Quiz Test

1. The nurse is assisting a client who has a bedside needle liver biopsy scheduled.  Which are the essential actions?  Select all that apply

2. School nurse observes a 3-year-old begin to choke and turn blue while eating lunch.  What should be the nurse's initial action?

3. Occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW).  The site must be assessed for a reaction afterward.  The nurse instructs the HCW to return in how many hours?

4. Nurse is caring for a client with newly prescribed hearing aids.  Which of the following actions by the client indicate proper use and care of hearing aids?  Select all that apply.

5. HCP prescribes a 24-hour urine collection for a client with suspected Cushing syndrome.  Which instructions should the nurse give the client regarding this test?  Select all that apply.

6. Nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals.  Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick?

7. The nurse is obtaining orthostatic vital signs on a client admitted for dehydration.  The nurse measures the client's blood pressure and pulse using the left brachial site with the client lying supine and then sitting.  Which action by the nurse is appropriate?

8. A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention.  The nurse observes urine leaking from the insertion site, past the catheter.  What is the nurse's first action?

9. The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion.  What should the nurse do next?

10. Nurse is performing open endotracheal suctioning for a client with a tracheostomy tube.  Which of the following actions by the nurse are appropriate?  Select all that apply.

11. Student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor.  Which of the following statements by the student indicate a correct understanding?  Select all that apply.

12. Student nurse is preparing to administer the hepatitis B vaccine to a newborn.  Which statement by the student nurse requires the preceptor to provide further teaching?

13. 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound.  Which actions by the new nurse would require the experienced nurse to intervene?  Select all that apply.

14. The nurse is caring for a group of clients.  Which finding requires immediate action by the nurse?

15. The nurse is caring for a client newly prescribed crutches.  Which finding indicates the need for further teaching?

16. The charge nurse is instructing a new graduate nurse on performing postmortem care.  Which client situations might cause the nurse to delay or not perform postmortem care?  Select all that apply.

17. Client is being discharged after having a coronary artery bypass grafting (CABG) x 5.  The client asks questions about the care of chest and leg incisions.  Which instructions should the registered nurse include?  Select all that apply.

18. The nurse reviews the laboratory results for an adult male client admitted with septic shock.  Which value requires the most immediate action?  Check the table for additional information.

19. Registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients.  The RN delegates client positioning to the LPN.  While evaluating the delegated task, the RN realizes that which client positions require intervention?  Select all that apply.

20. A client started a 24-hour urine collection test at 6:00 AM.  The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time.  What action should the nurse take?

21. The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter.  Which interventions will help prevent air embolism on removal?  Select all that apply.

22. The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube.  Which action by the graduate nurse requires intervention by the registered nurse?

23. What interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube?  Select all that apply.

24. Nurse notes muffled heart tones in a client with a pericardial effusion.  How would the nurse assess for a pulsus paradoxus?

25. The nurse is preparing to administer several medications through a client's feeding tube.  None of the medications are extended release.  Which of the following actions should the nurse implement?  Select all that apply.

26. The nurse is preparing to infuse 2 units of packed red blood cells (PRBCs) to a client with a gastrointestinal bleed.  Which actions should the nurse take?  Select all that apply.

27. Which procedures are appropriate for the nurse to use when obtaining an adult client’s blood for a laboratory test?  Select all that apply.

28. The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter.  The nurse should implement what actions to prevent complications during this procedure?  Select all that apply.

29. Nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands.  Which intervention is most important when inserting the urinary catheter?

30. The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed.  Which IV catheter size is best?

31. The nurse is administering cleansing enemas to a client the night before bowel surgery.  During instillation of the enema, the client reports cramping and pain.  What action should the nurse take?

32. Nurse is feeding a confused client via a small-bore nasoenteric tube.  The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark.  After immediately stopping the feeding, which action is appropriate for the nurse to take next?

33. Nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside.  The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now.  How should the nurse respond?

34. Nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein.  The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway.  Which nursing interventions are appropriate?  Select all that apply.

35. Nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity.  Which of the following client statements indicate that teaching has been effective?  Select all that apply.

36. The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter.  What are appropriate reasons for the nurse to change the site?  Select all that apply.

37. A charge nurse is monitoring a newly licensed registered nurse.  What action by the new nurse would warrant intervention by the charge nurse?

38. A child on the playground is experiencing an anaphylactic reaction.  The school nurse arrives with an EpiPen.  The weather is cold and the child is wearing several layers of clothing.  How should the nurse proceed with the EpiPen?

39. A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks.  Which of the following actions by the nurse are appropriate?  Select all that apply.

40. The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours.  The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation.  What action is most important for the nurse to take?

41. The nurse is suctioning the artificial airway of a conscious client.  Which actions demonstrate correct technique?  Select all that apply.

42. The nurse prepares to administer a cleansing enema to a client with constipation.  Which interventions are appropriate?  Select all that apply.

43. The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia.  The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes.  What is the nurse's priority action?

44. Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness.  What initial actions would be appropriate for the nurse to complete?  Select all that apply.

45. A nurse is caring for a 3-month-old client with a new tracheostomy.  Which findings would indicate a need for suctioning?  Select all that apply.

46. The nurse is drawing blood from a client's peripheral vein for laboratory specimens.  Which of the following are correct nursing actions?  Select all that apply.

47. The nurse helps the health care provider perform a thoracentesis at the bedside.  In which position does the nurse place the client to facilitate needle insertion and promote comfort?

48. A patient with altered mental status & fever has suspected bacterial meningitis with sepsis.
BP is 80/60 mm Hg. what nurse can do FIRST?

49. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding.

50. The nurse is caring for patient with Guillain Barre syndrome. which is the Priority??!!

51. Patient with acute Ishemic stroke have BP 178/95 mm Hg. The HCP provides prescription as needed antihypertensives to be given it the systolic BP is >200mm by the Hg. What action by the nurse is appropriate ?

52. A patient had head injury. was admitted to hospital. Previous nurse report GCS score is a 10. which assessment is most Imp. for nurse to report?

53. А nurse is working in Neurology clinic. which client should nurse call first?

54. The nurse is caring for female diagnosed with Epilepsy who has been prescribed phenytoin. which of the following should the nurse include in client teaching ?

55. A client with a C3 spinal cord injury has a sudden headache & nausea. The BP is 170/100 mm Hg. How should the nurse respond initially?

56. The nurse reinforces education about safety modifications in the home for the spouse. of a client diagnosed with Alzheimer disease.
Select all that apply:

57. A client is admitted to Hospital with an exacerbation of myasthenia gravis. what are appropriate nursing actions?

58. The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having tonic -clonic seizures with increasing Salivation. what actions are required? Select all that Apply:

59. The nurse provides education to caretakers of client with Alzheimer disease. which Instructions should the nurse include ?
Select all that apply:

60. A client develops haemorrhagic stroke and is transferred to ICU. select the  nursing Interventions included in the plan of care.

61. The nurse initiates IV therapy on an 80 years old patient ,which Important age consideration. should nurse includes?

62. which of the Interventions would the nurse anticipate for giving hospice care for a Muslim client who is terminally ill?
Select all that apply

63. The unit implemented a quality improvement program to address the client's pain relief. Which set of criteria is the best determinant that the goal has been met?

64. which statements about Palliative care are accurate ?
Select All that apply

65. A client is brought to emergency ward with multiple trauma. The patient belongs to Jehovian witnesses. while provide culturally competent care what should nurse anticipate?

66. which of the following interventions should the nurse include during post-mortem care in preparation for transfer to the funeral home.
Select all that apply.

67. The nurse teaches home oxygen safety precautions to a client with emphysema being discharged with a nasal cannula & portable O₂ tank. which statements indicates the need for further teaching?

68. The nurse is teaching the client with insomnia about techniques to improve sleep habits. which Statement by the client requires further teaching?

69. when assessing the client's pain level, what will, the nurse determine is the most reliable indicator of the pain?

70. Select the appropriate intervention should be included in patient with obesity & DM has an abdominal incision & is at risk for
poor wound healing.

71. UAP finds a reddened area on clients
Sacrum ? what is the nurse priority action?

72. An adolescent client is brought to the ED
after serious MVA. The client undergoing
CPR The nurse call family to inform them. is which an example of the ethical principle of beneficence when responding to the family.

73. The nurse is caring for a client with a feeding tube that has become obstructed. which interventions should nurse includes. to unclog the tube ?

74. A postoperative client who is receiving continuous enteral feedings via NG tube becomes dyspenic with a productive cough, and the nurse auscultates crackles & diminished breath sounds in lung bases which action is appropriate?

75. What are instruction appropriately followed by a nurse to prevent pressure injuries ?

76. Lab Test shows an absolute Neutrophil count of 450 cells/mm³ (0.45 X10 ⁹) what information in the admission history of patient undergoes Chemotherapy complications will need to be

addressed ?