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Questions 163

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Question 1 of 5

The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.

Correct Answer: C,D

Rationale:
To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.

Question 2 of 5

The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?

Correct Answer: B

Rationale: Assessing breath sounds is the first step to evaluate the extent of fluid overload and guide interventions in heart failure. Oxygen , monitoring , and IV insertion follow based on findings.

Question 3 of 5

Which statement, if made by the client, indicates a possible problem?

Correct Answer: B

Rationale: Black stools may indicate gastrointestinal bleeding, a serious concern requiring evaluation. Other statements reflect normal variations or minor issues.

Question 4 of 5

A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?

Correct Answer: C

Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.

Question 5 of 5

The nurse is repairing new prescriptions from the health care provider. Which prescription would require further clarification?

Correct Answer: C

Rationale: Cyclobenzaprine is contraindicated in hepatic impairment due to hepatitis, as it is metabolized by the liver, requiring clarification. Other prescriptions (A, B,
D) are appropriate for the conditions.

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