Professional Documents
Culture Documents
Question Number 1 of 13
After the death of a client, the family approaches the nurse and
requests that a family member be allowed to perform a ritual bath on
the deceased prior to moving the body. The appropriate response by
the nurse is
".
A) I will have to check on hospital regulations and policies.
B) These procedures have to be carried out by our staff.
C) Is there anything you need from me to perform the ritual bath?
D) A ritual bath will have to wait until after post-mortem care
Your response was "A".
Question Number 2 of 13
An elderly client with tuberculosis has difficulty coughing up secretions
for a sputum specimen. Which nursing action is appropriate?
Placing the client in semi or high fowler’s position will promote lung
expansion and effective coughing. While drinking liquids helps to
loosen secretions over time, they should not be given when collecting
a specimen. Spraying the throat with saline may cause irritation and
coughing and reduce oxygenation.
Question Number 3 of 13
A client has just returned from the Post-Anesthesia Care Unit (PACU)
to the surgical unit after a cholecystectomy. When initial vital signs are
taken the nurse notes a temperature of 94.8 degrees Fahrenheit.
Which first nursing action is appropriate?
Question Number 4 of 13
The client with amyotrophic lateral sclerosis is scheduled for 160 ml of
enteral feeding as a bolus every 4 hours. Before flushing with water
the nurse aspirates the feeding tube contents and gets back 180 ml of
feeding. What is the next appropriate nursing action?
If residual is greater than 150 ml, then the next feeding should be
held. Administering water or the next feeding does not help with the
digestion of this feeding. Discarding the feeding that was aspirated
depletes the body of enzymes and electrolytes that have been mixed
with the feeding
Question Number 5 of 13
The nurse is removing a fecal impaction on a 75 year-old client. It is
most important that the nurse remember that
A) the procedure be done prior to the bath
B) family members should be taught the procedure
C) cardiac dysrhythmias can result during the process
D) increased dietary fiber can minimize such problems
Your response was "A". The correct answer is C: cardiac dysrhythmias
can result during the process
Question Number 6 of 13
A client is being discharged home today, and will be taking K-dur
20mEq per day by mouth. The nurse should reinforce that potassium
levels will be decreased by
Question Number 7 of 13
When taking the client’s blood pressure (BP), the nurse cannot hear
the sounds through the stethoscope. Which action should the nurse
take first?
Question Number 8 of 13
On admission to the ambulatory surgery unit, the nurse notices the
client's painted finger nails. On reviewing the pre-op orders, the nurse
notes that pulse oximetry has been ordered. Which statement by the
nurse is appropriate?
Question Number 9 of 13
The client with multiple sclerosis has an order to change the
nasogastric tube. To promote safety when removing the tube, the
nurse should
Question Number 10 of 13
The client referred for a mammography questions the nurses about the
cancer risks from radiation exposure. What is the appropriate response
by the nurse?
Your response was "A". The correct answer is A: The radiation from a
mammography is equivalent to one hour of sun exposure. The
exposure of radiation from a mammography is equivalent to 1 hour of
sun exposure; a client would have to have several in a year’s time to
be at risk for cancer. This answer is concise and gives the client a
point of reference. Option 2 is judgmental and non-therapeutic. Option
3 is not accurate and can cause further concern about radiation
exposure. Option 4 does not clearly address the client’s question.
Question Number 11 of 13
A client experiences intense anxiety after the home was destroyed by
a fire. The client escaped from the fire with only minor injuries. The
nurse knows that the most important initial intervention would be to:
Question Number 13 of 13
The nurse is caring for a 16 year-old client with femur fracture14
hours after surgery. Assessment findings include tachycardia,
increased shortness of breath, a temperature of 100.2 degrees
Fahrenheit, complaints of feeling anxious, and oxygen saturation level
of 88%. In immediately notifying the provider of these findings, the
nurse recognizes the client is at risk for
A) compartment syndrome
B) atelectasis
C) myocardial infarction
D) fatty embolism
Your response was "A".