1. The charge nurse is observing a new nursing graduate perform an ear irrigation to remove impacted cerumen from

• The charge nurse is observing a new nursing graduate perform an ear irrigation to remove impacted cerumen from

the client’s ear. The charge nurse should intervene during the procedure if the new nursing graduate performs which action?

• Washes hands before performing the procedure.
• Position the client with the affected side up after the irrigation.
• Warms the irrigating solution to a temperature that is close to body temperature.
• Directs a slow, steady stream irrigation solution toward the upper wall of ear canal.

• The nurse is preparing to administer a medication to a client and notes that the dose prescribed is higher that the

recommended dosage. The nurse calls the primary health care provider (PHCP) to clarify the prescription, and the PHCP instructs the nurse to administer the does as prescribed. Which action should the nurse take?

• Call the pharmacy.
• Contact the nursing supervisor.
• Administer the dose as prescribed.
• Contact the medical director on call.

• The charge nurse is observing a new nursing graduate insert an indwelling urinary (Foley) catheter. The charge nurse

should intervene if the new nursing graduate begins to perform which actions? Select all that apply.

• Lubricates the catheter before inserting it.
• Positions the client in a side lying position.
• Inflates the balloon to test patency before inserting the catheter.
• Cleans the area around the urinary meatus before inserting the catheter.
• Inflates the balloon as soon as urine begins to flow through the catheter tubing.

• A hospitalized client tells the evening nurse that they have received pain medication at 10:00 am and again at 2:00 pm

and that the medication provided no relief from the pain. The nurse says to the nurse, “Whenever that daytime nurse takes care of me and gives me pain medication it never works! I am so glad that you are here so that I can get some relief from this pain.” The nurse has observed this same occurrence with other clients who were cared for by this same daytime nurse and suspects that the daytime nurse is self-abusing drugs. The nurse should implement which action?

• Report the information to the nursing supervisor.
• Talk with the daytime nurse who gave the medication to the client.
• Call the impaired nurse organization and report the daytime nurse.
• Report the information about the daytime nurse to the police department.

• The nurse determines that a client with a stroke is experiencing difficulty with fine motor coordination when

performing activities of daily living. The nurse should suggest that the client be referred to which member of the health care team?

1.Physical therapist

• Speech pathologist
• Recreational therapist
• Occupational therapist

• The nurse notes that unlicensed assistive personnel (UAP) dons’ clean gloves but has not washed their hands before

taking oral temperature on a client. The nurse implements a teaching session for UAPs and should incorporate which principle?

• Learning involves a change of behavior.
• Learning is a cognitive, passive process.
• UAPs need constant supervision when caring for clients.
• Negative rewards reduce undesirable behavior and should be used when an error is seen.

• The primary health care provider has prescribed a cleansing enema for an adult client. The nurse provides directions

to a nursing student who is trained to administer enemas and should tell the student that the maximum volume of fluid that can be administered is which volume?

• 100mL
• 300mL
• 500mL
• 1000mL

• A client requires a partial bed bath. The nurse gives instructions to unlicensed assistive personnel (UAP) about the

partial bed bath and should tell the UAP to perform which action?

• Just wash the client’s hands and face.
• Provide mouth care and perineal care only.
• Let the client decide what she or he wants washed.
• Be sure to bathe the client’s body parts that would cause discomfort or odor if left unbathed.

• The nurse is reviewing the pre-procedure care for a client who is scheduled for cardiac catheterization with a nursing

student. The nurse determines that the student needs further instruction while preparing the client if the nursing student made which statement?

• “The procedure takes about 5 hours.”
• “The client may experience flushing feelings during the procedure.”
• “The blood vessels and flow of blood will be examined with this procedure.”
• “There is minimal discomfort with catheter insertion because of local anesthetic used.”

• The nurse has instructed an unlicensed assistive personnel (UAP) in the procedure for collecting a 24-hour urine

specimen from a client. The nurse determines that the UAP understands the directions if the UAP makes which statement?

• “I need to keep the specimen at room temperature.”
• “I need to save the first urine specimen collected at the start time.”
• “I need to discard the last voided specimen at the end of the collection time.”
• “I need to ask the client void, discard the specimen, and note the start time.”

• The nurse is supervising a nursing student who is performing a pulse oximetry measurement on a client with

peripheral vascular disease. The nurse determines that the nursing student is performing the procedure accurately if the student places the oximetry probe on which anatomical area? Refer to figure.

• The nursing student is preparing a client who will have spinal anesthesia for surgery. The nurse in charge asks the

nursing student to identify which highest priority preoperative data to report to the nurse on the next shift who will care for the client postoperatively?

• Pulse rate of 78 beats/min
• Voided 300mL preoperatively
• Blood pressure of 126/78 mmHg
• Presence of weakness in the left lower extremity

• A client comes to the hospital emergency department with complaints of severe right lower abdominal pain

characteristic of appendicitis. The client does not have any health insurance. The nurse understands that legally the hospital has which obligation?

• Refer the client to the nearest public hospital.
• Provide uncompensated care in emergency.
• Have a health care provider see the client before admission.
• Respect the family’s requests to admit their family member to the hospital.

• The nurse tells an unlicensed assistive personnel (UAP) that a client recovering from a myocardial infarction requires

a complete bed bath. During the bath, the nurse should intervene if the nurse observed the UAP performing which action?

• Washing the client’s chest.
• Giving the client a back rub.
• Asking the client to wash her or his legs.
• Washing the client’s perineal area.

• The nurse is observing a nursing student auscultating the breath sounds of a client. The nurse should intervene if the

nursing student performs which action?

• Used the diaphragm of the stethoscope.
• Placed the stethoscope directly on the client’s skin.
• Asked the client to breathe slowly and deeply through the mouth.
• Asked the client to lie flat on the right side and then on the left side.

• The nurse administers a fatal dose of morphine sulfate to a client. During the subsequent investigation of error, it is

determined that the nurse did not check the client’s respiratory rate before the administering the medication. Failure to adequately asses the client is addressed under which function of the nurse practice act?

• Defining the specific educational requirements for licensure in the state.
• Describing the scope of practice of licensed and unlicensed care providers.
• Identifying the process for disciplinary action if standards of care are not met.
• Recommending specific terms of incarceration for nurses who violate the law.

• The nurse is caring for a child with juvenile idiopathic arthritis (JIA). The nurse should identify which problem as the

priority?

• Complaints of acute pain.
• Unsteadiness when ambulating.
• Embarrassment about appearance.
• Inability to perform self-hygienic measures.

• The nurse is caring for a client with an injury to the brainstem. The nurse should monitor which parameter as the

priority?

• Urine output
• Electrolyte results
• Peripheral vascular status
• Respiratory rate and rhythm

• The nurse checks the serum digoxin level for a client with heart failure who is taking digoxin and notes that the result

is 0.8 ng/mL (1.02 nmol/L). Which action should the nurse take based on this laboratory result?

• Notify the primary health care provider.
• Withhold the next scheduled dose of digoxin.
• Place the report in the client’s medical record.
• Obtain another serum digoxin level to verify the results.

• A client is receiving diazepam to treat painful muscle spasms. The nurse should monitor the client for which frequent

side effect of the medication?

• Ataxia
• Diarrhea
• Nervousness
• Hypertension

• The nurse is providing instructions to a client who is taking codeine sulfate. What instructions should the nurse

provide to the client?

• Decrease fluid intake.
• Change positions slowly.
• Maintain a low-fiber diet.
• Limit the intake of alcoholic beverages.

• Betaxolol eye drops have been prescribed for a client for the treatment of glaucoma. The nurse should tell the client

that it is important to return to the clinic for assessment of the presence of which condition?

• Hypotension
• Hyperglycemia
• The presence of Trousseau’s sign
• The presence of redness and warmth in the calf area

• The nurse is providing instructions to a client about lithium carbonate that has been prescribed for acute mania. The

nurse should provide which information to the client?

• Foods that contain salt need to be avoided.
• Medication blood levels need to be checked yearly.
• Vomiting and diarrhea are expected effects of the medication.
• Blurred vision needs to be reported to the primary health care provider.