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1. A client is brought to the emergency department following a motor-vehicle
crash. Drug use is suspected in the crash, and a voided urine specimen is
ordered. The client repeatedly refuses to provide the specimen. Which of the
following is the appropriate action by the nurse?
a. Tell the client that a catheter will be inserted.
b. Document the client’s refusal in the chart.
c. Assess the client for urinary retention.
d. Obtain a provider’s prescription for a blood alcohol level.
2. A nurse is making shift assignments in a hospital. Which of the following
tasks is appropriate to assign to a licensed practical nurse?
a. Pick up the meal trays after lunch.
b. Administer a nasogastric tube feeding.
c. Plan break times for assistive personnel.
d. Determine adequacy of ventilator settings.
3. A nurse preceptor is evaluating a newly licensed nurse’s competency in
assisting with a sterile procedure. Which of the following actions indicates
the newly licensed nurse is maintaining sterile technique? (SATA)
a. Places sterile items within a 1.25 cm (0.5 in) border around the edges
of the sterile field
b. Opens the sterile pack by first unfolding the top flap away from
her body
c. Prepares a container of sterile solution on the field after putting on
sterile gloves
d. Removes the outside packaging of a sterile instrument before
dropping it onto the sterile field
e. Holds the sterile solution bottle with the label facing up
4. A nurse enters a client’s room and identifies that the client is receiving too
much IV fluid because the IV pump is not working properly. Which of the
following actions should the nurse take first?
a. Auscultate the client’s lungs.
b. Notify the provider.
c. Place a faulty equipment tag on the pump.
d. Complete an incident report.
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