RLE

Question 1

What are the purpose of flushing the tubing with water after feedings or every 4 hours for continuous feedings

A. to maintain oxygen inhalation
B. to maintain patency of the tube
C. to assess for placement
D. to make the patient full

Answer 1

B. to maintain patency of the tube

Question 2

Hypokalemia is a condition characterized by:

A. Low blood sodium levels
B. High blood calcium levels
C. High blood magnesium levels
D. Low blood potassium levels

Answer 2

Low blood potassium levels

Question 3

It is a band of fabric or leather that is positioned around the patient’s waist to provide additional support during ambulation.

A. transfer/gait belt
B. stabilizer
C. back brace
D. waist belt

Answer 3

A. transfer/gait belt

Question 4

What class of drugs is used to lower blood pressure and reduce the workload on the heart?

A. Antibiotics
B. Diuretics
C. Anticoagulants
D. Antifungals

Answer 4

B. Diuretics

Question 5

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?

A. keep the patientension
B. Increase fluid intake to evacuate stool
C. keep the patient on soft diet
D. report any signs of headache

Answer 5

B. Increase fluid intake to evacuate stool

Question 6

Action of Atropine

A. vasoconstrictor
B. restore heart rate
C. increase blood pressure
D. relives allergic symptoms

Answer 6

B. restore heart rate

Question 7

Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take?

A. Discard the residual amount
B. Hold the due feeding.
C. Skip the feeding and administer the next feeding due in 4 hours
D. Reinstill the amount and continue with administering the feeding

Answer 7

D. Reinstill the amount and continue with administering the feeding

Question 8

The nurse js caring for a patient who has an ostotny. She notlces that the effluent is a thick liquid to a semiformed stool. Where does the nurse expect the ostomy to be located?

A. The descending colon
B. The ileal portion of the small inte.stine
C. The sigmoid colon
D. The transverse or ascending colon

Answer 8

B. The ileal portion of the small intestine

Question 9

A client had a new colostomy created 2 days earliet and is beginning to pass malodorous flatus for the stoma. what is the correct interpretation by the nurse?

A. This is a normal expected event
B. The client is experiencing early signs of ischemic bowe
C. The client should not have the NG tube removed
D. This indicates inadequate preoperative bowel preparation

Answer 9

A. This is a normal expected event

Question 10

Which risk factor is most strongly associated with an increased risk of stroke?

A. Physical activity
B. Low·blood pressure
C. Smoking
D. High-fiber diet

Answer 10

C. Smoking

Question 11

The client diagnosed with septi’cemia is receiving a broad spectrum antibiotic. Which laboratory data requires the nurse to notify the HCP?

A. The client’s potassium level is 3.8 mEq/L.
B. The urine culture indicates high sensitivity to the antibiotic
C. The client’s pulse oxirneter read.ing is 94o/o.
D. The culture and sensitivity is resistant to the client’s. antibiotic.

Answer 11

D. The culture and sensitivity is resistant to the client’s. antibiotic.

Question 12

One of your nursing responsibilities after doing an enema is to do the documentation. SATA on what to include in your documentation

Failure of defecation
Kind of procedure done
Amount of solution infused
Untoward reaction of the patient
Observation of the output

Answer 12

Kind of procedure done
Amount of solution infused
Untoward reaction of the patient
Observation of the output

Question 13

Which type of stroke occurs when a blood vessel in the brain ruptures and causes bleeding into the surrounding tissue?

lschemic stroke
Hemorrhagic stroke
Transient ischemic attack (TIA)
Embolic stroke

Answer 13

Hemorrhagic stroke

Question 14

Which of the following is a crucial practice for preventing catheter-related infections?

Routine catheter placement without indication
Sterile technique during catheter insertion
Delaying catheter ,removal
Reusing catheters for multiple patients

Answer 14

Sterile technique during catheter insertion

Question 15

The nurse js administering packed red blood cells (PRBCs) to a client. The nurse should first:

• Discontinue the I.V, cathe.ter if a blood transfusion reaction occurs.
• Flush PRBCs with 5°/o dextrose and 0.45°/o normal saline solution.
• Stay with the client during the first 15 minutes of infusion
• administer the blood transfusion in a IV line indicated for infusion pump

Answer 15

Stay with the client during the first 15 minutes of infusion

Question 16

All are purposes of enema EXCEPT

to relieve constipation
terminate a bowel training
for diagnostic purposes
removing of impacted feces from colon

Answer 16

terminate a bowel training

Question 17

One of the nursing responsibilities before starting an enema is to have an assessment to the patient. Which of the following should be included in your assessment. SATA

~ abdominal pain
~ last. bowel movement
~ mobility
~ hemorrhoids

Answer 17

~ abdominal pain
~ last bowel movement
~ hemorrhoids

Question 18

Which class of drugs is primarily prescribed to prevent or treat blood clots and reduce the risk of stroke or heart attack?

Antihistamines
Anticoagulants
Antidepressants
Anticonvulsants

Answer 18

Anticoagulants

Question 19

It is used when patients need to keep weigh off their legs or feet

Canes
walkers
crutches
wheelchair

Answer 19

crutches

Question 20

Which of the followin,g is not true regarding the types of a nasogastric tube?

Cantor tube is a single-lumen long tube with a small inflatable bag at the distal end.
Miller-Abbott tube is a long double-lumen used to drain and decompress the small intestine
Levin tube is a double lumen nasogastrjc tube with an air vent
Sengstaken-Blakemore tube is a three-lumen tube

Answer 20

Levin tube is a double lumen nasogastrjc tube with an air vent

Question 21

You are assessing the stoma of a patient health, welI healed colostomy. You expect the stoma to appear

Pale, pink and moist
Red and mo·ist
Dark or purple colored
Dry and black

Answer 21

Pale, pink and moist

Question 22

The nurse, in the emergency department has admitted five clients in the last 2 hours with reports of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to
determine if there is a bioterrorism threat?

“Do you work or live near any large power lines?”
“Where were you immediately before you got sick?” phy
“Can you write down everything you ate today?”
“What other health pro.blems do yo4 have?”

Answer 22

“Where were you immediately before you got sick?” phy

Question 23

79. Which class of medications is commonly prescribed to lower blood pressure by relaxing blood vessel walls?

Diuretics
Beta-blockers
ACE inhfbitors
Antibiotics

Answer 23

ACE inhfbitors

Question 24

What is the term for the temporary episode of neurological dysfunction caused by a brief disruption of blood flow to the brain, often referred to as a “mini-stroke”?

Hemorrhagic stroke
lschemic stroke
Transient ischemic attack (TIA)
Embolic stroke

Answer 24

Transient ischemic attack (TIA)

Question 25

One of the nursing responsibilities before starting an enema is to have an assessm·ent to the patient. Which of the following should be included in your assessment. SATA ~ abdominal pain ~ last bowel movement ~ mobility ~ hemorrhoids

Answer 25

abdominal pain last bowel movement hemorrhoids

Question 26

These are solutions vyhich can be used for cleansing enema EXCEPT NSS Lavender Oil Tap Water Fleet Enema

Answer 26

Lavender Oil

Question 27

The most appropriate assistive device used after surgery or by the elderly to assist with balance and stability Canes crutches walker wheelchair

Answer 27

walker

Question 28

Your patient has a PEG tube and you are about to administer a feeding. While checking residual you obtain 95 ml of stomach contents. What would be your next nursing intervention? Hold the feeding and immediately to notify the MD of the assessed amount of residual Administered the scheduled feeding Wait 30 minutes and reassess residual Skip this scheduled feeding and administer the next feeding due in 6 hours

Answer 28

Administered the scheduled feeding

Question 29

The physician orders 2 units of pa.eked RBC·s to be admin1stered to the client. At 0600 the nfght shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse notes the IV line has clotted off and the transfusion h.as not been completed. The nursing assessment revealed the transfusion was only approximately 75°/o compJete. Whlch of the actions by the nurse is most appropriate? Advise the bJood bank about the delay for the next unit. Restart another peripheral line with 0.9o/o NS and restart the blood transfusion with the remaining blood unit. Discontinue the transfusion Document the amount infused thus far and continue the transfusion.

Answer 29

Discontinue the transfusion

Question 30

Which of the following patients most likely requires special preoperative assessment and treatment as a result of his or her existing medication regimen? a woman who take daily anticoagulants to treat heart disease a woman who takes a daily thyrold suppJement to treat her longstanding hypothyroidism. a man who regularly treats his rheumatold arthritis with OTC NSAIDs. a man who takes an angiotensin converting enzyme i'nhibitor because he has hypertension

Answer 30

a woman who take daily anticoagulants to treat heart disease

Question 31

Which of the following emergency drug is indicated for hemorrhage? heparin tranexamic acid aspirin lidocaine

Answer 31

tranexamic acid

Question 32

Nurse Rochelle is doing a high enema to Patient Y. How high should she raise the container? 14 inches 16 inches 18 inches 12 inches

Answer 32

18 inches

Question 33

the nurse is caring for a client who begins to experience seizure activity while in bed. which action by the nurse is contraindicated? loosen-ing restrictive clothing removing the pillow and raising padded side rails restraining the clients limbs positioning the client to the side, if possible, with the head flexed forward

Answer 33

restraining the clients limbs

Question 34

While your patient is ambulating with crutches he moves both crutches forward along with the injured leg and then moves the non-injured forward. When you document you will note that the patient used what type of gait while ambulating with crutches? Two-point gait Three-point gait Four-poJnt gait Swing-to-gait

Answer 34

Three-point gait

Question 35

Patient X is experiencing constipation and hi physician ordered for cleansing enema, He is known to have a cardiac disease.Which of the following solution is contraindicated to our patient? Tap Water NSS Lavender Oil Fleet Enema

Answer 35

Tap Water

Question 36

Hyponatremia is often associated with: Excessive sodium intake Excessive potassium intake Low sodium levels in the blood High calcium levels in the blood

Answer 36

Low sodium levels in the blood

Question 37

You are advising a 21 yr old w/ a colostomy who reports problems with flatus. What food should you recommend? Peas Cabbage Broccoli Yogurt

Answer 37

Yogurt

Question 38

The nurse notes an irregular radial pulse in a patient. Further evaluation includes assessing for a pulse deficit the carotid pulse for drminished peripheral circulation the brachial pulse

Answer 38

for a pulse deficit

Question 39

Which actions will result in an inaccurate BP reading? Select all that apply. Obtaining a BP immediately after the patient has entered the room Using a BP cuff 80% of the arm circumference Asking the patient to hold out his or her arm above heart level Pumping the cuff 10 mm Hg above the palpated systoJic BP

Answer 39

Obtaining a BP immediately after the patient has entered the room Asking the patient to hold out his or her arm above heart level Pumping the cuff 10 mm Hg above the palpated systoJic BP

Question 40

The nurse is caring for several patients. Which patient is most likely to need a guaiac test? Patient reports dark amber colored urine Patient reports black stool. Patient vomits small amounts of bile. Patient complains of right upper quadrant pain.

Answer 40

Patient reports black stool.

Question 41

A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician ordered for the removal of it. The nurse would instruct the client to do which of the following before he removes the tube? Take a long breath and hold it. inhale and exhale simultaneously Do a Valsalva maneuver. Blow the nose.

Answer 41

Take a long breath and hold it.

Question 42

Your pati.ent attempts to sit down in the bedside chair after ambulating in the hallway with crutches. What finding requires you to re-educate the patient on how to sit down in the chair correctly while using crutches? The patient places poth crutches on the non-injured side before sitting down in the chair. The patient backs up to the chair's seat until he feels it with his non-injured leg and stops. The patient keeps the injured leg extended out in front of him while sitting down. The patient holds both crutches on one side and reaches for the hand grips on the crutches and places weight on them while sitting down.

Answer 42

The patient holds both crutches on one side and reaches for the hand grips on the crutches and places weight on them while sitting down.

Question 43

An adult patient is being discharged home on Digoxin. Which statements below verbalized by the patient they understand how to properly take this medication? "I will limit by intake of foods high in potassium." "I will not take this medication and notify the physician if my heart rate is less than 60 bpm." "It is important that I immediately report any vision changes I may experience while taking this medication." all of the above

Answer 43

"It is important that I immediately report any vision changes I may experience while taking this medication."

Question 44

Which type of gait is closest to the natural rhythm of walking four-point two-point. swing-to Swing-through

Answer 44

two-point.

Question 45

This type will allow the patient's weight to be more evenly distributed. Walker cane crutches Wheelchair

Answer 45

Walker

Question 46

The nurse carln,g for a client diagnosed with sepsis writes the client diagnosis of "alteration in comfort R/T chins and fever." Which intervention should be included in the plan of care? Ambulate the client in the hallway every shift. Monitor urinalysis, creatinine level, and BUN level. Apply sequential compression devices to the lower extremities. Administer an antipyretic medication every 4 hours PRN.

Answer 46

Administer an antipyretic medication every 4 hours PRN.

Question 47

The nurse js interviewing a surgical client in the holdihg area. Which information should the nurse report to the anesthesiologist? Select all that apply ~ The client has loose, decayed teeth ~ The client is experiencing anxiety ~ The client smokes two packs of cigarettes a day ~ The client has had a chest x ray which does not show infiltrates

Answer 47

~ The client is experiencing anxiety ~ The client smokes two packs of cigarettes a day ~ The client has had a chest x ray which does not show infiltrates

Question 48

Which intervention is most important for the nurse to implement when participating in a code? Elevate the arm after administering medicatjon. Maintain sterile technique throughout the code. Treat the client's crinical manifestations; do not treat the monitor. Provide accurate documentation of what happened during the code.

Answer 48

Treat the client's crinical manifestations; do not treat the monitor.

Question 49

This type is chosen depending on preferred grip, and balancing ability Crutches canes walkers wheelchair

Answer 49

canes

Question 50

Which patient would benefit from a Nasogastric Tube? A stroke victim who failed their swallow evaluation A pattent with Con·gestive Heart Failure A patient who had a left leg amputation A patient with a Platelet count of 50

Answer 50

A stroke victim who failed their swallow evaluation

Question 51

A nurse js checkin,g the nasogastric tube position of a client receiving a long term therapy of Omeprazole (Prisolec) by aspirating the stomach contents to check forlevel. The nurse proves that correct tube placement if the PH level is? 7.75 7.5 6.5 5.5

Answer 51

5.5

Question 52

A newly RN nurse is about to insert a nasogastric tube to a client with Guillain Syndrome. To determine the accurate measurement of the length of the tube be insert nurse should: Place the tube at the tip of the nose, and measure by extending the tube to the and then down to the top of the sternum. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the xiphoid process. Place the tube at the tip of the nose, and measure by extending the tub and then down to the top of the xiphoid process. Place the tube at the b.ase of the nose, and measure by extending the and then down to the top of the sternum.

Answer 52

Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the xiphoid process.

Question 53

The nurse determines that a client is having a transfusion· reaction. After the nurse stops the transfusion, which action should be taken NEXT? Remove the intravenous (IV) line. Bun a solution of 5o/o dextrose Run normal saline at a keep-vein-open rate. Obtain a culture of the ttp of the catheter device re.moved from the client

Answer 53

Run normal saline at a keep-vein-open rate.

Question 54

the nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. which measures should the nurse include in planning c are for the clients safety? SATA ~ placing an airway at the bedside ~ padding the side rails of the bed ~ placing oxygen and suction equipment at the bed sideure ~ providing a standby restraint

Answer 54

~ placing an airway at the bedside ~ padding the side rails of the bed ~ placing oxygen and suction equipment at the bed sideure

Question 55

You're caring for a patient with a sigmoid colostomy. The stool from this colostomy is: Formed Semisolid SemHiquid Watery

Answer 55

formed

Question 56

The nurse js caring for a patient with a transvetse colostomy. Which of the following should the nurse perform during ostomy care. Select all that apply: ~ lnspect the Stoma ~ Test the stool for Guiac ~ Clean the surrounding skin with alcohol ~ Apply skin prep to the skin before applying the ostomy appliance. ~ Trim the wafer to the approximate size of the stoma

Answer 56

lnspect the Stoma Apply skin prep to the skin before applying the ostomy appliance. Trim the wafer to the approximate size of the stoma

Question 57

As the nurse, how w,ould you correctly demonstrate to the patient the proper gait while using a walker? Hold onto the walker's hand grips, take a step forward with the strong side, then move walker forward, and then take a step with the weak side. Hold onto the walker's hand grips, move walker forward, then take a step forward with the weak side, and then take a step forward with the strong side. Hold onto the walker's hand grips, move walker forward, then take a step forward with the strong side, and then take a step forward with the weak side. Hold onto the walker's hand grips, take a step forward with the weak side, then move walker forward, and then take a step with the strong side.

Answer 57

Hold onto the walker's hand grips, move walker forward, then take a step forward with the weak side, and then take a step forward with the strong side.

Question 58

Your pati.ent is prescribed to use crutches for ambulation. The patient can bear partial weight and needs to be taught how to use the two-point gait while using crutches. Which description below best describes this type of gait with crutches? The patient moves both crutches forward and then moves both legs forward to the sanle point as the crutches. The patient moves the right crutch (injured side), then moves the left foot (non-injured side), then moves the left crutch (non-injured side), and then moves the right foot (injured side) The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward 'together. The patient moves both crutches and injured leg forward together, and then moves the ·non-injured leg forward.

Answer 58

The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together, and then moves the left crutch (non-injured side) and right foot (injured side) forward 'together.

Question 59

Which of the following patients should not have a temperature measured orally? An 84-year-old woman with diarrhea A 30-year-old patie-nt with an earache A 45-year-old man with chest pain A 62-year-old woman who has had oral surgery

Answer 59

A 62-year-old woman who has had oral surgery

Question 60

You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer: To the exact size of the storna About 1 /16" larger than the stoma About 1 /8" larger than the stoma About 1 /4" larger than the stoma

Answer 60

About 1 /16" larger than the stoma

Question 61

What is the most common cause of community acquired pneumonia? MycopJastna pheumoniae Staphylococcus aureus Influenza virus Streptococcus pneumoniae

Answer 61

Streptococcus pneumoniae

Question 62

Hyperkalemia can lead to which potentially life-threatening complication? Metabolic alkalosis Hypertension Cardiac arrhythmias Respiratory acidosis

Answer 62

Cardiac arrhythmias

Question 63

Which initial nursin,g action would best help the patient learn self- care of a colostomy pouching system? Giving the patient handouts on self care of a colostomy Allowing the patient to examine an ostomy device Identifying a family member who can participate in th.e ostomy appliance process Giving the patient a mirror to watch the nurse provide care

Answer 63

Giving the patient a mirror to watch the nurse provide care

Question 64

A patient need to go up the stairs while using crutches . What finding by the nurse demonstrates the patient ,understands how to ambulate upstairs with crutches? The patient moves the crutches forward up the step, then the injured and non-injured leg. The patient moves the non-injured leg forward onto the step and then the moves the injured leg and crutches up The patient moves the injured leg forward onto the steps, then moves the crutches and then moves the non-injured leg. The patient moves the crutches and non-injured leg forward to the step together, and then the non-injured leg

Answer 64

The patient moves the non-injured leg forward onto the step and then moves the injured leg and crutches up

Question 65

Assistive device that are useful for maintaining balance Walkers Canes Crutches wheelchair

Answer 65

Walkers

Question 66

Your pediatric patient has an ordered medication of digoxin. The following are the vitals of your client T- 37 PR-89 BP 90/60 RR- 30. Which of the following is an appropriate action of the nurse before the administration of the drug continue to give because the client has a normal vital signs hold the drug and inform the physician about the vitals ask the mother to urinate before administration of the drug ask her co-worker about her input

Answer 66

hold the drug and inform the physician about the vitals

Question 67

Which of the followin,g is a crucial practice for preventing catheter-related infections? Routine catheter placement without indication Reusing catheters for multiple patients Delaying catheter ,removal Sterile technique during catheter insertion

Answer 67

Sterile technique during catheter insertion

Question 68

What is the term for a catheter-related infection that occurs at the insertion site and may lead to local or systemic symptoms? Systemic infection Localized infection Superinfection Contamination

Answer 68

Localized infection

Question 69

primary indications for Lumbar puncture. SATA to obtain CSF fluid to measure lntra Cranial pressure to remove CSF to administer medication contrast and chemo agents

Answer 69

to obtain CSF fluid to measure lntra Cranial pressure to remove CSF

Question 70

While using crutches the patient moves both crutches forward and then moves both legs forward past the placement of the crutches. This is known as the: Two-point gait Swing-to-gait Swing-through-gait Three-point gait

Answer 70

Swing-through-gait

Question 71

action of narcan antidote of KCL antidote for narcotic overdose antidote for MgSo4 antidote for poisoning

Answer 71

antidote for narcotic overdose

Question 72

The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? A person is ventilating with an Ambu bag. A person is performing chest compressions correctly A person is administering medications as ordered. A person is keeping an accurate record of the code.

Answer 72

A person is keeping an accurate record of the code.

Question 73

It is a type of enema vyhich promotes complete evacuation of feces from the colon by stimulating the peristalsis through infusion of large volume of solution into the colon. Cleansing enema Carminative Enema Retenfion Enema Harris Flush

Answer 73

Cleansing enema

Question 74

How many minutes should you hold the buttocks when administering an enema to a child? 5-10 mins 5-9 mins 5-7 mins 5-8 mins

Answer 74

5-10 mins

Question 75

Which clinical sign is characteristic of bacterial pneumonia and is often detected during auscultation of the lungs? Wheezing Rhonchi Crackles Stridor

Answer 75

Crackles

Question 76

Which of the following medications is indicated to treat arrhythmia? sodium bicarbonate ondansetron lidocaine diphenhydramine

Answer 76

lidocaine