Q&A Hero

Q: A client requiring long-term catheterization is allergic to latex. Which catheter should the nurse choose to insert? 1. Silver alloy catheter 2. Antimicrobial-coatedcatheter 3. Silicone catheter 4. Latex catheter

Q: The nurse is caring for an older adult client with a medical diagnosis of benign prostatic hyperplasia resulting in urinary retention. When attempting to pass the catheter, the nurse encounters an obstruction, and cannot get the catheter to pass beyond it. Which action by the nurse is the most appropriate? 1. Documenting that catheterization is not possible, and notifying the health care provider 2. Attempting to pass a Coud catheter 3. Attempting to push the catheter past the obstruction 4. Applying ice to the base of the penis, and attempting to pass the catheter in 30 minutes

Q: When is it appropriate for the nurse to prepare a new ostomy pouch for a client? 1. After removing the old pouch in all instances 2. Before removing the old pouch in all instances 3. Before removing the old pouch whenever possible 4. After removing the old pouch whenever possible

Q: The nurse is initiating closed continuous bladder irrigation using a three-way catheter. Prior to beginning the flow of the irrigation fluid, which action by the nurse is the most appropriate? 1. Opening the roller clamp to the desired flow rate 2. Emptying the urine collection bag 3. Documenting the procedure 4. Assessing the drainage for amount, color, and clarity

Q: When performing catheter care, which action is least appropriate to perform? 1. Applying sterile gloves 2. Washing the meatus and proximal catheter with soap and water 3. Drying the catheter and urinary meatus 4. Performing hand hygiene

Q: The nurse is preparing to insert a urinary catheter. Place the steps for this procedure in the proper order. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Cleanse the meatus. Response 2. Apply sterile gloves. Response 3. Test the balloon of the indwelling catheter, if recommended by manufacturer. Response 4. Organize the supplies in the catheter kit. Response 5. Place a sterile drape under the buttocks of the female or penis of the male without contaminating the center of the drape.

Q: After emptying the urine from a urinal, which actions by the nurse are appropriate? Standard Text: Select all that apply. 1. Rinsing the urinal 2. Recording the output on the intake and output record, if indicated 3. Returning the urinal to the bedside area, where the client can reach it, if the male client prefers 4. Placing the urinal between the client's legs and propping the penis in the opening, if the client is unable to do this independently 5. Donning clean gloves

Q: Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)? 1. Inserting a urinary retention catheter 2. Inserting a straight catheter 3. Applying a condom catheter 4. Collecting data for a urinary elimination history

Q: Which term is not used interchangeably with urinary elimination? 1. Micturition 2. Voiding 3. Urination 4. Incontinence

Q: The nurse is caring for an older adult male client who demonstrates frequent urinary incontinence. Which option should the nurse use to reduce the risk of skin damage secondary to urinary incontinence for this client? 1. Coude catheter 2. Straight catheter 3. Condom catheter 4. Foley catheter

Q: The nurse completes a health history with a client scheduled for an MRI of the knee and immediately notifies the health care provider. What did the nurse assess to make this clinical decision? 1. Wears religious metals 2. History of heart failure 3. Metal in spine from a spinal fusion 4. Takes insulin for type 1 diabetes mellitus

Q: A client is returning to the care area after a bronchoscopy. What should the nurse make a priority when caring for this client? 1. Keep NPO 2. Encourage clear liquids 3. Report hoarseness or a sore throat 4. Assist with deep breathing and coughing

Q: The nurse is preparing a client for a liver biopsy. In which position should the client be placed? 1. Sims position 2. Seated in a chair 3. Leaning forward 4. Right arm raised and extended over the left shoulder

Q: A client scheduled for an outpatient endoscopy asks when he can eat since the black cup of coffee wasn"t enough. What should the nurse do? 1. Provide with dry crackers 2. Notify the radiology department 3. Document that the client had black coffee 4. Explain that a meal will be provided shortly

Q: The nurse notes that a client returning from a cardiac catheterization has the extremity used for the procedure elevated on a pillow. What should the nurse do? 1. Remove the pillow 2. Position on the left side 3. Keep the pillow in place 4. Raise the head of the bed

Q: The nurse is preparing to assess a client recovering from an arteriogram. What should be the priority for this client? 1. Monitor pulses distal to the puncture site 2. Elevate the extremity used for the puncture site 3. Place a pillow under the extremity used for the puncture sit 4. Increase intravenous fluids to ensure an adequate urine output

Q: A client is recovering from a myelogram in the outpatient ambulatory surgical center. What is a priority when caring for this client? 1. Restrict fluids 2. Keep the bed flat 3. Encourage ambulation 4. Raise the head of the bed to a 60 degree angle

Q: A client is scheduled for a diagnostic test using radioactive isotopes. What should the nurse expect to be provided to this client before the test? 1. A sedative 2. A blocking agent 3. Intravenous fluids 4. A dose of an antibiotic

Q: During an intravenous pyelogram the nurse suspects that a client is experiencing an allergic reaction to the contrast medium. What did the nurse assess to make this clinical determination? Select all that apply. 1. Onset of nausea 2. Hives on the neck 3. Respiratory rate 28 4. Complaint of being thirsty 5. Blood pressure 88/50 mm Hg

Q: A client is scheduled for a CT scan of the brain with and without contrast. What needs to be done to prepare the client for this diagnostic test? Select all that apply. 1. Explain what happens during the test 2. Review what needs to be done after the test is completed 3. Discuss what needs to be done before arriving for the test 4. Obtain information about the client's health insurance plan 5. Ask if the client has any questions after receiving instructions

Q: A staff nurse position has been posted for the radiology department. Which nurse is the most qualified for this position? 1. Nurse with 10 years of experience in the intensive care unit 2. Nurse with 6 months of experience in the post anesthesia care unit 3. Nurse with 7 years of experience working in the hemodialysis center 4. Nurse with 4 years of experience in the outpatient ambulatory center

Q: The nurse is assisting with a thoracentesis. Place the steps of the procedure for assisting the client in the correct order. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Help position the client and cover the client as needed with a bath blanket. Response 2. Observe the client for signs of distress, such as dyspnea, pallor, and coughing. Response 3. Support the client verbally and describe the steps as needed. Response 4. Support the client throughout the procedure. Response 5. Collect drainage and laboratory specimens. Then apply small sterile dressing over the site.

Q: The nurse is preparing the client for diagnostic testing using contrast media. The client is questioned regarding allergies. The nurse would contact the health care provider if the client reported an allergy to which item? 1. Eggs 2. Milk 3. Betadine 4. Scallops

Q: The nurse is preparing a client for diagnostic studies requiring the administration of contrast media. Which action by the nurse is the priority in this situation? 1. Obtaining informed consent 2. Obtaining results of lab tests 3. Checking for allergies 4. Checking if routine medications are to be held

Q: 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

Q: The nurse is assisting the health care provider collect cerebrospinal fluid for testing to rule out meningitis. Which are the nurse's responsibilities? Standard Text: Select all that apply. 1. Explain the procedure and obtain signed consent. 2. Teach the client how to assist during the procedure by maintaining proper positioning. 3. Observe sterile technique when preparing the equipment for the procedure. 4. Label all specimens collected and send them to the lab. 5. Assess the client before, during, and after the procedure.

Q: The health care provider performs a specimen collection by inserting a needle into the abdomen to collect fluid. Which term should the nurse use when documenting this procedure? 1. Paracentesis 2. Thoracentesis 3. Lumbar puncture 4. Venogram

Q: The nurse is obtaining a gum swab for an HIV test. What should the nurse include when performing this procedure? Select all that apply. 1. Check window display on device 2. Swab outer gum with device included in kit 3. Insert swab into vial containing special solution 4. Have the client flush the mouth with mouthwash 5. Instruct client to confirm results with a Western blot test

Q: The manager interrupts a new graduate at the completion of a venipuncture. What did the manager observe that caused this interruption? 1. Removed the tube before withdrawing the needle 2. Bent the client's elbow after withdrawing the needle 3. Released the tourniquet once blood began to flow into the tube 4. Held a gauze sponge on the puncture site after withdrawing the needle

Q: 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.

Q: The nurse has delegated the collection of a clean catch urine specimen to the unlicensed assistive personnel (UAP). Which statement by the UAP indicates an appropriate understanding of the procedure? 1. "I will have the client urinate in the specimen container the next time he or she urinates." 2. "I will provide the client with sterile gloves for collecting the urine specimen." 3. "I will ask the client to cleanse the urethra to avoid contamination of the urine specimen." 4. "I will watch the client obtain the urine specimen to ensure correct obtainment."

Q: A client is prescribed intravenous antibiotics however a culture and sensitivity has been ordered. What should the nurse do prior to starting the intravenous antibiotics? 1. Assess vital signs. 2. Collect the ordered culture and sensitivity specimen. 3. Start intravenous antibiotics. 4. Obtain culture after two doses have been given.

Q: The nurse is preparing to collect a stool specimen. Place the steps involved in the procedure in the correct order. Standard Text: Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Provide for client privacy. Response 2. Assist the clients who need help, either with bedside commode or a bedpan. Response 3. Perform hand hygiene and observe other appropriate infection control procedures. Response 4. Apply gloves to prevent contamination, and clean the client as required. Inspect the skin around the anus for any irritation, especially if the client defecates frequently and has liquid stools. Response 5. Transfer the required amount of stool to the stool specimen container. Use tongue blades to transfer some or the entire stool specimen container, taking care not to contaminate the outside of the container. Response 6. Prior to beginning of procedure, introduce self and verify the client's identity. Explain what is going to be done, why it is necessary, and how the client can help.

Q: The nurse obtains a specimen from the client's wound. Which items will the nurse include when documenting this procedure in the medical record? Standard Text: Select all that apply. 1. Source of specimen 2. Type of culture obtained 3. Appearance of wound 4. Dispersal of the specimen 5. Microorganism causing infection

Q: The nurse is obtaining a throat culture. Which action indicates correct technique? 1. Inserting the swab into the sterile tube without touching the outside of the container 2. Inserting a tongue blade to depress the anterior two-thirds of the tongue 3. Swabbing along the side of the cheek inside the mouth 4. Swabbing the pharynx gently and quickly, avoiding the tonsils

Q: How does the procedure change when a nurse collects a midstream urine specimen from a woman versus a man? 1. Women should be taught to begin their stream before collecting the specimen. 2. Women would be provided with three antimicrobial wipes, whereas men would be provided with only one or two. 3. Men should be taught not to touch the inside of the collection container or the lid. 4. Men should be taught to fill the container no more than one-half to one-third full.

Q: 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.

Q: The nurse is caring for several clients, and has unlicensed assistive personnel (UAP) and LPN/LVN assisting. Which client should the nurse delegate to the LPN/LVN as opposed to the UAP? 1. Assisting the health care provider with performance of a lumbar puncture 2. Collecting and testing a routine urine specimen for sugar, protein, and specific gravity 3. Testing stool for the presence of occult blood 4. Collecting a sterile urine specimen by straight-catheterizing the client

Q: Which specimens could the nurse safely delegate to the unlicensed assistive personnel (UAP) to collect? Standard Text: Select all that apply. 1. Wound culture 2. Routine urine specimen 3. Cerebrospinal fluid 4. Stool specimen 5. Sputum specimen

Q: The health care provider suspects the postoperative client has an infection, but is not sure of the source, and orders sputum, wound, urine, and nasal cultures. Which culture should be collected when the client wakes in the morning? 1. Urine 2. Sputum 3. Wound 4. Nasal

Q: The nurse suspects the client at the urgent care center might have a urinary tract infection. Based on this, which type of urine specimen should the nurse prepare to collect from the client? 1. 24-hour urine specimen 2. Midstream urine specimen 3. Routine urine specimen 4. Timed urine specimen

Q: The nurse performs a guaiac stool test and gets a positive result. Based on this test result, which diagnosis is least expected for this client? 1. Colon cancer 2. Hemorrhoids 3. Bleeding stomach ulcers 4. HIV/AIDS

Q: In which is a capillary blood specimen least likely to be indicated? 1. Testing a serum glucose level 2. Measuring a client's hematocrit 3. Obtaining blood specimens on an infant 4. Measuring an arterial blood gas

Q: The nurse receives an order to collect a midstream urine specimen from the client. Which is not a part of collecting this specimen? 1. Teaching the client how to clean the genitals prior to collecting the specimen 2. Labeling the specimen and sending it to the lab 3. Assuring that the specimen is collected following sterile technique 4. Documenting that the specimen has been collected and what was done with it

Q: A client is prescribed to receive enteral feedings to begin at 25 mL/hr 2 4 hours, 50 mL/hr x 2 hours, 75 mL/hr x 2 hours, and 100 mL/hr x 2 hours. In order to prepare the feeding bag for the entire 8 hour shift, how many mL of tube feeding should the nurse place in the feeding bag? Calculate to the nearest whole number.

Q: A client with a massive sacral wound is prescribed a 2800 calorie diet. Of these calories 55% are to be carbohydrates and 25% fats. How many calories should the client ingest of protein? Calculate to the nearest whole number.

Q: The nurse is preparing to administer medications via a client's nasogastric feeding tube that was inserted 4 weeks ago. When attempting to flush the tube, the nurse realizes that the tube is clogged. Which action by the nurse is the priority? 1. Using coke to unclog the tube 2. Giving the medication orally 3. Using ice water to irrigate the tube 4. Replacing the current tube with a new one

Q: The nurse is caring for a client who has no cough or gag reflex and is unable to take nutrients orally. Which device would be an appropriate choice for providing nutrition to this client? 1. A nasogastric tube 2. An orogastric tube 3. A nasoenteric tube 4. A jejunostomy tube

Q: Which clients should the nurse consider as candidates for an enteral access device? Standard Text: Select all that apply. 1. The client who is NPO in preparation for surgery 2. The client with an absent cough and gag reflex 3. The postoperative client who returns to the unit following bowel resection who is unconscious secondary to sedation 4. The client who needs stomach contents sent for laboratory analysis 5. The client who overdosed on an oral medication

Q: The nurse is checking the client's nasogastric tube for placement prior to administering the client's first tube feeding. Which is the most accurate means of assessing placement? 1. Checking the pH of stomach contents aspirated from the tube 2. Infusing air into the tube and auscultating for the sound of the air over the stomach 3. Obtaining an x-ray 4. Checking for residual

Q: The nurse administering a bolus tube feeding inserts a 60 mL syringe into the tube. After pouring formula into the syringe, where should the nurse hold the syringe? 1. 1"3 inches above the ostomy opening 2. 3"6 inches above the ostomy opening 3. 12-18 inches above the ostomy opening 4. 12 inches above the ostomy opening

Q: 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

Q: The nurse is inserting a small-bore nasogastric tube. Which action by the nurse is appropriate when completing this procedure? 1. Removing the stylet prior to inserting the tube into the client's nose 2. Measuring from the tip of the client's nose to the xiphoid process to determine length of tube to be inserted 3. Checking the nares for patency prior to passing the catheter 4. Applying sterile gloves before beginning the procedure

Q: The nurse is assisting the client to eat. Which action by the nurse is the most appropriate? 1. Sitting on the side of the bed while feeding the client 2. Telling the client to sit back and relax while the nurse does all the work 3. Asking what the client would like to eat or drink next 4. Feeding the client quickly to decrease the feeling of being a burden

Q: The nurse is caring for an older adult client who is weak and has not been eating due to lack of strength. Which task could the nurse safely delegate to unlicensed assistive personnel (UAP)? 1. Completing a nutritional screening 2. Determining why the client is feeling weak 3. Using therapeutic communication with the client to determine if psychosocial factors are influencing the ability to eat 4. Assisting the client with eating meals

Q: The nurse admits an older adult client, who reports following a full liquid diet over the past 3 months. The nurse anticipates this client will have which problems? 1. Low serum iron and high serum albumin 2. Low serum iron and high serum potassium 3. Low serum iron and serum albumin, high serum cholesterol 4. Low serum cholesterol and high serum albumin

Q: Which client would benefit from a clear liquid diet? 1. The client recovering from vomiting and diarrhea 2. The client experiencing malnutrition 3. The client requiring increased protein intake 4. The client with a newly placed gastrostomy tube

Q: When assessing the client's nutritional status and needs, which type of assessment is the most important for the nurse to use? 1. A complete nutritional assessment 2. A nutritional screening 3. A comprehensive nutritional assessment 4. An in-depth nutritional assessment

Q: The responsibility for nutritional assessment and support in most health care facilities belongs to which individuals? Standard Text: Select all that apply. 1. The client 2. The primary care provider 3. The nurse 4. The dietitian or nutritionist 5. The food service staff

Q: The nurse working in an oncology clinic is caring for a client diagnosed with breast cancer. The client reports anorexia and weight loss. The client's serum albumin is low, and there is visible muscle and fat wasting. Which term should the nurse use when documenting this client's appearance? 1. Malnutrition 2. Undernutrition 3. Overnutrition 4. Protein-calorie malnutrition

Q: The nurse is caring for a client with mild dysphagia. Which diet should the nurse anticipate being prescribed for this client? 1. Clear liquids 2. Full liquids 3. Pureed diet 4. Regular diet

Q: The nurse is preparing to provide an intramuscular injection. For which reason should the nurse use the Z-track technique? 1. Takes less time 2. Is an easier method 3. Prevents leakage into subcutaneous tissue 4. Able to use the deltoid muscle for the injection

Q: 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

Q: The nurse observes the student administer heparin subcutaneously into the client's abdomen. Which action indicates the need for further teaching? 1. The student determines the site by placing two fingers above the umbilicus and injecting the medication above the fingers. 2. The student cleans the site, wiping in a circular motion with an antimicrobial wipe. 3. The student uses a 25 gauge needle. 4. The student inserts the needle at a 90 angle.

Q: The nurse is preparing medication that is packaged in an ampule. Which are appropriate nursing actions when preparing this medication? Standard Text: Select all that apply. 1. Using a filter needle when administering the injection to the client 2. Using gauze when opening the ampule 3. Tapping the neck of the ampule to drop all medication into the body of the ampule prior to opening it 4. Checking the expiration date on the ampule 5. Wiping the container with an antimicrobial prior to opening the ampule

Q: The nurse is attempting to withdraw 1 mL of fluid into a 3 mL syringe, and is pulling on the plunger. The fluid is not flowing into the syringe, and the nurse has withdrawn the plunger to the 2.5 mL line. Which action should the nurse take to correct this problem? 1. Change the needle because the current needle is clogged. 2. Inject air into the vial and draw out the remaining fluid. 3. Throw the vial away and obtain a new one, because this one is defective. 4. Obtain a larger syringe to withdraw the medication.

Q: The nurse is preparing to administer an intradermal medication. Which item will form to indicate the medication was injected at the proper depth? 1. Diluent 2. Wheel 3. Wheal 4. Blister

Q: 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.

Q: When administering otic drops, which action by the nurse when pulling the pinna is the most appropriate? 1. Down and back for the child under 3 years of age 2. Down and back for the adult client 3. Down and back for the child under 5 years of age 4. Up and back for the child under 3 years of age

Q: The nurse receives a written order for ophthalmic medication to be administered OU to an adult client. Which action by the nurse when administering this medication is the most appropriate? 1. Pulling the pinna up and back, and dropping the medication into the left ear 2. Pulling the pinna down and forward, and dropping the medication into both ears 3. Exposing the lower conjunctival sac of the left eye, and dropping the medication into the sac 4. Exposing the lower conjunctival sac of both eyes, and dropping the medication into the sac

Q: Which nursing action should be questioned when applying a transdermal medication patch? 1. Removing the old patch prior to placing the new patch 2. Donning gloves prior to administering the medication 3. Applying the patch to the same area where the old patch was removed 4. Cleansing the site where the patch is to be applied with soap and water

Q: The nurse is preparing several medications to administer via nasogastric tube. Which action by the nurse demonstrates correct technique? 1. Administering one medication at a time every 15 minutes 2. Giving one medication at a time, flushing the tube with water, and then administering another medication 3. Mixing the medications together and giving them at one time 4. Calling the pharmacy to ask if all of the medications may be safely mixed together

Q: The nurse identifies the client using two forms of identification. Which methods would be acceptable? Standard Text: Select all that apply. 1. Ask the client, "Is your name Mr. xyz?" 2. Check the client's identification band. 3. Check the client's room number. 4. Ask the client for the birthdate. 5. Ask the client for the telephone number.

Q: The nurse is caring for a client with dyspnea resulting from pulmonary edema secondary to congestive heart failure. The health care provider is notified, and the nurse receives a verbal order for Lasix 40 mg STAT. Which action by the nurse is the most appropriate? 1. Administer the medication immediately. 2. Clarify the route for administration. 3. Give the medication IV because the client is in distress and rapid effects are needed. 4. Hold the medication until the prescriber comes to the unit to clarify route and sign the order.

Q: The nurse receives this order: "Administer Ativan (lorazepam) 0.1 mg IV whenever seizure occurs." The nurse recognizes this as which type of medication order? 1. Stat order 2. Single order 3. Routine order 4. PRN order

Q: The health care provider prescribes Ampicillin 850 mg PO. The medication is supplied as 1,000 mg per 5 mL. How many mL of medication would the nurse administer using the basic formula? ____ mL Standard Text: Record the answer rounding to the nearest hundredth.

Q: The health care provider prescribes 10 grains of medication. If the medication is calculated in milligrams, how many milligrams should the nurse administer to equal 10 grains? ____ mg Standard Text: Record the answer rounding to the nearest whole number.

Q: The health care provider prescribes 1,500 milligrams of medication. The nurse finds tablets in the client's drawer that are 1 gram each. How many tablets should the nurse administer to the client? ____ Tablets Standard Text: Record the answer rounding to the nearest tenth.

Q: A client with gastric ulcers has been taking licorice root. Which finding should suggest to the nurse that the client should stop taking this herbal preparation? 1. Diarrhea 2. Insomnia 3. Dry mouth 4. Elevated blood pressure

Q: A client takes warfarin for atrial fibrillation. Which herbal preparation should the nurse counsel the client to avoid? 1. Feverfew 2. Echinacea 3. Kava kava 4. Black cohosh