1. A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level

checked. The client asks the nurse to explain the laboratory test. Which of the following is an

appropriate response by the nurse?

a. “This test will indicate if you are at risk for developing blood clots.”

b. “This test will determine if your heart is performing properly”

c. “This test will provide information about the function of your liver”

d. “This test is used to check how your kidneys are working”

2. A nurse is caring for a client who has prescription for morphine 5mg IM accidentally administers

the whole 10 mg from the single dose vial. Which of the following action should the nurse take

first?

a. Notify the client’s provider

b. report the incident to the pharmacy

c. complete an incident report

d. measure the client's respiratory rate

3. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values

places the client at risk for poor wound healing?

a. Serum albumin 3 g/dl

b. Total lymphocyte count 2400 mm3

c. HCT 42%

d. HGB 16g/dL

4. A nurse is preparing to check a client's blood pressure. Which of the following actions should the

nurse take?

a. Apply the cuff above the client’s antecubital fossa.

b. Use a cuff with a width that is about 60% of the client’s arm circumference

c. Have the client sit with his arm resting above the level of the heart

d. release the pressure on the clients arm 5 to 6 millimeters per second

5. A nurse is preparing to perform nasotracheal suctioning for a client. Which of the following is an

appropriate action for the nurse to take?

a. Hold the suction catheter with the clean non dominant hand

b. apply sectioning for 20 to 30 seconds

c. place the catheter in a location that is clean and dry for later use

d. use surgically sepsis when performing the procedure.

6. A nurse is documenting client care period which of the following abbreviations should the nurse

use?

a. “SS” for sliding scale

b. “BRP” for bathroom privileges

c. “OJ” for orange juice

d. “SQ” for subcutaneous

7. Her nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse

determines that the client's blood pressure is 158/96. which of the following actions should the

nurse take?

a. Ensure that the width of the BP cuff is 50% of the client’s upper arm circumference.

b. Reposition the client supine and recheck her BP

c. recheck the clients BP on her other arm for comparison

d. request that another nurse check the clients BP in 30 minutes

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8. A nurse is caring for a client who has lower left atelectasis. in which of the following positions

should the nurse place the client for postural drainage?

a. Supine and low-Fowler’s position

b. Right lateral in Trendelenburg position

c. Side lying with the right side of the chest elevated

d. Prone with pillows under the extremities

9. A nurse is receiving the prescription for a client who is experiencing dysphagia following a

stroke. Which of the following prescriptions should the nurse clarify?

a. Dietitian consult

b. Speech therapy referral

c. Oral suction at bedside

d. Clear liquids

10. A nurse is administering a large volume enema to a client. Identify the sequence of steps the

nurse should follow after preparation and lubricating the enema set.

a. Administer the enema solution (2)

b. remove the enema tube from the client's rectum (4)

c. wrap the end of the enema tube with a disposable tissue (5)

d. insert the enema tube into the client's rectum (1)

e. clamp the enema tube (3)

11. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the

following actions should the nurse take to verify proper placement of the tube?

a. Place the end of the NG tube in water to observe for bubbling

b. auscultate 2.5 centimeter above the umbilicus while injecting 15 mL of sterile water

c. assess the client's gag reflex

d. measure the pH of the gastric aspirate

12. A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the

following responses by the newly licensed nurse indicates an understanding of the teaching?

a. The client's age is part of the measurement

b. the scale measures 6 elements

c. the higher the score the higher the pressure ulcer risk

d. each element has a range of one to five points

13. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the

nurse take?

a. Clean the skin around the stoma with normal saline.

b. Secure the tracheostomy ties with one finger to fit snugly underneath

c. soak the outer cannula in warm tap water

d. use a cotton tip applicator to clean the inside of the inner cannula

14. A nurse is documenting in a client's medical record. Which of the following entries should the

nurse record?

a. Incision without redness or drainage

b. drink adequate amounts of fluid with meals

c. oral temperature slightly elevated at 0800

d. administered pain medication

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