Transcript NCLEX-RN Exam Prep

NCLEX-RN Exam Prep
Entry-level RN
Congratulations!
Created by Professor
Jill Ray
Revised by Professor
Brenda Rowe
Types of Questions: The infamous “NCLEX
question”
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Multiple-choice
Fill in the Blank
usually a drug calculation, math problem
Multiple response
select all that apply. Note that these will be
clearly marked. The regular multiple-choice
won’t “let” you select more than one
response.
Drag & drop: order, sequence
Figure, illustration, hot spot
NCLEX-RN (1)
The nurse is completing the intake
and output record for a client who
had an abdominal cholecystectomy
2 days ago. The client has had the
following intake and output
during the shift.
Intake
4 oz of orange juice
½ serving of scrambled
eggs
6 oz of water
½ cup of fruit-flavored
gelatin
1 cup of chicken broth
400 cc of 0.45% sodium
chloride (half-strength
saline), IV
Output
1,000 ml of urine
120 ml of drainage from the
T-tube
How many milliliters should the
nurse document as the client’s intake?
Source: www.ncsbn.org
Signs and symptoms of postthyroidectomy respiratory obstruction vary with the
degree of severity. Which early sign(s) and symptoms (s) would the nurse expect
with pending respiratory distress? Select all that apply
1.
2.
3.
4.
5.
Hoarseness of voice
Stridor
Difficulty swallowing
Cyanosis
Choking sensation
Signs and symptoms of postthyroidectomy respiratory obstruction vary with the
degree of severity. Which early sign (s) and symptoms (s) would the nurse expect
with pending respiratory distress? Select all that apply
2.
Hoarseness of voice - common after this
surgery
Stridor - late
3.
Difficulty swallowing
4.
Cyanosis - late
1.
5.
Choking sensation
3&5
A patient is to receive a 250 mL unit of packed red blood cells to infuse
over two hours. The blood administration set has a drip factor of
10gtt/ml. What is the flow rate in drops per minute?
Answer:____________________________________
Pediatric:SMitchell:04.04
The nurse is preparing a staff education program about the stages of
childhood development. Place the stages listed below in ascending
chronological order. Use all the options.
Unordered Options
 Toddlers
 Adolescence
 Infancy
 School Age
 Preschooler
Source: www.ncsbn.org
Ordered Response
A heparin drip is being administered at a rate of 18
ml/hour. The bag of fluid has 25,000 units of heparin
in 500 ml of saline. How many units of heparin is the
client receiving per hour?
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900 units per hour (this mixture gives you 50
units of heparin in 1 ml. 50 units x 18 ml/hour
= 900 units/hour
The nurse is performing a cardiac assessment on a client. Identify the
area where the nurse should place the stethoscope to best auscultate
the mitral valve.
You enter your patient’s room and discover a fire. Place your actions in the
appropriate order.
Unordered Options
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Contain the fire.
Remove the patient
from the room.
Activate the alarm.
Extinguish the fire.
Ordered Response
Information: NCLEX-RN Including
Alternate Item Format Questions
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http://www.ncsbn.org
Test Taking Strategies
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Critical Thinking
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Creativity
Problem solving
Decision making
Never one right answer that is always correct
in every situation.
Select the safest nursing judgment among
the listed options.
General Test-taking Rules
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Identify the topic of the question
Select an answer by eliminating choices
Do not use background information unless
absolutely necessary.
Do not read into the question.
Remember this is TEXTBOOK NURSING.
Eliminating choices
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Once the choice is eliminated…don’t go back
to it!!!!!
Look for options that include same idea & the
eliminate – answer that is different is correct
A monoamine oxidase inhibitor is prescribed for the client. The nurse
instructs the client that which of the following is a sign/symptom of
toxicity related to the use of this medication?
1.
2.
3.
4.
Restlessness
Feeling of fatigue
Lack of energy
Lethargy
A monoamine oxidase inhibitor is prescribed for the client. The nurse
instructs the client that which of the following is a sign/symptom of
toxicity related to the use of this medication?
1.
2.
3.
4.
Restlessness
Feeling of fatigue
Lack of energy
Lethargy
Background information
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Find the question…what is it really asking?
Only use the background information if it is
needed to find the right answer.
Look for key word: best, first, initial, most
likely, least likely
A client with cardiac disease turns on his call light and tells
the nurse he is experiencing chest pain. What is the first
nursing action?
1.
2.
3.
4.
Begin oxygen administration
Listen to heart sounds for ectopic beats
Auscultate breath sounds and maintain airway.
Determine what the client was doing before onset of
pain.
A client with cardiac disease turns on his call light and tells
the nurse he is experiencing chest pain. What is the first
nursing action?
1.
2.
3.
4.
Begin oxygen administration
Listen to heart sounds for ectopic beats
Auscultate breath sounds and maintain airway.
Determine what the client was doing before onset of
pain.
Do not read into the question
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The information provided in the question is all you
need.
If you ask yourself, “What if….” you are reading into
the question.
Read the stem carefully before you read the answer
choices. Try to determine what the question is
asking before you read the answer choices.
If you can’t figure out what the question is asking –
then look to the alternatives for clues.
A GREAT NCLEX Review question…
A woman during the transition phase of labor
complains of lightheadedness and a tingling
sensation in her fingers. Which of the following
actions should the nurse take next?
1.
Have the woman breathe into a paper bag held
tightly against her mouth and nose.
2.
Encourage the woman to pant and blow with the
next contraction.
3.
Instruct the woman to take a cleansing breath and
refocus her concentration.
4.
Tell the woman to pant three times and exhale
against pursed lips.
What was going on with this pt?
She was in labor – but the s/s were of
hyperventilation…what do you do when
someone hyperventilates?
A woman during the transition phase of labor complains of
lightheadedness and a tingling sensation in her fingers. Which of
the following actions should the nurse take next?
1.
Have the woman breathe into a paper
bag held tightly against her mouth and
nose.
2.
Encourage the woman to pant and blow with
the next contraction.
Instruct the woman to take a cleansing breath
and refocus her concentration.
Tell the woman to pant three times and exhale
against pursed lips.
3.
4.
Textbook Nursing
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One patient….you have all the time in the
world for that one patient.
Do not rely on the experiences you have had
working as a nurse tech.
Pick the most right of the choices given.
More specific techniques…
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Are the answers a mix of Assessments and
Interventions?
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If so, do you have adequate assessment
information to intervene?
If all appropriate interventions – use Maslow to
select which is most appropriate to do first.
Note that if the situation described is an
emergency an intervention will most likely be the
correct response.
Pain….
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Psychosocial need…usually will address after
the physical needs are met.
The answer might be pain if
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Sudden increase in the level of pain (acute,
sudden pain)
Pain is not controlled by the pain med
The nurse prioritizes her morning schedule to assess which
of the following clients first?
1.
2.
3.
4.
A young adult with complaints of severe back pain.
An adult admitted to the unit with acute pancreatitis
complaining of unrelenting abdominal pain.
An older client who complains of foot and ankle pain.
A newly admitted client who complains of jaw pain and
indigestion.
The nurse prioritizes her morning schedule to assess which
of the following clients first?
1.
2.
3.
4.
A young adult with complaints of severe back pain.
An adult admitted to the unit with acute pancreatitis
complaining of unrelenting abdominal pain.
An older client who complains of foot and ankle pain.
A newly admitted client who
complains of jaw pain and
indigestion.
Psychosocial vs Physical Needs
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In general – eliminate the psychosocial
choices, then prioritize the physical
alternatives.
Use ABC’s to prioritize physical needs
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Airway
Breathing
Circulation
Watch out for tricks…
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Oxygen…Respiratory
Communication – avoid choices with “I”.
Many times there will be more than one right
answer…watch out for “which action should
the nurse take first…”; “Which of the
following is an early sign of …” etc.
A patient is admitted with a diagnosis of
ruptured abdominal aortic aneurysm.
Preoperatively, which goal is MOST
important for the nurse to include in the plan
of care?
1.
Fluid replacement
2.
Pain relief
3.
Emotional support
4.
Aerosol Treatment
1.
2.
3.
4.
Fluid replacement… physical or
psychosocial
Pain relief… physical or psychosocial?
Emotional support….physical or
psychosocial?
Aerosol therapy… physical or
psychosocial?
Absolute words
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All
Always
Every
Must
None
Never
Only
Delegation
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What tasks must be performed by an RN?
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What tasks are delegated to a NA, UAP,
CAN, CP?
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Teaching
Assessment
Most invasive interventions (irrigations…)
Routine, unchanging tasks.
What can an LPN, LVN do?
Pyramid Points
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Do not take antacids with meds
Do not crush enteric-coated and sustained-release
meds ( could have SR in the name)
Pt should never suddenly stop a med
Nurse never adjusts a med dose..
Pt avoid over-the-counter meds unless approved by
MD
Avoid alcohol & smoking
Never administer the med if order is difficult to read
or unclear.
Many patients have digestive problems asso with
milk products
Basic Care and Comfort
The nurse sees smoke coming from the nurse’s
lounge. Sequence her actions below in the order
in which they should be performed.
1.
1.
2.
3.
4.
Close the door to the nurses’ lounge.
Move the patients who are in the rooms closest to the
lounge to the other end of the hallway.
Ask the ward secretary to call a Code Red (fire).
Aim the fire extinguisher at the base of the fire and
sweep from side to side.
The nurse sees smoke coming from the nurse’s lounge. Sequence
her actions below in the order in which they should be
performed.
1.
2.
3.
4.
Close the door to the nurses’ lounge.
Move the patients who are in the rooms closest to
the lounge to the other end of the hallway.
Ask the ward secretary to call a Code Red (fire).
Aim the fire extinguisher at the base of the fire and
sweep from side to side.
2,3,1,4
2. Which of the following would require a nursing
intervention?
1.
2.
3.
4.
5.
The client’s family has brought in a blow-dryer just
purchased at Wal-Mart for her to use while in the
hospital.
A nursing student has unplugged the IMED pump as she
prepares to clean the device.
The client has brought in a two-prong extension cord so
that he can move his clock radio closer to his bed.
The CNA has used the unit’s three-prong extension cord
to plug in the intermittent pulsatile compression device
for an immobilized client. The cord is running along the
left side of the client’s bed.
The client was transferred to the acute care setting for
follow up treatment for chest pain. She has brought a
fan with her that she used at the long term care facility.
2. Which of the following would require a nursing intervention?
1.
*
2.
3.
* 4.
*
5.
*
The client’s family has brought in a blow-dryer just
purchased at Wal-Mart for her to use while in the hospital.
A nursing student has unplugged the IMED pump as she prepares to clean
the device.
The client has brought in a two-prong extension cord so that
he can move his clock radio closer to his bed.
The CNA has used the unit’s three-prong extension cord to
plug in the intermittent pulsatile compression device for an
immobilized client. The cord is running along the left side of
the client’s bed.
The client was transferred to the acute care setting for follow
up treatment for chest pain. She has brought a fan with her
that she used at the long term care facility.
1, 3, 4, & 5
1.
2.
3.
The client’s family has brought in a blow-dryer just
purchased at Wal-Mart for her to use while in the
hospital. Must be approved by facility…
A nursing student has unplugged the IMED pump as she
prepares to clean the device.
The client has brought in a two-prong extension cord so
that he can move his clock radio closer to his bed.
Three-prongs required on all electrical
devices.
4.
The CNA has used the unit’s three-prong extension cord
to plug in the sequential compression device for an
immobilized client. The cord is running along the left
side of the client’s bed. Must secure with
electrical tape.
5.
The client was transferred to the acute care setting for
follow up treatment for chest pain. She has brought a
fan with her that she used at the long term care facility
Must be approved by facility
3. Which actions described below would be appropriate
when caring for a client with a radioactive implant?
1. The RN organizes the client’s care so that all tasks are
done during one visit to the client’s room.
2. The RN delegates all tasks related to this client’s care to
the nurse extern (a senior nursing student) who is working
on her team.
3. The RN sits on the side of the bed as she informs the client
about lab results that are not “good”.
4. The RN wears a lead apron whenever she is in the client’s
room.
1.
The RN organizes the client’s care so that all tasks are
done during one visit to the client’s room.
Too much time in room
2.
The RN delegates all tasks related to this client’s care to
the nurse extern (a senior nursing student) who is
working on her team.
Inadequate knowledge base, experience
3.
The RN sits on the side of the bed as she informs the client about lab
results that are not “good”.
Too close!!!
4.
The RN wears a lead apron whenever she is in the
client’s room.
4. Physical restraints are being used to keep a
client from climbing out of bed. Which of the
following are true statements re: restraints?
1. Restraints can be ordered prn.
2. The MD order for restraints stands for the remainder of the
time the client is in the hospital. No further orders are
needed.
3. Skin integrity and neurovascular checks should be
performed every 30 minutes while the restraint is in place.
4. Restraints should be removed every four hours as the client
is assisted to perform ROM exercises.
1.
Restraints can be ordered prn.
NEVER! Must include type, client behavior that mandates, time
frame for use.
2.
The MD order for restraints stands for the remainder of
the time the client is in the hospital. No further orders
are needed.
Order must be renewed within a specified time frame.
3.
Skin integrity and neurovascular checks should be
performed every 30 minutes while the restraint is in
place.
4.
Restraints should be removed every four hours as the
client is assisted to perform ROM exercises.
Every two hours.
Which of the following is recommended in a
case of expected poisoning?
5.
1.
2.
3.
4.
Rush victim to the nearest Emergency
Department.
Induce vomiting, then call the Poison Control
Center.
Save all vomitus and deliver to the Poison
Control Center.
Induce vomiting immediately if a household
cleaner is the expected poison.
Which of the following is recommended in a
case of expected poisoning?
5.
1.
2.
3.
4.
Rush victim to the nearest Emergency
Department.
Induce vomiting, then call the Poison Control
Center.
Save all vomitus and deliver to the
Poison Control Center.
Induce vomiting immediately if a household
cleaner is the expected poison.
Which of the following clients would be
placed on airborne precautions?
6.
1.
2.
3.
4.
7 year old who is neutropenic.
22 year old who is HIV+.
18 year old with varicella (Chickenpox).
35 year old with MRSA.
Which of the following clients would be
placed on airborne precautions?
6.
1.
2.
3.
4.
7 year old who is neutropenic.
22 year old who is HIV+.
18 year old with varicella
(Chickenpox).
35 year old with MRSA.
Which of the following describes the proper
way to maintain droplet precautions during
client transport?
7.
1.
2.
3.
4.
A client on droplet precautions would never be
allowed to leave his room.
The nurse transporting the client should wear a
gown, glove, mask. The client is covered with a
sheet.
The client is required to wear a non-rebreathing
mask during transport.
The client should wear a mask during transport.
Which of the following describes the proper
way to maintain droplet precautions during
client transport?
7.
1.
2.
3.
4.
A client on droplet precautions would never be
allowed to leave his room.
The nurse transporting the client should wear a
gown, glove, mask. The client is covered with a
sheet.
The client is required to wear a non-rebreathing
mask during transport.
The client should wear a mask
during transport.
Which client described below would be at
highest risk of developing Anthrax?
8.
1.
2.
3.
4.
A postal worker with impetigo opens an envelope
with the Bacillus anthracis toxin inside.
A postman with COPD delivers a box that has
the Bacillus anthracis toxin inside.
A public high school lunch lady serves food that
has been contaminated with the Bacillus
anthracis.
A mother hugs her child after learning that the
child has Anthrax.
8.
Which client described below would be at
highest risk of developing Anthrax?
1. A postal worker with impetigo opens an
envelop with the Bacillus anthracis
toxin inside.
2.
3.
4.
A postman with COPD delivers a box that has
the Bacillus anthracis toxin inside.
A public high school lunch lady serves food that
has been contaminated with the Bacillus
anthracis.
A mother hugs her child after learning that the
child has Anthrax.
9.
The client has had 100 mg of Demerol
ordered IM. The medication is available in a
1 gm vial that contains 0.1gm/ml.
Administer ___ ml of medication.
100mg/xml = .1G/ml
100mg/xml = 100mg/1ml
1G=1000mg
.5G=500mg
4G=400mg
.
1G = Xmg?
.1G=100mg
X = 1 ml
10.
1.
2.
3.
4.
500 mg of Drug A has been ordered. This
medication is supplied as unscored 1gm
tablets. Which of the following actions is
indicated ?
Administer half a tablet.
Contact the MD.
Administer one tablet.
Hold the medication.
10.
500 mg of Drug A has been ordered. This
medication is supplied as unscored 1gm
tablets. Which of the following actions is
indicated ?
1.
Administer half a tablet.
2.
Contact the MD.
3.
4.
Administer one tablet.
Hold the medication.
11.
1.
2.
3.
4.
Which of the following is a true statement?
3 ml is the maximum amount that should be
administered into one IM site.
2 ml is the maximum amount that should be
administered into one sq site.
The tuberculin syringe holds 10 ml of solution.
Insulin may be administered using any 1 ml
syringe.
11.
1.
Which of the following is a true statement?
3 ml is the maximum amount that
should be administered into one
IM site.
2.
2 ml is the maximum amount that should be
administered into one sq site. 1ml
3.
The tuberculin syringe holds 10 ml of solution.
1ml
4.
Insulin may be administered using any 1 ml
syringe.
Only insulin syringes
12.
1.
2.
3.
4.
The 1000ml IV solution is to infuse over an
8 hour time period. Calculate drops per
minute if a minidrip or pedidrip(60 gtts/ml) is
being used.
50 gtts/minute
75 gtts/minute
100 gtts/minute
125 gtts/minute
12.
The 1000ml IV solution is to infuse over an
8 hour time period. Calculate drops per
minute if a minidrip or pedidrip(60 gtts/ml) is
being used.
3.
50 gtts/minute
75 gtts/minute
100 gtts/minute
4.
125 gtts/minute
1.
2.
13.
1.
2.
3.
4.
The MD has prescribed heparin sodium
(liquaemin) 1000 units per hour by
continuous IV infusion. The pharmacy
prepares the medication and delivers an IV
bag with 10,000 units per 100 ml. The
nurse sets the infusion pump at how many
ml per hr to deliver the prescribed dose?
10 ml/hr
15 ml/hr
20 ml/hr
25 ml/hr
The MD has prescribed heparin sodium
(liquaemin) 1000 units per hour by
continuous IV infusion. The pharmacy
prepares the medication and delivers an IV
bag with 10,000 units per 100 ml. The
nurse sets the infusion pump at how many
ml per hr to deliver the prescribed dose?
13.
1.
2.
3.
4.
10 ml/hr
15 ml/hr
20 ml/hr
25 ml/hr
100 units per ml. 100 units/1ml = 1000units/xml.
14.
1.
2.
3.
4.
A nurse in the Emergency Room discovers
an adult unconscious on the floor in the
waiting area. What action should she take
first?
Call a code.
Place the client in a supine position.
Use the head tilt method to open the airway.
Shake the client gently and shout, “Are you
OK?”.
14.
1.
2.
3.
4.
A nurse in the Emergency Room discovers
an adult unconscious on the floor in the
waiting area. What action should she take
first?
Call a code.
Place the client in a supine position.
Use the head tilt method to open the airway.
Shake the client gently and shout,
“Are you OK?”.
15.
1.
2.
3.
4.
Which of the following is not one of the
ABCDs of Basic Life Support?
Document the steps of the process.
Open the airway.
Assess for the pulse.
Attach the AED (Automatic External Defibrillator)
leads to the victim.
15.
1.
2.
3.
4.
Which of the following is not one of the
ABCDs of Basic Life Support?
Document the steps of the
process.
Open the airway.
Assess for the pulse.
Attach the AED (Automatic External Defibrillator)
leads to the victim.
16.
1.
2.
3.
4.
What is the appropriate
compression/ventilation ratio for one person
BLS (CPR)?
30 compressions to 1 ventilation
30 compressions to 2 ventilations
15 compressions to 1 ventilation
15 compressions to 2 ventilations.
16.
What is the appropriate
compression/ventilation ratio for one person
BLS (CPR)?
1.
30 compressions to 1 ventilation
2.
30 compressions to 2 ventilations
3.
4.
15 compressions to 1 ventilation
15 compressions to 2 ventilations.
17.
1.
2.
3.
4.
What is the proper way to check for a pulse
for a victim who is 4 years old?
Carotid artery
Cardiac apex
Brachial artery
Radial artery
17.
1.
2.
3.
4.
What is the proper way to check for a pulse
for a victim who is 4 years old?
Carotid artery
Cardiac apex
Brachial artery
Radial artery
Less than 1 year use the brachial; older than 1
year use the carotid.
18.
1.
2.
3.
4.
The Automatic External Defibrillator should
not be used on which of the following
clients?
58 year old male with Cardiovascular disease
72 year old female with a significant history of
CVA.
6 year old with asthma
28 year old with a history of a seizure disorder.
18.
The Automatic External Defibrillator should
not be used on which of the following
clients?
2.
58 year old male with Cardiovascular disease
72 year old female with a significant history of
CVA.
3.
6 year old with asthma
4.
28 year old with a history of a seizure disorder.
1.
Not recommended on:
• a child less than 8 years of age
• a child who weighs less than 25 kg.
19.
1.
2.
3.
4.
Which of the following is a true statement
about the nurse’s role in obtaining informed
consent?
The nurse who receives the client in the holding
area of the OR is responsible for obtaining
informed consent.
The nurse assigned to the client 24 hours before
the surgery is responsible for obtaining informed
consent for the surgical procedure.
The circulating nurse is responsible for obtaining
informed consent only if an outpatient surgical
procedure is performed.
The nurse is responsible for ensuring that
informed consent has been obtained by the MD
prior to the surgical procedure.
Which of the following is a true statement about
the nurse’s role in obtaining informed consent?
19.
1.
2.
3.
4.
The nurse who receives the client in the holding area of
the OR is responsible for obtaining informed consent.
The nurse assigned to the client 24 hours before the
surgery is responsible for obtaining informed consent for
the surgical procedure.
The circulating nurse is responsible for obtaining informed
consent only if an outpatient surgical procedure is
performed.
The nurse is responsible for ensuring
that informed consent has been
obtained by the MD prior to the surgical
procedure.
20.
1.
2.
3.
4.
When should NSAIDs be discontinued if a
client is scheduled for a surgical procedure?
2 weeks preop
48 hours preop
24 hours preop
6 hours preop
20.
When should NSAIDs be discontinued if a
client is scheduled for a surgical procedure?
1.
2 weeks preop
2.
48 hours preop
3.
4.
24 hours preop
6 hours preop
21.
1.
2.
3.
4.
The client has just experienced a wound
dehiscence. He tells the nurse that he felt
something “pop” and then began to
experience excruciating pain. Sequence the
actions the nurse should take in this
situation.
Notify the MD
Lower the client’s head.
Cover the area with a sterile saline dressing
Administer prn antiemetics.
The client has just experienced a wound dehiscence. He tells the nurse that he
felt something “pop” and then began to experience excruciating pain.
Sequence the actions the nurse should take in this situation.
1.
2.
3.
4.
Notify the MD
Lower the client’s head.
Cover the area with a sterile saline dressing
Administer prn antiemetics.
2,3,1,4
22.
1.
2.
3.
4.
Which of the following clients should not be
positioned in semi-Fowler’s position?
A client who is post op Laryngectomy
A client post op mastectomy
A client diagnosed with gastro esophageal reflux
disease
A client who has suffered a head injury
Which of the following nursing actions will facilitate
medical therapy for a client with COPD?
1.
2.
3.
4.
Limiting fluid intake to prevent volume
overload and heart failure.
Oral and endotracheal suctioning as
necessary.
Instructing the client in deep breathing and
coughing techniques and pursed-lip
exhalations.
Maintenance of bed rest and actvity
restrictions to reduce acidosis.
Which of the following nursing actions will facilitate
medical therapy for a client with COPD?
1.
2.
Limiting fluid intake to prevent volume
overload and heart failure.
Oral and endotracheal suctioning as
necessary.
3.
Instructing the client in deep
breathing and coughing techniques
and pursed-lip exhalations.
4.
Maintenance of bed rest and activity
restrictions to reduce acidosis.
22.
1.
2.
3.
Which of the following clients should not be
positioned in semi-Fowler’s position?
A client who is post op Laryngectomy
A client post op mastectomy
A client diagnosed with gastro
esophageal reflux disease
reverse trendelenburg
4. A client who has suffered a head injury
23.
1.
2.
3.
4.
The nurse is teaching a student nurse to
insert a nasogastic tube. Which of the
following describes the most appropriate
method to use to verify tube placement?
Insert 5-10 ml of air into the tube and listen for a
rush of air in the stomach.
Place the end of the tube in a glass of water and
assess for bubbling.
Aspirate gastric content to check for pH.
Obtain an X-ray.
23.
1.
2.
3.
The nurse is teaching a student nurse to
insert a nasogastic tube. Which of the
following describes the most appropriate
method to use to verify tube placement?
Insert 5-10 ml of air into the tube and listen for a
rush of air in the stomach.
Place the end of the tube in a glass of water and
assess for bubbling.
Aspirate gastric content to check for pH.
If use this method pH should be 4 or less
4. Obtain an X-ray.
Saunders states that radiography is most
reliable method to determine placement.
24.
1.
2.
3.
4.
The nurse is supervising a student as she
administers a tube feeding. The nurse
would intervene if she observed which of
the following:
The student nurse elevates the head of the bed
to 90 degrees.
The student nurse aspirates for residuals,
measures the residual, checks the pH of the
residuals, then discards the residuals.
The students nurse assesses for the presence of
bowel sounds.
The student nurse warms the feeding to room
temperature, then begins the feeding.
24.
1.
2.
3.
4.
The nurse is supervising a student as she
administers a tube feeding. The nurse
would intervene if she observed which of
the following:
The student nurse elevates the head of the bed
to 90 degrees.
The student nurse aspirates for
residuals, measures the residual,
checks the pH of the residuals, then
discards the residuals.
The students nurse assesses for the presence of
bowel sounds.
The student nurse warms the feeding to room
temperature, then begins the feeding.
25.
1.
2.
3.
4.
Which of the following medications could be
administered via a nasogastric tube?
Enteric coated ASA
Contact ER
Liquid Tylenol
Tussin SR
25.
Which of the following medications could be
administered via a nasogastric tube?
2.
Enteric coated ASA
Contact ER
3.
Liquid Tylenol
4.
Tussin SR
1.
26.
1.
2.
3.
4.
An endotracheal tube has just been
inserted. What action should be performed
first?
Assess for bilateral breath sounds
Call for a chest x-ray
Obtain an arterial blood gas
Administer prn for pain.
26.
1.
2.
3.
4.
An endotracheal tube has just been
inserted. What action should be performed
first?
Assess for bilateral breath sounds
Call for a chest x-ray
Obtain an arterial blood gas
Administer prn for pain.
27.
1.
2.
3.
4.
The nurse is supervising a student nurse as
she cares for a client with a chest tube to
water seal drainage via a Pleur-Evac
drainage system. Which action below
would necessitate an intervention by the
nurse?
The student nurse measures drainage by
emptying the contents of the Drainage Collection
Chamber.
The student nurse checks to ensure that the
drainage tubes are free of kinks.
The student nurse checks the water seal
chamber for bubbling.
The student nurse checks the fluid volume in the
suction control chamber.
27.
The nurse is supervising a student nurse as she
cares for a client with a chest tube to water seal
drainage via a Pleur-Evac drainage system.
Which action below would necessitate an
intervention by the nurse?
1.
The student nurse measures drainage by
emptying the content of the Drainage
Collection Chamber.
2.
3.
4.
The student nurse checks to ensure that the drainage
tubes are free of kinks.
The student nurse checks the water seal chamber for
bubbling.
The student nurse checks the fluid volume in the suction
control chamber.
28.
1.
2.
3.
4.
The nurse finds that the client’s Pleur-Evac
is cracked and leaking. The client’s
respiratory rate is 49 and he is complaining
of pain and severe “nervousness”. Which of
the following interventions should be
performed first?
Administer prn for anxiety/nervousness
Administer prn for pain
Place the chest tube in a bottle of sterile water.
Replace the damaged Pleur-Evac and reattach
the chest tube.
28.
1.
2.
3.
4.
The nurse finds that the client’s Pleur-Evac
is cracked and leaking. The client’s
respiratory rate is 49 and he is complaining
of pain and severe “nervousness”. Which of
the following interventions should be
performed first?
Administer prn for anxiety/nervousness
Administer prn for pain
Place the chest tube in a bottle of
sterile water.
Replace the damaged Pleur-Evac and reattach
the chest tube.
29. The client is to receive 0.1 mg of digoxin
(Lanoxin) IV. Digoxin comes in a
concentration of 0.5mg/2ml. The nurse
should administer how many milliliters?
1.
2.
3.
4.
0.2 m.
0.4 ml
2.2ml
2.5 ml
29. The client is to receive 0.1 mg of digoxin
(Lanoxin) IV. Digoxin comes in a
concentration of 0.5mg/2ml. The nurse
should administer how many milliliters?
1.
0.2 m.
2.
0.4 ml
3.
4.
2.2ml
2.5 ml
30. In preparing a client for a left lung
thoracentesis, how should the nurse position the
client?
1.
2.
3.
4.
Left lateral
Supine with arms over head
Prone without a pillow
Sitting forward with arms on bedside stand
30. In preparing a client for a left lung
thoracentesis, how should the nurse position the
client?
1.
2.
3.
4.
Left lateral
Supine with arms over head
Prone without a pillow
Sitting forward with arms on bedside
stand
31. A client is NPO and complains of thirst.
Which is the most appropriate nursing
intervention?
1.
2.
3.
4.
Provide frequent oral hygiene.
Offer ice chips frequently
Educate client about rationale for NPO
Provide client with newspaper for diversion
31. A client is NPO and complains of thirst.
Which is the most appropriate nursing
intervention?
Provide frequent oral hygiene.
Best intervention for given info.
2. Offer ice chips frequently
1.
Can’t change MD order.
3.
Educate client about rationale for NPO
Good idea…not the best choice
4.
Provide client with newspaper for diversion
Good idea…not best choice
32. A unlicensed assistive personnel (UAP) is caring for a
client with a nasogastric tube. Which of the following
interventions cannot be delegated to the UAP?
1.
2.
3.
4.
Repositioning the tube
Recording output
Documenting the color of drainage
Emptying the nasogastric bag.
32. A unlicensed assistive personnel (UAP) is caring for a
client with a nasogastric tube. Which of the following
interventions cannot be delegated to the UAP?
1.
Repositioning the tube
2.
Recording output
Documenting the color of drainage
Emptying the nasogastric bag.
3.
4.
33. A client with a nasogastric tube to suction begins to
complain of abdominal discomfort. Which intervention
would the nurse implement first?
1.
2.
3.
4.
Reposition the nasogastric tube
Check the function of the suction equipment
Irrigate the nasogastric tube
Call the physician
33. A client with a nasogastric tube to suction begins to
complain of abdominal discomfort. Which intervention
would the nurse implement first?
1.
Reposition the nasogastric tube
2.
Check the function of the suction
equipment
3.
Irrigate the nasogastric tube
Call the physician
4.
34. A client presents to the emergency department with upper
gastrointestinal bleeding and is in moderate distress. In planning
care, which nursing action would be the first priority for this client?
1.
2.
3.
4.
Thorough investigation of precipitating events
Insertion of a nasogastric tube and hematest of
emesis
Complete abdominal examination
Assessment of vital signs
34. A client presents to the emergency department with upper
gastrointestinal bleeding and is in moderate distress. In planning
care, which nursing action would be the first priority for this client?
1.
2.
3.
Thorough investigation of precipitating events
Insertion of a nasogastric tube and hematest of
emesis
Complete abdominal examination
Assessment of vital signs
ABC’s
4.
35. A client returns from surgery after a bowel
resection. Which of the nurse’s interventions has
the highest priority?
1.
2.
3.
4.
Administer intravenous fluids
Monitor vital signs frequently
Maintain the client’s NPO status
Assess client’s pain level
35. A client returns from surgery after a bowel
resection. Which of the nurse’s interventions has
the highest priority?
2.
Administer intravenous fluids
Monitor vital signs frequently
3.
Maintain the client’s NPO status
4.
Assess client’s pain level
1.
36. The nurse is preparing to administer an enema. The
nurse positions the client in the
1.
2.
3.
4.
Left lateral position with the right leg acutely
flexed
Right Sims’ position
Dorsal recumbent position
Right lateral position with the left leg acutely
flexed
36. The nurse is preparing to administer an enema. The
nurse positions the client in the
1.
2.
3.
4.
Left lateral position with the right leg
acutely flexed
Right Sims’ position
Dorsal recumbent position
Right lateral position with the left leg acutely
flexed
37. The client is about to undergo a lumbar puncture. The
nurse describes to the client that which of the following
positions will be used during the procedure?
1.
Side-lying with legs pulled up and the head
bent down onto the chest
2.
Side-lying with a pillow under the hip
3.
Prone with a pillow under the abdomen
4.
Prone in slight Trendelenburg’s position
37. The client is about to undergo a lumbar puncture. The
nurse describes to the client that which of the following
positions will be used during the procedure?
1.
Side-lying with legs pulled up and
the head bent down onto the chest
2.
Side-lying with a pillow under the hip
Prone with a pillow under the abdomen
Prone in slight Trendelenburg’s position
3.
4.
38. The client has had surgery to repair a fractured left
hip. The nurse obtains which of the following most
important items to use when repositioning the client from
side to side?
1.
2.
3.
4.
Abductor splint
Adductor splint
Bed pillow
Overhead trapeze
38. The client has had surgery to repair a fractured left
hip. The nurse obtains which of the following most
important items to use when repositioning the client from
side to side?
1.
Abductor splint
2.
Adductor splint
Bed pillow
Overhead trapeze
3.
4.
Preventing internal rotation of
leg…why?
39. Before administering an intermittent tube feeding
through a nasogastric tube, the nurse assesses for gastric
residual. The nurse understands that this procedure is
important to
1.
Confirm proper nasogastric tube placement
2.
Observe gastric contents
3.
Assess fluid and electrolyte status
4.
Evaluate absorption of the last feeding
39. Before administering an intermittent tube feeding
through a nasogastric tube, the nurse assesses for gastric
residual. The nurse understands that this procedure is
important to
1.
Confirm proper nasogastric tube placement
2.
Observe gastric contents
3.
Assess fluid and electrolyte status
4.
Evaluate absorption of the last
feeding
Which of the following statements explains why the foot
of the bed is elevated after vein-stripping surgery?
1.
2.
3.
4.
Decrease pain.
Aid venous return.
Increase blood supply to feet.
Make the client more comfortable.
Which of the following statements explains why the foot
of the bed is elevated after vein-stripping surgery?
1.
Decrease pain.
2.
Aid venous return.
3.
Increase blood supply to feet.
Make the client more comfortable
4.
40. The client is brought into the emergency room in ventricular
fibrillation. The advanced cardiac life support nurse prepares to
defibrillate by placing conductive gel pads on which part of the
chest?
1.
2.
3.
4.
To the upper and lower half of the sternum
To the right of the sternum just below the
clavicle and to the left of the precordium
To the right shoulder and in the back of the left
shoulder
Parallel between the umbilicus and the right
nipple
40. The client is brought into the emergency room in ventricular
fibrillation. The advanced cardiac life support nurse prepares to
defibrillate by placing conductive gel pads on which part of the
chest?
1.
To the upper and lower half of the sternum
2.
To the right of the sternum just below
the clavicle and to the left of the
precordium
3.
To the right shoulder and in the back of the left
shoulder
Parallel between the umbilicus and the right
nipple
4.