Preliminary Examination In Competency Appraisal

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1/75 Questions

A nurse is to administer promethazine (Phenergan®) 12.5 mg intramuscularly (IM) stat to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client?
- 0.125 mL
- 0.25 mL
- 0.3 mL
- 1 mL

About This Quiz

Aklan Polytechnic College
College of Nursing
1st Semester A. Y. 2020-2021
PRELIMINARY EXAMINATION
IN COMPETENCY APPRAISAL

Preliminary Examination In Competency Appraisal - Quiz

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2.

A nurse is preparing to provide phototherapy to a 4-day-old newborn who was admitted with hyperbilirubinemia. The nurse instructs the parents on how to care for their baby while receiving phototherapy in the hospital. The nurse’s teaching should include:
- Keeping the baby fully clothed to prevent hypothermia.
- Covering the baby’s eyes with eye shields to prevent retinal damage.
- Decreasing the number of feedings for their baby to reduce the number of soiled diapers.
- Discontinuing the phototherapy if a mild skin rash develops.
Correct Answer

A. Covering the baby’s eyes with eye shields to prevent retinal damage.

Explanation

The nurse should instruct the parents to cover the baby's eyes with eye shields to prevent retinal damage during phototherapy. Phototherapy involves exposing the baby's skin to special lights that help break down bilirubin, a substance that can build up and cause jaundice. However, the lights used in phototherapy can be harmful to the baby's eyes, so it is important to protect them with eye shields. This will help prevent any potential damage to the baby's retinas and ensure the safety and well-being of the newborn during treatment.

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3.

A client reports pain at an intravenous infusion site that has infiltrated. When a nurse applies a warm, moist compress to the site, the client asks how the treatment will help the condition. The nurse answers the client based on the understanding that the application of moist heat will:
- Alter tissue sensitivity by producing numbness.
- Decrease the metabolic needs of the involved tissues.
- Stop the local release of histamine in the tissues.
- Increase blood flow and improve capillary permeability.
Correct Answer

A. Increase blood flow and improve capillary permeability.

Explanation

The application of moist heat to an infiltrated intravenous infusion site will increase blood flow and improve capillary permeability. Moist heat helps to dilate blood vessels, which increases blood flow to the area. This increased blood flow can help to remove any accumulated fluid or medications that may be causing the infiltration. Additionally, improved capillary permeability allows for better exchange of oxygen, nutrients, and waste products between the blood vessels and the surrounding tissues, promoting healing and reducing inflammation.

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4.

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse assesses which priority item?
- Vital signs
- Skin color
- Urine output
- Latest hematocrit level
Correct Answer

A. Vital signs

Explanation

Before beginning a blood transfusion, it is important for the nurse to assess the patient's vital signs. This includes monitoring the patient's heart rate, blood pressure, respiratory rate, and temperature. Assessing vital signs can help the nurse determine if the patient is stable enough to receive the blood transfusion and can also help identify any potential complications or adverse reactions during the transfusion process. Therefore, assessing vital signs is a priority item before starting the transfusion.

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5.

A health-care agency has different receptacles for the various categories of institutional waste. Into which container should a nurse dispose of a suction canister used to collect drainage from a client’s nasogastric tube?
- Injurious waste receptacle
- Hazardous waste receptacle
- Infectious waste receptacle
- Wastebasket in the client’s bathroom
Correct Answer

A. Infectious waste receptacle

Explanation

The correct answer is the infectious waste receptacle. A suction canister used to collect drainage from a client's nasogastric tube would be considered infectious waste. This type of waste contains potentially harmful microorganisms and should be disposed of in a designated receptacle to prevent the spread of infection. The other options, such as the injurious waste receptacle, hazardous waste receptacle, or wastebasket in the client's bathroom, are not appropriate for disposing of infectious waste.

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6.

The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse continues to advance the catheter if:
- The catheter advances easily.
- The vein is distended under the needle.
- The client does not complain of discomfort.
- Blood return shows in the backflash chamber of the catheter
Correct Answer

A. Blood return shows in the backflash chamber of the catheter

Explanation

The nurse continues to advance the catheter if blood return shows in the backflash chamber of the catheter. This indicates that the catheter is properly inserted into the vein and blood is flowing through it. It is a positive sign that the catheter is in the correct position and can be secured in place.

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7.

A hospitalized client has daily weights ordered. The client is able to stand, and the nursing unit has an electronic digital scale to use for client weights. Which intervention best ensures that the client’s daily weight is accurate?
- Asking the client to wear supportive shoes before stepping on the scale
- Ensuring that the scale is calibrated and “zeroed” before a weight is obtained
- Weighing the client by moving the sliding indicator until the scale balances
- Weighing the client at different times of the day
Correct Answer

A. Ensuring that the scale is calibrated and “zeroed” before a weight is obtained

Explanation

To ensure that the client's daily weight is accurate, it is important to calibrate and "zero" the scale before obtaining a weight. This means that the scale should be adjusted to ensure that it is measuring accurately and that it starts at zero before the client steps on it. This helps to eliminate any potential errors or discrepancies in the weight measurement. Asking the client to wear supportive shoes, weighing the client by moving the sliding indicator, or weighing the client at different times of the day do not directly address the accuracy of the scale itself.

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8.

A client who was treated for constipation 1 month earlier comes to a primary care provider’s office for an appointment. A nurse interviews the client and obtains information from the client about bowel function and the effectiveness of the prescribed treatments. The nurse determines that the client is no longer constipated based on which statement?
- The client drinks 2,000 mL of fluids daily; including 4 ounces of prune juice.
- The client has had a soft, formed bowel movement without straining every other day for the past 2 weeks.
- The client self-administered one disposable enema the day of last month’s appointment.
- The client has minor discomfort from hemorrhoids during bowel movements.
Correct Answer

A. The client has had a soft, formed bowel movement without straining every other day for the past 2 weeks.

Explanation

The nurse determines that the client is no longer constipated based on the statement that the client has had a soft, formed bowel movement without straining every other day for the past 2 weeks. This indicates that the client's bowel movements are regular and normal, which is a sign of resolved constipation.

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9.

A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client?
- If ambulating 10 times daily for 5 minutes at a time, wearing the hose is unnecessary.
- The most appropriate time to apply the hose is before standing to get out of bed in the morning.
- If the hose becomes painful to the skin underneath, notify the nurse and request pain medication.
- Only cross the legs while wearing the antiembolism hose; otherwise keep the legs uncrossed.
Correct Answer

A. The most appropriate time to apply the hose is before standing to get out of bed in the morning.

Explanation

The most appropriate time to apply the hose before standing to get out of bed in the morning is the correct answer because it ensures that the client has the stockings on before any potential risk of thromboembolic disease occurs. Applying the stockings in the morning helps to prevent blood clots from forming while the client is inactive during sleep and prepares them for any activity throughout the day.

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10.

A 33-year-old client reports left leg pain, right-sided chest pain, and a sudden onset of shortness of breath. Which action should be taken immediately by the nurse?
- Take the client’s temperature
- Auscultate the client’s the lung sounds
- Percuss the client’s abdomen
- Request a stat chest x-ray
Correct Answer

A. Auscultate the client’s the lung sounds

Explanation

The client's symptoms of left leg pain, right-sided chest pain, and sudden onset of shortness of breath suggest a potential pulmonary embolism, which is a blockage in the pulmonary artery. Auscultating the client's lung sounds can help the nurse assess for any abnormal breath sounds, such as decreased or absent breath sounds on one side, which could indicate a pulmonary embolism. This action is crucial in identifying and addressing the client's condition promptly.

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1
11.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 PM. The nurse making rounds at 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
- Call the physician.
- Slow the IV infusion.
- Sit the client up in bed.
- Remove the IV catheter.
Correct Answer

A. Slow the IV infusion.

Explanation

The client's symptoms, including headache, dyspnea, chills, apprehension, and increased pulse rate, are indicative of a potential adverse reaction to the IV infusion. Slowing down the infusion rate can help alleviate these symptoms and prevent further complications. Calling the physician may be necessary, but addressing the immediate symptoms should be the first action. Sitting the client up in bed and removing the IV catheter are not appropriate actions for this situation.

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12.

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which of the following items is important to check regarding the age of blood cells before the transfusion is begun?
- Expiration date
- Presence of clots
- Blood group and type
- Blood identification number
Correct Answer

A. Expiration date

Explanation

The expiration date is important to check regarding the age of blood cells before the transfusion is begun because blood cells start to deteriorate after a certain period of time. If the blood cells have expired, they may not be as effective or safe for transfusion.

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13.

A client who underwent a surgical procedure the preceding day has a normal assessment with an oral temperature of 99.7°F (37.6°C) at 0800 hours. The client is to be discharged later in the day if the client’s condition is stable. Based on the client’s current temperature, which action should be taken by the nurse?
- Inform the surgeon since the discharge should be cancelled.
- Instruct the client to use the incentive spirometer 10 times every hour and drink plenty of fluids and then recheck the temperature in 2 hours
- Administer the dose of aspirin 81 mg earlier than the scheduled time
- Realize that the temperature is only mildly elevated and was taken during the time of day when temperatures are highest according to normal diurnal deviations
Correct Answer

A. Instruct the client to use the incentive spirometer 10 times every hour and drink plenty of fluids and then recheck the temperature in 2 hours

Explanation

The client's temperature of 99.7°F (37.6°C) is only mildly elevated and may be due to normal diurnal deviations, as temperatures are highest during certain times of the day. Therefore, there is no need to cancel the discharge or administer aspirin. Instructing the client to use the incentive spirometer and drink plenty of fluids can help promote lung expansion and prevent complications such as atelectasis. Rechecking the temperature in 2 hours will provide a better assessment of the client's condition and help determine if they are stable for discharge.

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4
14.

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse asks which initial question?
- “Have you ever had a transfusion before?”
- “Why do you think that you need the transfusion?”q
- “Have you ever gone into shock for any reason in the past?”
- “Do you know the complications and risks of a transfusion?”
Correct Answer

A. “Have you ever had a transfusion before?”

Explanation

The nurse asks the initial question, "Have you ever had a transfusion before?" to assess the client's previous experience with transfusions. This information is important to determine if the client has any known allergies or adverse reactions to blood products. It also helps the nurse to anticipate any potential complications or risks based on the client's previous transfusion history. By obtaining this information, the nurse can provide appropriate education and support to the client before the procedure.

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15.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next?
- Remove the intravenous (IV) line.
- Run a solution of 5% dextrose in water.
- Run normal saline at a keep-vein-open rate.
- Obtain a culture of the tip of the catheter device removed from the client.
Correct Answer

A. Run normal saline at a keep-vein-open rate.

Explanation

After stopping the transfusion, the next immediate action should be to run normal saline at a keep-vein-open rate. This is done to maintain the patency of the IV line and ensure that the client continues to receive fluid and medication. Running normal saline at a keep-vein-open rate helps to prevent blood clotting in the IV line and maintains the client's hydration status. It is important to address the transfusion reaction, but ensuring that the client's IV line remains open and functional is a priority to prevent further complications.

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16.

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client’s blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client’s temperature is 100.8 F orally from a baseline of 99.2 F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
- Septicemia
- Hyperkalemia
- Circulatory overload
- Delayed transfusion reaction
Correct Answer

A. Septicemia

Explanation

The client may be experiencing septicemia as a complication of the blood transfusion. Septicemia is a severe infection that occurs when bacteria or other infectious organisms enter the bloodstream. The client's symptoms of vomiting, decreased blood pressure, and elevated temperature suggest an infection. These symptoms are consistent with septicemia rather than the other options listed.

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8
17.

Which rationale should a nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving 2 liters of oxygen by nasal cannula?
- Prevents the burning sensation of direction oxygen
- Prevents drying of the nasal passages
- Prevents a chemical reaction between the tubing and oxygen
- Prevents contamination with environmental gases
Correct Answer

A. Prevents drying of the nasal passages

Explanation

Bubbling oxygen through a humidifier prevents drying of the nasal passages. Oxygen therapy can cause dryness and irritation in the nasal passages, which can lead to discomfort for the client. By passing the oxygen through a humidifier, moisture is added to the oxygen, ensuring that the nasal passages stay hydrated and preventing dryness. This helps to improve the client's comfort and overall well-being during oxygen therapy.

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18.

A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers the supplies and prepares the sterile field using a packaged sterile drape. Which option correctly describes how the nurse should set up the sterile field?
- Donning sterile gloves before opening the packaged sterile drape
- Cleansing the bottle of irrigating solution with alcohol before placing the bottle on the field
- Holding items 6 inches above the field and dropping them on the sterile field inside the 1-inch border along the edge of the drape
- Leaving the sterile field unattended to obtain supplies not in the area
Correct Answer

A. Holding items 6 inches above the field and dropping them on the sterile field inside the 1-inch border along the edge of the drape

Explanation

The nurse should hold items 6 inches above the field and drop them onto the sterile field inside the 1-inch border along the edge of the drape. This technique helps to prevent contamination of the sterile field by minimizing the risk of contact between non-sterile items and the sterile field. By holding items above the field, the nurse ensures that they do not come into direct contact with the potentially contaminated surface. Dropping them inside the 1-inch border along the edge of the drape further reduces the risk of contamination by keeping the items within the sterile area.

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19.

A nurse is caring for a client who is unable to perform oral hygiene. The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- Don sterile gloves before removing the dentures.
- Use a foam swab to pry the upper plate loose before removing it.
- Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal.
- Leave the dentures in the client’s mouth and use a toothbrush to brush the plates.
Correct Answer

A. Loosen the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal.

Explanation

The nurse should use the technique of loosening the upper plate by grasping it at the front teeth with a piece of gauze and moving the plate up and down to loosen it prior to removal. This technique ensures that the denture is loosened properly and can be safely removed without causing any discomfort or injury to the client. Using a foam swab or leaving the dentures in the client's mouth while brushing is not the correct technique for performing oral hygiene in this case. Donning sterile gloves before removing the dentures is not necessary for this procedure.

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2
20.

A nurse understands that which of the following is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider?
- One breath should be given for every five compressions.
- Two breaths should be given for every 15 compressions.
- Initially, two quick breaths should be given as rapidly as possible.
- Each rescue breath should be given over 1 second and should produce a visible chest rise.
Correct Answer

A. Each rescue breath should be given over 1 second and should produce a visible chest rise.

Explanation

Each rescue breath should be given over 1 second and should produce a visible chest rise. This guideline for adult CPR is correct because it ensures that the rescue breath is given with enough time and force to properly inflate the lungs and create a visible rise in the chest. This is important for effective oxygenation during CPR. Giving one breath for every five compressions or two breaths for every 15 compressions may not provide adequate ventilation, and initially giving two quick breaths as rapidly as possible may not allow for proper inflation of the lungs.

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1
21.

A home health nurse visits an 82-year-old client who has experienced multiple strokes and is unable to change position independently in bed. The nurse teaches family caregivers techniques to move and reposition the client, who is in a hospital bed. Which technique should be included in the teaching plan for this client?
- Before moving the client, family caregivers should raise the hospital bed to the level of their waists. After completing the move, the bed must be returned to the lowest level.
- The pillow should be removed from under the client’s head when positioned in a dorsal recumbent position.
- Family members should tighten their abdominal muscles and buttocks while keeping their feet about 12 inches apart when using a lift sheet to pull the client up in bed.
- The client’s heels should rest on the bed surface and feet kept in a position perpendicular to the legs when the client is lying on the back.
Correct Answer

A. Before moving the client, family caregivers should raise the hospital bed to the level of their waists. After completing the move, the bed must be returned to the lowest level.

Explanation

When moving and repositioning a client who is unable to change position independently, it is important to raise the bed to the level of the caregiver's waist. This helps to maintain proper body mechanics and prevents strain or injury to the caregiver's back. After completing the move, the bed should be returned to the lowest level to ensure the client's safety and comfort. This technique promotes proper body alignment and reduces the risk of falls or pressure ulcers.

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22.

A nurse instructs a client on safe disposal of insulin syringes and needles when at home. Which statement by the client indicates that additional teaching is needed?
- “After I draw up my insulin, I scoop the cap to cover it while I cleanse my skin.”
- “I have a needle destruction device that breaks the needles from the syringes so that others won’t get stuck by the needles.”
- “I plan to use this plastic milk container to discard my used needles and syringes and take it to the clinic for disposal.”
- “Because the needles are capped, the syringes are safe to dispose of with my household trash.”
Correct Answer

A. “Because the needles are capped, the syringes are safe to dispose of with my household trash.”

Explanation

The client's statement that the needles are safe to dispose of with household trash indicates a lack of understanding about proper disposal of insulin syringes and needles. Needles should never be disposed of in regular household trash because they can pose a risk of injury to others. Proper disposal methods include using a needle destruction device, placing the used needles and syringes in a puncture-proof container, or taking them to a clinic for proper disposal.

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23.

A nurse is discussing hearing aids with a client who began wearing hearing aids 5 weeks earlier. Which statement demonstrates that the client is successfully adapting to the hearing aids?
- “I just wear the hearing aids when I go out in public.”
- “I take a cotton-tipped swab and clean out my ear canals before I insert the hearing aids.”
- “I store the hearing aids in the protective box.”
- “I use mild soap and water weekly to soak the plastic parts of the hearing aids after I remove the batteries.”
Correct Answer

A. “I store the hearing aids in the protective box.”

Explanation

The statement "I store the hearing aids in the protective box" demonstrates that the client is successfully adapting to the hearing aids because it shows that the client understands the importance of properly storing the hearing aids when they are not in use. Storing the hearing aids in a protective box helps to prevent damage and prolong their lifespan. This indicates that the client is taking responsibility for the care and maintenance of their hearing aids, which is an important part of successfully adapting to them.

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7
24.

A nurse is caring for a client who has experienced a first-degree sprain of the ankle. A primary care provider writes a prescription for an analgesic medication. Which intervention, beside the analgesic, should the nurse advise the client to utilize for the first 24 hours after the injury?
- Applying ice directly to the ankle
- Soaking the foot in warm water for 20 minutes, three times per day
- Applying ice continuously to the ankle
- Resting and elevating the limb as much as possible
Correct Answer

A. Resting and elevating the limb as much as possible

Explanation

Resting and elevating the limb as much as possible is the appropriate intervention for the first 24 hours after a first-degree sprain of the ankle. This helps to reduce swelling and pain by promoting blood flow away from the injured area. Applying ice directly to the ankle can also help reduce swelling and pain, but it should not be done continuously as it can cause tissue damage. Soaking the foot in warm water is not recommended as it can increase swelling.

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3
25.

A physician has written a prescription to discontinue an intravenous (IV) line. The nurse obtains which of the following supplies from the unit supply area for applying pressure to the site after removing the IV catheter?
- Elastic wrap
- Betadine swab
- Adhesive bandage
- Sterile 2x2 gauze
Correct Answer

A. Sterile 2x2 gauze

Explanation

The physician has ordered to discontinue the IV line, which means that the IV catheter will be removed from the patient's site. After removing the catheter, the nurse needs to apply pressure to the site to prevent bleeding and promote clotting. Sterile 2x2 gauze is the most appropriate supply for this purpose as it can be used to apply direct pressure to the site and absorb any blood or fluids. Elastic wrap, Betadine swab, and adhesive bandage are not suitable for applying pressure and are not necessary for this procedure.

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1
26.

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?
- 5 minutes
- 15 minutes
- 30 minutes
- 45 minutes
Correct Answer

A. 15 minutes

Explanation

The nurse needs to stay with the client for approximately 15 minutes to ensure that a transfusion reaction is not occurring. This is because most transfusion reactions occur within the first 15 minutes of starting the transfusion. By closely monitoring the client during this time, the nurse can quickly identify any signs or symptoms of a reaction and take appropriate action.

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27.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred?
- Infection
- Phlebitis
- Infiltration
- Thrombosis
Correct Answer

A. Infiltration

Explanation

The nurse concludes that infiltration has occurred. Infiltration refers to the unintentional leakage of IV fluid into the surrounding tissue. The cool, pale, and swollen IV site indicates that the fluid is not properly infusing into the vein and is instead accumulating in the tissue. This can be caused by dislodgement of the IV catheter or improper placement, leading to fluid accumulation in the tissue. Infiltration can cause discomfort, tissue damage, and compromise the effectiveness of the IV therapy. Prompt intervention, such as discontinuing the IV and applying warm compresses, is necessary to prevent further complications.

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28.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the exposed tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?
- Obtain new IV tubing.
- Attach a new needleless device.
- Wipe the distal end of the tubing with Betadine.
- Scrub the needleless device with an alcohol swab.
Correct Answer

A. Obtain new IV tubing.

Explanation

The appropriate action by the nurse is to obtain new IV tubing. This is because when the exposed tubing drops and hits the top of the medication cart, it can become contaminated. To ensure patient safety and prevent the risk of infection, it is necessary to replace the IV tubing with a new, uncontaminated one.

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29.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that the rationale for transfusing fresh-frozen plasma in this client is:
- To treat the loss of platelets
- To promote rapid volume expansion
- That the transfusion must be done slowly
- That it will increase the hemoglobin and hematocrit levels
Correct Answer

A. To promote rapid volume expansion

Explanation

Fresh-frozen plasma is prescribed and transfused to promote rapid volume expansion in a client who has experienced blood loss due to an arterial laceration. This is because fresh-frozen plasma contains various clotting factors, proteins, and electrolytes that help increase the volume of circulating blood and restore the body's fluid balance. By rapidly expanding the volume, fresh-frozen plasma helps to stabilize the client's blood pressure and prevent further complications associated with hypovolemia.

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3
30.

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer?
- Partial-thickness skin loss involving the epidermis, dermis, or both
- Full-thickness skin loss involving damage to subcutaneous tissue
- Redness with intact skin that client reports as “itchy”
- Full-thickness skin loss with undermining and sinus tracks
Correct Answer

A. Full-thickness skin loss involving damage to subcutaneous tissue

Explanation

The best description of a stage III pressure ulcer is full-thickness skin loss involving damage to subcutaneous tissue. This means that the ulcer has progressed beyond the epidermis and dermis, and has reached the layer of tissue beneath the skin. The presence of damage to the subcutaneous tissue indicates that the ulcer is at a more advanced stage and requires appropriate treatment and care.

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31.

The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced:
- Phlebitis of the vein
- Infiltration of the IV line
- Hypersensitivity to the IV solution
- Allergic reaction to the IV catheter material
Correct Answer

A. Phlebitis of the vein

Explanation

The nurse notes that the client's peripheral IV catheter site is showing signs of inflammation, including redness, warmth, pain, and slight swelling proximal to the insertion point. These symptoms are indicative of phlebitis, which is the inflammation of a vein. Phlebitis can occur as a result of mechanical irritation from the catheter or chemical irritation from the IV solution. The nurse's documentation of phlebitis suggests that the client's symptoms are likely due to inflammation of the vein rather than other possibilities such as infiltration, hypersensitivity to the IV solution, or an allergic reaction to the catheter material.

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32.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which of the following?
- Increased hematocrit level
- Increased hemoglobin level
- Decline of elevated temperature to normal
- Decreased oozing of blood from puncture sites and gums
Correct Answer

A. Decreased oozing of blood from puncture sites and gums

Explanation

The client is benefiting most from the platelet transfusion if they exhibit a decreased oozing of blood from puncture sites and gums. Platelets are responsible for clotting and preventing excessive bleeding. Therefore, a decrease in oozing of blood indicates that the platelet transfusion has been effective in improving the client's clotting function. Increased hematocrit and hemoglobin levels may indicate improved red blood cell function, but they are not directly related to the benefits of platelet therapy. The decline of an elevated temperature to normal is not specifically related to platelet transfusion.

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33.

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with:
- An air vent.
- An in-line filter.
- A microdrip chamber.
- Tinted tubing to protect the blood from light
Correct Answer

A. An in-line filter.

Explanation

The nurse selects tubing with an in-line filter because it is specifically designed for blood products. An in-line filter helps to remove any potential contaminants or particles from the blood before it reaches the client. This ensures the safety and integrity of the transfusion, preventing any harm or adverse reactions to the client. The other options, such as an air vent, microdrip chamber, or tinted tubing, do not serve the same purpose of filtering the blood and ensuring its purity.

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34.

A new clinic nurse is teaching the mother of a 2-year-old child how to administer ear drops while an experienced nurse is observing. The new nurse is using an illustration of a child’s ear to teach the mother and states the following actions while pointing to the picture: clean the child’s ear, warm the solution, pull the child’s ear up and back, instill the medication, depress on the tragus of the ear, keep the child side-lying for about 5 minutes, and then insert a small cotton fluff loosely in the auditory canal for about 20 minutes. Which action should the experienced nurse take during or following the teaching?
- Suggest to the new nurse that the mother return demonstrate instilling ear drops
- Confirm with the new nurse and mother that the procedure was correctly described
- Interrupt to state that the child’s ear should be pulled down and back
- Praise the new nurse for the thorough teaching provided to the mother
Correct Answer

A. Interrupt to state that the child’s ear should be pulled down and back

Explanation

The experienced nurse should interrupt to state that the child's ear should be pulled down and back. This is because the new nurse is instructing the mother to pull the child's ear up and back, which is incorrect. Pulling the child's ear down and back helps to straighten the ear canal, allowing for easier administration of the ear drops. The experienced nurse should correct this mistake to ensure that the mother is taught the correct technique for administering ear drops to her child.

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35.

An experienced nurse is observing a new nurse providing care to a client. Which action requires the experienced nurse to intervene to ensure client safety?
- Turning on the client’s bathroom light and turning out the room lights after settling the client for sleep
- Checking the client’s room number and name on the client’s name band to verify client identity prior to administering medications
- Taking a telephone order from a physician, writing the order, and reading it back to the physician before implementing the order
- Delaying an on-coming physician from performing a right thoracentesis scheduled by a previous physician by calling “a timeout” to verify the client’s identity, consent, procedure, and site
Correct Answer

A. Checking the client’s room number and name on the client’s name band to verify client identity prior to administering medications

Explanation

The experienced nurse needs to intervene in this situation because verifying the client's identity is crucial before administering medications. This step ensures that the right medication is given to the right client, preventing any potential medication errors or adverse reactions. It is a standard safety practice to check the client's room number and name on the name band before administering any medication.

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1
36.

A client who is recovering from orthopedic surgery keeps an appointment at a clinic and uses a walker to ambulate with partial weight-bearing as instructed. Which observation should lead the nurse to conclude that the client is using the correct technique?
- Has elbows bent at a 30-degree angle
- Is bent over the walker
- Lifts the walker while walking; holding it about 2 inches above the floor
- Has a walker that has four wheels in place
Correct Answer

A. Has elbows bent at a 30-degree angle

Explanation

The correct technique for using a walker with partial weight-bearing involves keeping the elbows bent at a 30-degree angle. This position allows for better stability and support while walking.

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37.

A client who underwent surgery for colon cancer 6 weeks earlier has an appointment with a wound care nurse. After correctly demonstrating the changing of the stoma pouch, the client asks the nurse for advice regarding how to deal with gas coming from the stoma. To respond to the client’s concern, the nurse should ask the client to do which of the following? SELECT ALL THAT APPLY.
- Describe the usual dietary intake, including types of foods
- Include cruciferous vegetables in the diet daily
- Decrease fluid intake to 1,200 mL per 24 hours
- Prick the colostomy stoma pouch with a pin
- Limit intake of gas-producing beverages such as carbonated sodas
- Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp
Correct Answer(s)

A. Describe the usual dietary intake, including types of foods
A. Limit intake of gas-producing beverages such as carbonated sodas
A. Go to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp

Explanation

The client is concerned about gas coming from the stoma after undergoing surgery for colon cancer. To address this concern, the nurse should ask the client to describe their usual dietary intake, including types of foods, as certain foods can contribute to gas production. The nurse should also advise the client to limit intake of gas-producing beverages such as carbonated sodas, as this can further contribute to gas formation. Additionally, the nurse should suggest that the client goes to the restroom to release the gas that collects in the colostomy stoma pouch by opening the pouch clamp. Pricking the colostomy stoma pouch with a pin is not a recommended method to address this issue.

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4
38.

A nurse is observing a nursing student administering a clonidine (Catapres®) transdermal patch to a client diagnosed with hypertension. Which action requires the nurse to intervene?
- Applies gloves
- Asks the client to state name and also checks the client’s name band
- Applies patch, rubbing the patch against the skin, and then securing it in place
- Folds old patch with medication to the inside and discards in a medication disposal receptacle
Correct Answer

A. Applies patch, rubbing the patch against the skin, and then securing it in place

Explanation

The nurse needs to intervene when the nursing student applies the patch by rubbing it against the skin. Transdermal patches should not be rubbed or manipulated as it can alter the drug delivery rate and effectiveness. The patch should be applied gently and pressed firmly against the skin to ensure proper adhesion.

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39.

A nurse administers a prochlorperazine (Compazine®) suppository to an adult client. Which action by the nurse best ensures that the medication is correctly administered?
- Positioning the client on the left side
- Lubricating the suppository prior to insertion
- Feeling the sensation of the suppository pulling away when inserted against the rectal wall past the internal anal sphincter
- Noting soft, formed stool 30 minutes after the suppository
Correct Answer

A. Feeling the sensation of the suppository pulling away when inserted against the rectal wall past the internal anal sphincter

Explanation

The correct answer is feeling the sensation of the suppository pulling away when inserted against the rectal wall past the internal anal sphincter. This action ensures that the medication is correctly administered because it indicates that the suppository has been inserted far enough into the rectum for the medication to be absorbed. The sensation of the suppository pulling away suggests that it has passed the internal anal sphincter, which is the muscle that separates the rectum from the anus.

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40.

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6 F orally. Which of the following is the appropriate nursing action?
- Begin the transfusion as prescribed.
- Delay hanging the blood and notify the physician.
- Administer an antihistamine and begin the transfusion.
- Administer two tablets of acetaminophen (Tylenol) and begin the transfusion.
Correct Answer

A. Delay hanging the blood and notify the physician.

Explanation

The appropriate nursing action in this situation is to delay hanging the blood and notify the physician. A temperature of 100.6 F orally indicates a potential infection or fever, which can be a contraindication for blood transfusion. It is important to notify the physician to assess the client's condition and determine if it is safe to proceed with the transfusion.

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41.

A nurse is evaluating whether a client on multiple oral medications is taking the medications correctly. Which finding should be most concerning to the nurse because the absorption rate of medications can be increased?
- Taking afternoon oral medications with a carbonated soft drink
- Drinking a glass of milk with the tetracycline antibiotic oral medication
- Taking morning oral medications with water and consuming 2,500 mL of water daily
- Taking mealtime oral medications with a meal low in fiber and high in fatty foods
Correct Answer

A. Taking afternoon oral medications with a carbonated soft drink

Explanation

Taking afternoon oral medications with a carbonated soft drink should be most concerning to the nurse because carbonated soft drinks can increase the absorption rate of medications. The carbonation in the drink can increase the acidity in the stomach, which can enhance the absorption of certain medications. This can lead to higher levels of the medication in the bloodstream, potentially causing adverse effects or interactions with other medications.

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1
42.

A nurse, who is working the evening shift, is planning to administer insulin subcutaneously to a hospitalized child. Which statement made by the nurse to the mother would be inappropriate?
- “It is okay for your child to say ‘ouch,’ cry, or even scream when receiving an injection.”
- “I can give the injection while your child is sleeping; then the injection won’t be noticed.”
- “I will apply lidocaine/prilocaine (EMLA®) cream, a topical analgesic, 1 hour before the injection to reduce pain.”
- “The child will need to be lying, but after theinjection you can hold and comfort your child.”
Correct Answer

A. “I can give the injection while your child is sleeping; then the injection won’t be noticed.”

Explanation

The statement "I can give the injection while your child is sleeping; then the injection won't be noticed" would be inappropriate because it implies that the nurse is planning to administer medication without the child's knowledge or consent. It is important to involve the child in their own healthcare decisions and respect their autonomy. Additionally, administering medication without the child's awareness may cause confusion or anxiety when they wake up and realize they have been given an injection without their knowledge.

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43.

The nurse listening to morning report learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion?
- Hematocrit level
- Erythrocyte count
- Hemoglobin level
- White blood cell count
Correct Answer

A. White blood cell count

Explanation

The nurse should assess the results of the white blood cell count to assess the effectiveness of the granulocyte transfusion. Granulocytes are a type of white blood cells that play a crucial role in fighting off infections. By monitoring the white blood cell count, the nurse can determine if the transfusion has successfully increased the number of granulocytes in the client's bloodstream, indicating an improved ability to fight infections. Assessing the hemoglobin level, hematocrit level, or erythrocyte count would not provide relevant information in this case, as they primarily measure red blood cell function and oxygen-carrying capacity.

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44.

When using a hypothermia blanket for a febrile client, which findings should lead the nurse to suspect hypothermia? SELECT ALL THAT APPLY.
- Increased urine output
- Drowsiness
- Decreased heart rate (HR)
- Decreased blood pressure (BP)
- Increased BP
- Increased HR
Correct Answer(s)

A. Drowsiness
A. Decreased heart rate (HR)
A. Decreased blood pressure (BP)

Explanation

If a febrile client is using a hypothermia blanket, the purpose is to lower the body temperature. Hypothermia is a condition where the body temperature drops below normal. Drowsiness can be a sign of hypothermia as the body's metabolic rate decreases. Decreased heart rate (HR) and decreased blood pressure (BP) are also signs of hypothermia as the body tries to conserve energy and maintain core temperature. Increased urine output, increased BP, and increased HR are not typically associated with hypothermia.

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45.

A 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?
- Flexed position
- Head tilt–chin lift
- Jaw thrust maneuver
- Modified head tilt–chin lift
Correct Answer

A. Jaw thrust maneuver

Explanation

The jaw thrust maneuver is used to open the airway in a victim who may have a potential neck or spinal injury. It involves placing the fingers behind the angle of the jaw and lifting it forward, without tilting the head back. This maneuver helps to maintain the alignment of the neck and spine while ensuring the airway remains open. In this scenario, the nurse witnesses a fall from the roof, indicating the possibility of a neck or spinal injury, making the jaw thrust maneuver the appropriate method to open the airway.

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46.

A nurse is assessing a client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding would require an immediate intervention by the nurse?
- A nasogastric tube (NG) to low intermittent suction with small amounts of dark bloody returns
- A compressed Jackson-Pratt (JP) drain with 30 mL bright red blood
- A NG tube to low intermittent suction with pale green returns
- A round Jackson-Pratt (JP) drain with 20 mL serosanguineous drainage
Correct Answer

A. A round Jackson-Pratt (JP) drain with 20 mL serosanguineous drainage

Explanation

The assessment finding that would require immediate intervention by the nurse is a round Jackson-Pratt (JP) drain with 20 mL serosanguineous drainage. Serosanguineous drainage is a mixture of bloody and serous fluid, which is expected after surgery. However, a round JP drain should not have any drainage, as it indicates a possible dislodgement or malfunction of the drain. The nurse should assess the drain site, ensure proper placement, and notify the healthcare provider for further intervention if needed.

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1
47.

The nurse has a prescription to hang an intravenous (IV) bag of 1000 mL 5% dextrose in water with 20 mEq potassium chloride. The nurse should plan to do which of the following immediately after injecting the potassium chloride into the port of the IV bag?
- Rotate the bag gently.
- Attach the tubing to the client.
- Prime the tubing with the IV solution.
- Check the solution for yellowish discoloration.
Correct Answer

A. Rotate the bag gently.

Explanation

After injecting the potassium chloride into the port of the IV bag, the nurse should plan to rotate the bag gently. This is important to ensure proper mixing of the potassium chloride with the IV solution. By rotating the bag gently, the nurse can help distribute the potassium chloride evenly throughout the IV solution, which will help prevent concentration variations and ensure that the client receives the correct dosage of medication.

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48.

A client with a wound infection is ordered contact precautions based on culture results. When should a nurse caring for the client don disposable medical examination gloves?
- Upon entering the client’s room
- When anticipating contact with drainage from the wound
- When determining a potential for contamination with blood or body fluids of the client
- When providing care within 3 feet of the client
Correct Answer

A. Upon entering the client’s room

Explanation

When entering the client's room, the nurse should don disposable medical examination gloves. This is because the client has a wound infection and is on contact precautions, indicating that there is a potential for the transmission of infectious material. By wearing gloves upon entering the room, the nurse can minimize the risk of contamination and protect both themselves and the client from the spread of infection.

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49.

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which of the following intravenous (IV) solutions from the IV storage area to hang with the blood product at the client’s bedside?
- Lactated Ringer’s
- 0.9% sodium chloride
- 5% dextrose in 0.9% sodium chloride
- 5% dextrose in 0.45% sodium chloride
Correct Answer

A. 0.9% sodium chloride

Explanation

The nurse should obtain 0.9% sodium chloride from the IV storage area to hang with the blood product at the client's bedside. This solution is commonly used to administer blood products because it is isotonic, meaning it has the same concentration of solutes as blood. This helps to prevent hemolysis or damage to the red blood cells. Lactated Ringer's is not typically used for blood transfusions. 5% dextrose in 0.9% sodium chloride and 5% dextrose in 0.45% sodium chloride are not appropriate solutions for administering packed red blood cells.

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Preliminary Examination In Competency Appraisal

A nurse is to administer promethazine (Phenergan®) 12.5 mg intramuscularly (IM) stat to a client. The medication is supplied in an ampule of 50 mg/mL. How many milliliters should the nurse administer to the client?

Quiz Preview

A nurse is preparing to provide phototherapy to a 4-day-old newborn who was admitted with hyperbilirubinemia. The nurse instructs the parents on how to care for their baby while receiving phototherapy in the hospital. The nurse’s teaching should include:

A client reports pain at an intravenous infusion site that has infiltrated. When a nurse applies a warm, moist compress to the site, the client asks how the treatment will help the condition. The nurse answers the client based on the understanding that the application of moist heat will:

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse assesses which priority item?

A health-care agency has different receptacles for the various categories of institutional waste. Into which container should a nurse dispose of a suction canister used to collect drainage from a client’s nasogastric tube?

The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse continues to advance the catheter if:

A hospitalized client has daily weights ordered. The client is able to stand, and the nursing unit has an electronic digital scale to use for client weights. Which intervention best ensures that the client’s daily weight is accurate?

A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client?

A 33-year-old client reports left leg pain, right-sided chest pain, and a sudden onset of shortness of breath. Which action should be taken immediately by the nurse?

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which of the following items is important to check regarding the age of blood cells before the transfusion is begun?

The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse asks which initial question?

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next?

Which rationale should a nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving 2 liters of oxygen by nasal cannula?

A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers the supplies and prepares the sterile field using a packaged sterile drape. Which option correctly describes how the nurse should set up the sterile field?

A nurse is caring for a client who is unable to perform oral hygiene. The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?

A nurse understands that which of the following is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider?

A nurse instructs a client on safe disposal of insulin syringes and needles when at home. Which statement by the client indicates that additional teaching is needed?

A nurse is discussing hearing aids with a client who began wearing hearing aids 5 weeks earlier. Which statement demonstrates that the client is successfully adapting to the hearing aids?

A nurse is caring for a client who has experienced a first-degree sprain of the ankle. A primary care provider writes a prescription for an analgesic medication. Which intervention, beside the analgesic, should the nurse advise the client to utilize for the first 24 hours after the injury?

A physician has written a prescription to discontinue an intravenous (IV) line. The nurse obtains which of the following supplies from the unit supply area for applying pressure to the site after removing the IV catheter?

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred?

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the exposed tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that the rationale for transfusing fresh-frozen plasma in this client is:

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer?

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which of the following?

The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with:

An experienced nurse is observing a new nurse providing care to a client. Which action requires the experienced nurse to intervene to ensure client safety?

A client who is recovering from orthopedic surgery keeps an appointment at a clinic and uses a walker to ambulate with partial weight-bearing as instructed. Which observation should lead the nurse to conclude that the client is using the correct technique?

A nurse is observing a nursing student administering a clonidine (Catapres®) transdermal patch to a client diagnosed with hypertension. Which action requires the nurse to intervene?

A nurse administers a prochlorperazine (Compazine®) suppository to an adult client. Which action by the nurse best ensures that the medication is correctly administered?

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6 F orally. Which of the following is the appropriate nursing action?

A nurse is evaluating whether a client on multiple oral medications is taking the medications correctly. Which finding should be most concerning to the nurse because the absorption rate of medications can be increased?

A nurse, who is working the evening shift, is planning to administer insulin subcutaneously to a hospitalized child. Which statement made by the nurse to the mother would be inappropriate?

The nurse listening to morning report learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion?

When using a hypothermia blanket for a febrile client, which findings should lead the nurse to suspect hypothermia? SELECT ALL THAT APPLY.

A 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 nurse is assessing a client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding would require an immediate intervention by the nurse?

The nurse has a prescription to hang an intravenous (IV) bag of 1000 mL 5% dextrose in water with 20 mEq potassium chloride. The nurse should plan to do which of the following immediately after injecting the potassium chloride into the port of the IV bag?

A client with a wound infection is ordered contact precautions based on culture results. When should a nurse caring for the client don disposable medical examination gloves?

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which of the following intravenous (IV) solutions from the IV storage area to hang with the blood product at the client’s bedside?