Question 1

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed.  During insertion, after the tube passes the nasopharynx, the client begins to cough and gag.  Which action should the nurse take first?

Accepted Answer

A) Ask the client to take several small sips of water 
B) Continue to slowly advance the tube until placement is reached 
C) Gently remove the tube and reinsert in the other naris if possible 
D) Pull back on the tube slightly and then pause to give the client time to breathe

Question 2

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash.  The parent thinks that the bottle was about one quarter full.  What is the nurse's priority response?

Accepted Answer

A) "Call the poison control center.  I will give you the number." 
B) "Give your child about a cup of water to dilute the mouthwash." 
C) "How did your child get hold of the mouthwash?" 
D) "What is your child doing right now?"

Question 3

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer.  The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement."  What is the best response by the nurse?

Accepted Answer

A) "Are you concerned about how the surgery will affect your sexuality?" 
B) "If you are concerned about infertility, you could always bank your sperm." 
C) "The cancer is at an early stage.  You are going to be fine." 
D) "What have you and your future spouse discussed about your condition?"

Question 4

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle.  The client has HIV infection.  Place in order the steps the nurse should take.  All options must be used.

Accepted Answer

A) Remove gloves 
B) Go to employee health clinic 
C) Notify the nurse's supervisor 
D) Take postexposure prophylaxis 
E) Wash area with soap and water

Question 5

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens.  Which action by the nurse is appropriate?

Accepted Answer

A) Get the client out of bed and away from the radiation source 
B) Manually reinsert the implant and notify the health care provider 
C) Use long-handled forceps to secure the implant in a lead container 
D) Wrap the implant in the linens and place it in a biohazard bag

Question 6

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer.  Which of the following interventions would the nurse anticipate for this client?  Select all that apply.

Accepted Answer

A) Arrange for health care workers of the same sex to provide care for the client 
B) Coordinate with the registered dietician to provide halal meals 
C) Reposition the immobile client to face the city of Mecca during daily prayer times 
D) Restrict the number of visitors from the family to preserve the client's privacy 
E) Upon death, provide the family with supplies for postmortem care

Question 7

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5.  The client asks questions about the care of chest and leg incisions.  Which instructions should the registered nurse include?  Select all that apply.

Accepted Answer

A) Report any itching, tingling, or numbness around your incisions 
B) Report any redness, swelling, warmth, or drainage from your incisions 
C) Soak incisions in the tub once a week then clean with hydrogen peroxide and apply lotion 
D) Wash incisions daily with soap and water in the shower and gently pat them dry 
E) Wear an elastic compression hose on your legs and elevate them while sitting

Question 8

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy.  Which infection control measures are appropriate to implement?  Select all that apply.

Accepted Answer

A) Disinfect surfaces with diluted bleach solution 
B) Hand hygiene with alcohol-based hand rub 
C) Wear a face mask 
D) Wear a protective gown 
E) Wear nonsterile gloves

Question 9

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease.  Which action by the UAP will require follow-up by the nurse?

Accepted Answer

A) Assist the client in ambulating to the bathroom 
B) Dim the room lights 
C) Place the bed in low position with all side rails up 
D) Turn off the television

Question 10

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure.  The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily.  The client's child reports that the client has trouble swallowing the large KCl pill.  The client's potassium level is 3.7 mEq/L (3.7 mmol/L).  What action should the nurse take first?

Accepted Answer

A) Consult with the pharmacist to see if other oral forms of KCl are available 
B) Crush the pill and mix it with applesauce or pudding 
C) Hold the KCl until the health care provider makes rounds 
D) Instruct the client to tuck the chin to the chest when swallowing the pill

Question 11

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression.  After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris.  Place the remaining steps in the correct order.  All options must be used.

Accepted Answer

A) Advance tube to the marked point 
B) Ask client to flex head forward and swallow 
C) Gently insert tube just past nasopharynx 
D) Instruct client to extend neck back slightly 
E) Measure, mark, and lubricate tube
F)Verify tube placement and anchor

Question 12

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC).  The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

Accepted Answer

A) Administer intravenous (IV) total parenteral nutrition (TPN) at 50 mL/hr 
B) Change occlusive central line dressing every 7 days 
C) Flush unused lumens of the CVC with 1000 units heparin every 12 hours 
D) Use distal port of CVC to monitor central venous pressure (CVP)

Question 13

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound.  Which actions by the aide indicate adherence to appropriate infection control procedures?  Select all that apply.

Accepted Answer

A) Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 
B) Pull glove off over the soiled dressing to encase it before disposal 
C) Save unused sterile 4 x 4's by taping original package shut for the next dressing change 
D) Wash hands prior to putting on gloves and after removing them 
E) Wrap soiled dressing in paper towels before disposing of it in the trash can

Question 14

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test?  Select all that apply.

Accepted Answer

A) Avoid the arm on the affected side after a mastectomy 
B) Do not make further attempts to draw blood if unsuccessful on first 2 attempts 
C) If necessary to use an arm with IV infusing, draw proximal to infusion point 
D) Insert the needle bevel up at a 15-degree angle to the skin 
E) Obtain a finger capillary specimen from the middle of the finger pad

Question 15

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention.  The nurse observes urine leaking from the insertion site, past the catheter.  What is the nurse's first action?

Accepted Answer

A) Check the urethral catheter and drainage tubing 
B) Irrigate the catheter with 30 mL of sterile normal saline 
C) Notify the health care provider 
D) Remove and reinsert the next-larger-size catheter

Question 16

The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension.  Which teaching strategy implemented by the nurse is most likely to be effective for this client?

Accepted Answer

A) Leave diet pamphlets for the client to review at a later time 
B) Refer the client to the nurse case manager to follow up with diet instructions 
C) Sit with the client during meal selections and assist with identification of low sodium options 
D) Turn the television on in the client's room to the patient education channel to watch

Question 17

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness.  The client is flushed, sweating, nauseated, and slightly tachycardic.  Which action is most appropriate at this time?

Accepted Answer

A) Call emergency medical services and place ice packs on the client's axilla and groin 
B) Encourage the client to leave the venue to visit a health care provider 
C) Evaluate whether the client may be intoxicated 
D) Move the client to an air-conditioned booth and provide a cool sports drink

Question 18

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW).  The site must be assessed for a reaction afterward.  The nurse instructs the HCW to return in how many hours?

Accepted Answer

A) 12 hours 
B) 24 hours 
C) 36 hours 
D) 72 hours

Question 19

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD).  Which statement indicates that the client has a correct understanding of this medication?

Accepted Answer

A) "A capsule holds the powdered medication that I have to put in a special inhaler." 
B) "I do not need to rinse my mouth with water after taking tiotropium." 
C) "I have been taking tiotropium every time I have difficulty breathing." 
D) "Tiotropium helps control my COPD by reducing inflammation in my airway."

Question 20

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery.  The client is pleasant, cooperative, and able to fully bear weight.  What would be the most appropriate method for transferring this client safely?

Accepted Answer

A) 1-person safety standby with walker 
B) 2-person full-body sling lift 
C) 2-person standing-assist lift 
D) 4-person full-body sling lift

Exam 4: Fundamentals

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first?

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the nurse's priority response?

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse?

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle. The client has HIV infection. Place in order the steps the nurse should take. All options must be used.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens. Which action by the nurse is appropriate?

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply.

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the registered nurse include? Select all that apply.

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply.

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse?

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC) . The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?

The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy implemented by the nurse is most likely to be effective for this client?

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW) . The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours?

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD) . Which statement indicates that the client has a correct understanding of this medication?

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely?