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ACC Nurse Clinical Test
1
Name
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First Name
Last Name
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2
Select the correct description of a bounding pulse:
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a. None felt.
b. Easily felt but not palpable when moderate pressure applied.
c. Feels full and springlike even under moderate pressure.
d. Difficult to feel.
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3
The use of oxygen requires special instruction to prevent fires, due to the flammability of O2. All of the following should be instructed except:
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a. Keep the oxygen system upright.
b. Don't smoke or allow others to smoke near the oxygen system.
c. Keep the oxygen tubing out of the way under furniture or throw rugs.
d. Keep a fire extinguisher on hand is a good safety practice in case of fire.
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4
A physician's order is required for all of the following actions except:
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a. Increasing the frequency of established therapeutic visits in the plan of care (POC).
b. Missed visits.
c. Providing treatment.
d. Administering a medication.
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5
A patient must receive 50 units of Regular Insulin. The label reads 100units=1ml. How many milliliters should the nurse administer?
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a. 0.5ml
b. 0.75ml
c. 1ml
d. 2ml
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6
The physician order reads to give 250mg of a drug. The drug label reads 500 mg/ml. How much of the drug should the nurse give?
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a. 2ml
b. 1ml
c. 1/2ml
d. 1/4ml
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7
What nursing action is essential when providing continuous enteral feeding?Select all that apply
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a. Elevating the head of the bed 30-45 degrees.
b. Position client on left side.
c. Feeding should be room temperature by removing from fridge 15-20 mins prior to administration.
d. Warm the feeding.
e. Hang formula for 3-4 hours
f. Hang formula for 8 hours.
g. Administer feeding straight from the refrigerator.
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8
The nurse is most likely to report which finding to the primary care provider for a client who has an established gastrostomy tube?
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a. Stoma is moist.
b. Stoma color is deep red purple.
c. Stoma extends slightly above skin level.
d. Stoma is dark pink.
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9
While examining a client’s skin, the nurse notes an open ulceration with visible granulation tissue in the wound. What are the next steps the nurse should take?
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a. Apply a moist sterile saline gauze if available.
b. Document the wound.
c. Inform the family.
d. Call the clinical manager.
e. Call the physician.
f. All of the above.
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10
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
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a. Inadequate massaging of the affected area.
b. Inadequate vitamin D intake.
c. Moisture at the site of the ulcer.
d. Low calcium levels.
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11
The nurse is recording assessment data. She writes, “The patient seems worried. Other than that, he had a good night.” Which errors did the nurse make?Select all that apply.
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a. Used vague generality.
b. Did use the patients exact words.
c. Used a “waffle” word (seems).
d. Recorded an inference rather than a cue.
e. Did not record the patient’s vital signs.
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12
Nurse checks for residual before administering a bolus tube feeding to a client with a gastrostomy tube and obtains a residual amount of 200 mL. What is the appropriate action for the nurse to take?
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a. Hold the feeding.
b. Reinstill the amount and continue with administering the feeding.
c. Elevate the client’s head at least 45 degrees and administer the feeding.
d. Discard the residual and proceed with administering the feeding.
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13
When inserting a Nasogastric Tube the nurse should take the following steps:
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a. The tip should be directed parallel to the floor.
b. Directly toward the back of the client’s throat.
c. Advanced with firm constant pressure.
d. If client begins to cough and have respiratory distress pull back on the tube and wait for respiratory distress to subside.
e. All of the above.
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14
Which of the following nursing interventions should the nurse perform for a female client receiving enteral feedings through a gastrostomy tube?
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a. Change the feeding solutions and tubing at least every 48hrs.
b. Maintain the head of the bed at a 15 degree elevation continuously.
c. Check the GT for position prior to each feed and every 4hours during continuous feedings.
d. Maintain the client on bed rest during the feedings.
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15
While attempting to administer a feeding the tube becomes clogged. To remedy this problem what should the nurse not do?
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a. Change the tube if unable to unclog.
b. Apply intermittent suction to the tube.
c. Attach a 30ml or 60ml piston syringe to the feeding tube and pull back on the plunger.
d. Fill the flush syringe with warm water and reattach to the tube and attempt to flush.
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16
Nurse is evaluating a client’s fluid intake and output record. Fluid intake and urine output should relate in which way?
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a. Fluid intake should double the urine output.
b. Fluid intake should be approximately equal to the urine output.
c. Fluid intake should be half the urine output.
d. Fluid intake should be inversely proportional to the urine output.
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17
A client has a tracheostomy and requires tracheal suctioning. The first intervention in completing this procedure would be to:
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a. Change the tracheostomy dressing.
b. Provide humidity with a trach mask.
c. Apply oral or nasal suction.
d. Deflate the tracheal cuff.
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18
When the high-pressure alarm on the mechanical ventilator alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
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a. Kinking of the ventilator tubing.
b. A disconnected ventilator tube.
c. An endotracheal cuff leak.
d. A change in the oxygen concentration without resetting the oxygen level alarm.
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19
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
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a. Call the physician to reinsert the tube.
b. Grasp the retention sutures and spread the opening and attempt to reinsert.
c. Call 911.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.
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20
Please verify that you are human
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