Preliminary Examination In Competency Appraisal

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Preliminary Examination In Competency Appraisal - Quiz

Aklan Polytechnic College
College of Nursing
1st Semester A. Y. 2020-2021
PRELIMINARY EXAMINATION
IN COMPETENCY APPRAISAL

Questions and Answers

1.

A nurse is discussing hearing aids with a client who began wearing hearing aids 5 weeks earlier. Which statement demonstrates that the client is successfully adapting to the hearing aids?
- A.
  
  “I just wear the hearing aids when I go out in public.”
- B.
  
  “I take a cotton-tipped swab and clean out my ear canals before I insert the hearing aids.”
- C.
  
  “I store the hearing aids in the protective box.”
- D.
  
  “I use mild soap and water weekly to soak the plastic parts of the hearing aids after I remove the batteries.”
Correct Answer
C. “I store the hearing aids in the protective box.”

Explanation
The statement "I store the hearing aids in the protective box" demonstrates that the client is successfully adapting to the hearing aids because it shows that the client understands the importance of properly storing the hearing aids when they are not in use. Storing the hearing aids in a protective box helps to prevent damage and prolong their lifespan. This indicates that the client is taking responsibility for the care and maintenance of their hearing aids, which is an important part of successfully adapting to them.

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2.

A nurse is caring for a client who is unable to perform oral hygiene. The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- A.
  
  Don sterile gloves before removing the dentures.
- B.
  
  Use a foam swab to pry the upper plate loose before removing it.
- C.
  
  Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal.
- D.
  
  Leave the dentures in the client’s mouth and use a toothbrush to brush the plates.
Correct Answer
C. Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal.

Explanation
The nurse should use the technique of loosening the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal. This technique ensures that the denture is loosened properly and can be safely removed without causing any discomfort or injury to the client. Using a foam swab or leaving the dentures in the client's mouth while brushing is not the correct technique for performing oral hygiene in this case. Donning sterile gloves before removing the dentures is not necessary for this procedure.

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3.

A client who underwent surgery for colon cancer 6 weeks earlier has an appointment with a wound care nurse. After correctly demonstrating the changing of the stoma pouch, the client asks the nurse for advice regarding how to deal with gas coming from the stoma. To respond to the client’s concern, the nurse should ask the client to do which of the following? SELECT ALL THAT APPLY.
- A.
  
  Describe the usual dietary intake, including types of foods
- B.
  
  Include cruciferous vegetables in the diet daily
- C.
  
  Decrease fluid intake to 1,200 mL per 24 hours
- D.
  
  Prick the colostomy stoma pouch with a pin
- E.
  
  Limit intake of gas-producing beverages such as carbonated sodas
- F.
  
  Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp
Correct Answer(s)
A. Describe the usual dietary intake, including types of foods
E. Limit intake of gas-producing beverages such as carbonated sodas
F. Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp

Explanation
The client is concerned about gas coming from the stoma after undergoing surgery for colon cancer. To address this concern, the nurse should ask the client to describe their usual dietary intake, including types of foods, as certain foods can contribute to gas production. The nurse should also advise the client to limit intake of gas-producing beverages such as carbonated sodas, as this can further contribute to gas formation. Additionally, the nurse should suggest that the client goes to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp. Pricking the colostomy stoma pouch with a pin is not a recommended method to address this issue.

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4.

A male client undergoes surgery for a hernia repair. The client has orders to be discharged to home when stable. The client has tried several times to urinate into the urinal while in bed without success. Which interventions are appropriate to promote voiding for this client? SELECT ALL THAT APPLY.
- A.
  
  Apply an external catheter
- B.
  
  Assist the client to stand at the bedside to attempt to void
- C.
  
  Assess the pain level of the client and administer medication appropriately if in pain
- D.
  
  Assist the client to the bathroom and turn on running water within hearing distance of the client while the client attempts to void
- E.
  
  Discuss relaxation techniques and ask the client to imagine being at home and voiding in his own home bathroom
- F.
  
  Explain that the client should void within 8 hours of surgery or return to the hospital for catheterization.
Correct Answer(s)
B. Assist the client to stand at the bedside to attempt to void
C. Assess the pain level of the client and administer medication appropriately if in pain
D. Assist the client to the bathroom and turn on running water within hearing distance of the client while the client attempts to void
E. Discuss relaxation techniques and ask the client to imagine being at home and voiding in his own home bathroom

Explanation
The interventions that are appropriate to promote voiding for this client include assisting the client to stand at the bedside to attempt to void, assessing the pain level of the client and administering medication appropriately if in pain, assisting the client to the bathroom and turning on running water within hearing distance of the client while the client attempts to void, and discussing relaxation techniques and asking the client to imagine being at home and voiding in his own home bathroom. These interventions can help promote a more comfortable and relaxed environment for the client, which may facilitate successful voiding.

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5.

A client who was treated for constipation 1 month earlier comes to a primary care provider’s office for an appointment. A nurse interviews the client and obtains information from the client about bowel function and the effectiveness of the prescribed treatments. The nurse determines that the client is no longer constipated based on which statement?
- A.
  
  The client drinks 2,000 mL of fluids daily; including 4 ounces of prune juice.
- B.
  
  The client has had a soft, formed bowel movement without straining every other day for the past 2 weeks.
- C.
  
  The client self-administered one disposable enema the day of last month’s appointment.
- D.
  
  The client has minor discomfort from hemorrhoids during bowel movements.
Correct Answer
B. The client has had a soft, formed bowel movement without straining every other day for the past 2 weeks.

Explanation
The nurse determines that the client is no longer constipated based on the statement that the client has had a soft, formed bowel movement without straining every other day for the past 2 weeks. This indicates that the client's bowel movements are regular and normal, which is a sign of resolved constipation.

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6.

A client who is recovering from orthopedic surgery keeps an appointment at a clinic and uses a walker to ambulate with partial weight-bearing as instructed. Which observation should lead the nurse to conclude that the client is using the correct technique?
- A.
  
  Has elbows bent at a 30-degree angle
- B.
  
  Is bent over the walker
- C.
  
  Lifts the walker while walking; holding it about 2 inches above the floor
- D.
  
  Has a walker that has four wheels in place
Correct Answer
A. Has elbows bent at a 30-degree angle

Explanation
The correct technique for using a walker with partial weight-bearing involves keeping the elbows bent at a 30-degree angle. This position allows for better stability and support while walking.

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7.

A nurse reviews the record of a client who has been immobile because of a degenerative neurological condition. The nurse reads that the client has bilateral foot drop. Which finding during the nurse’s assessment supports the presence of foot drop?
- A.
  
  The great toe is dorsiflexed and the other toes are fanned out.
- B.
  
  The feet are unable to be maintained perpendicular to the legs.
- C.
  
  The client is unable to move feet into a position of plantar flexion.
- D.
  
  The client is only able to dorsiflex the feet bilaterally.
Correct Answer
B. The feet are unable to be maintained perpendicular to the legs.

Explanation
The finding that the feet are unable to be maintained perpendicular to the legs supports the presence of foot drop. Foot drop is a condition where the muscles that lift the front part of the foot are weak or paralyzed, causing the foot to drag or drop when walking. Inability to maintain the feet in a perpendicular position indicates a lack of muscle control and weakness in the muscles responsible for dorsiflexion, which is characteristic of foot drop.

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8.

A home health nurse visits an 82-year-old client who has experienced multiple strokes and is unable to change position independently in bed. The nurse teaches family caregivers techniques to move and reposition the client, who is in a hospital bed. Which technique should be included in the teaching plan for this client?
- A.
  
  Before moving the client, family caregivers should raise the hospital bed to the level of their waists. After completing the move, the bed must be returned to the lowest level.
- B.
  
  The pillow should be removed from under the client’s head when positioned in a dorsal recumbent position.
- C.
  
  Family members should tighten their abdominal muscles and buttocks while keeping their feet about 12 inches apart when using a lift sheet to pull the client up in bed.
- D.
  
  The client’s heels should rest on the bed surface and feet kept in a position perpendicular to the legs when the client is lying on the back.
Correct Answer
A. Before moving the client, family caregivers should raise the hospital bed to the level of their waists. After completing the move, the bed must be returned to the lowest level.

Explanation
When moving and repositioning a client who is unable to change position independently, it is important to raise the bed to the level of the caregiver's waist. This helps to maintain proper body mechanics and prevents strain or injury to the caregiver's back. After completing the move, the bed should be returned to the lowest level to ensure the client's safety and comfort. This technique promotes proper body alignment and reduces the risk of falls or pressure ulcers.

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9.

A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client?
- A.
  
  If ambulating 10 times daily for 5 minutes at a time, wearing the hose is unnecessary.
- B.
  
  The most appropriate time to apply the hose is before standing to get out of bed in the morning.
- C.
  
  If the hose becomes painful to the skin underneath, notify the nurse and request pain medication.
- D.
  
  Only cross the legs while wearing the antiembolism hose; otherwise keep the legs uncrossed.
Correct Answer
B. The most appropriate time to apply the hose is before standing to get out of bed in the morning.

Explanation
The most appropriate time to apply the hose before standing to get out of bed in the morning is the correct answer because it ensures that the client has the stockings on before any potential risk of thromboembolic disease occurs. Applying the stockings in the morning helps to prevent blood clots from forming while the client is inactive during sleep and prepares them for any activity throughout the day.

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10.

A client reports pain at an intravenous infusion site that has infiltrated. When a nurse applies a warm, moist compress to the site, the client asks how the treatment will help the condition. The nurse answers the client based on the understanding that the application of moist heat will:
- A.
  
  Alter tissue sensitivity by producing numbness.
- B.
  
  Decrease the metabolic needs of the involved tissues.
- C.
  
  Stop the local release of histamine in the tissues.
- D.
  
  Increase blood flow and improve capillary permeability.
Correct Answer
D. Increase blood flow and improve capillary permeability.

Explanation
The application of moist heat to an infiltrated intravenous infusion site will increase blood flow and improve capillary permeability. Moist heat helps to dilate blood vessels, which increases blood flow to the area. This increased blood flow can help to remove any accumulated fluid or medications that may be causing the infiltration. Additionally, improved capillary permeability allows for better exchange of oxygen, nutrients, and waste products between the blood vessels and the surrounding tissues, promoting healing and reducing inflammation.

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11.

A nurse is caring for a client who has experienced a first-degree sprain of the ankle. A primary care provider writes a prescription for an analgesic medication. Which intervention, beside the analgesic, should the nurse advise the client to utilize for the first 24 hours after the injury?
- A.
  
  Applying ice directly to the ankle
- B.
  
  Soaking the foot in warm water for 20 minutes, three times per day
- C.
  
  Applying ice continuously to the ankle
- D.
  
  Resting and elevating the limb as much as possible
Correct Answer
D. Resting and elevating the limb as much as possible

Explanation
Resting and elevating the limb as much as possible is the appropriate intervention for the first 24 hours after a first-degree sprain of the ankle. This helps to reduce swelling and pain by promoting blood flow away from the injured area. Applying ice directly to the ankle can also help reduce swelling and pain, but it should not be done continuously as it can cause tissue damage. Soaking the foot in warm water is not recommended as it can increase swelling.

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12.

An elderly client residing in a nursing home has bilaterally weak handgrips and has difficulty with self-feeding. Which nursing interventions should be implemented to promote independence for this client? SELECT ALL THAT APPLY.
- A.
  
  Ask the client for permission to open all containers, remove lids from items on the food tray, and cut up meats
- B.
  
  Obtain built-up silverware for the client to use
- C.
  
  Observe the client but do not provide assistance if the client is having difficulty
- D.
  
  Feed the client if the client is eating too slowly
- E.
  
  Ensure that the client is wearing prescribed dentures, eye glasses, or hearing aids before starting to eat
Correct Answer(s)
A. Ask the client for permission to open all containers, remove lids from items on the food tray, and cut up meats
B. Obtain built-up silverware for the client to use
E. Ensure that the client is wearing prescribed dentures, eye glasses, or hearing aids before starting to eat

Explanation
The correct answer is to ask the client for permission to open all containers, remove lids from items on the food tray, and cut up meats, obtain built-up silverware for the client to use, and ensure that the client is wearing prescribed dentures, eye glasses, or hearing aids before starting to eat. These interventions promote independence by allowing the client to have control over their meal and make it easier for them to feed themselves. Opening containers and removing lids make it easier for the client to access the food, while cutting up meats and providing built-up silverware accommodate their weak handgrips. Ensuring that they are wearing prescribed aids ensures that they can fully participate in the meal.

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13.

A dietitian, who is consulted to see a hospitalized client because of nutritional concerns, orders a calorie count. The nurse should participate in this intervention by:
- A.
  
  Asking the client to recall the food and beverages consumed on a normal day.
- B.
  
  Asking the client to recall the food and beverages consumed on the day the calorie count is initiated.
- C.
  
  Informing the client that a record is being maintained of food and beverages consumed.
- D.
  
  Asking the client to approximate how many times per week certain food groups, such as cereals and breads, are eaten.
Correct Answer
C. Informing the client that a record is being maintained of food and beverages consumed.

Explanation
The nurse should inform the client that a record is being maintained of food and beverages consumed because this is necessary for an accurate calorie count. By keeping track of what the client eats and drinks, the dietitian can assess their nutritional intake and make appropriate recommendations. Asking the client to recall their normal day or the day the calorie count is initiated may not provide an accurate representation of their overall dietary habits. Asking about the frequency of certain food groups may be helpful, but it does not address the need for a complete record of all food and beverage consumption.

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14.

A hospitalized client has daily weights ordered. The client is able to stand, and the nursing unit has an electronic digital scale to use for client weights. Which intervention best ensures that the client’s daily weight is accurate?
- A.
  
  Asking the client to wear supportive shoes before stepping on the scale
- B.
  
  Ensuring that the scale is calibrated and “zeroed” before a weight is obtained
- C.
  
  Weighing the client by moving the sliding indicator until the scale balances
- D.
  
  Weighing the client at different times of the day
Correct Answer
B. Ensuring that the scale is calibrated and “zeroed” before a weight is obtained

Explanation
To ensure that the client's daily weight is accurate, it is important to calibrate and "zero" the scale before obtaining a weight. This means that the scale should be adjusted to ensure that it is measuring accurately and that it starts at zero before the client steps on it. This helps to eliminate any potential errors or discrepancies in the weight measurement. Asking the client to wear supportive shoes, weighing the client by moving the sliding indicator, or weighing the client at different times of the day do not directly address the accuracy of the scale itself.

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15.

A nurse plans guidelines to assist nursing personnel in meeting the hygiene needs of adult clients with dementia. Which guidelines are appropriate for the nurse to include? SELECT ALL THAT APPLY.
- A.
  
  Utilizing two staff members to bathe the client quickly while limiting the client’s ability to physically resist
- B.
  
  Creating a calm environment during a bed bath by including music and dimmed lighting
- C.
  
  Allowing clients, who are willing and able, to participate in some of the hygiene activities
- D.
  
  Assessing and treating clients for pain before initiating hygiene activities
- E.
  
  Washing the hair and body separately if either activity causes distress or is overwhelming to the client
- F.
  
  Keeping the temperature of the bathing area warm and limiting body exposure of clients during bathing
Correct Answer(s)
B. Creating a calm environment during a bed bath by including music and dimmed lighting
C. Allowing clients, who are willing and able, to participate in some of the hygiene activities
D. Assessing and treating clients for pain before initiating hygiene activities
E. Washing the hair and body separately if either activity causes distress or is overwhelming to the client
F. Keeping the temperature of the bathing area warm and limiting body exposure of clients during bathing

Explanation
The nurse should include guidelines that promote a calm environment during a bed bath, such as including music and dimmed lighting. This can help reduce agitation and anxiety in clients with dementia. Allowing clients, who are willing and able, to participate in some hygiene activities is also important as it promotes independence and a sense of control. Assessing and treating clients for pain before initiating hygiene activities is necessary to ensure their comfort. Washing the hair and body separately if either activity causes distress or is overwhelming to the client is a suitable guideline to follow. Finally, keeping the temperature of the bathing area warm and limiting body exposure of clients during bathing helps maintain their comfort and dignity.

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16.

A nurse should inform a nursing assistant to avoid taking a rectal temperature for which client?
- A.
  
  The adult client who underwent ileostomy surgery because of a perforated bowel
- B.
  
  The adult client who has a frequent, productive cough and is receiving oxygen by nasal cannula
- C.
  
  The adult client who developed thrombocytopenia after receiving chemotherapy
- D.
  
  The adult client with hypothermia
Correct Answer
C. The adult client who developed thrombocytopenia after receiving chemotherapy

Explanation
Taking a rectal temperature involves inserting a thermometer into the rectum, which can cause trauma or bleeding. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased bleeding and difficulty in clotting. Therefore, it is important to avoid any procedures that may cause bleeding, such as taking a rectal temperature, for a client with thrombocytopenia.

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17.

A nursing assistant (NA), who is taking routine vital signs, tells a nurse that the small adult cuff is nowhere to be found and that a client’s arm is too small to use an adult-size cuff. In response to the NA’s report, which direction should the nurse give to the NA?
- A.
  
  Document the other vital signs and note that proper blood pressure (BP) equipment is not available
- B.
  
  Contact the nursing supervisor, obtain a small, adult BP cuff, and take the client’s BP with the small, adult-size cuff
- C.
  
  Use the adult size BP cuff to obtain the blood pressure, add 10 to both the diastolic and systolic readings, and document on the client’s record the BP was obtained with an adult cuff
- D.
  
  Take the client’s BP using any available cuff
Correct Answer
A. Document the other vital signs and note that proper blood pressure (BP) equipment is not available

Explanation
The nurse should give the direction to the NA to document the other vital signs and note that proper blood pressure (BP) equipment is not available. This is the appropriate action because using an incorrect cuff size can lead to inaccurate blood pressure readings. It is important to ensure that the correct equipment is used to obtain accurate measurements. By documenting the unavailability of the small adult cuff, the nurse can alert the appropriate personnel to ensure that the necessary equipment is provided in the future.

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18.

A nurse takes a client’s blood pressure with an automatic blood pressure machine. The blood pressure is 86/56 mm Hg with a pulse rate of 64 beats per minute. Which action should the nurse do first?
- A.
  
  Assess the client for dizziness and assess the skin on the extremities for warmth
- B.
  
  Obtain a manual blood pressure cuff and retake the client’s blood pressure
- C.
  
  Elevate the head of the client’s bed
- D.
  
  Read the client’s medical record and determine the client’s normal range of blood pressure
Correct Answer
A. Assess the client for dizziness and assess the skin on the extremities for warmth

Explanation
The nurse should assess the client for dizziness and assess the skin on the extremities for warmth because a blood pressure reading of 86/56 mm Hg indicates low blood pressure. Low blood pressure can cause dizziness and reduced blood flow to the extremities, which can result in cool or pale skin. Assessing for these symptoms will help the nurse determine if further intervention is needed to address the client's low blood pressure.

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19.

A nurse is using a tympanic thermometer to measure a client’s temperature. When using a tympanic thermometer, the nurse should:
- A.
  
  Check the setting to know the type of measurement reading, such as oral or core temperature.
- B.
  
  Irrigate the ear canal with sterile saline 6 hours before obtaining the temperature.
- C.
  
  Pull downward on the pinna in an adult when inserting the thermometer.
- D.
  
  Hold the thermometer loosely in the ear until the thermometer sounds that the reading is finished.
Correct Answer
A. Check the setting to know the type of measurement reading, such as oral or core temperature.

Explanation
The correct answer is to check the setting to know the type of measurement reading, such as oral or core temperature. This is important because different settings on the tympanic thermometer will give different readings. By checking the setting, the nurse can ensure that they are obtaining the correct measurement reading for the client's temperature.

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20.

A client who underwent a surgical procedure the preceding day has a normal assessment with an oral temperature of 99.7°F (37.6°C) at 0800 hours. The client is to be discharged later in the day if the client’s condition is stable. Based on the client’s current temperature, which action should be taken by the nurse?
- A.
  
  Inform the surgeon since the discharge should be cancelled.
- B.
  
  Instruct the client to use the incentive spirometer 10 times every hour and drink plenty of fluids and then recheck the temperature in 2 hours
- C.
  
  Administer the dose of aspirin 81 mg earlier than the scheduled time
- D.
  
  Realize that the temperature is only mildly elevated and was taken during the time of day when temperatures are highest according to normal diurnal deviations
Correct Answer
B. Instruct the client to use the incentive spirometer 10 times every hour and drink plenty of fluids and then recheck the temperature in 2 hours

Explanation
The client's temperature of 99.7°F (37.6°C) is only mildly elevated and may be due to normal diurnal deviations, as temperatures are highest during certain times of the day. Therefore, there is no need to cancel the discharge or administer aspirin. Instructing the client to use the incentive spirometer and drink plenty of fluids can help promote lung expansion and prevent complications such as atelectasis. Rechecking the temperature in 2 hours will provide a better assessment of the client's condition and help determine if they are stable for discharge.

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21.

A nurse is preparing to provide phototherapy to a 4-day-old newborn who was admitted with hyperbilirubinemia. The nurse instructs the parents on how to care for their baby while receiving phototherapy in the hospital. The nurse’s teaching should include:
- A.
  
  Keeping the baby fully clothed to prevent hypothermia.
- B.
  
  Covering the baby’s eyes with eye shields to prevent retinal damage.
- C.
  
  Decreasing the number of feedings for their baby to reduce the number of soiled diapers.
- D.
  
  Discontinuing the phototherapy if a mild skin rash develops.
Correct Answer
B. Covering the baby’s eyes with eye shields to prevent retinal damage.

Explanation
The nurse should instruct the parents to cover the baby's eyes with eye shields to prevent retinal damage during phototherapy. Phototherapy involves exposing the baby's skin to special lights that help break down bilirubin, a substance that can build up and cause jaundice. However, the lights used in phototherapy can be harmful to the baby's eyes, so it is important to protect them with eye shields. This will help prevent any potential damage to the baby's retinas and ensure the safety and well-being of the newborn during treatment.

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22.

When using a hypothermia blanket for a febrile client, which findings should lead the nurse to suspect hypothermia? SELECT ALL THAT APPLY.
- A.
  
  Increased urine output
- B.
  
  Drowsiness
- C.
  
  Decreased heart rate (HR)
- D.
  
  Decreased blood pressure (BP)
- E.
  
  Increased BP
- F.
  
  Increased HR
Correct Answer(s)
B. Drowsiness
C. Decreased heart rate (HR)
D. Decreased blood pressure (BP)

Explanation
If a febrile client is using a hypothermia blanket, the purpose is to lower the body temperature. Hypothermia is a condition where the body temperature drops below normal. Drowsiness can be a sign of hypothermia as the body's metabolic rate decreases. Decreased heart rate (HR) and decreased blood pressure (BP) are also signs of hypothermia as the body tries to conserve energy and maintain core temperature. Increased urine output, increased BP, and increased HR are not typically associated with hypothermia.

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23.

Which signs should indicate to a nurse that a client is experiencing a surgical site infection? SELECT ALL THAT APPLY.
- A.
  
  Temperature of 100.4°F (38°C)
- B.
  
  Localized pain and tenderness
- C.
  
  Well-approximated wound edges
- D.
  
  Redness or warmth at the affected site
- E.
  
  Purulent drainage at the incision site
- F.
  
  Thick, white drainage in the Jackson-Pratt (JP) tubing
Correct Answer(s)
A. Temperature of 100.4°F (38°C)
B. Localized pain and tenderness
D. Redness or warmth at the affected site
E. Purulent drainage at the incision site
F. Thick, white drainage in the Jackson-Pratt (JP) tubing

Explanation
Signs that indicate a client is experiencing a surgical site infection include a temperature of 100.4°F (38°C), localized pain and tenderness, redness or warmth at the affected site, purulent drainage at the incision site, and thick, white drainage in the Jackson-Pratt (JP) tubing. These symptoms are indicative of an infection as they suggest an elevated body temperature, inflammation, presence of pus or discharge, and abnormal drainage. Well-approximated wound edges, on the other hand, indicate proper healing and are not indicative of an infection.

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24.

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer?
- A.
  
  Partial-thickness skin loss involving the epidermis, dermis, or both
- B.
  
  Full-thickness skin loss involving damage to subcutaneous tissue
- C.
  
  Redness with intact skin that client reports as “itchy”
- D.
  
  Full-thickness skin loss with undermining and sinus tracks
Correct Answer
B. Full-thickness skin loss involving damage to subcutaneous tissue

Explanation
The best description of a stage III pressure ulcer is full-thickness skin loss involving damage to subcutaneous tissue. This means that the ulcer has progressed beyond the epidermis and dermis, and has reached the layer of tissue beneath the skin. The presence of damage to the subcutaneous tissue indicates that the ulcer is at a more advanced stage and requires appropriate treatment and care.

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25.

Which actions should a nurse plan when caring for a client with a stage III pressure ulcer to the right lower-extremity heel? SELECT ALL THAT APPLY.
- A.
  
  Monitor the client’s nutritional intake
- B.
  
  Assess for pain and premedicate prior to dressing changes
- C.
  
  Monitor pedal pulses and capillary refill of affected extremity
- D.
  
  Use hydrogen peroxide for cleaning of ulcer wound
- E.
  
  Turn and reposition client every 1 to 2 hours
- F.
  
  Elevate the extremity on pillows
Correct Answer
A. Monitor the client’s nutritional intake

Explanation
When caring for a client with a stage III pressure ulcer to the right lower-extremity heel, it is important for the nurse to monitor the client's nutritional intake. This is because proper nutrition is essential for wound healing. By monitoring the client's nutritional intake, the nurse can ensure that the client is receiving adequate nutrients to support the healing process. This can include assessing the client's dietary intake, providing nutritional counseling, and collaborating with a dietitian if necessary.

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26.

A nurse is assessing a client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding would require an immediate intervention by the nurse?
- A.
  
  A nasogastric tube (NG) to low intermittent suction with small amounts of dark bloody returns
- B.
  
  A compressed Jackson-Pratt (JP) drain with 30 mL bright red blood
- C.
  
  A NG tube to low intermittent suction with pale green returns
- D.
  
  A round Jackson-Pratt (JP) drain with 20 mL serosanguineous drainage
Correct Answer
D. A round Jackson-Pratt (JP) drain with 20 mL serosanguineous drainage

Explanation
The assessment finding that would require immediate intervention by the nurse is a round Jackson-Pratt (JP) drain with 20 mL serosanguineous drainage. Serosanguineous drainage is a mixture of bloody and serous fluid, which is expected after surgery. However, a round JP drain should not have any drainage, as it indicates a possible dislodgement or malfunction of the drain. The nurse should assess the drain site, ensure proper placement, and notify the healthcare provider for further intervention if needed.

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27.

A nurse is teaching a client, who is 24 hours post–abdominal surgery, how to use an incentive spirometer. Which instructions should the nurse include in the teaching? SELECT ALL THAT APPLY.
- A.
  
  Inhale slowly and deeply through mouth
- B.
  
  Seal lips tightly around mouthpiece
- C.
  
  After inhaling, hold breath for 2 to 3 seconds
- D.
  
  Sit with head of bed down and bed almost flat
- E.
  
  Splint incision with pillows
- F.
  
  Exhale forcefully, fast, and hard
Correct Answer(s)
A. Inhale slowly and deeply through mouth
B. Seal lips tightly around mouthpiece
C. After inhaling, hold breath for 2 to 3 seconds
E. Splint incision with pillows

Explanation
The nurse should include the instructions to inhale slowly and deeply through the mouth, as this promotes deep breathing and lung expansion. The nurse should also instruct the client to seal their lips tightly around the mouthpiece to ensure proper airflow. After inhaling, holding the breath for 2 to 3 seconds helps to fully expand the lungs and improve lung function. Splinting the incision with pillows provides support and reduces pain during deep breathing exercises.

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28.

A 33-year-old client reports left leg pain, right-sided chest pain, and a sudden onset of shortness of breath. Which action should be taken immediately by the nurse?
- A.
  
  Take the client’s temperature
- B.
  
  Auscultate the client’s the lung sounds
- C.
  
  Percuss the client’s abdomen
- D.
  
  Request a stat chest x-ray
Correct Answer
B. Auscultate the client’s the lung sounds

Explanation
The client's symptoms of left leg pain, right-sided chest pain, and sudden onset of shortness of breath suggest a potential pulmonary embolism, which is a blockage in the pulmonary artery. Auscultating the client's lung sounds can help the nurse assess for any abnormal breath sounds, such as decreased or absent breath sounds on one side, which could indicate a pulmonary embolism. This action is crucial in identifying and addressing the client's condition promptly.

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29.

Which rationale should a nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving 2 liters of oxygen by nasal cannula?
- A.
  
  Prevents the burning sensation of direction oxygen
- B.
  
  Prevents drying of the nasal passages
- C.
  
  Prevents a chemical reaction between the tubing and oxygen
- D.
  
  Prevents contamination with environmental gases
Correct Answer
B. Prevents drying of the nasal passages

Explanation
Bubbling oxygen through a humidifier prevents drying of the nasal passages. Oxygen therapy can cause dryness and irritation in the nasal passages, which can lead to discomfort for the client. By passing the oxygen through a humidifier, moisture is added to the oxygen, ensuring that the nasal passages stay hydrated and preventing dryness. This helps to improve the client's comfort and overall well-being during oxygen therapy.

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30.

A nurse, checking newly written physician orders, determines that which orders require the nurse to contact the physician to clarify the order? SELECT ALL THAT APPLY.
- A.
  
  Aspirin 325 mg orally qd
- B.
  
  MS 4 mg IV q1hr pr
- C.
  
  Furosemide (Lasix®) 40 mg IV now
- D.
  
  D5W with 20 mEq KCL IV at 125 mL/hr
- E.
  
  Heparin 5,000 u subcutaneously bid
Correct Answer(s)
A. Aspirin 325 mg orally qd
B. MS 4 mg IV q1hr pr
E. Heparin 5,000 u subcutaneously bid

Explanation
The nurse would need to contact the physician to clarify the order for Aspirin 325 mg orally qd because the frequency of administration is not specified. The nurse would also need to contact the physician to clarify the order for MS 4 mg IV q1hr pr because the abbreviation "pr" is not commonly used and needs clarification. The order for Heparin 5,000 u subcutaneously bid does not need clarification as it is clear and complete. Therefore, the correct answers are Aspirin 325 mg orally qd and MS 4 mg IV q1hr pr.

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31.

A nurse receives a medication order for an adult client to administer ferrous sulfate 300 mg PO bid. After thinking critically about this order, the nurse should:
- A.
  
  Administer the medication as ordered.
- B.
  
  Contact the physician to clarify the route of the medication.
- C.
  
  Contact the physician to question the twice daily administration of the medication.
- D.
  
  Withhold the medication because the dosage is not within acceptable ranges.
Correct Answer
A. Administer the medication as ordered.

Explanation
The nurse should administer the medication as ordered because the dosage and route of administration are appropriate for the client. Ferrous sulfate is commonly prescribed as a treatment for iron deficiency anemia, and the dosage of 300 mg PO (by mouth) twice daily is within the acceptable range for adults. Therefore, there is no need to contact the physician to clarify the route or question the frequency of administration. Withholding the medication is not necessary as the dosage is within the acceptable range.

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32.

Before a child’s hospital discharge, a nurse is teaching the parents how to administer an oral medication to the child. Which nurse instruction would be most appropriate?
- A.
  
  Administer the medication and then follow it with a small glass of milk
- B.
  
  Give the child a flavored ice pop just before the medication
- C.
  
  Tell the child that the medication will taste good
- D.
  
  Open all capsules and mix the contents with applesauce
Correct Answer
B. Give the child a flavored ice pop just before the medication

Explanation
Giving the child a flavored ice pop just before the medication would be the most appropriate instruction. This is because the cold temperature and sweet taste of the ice pop can help numb the taste buds and mask the unpleasant taste of the medication, making it easier for the child to swallow.

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33.

A nurse is evaluating whether a client on multiple oral medications is taking the medications correctly. Which finding should be most concerning to the nurse because the absorption rate of medications can be increased?
- A.
  
  Taking afternoon oral medications with a carbonated soft drink
- B.
  
  Drinking a glass of milk with the tetracycline antibiotic oral medication
- C.
  
  Taking morning oral medications with water and consuming 2,500 mL of water daily
- D.
  
  Taking mealtime oral medications with a meal low in fiber and high in fatty foods
Correct Answer
A. Taking afternoon oral medications with a carbonated soft drink

Explanation
Taking afternoon oral medications with a carbonated soft drink should be most concerning to the nurse because carbonated soft drinks can increase the absorption rate of medications. The carbonation in the drink can increase the acidity in the stomach, which can enhance the absorption of certain medications. This can lead to higher levels of the medication in the bloodstream, potentially causing adverse effects or interactions with other medications.

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34.

A nurse is observing a nursing student prepare and administer medications to adult clients. Which action by the nursing student warrants intervention by the nurse?
- A.
  
  Injecting air into a vial before withdrawing 20 mg furosemide (Lasix®) from a vial labeled 20 mg/mL
- B.
  
  Selecting a 1-mL syringe with a 5/8-inch needle to be used for administering 0.5 mL of heparin subcutaneously
- C.
  
  Instructing a client to place a buccal medication under the client’s tongue and allowing it to absorb
- D.
  
  Pouring the ordered medication “Robitussin® 2 tsp now” to the 10 mL mark on a medication cup
Correct Answer
C. Instructing a client to place a buccal medication under the client’s tongue and allowing it to absorb

Explanation
Injecting air into a vial before withdrawing medication is not recommended because it can introduce air bubbles into the syringe, which can be dangerous if injected into the patient. Selecting a syringe with a 5/8-inch needle for subcutaneous administration is appropriate because it is the correct size for the route of administration. Pouring the medication to the 10 mL mark on a medication cup is correct if the ordered dose is 2 tsp. However, instructing a client to place a buccal medication under the tongue is incorrect because buccal medications are intended to be placed between the cheek and gum, not under the tongue.

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35.

A nurse is planning to administer medications through a nasogastric (NG) tube. Which interventions should the nurse plan after checking the medications, checking client identification, and verifying tube placement? SELECT ALL THAT APPLY.
- A.
  
  Crush together all medications that are acceptable for crushing
- B.
  
  Pour crushed medications into one medication cup and mix with water
- C.
  
  Withdraw all medications and water solution from the medication cup with a syringe and administer
- D.
  
  Crush each medication separately
- E.
  
  Pour each individual crushed medication into individual medication cups and mix with water
- F.
  
  With a syringe, withdraw the single dose of medication from the medication cup and administer.
- G.
  
  Flush the tubing with water between medications
Correct Answer(s)
D. Crush each medication separately
E. Pour each individual crushed medication into individual medication cups and mix with water
F. With a syringe, withdraw the single dose of medication from the medication cup and administer.
G. Flush the tubing with water between medications

Explanation
After checking the medications, checking client identification, and verifying tube placement, the nurse should crush each medication separately to ensure proper administration. Each individual crushed medication should then be poured into individual medication cups and mixed with water. Using a syringe, the nurse should withdraw the single dose of medication from the medication cup and administer it. Additionally, the nurse should flush the tubing with water between medications to prevent any interactions between different medications.

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36.

A nurse is observing a nursing student administering a clonidine (Catapres®) transdermal patch to a client diagnosed with hypertension. Which action requires the nurse to intervene?
- A.
  
  Applies gloves
- B.
  
  Asks the client to state name and also checks the client’s name band
- C.
  
  Applies patch, rubbing the patch against the skin, and then securing it in place
- D.
  
  Folds old patch with medication to the inside and discards in a medication disposal receptacle
Correct Answer
C. Applies patch, rubbing the patch against the skin, and then securing it in place

Explanation
The nurse needs to intervene when the nursing student applies the patch by rubbing it against the skin. Transdermal patches should not be rubbed or manipulated as it can alter the drug delivery rate and effectiveness. The patch should be applied gently and pressed firmly against the skin to ensure proper adhesion.

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37.

A nurse administers a prochlorperazine (Compazine®) suppository to an adult client. Which action by the nurse best ensures that the medication is correctly administered?
- A.
  
  Positioning the client on the left side
- B.
  
  Lubricating the suppository prior to insertion
- C.
  
  Feeling the sensation of the suppository pulling away when inserted against the rectal wall past the internal anal sphincter
- D.
  
  Noting soft, formed stool 30 minutes after the suppository
Correct Answer
C. Feeling the sensation of the suppository pulling away when inserted against the rectal wall past the internal anal spHincter

Explanation
The correct answer is feeling the sensation of the suppository pulling away when inserted against the rectal wall past the internal anal sphincter. This action ensures that the medication is correctly administered because it indicates that the suppository has been inserted far enough into the rectum for the medication to be absorbed. The sensation of the suppository pulling away suggests that it has passed the internal anal sphincter, which is the muscle that separates the rectum from the anus.

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38.

A new clinic nurse is teaching the mother of a 2-year-old child how to administer ear drops while an experienced nurse is observing. The new nurse is using an illustration of a child’s ear to teach the mother and states the following actions while pointing to the picture: clean the child’s ear, warm the solution, pull the child’s ear up and back, instill the medication, depress on the tragus of the ear, keep the child side-lying for about 5 minutes, and then insert a small cotton fluff loosely in the auditory canal for about 20 minutes. Which action should the experienced nurse take during or following the teaching?
- A.
  
  Suggest to the new nurse that the mother return demonstrate instilling ear drops
- B.
  
  Confirm with the new nurse and mother that the procedure was correctly described
- C.
  
  Interrupt to state that the child’s ear should be pulled down and back
- D.
  
  Praise the new nurse for the thorough teaching provided to the mother
Correct Answer
C. Interrupt to state that the child’s ear should be pulled down and back

Explanation
The experienced nurse should interrupt to state that the child's ear should be pulled down and back. This is because the new nurse is instructing the mother to pull the child's ear up and back, which is incorrect. Pulling the child's ear down and back helps to straighten the ear canal, allowing for easier administration of the ear drops. The experienced nurse should correct this mistake to ensure that the mother is taught the correct technique for administering ear drops to her child.

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39.

An experienced nurse is supervising a new registered nurse who is administering medications to adult clients. Which action by the new registered nurse requires the experienced nurse to intervene?
- A.
  
  Withdraws 1 mL of purified protein derivative (PPD) from a vial for intradermal injection
- B.
  
  Pinches the abdominal tissue of a thin adult and inserts the needle at a 45-degree angle to administer insulin subcutaneously
- C.
  
  Measures three finger-breadths below the acromion process to inject codeine 15 mg/0.5 mL in the deltoid muscle
- D.
  
  Administers 5,000 units heparin subcutaneously in the abdomen without aspirating for a blood return
Correct Answer
A. Withdraws 1 mL of purified protein derivative (PPD) from a vial for intradermal injection

Explanation
The experienced nurse needs to intervene when the new registered nurse withdraws 1 mL of purified protein derivative (PPD) from a vial for intradermal injection. Intradermal injections typically require a small volume of medication, usually around 0.1 mL. Withdrawing 1 mL of PPD is excessive and may result in an inaccurate administration of the medication. The nurse should only withdraw the appropriate amount of medication for the specific injection technique being used.

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40.

A nurse, who is working the evening shift, is planning to administer insulin subcutaneously to a hospitalized child. Which statement made by the nurse to the mother would be inappropriate?
- A.
  
  “It is okay for your child to say ‘ouch,’ cry, or even scream when receiving an injection.”
- B.
  
  “I can give the injection while your child is sleeping; then the injection won’t be noticed.”
- C.
  
  “I will apply lidocaine/prilocaine (EMLA®) cream, a topical analgesic, 1 hour before the injection to reduce pain.”
- D.
  
  “The child will need to be lying, but after theinjection you can hold and comfort your child.”
Correct Answer
B. “I can give the injection while your child is sleeping; then the injection won’t be noticed.”

Explanation
The statement "I can give the injection while your child is sleeping; then the injection won't be noticed" would be inappropriate because it implies that the nurse is planning to administer medication without the child's knowledge or consent. It is important to involve the child in their own healthcare decisions and respect their autonomy. Additionally, administering medication without the child's awareness may cause confusion or anxiety when they wake up and realize they have been given an injection without their knowledge.

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41.

An experienced nurse is supervising a new nurse caring for a hospitalized child who is receiving intravenous (IV) therapy. Which action should indicate to the experienced nurse that the new nurse needs additional orientation regarding IV therapy for children?
- A.
  
  Determines that the current solution has been infusing for 24 hours and should be changed
- B.
  
  Selects a 1,000-mL bag of the prescribed IV solution and checks it against the orders
- C.
  
  Prepares new tubing and the prescribed IV solution 1 hour before it is due to be changed
- D.
  
  Removes the plastic cover, spikes the bag with the tubing spike, and squeezes the drip chamber
Correct Answer
B. Selects a 1,000-mL bag of the prescribed IV solution and checks it against the orders

Explanation
The new nurse needs additional orientation regarding IV therapy for children because selecting a 1,000-mL bag of the prescribed IV solution and checking it against the orders is not an appropriate action. The size of the IV bag should be based on the prescribed amount of fluid for the child, not a standard size. The nurse should calculate and select the appropriate size of the IV bag based on the prescribed fluid volume for the child.

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42.

A client adamantly refuses to take an oral dose of cephalexin (Keflex®) despite implementing measures to treat the client’s nausea. What is the action by the nurse?
- A.
  
  Administer the medication 1 hour after repeating the dose of antiemetic
- B.
  
  Have the client suck on ice chips for several minutes before taking the medication
- C.
  
  Crush the medication and mix it with applesauce for administration
- D.
  
  Report the information to the client’s physician and request a different medication order
Correct Answer
D. Report the information to the client’s pHysician and request a different medication order

Explanation
The client adamantly refusing to take an oral dose of cephalexin despite measures to treat nausea indicates that the client is experiencing a strong aversion to the medication. Crushing the medication and mixing it with applesauce may not address the client's refusal and could potentially lead to non-compliance. Administering the medication after repeating the dose of antiemetic may not be effective in alleviating the client's aversion. Having the client suck on ice chips before taking the medication may provide temporary relief but does not address the underlying issue. Therefore, the best action for the nurse is to report the information to the client's physician and request a different medication order.

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43.

A nurse is to administer promethazine (Phenergan®) 12.5 mg intramuscularly (IM) stat to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client?
- A.
  
  0.125 mL
- B.
  
  0.25 mL
- C.
  
  0.3 mL
- D.
  
  1 mL
Correct Answer
B. 0.25 mL

Explanation
The nurse is required to administer 12.5 mg of promethazine intramuscularly. The medication is supplied in an ampule of 50 mg/mL. To calculate the amount of medication to be administered, we can use the formula: dose (mg) = volume (mL) × concentration (mg/mL). Rearranging the formula, we get volume (mL) = dose (mg) / concentration (mg/mL). Plugging in the values, we have volume (mL) = 12.5 mg / 50 mg/mL = 0.25 mL. Therefore, the nurse should administer 0.25 mL of promethazine to the client.

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44.

A client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, a nurse assesses the client’s ability to get out of bed independently. Which client actions indicate that further instruction is needed? SELECT ALL THAT APPLY.
- A.
  
  Places the bed in the lowest position
- B.
  
  Raises the head of the bed (HOB)
- C.
  
  Rolls onto the left side
- D.
  
  Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position
- E.
  
  Slides legs off the bed while pushing against the mattress to raise the body off the bed
- F.
  
  Once in a sitting position, sits at the edge of the bed for a few minutes before standing
Correct Answer(s)
C. Rolls onto the left side
D. Pushes against the mattress with the weak elbow and stronger hand to rise to a sitting position

Explanation
The client's left-sided weakness indicates that they may have difficulty rolling onto the left side independently. This action requires strength and coordination on the affected side. Additionally, pushing against the mattress with the weak elbow and stronger hand to rise to a sitting position may put excessive strain on the weak side and increase the risk of injury or falls. Therefore, further instruction is needed to ensure the client's safety and independence in bed mobility.

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45.

An experienced nurse is observing a new nurse providing care to a client. Which action requires the experienced nurse to intervene to ensure client safety?
- A.
  
  Turning on the client’s bathroom light and turning out the room lights after settling the client for sleep
- B.
  
  Checking the client’s room number and name on the client’s name band to verify client identity prior to administering medications
- C.
  
  Taking a telephone order from a physician, writing the order, and reading it back to the physician before implementing the order
- D.
  
  Delaying an on-coming physician from performing a right thoracentesis scheduled by a previous physician by calling “a timeout” to verify the client’s identity, consent, procedure, and site
Correct Answer
B. Checking the client’s room number and name on the client’s name band to verify client identity prior to administering medications

Explanation
The experienced nurse needs to intervene in this situation because verifying the client's identity is crucial before administering medications. This step ensures that the right medication is given to the right client, preventing any potential medication errors or adverse reactions. It is a standard safety practice to check the client's room number and name on the name band before administering any medication.

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46.

An 82-year-old client has a right total hip arthroplasty with a hip prosthesis and is planning to move in with his son following discharge. A nurse is discussing home modifications with the son. Which modifications should the nurse recommend? SELECT ALL THAT APPLY.
- A.
  
  Pad bed side rails
- B.
  
  Install safety bars around the toilet and shower
- C.
  
  Install an elevated toilet seat in the bathroom
- D.
  
  Plan for the client’s bed to be in a main floor room
- E.
  
  Place a nonskid bathmat in the bathtub and have the client bathe daily
- F.
  
  Remove scatter rugs and secure electrical cords against baseboards
Correct Answer(s)
B. Install safety bars around the toilet and shower
C. Install an elevated toilet seat in the bathroom
D. Plan for the client’s bed to be in a main floor room
F. Remove scatter rugs and secure electrical cords against baseboards

Explanation
The nurse should recommend installing safety bars around the toilet and shower to provide stability and support for the client when using these facilities. An elevated toilet seat should be installed to make it easier for the client to sit down and stand up. Planning for the client's bed to be in a main floor room is important to prevent the client from having to navigate stairs, which could be challenging after hip surgery. Removing scatter rugs and securing electrical cords against baseboards helps to prevent tripping hazards and reduces the risk of falls.

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47.

A nurse enters a client’s hospital room at the beginning of the shift. A nurse surveys the client and the care area for potential sources of infection. Which options represent potential sources of infection to this client? SELECT ALL THAT APPLY.
- A.
  
  A bottle of saline irrigation solution has the cap tightly closed and a label identifying that it was opened 10 hours previously.
- B.
  
  The client’s abdominal dressing has three different areas of moist drainage saturating the dressing and soiling the client’s gown.
- C.
  
  The tubing of the client’s intravenous (IV) fluid is not labeled with the date of the last tubing change.
- D.
  
  The bathroom contains a calibrated graduate used to measure urine that is labeled with the word urine and the client’s initials.
- E.
  
  An opened package of gauze sponges is present on the window sill.
Correct Answer(s)
B. The client’s abdominal dressing has three different areas of moist drainage saturating the dressing and soiling the client’s gown.
C. The tubing of the client’s intravenous (IV) fluid is not labeled with the date of the last tubing change.
E. An opened package of gauze sponges is present on the window sill.

Explanation
The client's abdominal dressing with three different areas of moist drainage saturating the dressing and soiling the client's gown is a potential source of infection because the moisture provides a suitable environment for bacterial growth. The tubing of the client's intravenous (IV) fluid not being labeled with the date of the last tubing change is a potential source of infection because it is important to know when the tubing was last changed to prevent the risk of contamination. The opened package of gauze sponges on the window sill is a potential source of infection because it is exposed to the environment and could be contaminated.

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48.

A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers the supplies and prepares the sterile field using a packaged sterile drape. Which option correctly describes how the nurse should set up the sterile field?
- A.
  
  Donning sterile gloves before opening the packaged sterile drape
- B.
  
  Cleansing the bottle of irrigating solution with alcohol before placing the bottle on the field
- C.
  
  Holding items 6 inches above the field and dropping them on the sterile field inside the 1-inch border along the edge of the drape
- D.
  
  Leaving the sterile field unattended to obtain supplies not in the area
Correct Answer
C. Holding items 6 inches above the field and dropping them on the sterile field inside the 1-inch border along the edge of the drape

Explanation
The nurse should hold items 6 inches above the field and drop them onto the sterile field inside the 1-inch border along the edge of the drape. This technique helps to prevent contamination of the sterile field by minimizing the risk of contact between non-sterile items and the sterile field. By holding items above the field, the nurse ensures that they do not come into direct contact with the potentially contaminated surface. Dropping them inside the 1-inch border along the edge of the drape further reduces the risk of contamination by keeping the items within the sterile area.

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49.

A client with a wound infection is ordered contact precautions based on culture results. When should a nurse caring for the client don disposable medical examination gloves?
- A.
  
  Upon entering the client’s room
- B.
  
  When anticipating contact with drainage from the wound
- C.
  
  When determining a potential for contamination with blood or body fluids of the client
- D.
  
  When providing care within 3 feet of the client
Correct Answer
A. Upon entering the client’s room

Explanation
When entering the client's room, the nurse should don disposable medical examination gloves. This is because the client has a wound infection and is on contact precautions, indicating that there is a potential for the transmission of infectious material. By wearing gloves upon entering the room, the nurse can minimize the risk of contamination and protect both themselves and the client from the spread of infection.

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50.

A nurse instructs a client on safe disposal of insulin syringes and needles when at home. Which statement by the client indicates that additional teaching is needed?
- A.
  
  “After I draw up my insulin, I scoop the cap to cover it while I cleanse my skin.”
- B.
  
  “I have a needle destruction device that breaks the needles from the syringes so that others won’t get stuck by the needles.”
- C.
  
  “I plan to use this plastic milk container to discard my used needles and syringes and take it to the clinic for disposal.”
- D.
  
  “Because the needles are capped, the syringes are safe to dispose of with my household trash.”
Correct Answer
D. “Because the needles are capped, the syringes are safe to dispose of with my household trash.”

Explanation
The client's statement that the needles are safe to dispose of with household trash indicates a lack of understanding about proper disposal of insulin syringes and needles. Needles should never be disposed of in regular household trash because they can pose a risk of injury to others. Proper disposal methods include using a needle destruction device, placing the used needles and syringes in a puncture-proof container, or taking them to a clinic for proper disposal.

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Current Version
Nov 20, 2024

Quiz Edited by
ProProfs Editorial Team
Sep 22, 2020

Quiz Created by
Ibisatepearl

Preliminary Examination In Competency Appraisal

A nurse is discussing hearing aids with a client who began wearing hearing aids 5 weeks earlier. Which statement demonstrates that the client is successfully adapting to the hearing aids?

A nurse is caring for a client who is unable to perform oral hygiene. The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?

A male client undergoes surgery for a hernia repair. The client has orders to be discharged to home when stable. The client has tried several times to urinate into the urinal while in bed without success. Which interventions are appropriate to promote voiding for this client? SELECT ALL THAT APPLY.

A client who is recovering from orthopedic surgery keeps an appointment at a clinic and uses a walker to ambulate with partial weight-bearing as instructed. Which observation should lead the nurse to conclude that the client is using the correct technique?

A nurse reviews the record of a client who has been immobile because of a degenerative neurological condition. The nurse reads that the client has bilateral foot drop. Which finding during the nurse’s assessment supports the presence of foot drop?

A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client?

A client reports pain at an intravenous infusion site that has infiltrated. When a nurse applies a warm, moist compress to the site, the client asks how the treatment will help the condition. The nurse answers the client based on the understanding that the application of moist heat will:

A nurse is caring for a client who has experienced a first-degree sprain of the ankle. A primary care provider writes a prescription for an analgesic medication. Which intervention, beside the analgesic, should the nurse advise the client to utilize for the first 24 hours after the injury?

An elderly client residing in a nursing home has bilaterally weak handgrips and has difficulty with self-feeding. Which nursing interventions should be implemented to promote independence for this client? SELECT ALL THAT APPLY.

A dietitian, who is consulted to see a hospitalized client because of nutritional concerns, orders a calorie count. The nurse should participate in this intervention by:

A hospitalized client has daily weights ordered. The client is able to stand, and the nursing unit has an electronic digital scale to use for client weights. Which intervention best ensures that the client’s daily weight is accurate?

A nurse plans guidelines to assist nursing personnel in meeting the hygiene needs of adult clients with dementia. Which guidelines are appropriate for the nurse to include? SELECT ALL THAT APPLY.

A nurse should inform a nursing assistant to avoid taking a rectal temperature for which client?

A nursing assistant (NA), who is taking routine vital signs, tells a nurse that the small adult cuff is nowhere to be found and that a client’s arm is too small to use an adult-size cuff. In response to the NA’s report, which direction should the nurse give to the NA?

A nurse takes a client’s blood pressure with an automatic blood pressure machine. The blood pressure is 86/56 mm Hg with a pulse rate of 64 beats per minute. Which action should the nurse do first?

A nurse is using a tympanic thermometer to measure a client’s temperature. When using a tympanic thermometer, the nurse should:

A nurse is preparing to provide phototherapy to a 4-day-old newborn who was admitted with hyperbilirubinemia. The nurse instructs the parents on how to care for their baby while receiving phototherapy in the hospital. The nurse’s teaching should include:

When using a hypothermia blanket for a febrile client, which findings should lead the nurse to suspect hypothermia? SELECT ALL THAT APPLY.

Which signs should indicate to a nurse that a client is experiencing a surgical site infection? SELECT ALL THAT APPLY.

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer?

Which actions should a nurse plan when caring for a client with a stage III pressure ulcer to the right lower-extremity heel? SELECT ALL THAT APPLY.

A nurse is assessing a client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding would require an immediate intervention by the nurse?

A nurse is teaching a client, who is 24 hours post–abdominal surgery, how to use an incentive spirometer. Which instructions should the nurse include in the teaching? SELECT ALL THAT APPLY.

A 33-year-old client reports left leg pain, right-sided chest pain, and a sudden onset of shortness of breath. Which action should be taken immediately by the nurse?

Which rationale should a nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving 2 liters of oxygen by nasal cannula?

A nurse, checking newly written physician orders, determines that which orders require the nurse to contact the physician to clarify the order? SELECT ALL THAT APPLY.

A nurse receives a medication order for an adult client to administer ferrous sulfate 300 mg PO bid. After thinking critically about this order, the nurse should:

Before a child’s hospital discharge, a nurse is teaching the parents how to administer an oral medication to the child. Which nurse instruction would be most appropriate?

A nurse is evaluating whether a client on multiple oral medications is taking the medications correctly. Which finding should be most concerning to the nurse because the absorption rate of medications can be increased?

A nurse is observing a nursing student prepare and administer medications to adult clients. Which action by the nursing student warrants intervention by the nurse?

A nurse is planning to administer medications through a nasogastric (NG) tube. Which interventions should the nurse plan after checking the medications, checking client identification, and verifying tube placement? SELECT ALL THAT APPLY.

A nurse is observing a nursing student administering a clonidine (Catapres®) transdermal patch to a client diagnosed with hypertension. Which action requires the nurse to intervene?

A nurse administers a prochlorperazine (Compazine®) suppository to an adult client. Which action by the nurse best ensures that the medication is correctly administered?

An experienced nurse is supervising a new registered nurse who is administering medications to adult clients. Which action by the new registered nurse requires the experienced nurse to intervene?

A nurse, who is working the evening shift, is planning to administer insulin subcutaneously to a hospitalized child. Which statement made by the nurse to the mother would be inappropriate?

An experienced nurse is supervising a new nurse caring for a hospitalized child who is receiving intravenous (IV) therapy. Which action should indicate to the experienced nurse that the new nurse needs additional orientation regarding IV therapy for children?

A client adamantly refuses to take an oral dose of cephalexin (Keflex®) despite implementing measures to treat the client’s nausea. What is the action by the nurse?

A nurse is to administer promethazine (Phenergan®) 12.5 mg intramuscularly (IM) stat to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client?

A client with a left-sided weakness is to be discharged to home, where the client has an electrical bed. In preparation for discharge, a nurse assesses the client’s ability to get out of bed independently. Which client actions indicate that further instruction is needed? SELECT ALL THAT APPLY.

An experienced nurse is observing a new nurse providing care to a client. Which action requires the experienced nurse to intervene to ensure client safety?

An 82-year-old client has a right total hip arthroplasty with a hip prosthesis and is planning to move in with his son following discharge. A nurse is discussing home modifications with the son. Which modifications should the nurse recommend? SELECT ALL THAT APPLY.

A nurse enters a client’s hospital room at the beginning of the shift. A nurse surveys the client and the care area for potential sources of infection. Which options represent potential sources of infection to this client? SELECT ALL THAT APPLY.

A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers the supplies and prepares the sterile field using a packaged sterile drape. Which option correctly describes how the nurse should set up the sterile field?

A client with a wound infection is ordered contact precautions based on culture results. When should a nurse caring for the client don disposable medical examination gloves?

A nurse instructs a client on safe disposal of insulin syringes and needles when at home. Which statement by the client indicates that additional teaching is needed?