1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy

1) The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the
client's tracheostomy c

1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.



1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and
pressure should be assessed f

2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi;
increased risk of infection

3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma
to trachea with higher pressure

4) Implementation: outcome not desired; increases the risk of trauma to lower airways

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2) A young adult brings a friend to the emergency department and states that the friend has been using heroin.
Which action by the nurse is th

1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date.



1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose

2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and
possible respiratory arrest

3) Assessment: outcome not priority; most important to assess airway and breathing

4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority

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3) The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which
question is MOST important

1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?"



1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment

,2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching

3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and
myocardial oxygen consumption; inc

4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain
dental work

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4) The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client
has pressed the button 1

1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain.



1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated

2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of
the pain, region and radiat

3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first

4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation

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5) A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's
blood pressure changes from

1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated.



1) Implementation: outcome not desired; no increase in venous return

2) Implementation: outcome not desired; will decrease venous return

3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on
inferior vena cava reduced

4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena
cava will prevent blood retu

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,6) A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST
indicates improving fluid s

1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82.

, 1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output
decreased and concentrated

2) Assessment: outcome not priority; indicates that blood is hemoconcentrated

3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours

4) Assessment: outcome not priority; normal BP is 120/80

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7) The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which
medication should the nurse quest

1. 20 mg oral escitalopram (Celexa) in the morning.
2. 40 mg oral furosemide (Lasix) in the morning.
3. 300 mg of oral gabapentin (Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at bedtime.



1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant

2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE
inhibitors increases risk of "firs

3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label
use for neuropathic pain

4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors

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8) The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the
nurse?



1. "My wife looks at the pin sites every day."
2. "I like to bathe in the tub."
3. "I drove to the library yesterday."
4. "I drink with a straw."



1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflammation and
infection

2) Implementation: outcome desired; showers increase risk of infection at pin sites

3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to turn with halo
device; increases the risk of inju

4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized neck