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Question 1 of 5

The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:

Correct Answer: C

Rationale: Sitting in a straight chair can compress the graft, impairing blood flow, and should be avoided to promote graft patency.

Question 2 of 5

A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:

Correct Answer: C

Rationale: Immobilizing the arm with a splint prevents further tissue damage and promotes healing, which is a priority after initial wound care and antibiotic administration. Checking for allergies should have been done prior to administering antibiotics, and pain management, while important, is secondary to stabilization.

Question 3 of 5

The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?

Correct Answer: A

Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (
A). Intestinal aspirate (
B) has pH > 6, respiratory (
C) is > 7, and results are conclusive (
D).

Question 4 of 5

The nurse is delegating tasks to an experienced, unlicensed assistive personnel (UAP). Which of the following clients should the nurse delegate to the UAP?

Correct Answer: C

Rationale: Ambulating a client is within a UAP’s scope, requiring minimal clinical judgment, unlike wound care, tracheostomy care, or pain assessment.

Question 5 of 5

A client has a rate-responsive permanent pacemaker in his upper chest. The nurse understands rate-responsive to mean which of the following?

Correct Answer: D

Rationale: A rate-responsive pacemaker increases the pacing rate when sensors detect increased activity (
D), mimicking normal heart rate response. Other options (A, B,
C) describe different pacemaker functions.

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