A nurses planning to administer pain medication to a client following abdominal surgery. Which of the
following actions should the nurse take first?
use the pain scale to determine the client’s pain level
discuss the adverse effects of pain medication with the client
obtain the client’s vital signs
check the client’s allergies
use the pain scale to determine the client’s pain level
a nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine
for pain management. which of the following statements should the nurse identify as an indication that
the client understands the instructions?
I’ll limit pushing the button so I don’t get an overdose
if I push the button and still have pain after 2 minutes, I’ll push it again
I’ll ask my niece to push the button when I am sleeping
I can still use my transcutaneous electrical nerve stimulation unit while I’m pushing the PCA button
I can still use my transcutaneous electrical nerve stimulation unit while I’m pushing the PCA button
a nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the
exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse
plan to take?
auscultate over the stomach while injecting air
request an x-ray of the client’s abdomen
place the head of the client’s bed in a flat position
administer the feeding if the pH of the aspirated contents is >6
request an x-ray of the client’s abdomen
A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of
procedures. the nurse should anticipate that the client who has which of the following devices can safely
undergo magnetic resonance imaging (MRI)?
coronary artery stents
aneurysm clip
1 / 3
hearing aids
automated internal defibrillator
hearing aids
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the
following actions should the nurse take?
Hold the irrigator 1.25 cm (0.5 in) above the eye
direct the irrigation solution up toward the upper eyelid
exert pressure on the bony prominences when holding the eyelids open
direct the irrigation from the outer canthus to the inner canthus of the eye
exert pressure on the bony prominences when holding the eyelids open
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis.
Which of the following actions should the nurse plan to take?
Place the client in the trendelenburg position
perform percussion directly over the client’s bare skin
use a flattened hand to perform percussions
remind the client that chest percussions can cause mild pain
Place the client in the trendelenburg position
A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy.
The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as
which of the following types of drainage?
sanguineous exudate
serous exudate
serosanguineous exudate
purulent exudate
purulent exudate
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive
spirometer. Which of the following pieces of information should the nurse include in the teaching?
exhale slowly to reach the goal volume
hold the breath for 5 sec after goal volume is reached
continue to breathe deeply between each cycle
limit the repeat pattern of breathing to 5 breaths
hold the breath for 5 sec after goal volume is reached
2 / 3
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure.
which of the following actions should the nurse take?
Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube
position the client on the right side
insert the tip of the tubing 8 cm (3.1 in)
hold the enema container 61 cm (24 in) above the rectum
Insert the tip of the tubing 8 cm (3.1 in)
A nurse is performing a focused assessment of a client’s peripheral vascular system. Where should the
nurse palpate the posterior tibial pulse?
Below the medial malleoulus
A nurse is assessing a client’s peripheral pulses. How should the nurse document the findings?
Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities.
A nurse is caring for an older adult client who has dysphagia following a CVA. Which of the following
actions should the nurse take when assisting the client at mealtime?
Encourage the client to drink fluids before swallowing food
offer the client tart or sour foods first
tilt the client’s head backward when swallowing
turn on the tv
Offer the client tart or sour foods first
Explanation: A client who has impaired pharyngeal swallowing should consume tart and sour foods at
the beginning of the meal to stimulate saliva production, which aids chewing and swallowing.
A nurse teaching a client who is postoperative following a knee arthroplasty about the muscles he will
need to strengthen in physical therapy. which of the following muscle groups is responsible for
movement at the knee joint?
antigravity
antagonistic
synergistic
skeletal
antagonistic