Question 1

The nurse is preparing to assist a Jewish-American client with eating lunch. A kosher meal is delivered to the client. Which of the following nursing actions is most appropriate in assisting the client with the meal?

Accepted Answer

A)  Unwrap the eating utensils for the client. 
B)  Replace the plastic utensils with metal eating utensils. 
C)  Carefully place the food from the paper plates to glass plates. 
D)  Ask the client to unwrap the eating utensils, and allow the client to prepare the meal for eating.

Question 2

The nurse is initiating one-rescuer cardiopulmonary resuscitation (CPR) on an adult client. After ventilating the client, the nurse places the hands in which of the following positions to begin chest compressions?

Accepted Answer

A)  On the lower half of the sternum 
B)  On the lower third of the sternum 
C)  On the upper third of the sternum 
D)  On the upper half of the sternum

Question 3

An adult client is brought to the emergency department by emergency medical services after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which of the following is the best initial action?

Accepted Answer

A)  Obtain a court order for the surgical procedure. 
B)  Transport the victim to the operating room for surgery. 
C)  Call the police to identify the client and locate the family. 
D)  Ask the emergency medical services team to sign the informed consent.

Question 4

The nurse is reviewing the physician's prescription sheet for the preoperative client, which states that the client must be NPO after midnight. The nurse should clarify which of the following medications should be given to the client and not withheld?

Accepted Answer

A)  Ferrous sulfate 
B)  Atenolol (Tenormin) 
C)  Cyclobenzaprine (Flexeril) 
D)  Conjugated estrogen (Premarin)

Question 5

The client who underwent preadmission testing prior to a surgical procedure had serum laboratory studies drawn, including complete blood count, electrolytes, coagulation studies, and creatinine. Which of the following laboratory results should be reported to the surgeon immediately?

Accepted Answer

A)  Platelet count, 210,000/mm3 
B)  Serum sodium (Na) level, 141 mEq/L 
C)  Hemoglobin (Hgb) level, 8.9 g/dL 
D)  Serum creatinine level, 0.8 mg/dL

Question 6

A filled blood specimen tube was dropped and broken in the client's room. Which of the following actions by the nursing assistant is incorrect?

Accepted Answer

A)  Uses tongs to collect any broken glass 
B)  Wears gloves for the cleaning procedure 
C)  Blots up the spill with a face cloth or cloth towel 
D)  Disinfects the area of the blood spill with a dilute bleach solution

Question 7

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which of the following frequencies?

Accepted Answer

A)  Every hour 
B)  Every 2 hours 
C)  Every 3 hours 
D)  Every 4 hours

Question 8

A nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. The nurse then opens the victim's airway by using the:

Accepted Answer

A)  Head tilt-chin lift 
B)  Head tilt-jaw thrust 
C)  Jaw thrust maneuver 
D)  Chin lift position

Question 9

The registered nurse (RN) gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report. The RN notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the:

Accepted Answer

A)  Error will result in suspension. 
B)  Incident will be reported to the board of nursing. 
C)  Incident will be documented in the personnel file. 
D)  Incident report is a method of promoting quality care and risk management.

Question 10

The nurse is preparing to assist in examining a Hispanic-American child who was brought to the clinic by the mother. During assessment of the child, the nurse would avoid which of the following?

Accepted Answer

A)  Admiring the child 
B)  Taking the child's temperature 
C)  Obtaining an interpreter if necessary 
D)  Asking the mother questions about the child

Question 11

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions first?

Accepted Answer

A)  Ensure that the client has voided. 
B)  Administer all the daily medications. 
C)  Practice postoperative breathing exercises. 
D)  Verify that the client has not eaten for the last 24 hours.

Question 12

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client? Select all that apply.

Accepted Answer

A)  Sit leaning forward. 
B)  Inhale deeplyand quickly. 
C)  Sit upright or lean slightly back. 
D)  Hold the mouthpiece tightly with the teeth. 
E)  Keep a tight seal between the lips and the mouthpiece.
F) After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

Question 13

The nurse is caring for a client receiving parenteral nutrition (PN) via a central line. The nurse should monitor which of the following to detect the development of the most common complication of PN?

Accepted Answer

A)  Temperature 
B)  Daily weight 
C)  Intake and output (I&O) 
D)  Serum blood urea nitrogen (BUN) level

Question 14

The physician prescribes atenolol (Tenormin), 0.05 g orally daily. The label on the medication bottle states atenolol (Tenormin), 25-mg tablets. How many tablets will the nurse administer to the client? (Enter the answer in the space provided.)

Accepted Answer

The answer of The physician prescribes atenolol (Tenormin), 0.05 g...

Question 15

The physician prescribes 1000 mL of normal saline to be infused over a period of 10 hours. The drop factor is 15 drops/mL. The nurse adjusts the flow rate at how many drops per minute? (Enter the answer in the space provided.)

Accepted Answer

The answer of The physician prescribes 1000 mL of normal...

Question 16

The physician's prescription reads potassium chloride (KCl) 30 mEq to be added to 1000 mL normal saline and to be administered over a 10-hour period. The label on the medication bottle reads 4 mEq (KCl)/mL. The nurse prepares how many milliliters of potassium chloride (KCl) to administer the correct dose of medication? (Enter the answer in the space provided.)

Accepted Answer

The answer of The physician's prescription reads potassium chloride (KCl)...

Question 17

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. The nurse notes the urine beginning to flow and next:

Accepted Answer

A)  Immediately inflates the balloon 
B)  Inserts the catheter 2.5 to 5 cm farther, then inflates the balloon 
C)  Inserts the catheter until resistance is met, then inflates the balloon 
D)  Withdraws the catheter approximately 1 inch, then inflates the balloon

Exam 3: Fundamentals and Issues of Nursing