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1. A nurse is planning to collect a stool specimen for ova and parasites from a client who has
diarrhea. Which of the following actions should the nurse take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container for stool
collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a tongue
depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the laboratory
after labeling the specimen properly to prevent contamination with microorganisms and keep the
specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with the client
label on the container and the bag for easy identification. This will also prevent contamination
with microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of
thefollowing actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for several
minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
,C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage to the
tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
5. A nurse is caring for a client who has bilateral cats on her hands. Which of the following
actions should the nurse take when assisting the client with feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client withthe
nurse’s full attention during the feeding
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B. Order pureed foods
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-incorrect: Without any mouth or throat injuries that make chewing or swallowing difficult, the
client should be served foods of an appropriate variety of textures. Pureed foods are for clients
who cannot chew, have difficulty swallowing, or do not have teeth.
C. Make sure feedings are provided at room temperature
-incorrect: The nurse should ask the client if the food is the correct temperature
D. Offer the client a drink of fluid after every bite
-incorrect: If the client is unable to communicate, the nurse should offer the client fluids after
every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate.
Therefore, the client should tell the nurse when she would like a drink.
3. A nurse is providing teaching to a client regarding protein intake. Which of the
followingfoods should the nurse include as an example of an incomplete protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
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C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for the
synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables,
grains, nuts, and seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation
after a total hip arthroplasty. At which of the following times should the nurse begin discharge
planning?
A. One week prior to the client’s discharge
-incorrect: Beginning to plan for the client’s discharge a week prior to the event might not allow
sufficient time for planning. The nurse should begin discharge planning at the time of admission.
B. Upon the client’s admission to the care facility
-The nurse should begin discharge planning at the time that the client is admitted to the facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client’s discharge once the discharge date is identified might
not allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client’s discharge once the discharge date is identified might
not allow sufficient time for planning. The nurse should begin discharge planning at the time of
admission.
5. A nurse is preparing to administer a cleansing enema to a client. Which of the
followingactions should the nurse plan to take?
A. Insert the rectal tube 15.2 cm (6 in)
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent contamination.
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