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The nurse is teaching the client to use a metered-dose inhaler. Which information
should the nurse provide to the client?
1. Take a deep breath, hold it, and then gently squeeze the inhaler to dispense the
medication.
2. Take several slow deep breaths in through the nose and out through the mouth, then
squeeze the inhaler while taking a deep breath.
3. Exhale comfortably, squeeze the canister to discharge the medication, and inhale
slowly and deeply through the mouth, then hold the breath for 10 seconds, or as long as
possible.
4. Exhale deeply, squeeze the canister to discharge the medication, and inhale slowly
and deeply through the mouth, then hold the breath for 10 seconds, and exhale through
the nose.
Which is the nurse's most important role in assisting the health care provider to perform
an aspiration or biopsy?
1. Administering analgesic
2. Monitoring the client's condition before, during, and after procedure
3. Preparing the sterile tray with needed equipment
4. Documenting the specimen collection
When caring for an older adult client who does not speak English, which assessment
tool is the most appropriate for the nurse to use to assess this client's pain?
1. The FACES rating scale
2. An interpreter
3. The client's affect
4. The client's vital signs
A victim of cyanide exposure is transported to an urban medical center. Which
treatment should the nurse anticipate being prescribed for this client?
1. Valium
2. Atropine
3. Sulfur thiosulfate
4. Anti-Lewisite (BAL)
A client's x-ray report shows a fractured leg where one part of fractured bone is driven
into another. How should the nurse document this client's fracture?
1. Impacted
2. Greenstick
3. Comminuted
4. Compression
The nurse is planning to delegate ambulation of a client to the unlicensed assistive
personnel (UAP). In order to provide proper instructions to the UAP, which action by
the nurse is the most appropriate?
1. Ambulating the client first and then having the UAP ambulate the client
2. Quizzing the UAP to assure appropriate understanding of how to ambulate the client
3. Assessing the client's ability to ambulate
4. Observing the client ambulating
The nurse is preparing to administer a liter of fluid through a client's central line. What
should the nurse do after attaching the syringe to the designated port?
1. Ask the client to cough
2. Aspirate for a blood return
3. Withdraw 20 mL of blood
4. Inject 10 mL of saline flush
Which intervention should the nurse use to break the chain of infection by eliminating
the reservoir?
1. Ensure that all antibiotics are taken properly and only when needed, to avoid creation
of antibiotic-resistant microorganisms.
2. Avoid coughing or sneezing without covering the mouth.
3. Use sterile technique for invasive procedures.
4. Change dressings and bandages when they are soiled or wet.
The nurse is preparing to obtain a throat culture. Which observation indicates that the
nurse has performed this skill before?
1. The nurse allows the client to insert the swab in the mouth.
2. The nurse removes the swab while making sure to touch the sides of the tonsils.
3. The nurse has the client tilt the head back and say "ah" to relax the tongue to avoid
the gagging reflex.
4. The nurse asks the client to blow the nose to clear the nasal passageway and then
checks with penlight for patency.
The nurse is collecting a capillary blood specimen. Which statement demonstrates
proper technique for this procedure?
1. Clean the site with alcohol, and puncture the finger quickly, then collect the first drop
of blood.
2. If the puncture site is not bleeding, squeeze the finger as firmly as possible without
causing pain.
3. Clean the site with alcohol, puncture the finger, wipe the first drop of blood with
gauze, and then collect the specimen.
4. Puncture the finger in the center of the pad, which is more vascular.
A client arrives at the surgeon's office 1 week after surgery to have the sutures removed.
Which classification should the nurse use when documenting care for this client?
1. Preoperative
2. Postoperative
3. Perioperative
4. Intraoperative
Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?
1. Changing the postoperative dressing on a clean wound
2. Irrigating the client's wound
3. Apply a dry dressing
4. Performing a damp-to-damp dressing change
When putting a client in restraints, the nurse will need to assess the client per policy.
Which items will the nurse include when assessing this client?
Standard Text: Select all that apply.
1. The client's range of motion
2. That the client's restraint is tied in a knot
3. The client's vital signs
4. The client's circulation
5. The client's hydration
The nurse is assisting a client recovering from spinal fusion surgery with the application
of a back brace. What action should be done prior to placing the brace on the client?
1. Apply lotion to the skin
2. Assist the client to put on a T-shirt
3. Measure the client's abdominal girth
4. Dust the skin with baby or corn powder
When discontinuing the nasogastric tube, the nurse instructs the client to complete
which action?
1. Cough
2. Take a deep breath and hold it
3. Hold very still
4. Breathe deeply in through the nose and out through the mouth
The nurse caring for a client with a central line accidentally infuses an air embolism.
Which is the highest-priority action of the nurse?
1. Notifying the health care provider
2. Notifying the charge nurse
3. Assessing the client
4. Positioning the client in left Trendelenburg and applying oxygen
A client is prescribed NovoLog 70/30 15 units subcutaneous injection AC every
morning. At which time should the nurse provide this medication?
1. 15 minutes before breakfast
2. 15 minutes after eating breakfast
3. Immediately after morning report
4. Prior to completing the bath and linen change
The nurse is caring for a client with a newly created ostomy. After changing the ostomy
appliance, which items should the nurse include when documenting the procedure?
Standard Text: Select all that apply.
1. How the drainage was disposed
2. Quantity of drainage recorded on output record
3. Any client participation in the procedure
4. Assessment of stoma and skin around the stoma
5. The odor of the drainage
The nurse is caring for a client who is in skin traction. Which nursing actions are
appropriate for this client?
Standard Text: Select all that apply.
1. Assess neurovascular status every 4 hours, once stable.
2. Place sheep skin under pressure areas.
3. Massage the skin with lotion or alcohol every 4 hours if redness is noted.
4. Remove the weight first when removing nonadhesive traction.
5. Use a fracture bedpan to minimize movement during elimination.
Which action performed by the nurse will be the least effective to reduce the risk of
client falls?
1. Orienting clients to the unit and explaining how the call bell system works
2. Encouraging clients to use call bells for assistance and ensuring that the call bell is
within easy reach
3. Placing overbed and bedside tables out of the way
4. Using nonskid mats in the tub or shower
