1. A nurse is planning to collect a stool specimen for ova and parasites from a client who
has diarrhea. Which of the following actions should the nurse
... [Show More] take when collecting the
specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container for
stool collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a tongue
depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the
laboratory after labeling the specimen properly to prevent contamination with
microorganisms and keep the specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with the
client label on the container and the bag for easy identification. This will also prevent
contamination with microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which
of the following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for
several minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage to
the tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
lOMoARcPSD|15781121
Downloaded by zakeea McDuffie ([email protected])
3. A nurse is providing teaching to a client regarding protein intake. Which of the
following foods should the nurse include as an example of an incomplete protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for the
synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
1. A nurse is conduc 琀椀 ng an admission interview with a client. Which of the following pieces
of assessment informa 琀椀 on should the nurse collect during the introductory phase of the
interview?
A. Clients level of comfort and ability to par 琀椀 cipate in the interview
-The nurse should assess the client’s level of comfort and establish a rapport during the
introductory or orienta 琀椀 on phase. The nurse should engage in ac 琀椀 ve listening and
present a relaxed a 琀 tude to place the client at ease and encourage client par 琀椀 cipa 琀椀
on. This will assist the nurse in gaining the necessary data to formulate appropriate nursing
diagnoses and outcomes.
B. Previous illnesses and surgeries
-incorrect: The nurse should assess the client’s health history, including previous illnesses and
surgeries, during the working phase of the interview.
C. Events surrounding the client’s recent illness
-incorrect: The nurse should assess the client’s health history, including events surrounding the
recent or current illness, during the working phase of the interview.
D. Sociocultural history
-incorrect: The nurse should assess the client’s sociocultural history during the working phase of
the interview.
2. A nurse is performing an abdominal assessment of a client. Which of the following posi 琀椀
ons should the nurse tell the client to assume for this examina 琀椀 on?
A. Lithotomy
-incorrect: The lithotomy posi 琀椀 on is useful for gynecological examina 琀椀 ons.
B. Lateral
-incorrect: The lateral recumbent, or side-lying posi 琀椀 on, limits access to the abdomen. This
posi 琀椀 on is useful when ausculta 琀椀 ng the heart to detect murmurs.
C. Supine
lOMoARcPSD|15781121
Downloaded by zakeea McDuffie ([email protected])
-The nurse should tell the client to assume the supine posi 琀椀 on to promote relaxa 琀
椀 on of the abdominal muscles. Having the client bend the knees enhances relaxa 琀椀
on of the stomach muscles. D. Sims
-incorrect: The Sims’ posi 琀椀 on limits access to the abdomen. This posi 琀椀 on is useful for
rectal and vaginal examina 琀椀 ons.
3. A nurse is caring for a client who is postopera 琀椀 ve following an abdominal surgery. Which
of the following ac 琀椀 ons should the nurse perform 昀椀 rst a 昀琀 er discovering the
client’s wound has eviscerated?
A. Cover the incision with a moist sterile dressing
- The nurse should apply the safety and risk-reduc 琀椀 on priority-se 琀 ng framework, which
assigns priority to the factor or situa 琀椀 on posing the greatest safety risk to the client. When
there are several risks to client safety, the one posing the greatest threat is the highest priority.
The nurse should use Maslow’s Hierarchy of Needs, the ABC priority-se 琀 ng framework,
and/or nursing knowledge to iden 琀椀 fy which risk poses the greatest threat to the client. An
open wound increases the risk of peritoni 琀椀 s, and any exposed organ 琀椀 ssue could dry
out. Therefore, covering the wound with a moist sterile dressing is the 昀椀 rst ac 琀椀 on the
nurse should take to protect the client.
B. Have the client lie on his back with his knees 昀氀 exed
-incorrect: The nurse should use this posi 琀椀 on to reduce pressure on the incision. However,
the nurse should take another ac 琀椀 on 昀椀 rst.
C. Call the client’s surgeon
-incorrect: The nurse should no 琀椀 fy the surgeon or direct a colleague to no 琀椀 fy the
surgeon while tending to the client’s immediate need. However, the nurse should take another
ac 琀椀 on 昀椀 rst.
D. Reassure the client
-incorrect: The nurse should respond to the client’s emo 琀椀 onal needs. However, the nurse
should take another ac 琀椀 on 昀椀 rst.
4. A nurse is preparing to insert an NG tube for a client who has a bowel obstruc 琀椀 on.
Which of the following ac 琀椀 ons should the nurse take 昀椀 rst?
A. Give the client a glass of water
lOMoARcPSD|15781121
Downloaded by zakeea McDuffie ([email protected])
-incorrect: The nurse should provide a glass of water to facilitate swallowing during tube inser
琀椀 on of the NG tube. However, there is another ac 琀椀 on the nurse should take 昀椀 rst.
B. Assist the client into a si 琀 ng posi 琀椀 on
-incorrect: The nurse should assist the client into a si 琀 ng posi 琀椀 on to insert the NG
tube more easily and allow gravity to help facilitate the passage of the tube. However, there
is another ac 琀椀 on the nurse should take 昀椀 rst. C. Explain the procedure to the client
-The nurse should apply the least invasive priority-se 琀 ng framework when caring for this
client, which assigns priority to nursing interven 琀椀 ons that are least invasive to the client,
as long as those interven 琀椀 ons do not jeopardize client safety. The nurse should take
interven 琀椀 ons that are not invasive to the client before interven 琀椀 ons that are invasive.
This reduces the number of organisms introduced into the body, decreasing the number of
facility-acquired infec 琀椀 ons. Informing the client about the procedure reduces fear and
assists in gaining the client’s coopera 琀椀 on, which is important for NG tube inser 琀椀 on
and is the priority nursing interven 琀椀 on.
D. Measure the length of tubing to be inserted
-incorrect: The nurse should measure the length of the tubing to be inserted to ensure proper
tube placement. However, there is another ac 琀椀 on the nurse should take 昀椀 rst.
5. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity ac 琀椀 vi 琀椀 es of daily
living. Which of the following ac 琀椀 vi 琀椀 es should the nurse recommend to the client?
A. Sweeping the 昀氀 oor
-incorrect: sweeping the 昀氀 oor is moderate-intensity ac 琀椀 vity
B. Shoveling snow
-incorrect: Shoveling snow is a high-intensity ac 琀椀 vity
C. Cleaning windows
-incorrect: Cleaning windows is a moderate-intensity ac 琀椀
vity D. Washing dishes
-Washing dishes requires a low level of ac 琀椀 vity and is appropriate for this client.
6. A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and
has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr 昀氀 uid intake in milliliters
that the nurse should document for this client? (round to nearest whole number) [Show Less]