1. A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the followi... [Show More] ng statements by the newly licensed nurse indicates a need for further teaching?
A. "Information about a client can be disclosed to family members at any time."
B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form."
C. "A client's address would be an example of personally identifiable information."
D. "HIPAA is a federal law, not a state law."
2. A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
A. Adjust the water temperature to feel hot.
B. Apply 4 to 5 mL of liquid soap to the hands.
C. Hold the hands higher than the elbows.
D. Rub hands and arms to dry.
3. A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?
A. Tell the client to blow her nose gently before the instillation.
B. Assist the client to a side-lying position.
C. Hold the dropper 2 cm (1 in) above the naris.
D. Instruct the client to stay in the same position for 2 min.
4. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
A. Secure the restraints using a quick-release tie.
B. Ensure four fingers fit under the restraints to prevent constriction.
C. Secure the restraints to the lowest bar of the side rail.
D. Anticipate removing the restraints every 4 hr.
5. The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?
A. He is hard of hearing.
B. Pain
C. Confusion
D. Language barrier
6. A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
A. Remove the catheter and insert another into a different site.
B. Administer an analgesic PO.
C. Request a prescription for placement of a central venous access device.
D. Administer a local anesthetic.
7. A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?
A. Close the fire doors on the unit.
B. Activate the fire alarm.
C. Move any clients in the immediate vicinity.
D. Use a fire extinguisher to put out the fire.
8. A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?
A. Invasion of privacy
B. Assault
C. Battery
D. False imprisonment
9. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
A. Suction two to three times with a 60-second pause between passes.
B. Perform chest physiotherapy prior to suctioning.
C. Lubricate the suction catheter tip with sterile saline.
D. Hyperventilate the client on 100% oxygen prior to suctioning.
10. A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?
A. Dorsal metacarpal vein
B. Radial vein in the wrist
C. Antecubital vein
D. Median vein in the forearm
11. A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
A. Use a stiff toothbrush to clean the client's teeth.
B. Use the thumb and index finger to keep the client's mouth open.
C. Turn the client on his side before starting oral care.
D. Apply petroleum jelly to the client's lips after oral care.
12. A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
A. An upper respiratory infection
B. Pulmonary edema
C. Atelectasis
D. Delayed gastric emptying
13. A nurse is assessing a client and discovers the infusion pump with the client’s total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?
A. Excessive thirst and urination
C. Fever and chills
D. Hypertension and crackles
14. AA nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
A. The client who has a tracheostomy tube attached to humidified oxygen
B. The client who has an indwelling urinary catheter to gravity drainage
C. The client who has a chest tube to water seal
D. The client who has a nasogastric (NG) tube to suction
15. AA nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
A. Testing visual acuity
B. Observing for facial symmetry
C. Eliciting the gag reflex
D. Checking the pupillary response to light
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