A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action 

should the nurse take?

(correct Answer- Administer the medication as prescribed with a glass of water

Which client should the nurse assess frequently because of the risk for overflow incontinence?

A client Who is confused and frequently forgets to go to the bathroom

While monitoring a client during a seizure, which interventions should the nurse implement? (Select all 

that apply)

(correct AnswerMove obstacle away from client Monitor physical movements Observe for a patent airway Record the 

duration of the seizure

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor 

tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after 

his brother died of lung cancer. Which intervention is most important for the nurses to include in the 

client's plan of care?

(correct Answer- Observe for changes in level of consciousness.

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with 

ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial 

blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To 

normalize the client's ABG finding, which action is required?

correct Answer- Increase ventilator rate.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing 

congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of 

appetite. What instruction should the nurse provide?

(correct Answer- CPT should be performed more frequently, but at least an hour before meals.

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates 

that the client understands the dietary recommendation for hypertension?

(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key- lime pie

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a 

glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at 

bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include 

in this client's plan of care?

(correct Answer- Fingerstick glucose assessment q6h with meals Review with the client proper foot care 

and prevention of injury

Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous 

injection technique, site rotation and insulin management

Which problem reported by a client taking lovastatin requires the most immediate fallow up by the 

nurse?

(correct Answer- Muscle pain

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the 

chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 

beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should 

the nurse implement?

(correct Answer- Provide supplemental oxygen Auscultate bilateral lung fields

Reinforce occlusive CT dressing

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach 

the client's wrist restraints to the movable portion of the client's bed frame. What action should the 

nurse take before leaving the room?

(correct Answer- Ensure that the knot can be quickly released.

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and 

benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse 

emphasize concerning the installation of the antipyrine/benzocaine otic solution?

(correct Answer- Have the child lie with the ear up for one to two minute after installation