Pre Test

1. Of the following infection control method which would prevent hepatitis B most effectively
a. Hand washing
b. Hepatitis B vaccine
c. Proper personal hygiene
d. Immune globulin

2. A newly RN nurse is about to insert a nasogastric tube to a client with Guillain-Barre Syndrome. To
determine the accurate measurement of the length of the tube be inserted, the nurse should:

a. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and
then down to the top of the sternum.

b. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and
then down to the xiphoid process.

c. Place the tube at the tip of the nose, and measure by extending the tube down to the chin
and then down to the top of the xiphoid process.

d. Place the tube at the base of the nose, and measure by extending the tube to the earlobe
and then down to the top of the sternum.

3. A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician
ordered for the removal of it. The nurse would instruct the client to do which of the following
before he removes the tube?

a. Inhale and exhale simultaneously.

b. Take a long breath and hold it.
c. Do a Valsalva maneuver.
d. Blow the nose.

4. The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client.
Which of the following actions is an inappropriate practice by the nurse?

a. A. If bowel sounds are absent, hold the feeding and notify the physician.
b. Assess tube placement by aspirating gastric content and check the PH level.
c. Warm the feeding to room temperature to prevent the occurrence of diarrhoea and cramps.
d. Elevate the head of the bed to 45 degrees and maintains for 30 minutes after instillation of
feeding.

5. Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of
90ml. What is the appropriate action for the nurse to take?

a. Discard the residual amount.

b. Hold the due feeding.
c. Skip the feeding and administer the next feeding due in 4 hours.
d. Reinstill the amount and continue with administering the feeding.
6. The nurse is assessing a client with an endotracheal tube and observes that the client can make
verbal sounds. What is the most likely cause of this?

a. This is a normal finding.

b. There is a leak.
c. There is an occlusion.
d. The endotracheal tube is displaced.

7. While changing the tapes on a tracheotomy tube, the client coughs and the tube is dislodged.
Which is the initial nursing action?

a. Call a respiratory therapist to reinsert the tracheotomy.

b. Cover the tracheotomy site with a sterile dressing.
c. Call the physician to reinsert the tracheotomy.
d. Grasp the retention sutures to spread the opening.

8. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle bubbling in the suction control chamber. What action is most appropriate of the
nurse?

a. Increase the suction pressure so that the bubbling becomes vigorous.

b. Do nothing since this is an expected finding.
c. Immediately clamp the chest tube and notify the physician.
d. Check for an air leak because the bubbling should be intermittent.

9. A nurse is supervising a student nurse who is performing tracheotomy care for a client. Which of
the following actions by the student should the nurse intervene?

a. Removing the inner cannula and cleaning using universal precaution.

b. Suctioning the tracheotomy tube before performing tracheotomy care.
c. Changing the old tracheotomy ties and securing the tube in place.
d. Replacing the inner cannula and cleaning the site of the stoma.

10. The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally
disconnected, what is the most appropriate action for the nurse to take?

a. Secure the chest tube using a tape.

b. Clamp the chest tube immediately.
c. Place the end of the chest tube in a container of normal sterile saline.
d. Apply an occlusive dressing and notify the physician.

11. Care for an indwelling urinary catheter should include which of the following interventions?

a. Insert the catheter using clean technique.

b. Keep the drainage bag on the bed with the client.
c. Remove obvious encrustations from the external catheter surface by washing it gently with
soap and water.
d. None of the above

12. The nurse recognizes that urinary elimination changes may occur even in healthy older adults
because of which of the following?
 a. The bladder distends and its capacity increase
b. Older adults ignore the need to void
c. Urine becomes more concentrated
d. The amount of urine retained after voiding increase

13. The catheter slips into the vagina during a straight catheterization of a female client. The nurse
does which action?
a. Leaves the catheter in place and gets a new sterile catheter
b. Leaves the catheter in place and asks another nurse to attempt the procedure
c. Removes the catheter and redirects it to the urinary meatus
d. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus

14. Which statement indicates a need for further teaching of a home care client with a long term
indwelling catheter?
a. “I will keep the collecting bag below the level of the bladder at all times”
b. “Intake of cranberry juice may help decrease the risk of infection”
c. “Soaking in a warm tub bath may ease the irritation associates with the catheter”
d. I should use clean tech. When emptying the collecting bag

15. A patient’s urine is cloudy, is amber, and has an unpleasant odor. What problem may this
information indicate that requires the nurse to make a focused assessment?
a. Urinary retention
b. Urinary tract infection
c. Ketone bodies in the urine
d. High Urinary calcium level

16. A client who has an indwelling catheter reports I need to urinate. Which of the following
interventions should the nurse perform?

a. Check to see whether the catheter is patent

b. Reassure the client that it is not possible for her to urinate
c. Re-catheterize the bladder with a larger gauge catheter
d. Collect a urine specimen for analysis

17. A provider prescribes a 24 hour urine collection for a client. Which of the following actions should
the nurse take?

a. Discard the first voiding

b. Keep all voiding in a container at room temperature
c. Ask the client to urinate and pour the urine into a specimen container
d. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the
specimen container

18. What is Paracentesis?

a. Is a procedure during which fluid from the abdomen is removed through aneedle.
b. Is a procedure used to drain the fluid within the chest cavity surrounding the lungs.
c. Is a procedure where fluid is aspirated from the pericardium Contents.
d. None of the above

19. What is Thoracentesis?

 a. Is a procedure during which fluid from the abdomen is removed through a needle.
b. Is a procedure used to drain the fluid within the chest cavity surrounding the lungs.
c. Is a procedure where fluid is aspirated from the pericardium Contents.
d. None of the above

20. What is Pericardiocentesis?

a. Is a procedure during which fluid from the abdomen is removed through aneedle.
b. Is a procedure used to drain the fluid within the chest cavity surrounding the lungs.
c. Is a procedure where fluid is aspirated from the pericardium Contents.
d. None of the above.

21. What is code Blue?

a. It is announced when cardiac arrest happens

b. It is announced when external disaster happens
c. It is announced when internal disaster happens
d. It is announced in the case of child abduction

22. What is code Red?

a. It is announced when cardiac arrest happens

b. It is announced when external disaster happens
c. It is announced when internal disaster happens
d. It is announced in the case of child abduction

23. What is code Brown?

a. It is announced when cardiac arrest happens

b. It is announced when external disaster happens
c. It is announced when internal disaster happens
d. It is announced in the case of child abduction

24. What is code Pink?

a. It is announced when cardiac arrest happens

b. It is announced when external disaster happens
c. It is announced when internal disaster happens
d. It is announced in the case of child abduction

25. What is Lithotripsy?

a. It is a treatment, typically using ultrasound shock waves, by which a kidney stone or other
calculus is broken into small particles that can be passed out by the body.
b. It is a surgical procedure to remove kidney stones.
c. Is a procedure during which fluid from the abdomen is removed through a needle.
d. None of the above
 Post Test
1. Of the following infection control method which would prevent hepatitis B most effectively
e. Hand washing
f. Hepatitis B vaccine
g. Proper personal hygiene
h. Immune globulin

2. A newly RN nurse is about to insert a nasogastric tube to a client with Guillain-Barre Syndrome. To
determine the accurate measurement of the length of the tube be inserted, the nurse should:

e. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and
then down to the top of the sternum.

f. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and
then down to the xiphoid process.

g. Place the tube at the tip of the nose, and measure by extending the tube down to the chin
and then down to the top of the xiphoid process.

h. Place the tube at the base of the nose, and measure by extending the tube to the earlobe
and then down to the top of the sternum.

3. A stroke client who was initially on NGT feeding was able to tolerate soft diet so the physician
ordered for the removal of it. The nurse would instruct the client to do which of the following
before he removes the tube?

e. Inhale and exhale simultaneously.

f. Take a long breath and hold it.
g. Do a Valsalva maneuver.
h. Blow the nose.

4. The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a comatose client.
Which of the following actions is an inappropriate practice by the nurse?

e. A. If bowel sounds are absent, hold the feeding and notify the physician.
f. Assess tube placement by aspirating gastric content and check the PH level.
g. Warm the feeding to room temperature to prevent the occurrence of diarrhoea and cramps.
h. Elevate the head of the bed to 45 degrees and maintains for 30 minutes after instillation of
feeding.

5. Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of
90ml. What is the appropriate action for the nurse to take?

e. Discard the residual amount.

f. Hold the due feeding.
g. Skip the feeding and administer the next feeding due in 4 hours.
h. Reinstill the amount and continue with administering the feeding.
6. The nurse is assessing a client with an endotracheal tube and observes that the client can make
verbal sounds. What is the most likely cause of this?

e. This is a normal finding.

f. There is a leak.
g. There is an occlusion.
h. The endotracheal tube is displaced.

7. While changing the tapes on a tracheotomy tube, the client coughs and the tube is dislodged.
Which is the initial nursing action?

e. Call a respiratory therapist to reinsert the tracheotomy.

f. Cover the tracheotomy site with a sterile dressing.
g. Call the physician to reinsert the tracheotomy.
h. Grasp the retention sutures to spread the opening.

8. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle bubbling in the suction control chamber. What action is most appropriate of the
nurse?

e. Increase the suction pressure so that the bubbling becomes vigorous.

f. Do nothing since this is an expected finding.
g. Immediately clamp the chest tube and notify the physician.
h. Check for an air leak because the bubbling should be intermittent.

9. A nurse is supervising a student nurse who is performing tracheostomy care for a client. Which of
the following actions by the student should the nurse intervene?

e. Removing the inner cannula and cleaning using universal precaution.

f. Suctioning the tracheotomy tube before performing tracheotomy care.
g. Changing the old tracheotomy ties and securing the tube in place.
h. Replacing the inner cannula and cleaning the site of the stoma.

10. The nurse is handling a client with a chest tube. Suddenly, the chest drainage system is accidentally
disconnected, what is the most appropriate action for the nurse to take?

e. Secure the chest tube using a tape.

f. Clamp the chest tube immediately.
g. Place the end of the chest tube in a container of normal sterile saline.
h. Apply an occlusive dressing and notify the physician.

11. Care for an indwelling urinary catheter should include which of the following interventions?

e. Insert the catheter using clean technique.

f. Keep the drainage bag on the bed with the client.
g. Remove obvious encrustations from the external catheter surface by washing it gently with
soap and water.
h. None of the above
12. The nurse recognizes that urinary elimination changes may occur even in healthy older adults
because of which of the following?

e. The bladder distends and its capacity increase

f. Older adults ignore the need to void
g. Urine becomes more concentrated
h. The amount of urine retained after voiding increase

13. The catheter slips into the vagina during a straight catheterization of a female client. The nurse
does which action?
e. Leaves the catheter in place and gets a new sterile catheter
f. Leaves the catheter in place and asks another nurse to attempt the procedure
g. Removes the catheter and redirects it to the urinary meatus
h. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus

14. Which statement indicates a need for further teaching of a home care client with a long term
indwelling catheter?
e. “I will keep the collecting bag below the level of the bladder at all times”
f. “Intake of cranberry juice may help decrease the risk of infection”
g. “Soaking in a warm tub bath may ease the irritation associates with the catheter”
h. I should use clean tech. When emptying the collecting bag

15. A patient’s urine is cloudy, is amber, and has an unpleasant odor. What problem may this
information indicate that requires the nurse to make a focused assessment?
e. Urinary retention
f. Urinary tract infection
g. Ketone bodies in the urine
h. High Urinary calcium level

16. A client who has an indwelling catheter reports I need to urinate. Which of the following
interventions should the nurse perform?

e. Check to see whether the catheter is patent

f. Reassure the client that it is not possible for her to urinate
g. Re-catheterize the bladder with a larger gauge catheter
h. Collect a urine specimen for analysis

17. A provider prescribes a 24 hour urine collection for a client. Which of the following actions should
the nurse take?

e. Discard the first voiding

f. Keep all voiding in a container at room temperature
g. Ask the client to urinate and pour the urine into a specimen container
h. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the
specimen container

18. What is Paracentesis?

e. Is a procedure during which fluid from the abdomen is removed through aneedle.
f. Is a procedure used to drain the fluid within the chest cavity surrounding the lungs.
g. Is a procedure where fluid is aspirated from the pericardium Contents.
 h. None of the above

19. What is Thoracentesis?

e. Is a procedure during which fluid from the abdomen is removed through aneedle.
f. Is a procedure used to drain the fluid within the chest cavity surrounding the lungs.
g. Is a procedure where fluid is aspirated from the pericardium Contents.
h. None of the above

20. What is Pericardiocentesis?

e. Is a procedure during which fluid from the abdomen is removed through aneedle.
f. Is a procedure used to drain the fluid within the chest cavity surrounding the lungs.
g. Is a procedure where fluid is aspirated from the pericardium Contents.
h. None of the above.

21. What is code Blue?

e. It is announced when cardiac arrest happens

f. It is announced when external disaster happens
g. It is announced when internal disaster happens
h. It is announced in the case of child abduction

22. What is code Red?

e. It is announced when cardiac arrest happens

f. It is announced when external disaster happens
g. It is announced when internal disaster happens
h. It is announced in the case of child abduction

23. What is code Brown?

e. It is announced when cardiac arrest happens

f. It is announced when external disaster happens
g. It is announced when internal disaster happens
h. It is announced in the case of child abduction

24. What is code Pink?

a. It is announced when cardiac arrest happens

b. It is announced when external disaster happens
c. It is announced when internal disaster happens
d. It is announced in the case of child abduction

25. What is Lithotripsy?

a. It is a treatment, typically using ultrasound shock waves, by which a kidney stone or other
calculus is broken into small particles that can be passed out by the body.
b. It is a surgical procedure to remove kidney stones.
c. Is a procedure during which fluid from the abdomen is removed through a needle.
d. None of the above