The nurse stops on the way home to assist in the care of victims of a multi-motor
vehicle crash site. The emergency response team uses a five level triage system. In
which order should the nurse triage victims?
1. Victim walking with a limp
2. Victim bleeding from a gaping leg wound
3. Victim with a pulse of 20 and apneic periods
4. Victim sitting on the side of the road staring
5. Victim with shallow respirations and chest pain
A client has been doing tai chi and performing visualization to help reduce stress
however continues to feel anxious. What dietary changes should the nurse recommend
to this client? Select all that apply.
1. Eliminate caffeine products
2. Avoid sugar and carbohydrates
3. Eat more raw fruits and vegetables
4. Limit the use of vitamin supplements
5. Limit protein intake to 10%”15% of consumed calories
The nurse is caring for a conscious adult client with an obstructed airway. When
performing abdominal thrusts, which action by the nurse is appropriate?
1. Making a fist with one hand, with the thumb on top, and placing the thumb just
below the xiphoid process
2. Using the side of the hand and placing it just above the xiphoid process
3. Grasping the fist with the other hand and placing the flat of the hand into the client’s
abdomen
4. Making a fist with one hand, tucking the thumb inside the fist, grasping the hand with
the other fist, and pushing the fist above the victim’s navel and below the xiphoid
process
Which joint would the nurse pronate when performing range of motion on the
hospitalized client?
1. Neck
2. Knee
3. Elbow
4. Finger
The nurse is preparing preoperative medications for a client. Which medication will
reduce the amount of respiratory secretions?
1. Opiate
2. Antibiotic
3. Antianxiolytic
4. Anticholinergic
A client recovering from abdominal surgery is being discharged home. What should the
nurse emphasize when providing this client with discharge instructions?
1. Wound care
2. Time family should arrive
3. Where family should park
4. Antibiotics received while hospitalized
A client requiring long-term catheterization is allergic to latex. Which catheter should
the nurse choose to insert?
1. Silver alloy catheter
2. Antimicrobial-coatedcatheter
3. Silicone catheter
4. Latex catheter
Prior to applying the condom catheter, which action by the nurse is the most
appropriate?
1. Documenting the use of the catheter
2. Inspecting and cleansing the penis
3. Calling the health care provider to obtain an order
4. Attaching the urinary drainage system securely
The manager interrupts a new graduate at the completion of a venipuncture. What did
the manager observe that caused this interruption?
1. Removed the tube before withdrawing the needle
2. Bent the client’s elbow after withdrawing the needle
3. Released the tourniquet once blood began to flow into the tube
4. Held a gauze sponge on the puncture site after withdrawing the needle
The waste water created from the decontaminating victims of radiation exposure is
being collected. What should be done with this water?
1. Rinse down the sink
2. Flush down the commode
3. Place in bins and label “radioactive”
4. Take outside and pour it on the ground
Which transmission of organisms is least effected by the nurse performing hand
hygiene?
1. Vehicle-borne transmission
2. Vector-borne transmission
3. Indirect contact transmission
4. Direct contact transmission
The nurse notes that a client returning from a cardiac catheterization has the extremity
used for the procedure elevated on a pillow. What should the nurse do?
1. Remove the pillow
2. Position on the left side
3. Keep the pillow in place
4. Raise the head of the bed
While the nurse is removing a fecal impaction, the client begins to perspire profusely
and complains of shortness of breath. The nurse notes that the client’s pulse rate has
slowed to 44 beats per minute. Which is the priority action by the nurse?
1. Holding the fingers still until the symptoms stop, and then resuming removal of fecal
impaction
2. Stopping the procedure immediately
3. Continuing the procedure, and monitoring the client carefully
4. Stopping the procedure and calling the health care provider immediately
The nurse is helping a client with teeth flossing. What should the nurse instruct the
client to do with the dental floss?
1. Wrap the length of dental floss around the wrist
2. Make a knot at the end of a length of dental floss
3. Weave the dental floss between the upper row of teeth
4. Wrap one length of floss loosely around index fingers of both hands
The nurse is caring for several clients during the shift. Which action demonstrates
appropriate hand hygiene?
1> Putting on gloves
2> Washing hands with soap and water
3> Wiping hands off when entering room
4> Using the client’s soap on hands
A client treated for head lice a week ago continues to complain of scalp itching. There
is evidence of nits along the shafts of the hair. What should the nurse do first?
1. Wash the client’s comb and brush
2. Obtain an order for medicated shampoo
3. Vigorously brush the client’s hair over a sink
4. Washing the client’s hair and apply conditioner