1. The nurse is preparing to move an adult who has right-sided paralysis from the bed to the wheelchair. Which statement describes the best action for the nurse to take?
a. position the wheelchair on the left side of the bed
b. keep the head of the bed elevated at 10o
c. protect the client’s left arm with a sling during the transfer
d. bend at the waist while helping the client into a standing position
2. Which statement by the nurse best indicates a correct understanding of “log rolling” when moving a client?
a. one nurse may perform this task alone
b. pillows are needed for positioning in order to provide support
c. the legs should be moved before the head is moved
d. keeping the neck in a straight position is the primary concern
3. The nurse is caring for a client who has temperature of 105oF (40.50C). The physician orders the application of a cooling blanket. The nurse should know that which of the following statements is true about the use of a cooling blanket?
a. cold application will increase the metabolic rate
b. vital signs should be monitored every 8 hours
c. the client should remain in one position to conserve energy
d. skin hygiene and protection of body surface areas is essential
4. The nurse is preparing to administer a sponge bath to an infant with a high fever. Administration of the bath should include:
a. large amounts of alcohol to increase evaporation of heat
b. adjustment of the water temperature to 60-70 0F
c. wet clothes applied to all areas where blood circulates close to skin surfaces
d. small areas of the body sponged at a time to avoid rapid heat loss
5. The nurse is instructing the family of a homebound bedridden client in the general prevention of pressure sores. Measures to include in the teaching include:
a. promoting lifting rather than dragging when turning the client
b. massaging directly over pressure sites
c. changing the client’s position every 4 hours
d. cleaning soiled areas with hot water
6. Which of the following findings would the nurse note when assessing a client with Stage I pressure ulcer? The ulcer displays:
a. superficial skin breakdown c. subcutaneous damage or necrosis
b. deep pink, red, or mottled skin d. damage to muscle or bone
7. An adult has developed a Stage II pressure ulcer. He is scheduled to receive wet to dry dressings every shift. The nurse realizes that the purpose of receiving this type of dressing is to:
a. draw in wound exudate and decrease bacteria
b. debride slough and eschar
c. promote healing by gas exchange
d. promote a moist environment and soften exudate
8. The nurse is performing a wound irrigation and dressing change. Which action, when taken by the nurse, would be a break in the technique?
a. consistently facing the sterile field
b. washing hands before opening the sterile set
c. opening the bottle of irrigating solution and pouring directly into a container on the sterile field
d. opening the sterile set so that the initial flap is opened away from the nurse
9. Total Parenteral Nutrition (TPN) is ordered for an adult client. The nurse expects the solution will contain all of the following nutrients except:
a. dextrose 10% c. electrolytes
b. trace minerals d. amino acids
10. The nurse caring for an adult client who is receiving TPN will need to monitor him for which of the following metabolic complications:
a. hypocalcemia and hypercalcemia c. hyperglycemia and hyperkalemia
b. hyperglycemia and hypokalemia d. hyperkalemia and hypercalcemia
11. The nurse is caring for a client who is receiving IV fluids. Which observation the nurse makes best indicates the IV has infiltrated?
a. pain at the site
b. a change in flow rate
c. coldness around the insertion site
12. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The most appropriate initial response by the nurse is to:
a. force fluids c. increase the flow rate of IV fluids
b. continue to monitor the vital signs d. stop the transfusion
13. The nurse is caring for a client who has had a chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed?
a. continuous bubbling in the water seal chamber
b. fluctuation in the water seal chamber
c. suction tubing attached to a wall unit
d. vesicular breath sounds throughout the lung fields
14. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should:
a. observe for intermittent bubbling in the water seal chamber
b. flush the chest tubes with 30-60 ml of NSS every 4-6 hours
c. maintain the client in an extreme lateral position
d. strip the chest tubes in the direction of the client
15. The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:
a. notify the physician
b. insert a new chest tube
c. cover the insertion site with petroleum gauze
d. instruct the client to breathe deeply until help arrives
16. A patient is ordered oxygen via nasal prongs. The nurse administering oxygen via this low-flow system recognizes that this method of delivery:
a. mixes room air with oxygen
b. delivers a precise concentration of oxygen
c. requires humidity during delivery
d. is less traumatic to the respiratory tract
17. An adult is receiving oxygen by nasal prongs. Which statement by the client indicates that the client teaching regarding oxygen therapy has been effective?
a. “I was feeling fine so I removed my nasal prongs.”
b. “I’ve increased my fluids to six glasses of water daily.”
c. “Don’t forget to come back quickly when you get me out of bed; I don’t like to be without my oxygen for too long.”
d. “My family was angry when I told them they could not smoke in my room.”
18. An adult client has a nasogastric tube in place to maintain gastric decompression. Which nursing action will relieve discomfort in the nostril with the NG tube?
a. remove any tape and loosely pin the tube to his gown
b. lubricate the NG tube with viscous xylocaine
c. loop the NG tube to avoid pressure on the nares
d. replace the NG tube with a smaller diameter tube
19. An adult client has just returned to his room following a bowel resection and end-to-end anastomosis. The nurse can expect the drainage from the NG tube in the early post-op period to be:
a. Clear c. Scant
b. Mucoid d. Discolored
20. The physician inserts a central venous catheter; the nurse should assist the client to assume which of the following positions?
a. supine c. reverse trendelenburg’s
b. trendelenburg’s d. high fowler’s
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