1. Which of the following is the most appropriate nursing intervention
when administering medication via a nasogastric (NG) tube?
A) Crush the tablets and mix them with warm water
B) Crush the tablets and mix them with a small amount of pudding
C) Check the NG tube for patency and flush with water before
administering medication
D) Use a syringe to administer the crushed tablets directly into the tube
Answer: C) Check the NG tube for patency and flush with water before
administering medication.
Rationale: Ensuring the NG tube is patent before administering
medication helps prevent blockages. Flushing with water before and
after medication administration ensures the medication is effectively
delivered and reduces the risk of tube occlusion.
2. A nurse is caring for a client with pneumonia who is receiving
oxygen therapy via nasal cannula. Which finding indicates that the
client may be receiving too much oxygen?
A) Cyanosis of the lips and fingertips
B) Increased respiratory rate
C) Restlessness and confusion
D) Respiratory rate of 18 breaths per minute
Answer: C) Restlessness and confusion.
Rationale: Restlessness and confusion are signs of oxygen toxicity or
hypercapnia (elevated carbon dioxide levels), which can occur with
excessive oxygen administration. A respiratory rate of 18 breaths per
minute is within normal limits, and cyanosis usually indicates
inadequate oxygenation, not excess.
,3. A nurse is caring for a client who is postoperative following a hip
replacement. The nurse should assess the client for which of the
following complications first?
A) Deep vein thrombosis (DVT)
B) Infection
C) Urinary retention
D) Constipation
Answer: A) Deep vein thrombosis (DVT).
Rationale: The most immediate concern postoperatively is the risk for
DVT due to decreased mobility. DVT can lead to serious complications
such as pulmonary embolism, which requires urgent intervention.
Infection, urinary retention, and constipation are also important but
typically not the first priority.
4. Which of the following tasks can a nurse delegate to a nursing
assistant?
A) Assessing a client’s wound for signs of infection
B) Administering oral medication to a stable client
C) Measuring vital signs on a stable client
D) Creating a care plan for a newly admitted client
Answer: C) Measuring vital signs on a stable client.
Rationale: Measuring vital signs for stable clients is within the scope of
practice for nursing assistants. Assessing wounds, administering
medications, and creating care plans require professional nursing
judgment and should be performed by a nurse.
, 5. A nurse is teaching a client about a low-sodium diet. Which of the
following foods should the nurse identify as high in sodium?
A) Fresh fruit
B) Whole grain bread
C) Canned soup
D) Fresh vegetables
Answer: C) Canned soup.
Rationale: Canned soups are often high in sodium due to added
preservatives and flavor enhancers. Fresh fruit, vegetables, and whole
grain bread typically contain little to no sodium unless otherwise
processed.
6. A nurse is caring for a client with a history of hypertension. Which
of the following actions should the nurse prioritize?
A) Assessing the client’s potassium levels
B) Educating the client on the importance of blood pressure monitoring
C) Administering prescribed antihypertensive medications
D) Monitoring for signs of fluid retention
Answer: C) Administering prescribed antihypertensive medications.
Rationale: Administering prescribed antihypertensive medications is the
priority intervention to manage hypertension. While assessing
potassium, educating the client, and monitoring for fluid retention are
important, controlling blood pressure is the immediate focus.
7. A nurse is caring for a client who has an indwelling urinary catheter.
Which of the following actions should the nurse take to reduce the
risk of catheter-associated urinary tract infection (CAUTI)?
when administering medication via a nasogastric (NG) tube?
A) Crush the tablets and mix them with warm water
B) Crush the tablets and mix them with a small amount of pudding
C) Check the NG tube for patency and flush with water before
administering medication
D) Use a syringe to administer the crushed tablets directly into the tube
Answer: C) Check the NG tube for patency and flush with water before
administering medication.
Rationale: Ensuring the NG tube is patent before administering
medication helps prevent blockages. Flushing with water before and
after medication administration ensures the medication is effectively
delivered and reduces the risk of tube occlusion.
2. A nurse is caring for a client with pneumonia who is receiving
oxygen therapy via nasal cannula. Which finding indicates that the
client may be receiving too much oxygen?
A) Cyanosis of the lips and fingertips
B) Increased respiratory rate
C) Restlessness and confusion
D) Respiratory rate of 18 breaths per minute
Answer: C) Restlessness and confusion.
Rationale: Restlessness and confusion are signs of oxygen toxicity or
hypercapnia (elevated carbon dioxide levels), which can occur with
excessive oxygen administration. A respiratory rate of 18 breaths per
minute is within normal limits, and cyanosis usually indicates
inadequate oxygenation, not excess.
,3. A nurse is caring for a client who is postoperative following a hip
replacement. The nurse should assess the client for which of the
following complications first?
A) Deep vein thrombosis (DVT)
B) Infection
C) Urinary retention
D) Constipation
Answer: A) Deep vein thrombosis (DVT).
Rationale: The most immediate concern postoperatively is the risk for
DVT due to decreased mobility. DVT can lead to serious complications
such as pulmonary embolism, which requires urgent intervention.
Infection, urinary retention, and constipation are also important but
typically not the first priority.
4. Which of the following tasks can a nurse delegate to a nursing
assistant?
A) Assessing a client’s wound for signs of infection
B) Administering oral medication to a stable client
C) Measuring vital signs on a stable client
D) Creating a care plan for a newly admitted client
Answer: C) Measuring vital signs on a stable client.
Rationale: Measuring vital signs for stable clients is within the scope of
practice for nursing assistants. Assessing wounds, administering
medications, and creating care plans require professional nursing
judgment and should be performed by a nurse.
, 5. A nurse is teaching a client about a low-sodium diet. Which of the
following foods should the nurse identify as high in sodium?
A) Fresh fruit
B) Whole grain bread
C) Canned soup
D) Fresh vegetables
Answer: C) Canned soup.
Rationale: Canned soups are often high in sodium due to added
preservatives and flavor enhancers. Fresh fruit, vegetables, and whole
grain bread typically contain little to no sodium unless otherwise
processed.
6. A nurse is caring for a client with a history of hypertension. Which
of the following actions should the nurse prioritize?
A) Assessing the client’s potassium levels
B) Educating the client on the importance of blood pressure monitoring
C) Administering prescribed antihypertensive medications
D) Monitoring for signs of fluid retention
Answer: C) Administering prescribed antihypertensive medications.
Rationale: Administering prescribed antihypertensive medications is the
priority intervention to manage hypertension. While assessing
potassium, educating the client, and monitoring for fluid retention are
important, controlling blood pressure is the immediate focus.
7. A nurse is caring for a client who has an indwelling urinary catheter.
Which of the following actions should the nurse take to reduce the
risk of catheter-associated urinary tract infection (CAUTI)?
