1. The graduate nurse GN prepares to place an oropharyngeal airway into an unconscious adult client

1.) The graduate nurse (GN) prepares to place an oropharyngeal airway into an unconscious adult client who is emerging from general anesthesia. Which action by the GN requires the precepting nurse to intervene?

• Insert the device with the tip pointed up, then rotates it downward at the back of the mouth
• Selects the device size by measuring from the corner of the client’s mouth to the earlobe
• Suctions secretions from the mouth and pharynx prior to and following device insertion
• Tapes the orpharyngeal airway in place after ensuring correct device placement

2.) A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client’s pulse oximeter reading is inaccurate. Which factors could be contributing to this reading?Select all that apply.

• Black fingernail polish
• Cold extremities
• Elevated WBC count
• Hypotension
• Peripheral arterial disease

3.) A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound. Which actions by the new nurse would require the experienced nurse to intervene? Select all that apply.

• Administers the prescribed analgesic 30 minutes before irrigating the wound
• Cleanses the wound from the most to the least contaminated area
• Obtains a 10-mL syringe and a 27-gauge needle
• Reviews the child’s most recent immunization record
• Uses continuous pressure to irrigate and repeats until drainage is clear

4.) The nurse prepares to draw up regular insulin and NPH insulinin one syringe. Place in order the steps the nurse should do when mixing the insulins. ALL MUST BE USED.

1.) Clean the vial tops with alcohol swab 2.) Draw up the NPH insulin solution 3.) Draw up the regular insulin solution 4.) Inject air into the NPH insulin vial 5.) Inject air into the regular insulin vial

5.) The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor.Which of the following statements by the student indicate a correct understanding? Select all that apply.

• “I will apply the prescribed bacitracin ointment after collecting the wound culture.”
• “I will cleanse the wound by gently flushing it with normal saline.”
• “I will obtain a sample of the drainage accumulated since the last dressing change.”
• “I will perform hand hygiene and apply new gloves before obtaining the wound culture.”
• “I will swab the wound from the outermost margin toward the center.”

6.) The nurse attempts to flush a client’s subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion.What should the nurse do next?

• Flush and lock with heparinized saline flush

• Flush with normal saline using a 5-mL syringe
• Notify the health care provider
• Reposition the client

7.) A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply.

• Discard aspirated gastric residual in a biohazard container
• Flush the nasogastric tube before and after administering the feeding
• Place the client in the semi-Fowler position
• Start the feeding after obtaining a gastric residual volume of 75 mL
• Start the feeding when the gastric residual has pH of 6

8.) The nurse is assisting with procedural moderate sedation (conscious sedation) at a client’s bedside.The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?

• Ask the UAP to go back and ask the client what the current needs are
• Ask the UAP to stay and take over while the nurse goes to check on the client in the next

room

• Tell the UAP to inform the client in the next room that the nurse will be there shortly
• Tell the UAP to the tell charge nurse about the needs of the clients in the next room

9.) A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client’s blood glucose level is 220 mg/dL (12.2 mmol/L), and the client’s breakfast tray has arrived. What action should the nurse take?Click on the exhibit button for additional information.

• Administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning

meal

• Administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2

separate injections

• Administer 26 units of insulin: 20 units of UNP mixed with 6 units of regular insulin in the

same syringe, drawing up the NPH into the syringe first

• Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the

same syringe, drawing up the regular insulin first

10.) The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions. The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask. Place the steps for suctioning the tracheostomy tube in the correct order. All options must be used.

UNORDERED OPTIONS

• Apply intermittent suction while rotating the suction catheter while withdrawing
• If resistance is felt, withdraw the catheter 0.4-0.8 in (1-2 cm)
• Insert catheter the length of the airway without applying suction
• Place client in semi-Fowler’s position
• Preoxygenate (hyper-oxygenate) with 100% oxygen

11.) Which procedures are appropriate for the nurse to use when obtaining an adult client’s blood for a laboratory test? Select all that apply.

• Avoid the arm on the affected side after a mastectomy
• Do not make further attempts to draw blood if unsuccessful on first 2 attempts
• If necessary to use an arm with IV infusing, draw proximal to infusion point
• Insert the needle bevel up at a 15-degree angle to the skin
• Obtain a finger capillary specimen from the middle of the finger pad

12.) A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick?

• Apply adhesive urine collection bag around the genital area and wait for the child to void
• Intermittently catheterize the child every morning to avoid contaminating the specimen
• Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick
• Place urine dipstick in the child’s diaper overnight and check result in the morning

13.) A nurse preparing to insert a peripheral IV catheter dons cleans gloves, applies a tourniquet to the client’s arm, and immediately identifies a site for venipuncture. Place in order the remaining steps that the nurse should take. All options must be used.

YOUR RESPONSE / INCORRECT RESPONSE

• Cleanse selected site using an antiseptic swab
• Insert needle bevel-side up until blood return is observed
• Advance catheter hub while retracting stylet
• Remove stylet and attach extension or infusion set
• Anchor vein by holding skin taut
• Apply a transparent dressing

14.) The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order. All option must be used.

UNORDERED OPTIONS

• Advance the affected leg and crutches up the stair
• Assume the tripod position, then bear body weight on the crutches
• Place the unaffected leg onto the stair
• Transfer body weight to the unaffected leg and raise the body onto the stair

15.) The charge nurse observes a new staff nurse collecting a urine sample for urinalysis and culture as pictured. What is the charge nurse’s best action? Click on the exhibit button for additional information.

• Advise the staff nurse to discard the collected urine specimen and record the output
• Advise the staff nurse to put the lid on the cup and immediately transfer it to a biohazard bag
• Instruct the staff nurse to discard the first small amount of urine before collecting the sample
• Remind the staff nurse that the specimen should be kept cool until is sent to the laboratory

16.) A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse?

• Administers hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale
• Notifies physician of occasional premature ventricular beats in a client with myocardial

infarction

• Positions a postoperative pneumonectomy client on the affected side
• Prepares to administer IVPB potassium chloride via gravity infusion for a client with

hypokalemia

17.) The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. All options must be used.

YOUR RESPONSE / INCORRECT RESPONSE

• Perform hand hygiene and don clean gloves
• Hyperoxygenate the lungs (100% FiO2)
• Advance catheter into the trachea
• Gently rotate the catheter while suctioning
• Suction the oropharynx and perform oral care
• Evaluate client tolerance and document