RN Fundamentals Online Practice 2023 B

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid.Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

A. "This type of hearing aid does not allow for fine tuning of volume.

"B. "I shouldn't have trouble keeping the hearing aid in place during exercise."

C. "I expect to hear a whistling sound when I first insert the hearing aid."

D. "I will be sure to remove my hearing aid before taking a shower."

✅ D. "I will be sure to remove my hearing aid before taking a shower."

Clients should remove any hearing devices before showering because exposure to water can damage them.

A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration.Which of the following actions should the nurse take first?

A. Encourage the client to include a support person in the teaching.

B. Schedule a series of teaching sessions.

C. Provide written directions for the client to use.

D. Determine the client’s learning style.

Correct Answer:

✅ D. Determine the client’s learning style.

Using the nursing process, the first action the nurse should take is to assess the client's learning style.

A nurse is reviewing a client’s medication prescription that reads, “digoxin 0.25 by mouth every day.”Which of the following components of the prescription should the nurse verify with the provider?

A. Medication name

B. Route of administration

C. Medication dose

D. Frequency of administration

Correct Answer:

✅ C. Medication dose

In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change.Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

B. The newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field.

C. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring.

D. The sterile field is positioned at the level of the newly licensed nurse’s waist.

Correct Answer:

✅ A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

A nurse is providing teaching to a client who is on protective isolation precautions.Which of the following client statements indicates an understanding of the teaching?

A. "I can shower up to three times a week."

B. "I will inform my friends and family to visit when I'm feeling well."

C. "I can take a plane to visit my grandchildren."

D. "I will wear a face mask when leaving my hospital room."

Correct Answer:

✅ D. "I will wear a face mask when leaving my hospital room."

The client is encouraged to wear a face mask because of increased risk for exposure to micro-organisms.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis.The prescription reads:25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr.At what rate should the nurse set the infusion pump?(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

✅ Final Answer:

8 mL/hr

A nurse is performing a Romberg test during the physical assessment of a client.Which of the following techniques should the nurse use?

A. Touch the face with a cotton ball.

B. Apply a vibrating tuning fork to the client's forehead.

C. Have the client stand with their arms at their sides and their feet together.

D. Perform direct percussion over the area of the kidneys.

Correct Answer:

✅ C. Have the client stand with their arms at their sides and their feet together.

A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is administering an otic medication to an older adult client.Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

A. Press gently on the tragus of the client’s ear.

B. Pack a small piece of cotton deep into the client’s ear canal.

C. Move the client’s auricle down and back toward their head.

D. Tilt the client’s head backward for 5 min.

Correct Answer:

✅ A. Press gently on the tragus of the client’s ear.

Pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is caring for a client who has decreased mobility.Which of the following actions should the nurse take to decrease the client’s risk of developing plantar flexion contractures?

A. Place a pillow under the client’s knees.

B. Position a trochanter roll under each of the client’s hips.

C. Advise the client to wear rubber-soled slippers.

D. Apply an ankle-foot orthotic device to the client’s feet.

Correct Answer:

✅ D. Apply an ankle-foot orthotic device to the client’s feet.

The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A nurse is preparing to administer an injection of an opioid medication to a client.The nurse draws out 1 mL of the medication from a 2 mL vial.Which of the following actions should the nurse take?

A. Ask another nurse to observe the medication wastage.

B. Notify the pharmacy when wasting the medication.

C. Lock the remaining medication in the controlled substances cabinet.

D. Dispose of the vial with the remaining medication in a sharps container.

Correct Answer:

✅ A. Ask another nurse to observe the medication wastage.

A second nurse must witness the disposal of any portion of a dose of a controlled substance.

A nurse is caring for a client who reports pain.When documenting the quality of the client’s pain on an initial pain assessment, the nurse should record which of the following client statements?

A. "I'm having mild pain."

B. "The pain is like a dull ache in my stomach."

C. "I notice that the pain gets worse after I eat."

D. "The pain makes me feel nauseous."

Correct Answer:

✅ B. "The pain is like a dull ache in my stomach."

The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse is caring for a group of clients on a medical-surgical unit.In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A. A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively.

B. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client’s wishes.

C. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client’s family.

D. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.

Correct Answer:

✅ A. A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively.

Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer.Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A. A lesion with uniform pigmentation

B. New appearance of petechiae

C. A mole with an asymmetrical appearance

D. The presence of a papule

Correct Answer:

✅ C. A mole with an asymmetrical appearance.

An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.Which of the following actions should the nurse take?

A. Assist the client into a prone position.

B. Place a sleeve over the top of each leg with the opening at the knee.

C. Make sure two fingers can fit under the sleeves.

D. Set the ankle pressure at 65 mm Hg.

Correct Answer: C. Make sure two fingers can fit under the sleeves.

The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Options:

Use a resuscitation bag with 80% oxygen prior to the procedure.

Select a suction catheter that is half the size of the lumen.

Place the end of the suction catheter in water-soluble lubricant.

Adjust the wall suction apparatus to a pressure of 170 mm Hg.

✅ Correct Answer:

Select a suction catheter that is half the size of the lumen.

The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is assessing an older adult client’s risk for falls. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select all that apply.)

Options:

Lacrimal apparatus

Pupil clarity

Appearance of bulbar conjunctivae

Visual fields

Visual acuity

✅ Correct Answers:

Visual fields

Visual acuity

Pupil Clarity

Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly.

The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall.

The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Options:

Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube.

Remove the NG tube if the client begins to gag or choke.

Apply suction to the NG tube prior to insertion.

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

✅ Correct Answer:

4. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Options:

Combine client care tasks when caring for multiple clients.

Wait until the end of the shift to document client care.

Use the planning step of the nursing process to prioritize client care delivery.

Allow for interruptions in tasks to discuss client care issues with colleagues.

✅ Correct Answer:

3. Use the planning step of the nursing process to prioritize client care delivery.

Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client’s diet?

Options:

Cucumbers

Corn

Asparagus

Avocados

✅ Correct Answer:

4. Avocados

The nurse should suggest the client eat avocados, which are an excellent dietary source of potassium.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Options:

Walking briskly

Riding a bicycle

Performing isometric exercises

Engaging in high-impact aerobics

✅ Correct Answer:

1. Walking briskly

Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Options:

Carry a client's soiled linens out of the room in a mesh linen bag.

Place a client who has tuberculosis in a room with negative-pressure airflow.

Provide disposable plates and utensils for a client who is HIV-positive.

Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

✅ Correct Answer:

2. Place a client who has tuberculosis in a room with negative-pressure airflow.

A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Options:

Rock the client up to a standing position.

Pivot on the foot that is the farthest from the chair.

Assess the client for orthostatic hypotension.

Apply a gait belt to the client.

Assess the client for orthostatic hypotension.

The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter.Which of the following findings at the IV site should the nurse identify as indicating infiltration?

Options:

A. Purulent exudate

B. Warmth

C. Skin blanching

D. Bleeding

✅ Correct Answer: C. Skin blanching

Skin blanching, edema, and coolness at the IV site indicate infiltration.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present.Which of the following findings should the nurse identify as a potential indication of elder abuse?

Options:

A. The caregiver is the client’s financial power of attorney.

B. The client is in a wheelchair with the wheels locked.

C. The client reports receiving a full bath twice each week

.D. The caregiver insists on remaining in the room.

✅ Correct Answer: D. The caregiver insists on remaining in the room.

A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A nurse is evaluating a client’s use of a cane.Which of the following actions should the nurse identify as an indication of correct use?

Options:

A. The top of the cane is parallel to the client’s waist.

B. When walking, the client moves the cane 46 cm (18 in) forward.

C. The client holds the cane on the stronger side of their body.

D. The client moves their stronger limb forward with the cane.

✅ Correct Answer: C. The client holds the cane on the stronger side of their body.

The client should hold the cane on the stronger side of their body to increase support and maintain alignment.

A nurse is providing discharge teaching to a client about self-administering heparin.Which of the following instructions should the nurse include in the teaching?

Options:

A. Insert the needle at a 15° angle.

B. Aspirate for blood return prior to administration.

C. Administer the medication into the abdomen.

D. Massage the site following the injection.

✅ Correct Answer: C. Administer the medication into the abdomen.

The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy.Which of the following interventions should the nurse implement to prevent infection?

Options:

A. Apply transparent dressing over the IV insertion site and securement device.

B. Shave excess hair from around the IV insertion site.

C. Cleanse the site with hydrogen peroxide before IV catheter insertion.

D. Palpate the site carefully just before inserting the IV catheter.

✅ Correct Answer: A. Apply transparent dressing over the IV insertion site and securement device.

Transparent dressing prevents infection by protecting the IV site.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy.Which of the following methods should the nurse use as a psychomotor approach to learning?

Options:

A. Role play

B. Group discussions

C. Question–answer meetings

D. Practice sessions

✅ Correct Answer: D. Practice sessions

Practice sessions require psychomotor skills when learning.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Options:

A. Auscultate lung sounds.

B. Measure urine output.

C. Monitor blood pressure readings.

D. Monitor electrolyte levels.

✅ Correct Answer: A. Auscultate lung sounds.

The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery.Which of the following actions is the nurse’s priority?

Options:

A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client.

B. Determine the reasons why the client is refusing to use the incentive spirometer.

C. Document the client’s refusal to participate in health restorative activities.

D. Administer a pain medication to the client.

✅ Correct Answer: B. Determine the reasons why the client is refusing to use the incentive spirometer.

The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.

A nurse is providing discharge instructions to a client who will be using a walker.Which of the following statements by the client indicates the teaching has been effective?

Options

A. "I will use an extension cord so I can watch television in the living room."

B. "I will hire someone to trim the tree that overhangs the front porch stairs."

C. "I will place my alarm clock on my bedroom dresser."

D. "I will replace the old throw rug in the kitchen with a new one."

"I will hire someone to trim the tree that overhangs the front porch stairs."

Clearing stairwells of any object that could cause the client to trip or the need to bend over will decrease the risk for falls.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

Options:

A. "When descending stairs, I will first shift my weight to my right leg."

B. "I should place my crutches 12 inches in front and to the side of each foot."

C. "As I sit down, I will hold one crutch in each hand."

D. "I will make sure the shoulder rests are snug against my armpits."

✅ Correct Answer: A. "When descending stairs, I will first shift my weight to my right leg."

To descend stairs, the client should first shift their body weight to their right, unaffected leg.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Options:

A. Insert the suction catheter while the client is swallowing.

B. Apply intermittent suction when withdrawing the catheter.

C. Place the catheter in a location that is clean and dry for later use.

D. Hold the suction catheter with their clean, nondominant hand.

✅ Correct Answer: B. Apply intermittent suction when withdrawing the catheter.

The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Options:

A. Erythema on pressure points

B. Lower-extremity pulse strength of 2+

C. Fluid intake of 3,000 mL per day

D. One bowel movement every other day

✅ Correct Answer: A. Erythema on pressure points

Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

Options:

A. "They allow the court to overrule an adult client’s refusal of medical treatment."

B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness."

C. "They permit a client to withhold medical information from health care personnel."

D. "They allow health care personnel in the emergency department to stabilize a client’s condition."

✅ Correct Answer: B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness."

Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Options:

A. Use a bed exit alarm system.

B. Raise four side rails while the client is in bed.

C. Apply one soft wrist restraint.

D. Dim the lights in the client’s room.

✅ Correct Answer: A. Use a bed exit alarm system

The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Options:

A. Check the client for injuries.

B. Move hazardous objects away from the client.

C. Notify the provider.

D. Ask the client to describe how they felt prior to the fall.

✅ Correct Answer: A. Check the client for injuries.

The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

Options:

A. "What could I have done to deserve this illness?"

B. "I blame medical science for not curing me."

C. "Where is my daughter at a time like this?"

D. "Will I ever begin to feel in charge of my life again?"

✅ Correct Answer: A. "What could I have done to deserve this illness?"

The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

Options:

A. "I'll get a blood sample from you and send it for a screening test."

B. "Beginning at age 60, you should have a colonoscopy."

C. "You should have a fecal occult blood test every year."

D. "The recommendation is to have a sigmoidoscopy every 10 years."

✅ Correct Answer: C. "You should have a fecal occult blood test every year."

Colorectal cancer screening for clients who are at average risk begins at age 45. One option for screening is a fecal occult blood test annually.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Options:

1️⃣ Wear sterile gloves when removing the old dressing.

2️⃣ Warm the irrigation solution to 40.5° C (105° F).

3️⃣ Cleanse the wound from the center outward.

4️⃣ Use a 20-mL syringe to irrigate the wound.

✅ Correct Answer:Cleanse the wound from the center outward.

The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Options:

1️⃣ Admitting diagnosis

2️⃣ Breath sounds

3️⃣ Body temperature

4️⃣ Diagnostic test results

✅ Correct Answer:Breath sounds

When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse is teaching a client and their family how to care for the client’s tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Options:

A. Remove the outer cannula cautiously for routine cleaning.

B. Use tracheostomy covers when outdoors.

C. Use sterile technique when performing tracheostomy care at home.

D. Cleanse irritated skin with full-strength hydrogen peroxide.

Correct Answer:✅ B. Use tracheostomy covers when outdoors.

Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and their family? (Select all that apply.)

Options:

A. Check the cord routinely for frays or tearing.

B. Keep the unit at least 1.2 m (4 ft) away from a gas stove.

C. Consider purchasing a generator for power backup.

D. Observe for signs of hypoxia.E. Select synthetic clothing and bedding.

Correct Answers:✅

A. Check the cord routinely for frays or tearing

C. Consider purchasing a generator for power backup.

D. Observe for signs of hypoxia.

Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.

Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.

wThe nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

Options:

A. Biofeedback

B. Aloe

C. Feverfew

D. Acupuncture

Correct Answer:✅ D. Acupuncture

The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

Correct Order of Steps:

1️⃣ Inject 10 units of air into the bottle of NPH insulin.

2️⃣ Inject 5 units of air into the bottle of regular insulin.

3️⃣ Withdraw the correct dose of regular insulin from the bottle.

4️⃣ Withdraw the correct dose of NPH insulin from the bottle.

✅ Final Answer (in order):

Inject 10 units of air into the bottle of NPH insulin.

Inject 5 units of air into the bottle of regular insulin.

Withdraw the correct dose of regular insulin from the bottle.

Withdraw the correct dose of NPH insulin from the bottle.

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

Answer Choices:

A. "We would consult the person appointed by your health care proxy to make decisions."

B. "We would give you oxygen through a tube in your nose."

C. "You would be unable to change your previous wishes about your care."

D. "We would insert a breathing tube while we evaluate your condition."

✅ Correct Answer: B. "We would give you oxygen through a tube in your nose."

Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse is calculating a client’s fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client’s intake and output record as 120 mL of fluid?

Answer Choices:

A. 2 cups of soup

B. 1 quart of water

C. 8 oz of ice chips

D. 6 oz of tea

✅ Correct Answer: C. 8 oz of ice chips

The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Answer Choices:

A. Discuss the risk factors for colon cancer.

B. Focus teaching on what the client will need to do in the future to manage their illness.

C. Provide the client with written information about the phases of loss and grief.

D. Reassure the client that this is an expected response to grief.

✅ Correct Answer: D. Reassure the client that this is an expected response to grief.

During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

A client demonstrates anger when the nurse does not respond within 5 minutes of ringing for the nurse. Which of the following is an appropriate response by the nurse?

Answer Choices:

A. "I'm sorry, but another client needed my attention."

B. "I could not arrive any sooner. What can I do for you?"

C. "We had an emergency on the unit and that was a priority, but now I'm here."

D. "That must be frustrating for you. How can I help you right now?"

✅ Correct Answer: D. "That must be frustrating for you. How can I help you right now?"

This response is therapeutic because the nurse is acknowledging the client's feelings and offering help.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Answer choices:

A. Insert the catheter at a 45° angle.

B. Place the client's arm in a dependent position.

C. Shave excess hair from the insertion site.

D. Initiate IV therapy in the veins of the hand.

✅ Correct Answer: B. Place the client's arm in a dependent position.

The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Answer choices:

A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.

B. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.

C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.

D. Use petroleum jelly to lubricate the client's nares, face, and lips.

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.

Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).