Question 1
Custom NURS307a Exam 2. A nurse is assessing a client who has a pressure ulcer and notes a full-thickness skin loss with a deep crater and no bone or muscle exposure. Which of the following stages should the nurse document?
- Stage I
- Stage II
- Stage III
- Stage IV
Question 2
A nurse is caring for a client who has a chest tube connected to a water seal drainage system. Which of the following findings should the nurse expect?
- The water level in the water seal chamber rises with inspiration.
- Constant bubbling in the water seal chamber.
- The drainage system is kept at the level of the client’s chest.
- The chest tube is clamped during ambulation.
Question 3
A nurse is preparing to provide care for a client. Which of the following actions should the nurse take to maintain standard precautions?
- Wear a gown for all client contact.
- Wear a mask when working within 3 feet of the client. Custom NURS307a Exam 2.
- Wear gloves when in contact with body fluids.
- Use a private room for the client.
Question 4
A nurse is caring for a client who has a tracheostomy tube. Which of the following actions should the nurse take if the tube becomes dislodged?
- Attempt immediate reinsertion of the tracheostomy tube.
- Perform a respiratory assessment.
- Notify the provider.
- Place the client in a side-leaning position.
Question 5
A nurse is preparing a sterile field. Which of the following actions should the nurse take?
- Consider the 1-inch border of the sterile field to be sterile.
- Continue to use the sterile field if the outer edge becomes contaminated.
- Place sterile items on the field with clean hands.
- Reach across the sterile field to pick up an item.
Question 6
A nurse is preparing to insert a nasopharyngeal airway (NPA). Which of the following actions should the nurse take to determine the correct size?
- Measure from the tip of the nose to the tip of the chin.
- Measure from the tip of the nose to the corner of the mouth.
- Measure from the tip of the nose to the earlobe.
- Measure from the corner of the mouth to the earlobe.
Question 7
A nurse is suctioning a client’s tracheostomy. Which of the following actions should the nurse take?
- Suction for 20 seconds with each pass.
- Apply suction while inserting the catheter.
- Limit suctioning to 1 to 2 passes with a 60-second pause between each.
- Use a clean technique during the procedure.
Question 8
A nurse is monitoring a client who is receiving a blood transfusion. The client reports itching and has hives. Which of the following actions should the nurse take?
- Slow the rate of the transfusion.
- Stop the transfusion.
- Administer an antihistamine and continue the transfusion.
- Notify the provider after the transfusion is complete.
Question 9
A nurse is preparing to administer a medication to a client. Which of the following actions should the nurse take?
- Verify the client’s identity before administration.
- Administer the medication if it is not labeled.
- Rely on the client’s room number for identification.
- Document the administration before giving the medication.
Question 10
A nurse is preparing to prime an IV tubing set for a client who is to receive a blood transfusion. Which of the following solutions should the nurse use? Custom NURS307a Exam 2.
- 5% Dextrose in water
- 0.9% Sodium Chloride
- Lactated Ringer’s
- 0.45% Sodium Chloride
Question 11
A nurse is caring for a client who had a urinary catheter removed 4 hours ago. The client reports the inability to void. Which of the following actions should the nurse take first?
- Perform a bladder scan.
- Insert a straight catheter.
- Encourage the client to increase fluid intake.
- Notify the provider.
Question 12
A nurse is reviewing the indications for urinary catheterization. Which of the following situations are appropriate for an indwelling urinary catheter? (Select all that apply.)
- A client who has an open perineal wound.
- A client who requires relief of urinary retention.
- A client who has a post-void residual (PVR) of 600 mL.
- A client who is incontinent of urine.
Question 13
A nurse is preparing to administer an IV medication and notes the client’s IV site is red, warm, and painful. Which of the following actions should the nurse take?
- Remove the catheter and prepare a different site.
- Apply a warm compress and continue the infusion.
- Slow the rate of the infusion.
- Flush the IV site with normal saline.
Question 14
A nurse is preparing to insert a nasogastric (NG) tube for a client. Which of the following actions should the nurse take?
- Assess both nares to select the more patent nostril.
- Have the client tilt their head back during insertion.
- Lubricate the tube with a petroleum-based jelly.
- Measure the tube from the tip of the nose to the earlobe.
Question 15
A nurse is preparing to administer a medication. The order is for 20 mg and the medication is available in 5 mg tablets. How many tablets should the nurse administer?
- 1
- 2
- 3
- 4.0
Question 16
A nurse is caring for a client who is experiencing a transfusion reaction. The client has low back pain and hemoglobinuria. Which of the following types of reactions is the client experiencing?
- Acute Hemolytic
- Febrile Non-hemolytic
- Allergic
- Circulatory Overload Custom NURS307a Exam 2.
Question 17
A nurse is preparing a sterile field. Which of the following actions should the nurse recognize as a contamination of the field?
- Opening a sterile package over the middle of the sterile field.
- Keeping sterile objects within the field of vision.
- Placing a sterile object 2 inches from the edge of the field.
- Dropping a sterile item onto the center of the field.
Question 18
A nurse is assessing a client who is in respiratory distress. Which of the following actions should the nurse take first?
- Administer supplemental oxygen via nasal cannula.
- Obtain a chest X-ray.
- Collect an arterial blood gas (ABG) sample.
- Notify the provider.
Question 19
A nurse is preparing to administer a blood transfusion. Which of the following actions should the nurse take?
- Administer the transfusion over 2 to 4 hours.
- Use a 24-gauge IV catheter.
- Verify the blood product with one other nurse.
- Start the transfusion within 1 hour of receiving it from the blood bank.
Question 20
A nurse is preparing to administer cefadroxil oral suspension 15 mg/kg PO to a client who weighs 98 lb. Available is cefadroxil 250 mg/5 mL. Which of the following actions should the nurse take first?
- Round the amount to be administered to the nearest whole number.
- Calculate the dosage in milligrams.
- Convert the client’s weight to kilograms.
- Calculate the dosage in milliliters.
Question 21
A nurse is assessing a client who has a pressure ulcer with subcutaneous tissue and slough present. The nurse should perform which of the following actions when completing a dressing change on the client’s wound?
- Use several small pieces of gauze to gently pack any tunneling that is present in the wound.
- Apply a debriding agent to the granulation tissue in the base of the wound bed with a sterile applicator.
- Don new gloves after disposing of the old dressing.
- Gently irrigate the wound with warm tap water.
Question 22
A nurse is preparing to administer medication through a central venous catheter. After donning nonsterile gloves, what is the most critical action the nurse should take before connecting the medication administration set to the catheter hub?
- Apply a transparent sterile dressing over the hub before connecting the medication administration set.
- Flush the catheter with sterile saline before scrubbing the hub to confirm patency first.
- Clamp the tubing before connecting to the catheter hub to prevent air embolism.
- Vigorously scrub the hub of the catheter with a facility-approved antiseptic wipe and allow it to dry.
Question 23
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? Custom NURS307a Exam 2.
- Dehydration
- Bladder infection
- Pernicious anemia
- Prostate enlargement
Question 24
A nurse is caring for a patient with a stage III pressure ulcer on the sacrum. Which of the following assessment findings should the nurse recognize as typical for a stage III pressure ulcer?
- Partial-thickness skin loss involving the epidermis and/or dermis
- Muscle, bone, or tendon may be visible
- Full-thickness skin loss with visible subcutaneous fat.
- Presence of intact or ruptured blister filled with serous fluid
Question 25
A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?
- Clear breath sounds
- Brisk capillary refill
- Oxygen saturation of 90%
- Increased respiratory rate
Question 26
The nurse would identify all of the following as indications for suctioning a patient with a tracheostomy tube EXCEPT:
- Tachypnea.
- Respiratory distress.
- Oxygen saturation of 88%.
- Routine suctioning every 4 hours.
Question 28
What type of needle would you select when cannulating an implanted port? Custom NURS307a Exam 2.
- Filter needle
- Spinal needle
- Non-coring needle
- Hypodermic needle
Question 29
The nurse forgets to properly cleanse the end of the client’s PICC line prior to flushing the line. Which of the following complications would you be most concerned about?
- Air embolism
- Occlusion
- Phlebitis
- Infection
Question 30
A nurse is caring for a patient whose chest tube was accidentally dislodged during repositioning. After applying a sterile occlusive dressing taped on three sides, which intervention should the nurse prioritize next to ensure patient safety?
- Notify the healthcare provider to prepare for reinsertion of the chest tube.
- Assess the patient’s respiratory status, including lung sounds and oxygen saturation.
- Elevate the head of the bed to 45 degrees to facilitate breathing and comfort.
- Immediately clamp the chest tube to prevent air from entering the pleural space.
Question 31
A nurse is caring for a postoperative patient with an indwelling Foley catheter. The patient reports mild lower abdominal discomfort, and the nurse notes cloudy urine in the drainage bag. Which nursing action should the nurse prioritize to reduce the risk of catheter-associated urinary tract infection (CAUTI) and ensure patient safety?
- Clamp the catheter tubing for 30 minutes to allow bladder filling, which can reduce discomfort and promote natural voiding.
- Ensure the catheter tubing is free from kinks and the drainage bag is positioned below the bladder to promote urine flow.
- Irrigate the Foley catheter with sterile saline to flush out any cloudy urine and relieve discomfort.
- Remove the Foley catheter immediately and replace it with a straight catheter to decrease infection risk.
Question 32
You are caring for a client that has a PICC in their right upper arm. How frequently would you anticipate changing the PICC dressing if there is a Biopatch™ around the insertion site? Custom NURS307a Exam 2.
- Every 7 days
- Every 10 days
- Every 3 days
- Daily
Question 33
A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter?
- Use a 10-mL syringe to flush the catheter.
- Ensure a clean fluid pathway when accessing the catheter.
- Flush the lumen with sterile water after each use.
- Apply firm pressure to the syringe plunger if resistance is met when flushing the lumen.
Question 34
A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?
- Reach around the pack and open the top flap away from the body.
- Place the pack on a sterile work surface.
- Move to the opposite side of the pack to open the fourth flap.
- Open the right flap with the left hand.
Question 35
Which needle is the smallest?
- 22 gauge
- 16 gauge
- 18 gauge
- 24 gauge
Question 36
A nurse is caring for a client who has a chest tube connected to a closed drainage system and has received an order to ambulate the client. Which of the following actions should the nurse take?
- Empty the collection chamber prior to ambulating.
- Clamp the chest tube prior to ambulating the client.
- Keep the drainage system below the level of the client’s chest at all times.
- Disconnect the chest tube from the drainage system while ambulating to prevent tripping.
Question 37
A nurse is caring for a client who has urinary incontinence. The client’s skin is healthy and intact. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
- Clean the client’s skin and perineum with hot water after each episode of incontinence.
- Apply a moisture barrier ointment to the client’s skin.
- Check the client’s skin once each shift for skin breakdown.
- Request an order for the insertion of an indwelling urinary catheter. Custom NURS307a Exam 2.
Question 38
The nurse is caring for a postoperative client who has a chest tube with a water seal drainage system connected to wall suction. The nurse notes gentle, steady bubbling in the SUCTION CONTROL chamber. Which of the following actions should the nurse take?
- Clamp the chest tube.
- Continue to monitor the client.
- Turn off the suction at the control outlet on the wall.
- Strip the tubing.
