap water to flush the NG tube before and after
each feeding. Using 0.9% sodium chloride irrigation can lead to hypernatremia.
C) The nurse should avoid adding dye to the feeding to detect aspiration because
using dye can increase the risk of complications.
A charge nurse is planning an education session for staff nurses about working with
parents whose terminally ill children are candidates for donating their organs. Which
of the following information should the nurse plan to include?
a. Choosing to donate organs can delay the timing of the child's funeral.
b. The family can have the child in an open casket without fearing that the organ
donation might disfigure the child's body.
c. The family should understand that an autopsy is mandatory prior to organ donation.
d. The nurse should introduce the option of organ donation to the parent's when first
discussing the child's impending death. - ANSb. The family can have the child in an
open casket without fearing that the organ donation might disfigure the child's body.
Removal of organs does not damage or violate the child's body in a way that would
prevent an open casket funeral.
A charge nurse is planning care for a client who has mechanical restrains in place.
Which of the following interventions should the nurse include in the plan?
Remove the client's restraints while
sleeping. Document the client's status
every 60 min.
Check for a new prescription every 6 hr.
Provide a staff member to stay with the client continuously. - ANSProvide a staff
member to stay with the client continuously.
A staff member must remain continuously with a client who is in restraints or view
the client via audiovisual equipment, if necessary, due to the risk of injury.
B) The nurse should assess the client for physical needs, safety, and comfort
,RN Comprehensive Online Practice 2019 A
every 15 to 30 min and document the findings.
C) The provider must renew a prescription for restraints every 4 hr for clients 18
years or older, every 2 hr for children ages 9 to 17 years, and every 1 hr for children
under the age of 9 years.
A charge nurse is preparing to administer 0900 medications and is told by the
pharmacy staff that the medications are not available. Medication availability has
been an ongoing problem, and the charge nurse has previously discussed this issue
with the pharmacy staff. Which of the following actions should the charge nurse take
first?
,RN Comprehensive Online Practice 2019 A
Document the actual time of medication
administration. Notify the risk manager.
Complete an incident report.
Inform the nurse manager of the issue - ANSInform the nurse manager of the issue
The greatest risk to clients is injury from not receiving medications on time and
developing a medical complication. Therefore, the priority intervention the charge
nurse should take is to follow the chain of command and contact the nurse manager.
A charge nurse is teaching a newly licensed nurse how to identify true labor. Which
of the following should the nurse include in the teaching?
A) Contractions will be felt primarily in the upper abdomen
B) The cervix transitions to an anterior position.
C) Contraction intensity decreases with ambulation
D) The cervix progressively thickens - ANSThe cervix transitions to an anterior
position.
In true labor, the cervix transitions to an anterior position.
A) Felt in lower abdomen and back
C) Contraction intensity increases with ambulation
D) Cervix progressively shortens and thins
A charge nurse observes a staff nurse document a dressing change in a client's chart
that he did not perform. Which of the following actions should the charge nurse take
first?
Ensure that the staff nurse changes the
dressing. Notify the nurse manager.
Gather more information about the staff nurse's actions.
Complete an incident report. - ANSGather more information about the staff nurse's
actions.
The first action the nurse should take when using the nursing process is to assess
the reasons for the staff nurse's negligent actions. Therefore, the charge nurse
should gather additional information and discuss the issue with the staff nurse
before deciding on the next course of action.
A client is receiving lorazepam IV for panic attacks and develop s a RR of 6 and a BP
of 90/44. Which of the following meds should the nurse anticipate administering?
Naloxone
Flumazenil
Acetylcystein
e
Atropine - ANSFlumazenil
The nurse should anticipate administering flumazenil, a competitive benzodiazepine
receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the
nurse should continue to support the client's respirations with a bag-valve mask.
, RN Comprehensive Online Practice 2019 A
A) Naloxone --> counteract opiate overdose (morphine)
C) Acetylcysteine --> counteracts acetaminophen OD (tylenol)
D) Atropine --> counteracts cholinesterase inhibitor OD (Neostigmine)
A client who is 24 hr postoperative following abdominal surgery refuses to
ambulate. Which of the following actions should the nurse take first?
Ask the client to rate their
pain level. Assist the client in
changing positions.
A charge nurse is observing a newly licensed nurse administer eternal feedings via
NG tube. Which of the following actions by the newly licensed nurse indicates an
understanding of the procedure?
Instills 100 mL of air into the NG tube after checking for
residual Flushes the NG tube with 0.9% sodium chloride
irrigation every 2 hr Adds 20 mL of blue dye to each
feeding to help detect aspiration
Keeps the head of the bed elevated to 45° for 1 hr after feedings - ANSKeeps the
head of the bed elevated to 45° for 1 hr after feedings
The nurse should keep the client's head elevated to 30° to 45° for 1 to 2 hr after
feedings to decrease the risk for aspiration.
A) The nurse should inject 10 to 30 mL of air into the NG tube before checking for
residual to clear the tube of any feeding. Instilling excessive air into the tube can
cause abdominal distention and discomfort.
B) The nurse should use 20 mL of tap water to flush the NG tube before and after
each feeding. Using 0.9% sodium chloride irrigation can lead to hypernatremia.
C) The nurse should avoid adding dye to the feeding to detect aspiration because
using dye can increase the risk of complications.
A charge nurse is planning an education session for staff nurses about working with
parents whose terminally ill children are candidates for donating their organs. Which
of the following information should the nurse plan to include?
a. Choosing to donate organs can delay the timing of the child's funeral.
b. The family can have the child in an open casket without fearing that the organ
donation might disfigure the child's body.
c. The family should understand that an autopsy is mandatory prior to organ donation.
d. The nurse should introduce the option of organ donation to the parent's when first
discussing the child's impending death. - ANSb. The family can have the child in an
open casket without fearing that the organ donation might disfigure the child's body.
Removal of organs does not damage or violate the child's body in a way that would
prevent an open casket funeral.
A charge nurse is planning care for a client who has mechanical restrains in place.
Which of the following interventions should the nurse include in the plan?
Remove the client's restraints while
sleeping. Document the client's status
every 60 min.
Check for a new prescription every 6 hr.
Provide a staff member to stay with the client continuously. - ANSProvide a staff
member to stay with the client continuously.
A staff member must remain continuously with a client who is in restraints or view
the client via audiovisual equipment, if necessary, due to the risk of injury.
B) The nurse should assess the client for physical needs, safety, and comfort
,RN Comprehensive Online Practice 2019 A
every 15 to 30 min and document the findings.
C) The provider must renew a prescription for restraints every 4 hr for clients 18
years or older, every 2 hr for children ages 9 to 17 years, and every 1 hr for children
under the age of 9 years.
A charge nurse is preparing to administer 0900 medications and is told by the
pharmacy staff that the medications are not available. Medication availability has
been an ongoing problem, and the charge nurse has previously discussed this issue
with the pharmacy staff. Which of the following actions should the charge nurse take
first?
,RN Comprehensive Online Practice 2019 A
Document the actual time of medication
administration. Notify the risk manager.
Complete an incident report.
Inform the nurse manager of the issue - ANSInform the nurse manager of the issue
The greatest risk to clients is injury from not receiving medications on time and
developing a medical complication. Therefore, the priority intervention the charge
nurse should take is to follow the chain of command and contact the nurse manager.
A charge nurse is teaching a newly licensed nurse how to identify true labor. Which
of the following should the nurse include in the teaching?
A) Contractions will be felt primarily in the upper abdomen
B) The cervix transitions to an anterior position.
C) Contraction intensity decreases with ambulation
D) The cervix progressively thickens - ANSThe cervix transitions to an anterior
position.
In true labor, the cervix transitions to an anterior position.
A) Felt in lower abdomen and back
C) Contraction intensity increases with ambulation
D) Cervix progressively shortens and thins
A charge nurse observes a staff nurse document a dressing change in a client's chart
that he did not perform. Which of the following actions should the charge nurse take
first?
Ensure that the staff nurse changes the
dressing. Notify the nurse manager.
Gather more information about the staff nurse's actions.
Complete an incident report. - ANSGather more information about the staff nurse's
actions.
The first action the nurse should take when using the nursing process is to assess
the reasons for the staff nurse's negligent actions. Therefore, the charge nurse
should gather additional information and discuss the issue with the staff nurse
before deciding on the next course of action.
A client is receiving lorazepam IV for panic attacks and develop s a RR of 6 and a BP
of 90/44. Which of the following meds should the nurse anticipate administering?
Naloxone
Flumazenil
Acetylcystein
e
Atropine - ANSFlumazenil
The nurse should anticipate administering flumazenil, a competitive benzodiazepine
receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the
nurse should continue to support the client's respirations with a bag-valve mask.
, RN Comprehensive Online Practice 2019 A
A) Naloxone --> counteract opiate overdose (morphine)
C) Acetylcysteine --> counteracts acetaminophen OD (tylenol)
D) Atropine --> counteracts cholinesterase inhibitor OD (Neostigmine)
A client who is 24 hr postoperative following abdominal surgery refuses to
ambulate. Which of the following actions should the nurse take first?
Ask the client to rate their
pain level. Assist the client in
changing positions.
