A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled
analgesia (PCA) bolus doses. The PCA and normal saline tubing are connected at the “Y” site.
The nurse reviews a prescription from the health care provider to discontinue the normal saline.
What is the most appropriate nursing action?
1. Change the rate of the normal saline to 10 mL/hr
2. Clarify the prescription with the health care provider
3. Flush the IV with normal saline and then convert it to a saline lock
4. Turn off the normal saline and disconnect it from the “Y” site
The nurse provides instruction to a community group about lung cancer prevention, health
promotion, and smoking cessation. Which statement made by a member of the group indicates
the need for further instruction?
1. “Even though I am getting nicotine in my patches, I am not being exposed to all of
the other toxic stuff in cigarettes.”
2. “I can’t get lung cancer because I don’t smoke.”
3. “My husband needs to take smoking cessation classes.”
4. “We installed a radon detector in our home.”
A client is being discharged home after an open radical prostatectomy. Which statement
indicates a need for further teaching?
1. “I will try to drink lots of water.”
2. “I will try to walk in my driveway twice a day.”
3. “I will wash around my catheter twice a day.”
4. “If I get constipated, I will use a suppository.”
The nurse is calculating IV fluid resuscitation for a client weighing 85 kg with visible partialthickness burns covering 40% of the body. Using the Parkland formula, how many liters of IV
fluid resuscitation are needed during the first 8 hours? Record your answer using one decimal
The health care provider (HCP) orders a small bowel follow-through (SBFT) for a client. Which
instructions should the nurse include when teaching the client about this test?
1. “After the test, you may notice your stools are tarry black for a few days.”
2. “During the test, a series of x-rays will be taken to assess the function of the small
3. “The HCP will use an endoscope to visualize your small bowel.”
4. “Your examination is scheduled for 8:00 AM. Please drink all of the polyethylene
glycol by midnight.”
The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse assesses an
increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles,
respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular
venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which
prescription does the nurse anticipate?
1. Bolus dose of IV morphine
2. Incentive spirometer
3. IV furosemide
4. Non-rebreather mask
The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis
(ALS). The client asks, “There’s no cure for ALS, so why should I keep taking this expensive
drug?” What is the nurse’s best response?
1. “It may be able to slow the progression of ALS.”
2. “It reduces the amount of glutamate in your brain.”
3. “The case manager may be able to find a program to assist with cost.”
4. “You have the right to refuse the medication.”
The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on
antiretroviral drugs for the past 2 months. Which statement by the client indicates a need
for further instruction?
1. “I can stop taking these HIV drugs once my viral levels are undetectable.”
2. “I need to get tested regularly for sexually transmitted infections because I’m sexually
3. “I should use latex condoms and barriers when having anal, vaginal, or oral sex.”
4. “I won’t stop injecting drugs, but I will use a needle exchange program.”
A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the
psychiatric unit. Which of the following is the priority nursing diagnosis?
1. Impaired social interaction
2. Impaired verbal communication
3. Risk for deficient fluid volume
4. Risk for impaired skin integrity
A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular
cancer. The client says to the nurse, “I’m so worried that my future spouse is going to call off our
engagement.” What is the best response by the nurse?
1. “Are you concerned about how the surgery will affect your sexuality?”
2. “If you are concerned about infertility, you could always bank your sperm.”
3. “The cancer is at an early stage. You are going to be fine.”
4. “What have you and your future spouse discussed about your condition?”