Question 1

The client is about to undergo a lumbar puncture (LP). The nurse tells the client that which of the following positions will be used during the procedure?

Accepted Answer

A)  Side-lying position, with a pillow under the hip 
B)  Prone, with a pillow under the abdomen 
C)  Prone, in a slight Trendelenburg's position 
D)  Side-lying position, with legs pulled up and head bent down onto chest

Question 2

The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. When meeting the client, the nurse should plan to do which of the following?

Accepted Answer

A)  Avoid touching the client. 
B)  Greet the client with a handshake. 
C)  Smile and use humor throughout the entire admission process. 
D)  Avoid any affirmative nods during the conversations with the client.

Question 3

The nurse is assigned to assist in caring for a client who recently returned from the operating room (OR). On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which of the following actions should the nurse plan to take first?

Accepted Answer

A)  Shake the client gently to arouse. 
B)  Call the surgeon immediately. 
C)  Cover the client with a warm blanket. 
D)  Recheck the vital signs in 15 minutes.

Question 4

The nurse has a prescription to give ear drops to a 2-year-old child. The nurse positions the child's ear properly by pulling the pinna of the ear:

Accepted Answer

A)  Upward and outward 
B)  Downward and outward 
C)  Downward and backward 
D)  Upward and backward

Question 5

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced:

Accepted Answer

A)  Phlebitis of the vein 
B)  Infiltration of the IV line 
C)  Hypersensitivity to the IV solution 
D)  Allergic reaction to the IV catheter material

Question 6

The nurse is providing instructions to the client being discharged to home with a peripherally inserted central catheter (PICC). The nurse provides which instructions to the client? Select all that apply.

Accepted Answer

A)  Wear a Medic-Alert tag or bracelet. 
B)  Report redness or swelling at the catheter insertion site. 
C)  Have a repair kit available in the home for use if needed. 
D)  Keep activity level to a minimum while this catheter is in place. 
E)  Cover the PICC dressing with plastic when in the shower or bath.

Question 7

The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. The nurse managers anticipate that the channel of communication and authority will be characterized by an organizational chart that is:

Accepted Answer

A)  Flat 
B)  Vertical 
C)  Circular 
D)  Horizontal

Question 8

The nurse has completed four cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the nurse should:

Accepted Answer

A)  Stop CPR. 
B)  Continue CPR. 
C)  Prepare for defibrillation. 
D)  Prepare for the administration of bicarbonate.

Question 9

The client has been defibrillated unsuccessfully three times using an automatic external defibrillator (AED). The nurse determines that which of the following actions should be taken next?

Accepted Answer

A)  Defibrillate one more time, and then terminate the resuscitation effort. 
B)  Perform cardiopulmonary resuscitation (CPR) for 5 minutes, and then defibrillate three more times. 
C)  Administer sodium bicarbonate intravenously, and resume defibrillation attempts. 
D)  Perform cardiopulmonary resuscitation (CPR) for 1 minute, assess, and then defibrillate up to three more times.

Question 10

The nurse is providing care to a client with continuous tube feedings through a nasogastric (NG) tube. The nurse should avoid doing which of the following, which is not part of the standard care for a client receiving enteral nutrition?

Accepted Answer

A)  Check the residual every 4 hours. 
B)  Check for placement every 4 hours. 
C)  Hang a new feeding bag every 72 hours. 
D)  Check for placement prior to administering medications through the tube.

Question 11

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse takes which priority action?

Accepted Answer

A)  Obtains a court order for the surgery 
B)  Sends the client to surgery without the consent form being signed 
C)  Has the hospital chaplain sign the informed consent immediately 
D)  Obtains a telephone consent from the family member witnessed by two persons

Question 12

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should do which of the following when caring for this client to maintain client safety?

Accepted Answer

A)  Keep the client in a supine position. 
B)  Change the NG tube with every other feeding. 
C)  Check for tube placement and residual amount at least every 4 hours. 
D)  Increase the rate of the feeding if the infusion falls behind schedule.

Question 13

The nurse employed in the pediatric unit working on the 11 PM to 7 AM shift finds an infant unresponsive and without respirations or a pulse. After opening the airway and initiating ventilation, the nurse delivers chest compressions at a minimum rate of:

Accepted Answer

A)  140 times/min 
B)  100 times/min 
C)  80 times/min 
D)  60 times/min

Question 14

The nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the physician has prescribed a medication dose that is twice the amount that the cl ient has reported taking prior to admission. The most appropriate nursing action is to:

Accepted Answer

A)  Contact the physician directly. 
B)  Administer the medication as prescribed. 
C)  Question the client regarding the accuracy of the reported dosage. 
D)  Ask the physician about the prescription the next time the physician makes rounds.

Question 15

A nurse is conducting a basic life support (BLS) recertification class and is discussing automated external defibrillation (AED) when a member of the class asks the nurse to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The nurse correctly responds with:

Accepted Answer

A)  Bilaterally, under the right-sided and left-sided clavicles 
B)  Parallel, between the umbilicus and the left-sided nipple 
C)  Centered on the upper and lower halves of the sternum 
D)  Under the right-sided clavicle and to the left of the nipple in the midaxillary line

Question 16

The registered nurse (RN) has been caring for a terminally ill client. The RN has developed a close relationship with the family of the client. Which of the following nursing interventions will the RN avoid in dealing with the family during this difficult time?

Accepted Answer

A)  Making decisions for the family 
B)  Encouraging family discussion of feelings 
C)  Accepting the family's expressions of anger 
D)  Facilitating the use of spiritual practices identified by the family

Question 17

The nurse plans to do dietary teaching with an African-American client. The nurse understands that foods preferred by individuals of this culture are which of the following?

Accepted Answer

A)  Rice 
B)  Fruits 
C)  Red meat 
D)  Fried foods

Question 18

For which of the following client situations would a consultation with a rapid response team (RRT) be most appropriate?

Accepted Answer

A)  45-year-old, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4° F, heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg 
B)  72-year-old, 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion), temperature 97.8° F, heart rate 92 beats/min, respirations 28 breaths/min, blood pressure 136/86 mm Hg, anxious about going home 
C)  56-year-old, fourth hospital day after coronary artery bypass procedure, sore chest, pain with walking, temperature 97° F, heart rate 84 beats/min, respirations 22 breaths/min, blood pressure 122/78 mm Hg, bored with hospitalization 
D)  86-year-old, 48 hours after operative repair of fractured hip (nail inserted), alert, oriented, using patient-controlled analgesia (PC
A)  pump, temperature 96.8° F, heart rate 60 beats/min, respirations 16 breaths/min, blood pressure 120/82 mm Hg, talking with daughter

Question 19

The client is to receive 1000 mL of D₅W at 100 mL/hr. The drop factor is 10 drops/mL. The nurse adjusts the flow rate to deliver how many drops per minute? (Enter the answer in the space provided.)

Accepted Answer

The answer of The client is to receive 1000 mL...

Question 20

The nurse is monitoring the nutritional status of the client receiving enteral nutrition. The nurse monitors which of the following to determine the effectiveness of the tube feedings for this client?

Accepted Answer

A)  Daily weight 
B)  Calorie count 
C)  Serum protein level 
D)  Daily intake and output

Exam 3: Fundamentals and Issues of Nursing

The client is about to undergo a lumbar puncture (LP) . The nurse tells the client that which of the following positions will be used during the procedure?

The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. When meeting the client, the nurse should plan to do which of the following?

The nurse has a prescription to give ear drops to a 2-year-old child. The nurse positions the child's ear properly by pulling the pinna of the ear:

The nurse is providing instructions to the client being discharged to home with a peripherally inserted central catheter (PICC) . The nurse provides which instructions to the client? Select all that apply.

The nurse has completed four cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the nurse should:

The client has been defibrillated unsuccessfully three times using an automatic external defibrillator (AED) . The nurse determines that which of the following actions should be taken next?

The nurse is providing care to a client with continuous tube feedings through a nasogastric (NG) tube. The nurse should avoid doing which of the following, which is not part of the standard care for a client receiving enteral nutrition?

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse takes which priority action?

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should do which of the following when caring for this client to maintain client safety?

The nurse employed in the pediatric unit working on the 11 PM to 7 AM shift finds an infant unresponsive and without respirations or a pulse. After opening the airway and initiating ventilation, the nurse delivers chest compressions at a minimum rate of:

The registered nurse (RN) has been caring for a terminally ill client. The RN has developed a close relationship with the family of the client. Which of the following nursing interventions will the RN avoid in dealing with the family during this difficult time?

The nurse plans to do dietary teaching with an African-American client. The nurse understands that foods preferred by individuals of this culture are which of the following?

For which of the following client situations would a consultation with a rapid response team (RRT) be most appropriate?

The client is to receive 1000 mL of D₅W at 100 mL/hr. The drop factor is 10 drops/mL. The nurse adjusts the flow rate to deliver how many drops per minute? (Enter the answer in the space provided.)

The nurse is monitoring the nutritional status of the client receiving enteral nutrition. The nurse monitors which of the following to determine the effectiveness of the tube feedings for this client?

Exam 3: Fundamentals and Issues of Nursing

The client is about to undergo a lumbar puncture (LP) . The nurse tells the client that which of the following positions will be used during the procedure?

The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. When meeting the client, the nurse should plan to do which of the following?

The nurse has a prescription to give ear drops to a 2-year-old child. The nurse positions the child's ear properly by pulling the pinna of the ear:

The nurse is providing instructions to the client being discharged to home with a peripherally inserted central catheter (PICC) . The nurse provides which instructions to the client? Select all that apply.

The nurse has completed four cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the nurse should:

The client has been defibrillated unsuccessfully three times using an automatic external defibrillator (AED) . The nurse determines that which of the following actions should be taken next?

The nurse is providing care to a client with continuous tube feedings through a nasogastric (NG) tube. The nurse should avoid doing which of the following, which is not part of the standard care for a client receiving enteral nutrition?

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse takes which priority action?

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should do which of the following when caring for this client to maintain client safety?

The nurse employed in the pediatric unit working on the 11 PM to 7 AM shift finds an infant unresponsive and without respirations or a pulse. After opening the airway and initiating ventilation, the nurse delivers chest compressions at a minimum rate of:

The registered nurse (RN) has been caring for a terminally ill client. The RN has developed a close relationship with the family of the client. Which of the following nursing interventions will the RN avoid in dealing with the family during this difficult time?

The nurse plans to do dietary teaching with an African-American client. The nurse understands that foods preferred by individuals of this culture are which of the following?

For which of the following client situations would a consultation with a rapid response team (RRT) be most appropriate?

The client is to receive 1000 mL of D5W at 100 mL/hr. The drop factor is 10 drops/mL. The nurse adjusts the flow rate to deliver how many drops per minute? (Enter the answer in the space provided.)

The nurse is monitoring the nutritional status of the client receiving enteral nutrition. The nurse monitors which of the following to determine the effectiveness of the tube feedings for this client?

The client is to receive 1000 mL of D₅W at 100 mL/hr. The drop factor is 10 drops/mL. The nurse adjusts the flow rate to deliver how many drops per minute? (Enter the answer in the space provided.)