When delegating bed-making to unlicensed assistive personnel (UAP), on which items
should the nurse instruct the UAP?
Standard Text: Select all that apply.
1. Proper disposal of linens that contain drainage
2. What tubes or dressings the client might have
3. How to make hospital corners
4. Whom to inform if they notice anything unusual
5. Placing the call bell in a specific location for a client with mobility concerns
A client arrives to the hospital the day before orthopedic surgery. What should be
completed before the client is escorted to the care area? Select all that apply.
1. Orient to the hospital room
2. Receive an identification band
3. Assign a medical record number
4. Sign consent for treatment forms
5. Document demographic information
The nurse is preparing medication that is packaged in an ampule. Which are appropriate
nursing actions when preparing this medication?
Standard Text: Select all that apply.
1. Using a filter needle when administering the injection to the client
2. Using gauze when opening the ampule
3. Tapping the neck of the ampule to drop all medication into the body of the ampule
prior to opening it
4. Checking the expiration date on the ampule
5. Wiping the container with an antimicrobial prior to opening the ampule
A client comes into the emergency department after exposure to a biological agent.
What should the nurse do after removing the victim’s clothing?
1. Place the victim in an isolation room
2. Administer a broad spectrum antibiotic
3. Send the victim home to wash with soap and water
4. Cleanse exposed areas with sodium hypochlorite and tepid water
The nurse needs to deliver the highest concentration of oxygen (95% to 100%). Which
type of oxygen delivery device should the nurse choose?
1. Face mask
2. Nasal cannula
3. Partial rebreather mask
4. Nonrebreather mask
Which teaching point is least likely to be included when instructing a client to perform
breathing exercises?
1. Breathing in deeply through the nose with the mouth closed
2. Avoiding arching the back
3. Holding the breath for 30″40 seconds
4. Breathing out slowly
The nurse is instructing the unlicensed assistive personnel (UAP) to apply a warm
compress to the client’s knee. Which statement made by the UAP indicates that further
instruction should be given?
1. “I can place the heating pad directly to the client’s knee.”
2. “I will maintain the proper temperature of the heating pad.”
3. “I will inform you of any redness of the skin.”
4. “I will report to you when the treatment is over.”
The nurse is caring for a client with chronic back pain. Which alternative therapy
should the nurse recommend to this client?
1. Prayer
2. Chiropractic
3. Herbal medicine
4. Energy medicine
The healthcare provider is preparing to insert a percutaneous central vascular device.
What should the nurse instruct the client to do while the catheter is being inserted?
1. Hum
2. Cough
3. Count to 10
4. Take a deep breath
The nurse is caring for a client who is unconscious. In which order should the nurse
provide oral care to this client?
Standard Text: Click on the down arrow for each response in the right column and
select the correct choice from the list.
Response 1. Prepare the client by positioning in a side-lying position with the head of
the bed lowered.
Response 2. Clean the teeth and rinse the mouth. Brush the teeth gently to prevent
irritating the gums.
Response 3. Ensure client comfort and document procedure per policy.
Response 4. Perform hand hygiene and observe other appropriate infection control
procedures.
Response 5. Place a towel under the client’s chin. Place the curved basin against the
client’s chin and lower cheek to collect fluid.
Which client would be in particular need of a closed airway suctioning system?
1. The client post-bone marrow transplant
2. The postoperative client
3. The client with a long-term tracheostomy on 25% oxygen via mask
4. The client with excessive oral secretions
The health care provider prescribes Ampicillin 850 mg PO. The medication is supplied
as 1,000 mg per 5 mL. How many mL of medication would the nurse administer using
the basic formula?
____ mL
Standard Text: Record the answer rounding to the nearest hundredth.
The nurse is caring for a client with a central venous catheter used for intermittent
medication administration. When flushing the catheter prior to administering the next
dose of medication, which initial action by the nurse is the most appropriate?
1. Aspirating the catheter for blood
2. Obtaining a 3 mL syringe and filling it with normal saline for flushing the line
3. Flushing the catheter, using as much force as required in order to clear the line
4. Positioning the client in reverse Trendelenburg position
The nurse is caring for a 31-week premature infant requiring oxygen therapy after
delivery. Which would be the most effective means of delivering oxygen?
1. Partial rebreather mask
2. Nonrebreather mask
3. Face mask
4. Oxygen hood
A client in respiratory distress and has see-saw respirations with the chest and abdomen
alternately rising, blue discoloration of the fingertips, and noisy difficult respirations.
How should the nurse describe the client’s condition when calling the health care
provider?
1. Client is tachypneic with costal breathing and cyanosis.
2. Client is bradycardic with diaphragmatic breathing and cyanosis.
3. Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic.
4. Client is demonstrating diaphragmatic breathing with audible Korotkoff’s sounds.
The nurse is ambulating with a client who is moderately weak. Which action by the
nurse is appropriate when applying support?
1. Grasp the gait belt firmly at the back
2. Wrapping the arm closest to the client around the client’s waist
3. Holding on to the client’s waistband located on the robe
4. Holding the client under the axilla