San Jose State University

BIOLOGY 2B

1)A nurse is preparing to administer 750ml of 0.9% sodium chloride IV to infuse over 7hrs. the nurse should set the infusion pump to deliver how many ml/hr?

1. A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

2. A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following response should the nurse provide?

3. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following food should the nurse suggest that the client add to his diet?

4. A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individual’s signatures may the nurse legally witness?

5. A nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

6. A nurse is preparing to insert an IV catheter into a client's arm prior to initiate IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

7. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
8. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

9. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statement should the nurse identify as an indication that the client understand the teaching?
10. A nurse is caring for a client who has sodium level of 125 mEq/L. which of the following finding should the nurse expect?
11. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
12. A nurse has an order to remove suture from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
13. A nurse is caring for a client who is postoperative following knee arthroplasty and require the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?
14. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
15. A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
16. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following

assessment findings indicates that the catheter requires irrigation?

17. a nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter?
18. A nurse is inititating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

19. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provides?

20. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following action should the charge nurse identify as contaminating the sterile field?

21. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?

22. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
23. A nurse is completing an admission assessment of an older adult client. Which of the following finding should the nurse identify as a potential indication of abuse?
24. A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretion in her airway and she is short of breath. Which of the following actions should the nurse take?
25. A nurse is reviewing evidence-based practice principle about administration of oxygen therapy with a

newly licensed nurse. Which of the following actions should the nurse include?

26. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. when the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 minutes and call him back in 1 hr. From legal perspective, which of the following actions should the nurse take next?
27. A nurse is performing a skin assessment of a client who has a lesion on high anterior thigh and expresses concern about skin cancer. which of the following finding should the nurse report to the provider as a possible indication of a skin malignancy.
28. A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
29. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
30. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

31. A nurse is calculating a client's fluid intake over the past 8 hour. Which of the following items should the nurse plan to document on the client's intake and output record as 120ml of fluid?
32. A nurse is auscultating the anterior chest of a client newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through his stethoscope and identify the type of breath sound he hears.
33. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?
34. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurs identify as indicating the correct technique for eliciting the client's patellar reflex?
35. a nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?
36. A nurse is caring for a client who does not speak the same language as the nurse. When working

with the client through an interpreter, which of the following action should the nurse take?

37. A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-

volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

38. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oil is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
39. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as in indication that she understands the use of this assistive device?
40. A nurse is planning care for a client who has a stroke, resulting in aphasia and dysphagia. Which of the following should the nurse assign to an assistive personnel (AP)? (Select all that apply)

41. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
42. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
43. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?
44. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
45. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precaution should the nurse take?
46. A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
47. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
48. A nurse is caring for a child who has a prescription for a blood transfusion. the parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

49. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feeding reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?