Question 1

When a nurse is adding additional dressings to a sterile field,which of these steps is correct?

Accepted Answer

A) Grasp the bottom,use a sterile clamp to remove dressing,and drop it anywhere on the field. 
B) Place the unopened package directly on the field. 
C) Grasp top flaps,pull downward,and drop dressing in center of field. 
D) Hold the sides,pull them outward,and drop dressing on the field. 
A) Grasp the bottom,use a sterile clamp to remove dressing,and drop it anywhere on the field. 
B) Place the unopened package directly on the field. 
C) Grasp top flaps,pull downward,and drop dressing in center of field. 
D) Hold the sides,pull them outward,and drop dressing on the field.

Question 2

A client requires nasopharyngeal suctioning.To ensure the suction catheter is properly placed,the nurse should do which of the following?

Accepted Answer

A) Ensure a sterile suction set is available at the client's bedside. 
B) Check the function of the suction device before beginning the procedure. 
C) Use the estimated distance from the tip of the client's nose to the earlobe,and grasp catheter at this point. 
D) Advance the catheter gently until resistance is met,and continue rotating the catheter until secretions are obtained. 
A) Ensure a sterile suction set is available at the client's bedside. 
B) Check the function of the suction device before beginning the procedure. 
C) Use the estimated distance from the tip of the client's nose to the earlobe,and grasp catheter at this point. 
D) Advance the catheter gently until resistance is met,and continue rotating the catheter until secretions are obtained.

Question 3

A client who has an indwelling urinary catheter develops increased sediment in the drainage tubing,and a catheter irrigation is prescribed.Before the irrigating solution is introduced into the catheter,the nurse must FIRST do which of the following actions?

Accepted Answer

A) Insert the tip of the irrigating syringe into the catheter;then fill it with 60 cc of solution. 
B) Disinfect the connection between the catheter and drainage tubing before separating them. 
C) Separate the catheter and drainage tubing,and let the catheter drain to empty the bladder. 
D) Remove the current catheter;then reinsert another catheter before starting the procedure. 
A) Insert the tip of the irrigating syringe into the catheter;then fill it with 60 cc of solution. 
B) Disinfect the connection between the catheter and drainage tubing before separating them. 
C) Separate the catheter and drainage tubing,and let the catheter drain to empty the bladder. 
D) Remove the current catheter;then reinsert another catheter before starting the procedure.

Question 4

A nurse is preparing to change a client's wet-to-moist dressing and notes the dressing is extremely dry.Which of these steps should the nurse take NEXT?

Accepted Answer

A) Check the client record as to the time of the last dressing change. 
B) Ask another nurse to help remove the current dressing. 
C) Moisten the dressing with a small amount of saline before removing it. 
D) Supersaturate the new dressing and cover with dry 4 x 4 gauze pads. 
A) Check the client record as to the time of the last dressing change. 
B) Ask another nurse to help remove the current dressing. 
C) Moisten the dressing with a small amount of saline before removing it. 
D) Supersaturate the new dressing and cover with dry 4 x 4 gauze pads.

Question 5

A nurse is administering tuberculin screening tests to people attending a health fair.When injecting the solution,the nurse should take which of these steps?

Accepted Answer

A) Insert the needle at a 10-degree angle,inject rapidly,note formation of a bleb,and withdraw needle. 
B) Insert the needle at a 5- to 15-degree angle,inject slowly,note formation of a bleb,withdraw needle,and massage the site. 
C) Insert the needle at a 5- to 15-degree angle,inject slowly,note formation of a bleb,and withdraw needle. 
D) Insert the needle at a 10-degree angle,inject rapidly,note formation of a bleb,withdraw needle,and massage the site. 
A) Insert the needle at a 10-degree angle,inject rapidly,note formation of a bleb,and withdraw needle. 
B) Insert the needle at a 5- to 15-degree angle,inject slowly,note formation of a bleb,withdraw needle,and massage the site. 
C) Insert the needle at a 5- to 15-degree angle,inject slowly,note formation of a bleb,and withdraw needle. 
D) Insert the needle at a 10-degree angle,inject rapidly,note formation of a bleb,withdraw needle,and massage the site.

Question 6

A nurse is preparing to change a client's colostomy pouch.After removing the pouch,which of these steps should the nurse take NEXT?

Accepted Answer

A) Prepare solution for cleansing the stoma. 
B) Measure the stoma to fit the new pouch. 
C) Remove gloves,cleanse hands,and apply clean gloves. 
D) Place a gauze pad over the stoma while preparing to cleanse it and apply new pouch. 
A) Prepare solution for cleansing the stoma. 
B) Measure the stoma to fit the new pouch. 
C) Remove gloves,cleanse hands,and apply clean gloves. 
D) Place a gauze pad over the stoma while preparing to cleanse it and apply new pouch.

Question 7

Prior to medication administration,the nurse would ensure safety by verifying the right client,the right medication,the right dose,and:

Accepted Answer

A) the right color,and the right manufacturer 
B) the right generic substitute,and the right-size tablet or capsule 
C) the right route,and the right time 
D) the right name,and the right room 
A) the right color,and the right manufacturer 
B) the right generic substitute,and the right-size tablet or capsule 
C) the right route,and the right time 
D) the right name,and the right room

Question 8

How will the nurse document a bladder irrigation on the client's intake and output record?

Accepted Answer

A) by recording only the amount of irrigant instilled 
B) by recording the amount of irrigant instilled and the amount of drainage measured 
C) by recording only the amount of drainage 
D) by measuring drainage before and after irrigation is completed 
A) by recording only the amount of irrigant instilled 
B) by recording the amount of irrigant instilled and the amount of drainage measured 
C) by recording only the amount of drainage 
D) by measuring drainage before and after irrigation is completed

Question 9

A client has a prescription for an ice bag to be applied to a sprained ankle.The nurse would return to remove the ice bag in:

Accepted Answer

A) 10 minutes 
B) 20 minutes 
C) 45 minutes 
D) 1 hour 
A) 10 minutes 
B) 20 minutes 
C) 45 minutes 
D) 1 hour

Question 10

When a nurse is replacing a client's tracheostomy ties,which of these steps is correct?

Accepted Answer

A) Hold the neck plate firmly with one hand while untying and removing soiled tapes. 
B) Remove soiled tapes,cleanse the neck plate,and replace with clean tapes. 
C) Suction the tracheostomy,perform tracheostomy cleaning,cut the soiled tapes,and replace with clean tapes. 
D) Sedate the client,remove soiled tapes,perform tracheostomy cleaning,and apply clean tapes. 
A) Hold the neck plate firmly with one hand while untying and removing soiled tapes. 
B) Remove soiled tapes,cleanse the neck plate,and replace with clean tapes. 
C) Suction the tracheostomy,perform tracheostomy cleaning,cut the soiled tapes,and replace with clean tapes. 
D) Sedate the client,remove soiled tapes,perform tracheostomy cleaning,and apply clean tapes.

Question 11

What is the maximum amount of medication that should be administered subcutaneously?

Accepted Answer

A) l mL 
B) 1.5 mL 
C) 2 mL 
D) 2.5 mL 
A) l mL 
B) 1.5 mL 
C) 2 mL 
D) 2.5 mL

Question 12

A client is to receive continuous bladder irrigation following prostate surgery.Which type of catheter will be used for this procedure?

Accepted Answer

A) straight catheter 
B) indwelling catheter to straight drainage 
C) three-way catheter 
D) two-way catheter 
A) straight catheter 
B) indwelling catheter to straight drainage 
C) three-way catheter 
D) two-way catheter

Question 13

A client is receiving oxygen therapy via a Venturi mask.Which of these actions is essential when a nurse is caring for this client?

Accepted Answer

A) Check the flow rate at least every 2 hours. 
B) Ensure that the mask ports are cleansed every 4 hours. 
C) Begin to wean the client to a nasal cannula as soon as possible. 
D) Assess client's face and ears for signs of pressure from the mask. 
A) Check the flow rate at least every 2 hours. 
B) Ensure that the mask ports are cleansed every 4 hours. 
C) Begin to wean the client to a nasal cannula as soon as possible. 
D) Assess client's face and ears for signs of pressure from the mask.

Question 14

Before a nurse administers an enteral feeding,it is essential to take which of the following actions?

Accepted Answer

A) Determine if the client has had a bowel movement in the past 24 hours. 
B) Ask the client about any feeling of gastric fullness. 
C) Weigh the client and compare with previous weight. 
D) Auscultate for bowel sounds to determine gastric motility. 
A) Determine if the client has had a bowel movement in the past 24 hours. 
B) Ask the client about any feeling of gastric fullness. 
C) Weigh the client and compare with previous weight. 
D) Auscultate for bowel sounds to determine gastric motility.

Question 15

Which of these steps is correct when a nurse is instilling two medications into a client's enteral tube?

Accepted Answer

A) Clamp the tube,attach the syringe,add both medications,release the clamp,and flush with 30 cc water. 
B) Attach the syringe,pour 30 cc of one medication,open the clamp,rinse with 5 cc water,pour remaining medication into the tube,and flush with 30 to 50 cc water. 
C) Attach the syringe,pour both medications into the tube,open the clamp,and flush with 30 to 50 cc water. 
D) Aspirate gastric contents,attach the syringe,pour each medication sequentially into the tube,and flush with 100 cc water 
A) Clamp the tube,attach the syringe,add both medications,release the clamp,and flush with 30 cc water. 
B) Attach the syringe,pour 30 cc of one medication,open the clamp,rinse with 5 cc water,pour remaining medication into the tube,and flush with 30 to 50 cc water. 
C) Attach the syringe,pour both medications into the tube,open the clamp,and flush with 30 to 50 cc water. 
D) Aspirate gastric contents,attach the syringe,pour each medication sequentially into the tube,and flush with 100 cc water

Question 16

Which of these steps in administering eyedrops to a client is MOST important?

Accepted Answer

A) placing a tissue below the lower lid 
B) pulling down on the cheek 
C) having client close eyes after drops are instilled 
D) holding the eyedropper at least 1/2 inch above the eyeball 
A) placing a tissue below the lower lid 
B) pulling down on the cheek 
C) having client close eyes after drops are instilled 
D) holding the eyedropper at least 1/2 inch above the eyeball

Question 17

Which of these exercises,if taught to a client prior to surgery,can BEST prevent development of postoperative respiratory complications?

Accepted Answer

A) turning 
B) coughing 
C) deep breathing and spirometry 
D) splinting 
A) turning 
B) coughing 
C) deep breathing and spirometry 
D) splinting

Question 18

A client who experienced respiratory distress had a tracheostomy performed 2 hours ago.The nurse must use which of these approaches when caring for the tracheostomy?

Accepted Answer

A) clean technique 
B) sterile technique 
C) clean technique to remove the cannula and sterile technique to suction it 
D) client self-care technique 
A) clean technique 
B) sterile technique 
C) clean technique to remove the cannula and sterile technique to suction it 
D) client self-care technique

Question 19

A client has a percutaneous endoscopic gastrostomy (PEG)tube in place.Which of these actions must the nurse take when caring for this client?

Accepted Answer

A) Rotate the PEG tube daily. 
B) Keep the PEG tube pinned to the client's gown at all times. 
C) Minimize flushing of the PEG tube. 
D) Cleanse the skin around the client's PEG tube with hydrogen peroxide. 
A) Rotate the PEG tube daily. 
B) Keep the PEG tube pinned to the client's gown at all times. 
C) Minimize flushing of the PEG tube. 
D) Cleanse the skin around the client's PEG tube with hydrogen peroxide.

Question 20

A nurse should instruct a client who is to use a metered-dose nebulizer to follow which of these steps?

Accepted Answer

A) Exhale,place mouthpiece in mouth,press down on dispenser while simultaneously inhaling,and hold for 10 seconds before exhaling slowly. 
B) Inhale and exhale several times,place mouthpiece in mouth,press down on dispenser,inhale,and hold for 20 seconds before exhaling slowly. 
C) Place mouthpiece in mouth,press down on dispenser,take two deep breaths,and exhale rapidly. 
D) Rest quietly for 5 minutes before placing mouthpiece in mouth,press down on dispenser,take two deep breaths,and exhale rapidly. 
A) Exhale,place mouthpiece in mouth,press down on dispenser while simultaneously inhaling,and hold for 10 seconds before exhaling slowly. 
B) Inhale and exhale several times,place mouthpiece in mouth,press down on dispenser,inhale,and hold for 20 seconds before exhaling slowly. 
C) Place mouthpiece in mouth,press down on dispenser,take two deep breaths,and exhale rapidly. 
D) Rest quietly for 5 minutes before placing mouthpiece in mouth,press down on dispenser,take two deep breaths,and exhale rapidly.

Exam 30: Intermediate Procedures

When a nurse is adding additional dressings to a sterile field,which of these steps is correct?

A client requires nasopharyngeal suctioning.To ensure the suction catheter is properly placed,the nurse should do which of the following?

A client who has an indwelling urinary catheter develops increased sediment in the drainage tubing,and a catheter irrigation is prescribed.Before the irrigating solution is introduced into the catheter,the nurse must FIRST do which of the following actions?

A nurse is preparing to change a client's wet-to-moist dressing and notes the dressing is extremely dry.Which of these steps should the nurse take NEXT?

A nurse is administering tuberculin screening tests to people attending a health fair.When injecting the solution,the nurse should take which of these steps?

A nurse is preparing to change a client's colostomy pouch.After removing the pouch,which of these steps should the nurse take NEXT?

Prior to medication administration,the nurse would ensure safety by verifying the right client,the right medication,the right dose,and:

How will the nurse document a bladder irrigation on the client's intake and output record?

A client has a prescription for an ice bag to be applied to a sprained ankle.The nurse would return to remove the ice bag in:

When a nurse is replacing a client's tracheostomy ties,which of these steps is correct?

What is the maximum amount of medication that should be administered subcutaneously?

A client is to receive continuous bladder irrigation following prostate surgery.Which type of catheter will be used for this procedure?

A client is receiving oxygen therapy via a Venturi mask.Which of these actions is essential when a nurse is caring for this client?

Before a nurse administers an enteral feeding,it is essential to take which of the following actions?

Which of these steps is correct when a nurse is instilling two medications into a client's enteral tube?

Which of these steps in administering eyedrops to a client is MOST important?

Which of these exercises,if taught to a client prior to surgery,can BEST prevent development of postoperative respiratory complications?

A client who experienced respiratory distress had a tracheostomy performed 2 hours ago.The nurse must use which of these approaches when caring for the tracheostomy?

A client has a percutaneous endoscopic gastrostomy (PEG)tube in place.Which of these actions must the nurse take when caring for this client?

A nurse should instruct a client who is to use a metered-dose nebulizer to follow which of these steps?

Student Nurse Skills for Success

Holistic Care

Nursing History, Education, and Organizations

Legal and Ethical Responsibilities

The Health Care Delivery System

Arenas of Care

Communication

Client Teaching

Nursing Processdocumentationinformatics

Life Span Development

Cultural Considerations

Stress, Adaptation, and Anxiety

Loss, Grief, and Death

Wellness Concepts

Self-Concept

Spirituality

Complementary Alternative Therapies

Basic Nutrition

Rest and Sleep

Safety-Hygiene

Infection Controlasepsis

Standard Precautions and Isolation

Bioterrorism

Fluid, Electrolyte, and Acid-Base Balance

Medication Administration and IV Therapy

Assessment

Pain Management

Diagnostic Tests

Basic Procedures

Advanced Procedures

Anesthesia

Surgery

Oncology

Respiratory System

Cardiovascular System

Hematologic and Lymphatic Systems

Gastrointestinal System

Urinary System

Musculoskeletal System

Neurological System

Sensory System

Endocrine System

Reproductive System

Sexually Transmitted Diseases

Integumentary System

Immune System

Mental Illness

Substance Abuse

The Older Adult

Ambulatory, Restorative, and Palliative Care in Community Settings

Responding to Emergencies

Integration

Prenatal Care

Complications of Pregnancy

The Birth Process

Postpartum Care

Newborn Care

Basics of Pediatric Care

Infants With Special Needs: Birth to 12 Months