A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a
long-term care facility. Which of the following documentation should the nurse include?
A. Client flow sheet
B. Acuity ratings
C. Current medications
D. Incident reports - (correct Answer) - C. Current medications
The nurse should include the client's medications in the discharge summary to ensure client safety and
continuity of care.
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?
A. Use a resuscitation bag with 80% oxygen prior to the procedure.
B. Select a suction catheter that is half the size of the lumen.
C. Place the end of the suction catheter in water-soluble lubricant.
D. Adjust the wall suction apparatus to a pressure of 170 mm Hg. - (correct Answer) - B. 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 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 manager is overseeing the care activities on a unit. For which of the following situations should
the nurse manager intervene due to a violation of HIPAA guidelines?
A. A nurse who is caring for a client reviews the client's medical chart with a nursing student who is
working with the nurse.
B. A nurse asks a nurse from another unit to assist with documentation for a client.
C. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to
discuss the client's care.
D. A nurse discusses a client's status with the physical therapist who is caring for the client. - (correct
Answer) - B. A nurse asks a nurse from another unit to assist with documentation for a client.
Only health care professionals directly caring for a client should have access to the client's medical
information; therefore, this is a violation of HIPAA guidelines.
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the
following actions should the nurse take?
A. Gently shake the container of medication prior to administration.
B. Transfer the medication to a medicine cup.
C. Place the client in a semi-Fowler's position prior to medication administration.
D. Verify the dosage by measuring the liquid before administering it. - (correct Answer) - A. Gently shake
the container of medication prior to administration.
,The nurse should gently shake the liquid medication to ensure that the medication is mixed.
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?
A. Seal unused medications from the facility in a plastic bag.
B. Evaluate the client's ability to self-administer medications.
C. Report an identified discrepancy to The Joint Commission.
D. Compare prescriptions with medications the client received while at the facility. - (correct Answer) - D.
Compare prescriptions with medications the client received while at the facility.
When performing medication reconciliation, the nurse should create a current, accurate list of every
medication the client is or should be taking. Part of the process is comparing the medications the client
received at the facility with those the provider has prescribed for the client to take after discharge.
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?
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 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. (Move the steps into the box on the right, placing them in the order of performance. Use all
the steps.)
, A. Inject 5 units of air into the bottle of regular insulin.
B. Withdraw the correct does of NPH insulin from the bottle.
C. Inject 10 units of air into the bottle of NPH insulin.
D. Withdraw the correct does of regular insulin from the bottle. - (correct Answer) - C. Inject 10 units of
air into the bottle of NPH insulin.
A. Inject 5 units of air into the bottle of regular insulin.
D. Withdraw the correct does of regular insulin from the bottle.
B. Withdraw the correct does 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 completing an admission assessment for a client who reports vomiting and diarrhea for the
past 3 days. Which of the following findings should the nurse expect?
A. Neck vein distention
B. Urine specific gravity 1.010
C. Rapid heart rate
D. Blood pressure 144/82 mm Hg - (correct Answer) - C. Rapid heart rate
Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting
and diarrhea for 3 days.
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?
A. Rock the client up to a standing position.