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A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through
an open system. Which of the following actions should the nurse take first?
Rinse the feeding back with water between feedings
Tell the client to keep the head of the bed elevated at least 30 degrees
Make sure the enteral formula is at room temperature
Wipe the top of the formula can with alcohol
Tell the client to keep the head of the bed elevated at least 30 degrees
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following
examples should the nurse include in the teaching? (Select all)
A. Home health care
B. Rehabilitation facilities
C. Diagnostic centers
D. Skilled nursing facilities
E. Oncology center
A. home health care
B. rehabilitation facilities
D. skilled nursing facilities
A nurse is explaining the various types of healthcare coverage clients might have To a group of
nursing students. Which of the following healthcare financing mechanisms are federally
funded? (Select all)
A. Preferred provider organization (PPO)
B. Medicare
C. Long term care insurance
D. Exclusive provider organization (EPO)
E. Medicaid
B. Medicare
E. Medicaid
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should
the nurse take?
Record the time and length of the seizure.
,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?
Medication name
Route of administration
Medication dose
Frequency of administration
Medication dose
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?
"This type of hearing aid does not allow for fine tuning of volume"
"I shouldn't have trouble keeping the hearing aid in place during exercise"
"I expect to hear a whistling sound when I first insert the hearing aid"
"I will be sure to remove my hearing aid before taking a shower"
"I will be sure to remove my hearing aid before taking a shower"
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the
client was trying to get out of bed and fell over the side rail onto the floor. Which of the
following statements should the nurse document about this incident?
"Incident report completed"
"Client climbed over the side rails"
"Client found lying on the floor"
"Client was trying to get out of bed"
"Client found lying on the floor"
A nurse on a medical unit is preparing to discharge a client to home. Which of the following
actions should the nurse take as part of the medication reconciliation process?
Seal unused medications from the facility in a plastic bag
Evaluate the client's ability to self administer medications
Report an identified discrepancy to The Joint Commission
Compare prescriptions with medications the client received while at the facility
Compare prescriptions with medications the client received while at the facility
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A nurse is caring for a client who requires an informed consent for a surgical procedure. Which
of the following actions is the nurse's responsibility?
Describe the procedure to the client
Witness the client's signature on the consent form
Inform the client of alternatives to the procedure
Tell the client which team members will assist with the procedure
Witness the client's signature on the consent form
A nurse is planning an educational program for a group of older adults at a senior living center.
Which of the following recommendations should the nurse include?
"You should have an eye examination every 2 years"
"You should receive a tetanus booster every 5 years"
"You should receive a shingles vaccine when you are 70 years old"
"You should receive a pneumococcal vaccine when you are 65 years old"
"You should receive a pneumococcal vaccine when you are 65 years old"
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The
client's partner wants the client to have the blood transfusion. Which of the following actions
should the nurse take?
Ask the client to consider a direct donation
Withhold the blood transfusion
Request a consultation with the ethics committee
Ask the client's family to intervene
Withhold the blood transfusion
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A nurse is admitting a client who has rubella. Which of the following types of transmission
based precautions should the nurse initiate?
droplet
airborne
contact
protective environment