NURS 100 Assessment 5

Question 1

A nurse is assisting a massage therapist to identify the best client for massage therapy. Which of the following clients should the nurse recommend?

A. A client who is receiving anticoagulants following a mitral valve replacement
B. An older adult client who has osteoporosis
C. A client who has postpartum depression
D. A client who has a thrombophlebitis

Answer 1

C. A client who has postpartum depression

This client has the lowest risk for an adverse effect from a massage. Massage therapy can relax the mind, reduce anxiety & depression, and relieve pain.

Question 2

A nurse is completing a preoperative health history for a client who reports taking several herbal supplements. Which of the following herbal supplements is the priority for the nurse to report?

A. Ginkgo biloba
B. Echinacea
C. Valerian
D. Aloe vera

Answer 2

A. Gingko biloba

The greatest risk to this client is injury from bleeding.

Question 3

A nurse is assisting with teaching a newly licensed nurse about holistic nursing. Which of the following information should the nurse include? (Select all that apply.)

1. Use deep breathing to promote relaxation in clients
2. Encourage clients to use guided imagery to decrease pain
3. Apply essential oils to treat anxiety in clients
4. Treat one medical issue for clients at a time
5. Discourage family involvement in client care

Answer 3

1, 2, 3

Question 4

A nurse is planning complementary therapy for a client who has breast cancer. Which of the following treatments is a complementary therapy that the nurse can implement?

A. Massage therapy
B. Chemotherapy
C. Teletherapy
D. Brachytherapy

Answer 4

A. Massage therapy

Question 5

A nurse is caring for a client who asks about naturopathy. The nurse should include that which of the following is a component of naturopathy? (Select all that apply.)

1. Dietary supplements
2. Exercise
3. Establishing harmony between fire, water, air, earth, and sky
4. Traditional Chinese medicine
5. Homeopathy

Answer 5

1, 2, 4, 5

Question 6

A nurse is assisting with teaching a class about using holistic nursing interventions to care for clients. Which of the following information should the nurse include?

A. Holistic nurses use herbal supplements because they do not cause adverse effects
B. The goal of holistic nursing is to cure a client’s illness
C. Holistic nurses empower clients to actively participate in their own care
D. A holistic nurse discourages the use of prescribed medications for clients

Answer 6

C. Holistic nurses empower clients to actively participate in their own care

Question 7

A nurse is caring for a client who has a sunburn. The nurse should identify that which of the following herbal supplements is used to treat sunburns?

A. Green tea
B. Aloe vera
C. Lavender
D. Milk thistle

Answer 7

B. Aloe vera

Question 8

A nurse is assisting in recommending clients for chiropractic treatment. Which of the following clients should the nurse recommend?

A. A client who has a sinus infection
B. A client who has shoulder pain
C. A client who has appendicitis
D. A client who has heart failure

Answer 8

B. A client who has shoulder pain

Question 9

A nurse is assisting with providing an in-service for staff members about complementary and integrative health. Which of the following statements by a staff member indicates an understanding of the teaching?

A. “Scented oils might decrease discomfort”
B. “Natural substances do not have adverse effects”
C. “Acupressure and acupuncture are the same thing”
D. “Meditation involves the use of an electronic device to regulate body function”

Answer 9

A. “Scented oils might decrease discomfort”

Question 10

A nurse is caring for a client who is scheduled for an emergency appendectomy and reports increasing anxiety. Which of the following should the nurse make to implement a complementary health strategy?

A. “Try to take slow, deep breaths in and out”
B. “Would you like a prescription for an anti-anxiety medication?”
C. “Why are you feeling anxious”
D. “You’ll have that appendix out in no time, then you’ll feel better”

Answer 10

A. “Try to take slow, deep breaths in and out”

Question 11

A nurse is assisting with teaching a client about homeopathy. Which of the following client statements indicates an understanding of the teaching?

A. “Homeopathy uses traditional Chinese medicine to treat diseases”
B. “Homeopathy uses imagery to promote wellness”
C. “Homeopathy uses incantations to treat diseases”
D. “Homeopathy believes a substance that can cause a disease can also cure it”

Answer 11

D. “Homeopathy believes a substance that can cause a disease can also cure it”

Question 12

A nurse is caring for a client who is receiving palliative care. Which of the following non-pharmacological nursing interventions should the nurse provide the client?

A. Acupuncture
B. Acupressure
C. Chiropractic therapy
D. Therapeutic touch

Answer 12

D. Therapeutic touch

Question 13

A nurse is caring for a client who follows a vegan diet and reports lethargy. Which of the following interventions should the nurse implement?

A. Offer a massage with lavender oil
B. Request a prescription for vitamin B12 supplements
C. Give the client a cup of chamomile tea
D. Provide peppermint oil for the client to inhale

Answer 13

B. Request a prescription for vitamin B12 supplements

Question 14

A nurse is assisting with teaching a class about U.S. Food and Drug Administration (FDA) regulation of nutritional supplements. Which of the following information should the nurse include in the teaching?

A. A nutritional supplement can be applied topically
B. If a nutritional supplement contains natural products, it is considered safe
C. The FDA approves nutritional supplements for safety before they are placed on the market
D. A nutritional supplement contains at least one nutritional component

Answer 14

D. A nutritional supplement contains at least one nutritional component

Question 15

A nurse is assisting with an in-service for staff members about culturally competent care. Which of the following information should the nurse include about traditional Native American beliefs?

A. There should be a balance between yin and yang
B. Cupping is used to promote wellness
C. Use biofeedback to reduce stress
D. Music can produce healing energy

Answer 15

D. Music can produce healing energy

Question 16

A nurse is reinforcing teaching about traditional Chinese medicine (TCM) to a client. Which of the following statements by the client demonstrates an understanding of the teaching?

A. “I will take my blood pressure medication every morning”
B. “I will have my heart rate checked once a month”
C. “I will practice Tai Chi every day”
D. “I will weigh myself weekly”

Answer 16

C. “I will practice Tai Chi every day”

Question 17

A nurse is assisting with teaching a client, who has a history of alcohol use disorder and is to be discharged following cataract surgery, about non-pharmacological therapies. Which of the following client statements indicates an understanding of the teaching?

A. “I will take kava to reduce my eye pain”
B. “I will find a Rolfing practitioner to help decrease my alcohol cravings”
C. “I will practice meditating when I feel stressed”
D. “I will take niacin to promote healing for my eyes

Answer 17

C. “I will practice meditating when I feel stressed”

Question 18

A nurse is caring for a client who asks about using aromatherapy for nausea. Which of the following scents should then nurse recommend? (Select all that apply.)

1. Ginseng
2. Evening primrose
3. Peppermint
4. Ginger
5. Orange

Answer 18

3, 4, 5

Question 19

A nurse is explaining the practice of Ayurveda to a newly licensed nurse. The nurse should include that Ayurveda is based on establishing a balance between the body, mind, and spirit with which of the following elements? (Select all that apply.)

1. Earth
2. Sky
3. Darkness
4. Light
5. Water

Answer 19

1, 2, 5

Question 20

A nurse is teaching a client about food choices that promote immunity and healing. Which of the following foods is the best source of vitamin C?

A. 1 cup grapes
B. 1 cup strawberries
C. 1 cup sliced apple
D. 1 small banana

Answer 20

C. “I will practice meditating when I feel stressed”

Question 21

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity?

A. A client who has a respiratory infection
B. A client who has rheumatoid arthritis
C. A client who has impaired kidney function
D. A client who has hyperthyroidism

Answer 21

C. A client who has impaired kidney function

A decrease in the function of the kidneys can result in a buildup of medication metabolites

Question 22

A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action?

A. Intramuscular
B. Oral
C. Buccal
D. Intravenous

Answer 22

B. Oral

Question 23

A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take?

A. Administer the medication whenever the client reports specific manifestations, such as pain
B. Administer the medication at specific times until directed by health care provider
C. Administer the medication at regular intervals of 4 hr
D. Administer the medication within 30 min of the health care provider prescribing the medication

Answer 23

D. Administer the medication within 30 min of the health care provider prescribing the medication

Question 24

A nurse is preparing to administer an intradermal injection to a client. At which of the following degree angles should the nurse insert the needle?

A. 60 degree angle
B. 90 degree angle
C. 45 degree angle
D. 10 degree angle

Answer 24

D. 10 degree angle

Question 25

A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should the nurse take?

A. Mix the medication with the client’s feeding infusion
B. Flush the feeding tube with 10 mL of water prior to administration of the medication
C. Administer the medication to the client in a liquid form
D. Place the client in a supine position prior to administering the medication

Answer 25

C. Administer the medication to the client in a liquid form

Question 26

A nurse is performing a medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? (Select all that apply.)

1. Place the medication reconciliation form with the client’s transfer documents
2. Reinforce teaching about the medications to the client upon discharge
3. Add medications the client is no longer taking in the medication reconciliation
4. Include over-the-counter medications in the medication reconciliation
5. Compare the client’s home medications with prescribed discharge medications

Answer 26

1, 2, 4, 5

Question 27

A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications?

A. Verify the client’s identity using their diagnosis
B. Use one identifier to confirm the client’s identity
C. Use the client’s room number to identify the client
D. Have the client confirm their name and date of birth

Answer 27

D. Have the client confirm their name and date of birth

Question 28

A nurse is preparing to administer insulin to a client. Which of the following actions should the nurse take first?

A. Document the insulin administration
B. Assist with teaching the client about the insulin
C. Have a second nurse confirm the insulin dose
D. Monitor the client for adverse effects of the insulin

Answer 28

C. Have a second nurse confirm the insulin dose

Question 29

A nurse is preparing to administer medications to a preschooler. Which of the following information should the nurse keep in mind when administering medications to this client?

A. The dosage is calculated by height
B. The preschooler is unable to take capsules
C. Preschoolers receive the same amount of medication as adults
D. The deltoid muscle can be used to administered intramuscular injections

Answer 29

D. The deltoid muscle can be used to administered intramuscular injections

Question 30

A nurse is reviewing the pharmacokinetics of medications with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption? (Select all that apply.)

1. Age of the client
2. First pass effect
3. Lipid solubility of a medication
4. Route of administration
5. Metabolism of the medication

Answer 30

1, 3, 4

Question 31

A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take?

A. Repeat the least important information to the client
B. Have the client perform a return demonstration of the procedure
C. Provide the client with educational materials written at an 8th-grade reading level
D. Dim the lights in the client’s room before beginning the teaching

Answer 31

B. Have the client perform a return demonstration of the procedure

Question 32

A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary tract infection. Which of the following statements should the nurse make?

A. “You can expect to experience a rash while taking this medication”
B. “Natural supplements do not interact with antibiotics”
C. “This medication is used to treat a viral infection
D. “Finish the entire course of the prescription”

Answer 32

D. “Finish the entire course of the prescription”

Question 33

A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first?

A. Notify the client’s provider
B. Stop the vancomycin
C. Administer diphenhydramine to the client
D. Document the incident in the client’s chart

Answer 33

B. Stop the vancomycin

Question 34

A nurse is participating in a committee to reduce medication errors on a medical unit. Which of the following interventions should the nurse recommend? (Select all that apply.)

1. Mark the area around the automated medication dispensing system
2. Encourage the use of cell phones while dispensing medications
3. Override the automated medication dispensing system during emergencies
4. Provide the nurse administering medications with a vest
5. Double check dosages of high-alert medications

Answer 34

1, 4, 5

Question 35

A nurse is assisting with teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? (Select all that apply.)

1. Ask the client what they know about the nitroglycerin patch
2. Find out whether the client is able to pay for the medication
3. Determine the client’s ability to apply the patch
4. Check the client’s reading comprehension level
5. Use medical terminology to instruct the client about the patch

Answer 35

1, 3, 4

Question 36

A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include?

A. Use close-ended questions
B. Provide written material at a 9th-grade reading level
C. Use passive listening skills
D. Encourage the client to ask questions

Answer 36

D. Encourage the client to ask questions

Question 37

A nurse is preparing to administer medications to a client. The nurse should identify that which of the following factors contributes to medication errors?

1. The use of automated dispensing systems
2. Administering a generic medication
3. Administering medication outside of prescribed time intervals
4. Failing to administer a medication
5. Incorrect dose of the prescribed medication administered to the client

Answer 37

3, 4, 5

Question 38

A nurse is planning to use the teach-back method to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method?

A. Provide the client with an internet link to research the medications
B. Refer the client to the American Heart Association
C. Give the client written educational material about the medication
D. Ask the client to explain the information using their own words

Answer 38

D. Ask the client to explain the information using their own words

Question 39

A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include?

A. To convert g to mg, move the decimal point 3 places to the right
B. Liters is a unit of measurement for distance
C. The metric system uses fractions rather than decimals
D. Grains is used as a measurement of weight in the metric system

Answer 39

A. To convert g to mg, move the decimal point 3 places to the right

Question 40

A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include?

A. Place a new transdermal patch over the same site as an old patch
B. Apply no more than two transdermal patches at a time
C. Expect the transdermal medication to absorb rapidly
D. Wear clean gloves to apply the transdermal medication

Answer 40

D. Wear clean gloves to apply the transdermal medication

Question 41

A nurse is preparing to perform a capillary blood glucose test. Identify the sequence of steps the nurse should follow.

1. Cleanse puncture site
2. Document results
3. Apply blood sample onto test strip
4. Perform a quality control test
5. Perform hand hygiene
6. Check expiration date on test strips

Answer 41

6, 4, 5, 1, 3, 2

Question 42

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

A. The nurse initiates the feeding after aspirating 50 mL of gastric residual
B. The nurse irrigates the NG tube with tap water after feeding
C. The nurse administers the feeding through a syringe barrel by gravity
D. The nurse allows the client to rest in a supine position during feeding

Answer 42

D. The nurse allows the client to rest in a supine position during feeding

Question 43

A nurse is administering an enteral feeding through a client’s NG tube. Which of the following actions should the nurse take?

A. Keep the formula cold until instillation
B. Withhold the feeding the the residual volume is 150 mL
C. Cleanse the top of the can of formula with an alcohol wipe
D. Flush the tube with 30 mL of sterile water before the feeding

Answer 43

C. Cleanse the top of the can of formula with an alcohol wipe

Question 44

A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

A. Use a 20-gauge needle
B. Use a 1.8 mm (0.5 in) needle
C. Insert the need just below the acromion process
D. Insert the needle at a 15 degree angle

Answer 44

B. Use a 1.8 mm (0.5 in) needle

Question 45

A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin?

A. Cranberry juice
B. Aloe vera
C. Feverfew
D. Flaxseed

Answer 45

C. Feverfew

Feverfew suppresses platelet aggregation and places the client at risk for bleeding when taken with aspirin.

Cranberry juice potentially increases the risk of bleeding in clients who take warfarin.

Question 46

A nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make?

A. “Many herbal products have not undergone long-term testing for safety and efficacy”
B. “Herbal therapies have no benefits and will not help your discomfort”
C. “You should begin immediately as they will help you”
D. “There are no ill effects associated with the use of herbal therapies”

Answer 46

A. “Many herbal products have not undergone long-term testing for safety and efficacy”

Question 47

A nurse is caring for a client who is menopausal and asks the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make?

A. “Many herbal products have not undergone long-term testing for safety and efficacy”
B. “Herbal therapies have no benefits and will not help your discomfort”
C. “You should begin immediately as they will help you”
D. “There are no ill effects associated with the use of herbal therapies”

Answer 47

A. “Many herbal products have not undergone long-term testing for safety and efficacy”

Question 48

A nurse is teaching a class about safe medication administration. The nurse should include in the teaching that which of the following references are acceptable for safe medication administration?

1. A website that ends in .com
2. Published journals
3. Pharmacists
4. Physician’s Desk Reference
5. Pharmaceutical sales representatives

Answer 48

2, 3, 4

Question 49

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client’s ventrogluteal muscle?

A. 45 degrees
B. 60 degrees
C. 75 degrees
D. 90 degrees

Answer 49

D. 90 degrees

Question 50

A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse. Which of the following clients should the nurse suggest offering the therapy to?

A. Post-traumatic Stress Disorder
B. Schizophrenia
C. Pedophilia
D. Paranoid personality disorder

Answer 50

A. Post-traumatic Stress Disorder

Guided imagery is a recommended treatment to relieve the anxiety associated with PTSD. It is a complementary alternative therapy also used to treat sleep disorders, anxiety, and pain

Question 51

A nurse is teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. Which of the following instructions should the nurse include?

A. “Cover areas of excoriated skin with cream”
B. “Use hot water to sooth the lesions”
C. “Cover area with an occlusive dressing after application”
D. “Use the cream for a few days after the area has healed”

Answer 51

D. “Use the cream for a few days after the area has healed”

The client should continue to apply steroid cream to affected area for a few days after the area has healed to reduce the risk for reoccurrence

Question 52

A nurse is preparing to administer an intramuscular injection to a client. Which of the following actions should the nurse plan to take?

A. Recap the needle after administration
B. Use a needle that retracts
C. Dispose of the needle in a wastebasket
D. Break the needle before disposal

Answer 52

B. Use a needle that retracts

Question 53

A nurse is preparing to administer a rectal suppository to a client. In which of the following positions should the nurse place the client for insertion of the suppository?

A. Sim’s position
B. Prone position
C. Lying on the right side
D. Supine

Answer 53

A. Sim’s position

Question 54

A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching?

A. Shake the inhaler for 3 to 5 seconds
B. Rinse the mouth with mouthwash after inhaling the medication
C. Wait 2 min between inhalations
D. Press down twice on the MDI canister

Answer 54

A. Shake the inhaler for 3 to 5 seconds

The client only needs to wait 20 to 30 seconds between inhalations if receiving more than one inhalation of medication

Question 55

A nurse is preparing an in-service for coworkers about various herbal supplements clients might report using. The nurse should include in the presentation that which of the following herbal supplements is used to help the client lose weight?

A. Licorice
B. Feverfew
C. Comfrey
D. Ephedra

Answer 55

D. Ephedra

Question 56

A nurse is caring for a client who reports having chronic constipation. Which of the following herbal supplements should the nurse recommend?

A. Ginseng
B. Coenzyme Q-10
C. Cranberry juice
D. Flaxseed

Answer 56

D. Flaxseed

Question 57

A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide?

A. Wash the affected area with soap and water before applying cream
B. Increase intake of fluids while using this medication
C. The medication might cause temporary blurred vision
D. Apply the cream to large areas around the infection

Answer 57

A. Wash the affected area with soap and water before applying cream

Question 58

A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society’s phlebitis scale to assess the severity of phlebitis and documents the client’s phlebitis as a grade level 1. Which of the following assessment findings correlates with a grade level of 1?

A. Redness at the intravenous access site with pain
B. Red streaks on the affected extremity
C. Palpable venous cord in the affected extremity
D. Purulent drainage at the intravenous access site

Answer 58

A. Redness at the intravenous access site with pain

B is grade level 3, C is grade level 3, D is grade level 4

Question 59

A nurse is caring for a client who has a gastric ulcer. Which of the following herbal supplements should the nurse recommend?

A. Licorice
B. Feverfew
C. Comfrey
D. Ephedra

Answer 59

A. Licorice

Question 60

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

A. Report the incident to the charge nurse
B. Wash the area of the puncture thoroughly with soap and water
C. Complete an incident report
D. Go to employee health services

Answer 60

B. Wash the area of the puncture thoroughly with soap and water

Question 61

A nurse is preparing to administer Bisacodyl suppository to a client. Which of the following actions should the nurse take?

1. Don sterile gloves
2. Lubricate index finger
3. Use a rectal applicator for insertion
4. Position client supine with knees bent
5. Insert suppository just beyond internal sphincter

Answer 61

2, 5

Question 62

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse place to take?

1. Spread the cream over the lateral surface of both forearms
2. Apply to intact skin
3. Apply the medication an hour before the procedure begins
4. Cleanse the skin prior to procedure
5. Use a visual pain rating scale to evaluate effectiveness of the treatment

Answer 62

2, 3, 4, 5

Question 63

A nurse is providing teaching to a client who has psoriasis and a new prescription for the topical corticosteroid cream betamethasone valerate. Which of the following information should the nurse include in the teaching?

A. The medication should be applied in a thick layer to completely cover the lesions
B. The medication should be applied every 2 hours
C. Rubbing the medication vigorously into the lesions will increase its absorption
D. Wrapping plastic around the site can increase the medication’s effectiveness

Answer 63

D. Wrapping plastic around the site can increase the medication’s effectiveness

Question 64

A nurse is preparing to administer a metered dose inhaler (MDI) medication to a client. Which of the following actions should the nurse take?

A. Ask the client to inhale the medication quickly for 1 second
B. Shake the MDI prior to administration
C. Wash the MDI canister in warm water after each use
D. Ask the client to hold their breath for 2 seconds after inhalation

Answer 64

B. Shake the MDI prior to administration

Question 65

A nurse is caring for a client who has a delayed hypersensitivity reaction. The nurse should expect which of the following manifestations?

A. Bronchospasm
B. Serum sickness
C. Tissue damage at the site
D. Excessive mucus secretion

Answer 65

C. Tissue damage at the site

The nurse should expect manifestations of edema, induration, ischemia, and tissue damage at the site occurring hours to days after exposure.

Question 66

A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. The nurse notes the catheter site is warm and painful to touch. Which of the following actions should the nurse take?

A. Slow the IV infusion
B. Place the affected extremity below the level of the client’s heart
C. Place a pressure dressing over the IV site
D. Apply a warm compress to the IV site

Answer 66

D. Apply a warm compress to the IV site

Question 67

A nurse is reviewing new prescriptions for a client. The nurse should identify that which of the following abbreviations used y the provider indicates “to administer before meals”?

A. ac
B. DNR
C. Tx
D. NG

Answer 67

A. ac

Question 68

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse’s priority intervention?

A. Insert an IV line
B. Count the respiratory rate
C. Administer oxygen
D. Prepare equipment for intubation

Answer 68

B. Count the respiratory rate

Question 69

A nurse is teaching a group of young women about the use of oral contraceptives. The nurse should teach that taking which of the following herbal preparations reduces the effectiveness of this birth control method?

A. Ginseng
B. Gingko biloba
C. St. John’s wort
D. Saw palmetto

Answer 69

C. St. John’s wort

Question 70

A nurse is teaching a client who is to start taking warfarin about herbal supplements. The nurse should inform the client that which of the following herbal supplements can interact adversely with warfarin?

A. Valerian
B. Black cohosh
C. Echinacea
D. St. John’s wort

Answer 70

D. St. John’s wort

Question 71

A nurse is planning to administer an IM injection into a client’s deltoid muscle. Which of the following actions should the nurse take?

A. Inject the medication at a 90 degree angle
B. Inject a volume of less than 2 mL
C. Inject the medication 12.7 cm (5 in) below the client’s acromion process
D. Use a 21-gauce needle for the injection

Answer 71

A. Inject the medication at a 90 degree angle

Question 72

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?

A. “The spacer increases the amount of medication delivered to the oropharynx”
B. “The spacer increases the amount of medication delivered to the lungs”
C. “Inhale rapidly using the space with the MDI”
D. “Cover exhalation slots of the spacer with lips when inhaling”

Answer 72

B. “The spacer increases the amount of medication delivered to the lungs”

Question 73

A nurse is planning to administer ceftriaxone IM to an adult client. Which of the following actions should the nurse plan to take?

A. Administer the medication using a 5/8-inch needle
B. Administer the medication at a 45 degree angle
C. Administer the medication in the deltoid muscle
D. Administer the medication using a Z-track technique

Answer 73

D. Administer the medication using a Z-track technique

Z-track is used to reduce pain and prevent medication to leak into subcutaneous tissue

Question 74

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse that the client has phlebitis at the IV insertion site?

A. “The infusion rate has stopped, but the tubing is not kinked”
B. “The area surround the insertion site feels warm to the touch”
C. “There is fluid leaking around the insertion site”
D. “There is no blood return when the tubing is aspirated”

Answer 74

B. “The area surround the insertion site feels warm to the touch”

Question 75

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

A. Urticaria
B. Stridor
C. Vomiting
D. Hypotension

Answer 75

B. Stridor

Question 76

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client’s hospitalization. The client could rightfully sue the nurse for which of the following?

A. Battery
B. Assault
C. Malpractice
D. Abuse

Answer 76

C. Malpractice

Question 77

A nurse is providing teaching to a client who has a new prescription for levothyroxine for hypothyroidism. The nurse should instruct the client to avoid which of the following herbal supplements?

A. Saw palmetto
B. Cranberry
C. Soy
D. Garlic

Answer 77

C. Soy

Soy can reduce the effectiveness of the levothyroxine

Question 78

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

A. Mix the three medications together prior to administering
B. Dilute each medication with 10 mL of tap water
C. Maintain the head of the bed in a flat position for 30 min following medication administration
D. Flush the NG feeding tube with 30 mL of water immediately following medication administration

Answer 78

D. Flush the NG feeding tube with 30 mL of water immediately following medication administration

Question 79

A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include?

A. “Check your heart rate before each dose”
B. “Inspect your mouth for lesions daily”
C. “Use this medication to relieve an acute attack”
D. “Skip the morning dose if you do not have any symptoms”

Answer 79

B. “Inspect your mouth for lesions daily”

Question 80

A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy?

A. Encourage the client to verbalize questions
B. Insist the client take prescribed medications
C. Inform the client that the medication is the same as taken at home
D. Tell the client that refusal of the medication is considered noncompliance

Answer 80

A. Encourage the client to verbalize questions

Question 81

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

1. Elevate the extremity
2. Stop the infusion
3. Apply warm or cold compresses
4. Remove the IV catheter
5. Apply a sterile dressing

Answer 81

2, 4, 5, 3, 1

Question 82

A nurse is preparing an in-service about the various supplements clients might use. Which of the following herbal supplements should the nurse include as potentially increasing the anticoagulant effects of aspirin and other oral anticoagulants?

A. Valerian
B. Feverfew
C. Milk thistle
D. Saw palmetto

Answer 82

B. Feverfew

Question 83

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

A. The client reports numbness at the site
B. Purulent drainage is noted from the site
C. The vein appears cordlike
D. Skin over the site is sloughing

Answer 83

B. Purulent drainage is noted from the site

Question 84

A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take?

A. Recap the needle
B. Place the cap on the bedside table and slide the needle into the cap
C. Wrap the needle with gauze
D. Dispose of the needle uncapped

Answer 84

D. Dispose of the needle uncapped

Question 85

A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

A. Lethargy
B. Pallor
C. Tremors
D. Shallow respirations

Answer 85

A. Lethargy

Question 86

A nurse is teaching an adult client who has a low literacy level about self administration of a subcutaneous medication. Which of the following strategies should the use to promote the client’s understanding?

A. Simplify terms using acronyms
B. Ask the client to demonstrate the skill
C. Provide the client with written materials using large print
D. Provide a long teaching session

Answer 86

B. Ask the client to demonstrate the skill

Question 87

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier?

1. Client’s full name
2. Facility room number
3. Partner’s full name
4. Provider’s name
5. Facility-assigned ID number

Answer 87

1, 5

Question 88

A nurse is teaching a client about how to administer a topical medication. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse using?

A. Discussion
B. Role play
C. Question and answer
D. Return demonstration

Answer 88

D. Return demonstration

Question 89

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption?

A. Enteral
B. Intramuscular
C. Intravenous
D. Topical

Answer 89

C. Intravenous

Question 90

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?

A. At the client’s bedside before administration
B. In the area where the nurse obtained the medication
C. At the time of documentation
D. At the nurses’ station while reviewing the provider’s prescription

Answer 90

A. At the client’s bedside before administration

Question 91

A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?

A. Transdermal patch
B. Sublingual
C. Suspended-release
D. Topical ointment

Answer 91

B. Sublingual

Question 92

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

A. Tell the client to blow her nose gently before the instillation
B. Assist the client to a side-lying position
C. Hold the dropped 2 cm (1 in) above the naris
D. Instruct the client to stay in the same position for 2 min

Answer 92

A. Tell the client to blow her nose gently before the instillation

Question 93

A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow.

1. Inhale deeply and then exhale completely
2. Place her lips firmly around the mouthpiece
3. Breathe in deeply over 2-3 seconds while pushing down on the canister
4. Hold her breath for 10 seconds
5. Exhale slowly through pursed lips
6. Wait 60 seconds between each puff

Answer 93

1, 2, 3, 4, 5, 6

Question 94

A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis?

1. Erythema
2. Damp dressing
3. Throbbing
4. Warmth at insertion site
5. Streak formation

Answer 94

1, 3, 4, 5

Question 95

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

A. The nurse initiates the feeding after aspirating 50 mL of gastric residual
B. The nurse irrigates the NG tube with tap water after feeding
C. The nurse administers the feeding through a syringe barrel by gravity
D. The nurse allows the client to rest in a supine position during feeding

Answer 95

D. The nurse allows the client to rest in a supine position during feeding

Question 96

A nurse is teaching a class about herbal supplements that can decrease nausea. Which of the following supplements should the nurse include?

A. Garlic
B. Ginger
C. Echinacea
D. Cranberry

Answer 96

B. Ginger