A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral
solution 5 mg/1 mL. How many mL should the nurse administer with each dose? (Use a leading zero if it
applies. Do not
...
A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral
solution 5 mg/1 mL. How many mL should the nurse administer with each dose? (Use a leading zero if it
applies. Do not use a trailing zero. Round the answer to the nearest tenth.)
0.4
A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who
have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of
the following clients?
A client who has chronic back pain and a history of being physically abused
Therapeutic touch consists of using the nurse's hands to harmonize energy fields and to facilitate relief of pain
or anxiety, such as for a client who has chronic back pain. The nurse can touch the client with their palms or
move the palms near, but not touching the client's body. Prior physical maltreatment and some mental health
disorders are contraindications for therapeutic touch, because touch or near touch could cause severe anxiety.
A nurse in a rehabilitation unit is assessing a group of clients who have traumatic brain injuries. The nurse
should identify that which of the following clients requires a priority referral?
A client who coughs after drinking liquids
The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse should address
first. The priority referral the nurse should make is to a speech-language pathologist because a client who
coughs after drinking liquids is at risk for aspiration. Manifestations of dysphagia include changes in voice tone,
coughing, delayed swallowing, pocketing of food, and occasional silent aspiration, which can occur if a client is
experiencing a decrease in sensation.
A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?
Raise the height of the bed to the level of the nurse's elbows.
A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. The nurse should
place the client in which of the following positions to reduce pressure on the client's bony prominences?
30° lateral
The 30° lateral position, along with positioning devices, can prevent pressure directly over the client's most
vulnerable bony prominences. This position can, however, cause pressure on the shoulder, ankle, anterior iliac
spine, and trochanter. Therefore, the nurse should ensure the client's head is midline and supported, rotation of
the spine is avoided, and position changes are implemented every 1 to 2 hr
A nurse is preparing to administer vancomycin 500 mg by intermittent IV infusion every 6 hr. Available is
vancomycin 500 mg in 0.9% sodium chloride 100 mL to infuse over 2 hr. The nurse should set the IV pump to
deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if applicable.
Do not use a trailing zero.)
50
A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination
Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance
directives?
Ask the client whether he has created advance directives.
A nurse is assessing a client who has hypokalemia. Which of the following manifestations should the nurse
expect?
Decreased bowel sounds
Decreased bowel sounds are an indication of hypokalemia because of decreased excitability of cells, resulting
in less responsiveness to normal stimuli in nerves and muscles.
A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation.
Which of the following interventions should the nurse include to reduce the client's risk for ventilatorassociated pneumonia?
Swab the client's mouth with chlorhexidine solution.
A nurse is providing teaching to a client following a thoracentesis. Which of the following actions should the
nurse take?
Position the client on her unaffected side.
The nurse should position the client on the unaffected side to help facilitate expansion of the affected lung
A nurse is completing a neurological assessment of an older adult client and notes that the client has become
increasingly confused and agitated in the last 48 hr. Which of the following conditions is the priority
assessment by the nurse?
Infection
A nurse is assessing a client who is receiving intermittent catheter irrigation following a transurethral
resection of the prostate (TURP). Which of the following manifestations is the priority for the nurse to report
to the provider?
Increase in bladder spasms
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following foods should the nurse recommend to the client as the best source of
potassium?
1 cup cantaloupe
A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the
following actions should the nurse take?
Ask a second nurse to witness the discarding of unused opioid medication.
The nurse should ask a second nurse to witness the discarding of unused opioid medication and sign the
designated form.
A nurse is providing discharge teaching to a client who is prescribed home oxygen therapy using a
compressed oxygen system. Which of the following statements by the client indicates to the nurse that the
teaching has been effective?
"I will store oxygen tanks in an upright position."
This statement by the client indicates an understanding of the teaching. The nurse should instruct the client to
store oxygen tanks in an upright position in a holder to prevent damage to the tank and injury to the client and
the client's family.
A school nurse is teaching a group of parents about measures to prevent firearm injuries in the home. Which
of the following instructions should the nurse include in the teaching?
"Keep ammunition and guns in separate, locked locations."
A nurse is performing postmortem care for an older adult client who has just died. Which of the following
actions should the nurse take?
Identify the client using two identifiers.
The nurse should identify the deceased client using two identifiers, such as name and birth date, or name and
account number, and then compare the identifiers to the information in the client's medical records.
A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the
nurse take to maintain the client's skin integrity?
Use an alcohol-free barrier product
The nurse should apply an alcohol-free barrier film to keep the client's skin dry and protect it from the collection
of moisture. This action will help to maintain the integrity of the client's skin.
Repostion every 2 hours
A nurse is preparing to administer an intramuscular injection to a client. At which of the following angles
should the nurse insert the needle?
90°
The nurse should plan to insert the needle at a 90° angle when administering medication via the intramuscular
route. The intramuscular route promotes quicker medication absorption into the muscle than the other routes of
medication administration.
45 60 degree- sub q
15 degree- intradermal
A nurse is providing teaching to an older adult client who has kyphosis and osteoporosis. Which of the
following statements by the client indicates to the nurse that the teaching has been effective?
"I will increase daily intake of calcium and vitamin D."
A nurse is assessing a client who has an NG tube with continuous enteral feedings. The nurse auscultates
coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the
nurse take next?
Position the client on her side.
The greatest risk to this client is aspiration from possible dislodgment of the NG tube and aspirated stomach
contents into the respiratory tract. Therefore, the priority nursing action to decrease exacerbation of the
condition is to position the client on their side.
A nurse is caring for a client who is receiving intermittent enteral feedings via gastrostomy tube (G-tube).
Which of the following actions should the nurse take when administering the feeding?
Pour the client's formula into the syringe, raising or lowering it to control the rate of flow.
A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess
before giving the client ice chips or fluids. (You will find "hot spots" to select in the artwork below. Select only
the hot spot that corresponds to your answer.)
A nurse is providing teaching about cough etiquette to a client who has influenza. Which of the following
instructions should the nurse include in the teaching?
Cover your nose and mouth with a tissue when coughing."
The nurse should instruct the client to cover their nose and mouth with a tissue when coughing. The client
should discard the tissue promptly in the nearest trash container.
A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the
following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.)
Examine the color
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