The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central
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line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run
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out and the next TPN solution is not available. What immediate action should the nurse take?
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A. Infuse normal saline at a keep vein open rate.
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B. Discontinue the IV and flush the port with heparin.
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C. Infuse 10% dextrose and water at 54 ml/hour.
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D. Obtain a stat blood glucose level and notify the healthcare provider. - (correct answer) -C
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A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse
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implement?
gi
A. Notify the healthcare provider of the measurement.
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B. Quiet the child and retake the blood pressure.
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C. Ask the parent if the child has a history of hypertension.
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D. Document the finding and recheck in 4 hours. - (correct answer) -B
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The mother of a neonate asks the nurse why it is so important to keep the infant warm. What
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information should the nurse provide?
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A. The kidneys and renal function are not fully developed.
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B. Warmth promotes sleep so the infant will grow quickly.
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C. A large body surface area favors heat loss to the environment.
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D. The thick layer of subcutaneous fat is inadequate for insulation. - (correct answer) -C
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What action by the nurse demonstrates culturally sensitive care?
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A. Asks permission before touching a client.
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B. Avoids questions about male-female relationships.
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C. Explains the differences between Western medical care and cultural folk remedies.
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,D. Applies knowledge of a cultural group unless a client embraces Western customs. - (correct
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answer) -A
gi gi
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to
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impending death." What intervention is best for the nurse to implement when caring for this client?
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A. Help the client to accept the final stage of life.
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B. Assist and support the client in establishing short-term goals.
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C. Encourage the client to make future plans, even if they are unrealistic.
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D. Instruct the client's family to focus on positive aspects of the client's life. - (correct answer) -B
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A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day.
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Which question is most important for the nurse to include during the preoperative assessment?
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A. "What is your daily calorie consumption?"
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B. "What vitamin and mineral supplements do you take?"
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C. "Do you feel that you are overweight?"
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D. "Will a clear liquid diet be okay after surgery?" - (correct answer) -B
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The nurse working in the emergency department is assessing four clients' ability to tolerate pain.
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Which client is likely to tolerate a higher level of pain?
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A. A 10-year-old who was burned by a camp fire earlier today.
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B. A 70-year-old who has a postoperative infection from a surgery one week ago.
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C. A 23-year-old woman who sprained her knee while bicycling.
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D. A 55-year-old woman who has had moderate low back pain for three months. - (correct answer) -
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D
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
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continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago,
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but feels fine now. What action is best for the nurse to take?
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A. Record the coughing incident. No further action is required at this time.
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B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
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C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
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D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - (correct answer)
gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi gi
-C
gi
,In evaluating client care, which action should the nurse take first?
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A. Determine if the expected outcomes of care were achieved.
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B. Review the rationales used as the basis of nursing actions.
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C. Document the care plan goals that were successfully met.
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D. Prioritize interventions to be added to the client's plan of care. - (correct answer) -A
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A female client asks the nurse to find someone who can translate her treatment concerns into her
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native language. Which action should the nurse take?
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A. Explain that anyone who speaks her language can answer her questions.
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B. Provide a translator only in an emergency situation.
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C. Ask a family member or friend of the client to translate.
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D. Request and document the name of the certified translator. - (correct answer) -D
gi gi gi gi gi gi gi gi gi gi gi gi gi
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering
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a soap suds enema. Which instruction should the nurse provide the UAP?
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A. Position the client on the right side of the bed in reverse Trendelenburg.
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B. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap.
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C. Reposition in a Sims' position with the client's weight on the anterior ilium.
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D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - (correct answer) -
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C
A child with a penetrating eye injury comes to the school clinic. What action should the nurse
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implement?
gi
A. Remove the object impaled in the eye and then apply a regular eye patch.
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B. Place an ice bag over the eye until the healthcare provider is seen.
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C. Irrigate the affected eye copiously with a cool sterile saline solution.
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D. Apply a Fox shield to the affected eye and any type of patch to the other eye. - (correct answer) -
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D
When making the bed of a client who needs a bed cradle, which action should the nurse include?
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A. Teach the client to call for help before getting out of bed.
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, B. Keep both the upper and lower side rails in a raised position.
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C. Keep the bed in the lowest position while changing the sheets.
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D. Drape the top sheet and covers loosely over the bed cradle. - (correct answer) -D
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A male client with venous incompetence stands up and his blood pressure subsequently drops.
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Which finding should the nurse identify as a compensatory response?
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A. Bradycardia.
gi
B. Increase in pulse rate.
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C. Peripheral vasodilation.
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D. Increase in cardiac output. - (correct answer) -B
gi gi gi gi gi gi gi gi
When assessing a preschooler, which finding warrants further assessment by the nurse?
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A. Able to ride a tricycle.
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B. Talks about an imaginary friend.
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C. Dresses independently.
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D. Gains 2 pounds (0.9kg) in 12 months. - (correct answer) -D
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The nurse completes visual inspection of a client's abdomen. What technique should the nurse
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perform next in the abdominal examination?
gi gi gi gi gi gi
A. Percussion.
gi
B. Auscultation.
gi
C. Deep palpation.
gi gi
D. Light palpation. - (correct answer) -B
gi gi gi gi gi gi
The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and
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frequency and stress incontinence. She also reports difficulty in emptying her bladder. These
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complaints are most likely due to which condition?
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A. Cystocele.
gi
B. Bladder infection.
gi gi
C. Pyelonephritis.
gi
D. Irritable bladder. - (correct answer) -A
gi gi gi gi gi gi
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