Week 1 Practice Questions

Question 1

A nurse is caring for a client and identifies an infiltration at the IV catheter site. What should the nurse do?

Answer 1

Stop the infusion
Remove the IV cath
Apply a sterile dressing
Elevate the extremity
Apply warm or cold compresses

Question 2

A nurse is planning care for a client who has hypernatremia. Which solution should the nurse plan to initiate?

Answer 2

Dextrose 5% in water

Question 3

A nurse is assessing a client who is receiving a blood transfusion. What finding is a manifestation of a hemolytic transfusion reaction?

Answer 3

Report of low-back pain

Question 4

A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device. What will the nurse instruct the client to do?

Answer 4

turn head in the opposite direction during insertion

Question 5

A nurse is caring for a client who has a prescription for one unit of packed RBCs. How long should the nurse be in the room to observe for a transfusion reaction?

Answer 5

the first 15 minutes

Question 6

A nurse is teaching a client who is on a low potassium diet. What should the nurse instruct the client to do?

Answer 6

avoid using salt substitutes when cooking

Question 7

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. What is a possible reason for this level?

Answer 7

client has NG tube to gastric suction

Question 8

A nurse is assessing a client who has a calcium level of 8.0 mg/dL. What finding should the nurse expect?

Answer 8

muscle tremors

Question 9

A nurse is caring for a client who has a single lumen central venous catheter. What should the nurse do when accessing the catheter?

Answer 9

use a 10 mL syringe to flush the catheter

Question 10

A nurse is developing a plan of care for a client who is postop. What should the nurse instruct the client to do to prevent pulmonary complications?

Answer 10

encourage the use of an incentive spirometer

Question 11

A nurse is caring for a client who is postop and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid what unsafe action?

Answer 11

massaging her legs

Question 12

A nurse is caring for a client who is postop following an open cholecystectomy. What action should the nurse take when caring for the client’s Jackson-Pratt (JP) drain?

Answer 12

expel air from the JP bulb after emptying to re-establish suction

Question 13

A nurse is teaching a client who is preop how to do deep breathing exercises and cough effectively after surgery. What will the nurse instruct the client to do?

Answer 13

splint the incision with a pillow to cough

Question 14

A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The client reports being nervous about surgery, last had food at 2330 the previous evening, and signed the surgical consent 2 days ago. What should the nurse do?

Answer 14

document the findings in the client’s medical record

Question 15

A nurse is assessing a client who is 48 hr postop following abdominal surgery. What should the nurse report to the provider?

Answer 15

yellow-green drainage on the surgical incision

Question 16

A nurse is caring for a client who just returned from the post anesthesia care unit with an IV infusion and a NG tube in place following abdominal surgery. What is a priority for the nurse to assess?

Answer 16

the surgical dressing

Question 17

A nurse is planning to perform a blood transfusion for a client. What should the nurse do?

Answer 17

Check vital signs before transfusion
Insert IV with a 20G needle
Check the expiration date of the blood product with a second nurse

Question 18

A client has a right subclavian central venous catheter. When reconnecting a new administration set, what instructions should the nurse give the client?

Answer 18

bear down while holding breath

Question 19

After receiving change-of-shift report, which client would the nurse assess first?

Answer 19

a client with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes

Question 20

An older adult client receiving enteral nutrition develops restless, agitation, and weakness. What laboratory result would the nurse report to the health care provider?

Answer 20

serum sodium 154 mEq/L

Question 21

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, what action is considered outside the nurse’s responsibilities?

Answer 21

Explaining the operative procedure, risks, and benefits

Question 22

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client’s blood pressure is 80/54. What action should the nurse take first?

Answer 22

stop the infusion of blood

Question 23

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. What action should the nurse take first?

Answer 23

discontinue the existing IV line

Question 24

A nurse is preparing to administer a unit of red blood cells. The nurse’s responsibility is to compare and verify the information on the blood label with the client’s info. What should the nurse use as a priority source of verification?

Answer 24

identification band