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Nursing Practice I Basic Foundation of Nursing and Professional Nursing Practice

1. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse
notes that a clients 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?
A. Infection
B. Phlebitis
C. Infiltration
D. Thrombosis
2.When two nursing diagnoses appear closely related, what should the nurse do first todetermine which
diagnosis most accurately reflects the needs of the patient?
A. Reassess the patient
C. Analyze the secondary to factors
B. Examine the related to factors
D. Review the defining characteristics
3. The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission
assessment is conducted primarily to:
A. Diagnose if the patient is at risk for falls
C. Establish a therapeutic relationship
B. Ensure that the patients skin is intact
D. Identify important data
4. The nurse identifies that the patient statement that provides subjective data is:
A. Im not sure that I am going to be able to manage at home by myself.
B. I can call a home-care agency if I feel I need help at home.
C. What should I do if I have uncontrollable pain at home?
D. Will a home health aide help me with my care at home?
5. The nurse understands that evaluation most directly relates to which aspect of theNursing Process?
A. Goal
B. Problem
C. Etiology
D. Implementation
6. The nurse comes to the conclusion that a patients elevated temperature, pulse, and respirations are
significant. What step of the Nursing Process is being used when thenurse comes to this conclusion?
A. Implementation B. Assessment
C. Evaluation
D. Diagnosis
7. When the nurse considers the Nursing Process, the word identify is to recognizeas the word do is to:
A. Plan
B. Evaluate C. Diagnose D. Implement
8. The nurse is collecting subjective data associated with a patients anxiety. Whichassessment method should
be used to collect this information?
A. Observing
B. Inspecting
C. Auscultation
D. Interviewing
9. Which nursing action reflects an activity associated with the diagnosis step of theNursing Process?
A. Formulating a plan of care
B. Identifying the patients potential risks
C. Designing ways to minimize a patients stressors
D. Making decisions about the effectiveness of patient care
10.The nurse collects objective data when a hospitalized patient states:
A. I am hungry.
C. I ate half my lunch.
B. I feel very warm.
D. I have the urge to urinate.
11. During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care
are achieved?
A. Implementation B. Evaluation
C. Diagnosis
D. Planning
12. When considering the Nursing Process, the nurse understands that the word observeis to assess as the
word determine is to:
A. Plan
B. Analyze
C. Diagnose D. Implement
13. An essential concept related to understanding the Nursing Process is that it:
A. Is dynamic rather than static
C. Moves from the simple to the complex
B. Focuses on the role of the nurse
D. Is based on the patients medical problem
14. The nurse is caring for a male patient with a urinary elimination problem. Which is the most accurately
stated goal? The patient will:
A. Be taught how to use a urinal when on bed rest.
B. Experience fewer incontinence episodes at night.
C. Be assisted to the toilet every two hours and whenever necessary.
D. Transfer independently and safely to a commode before discharge.

15. Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the
patient holistically?
A. Teacher
B. Advocate C. Surrogate D. Counselor
16. The nurse understands that the word most closely associated with scientific principles is:
A. Data
B. Problem
C. Rationale D. Evaluation
17. The nurse teaches a patient to use visualization to cope with chronic pain. This action reflects which step of
the Nursing Process?
A. Planning B. Diagnosis C. Evaluation D. Implementation
18. The nurse understands that the primary goal of the assessment phase of the NursingProcess is to:
A. Build trust and rapport
C. Establish goals and outcomes
B. Collect and cluster data
D. Identify and validate the medical diagnosis
19. Which human response identified by the nurse is an example of objective data?
A. Pain of 5 on a 1 to 10 pain scale
C. Shortness of breath
B. Irregular radial pulse of 50 bpm
D. Dizziness
20. The Planning step of the Nursing Process is influenced most directly by the:
A. Related factors
B. Diagnostic label
C. Secondary factors D. Medical diagnosis
21. The nurse is obtaining a patients blood pressure.Which information is most importantfor the nurse to
A. Staff member who took the blood pressure
B. Patients tolerance to having the blood pressure taken
C. Position of the patient if the patient is not in a sitting position
D. Difference between the palpated and auscultated systolic readings
22. The nurse is assessing a patients bilateral pulses for symmetry. However, the nurse should not assess which
pulse sites on both sides of the body at the same time?
A. Radial
B. Carotid
C. Femoral
D. Brachial
23. The nurse is caring for a patient who is experiencing an increase in symptoms associated with multiple
sclerosis. Which term best describes a recurrence of symptoms associatedwith a chronic disease?
A. Variance
B. Remission
C. Adaptation
D. Exacerbation
24. A patient with hypertension is given discharge instructions to take the blood pressure every day. The nurse is
evaluating a family member taking the patients blood pressure as part of the patients discharge teaching plan.
The nurse identifies that further teaching is necessary when the family member:
A. Places the diaphragm of the stethoscope over the brachial artery
B. Applies the center of the bladder of the cuff directly over an artery
C. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat
D. Inserts the 2 earpieces of the stethoscope into the ears so that they tilt slightly forward
25. The nurse must assess for the presence of bowel sounds in a postoperative patient. The nurse should
auscultate the patients abdomen:
A. Prior to palpation
C. Starting at the left lower quadrant
B. Using a warmed stethoscope
D. For at least three minutes in each quadrant
26. The nurse is unable to palpate a patients brachial pulse. Which pulse should the nurse assess to determine
adequate brachial blood flow in this patient?
A. Radial
B. Carotid
C. Femoral
D. Popliteal
27. The nurse is assessing a patients heart rate by palpating the carotid artery. What is the most important thing
the nurse should do when assessing a pulse at this site?
A. Monitor for a full minute
C. Press gently when palpating the site
B. Palpate just below the ear
D. Massage the site before assessing for rate
28. Which usually is unrelated to a nursing physical assessment?
A. Posture and gait
C. Hygiene and grooming
B. Balance and strength
D. Blood and urine values
29. A patient consistently tries to pull out a urinary retention catheter. As a last resort to maintain integrity of the
catheter and patient safety, the nurse obtains an order for a restraint. Which type of restraint is most appropriate
in this situation?
A. Mummy restraint
B. Elbow restraint
C. Jacket restraint
D. Mitt restraint
30. The nurse must apply a hospital gown to a patient receiving an intravenous infusion inthe forearm. The
nurse should:
A. Insert the IV bag and tubing through the sleeve from inside of the gown first
B. Disconnect the IV at the insertion site, apply the gown, and then reconnect the IV
C. Close the clamp on the IV tubing no more than 15 seconds while putting on thegown
D. Don the gown on the arm without the IV, drape the gown over the other shoulder, and adjust the
closure behind the neck
31. An appropriately worded goal associated with the nursing diagnosis Risk for Injury is,The patient will be:
A. Taught how to call for help to ambulate.
B. Kept on bed rest when dizzy.

C. Restrained when agitated.

D. Free from trauma.
32. When teaching children about fire safety procedures, the school nurse should teach them that if their clothes
catch on fire they should:
A. Yell for help
C. Take their clothes off
B. Roll on the ground
D. Pour water on their clothes
33. The nurse is assessing a patient who is being admitted to the hospital. Which is the most important
information collected by the nurse that indicates whether the patient is at risk for physical injury?
A. Weakness experienced during a prior admission C. Two recent falls that occurred at home
B. Medication that increases intestinal motility
D. The need for corrective eyeglasses
34. The nurse is caring for a patient with a nasogastric tube for gastric decompression.Which nursing action
takes priority?
A. Positioning the patient in the semi-Fowlers position
B. Instilling the tube with 30 mL of air every 2 hours
C. Providing care to the nares at least every 8 hours
D. Discontinuing wall suction when providing care
35. The nurse is preparing to draw up medication from a vial. What should the nurse do first?
A. Ensure that the needle is firmly attached to the syringe
B. Rub vigorously back and forth over the rubber cap with an alcohol swab
C. Inject air into the vial with the needle bevel below the surface of the medication
D. Draw up slightly more air than the volume of medication to be withdrawn from thevial
36. The instructions with a medication states to use the Z-track technique when administeringthe injection.
Therefore, the nurse should:
A. Pinch the site throughout the injection
B. Massage the site after the needle is removed
C. Remove the needle immediately after the medication is injected
D. Change the needle after the medication is drawn into the syringe
37. The nurse understands that a contraindication for the intake of medications via the oral route is:
A. Difficulty swallowing
B. Gastric suctioning
C. Unconsciousness
D. Nausea
38. The nurse teaches the spouse of a patient how to insert a rectal suppository. The nurse identifies that further
teaching is necessary when the spouse:
A. Lubricates the tip of the suppository
B. Wears a glove when inserting the suppository
C. Places the suppository two inches into the rectum
D. Inserts the suppository while the patient bears down
39. The physician orders a medication that must be administered via the intramuscularroute. When
administering this medication, the nurse knows that the site that has the highest risk for injury is the:
A. Vastus lateralis
B. Rectus femoris
C. Ventrogluteal
D. Dorsogluteal
40. The nurse adds a medication to an intravenous fluid bag. Which nursing action is the priority?
A. Attaching a completed IV additive label to the bag
B. Mixing the medication and solution by rotating the bag
C. Maintaining sterile technique throughout the procedure
D. Ensuring that the drug and the IV solution are compatible
41. The nurse understands that the route of drug administration not considered parenteral is:
A. Epidural
B. Transdermal
C. Subcutaneous
D. Intramuscular
42. The nurse identifies that a patients pressure ulcer has just partial-thickness skin lossinvolving the epidermis
and dermis. The nurse documents that the patients pressureulcer is:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
43. Which is the most important nursing action when assisting a patient to move from abed to a wheelchair?
A. Applying pressure under the patients axillae areas when standing up
B. Lowering the bed to below the height of the patients wheelchair
C. Letting the patient help as much as possible when permitted
D. Keeping the patients feet within six inches of each other
44. A cane assists the client to walk with greater balance and support. Canes have the following features for
safetyand support:
A. feet (four, three, straight), adjustable to allow the elbow to bend slightly, a rubber cap.
B. feet (straight or two), adjustable to what the client feels is best.
C. four feet, a rubber tip at both ends.
D. three feet, enables speed, using two canes.
45. The standard walker is used when clients:
A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
B. have poor balance, broken leg, or amputation.
C. have poor balance, cardiac problems, and cannot use crutches or cane.

D. have poor balance, autoimmune diseases, and weak arms.

46. Which of the following clients are not a candidate for magnetic resonance imaging?
A. client with a pacemaker
C. client with an arrythmia
B. client with a porcine heart valve
D. client with an indwelling catheter
47. Which statement by a client indicates adequate understanding of care after a colposcopy?
A. I can use contraceptive foam tomorrow.
C. I will place a pad to absorb the bleeding.
B. I will place a diaphragm in now.
D. I can have intercourse with my spouse tonight.
48.Prior to an amniocentesis, what is important for the nurse to instruct the client to do?
A. Do not eat after midnight.
C. Urinate just before the test.
B. Do not drink after midnight.
D. Urinate just after the test.
49. Which of the following clients is most likely to receive an amniocentesis?
A. a hypertensive 28-year-old woman
C. a depressed 32-year-old woman
B.a 40-year-old pregnant woman
D. a healthy 18-year-old woman
50. Which of the following statements by a client indicates adequate understanding of a bone marrow biopsy
toobtain a laboratory specimen?
A. The procedure will take less than five minutes.
C. I will be given medication to minimize
B. I can go for a walk right after the procedure.
D. It is okay if the injection site becomes swollen.
51. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse
notes that a clients 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?
A. Infection
B. Phlebitis
C. Infiltration D. Thrombosis
52. A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse
assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of
this client? Select all that apply.
1. Notifies the physician
2. Removes the IV catheter at that site
3. Applies warm moist packs to the site
4. Starts a new IV line in a proximal portion of the same vein
5. Documents the occurrence, actions taken, and the clients response
A. 1,2,3,5 B. 1,3,4,5 C. 1,2,3,4 D. 1,2,3,4,5
53. 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?
A. Have you ever had a transfusion before?
B. Why do you think that you need the transfusion?
C. Have you ever gone into shock for any reason in the past?
D. Do you know the complications and risks of a transfusion?
54. 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?
A. Increased hematocrit level
B. Increased hemoglobin level
C. Decline of elevated temperature to normal
D. Decreased oozing of blood from puncture sites and gums
55. 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
A. 5 minutes
B. 15 minutes
C. 30 minutes
D. 45 minutes
56. 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?
A. Hematocrit level
B. Erythrocyte count C. Hemoglobin level D. White blood cell count
57. 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. To treat the loss of platelets

B. To promote rapid volume expansion

C. That the transfusion must be done slowly
D. That it will increase the hemoglobin and hematocrit levels
58. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the
procedure. The nurse suggests to the client to do which of the following to reduce the risk of possible
transfusion complications?
A. Give an autologous blood donation before the surgery.
B. Ask a friend or family member to donate blood ahead of time.
C. Take iron supplements before surgery to boost hemoglobin levels.
D. Request that any donated blood be screened twice by the blood bank.
59. Which of the following fluids would be appropriate for a client who may be experiencing excess fluid
volume secondary to congestive heart failure?

A. 0.9% normal saline

C. Lactated Ringers solution

B. 0.45% normal saline

D. 5% dextrose in 0.9% normal saline

60. A client with a traumatic closed head injury shows signs that indicate the presence of cerebral edema. Which
of the following fluids would increase cellular swelling and cerebraledema?
A. 0.9% normal saline B. 0.45% normal saline C. 5% dextrose in water
D. Lactated Ringers solution
61. A nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which of the
following actions should the nurse perform when administering this test to the client?
A. Inject the medication and place a pressure dressing over the medication site.
B. Massage the area with an alcohol swab after injection to ensure that the medication is absorbed.
C. Administer the injection with the needle bevel facing downward at a 10- to 15-degree angle.
D. Make a circular mark around the injection site after administration of the tuberculin test.
62. A nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in
which of the following positions for this examination?
A. Supine with the head raised slightly and the knees slightly flexed
B. Semi-Fowlers position with the head raised 45 degrees and the knees flat
C. Sims position
D. Supine with the head and feet flat
63. A nurse is performing a respiratory assessment and is auscultating the clients breath sounds. On
auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client
A. Rhonchi
B. Crackles
C. Pleural friction rub
D. Wheezes
64. A nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and do which
of the following?
A. Identify three numbers or letters traced in the clients palm.

B. Identify three objects placed in the hand one at a time.

C. State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place.
D. Identify the smallest distance between two detectable pinpricks, made with two pins held at various
65. A nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves Ill, IV,
and VI. Using a flashlight, the nurse would perform which of the following to obtain the assessment data?
A. Turn the flashlight on directly in front of the eye and watch for a response.
B. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiners finger.
C. Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the
D. Ask the client to follow the flashlight through the six cardinal positions of gaze.
66. The clinic nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted
cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply.
1. Position the client to turn the head so that the ear to be irrigated is facing upward.
2. Warm the irrigating solution to a temperature that is close to body temperature.
3. Direct a slow steady stream of irrigation solution toward the upper wall of the ear canal.
4. Position the client with the affected side down after the irrigation.
5. Apply some force when instilling the irrigation solution.
A. 2, 3, 4

B. 3, 4, 5

C. 1, 2, 4

D. 2, 4, 5

67. A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes
the student perform this procedure. Which observation by the instructor indicates that the student is using
correct technique for the procedure?
A. Pulling the pinna down and back before inserting the speculum
B. Pulling the earlobe down and back before inserting the speculum
C. Using the smallest speculum available
D. Tilting the clients head slightly away and holding the otoscope upside down before inserting the
68. A nurse is preparing to perform a Weber test on a client. The nurse obtains which item needed to perform
this test?
A. A tongue blade
B. A stethoscope
C. A tuning fork
D. A reflex hammer
69. A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an
insect flew into the ear. Which intervention should the nurse implement initially?

A. Irrigation of the ear

B. Instillation of mineral oil

C. Instillation of antibiotic eardrops

D. Instillation of corticosteroid ointment

70. A nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor asks the
student to describe the physiology associated with this diagnosis. The nursing instructor determines that the
student understands this condition if the student states that presbycusis is:

A. A loss of vision associated with aging

B. A loss of balance that occurs with aging

C.A sensorineural hearing loss that occurs with aging

D. A conductive hearing loss that occurs with aging

71. A nurse is caring for a client with acute otitis media. In order to reduce pressure and allow fluid to drain, the
nurse anticipates that which of the following would most likely be recommended to the client?
A. The administration of diphenhydramine (Benadryl) capsules
B. A myringotomy
C. Strict bed rest
D. A mastoidectomy
72. A nursing student is assigned to administer an iron injection to a client. The co-assigned nurse asks the
student about the technique for administration of this medication. The student indicates understanding of the
administration procedure by identifying the correct injection site and method as:
A. Anterolateral thigh using an air lock
B. Gluteal muscle using Z-track technique
C. Subcutaneous tissue of the abdomen using a 1-inch needle
D. Deltoid muscle using a 1-inch needle
73. A clinic nurse is performing a cardiovascular assessment on a client. In preparing to assess the clients apical
pulse, the nurse places the stethoscope over the hearts apex in which of the following positions?
A. At the midline of the chest just below the xiphoid process
B. At the midclavicular line at the fifth left intercostal space
C. At the midaxillary line on the left side of the chest
D. Midsternum, equal with the nipple line
74. A clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse performs
this test for the purpose of determining:
A. The clients ability to ambulate
B. The functional status of the vestibular apparatus in the inner ear
C. The intactness of the retinal structure of the eye
D. The intactness of the tympanic membrane
75. A client has an order for an injection to be administered by the intradermal route. The nurse avoids which of
the following actions when administering this medication?
A. Inserting the needle at a 10- to 15-degree
B. Injecting the medication slowly

C. Massaging the area after removing the needle

D. Making a circular mark around the injection site

76. A nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which of the
following areas least helpful in assessing for pallor or cyanosis?
A. Sclera B. Tongue
C. Mucous membranes
D. Nailbeds
77. A nurse instructs a client in the use of a hearing aid. The nurse includes which of the following instructions?

A. Check the battery to ensure that it is working before use.

B. Leave the hearing aid in place while showering.
C. Hearing aids do not require any care.
D. A water-soluble lubricant is used on the hearing aid before insertion.
78. A nurse is performing a physical examination of the client. The nurse selects which of the following items to
test the function of cranial nerve II (optic nerve)?
A. Flashlight B. Ophthalmoscope C. Reflex hammer
D. Snellen chart
79. A nurse notes that a clients parenteral nutrition solution is 4 hours behind. The nurse should take which
A. Administer the parenteral nutrition solution using gravity flow because the infusion pump is
B. Replace the parenteral nutrition solution with 10% dextrose and restart the solution the following day.
C. Assess the infusion pump to be sure it is functioning properly and is set at the correct rate.
D. Increase the infusion rate to a rate that allows the infusion volume to correct itself within a 2-hour period.
80. A nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The
nurse should plan to ensure that which of the following is done to prevent the client from injury?

A. Calculate daily intake and output.

B. Monitor the temperature once daily.

C. Secure all connections in the PN system.

D. Monitor blood glucose levels every 12 hours

81. Contact precautions are initiated for a client with a health careassociated (nosocomial) infection caused
by methicillin resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and obtains which
of the following protective items needed to perform this procedure?

A. Gloves and gown

B. Gloves and goggles

C. Gloves, gown, and shoe protectors

D. Gloves, gown, goggles, and face shield

82. A client is being prepared for a thoracentesis. A nurse assists the client to which position for the procedure?
A. Lying in bed on the affected side
B. Lying in bed on the unaffected side
C. Sims position with the head of the bed flat
D. Prone with the head turned to the side and supported by a pillow
83. A nurse is preparing to insert a nasogastric tube into a client. The nurse places the client in which position
for insertion?
A. Right side
B. Low Fowlers
C. High Fowlers D. Supine with the head flat
84. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best
position inwhich the nurse should place the client?

A. Side-lying on the operative side

B. On the nonoperative side with the legs abducted
C. Side-lying with the affected leg internally rotated
D. Side-lying with the affected leg externally rotate

85. A nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the
enema, the nurse places the client in which position?
A. Left Sims position
B. Right Sims position
C. On the left side of the body, with the head of the bed elevated 45 degrees
D. On the right side of the body, with the head of the bed elevated 45 degrees
86. A nurse is preparing to remove a nasogastric tube from a client. The nurse should instruct the client to do
which of the following just before the nurse removes the tube?

A. Exhale.
B. Inhale and exhale quickly.

C. Take and hold a deep breath.

D. Perform a Valsalva maneuver

87. A nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To
administer the medication, the nurse would:
A. Position the client supine to assist in medication absorption.
B. Aspirate the nasogastric tube after medication administration to maintain patency.
C. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.
D. Change the suction setting to low intermittent suction for 30 minutes after medication administration.
88. A nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents
and checks the contents for pH. The nurse verifies correct tube placement if which pH value is noted?
A. 3.5
B. 7.0
C. 7.35
D. 7.5
89. A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:
A. Exhale slowly.
B. Stay very still.

C. Inhale and exhale quickly.

D. Perform the Valsalvamaneuver

90. A nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous
gentle bubbling in the suction control chamber. What action is appropriate?
A. Do nothing, because this is an expected finding.
B. Immediately clamp the chest tube and notify the physician.
C. Check for an air leak because the bubbling should be intermittent.
D. Increase the suction pressure so that the bubbling becomes vigorous.
91. A nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from
the recovery room following a thoracotomy with wedge resection. Select the expected assessment findings.
Select all that apply.
1. Excessive bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. 50 mL of drainage in the drainage collection chamber
4. Drainage system maintained below the clients chest
5. Occlusive dressing in place over the chest tube insertion site

6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
A. 3,4,5,6
B. 1,2,3,4
C. 2,3,4,5
D. 1,2,3,4,5,6
92. The home care nurse is performing an environmental assessment in the home of an older client. Which of
the following, if observed by the nurse, requires immediate attention?

A. Unsecured scatter rugs

C. An operable smoke detector

B. Clear exit passageways

D. A prefilled medication cassette

93. A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the
balloon, the client complains of discomfort. The appropriate nursing action is to:
A. Aspirate the fluid, remove the catheter, and insert a new catheter.
B. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
C. Remove the syringe from the balloon; discomfort is normal and temporary.
D. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
94. A nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the
urethra, urine begins to flow into the tubing. At this point, the nurse:
A. Immediately inflates the balloon
B. Inserts the catheter 2.5 to 5 cm and inflates the balloon
C. Withdraws the catheter about 1 inch and inflates the balloon
D. Inserts the catheter until resistance is met and inflates the balloon
95. A nurse is preparing to care for a client with esophageal varices who has just had a Sengstaken-Blakemore
tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside
at all times?
A. An obturator
B. A Kelly clamp C. An irrigation set D. A pair of scissors
96. Two nurses are leaving a clients room whose care required them to wear a gown, mask, and gloves. Which
of the following actions by these nurses could lead to the spread of infection?
A. Removing the gown without rolling it from inside out
B. Taking off the gloves first before removing the gown
C. Washing the hands after the entire procedure has been completed
D. Removing the gloves and then removing the gown using the neck ties
97. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate
instruction by the nurse?
A. Report to the physician the effects of the medication on urination.
B. Take the medicine early in the morning
C. Take a full glass of water with the medicine
D. Measure frequency of urination in 24 hours
98. A nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use
of a cane. Which of the following instructions should the nurse provide to the client?
A. Hold the cane on the affected (weak) side.
B. Hold the cane on the unaffected (strong) side.
C. Move the cane forward first along with the unaffected (strong) leg.
D. Move the cane and the unaffected (strong) leg down first when going down stairs.
99. The home care nurse visits a client at home who has been experiencing increased weakness. The client tells
the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the
clients use of the cane and determines that the cane is sized correctly if:
A. The handle of the cane is even with the clients waist.
B. The clients elbow is flexed at a 15- to 30-degree angle when ambulating with the cane.
C. The clients elbow is flexed at a 50- to 75-degree angle when ambulating with the cane.
D. The clients elbow is straight when ambulating with the cane.
100. A home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions
to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the
client, indicates a need for further instruction?
A. I need to be sure that no one smokes in my home.
B. I need to be sure that I stay at least 10 feet away from any burning candles.
C. It is all right to use an electric razor for shaving only if I leave it plugged in for a short time.

D. I need to be sure that there is space between the oxygen concentrator and the wall in the room.