What instruction should the nurse give a patient after administering ear drops?

“Remain in the same position with your head turned upward.”

Which nursing action is most appropriate when caring for a patient newly diagnosed with a terminal illness?

Gently guide care while encouraging the pt to express feelings and fears

A nurse walks into a patient’s room. What should be the first assessment for signs of respiratory distress?

Look for nasal flaring, grunting, retractions, or cyanosis

A nurse takes a pt's vital signs and notes an elevated blood pressure and heart rate. What should the nurse do next?

Document and refer the findings to the provider

A nurse needs to take a rectal temperature on an infant. Which action is correct?

Lubricate the red probe and insert toward the umbilicus no more than 1 inch

A nurse is caring for a client in the PACU following neck surgery. Which should reported to the immediately

Excessive swallowing and restlessness

A nurse is teaching a client with a new ileostomy. Which statement by the client indicates correct understanding?

"I’ll clean the skin around my stoma and keep it dry."

A nurse is about to assist a visually impaired patient. Which action shows best practice?

Explaining all actions before performing them

Which of the following strategies can help improve sleep hygiene? Select all that apply.

Avoid electronics in the sleeping area, Take a warm bath or shower before bed

A nurse notices a patient with a terminal illness is hesitant about hospice care. What is the best action?

Encourage the pt to ask questions &offer to relay concerns to the physician

What is true about intradermal injections?

Inject at a 5–15° angle with a small-gauge needle

What is the primary role of a Certified Nursing Assistant (CNA)?

Assist with activities of daily living (ADLs) and communicate patient needs

A visually impaired patient is about to eat. What is the most helpful action by the nurse?

Describe the location of food using a clock format

How should a 24-hour urine specimen be handled?

It should be refrigerated and kept on ice at all times

A confused patient is admitted to the unit. What is the most appropriate room assignment to promote safety?

A room near the nurse’s station for frequent observation

What is the primary goal of medication reconciliation?

To identify any potential medication errors or interactions

A client with an ileostomy asks why the bag needs to be emptied when it’s only half full. What is best response?

“Emptying it halfway prevents leaks and skin irritation.”

A nurse has four patients to see at the beginning of the shift. Which patient should the nurse see last?

A confused older adult who needs orientation and basic care

A patient complains of burning after cold therapy was applied for 25 minutes without a barrier. priority action?

Assess the skin for injury and stop the therapy

What is the primary goal when applying restraints to a patient?

To use the least amount of restraint for the least amount of time

Which of the following best describes developmental changes due to aging?

Natural, progressive changes that occur over time

A nurse is preparing a deceased patient’s body for the coroner. Which behavior is appropriate?

Keep conversation minimal and maintain a respectful silence

A nurse is applying heat therapy to a patient's knee. Which of the following actions is appropriate?

Place a towel between the skin and the heat source

A nurse is preparing to take an oral temperature. The patient just drank a cup of hot tea. What should the nurse do?

Take an axillary temperature instead

A nurse is assisting a visually impaired patient with meals. Which of the following actions is most appropriate?

Describing the plate using the clock method and offering choice

A nurse is preparing to take a patient’s blood pressure. Which of the following actions ensures an accurate reading?

Confirming the monitor is calibrated and using the correct cuff size

The nurse observes the skin around a client's colostomy and notes redness and irritation. What should nurse do first?

Notify the provider immediately

A nurse is assessing oxygenation using a pulse oximeter. Which should be done to ensure an accurate reading?

Assess capillary refill and warm the site before placement

When taking diuretics, which of the following is the recommended timing to minimize nighttime disruptions?

Take diuretics in the early morning

What is a primary advantage of cold therapy?

Reduces tissue swelling through vasoconstriction

A patient with a tracheostomy is being suctioned when their oxygen saturation drops to 88%. nurse's priority action?

Stop suctioning and begin oxygenation with an Ambu bag

A patient has just been diagnosed with a terminal illness. What is the nurse’s priority when beginning care?

Determine the patient’s preferences and prevent discomfort

When performing medication reconciliation, what is the recommended method for collecting a patient's medication list?

Having the family bring in the medications in a plastic bag for review

How should the nurse approach the patient when asking for their medication history?

By apologizing for asking the same info again, being kind, getting hx

What is the primary purpose of using the Z-track method when administering intramuscular injections?

To prevent leakage of medication into subcutaneous tissue

pt who was recently started on antidepressants suddenly appears cheerful &begins giving away personal belongings.

Immediately assess for suicidal ideation and a possible plan

Which of the following is a respectful and appropriate nursing action when providing postmortem care?

Wait to call the coroner until the family is ready

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part 2

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Questions 81

Answers

1
What instruction should the nurse give a patient after administering ear drops?
“Drink water to help absorption.”
“Remain in the same position with your head turned upward.”
“Blink quickly for 30 seconds.”
“Blow your nose.”
2
Which nursing action is most appropriate when caring for a patient newly diagnosed with a terminal illness?
Focus only on the physical symptoms, not emotional concerns
Gently guide care while encouraging the pt to express feelings and fears
Avoid discussing hospice to protect the patient’s emotions
Give advice about treatment options without delay
3
What should the nurse do before administering nose drops to a patient?
Administer eye drops first
Tilt the head back and immediately drop medication
Clean the nose with a tissue
Ask the patient to cough
4
A nurse walks into a patient’s room. What should be the first assessment for signs of respiratory distress?
Ask the patient to describe their pain
Look for nasal flaring, grunting, retractions, or cyanosis
Listen to breath sounds
Check pulse oximetry
5
A nurse takes a pt's vital signs and notes an elevated blood pressure and heart rate. What should the nurse do next?
Ignore the results if the patient appears fine
Document and refer the findings to the provider
Continue with height and weight measurements
Take the blood glucose immediately
6
The nurse is preparing to administer a 2 mL intramuscular injection into the deltoid. Which needle size
5/8 inch, 25-gauge
1½ inch, 18-gauge
1 inch, 22-gauge
2 inch, 20-gauge
7
A nurse needs to take a rectal temperature on an infant. Which action is correct?
Use the blue probe and insert toward the spine
Insert the probe 2 inches straight in
Use an oral thermometer with a cover
Lubricate the red probe and insert toward the umbilicus no more than 1 inch
8
A nurse is caring for a client in the PACU following neck surgery. Which should reported to the immediately
Slight swelling around the surgical site
SpO₂ of 95% on room air
Patient reports 5/10 pain
Excessive swallowing and restlessness
9
When collecting a specimen, how should it be labeled?
With a generic label
On the container itself
On the lid of the container
With the patient's initials only
10
A nurse is teaching a client with a new ileostomy. Which statement by the client indicates correct understanding?
I should empty my ostomy bag when it’s completely full."
"I’ll clean the skin around my stoma and keep it dry."
"My stool will be solid and formed."
If the stoma is pink or pale, that’s normal."
11
A nurse is about to assist a visually impaired patient. Which action shows best practice?
Standing silently until the patient notices them
Keeping lights dim to protect the patient’s eyes
Using hand signals to enhance communication
Explaining all actions before performing them
12
Which of the following strategies can help improve sleep hygiene? Select all that apply.
Avoid electronics in the sleeping area
Engage in vigorous exercise right before bed
Take a warm bath or shower before bed
Sleep with a full stomach to prevent heartburn
13
A nurse notices a patient with a terminal illness is hesitant about hospice care. What is the best action?
Avoid bringing it up again unless the patient asks
Encourage the pt to ask questions &offer to relay concerns to the physician
Begin hospice enrollment without the patient’s input
Tell the patient that hospice is the only option
14
What is true about intradermal injections?
Inject at a 5–15° angle with a small-gauge needle
Insert 1 inch into the skin
Aspirate before injecting
Use a 21-gauge needle at a 45° angle
15
A nurse is assessing a client at a clinic visit. What is the first step in the initial assessment process?
Ask about the client’s medical history
Take vital signs
Meet and greet the client
Weigh the client
16
What is the primary role of a Certified Nursing Assistant (CNA)?
Assist with activities of daily living (ADLs) and communicate patient needs
Administer IV push medications
Create care plans and conduct initial assessments
Perform physical assessments and develop care strategies
17
A visually impaired patient is about to eat. What is the most helpful action by the nurse?
Describe the location of food using a clock format
Turn the tray so the meat is facing forward
Feed the patient without explanation
Ask the patient to guess what is on the tray
18
How should a 24-hour urine specimen be handled?
It should be stored in the patient's room until it's ready to be sent
t can be collected without keeping track of time
It can be left at room temperature
It should be refrigerated and kept on ice at all times
19
Which of the following routes is considered parenteral?
Sublingual
Buccal
Oral
Intramuscular (IM)
20
A confused patient is admitted to the unit. What is the most appropriate room assignment to promote safety?
A room near the nurse’s station for frequent observation
A private room far from the nurse’s station
A quiet room with the door closed
A room with another confused patient
21
What is the primary goal of medication reconciliation?
To eliminate all over-the-counter medications
To track the medications a patient takes for future reference
To identify any potential medication errors or interactions
To ensure all medications are prescribed by one doctor
22
When is the best time to perform postural drainage in the prone position?
Right after lunch
Before breakfast
Before bedtime
Immediately after fluid intake
23
A client with an ileostomy asks why the bag needs to be emptied when it’s only half full. What is best response?
“It’s easier to manage if it’s fuller.”
That’s just the hospital’s policy.”
“Waiting until it’s full helps reduce odor.”
“Emptying it halfway prevents leaks and skin irritation.”
24
A nurse has four patients to see at the beginning of the shift. Which patient should the nurse see last?
A post-op patient requesting pain medication
A patient waiting for discharge teaching
A patient with shortness of breath
A confused older adult who needs orientation and basic care
25
A patient complains of burning after cold therapy was applied for 25 minutes without a barrier. priority action?
Apply heat to counteract the cold
Reapply the cold pack with a towel
Continue cold therapy for another 5 minutes
Assess the skin for injury and stop the therapy
26
What is the primary goal when applying restraints to a patient?
To prevent any movement from the patient
To use the least amount of restraint for the least amount of time
To keep the patient immobilized for as long as possible
To cause discomfort so the patient stops resisting
27
How many suction passes should the nurse perform during one suctioning session for a tracheostomy patient?
As many as needed
One
Two
Three
28
Which of the following best describes developmental changes due to aging?
Changes resulting from life experiences or learning
Changes due to a traumatic event in early life
Changes caused by a recent illness or injury
Natural, progressive changes that occur over time
29
During postural drainage, which healthcare professional is most likely to assist w/inducing coughing to clear secretions
Respiratory Therapist
Dietitian
Nurse Practitioner
Physical Therapist
30
A nurse is preparing a deceased patient’s body for the coroner. Which behavior is appropriate?
Immediately move on to other tasks without acknowledging the death
Leave the door open for air circulation
Laugh and chat with coworkers to ease tension
Keep conversation minimal and maintain a respectful silence
31
A nurse is applying heat therapy to a patient's knee. Which of the following actions is appropriate?
Apply cold immediately after to reduce swelling
Place a towel between the skin and the heat source
Leave the heat pack on for 40 minutes continuously
Apply heat directly to the skin for faster relief
32
While auscultating the carotid artery, the nurse hears a turbulent, whooshing sound. How should this be documented?
Murmur
Thrill
Gallop
Bruit
33
A nurse is preparing to take an oral temperature. The patient just drank a cup of hot tea. What should the nurse do?
Proceed with the oral temperature
Take an axillary temperature instead
Take a rectal temperature immediately
Wait 15 minutes before taking an oral temp
34
A nurse is reviewing strategies for improving sleep with a pt. Which suggestions are appropriate? Select all that apply.
Use a nightlight in the bathroom for safety
Eliminate technology in the bedroom
All the above
Keep a consistent bedtime routine
35
A nurse is assisting a visually impaired patient with meals. Which of the following actions is most appropriate?
Describing the plate using the clock method and offering choice
Feeding the patient without asking preferences
Asking the family to feed the patient instead
Letting the patient explore the tray independently
36
A nurse is preparing to take a patient’s blood pressure. Which of the following actions ensures an accurate reading?
Taking the BP immediately after the patient walks
Placing the cuff over clothing
Using a small adult cuff for all adults
Confirming the monitor is calibrated and using the correct cuff size
37
A nurse palpates a vibratory sensation over a patient’s chest near the heart. best term to document this finding?
Murmur
Thrill
Bruit
Gallop
38
When caring for a patient with suspected sepsis and high fever, most appropriate method accurate core temperature?
Tympanic
Axillary
Rectal
Oral
39
A client’s blood glucose level is 132 mg/dL. The client reports they were fasting. How should interpret this result?
Diabetic level
Normal fasting blood glucose
Prediabetic level
Hypoglycemic level
40
Which type of ostomy will most likely produce liquid stool?
Colostomy
Ileostomy
Urostomy
Gastrostomy
41
The nurse observes the skin around a client's colostomy and notes redness and irritation. What should nurse do first?
Wash with soap and water and apply lotion
Suggest the client avoid emptying the pouch for 24 hours
Notify the provider immediately
Apply talcum powder
42
A nurse is assessing oxygenation using a pulse oximeter. Which should be done to ensure an accurate reading?
Use any size sensor; size doesn't affect reading
Assess capillary refill and warm the site before placement
Place the sensor on a cold finger
Choose the largest finger for the clip
43
When taking diuretics, which of the following is the recommended timing to minimize nighttime disruptions?
Take diuretics in the early morning
Take diuretics at bedtime to ensure effectiveness
Take diuretics with dinner
Take diuretics in the late evening before bed
44
What is a primary advantage of cold therapy?
Prevents infection
Promotes vasodilation
Reduces tissue swelling through vasoconstriction
Increases tissue elasticity
45
A patient with a tracheostomy is being suctioned when their oxygen saturation drops to 88%. nurse's priority action?
Wait 30 seconds and attempt suction again
Continue suctioning to fully clear the airway
Stop suctioning and begin oxygenation with an Ambu bag
Recheck the pulse oximeter for accuracy
46
A patient has just been diagnosed with a terminal illness. What is the nurse’s priority when beginning care?
Determine the patient’s preferences and prevent discomfort
Ask the family to take over care decisions
Offer reassurance that everything will be fine
Encourage the patient to start treatment immediately
47
When performing medication reconciliation, what is the recommended method for collecting a patient's medication list?
Asking the patient to recall their medications from memory
Only focusing on prescription medications& excluding OTC or herbal remedies
Relying on the pharmacy to provide the list
Having the family bring in the medications in a plastic bag for review
48
How should the nurse approach the patient when asking for their medication history?
By making it a quick process and asking yes/no questions only
By rushing to avoid taking up too much of the patient’s time
asking for the list without acknowledging the patient’s previous responses
By apologizing for asking the same info again, being kind, getting hx
49
What is the primary purpose of using the Z-track method when administering intramuscular injections?
To reduce the size of the wheal formed
To minimize medication absorption
To prevent leakage of medication into subcutaneous tissue
To aspirate for blood return
50
pt who was recently started on antidepressants suddenly appears cheerful &begins giving away personal belongings.
Inform the family to keep an eye out
Document the behavior and monitor for changes
Immediately assess for suicidal ideation and a possible plan
Praise their improved mood
51
Which of the following is a respectful and appropriate nursing action when providing postmortem care?
Immediately remove the body from the room before the family arrives
Wait to call the coroner until the family is ready
Leave the body uncovered for easy access
Leave all jewelry on the patient at all times
52
Which of the following practices supports a healthy sleep environment?
Doing taxes in bed
Watching TV until falling asleep
Using the bedroom only for sleep and sex
Drinking soda with dinner every night
53
A nurse is suctioning a client with a tracheostomy. Which action is correct during the procedure?
Suction continuously for at least 15 seconds
Apply suction only while withdrawing the catheter
Suction as many times as needed until secretions stop
Apply suction while inserting the catheter
54
A nurse is caring for a confused older adult. What is the best strategy to help maintain the patient’s orientation?
Keep the room dark and quiet
Limit conversation to reduce stimulation
Use a clock, calendar, and family photos in the room
Turn on the TV at all times to provide background noise
55
A nurse is educating a client on sleep hygiene. Which statement indicates a need for further teaching?
I’ll take a hot shower and immediately go to bed afterward.”
I’ll do breathing exercises before bed.”
“I’ll stop drinking fluids after 6 p.m.”
“I’ll use blackout curtains to block light in my room.”
56
A nurse is performing an initial assessment in the PACU. Which of the following is the priority action?
Ask the patient about their pain level
Check the IV site for infiltration
Check for bowel sounds
Monitor the oxygen flow and mask placement
57
A nurse hears an abnormal, rhythmic heart sound with a cadence like a horse’s gallop. This is most likely associated
Carotid artery narrowing
Normal aging
Heart failure
Valvular stenosis
58
Which of the following pulse rates is within the normal adult range at rest?
38 bpm
68 bpm
102 bpm
52 bpm
59
A post-op pt is experiencing airway swelling. what med is most likely to be given to reduce reduce airway inflammation
Ondansetron
Prednisone
Acetaminophen
Morphine
60
A nurse is preparing a patient for postural drainage. Which of the indicates the pt needs further teaching?
"I should drink a full glass of water right before the session."
"The therapist may use a vest that applies pressure to my back."
"I should expect to cough up a lot of mucus."
"I may feel nauseous or vomit after the procedure."
61
Which of the following is required before applying restraints?
No documentation or assessment is needed
Restraints can be applied without notifying the physician
A physician’s order and the doctor’s presence for application
Informing family members only
62
Where should eye drops be administered to ensure proper absorption and avoid contamination?
In the outer corner of the eye
Into the conjunctival sac (lower eyelid pouch)
On the upper eyelid
Directly on the cornea
63
Which of the following specimens are typically collected in a sterile manner? Select all that apply.
Blood
Urine
Stool for a guiac test
Phlegm (sputum)
64
What should the nurse specifically look for in a patient's medication list?
Possible interactions between prescribed meds and over-the-counter drugs
The total number of medications the patient is taking
The patient's preferred method of taking their medications
Only the medications prescribed by the current healthcare provider
65
What should the nurse do if an autopsy is planned for a deceased patient?
Begin bathing and dressing the patient immediately
Cover the body and call the coroner without delay
Inform the family and leave all medical equipment in place
Remove all tubes and lines from the body
66
What should a nurse or healthcare provider do before entering a patient's room to collect medication information?
Wait for the patient to explain their medical history
Only read the patient’s name and date of birth
Read the chart, admission notes, past medical history, and chief complaint
Focus only on the patient’s current medications
67
A client asks how to fall asleep more easily. What advice should the nurse give?
“Taper fluid intake after 6 p.m. to avoid nighttime bathroom trips.”
Use your bedroom for work to save time.”
“Exercise right before bed to tire yourself out.”
Check your phone in bed to relax before sleeping.”
68
What is the primary goal of postural drainage in the prone position for a patient with lower lobe atelectasis?
Reduce respiratory rate
Mobilize secretions from the lower lobes
Improve circulation to the lungs
Increase oxygen saturation by 10% immediately
69
What should the nurse do if they identify any urgent potential medication reactions during history-taking?
Report info to the healthcare team, especially if there’s a risk of harm
Only report the issue if the patient complains of a side effect
Ignore the findings unless the patient shows symptoms
Wait until the next shift to address the concern
70
Which of the following tasks can a Licensed Vocational Nurse (LVN) perform?
Conduct initial patient assessments
Perform the initial teaching session for a patient
Create a care plan for the patient
Insert a catheter and monitor blood glucose
71
How does the role of a Registered Nurse (RN) differ from that of an LVN?
RNs cannot administer any medications
LVNs can perform initial assessments
RNs create the care plan and perform initial assessments
RNs are responsible for stocking supplies
72
What is the correct first step in a 24-hour urine collection?
Start timing immediately
Place container at bedside
Discard the first void
Put the first void in the container
73
Which of the following are appropriate actions when you suspect someone is contemplating suicide?
Stay with the person and refer them to crisis services
Assess whether they have a plan and means to carry it out
Stay with the person and refer them to crisis services
Ask directly if they are thinking about suicide
74
Asking the patient to recall their medications from memory
Only the medications prescribed by the current healthcare provider
Only prescription and over-the-counter medications
Only prescription medications
All meds, including OTC, prescription, herbal supplements, and substances
75
Which IM site is best for giving a large, thick medication to a post-op abdominal patient?
Vastus lateralis
Ventrogluteal
Deltoid
Dorsogluteal
76
What best describes a murmur heard during auscultation?
It is a result of peripheral arterial disease
It is a vibratory sensation on palpation
It is a high-pitched heart sound from turbulent blood flow
It is a normal variant in young adults
77
A nurse is monitoring a client in the PACU after throat surgery. Which finding is most concerning?
Inability to speak
Mild incisional discomfort
Audible stridor and labored breathing
Patient nods in response to questions
78
Which of the following medications is commonly administered sublingually for rapid absorption?
Nitroglycerin
Acetaminophen
Morphine sulfate (extended-release)
Amoxicillin
79
A nurse is caring for a hospice patient. Which statement best reflects the focus of hospice care?
We’ll try different antibiotics to fight the disease."
"Our goal is to keep you comfortable and manage your symptoms."
"There is still time to consider surgery or chemotherapy."
"We’re here to cure your condition and get you home quickly."
80
When administering oral medications, what must the nurse do?
Leave the room after handing the patient the meds
Check the patient's mouth to ensure the medication has been swallowed
Crush every pill to aid in swallowing
Let the patient decide when to take the pills
81
What is the correct site for administering a subbuccal medication?
On top of the tongue
In the cheek pouch
Under the tongue
At the back of the throat

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