Question

A nurse is discussing the process of obtaining provider prescriptions with a newly licensed nurse. Which of the following interventions requires a prescription?

Answer 1

Correct Answers:

Obtaining a client's fasting blood glucose level.

Rationale :

🟩 Diagnostic testing such as obtaining blood glucose levels requires a provider’s prescription because it involves collecting laboratory data that may impact diagnosis and treatment.

🟩 Nurses cannot initiate diagnostic testing independently unless operating under standing orders or facility protocols.

🟩 A fasting glucose test is a medical assessment that requires provider authorization to ensure proper interpretation and follow-up.

🟩 Performing such tests without a prescription exceeds the nurse’s scope of practice.

❌ Incorrect Answers

❌ Teaching nonpharmacologic pain management — Teaching is an independent nursing function.

❌ Positioning to prevent pressure injuries — Preventive positioning is nursing judgment, not a provider-ordered intervention.

❌ Discussing stress management techniques — Education and counseling fall within independent nursing practice.

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Answer 2

Correct Answers:

Dangle the client's arm over the edge of the bed.

Rationale :

🟦 Dangling the arm lowers it below the level of the heart, which increases venous pressure and promotes venous filling.

🟦 Gravity helps blood pool in the veins, making them larger, easier to visualize, and easier to cannulate.

🟦 This technique is simple, noninvasive, and widely recommended for adults with difficult venous access.

🟦 It increases the success rate of IV insertion and reduces the number of attempts required.

❌ Incorrect Answers

❌ Apply a cool compress — Cold causes vasoconstriction, making the vein smaller.

❌ Stroke the skin proximal to the site — Stroking distally may help, but stroking proximal does not dilate the vein.

❌ Have the client flex the arm with hand open — Flexing can collapse the vein, not dilate it.

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Answer 3

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

1️⃣ Use the nondominant hand to stretch the skin

🟦 The nurse first uses the nondominant hand to gently pull the skin taut at the injection site.

🟦 Stretching the skin creates a smooth, flat surface, which makes needle insertion easier and more precise.

🟦 This is especially important for intradermal injections because the medication needs to be placed just under the epidermis.

🟦 Proper skin tension also reduces discomfort and helps ensure accurate needle depth.

2️⃣ Insert the needle at a 15° angle

🟩 The nurse inserts the needle bevel up at approximately a 15-degree angle to the skin surface (not 150°—that’s a typo in the options).

🟩 This shallow angle allows the needle to enter the dermis, which is exactly where intradermal medications (like TB tests, allergy tests) must be deposited.

🟩 If the angle is too steep, the needle will go subcutaneous; too shallow, and it may not pierce the skin properly.

🟩 Correct angle = correct layer = reliable test or medication effect.

3️⃣ Inject the medication

🟨 After confirming the needle is in the dermis, the nurse slowly injects the medication.

🟨 A small wheal or bleb should form, indicating the fluid has been placed in the correct layer.

🟨 Injecting too fast or too deep can disrupt this and reduce the accuracy of diagnostic injections (like tuberculin).

🟨 The nurse must stabilize the syringe while injecting to avoid movement or discomfort.

4️⃣ Withdraw the needle

🟧 Once the full dose is administered, the nurse withdraws the needle smoothly and at the same angle.

🟧 Prompt removal prevents leakage and minimizes tissue trauma.

🟧 The site is typically left uncovered for intradermal injections (unless otherwise ordered), so the wheal can be observed.

🟧 Withdrawing before activating safety ensures the device is engaged safely and away from the skin.

5️⃣ Activate the needle safety device

🟥 After removal, the nurse immediately activates the needle’s safety device to prevent accidental needlestick injury.

🟥 This is a critical safety step and must be done before disposal.

🟥 Safe handling aligns with standard precautions and protects both the nurse and others handling waste.

🟥 The syringe is then discarded into a designated sharps container.

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Answer 4

Correct Answers:

"We can review your partner's wishes."

Rationale :

🟦 A living will is a legal document that expresses the client’s autonomous medical wishes, including DNR directives.

🟦 The nurse should support client-centered decision making, meaning the client’s wishes take priority over the partner’s preferences.

🟦 Reviewing the client's stated wishes helps clarify what the client legally chose, reducing confusion and guiding care appropriately.

🟦 This response is therapeutic, respects autonomy, and avoids conflict while reinforcing the legal validity of the advance directive.

❌ Incorrect Answers

❌ “Let’s discuss this with your partner’s provider” — The provider cannot override a valid living will.

❌ “Why do you want your partner resuscitated…?” — Non-therapeutic, confrontational, and judgmental.

❌ “I can talk to your partner about changing the living will” — The client is terminally ill; the nurse should not suggest altering legal documents.

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Answer 5

Correct Answers:

Have the client tuck their chin and tilt their head forward when swallowing

Rationale :

🟩 The chin-tuck maneuver narrows the airway opening and redirects the bolus toward the esophagus.

🟩 This helps prevent aspiration, which is the biggest risk in clients with dysphagia.

🟩 The position gives the client more control over swallowing and improves airway protection.

🟩 It is evidence-based and widely used in speech/swallow therapy for dysphagia management.

❌ Incorrect Answers

❌ Two-way conversation during meals — Talking increases aspiration risk.

❌ Offer water with each bite — Thin liquids increase aspiration risk.

❌ 45-degree positioning — Insufficient elevation; they should be upright (≥ 75–90 degrees).

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Answer 6

Correct Answers:

"Hyperoxygenate the client before suctioning."

Rationale :

🟧 Suctioning briefly removes oxygen from the airway, putting the client at risk for hypoxemia.

🟧 Hyperoxygenation increases reserve oxygen, reducing the risk of desaturation during the procedure.

🟧 This is a required safety step in hospitals and critical care settings.

🟧 Proper suctioning technique prevents airway trauma, hypoxia, and dysrhythmias.

❌ Incorrect Answers

❌ Apply suction while inserting — Causes trauma; suction only when withdrawing.

❌ Pull catheter back when feeling resistance — Resistance means the catheter is at the carina; do not advance further.

❌ Constant suction for 20 seconds — Too long; max duration is 10–15 seconds.

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Answer 7

Correct Answers:

"Hyperoxygenate the client before suctioning."

Rationale :

🟧 Suctioning briefly removes oxygen from the airway, putting the client at risk for hypoxemia.

🟧 Hyperoxygenation increases reserve oxygen, reducing the risk of desaturation during the procedure.

🟧 This is a required safety step in hospitals and critical care settings.

🟧 Proper suctioning technique prevents airway trauma, hypoxia, and dysrhythmias.

❌ Incorrect Answers

❌ Apply suction while inserting — Causes trauma; suction only when withdrawing.

❌ Pull catheter back when feeling resistance — Resistance means the catheter is at the carina; do not advance further.

❌ Constant suction for 20 seconds — Too long; max duration is 10–15 seconds.

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Answer 8

Correct Answers:

Telephone service

Rationale :

🟫 Professional interpreter services (including certified telephone interpretation) ensure accuracy, confidentiality, and legal compliance.

🟫 Telephone interpretation is approved for clinical settings and accessible 24/7.

🟫 Using family, friends, or staff members who are not certified violates HIPAA, increases errors, and creates bias.

🟫 Professional interpreters protect client autonomy and ensure informed consent is valid.

❌ Incorrect Answers

❌ Family member — Violates confidentiality; unreliable, biased.

❌ Health care provider — Not trained; unsafe.

❌ Family friend — Also unqualified; inappropriate.

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Answer 9

Correct Answers:

"l know I am deeply connected to a higher power."

Rationale :

🟦 This statement shows the client is experiencing spiritual grounding, connection, and support, which are key signs of improved spiritual well-being.

🟦 Feeling connected to a higher power indicates hope, meaning, and inner strength, which helps individuals cope with loss or illness.

🟦 It reflects progress from despair toward spiritual acceptance and healing.

🟦 This is an appropriate outcome after involvement from pastoral care.

❌ Incorrect Answers

❌ “I do not know how to reconnect…” — Indicates spiritual distress.

❌ “There is no purpose in living…” — Suggests hopelessness and depression.

❌ “This is proof I needed to be more faithful…” — Shows guilt-based thinking, not spiritual comfort.

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Answer 10

Correct Answers:

Resisting care

Rationale :

🟩 The FLACC scale assesses pain based on observable behaviors when the client cannot self-report.

🟩 Resisting care is a sign of discomfort, guarding, or distress and scores under the "Consolability" or "Activity" categories.

🟩 Clients with cognitive impairment often show pain through agitation or physical resistance.

🟩 This behavior indicates the need for PRN pain medication.

❌ Incorrect Answers

❌ Relaxed posturing — Suggests comfort, not pain.

❌ Absent cry — Indicates no distress.

❌ Rhythmic respirations — Normal finding, not pain-related.

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RN Fundamentals 2023 DEC

No.

1 :
A nurse is discussing the process of obtaining provider prescriptions with a newly licensed nurse. Which of the following interventions requires a prescription?

2 :
A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

4 :
A nurse is caring for a client who has a terminal illness and has a living will that contains a do-not-resuscitate prescription. The client's partner says to the nurse, "I want my partner to be resuscitated if needed." Which of the following responses should the nurse make?

5 :
A nurse is planning care for a client who has dysphagia. Which of the following actions should the nurse plan to take?

6 :
A charge nurse is reviewing endotracheal suctioning with a newly licensed nurse. Which of the following statements should the charge nurse include in the review?

7 :
A charge nurse is reviewing endotracheal suctioning with a newly licensed nurse. Which of the following statements should the charge nurse include in the review?

8 :
A nurse is caring for a client in an outpatient clinic who does not speak the same language as the nurse. Which of the following individuals should the nurse use as an interpreter?

9 :
A nurse consulted pastoral care for a client who has cancer and is in a state of depression after the death of their partner. Which of the following client statements indicates their spiritual needs are being met?

10 :
A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?

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RN Fundamentals 2023 DEC

No.

1 : A nurse is discussing the process of obtaining provider prescriptions with a newly licensed nurse. Which of the following interventions requires a prescription?

2 : A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

4 : A nurse is caring for a client who has a terminal illness and has a living will that contains a do-not-resuscitate prescription. The client's partner says to the nurse, "I want my partner to be resuscitated if needed." Which of the following responses should the nurse make?

5 : A nurse is planning care for a client who has dysphagia. Which of the following actions should the nurse plan to take?

6 : A charge nurse is reviewing endotracheal suctioning with a newly licensed nurse. Which of the following statements should the charge nurse include in the review?

7 : A charge nurse is reviewing endotracheal suctioning with a newly licensed nurse. Which of the following statements should the charge nurse include in the review?

8 : A nurse is caring for a client in an outpatient clinic who does not speak the same language as the nurse. Which of the following individuals should the nurse use as an interpreter?

9 : A nurse consulted pastoral care for a client who has cancer and is in a state of depression after the death of their partner. Which of the following client statements indicates their spiritual needs are being met?

10 : A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?

1 :
A nurse is discussing the process of obtaining provider prescriptions with a newly licensed nurse. Which of the following interventions requires a prescription?

2 :
A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

4 :
A nurse is caring for a client who has a terminal illness and has a living will that contains a do-not-resuscitate prescription. The client's partner says to the nurse, "I want my partner to be resuscitated if needed." Which of the following responses should the nurse make?

5 :
A nurse is planning care for a client who has dysphagia. Which of the following actions should the nurse plan to take?

6 :
A charge nurse is reviewing endotracheal suctioning with a newly licensed nurse. Which of the following statements should the charge nurse include in the review?

7 :
A charge nurse is reviewing endotracheal suctioning with a newly licensed nurse. Which of the following statements should the charge nurse include in the review?

8 :
A nurse is caring for a client in an outpatient clinic who does not speak the same language as the nurse. Which of the following individuals should the nurse use as an interpreter?

9 :
A nurse consulted pastoral care for a client who has cancer and is in a state of depression after the death of their partner. Which of the following client statements indicates their spiritual needs are being met?

10 :
A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?