What to do, what to do
Staying alive, staying alive
Keep it moving
Let's put our safety glasses on
Tube a lube
100
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A. urinary output of 20 mL/hour B. temperature of 37.6 degrees Celsius (99.6 degrees Fahrenheit) C. blood pressure of 100/70 mm Hg D. serous drainage on the surgical dressing
What is urinary output of 20 mL/h
100
The nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse and the nurse immediately calls for help. Which is the next nursing action? A. open the airway B. give the client oxygen C. start chest compressions D. ventilate with a mouth-to-mask device
What is start chest compressions?
100
The nurse is administering a cleansing enema to a client with fecal impaction. Before administering the enema, the nurse should place the client in which position? A. left Sims' position B. right Sims' position C. on the left side of the body with the head of bed elevated 45 degrees D. on the right side of the body, with the head of the bed elevated 45 degrees
What is left Sims position?
100
The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? A. initiate the intravenous line without the use of a pump B. contact the electrical maintenance department for assistance C. plug in the pump cord in the available plug above the room sink D. use an extension cord from the nurses' lounge for the pump plug
What is contact the electrical maintenance department for assistance?
100
The nurse is planning to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? A. position the client supine to assist in medication absorption B. aspirate the nasogastric tube after medication administration to maintain patency C. clamp the nasogastric tube for 30 to 60 minutes following administration of the medication D. change the suction setting to low intermittent suction for 30 minutes after medication administration
What is clamp the nasogastric tube for 30 to 60 minutes following administration of the medication
200
A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? A. pneumonia B. hypoxemia C. fluid imbalance D. pulmonary embolism
What is pneumonia?
200
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method? A. flexed position B. head tilt-chin lift C. jaw thrust maneuver D. modified head tilt-chin lift
What is jaw thrust maneuver
200
The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catherization performed through the femoral artery. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure? A. bed rest in high Fowler's position B. bed rest with bathroom privileges only C. bed rest with head elevation at 60 degrees D. bed rest with head elevation no greater than 30 degrees
What is bed rest with head elevation no greater than 30 degrees
200
The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? A. placing a safety knot in the safety device straps B. safely securing the safety device straps to the side rails C. applying safety device straps that do not tighten when force is applied against them D. securing so that two fingers can slide easily between the safety device and the client's skin
What is safely securing the safety device straps to the side rails
200
The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? A. mark the tube at 10 inches B. mark the tube at 32 inches C. place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process D. place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum
What is place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process?
300
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? A. obtain a court order for the surgery B. have the charge nurse sign the informed consent immediately C. send the client to surgery without the consent form being signed D. obtain a telephone consent from a family member following agency policy
What is obtain a telephone consent from a family member following agency policy
300
The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider (HCP)? A. one breath should be given for every five compressions B. Two breaths should given for every 15 compressions C. initially, two quick breaths should be given as rapidly as possible D. each rescue breath should be given over 1 second and should produce a visible chest rise
What is each rescue breath should be given over 1 second and should produce a visible chest rise
300
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? A. right side B. Low Fowler's C. High Fowler's D. supine with the head flat
What is high Fowler's?
300
Contact precautions are initiated for a client with a health-care associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A. gloves and gown B. gloves and goggles C. gloves, gown, and shoe protectors D. gloves, gown, goggles, and face shield
What is gloves, gown, goggles and face shield
300
The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? A. stridor B. occasional pink-tinged sputum C. respiratory rate of 24 breaths/minute D. a few basilar lung crackles on the right
What is stridor?
400
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? A. "If it's any help, everyone is nervous before surgery." B. "I will be happy to explain the entire surgical procedure to you." C. "Can you share with me what you've been told about your surgery?" D. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."
What is "Can you share with me what you've been told about your surgery?"
400
The nurse witnesses the collapse of a victim in her neighborhood and suspects cardiac arrest. Which action should the nurse take first? A. initiate rescue breathing B. begin giving chest compressions C. activate the emergency response system D. obtain an automated external defibrillator
What is activate the emergency response system
400
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? A. side lying on the operative side B. on the nonoperative side with the legs abducted C. side lying with the affected leg internally rotated D. side lying with the affected leg externally rotated
What is on the nonoperative side with the legs abducted
400
A mother calls a neighbor who is a nurse and tells the nurse that her 3 year old child has just ingested furniture polish. the nurse would direct the mother to take which immediate action? A. induce vomiting B. call an ambulance C. call the Poison Control Center D. bring the child to the emergency department
What is call the Poison Control Center?
400
THe nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action? A. quickly insert the tube B. notify the health care provider immediately C. remove the tube and reinsert when the respiratory distress subsides D. pull back on the tube and wait until the respiratory distress subsides
What is pull back on the tube and wait until the respiratory distress subsides
500
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. red, hard skin B. serous drainage C. purulent drainage D. warm, tender skin
What is serous drainage
500
The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)? A. 3/4 inch B. 1 inch C. 2 inches D. 3 inches
What is 2 inches?
500
A client has just returned to a nursing unit after an above the knee amputation of the right leg. The nurse should place the client in which position? A. prone B. reverse Trendelenburg's C. supine with the amputated limb flat on the bed D. supine, with the amputated limb supported with pillows
What is supine with the amputated limb supported with pillows
500
The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. The nurse should take which initial action? A. prepare the triage rooms B. activate the emergency response plan C. obtain additional supplies from the central supply department D. obtain additional nursing staff to assist in treating the casualties
What is activate the emergency response plan
500
The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. A. check the residual volume B. aspirate the stomach contents C. turn off the suction to the nasogastric tube D. remove the tube and place it in the other nostril E. test the stomach contents for a pH of less than 3.5.
What is check the residual volume, aspirate the stomach contents, turn off the suction to the nasogastric tube and test the stomach contents for a pH of less than 3.5
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