Question: A nurse is caring for a client who has COPD. For which inhalation delivery method should the nurse assess the client’s ability to inhale deeply?
Answer Options: A. Dry powder inhaler (DPI)
B. Nasal spray
C. Metered dose inhaler (MDI) with attached spacer
D. Use of a nebulizer via a mask
Answer: A. Dry powder inhaler (DPI)
Question: A nurse is preparing to instill antibiotic ear drops into the ear of a 2-year-old child. Which technique should the nurse use?
Answer Options: A. Have the client maintain a side-lying position for 30 min after administration.
B. Pull the client’s auricle down and back to open the canal when administering the ear drops.
C. Don sterile gloves prior to administration of the ear drops.
D. Insert the tip of the dropper into the ear canal when administering the ear drops.
Answer: B. Pull the client’s auricle down and back to open the canal when administering the ear drops.
Question: A nurse is caring for a client who has a prescription for a fluticasone propionate inhaler with a spacer. The client asks why a spacer is needed. Which response is correct?
Answer Options: A. “By using a spacer, you can take the medication correctly without any spills.”
B. “You can inhale five or more puffs in 1 minute when using a spacer.”
C. “By using a spacer, you eliminate the need for mouth rinsing after administration.”
D. “More medication is delivered to the lungs when you use a spacer.”
Answer: D. “More medication is delivered to the lungs when you use a spacer.”
Question: A nurse is administering aspirin 81 mg PO daily to a client with a history of myocardial infarction. The medication is scheduled for 0800. Which scenario demonstrates proper use of one of the Ten Rights?
Answer Options: A. The nurse performs the first check of the correct dosage at the client’s bedside.
B. The nurse identifies the client by stating the client’s name as written on the medication administration record.
C. The nurse documents that the aspirin was given at 0825.
D. The nurse opens the 81 mg aspirin unit-dose package prior to entering the client’s room.
Answer: C. The nurse documents that the aspirin was given at 0825.
Question: A nurse is teaching the adult child of a client about instilling eye drops in the client’s right eye. Which statement by the adult child indicates understanding?
Answer Options: A. “I will have my mother look down while dropping the medication into her eye.”
B. “I will instruct my mother to tightly close her eye for 30 to 60 seconds after the medication has been given.”
C. “I should apply the medication using a thin stream from the inner canthus to the outer canthus.”
D. “I will pull down her lower eyelid and drop the medication inside.”
Answer: D. “I will pull down her lower eyelid and drop the medication inside.”
Question: A nurse is providing discharge teaching to a client who is 3 days postpartum and is formula feeding their newborn. Which instruction should the nurse include when discussing engorgement?
Answer Options: Apply ice packs to the breasts for 15 min to relieve swelling and discomfort.
Wear a loose-fitting bra for 1 week to minimize pressure on the breasts.
Manually express small amounts of breastmilk three times per day.
Allow warm water from a shower to run over the breasts twice a day.
Answer: Apply ice packs to the breasts for 15 min to relieve swelling and discomfort.
Question: A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which movement indicates full shoulder range of motion?
Answer Options: A. Adducting the arm so that it lies next to the client’s side
B. Flexing the shoulder by raising the arm from a side position to a 180° angle
C. Abducting the arm to a 90° angle from the side of the body
D. Circumducting the shoulder in a 180° half circle
Answer: B. Flexing the shoulder by raising the arm from a side position to a 180° angle.
Question: A nurse is providing teaching about breastfeeding to a client who gave birth 8 hr ago. Which information should the nurse include?
Answer Options: The newborn should be fed six times in 24 hr.
The newborn should have six wet diapers per day after day 4.
The breasts will become engorged within 24 hr of the first feeding.
The newborn should be breastfed on a set schedule.
Answer: The newborn should have six wet diapers per day after day 4.
Question: A nurse stands facing a client to demonstrate active range-of-motion exercises. Which action demonstrates hip hyperextension?
Answer Options: A. Move their leg behind their body
B. Move their leg forward and up
C. Move their leg medially toward their other leg
D. Turn their foot and leg away from their other leg
Answer: A. Move their leg behind their body.
Question: A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using axillary crutches for the first time. Which instruction should the nurse include?
Answer Options: A. “Lean on the crutches to support your body weight when standing.”
B. “Fully extend your arms when holding onto the hand grips.”
C. “Hold the crutches on your unaffected side when preparing to sit in a chair.”
D. “Hold the crutches 9 inches in front of and to the side of each foot.”
Answer: C. “Hold the crutches on your unaffected side when preparing to sit in a chair.”
Question: A nurse is preparing to administer a client’s medication. The client states the medication makes them feel nauseated and refuses to take it. Which action should the nurse take?
Answer Options: A. Document the reason for refusal along with the date and time in the client’s medical record.
B. Tell the client that if they don’t take the medication they will not get any better.
C. Place the medication on the client’s bedside so they can take it when they are no longer nauseated.
D. Notify the pharmacist that the client refuses to take the medication.
Answer: A. Document the reason for refusal along with the date and time in the client’s medical record.
Question: A nurse is assigning a 1-minute Apgar score to a newborn who is crying loudly. The newborn has a heart rate of 140/min, well-flexed arms and legs, grimaces when the nurse rubs the soles of their feet, and is pink with mild acrocyanosis. What Apgar score should the nurse assign?
Answer Options: (fill-in-the-blank)
Answer: 8.
Question: A nurse is caring for a client who has a new prescription for prednisone 12.5 mg PO daily. The medication is available in 5 mg tablets. How many tablets should the nurse administer per dose?
Answer Options: (fill-in-the-blank)
Answer: 2.5 tablets.
Question: A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?
Answer Options: A. Place the stockings on the client after the client ambulates to the restroom.
B. Ensure the client’s toes are visible after placing the stockings on the client.
C. After applying the stockings, place two fingers between the client’s leg and stocking to check the fit.
D. Measure the client’s calf circumference and leg length from heel to knee.
Answer: D. Measure the client’s calf circumference and leg length from heel to knee.
Question: A nurse is preparing to administer several medications to a client who is receiving enteral feedings through a small-bore nasogastric tube. Which action ensures correct administration?
Answer Options: A. Add crushed medications to the enteral tube feedings and infuse via an electronic pump.
B. Infuse each medication by gravity and flush with water before and after instillation.
C. Administer medications through a 5-mL syringe.
D. Lower the syringe to facilitate instillation of the medication.
Answer: B. Infuse each medication by gravity and flush with water before and after instillation.
Question: A nurse is preparing to administer medications for a client who has a nasogastric tube. Which action should the nurse take prior to administering the medications?
Answer Options: A. Check tube placement by inserting air into the tube while auscultating at the gastric fundus.
B. Percuss the client’s abdomen to assess for areas of tympany and dullness.
C. Observe the amount of residual volume left in the stomach.
D. Determine the client’s ability to cooperate with instructions.
Answer: C. Observe the amount of residual volume left in the stomach.
Question: A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which action by the AP should the nurse intervene?
Answer Options: A. Places a removable cover over the sling
B. Leaves the bed in the lowest position throughout the procedure
C. Locks the hydraulic valve before attaching the sling to the lift
D. Raises the head of the bed to a sitting position just before transfer
Answer: B. Leaves the bed in the lowest position throughout the procedure.
Question: A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which action demonstrates correct transfer technique?
Answer Options: A. Positioning the chair slightly behind the nurse so that the seat faces the client’s bed
B. Placing the client’s left leg in front of the right leg just prior to the transfer
C. Aligning the nurse’s knees with the client’s knees just before the transfer
D. Grasping the client under the axillae to assist them to their feet
Answer: C. Aligning the nurse’s knees with the client’s knees just before the transfer.
Question: A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which action should the nurse take?
Answer Options: A. Wrap both arms around the client’s arms and shoulders
B. Move both feet together when the client begins to fall
C. Protect the client’s extremities while lowering them to the floor
D. Extend one leg and allow the client to slide down the leg to the floor
Answer: D. Extend one leg and allow the client to slide down the leg to the floor.