Question 1

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan.  When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room.  Which instruction should the nurse give the transporter?

Accepted Answer

A) Have the client wear a mask 
B) Have the client wear gloves 
C) Wear a mask 
D) Wear an isolation gown

Question 2

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia.  The client needs a peripheral IV line for fluid administration.  Which IV site should the nurse select to reduce the risk for infection?

Accepted Answer

A) Antecubital fossa 
B) Dorsal surface of hand 
C) Dorsum of foot 
D) Lateral surface of wrist

Question 3

The nurse is drawing blood from a client's peripheral vein for laboratory specimens.  Which of the following are correct nursing actions?  Select all that apply.

Accepted Answer

A) Do not leave a tourniquet on more than 1 minute while looking for a vein 
B) Draw the specimen while the skin is still wet with the alcohol prep 
C) If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes 
D) Use a highly visible vein on the ventral side of the client's wrist 
E) Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

Question 4

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision.  Which actions should the nurse take?

Accepted Answer

A) Have the client remove the existing dressing while the nurse prepares sterile supplies 
B) Wear clean gloves for removal and application of a new dressing 
C) Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing 
D) Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

Question 5

The nurse plans to start an IV line on a female client hospitalized with pneumonia.  The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal.  Which site is best for the nurse to select for the client's IV line?

Accepted Answer

A) Basilic vein of the left forearm 
B) Cephalic vein in the right antecubital space 
C) Median vein of the right forearm 
D) Radial vein of the left wrist

Question 6

The home health nurse visits a client who is rehabilitating after a tibial fracture.  Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches?  Select all that apply.

Accepted Answer

A) Keep a clear path to the bathroom 
B) Look down at the feet when walking 
C) Remove scatter rugs from floors 
D) Use a small backpack/shoulder bag to hold personal items 
E) Wear rubber-soled shoes, preferably without laces

Question 7

A client is scheduled for an elective laparoscopic prostatectomy in the morning.  The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery?

Accepted Answer

A) Hemoglobin 15 g/dL (150 g/L), hematocrit 45% (0.45) 
B) International Normalized Ratio (INR) 1.3 
C) Platelet count 295,000/mm3 (295 × 109/L) 
D) Temperature 100.4 F (38 
C)  with cough

Question 8

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L).  Which of the following actions by the registered nurse are appropriate?  Select all that apply.

Accepted Answer

A) Asks another licensed nurse to verify client identifiers and blood before administration 
B) Delegates all vital sign measurements to the unlicensed assistive personnel 
C) Prepares O-negative blood for an AB-positive client 
D) Transfuses the blood over a 6-hour period of time 
E) Uses filtered tubing with normal saline to administer blood

Question 9

A client is scheduled for coronary artery bypass surgery in the morning.  In the middle of the night, the nurse finds the client wide awake.  The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery.  Which statement by the nurse would be most appropriate?

Accepted Answer

A) "Please try not to worry, you have an excellent surgeon." 
B) "Tell me about how you feel about your surgery." 
C) "Why are you considering refusing the surgery?" 
D) "You have the right to make your own decisions and can refuse the surgery."

Question 10

The nurse prepares to administer medications to a client.  Which of the following client data are acceptable for use as client identifiers?  Select all that apply.

Accepted Answer

A) Date of birth 
B) First and last name 
C) Health care provider 
D) Medical record number 
E) Room number

Question 11

A nurse administers an intramuscular (IM) injection using the Z-track technique.  Place the steps in chronological order.  All options must be used.

Accepted Answer

A) Apply gentle pressure at the injection site but do not massage 
B) Inject medication slowly with dominant hand while maintaining traction 
C) Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle 
D) Pull the skin 1-1 ½" (2.5-3.5 cm) laterally and away from the injection site 
E) Release the hold on the skin, allowing the layers to slide back to their original position
F)Wait 10 seconds after injecting the medication and withdraw the needle

Question 12

A client is brought to the emergency department with multiple trauma injuries.  The nurse sees the client's Jehovah's Witness identification card.  As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following?  Select all that apply.

Accepted Answer

A) Epoetin alfa 
B) Fresh frozen plasma 
C) Homologous packed red blood cells 
D) Normal saline 
E) Platelet transfusion

Question 13

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen.  The nurse intervenes when the student performs which action?

Accepted Answer

A) Instills ear drops at room temperature 
B) Instills ear drops with dropper by occluding the ear canal 
C) Places a cotton ball loosely in outermost auditory canal after the instillation 
D) Pulls pinna up and back and instills drops

Question 14

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?

Accepted Answer

A) High-Fowler's position with the affected side's arm resting on the bed 
B) Semi-Fowler's position with the affected side's arm on several pillows 
C) Supine with the affected side's arm on several pillows 
D) Supine with the affected side's arm resting on the bed

Question 15

The client screams at the nurse, "You are all incompetent here!  I have been waiting for 2 hours!"  How should the nurse respond initially?

Accepted Answer

A) "I know you are upset, but I will have to call security if you continue to scream." 
B) "I see that you are frustrated, but the delay cannot be avoided." 
C) "It is upsetting to wait so long.  How can I best help you?" 
D) "The wait is long today, but you will receive quality, unhurried care when it is your turn."

Question 16

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication.  Which student action indicates that further instruction is needed?

Accepted Answer

A) Instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds 
B) Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac 
C) Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus 
D) Rests hand on client's forehead and holds dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac

Question 17

The nurse is preparing to administer an IM immunization to a 6-month-old infant.  Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components?

Accepted Answer

A) 3⁄8-in (9-mm) needle in the anterolateral thigh 
B) 5⁄8-in (16-mm) needle in the ventrogluteal muscle 
C) 1-in (25-mm) needle in the anterolateral thigh 
D) 1½-in (38-mm) needle in the ventrogluteal muscle

Question 18

The nurse is preparing a client for a magnetic resonance cholangiopancreatography.  Which statements by the client would require the nurse to obtain further assessment data?  Select all that apply.

Accepted Answer

A) "I ate lunch about 4 or 5 hours ago." 
B) "I got a rash the last time I had IV contrast." 
C) "I had my last period 6 weeks ago." 
D) "I have a hearing aid implanted in my ear." 
E) "I smoked a cigarette about an hour ago."

Question 19

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend.  Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention?

Accepted Answer

A) Heating pad 
B) Positioning for comfort 
C) Rest from pain-aggravating activities 
D) Stretching exercises

Question 20

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank.  Which client statement indicates the need for further teaching?  Select all that apply.

Accepted Answer

A) "I can apply Vaseline to my nose when my nostrils feel dry from the oxygen." 
B) "I can cook on my gas stove as long as I have a fire extinguisher in the kitchen." 
C) "I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath." 
D) "I should not polish my nails when using my oxygen." 
E) "I should not use a wool blanket on my bed."

Exam 4: Fundamentals

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection?

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches? Select all that apply.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery?

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L) . Which of the following actions by the registered nurse are appropriate? Select all that apply.

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.

A nurse administers an intramuscular (IM) injection using the Z-track technique. Place the steps in chronological order. All options must be used.

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply.

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action?

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?

The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours!" How should the nurse respond initially?

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed?

The nurse is preparing to administer an IM immunization to a 6-month-old infant. Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components?

The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention?

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply.