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Question 1 of 5

A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:

Correct Answer: D

Rationale: Cutting a nitroglycerin patch can alter the dose by disrupting the drug delivery system, so clients should be instructed to avoid this.

Question 2 of 5

Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.

Order the Items

Source Container

Suction the oral cavity.
Auscultate breath sounds for effectiveness.
Set suction control at 80-120 mm Hg.
Ambu or oxygenate at 100% O2
Apply suction while withdrawing the suction catheter.
Turn the head toward the side to be suctioned.
Auscultate breath sounds prior to suctioning.

Correct Answer: G, C, D, F, E, B, A

Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (
C), oxygenate (
D), turn head (F), apply suction (E), auscultate post-suction (
B), suction oral cavity (
A) to clean.

Question 3 of 5

A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?

Correct Answer: A

Rationale: Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. Urine specific gravity does not necessarily indicate fluid volume excess. Edema may not be apparent, yet the client may have fluid volume excess.

Question 4 of 5

The nurse is preparing to collect a sputum specimen from the client suspected of having tuberculosis. What is the correct method for obtaining a sputum specimen?

Question Image

Correct Answer: A, B, C, D

Rationale: Morning collection (
A) yieldsthough sputum is most concentrated. Three consecutive days (
B) ensure reliable tuberculosis diagnosis. Immediate transport (
C) prevents degradation. Mouth care (
D) maintains hygiene. Antiseptic rinse (E) may kill bacteria, invalidating the sample.

Question 5 of 5

A client with a history of glaucoma is prescribed timolol (Timoptic) eye drops. Which instruction should the nurse include in the teaching?

Correct Answer: B

Rationale: Pressing the inner corner (nasolacrimal occlusion) after instilling timolol prevents systemic absorption. Direct corneal application (
A) is incorrect, pain-based use (
C) is wrong, and refrigeration (
D) is unnecessary.

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