BLUEBOOK for NURSES: A Practice Guide Book for Licensure Examination

DIAGNOSTIC PROCEDURES

– PRACTICE TEST –
DIAGNOSTIC PROCEDURES
1. The nurse explains that visualization of the GI tract after a barium enema is made possible by:
a. Barium physically coloring the stool
b. The high x-ray absorbing properties of barium
c. The high x-ray transmitting properties of barium
d. The chemical interaction between barium and electrolytes

2. A 52-year-old is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse can
expect that the client will be
a. Placed on a low-residue diet 1 to 2 days before the study.
b. Given an oil retention enema the morning of the study.
c. Instructed to swallow six radiopaque tablets the evening before the study.
d. Positioned in a high Fowler’s position immediately following the procedure.

3. A 78-year-old client’s hematocrit and hemoglobin are 32.1% and 11.5 g/dl respectively. Based on these results,
the most appropriate nursing intervention would be to:
a. Conduct a complete nutritional assessment of the client
b. Advise the client to have the test repeated in three months
c. Nothing because these are normal values for this age adult
d. Understand that mild anemia is a normal response to the aging process

4. A client is suspected to have a developing infection. Which of the following laboratory results would indicate
that an infection is present?
a. Negative blood culture c. Decreased neutrophils
b. Decreased eosinophils d. Increased leukocytes

5. A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
a. Should be packed on ice c. Should be double-bagged
b. Should be kept warm d. Requires no special handling

6. Within 20 minutes of the start of blood transfusion, the client develops a sudden fever. The most appropriate
initial response by the nurse is to
a. Force fluids. c. Increase the flow rate of IV fluids.
b. Continue to monitor the vital signs. d. Stop the transfusion.

7. A nurse is administering a blood transfusion to a client on the oncology unit. Which clinical manifestation
indicates an acute haemolytic reaction to the blood?
a. Low back pain c. Urticaria
b. A temperature of 101 degrees Fahrenheit d. Neck vein distention

8. A clinical nurse specialist is orienting a new graduate registered nurse to an oncology unit where blood product
transfusions are frequently administered. In discussing ABO compatibility, the nurse presents several
hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic
reaction would occur when giving:
a. A-positive blood to an A-negative client c. O-positive blood to an A-positive client
b. O-negative blood to an O-positive client d. B-positive blood to an AB-positive client

9. The nurse is preparing to start an IV infusion before the administration of unit of packed red blood cells. What
fluid will the nurse select to maintain the infusion before hanging the unit of blood?
a. D5 W c. Lactated Ringer’s solution
b. D5 W/0.45 NaCl d. 0.9 % NaCl

10. A client with B positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing
intervention?
a. The available blood has been banked for 2 weeks
b. The blood available for transfusion is Rh negative
c. The client has a peripheral IV of D5 ½ normal saline

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d. The blood available for transfusion is type O positive

11. A client has a bone marrow aspiration performed. Immediately after the procedure, the nurse should:
a. Position the client on the affected side c. Cleanse the site with an antiseptic solution
b. Begin frequent monitoring of vital signs d. Briefly apply pressure over the aspiration site

12. The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:
a. Fluid volume deficit c. Impaired oxygen exchange
b. Alteration in body image d. Alteration in elimination

13. The nurse is caring for a patient with a colostomy. The patient asks, “Will I ever be able to swim again?” The
nurse’s best response would be:
a. “Yes, you should be able to swim again, even with the colostomy.”
b. “You should avoid immersing the colostomy in water.”
c. “No, you should avoid getting the colostomy wet.”
d. “Don’t worry about that. You will be able to live just like you did before.”

14. A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end
of a double barrel colostomy:
a. Is the opening on the client’s left side c. Is the opening on the client’s right side
b. Is the opening on the distal end on the client’s left side d. Is the opening on the distal right side

15. The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
a. Using Karaya powder to seal the bag c. Using stomahesive as the best skin protector
b. Irrigating the ileostomy daily d. Using Neosporin ointment to protect the skin

16. A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse
notes that the client's stoma appears dusky. How should the nurse interpret this finding?
a. Blood supply to the stoma has been interrupted c. The ostomy bag should be adjusted
b. This is a normal finding 1 day after surgery d. An intestinal obstruction has occurred

17. Following ileostomy, the drainage appliance is applied to the stoma:

a. 24 hours later, when edema has subsided c. After the ileostomy begins to function
b. In the operating room d. when the patient is able begin self-care procedure

18. After discharge, Ms. Santos calls the nurse at the hospital to report the sudden onset of abdominal cramps,
vomiting, and watery discharge from her ileostomy. What should the nurse tell Ms. Santos?
a. Call the physician if symptoms persist for 24 hours c. NPO until vomiting stops
b. Take 30 cc of m.o.m. (milk of magnesia) d. Call physician immediately

19. A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the
following nursing interventions for this client?
a. Administering atropine intravenously
b. Administering small doses of midazolam
c. Encouraging additional fluids for the next 24 hours
d. Ensuring the return of the gag reflex before offering food or fluids

20. A client has a bronchoscopy in ambulatory surgery. To prevent laryngeal edema, the nurse should:
a. Place ice chips in the client’s mouth c. Keep the client in the semi-Fowler’s position
b. Offer the client liberal amounts of fluid d. Tell the client to suck on medicated lozenges

21. A client has a bronchoscopy. The nurse should assess for return of the gag reflex by:
a. Having the client say a few words c. Giving the client a small swallow of water
b. Stroking the anterior third of the tongue d. Touching the pharynx with a tongue depressor

22. The nurse is preparing a client for a cardiac catheterization. What is the best explanation regarding the purpose
of a cardiac catheterization with coronary angiography?
a. Evaluate the exercise tolerance c. Evaluate coronary artery blood flow
b. Study the conduction system d. Measure the pumping capacity of the heart

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23. Chest physiotherapy is a standard adjunct to the treatment of chronic asthma. When should the nurse administer
the child’s bronchodilator in conjunction with postural drainage?
a. one hour before postural drainage c. one hour after postural drainage
b. during postural drainage d. between postural drainage treatments

24. The nurse will perform chest physiotherapy (CPT) on the client every 4 hours. It is important for the nurse to
a. Gently slap the chest wall.
b. Use vibration techniques to move secretions from affected lung areas during the inspiration phase.
c. Perform CPT at least 2 hours after meals.
d. Plan apical drainage at the beginning of the CPT session.

25. The nurse is caring for a client with a closed chest drainage system. If the tubing becomes disconnected from
the system, the nurse should?
a. Instruct the client to perform the Valsalva maneuver c. Decrease the amount of suction being applied
b. Elevate the tubing above the client’s chest level d. Form a water seal and obtain a new connector

26. The doctor inserts a chest tube and attaches it to a water-seal drainage device at 20 cm of suction. The doctor
orders a chest X-ray to;
a. check the position of the chest tube c. visualize a single layer of the lungs
b. advance the tube 1 cm further d. record sound waves that penetrate the lungs

27. Which of the following should the nurse expect in a 3 bottle chest tube drainage system for the client with a
hemothorax 4 hours after chest tube insertion?
a. Intermittent bubbling in the suction camber
b. Bloody drainage
c. Continuous bubbling in water seal chamber
d. Fluctuation with inspiration and expiration in water seal chamber

28. The essential purpose of the water-sealed drainage system is to:

a. Prevent early precipitous reinflation of the lung
b. Drain off excess fluid and air, thereby promoting reestablishment of negative intrapleural pressures
c. Drain off excess fluid and air, thereby promoting reestablishment of positive intrapleural pressures
d. Decrease atelectasis in unaffected lung tissue and to monitor blood loss.

29. On the second postoperative day, the fluid in the suction bottle’s glass tube ceases to fluctuate. This most likely
indicates:
a. The chest tube is obstructed
b. There is an air leak in the system
c. Pulmonary edema has occurred due to increased blood volumes in remaining lung tissue
d. The patient’s position needs to change to facilitate drainage

30. A nurse is planning care for a client with a chest tube attached to a Pleurevac drainage system. The nurse avoids
which of the following activities to prevent a tension pneumothorax?
a. Adding water to the suction chamber as it evaporates
b. Taping the connection between the chest tube and the drainage system
c. Maintaining the collection chamber below the client’s waist
d. Clamping the chest tube

31. A client who is confused inadvertently pulled out the chest tube. What is the most appropriate initial nursing
intervention?
a. Cover the wound immediately with a sterile dry dressing
b. Apply a wet dressing on the chest wound
c. Apply an occlusive dressing
d. Leave the wound open to air till the physician arrives

32. A client with chest tubes is admitted to the nursing unit. The nurse should place the highest priority during
admission on doing which of the following?
a. Plan to measure client's vital signs, respiratory and cardiovascular status regularly
b. Explain the importance of deep-breathing and coughing regularly
c. Report if drainage exceeds 100 mL/h

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d. Place rubber-tipped clamps, sterile water, and a sterile occlusive dressing materials near the client

33. A client with suspected brain tumor was scheduled for computed tomography (CT). What should the nurse do
when preparing the client for this test?
a. Immobilize the neck before the client is moved onto the stretcher
b. Determine whether the client is allergic to iodine, contrast des, or shellfish
c. Place a cap the cap over the client’s head
d. Administer sedative as ordered

34. An adult’s Glasgow Coma Scale score is indicative of coma. Her score is
a. 15 b. 10 c. 8 d. 6

35. The Glasgow Coma Scale is the most widely recognized; standardize level of consciousness (LOC) assessment
tool. What is the lowest score possible?
a. 0 b.3 c. 5 d. 8

36. The nurse assesses the LOC of Ms. Santos using the Glasgow Coma scale and observes the following: The
client responds to pain (eye opening), uses inappropriate words and show extension of the extremities upon
application of painful stimuli. The score is:
a. 6 b. 7 c. 8 d. 9

37. During a hearing assessment, Nurse Ashley notes that the sound lateralizes to the client’s left ear with the
Weber test. Nurse Ashley analyses these results as:
a. A normal finding c. A sensorineural or conductive loss
b. A conductive hearing loss in the right ear d. The presence of nystagmus

38. The patient has been diagnosed with conductive hearing loss. The nurse is going to perform the Weber test.
Which results would the nurse expect to find?
a. The sound will be louder in the affected ear c. Air conduction is shorter than bone conduction
b. The sound will be louder in the good ear d. No sounds will be heard

39. The nurse is caring for a 12-year-old client with appendicitis. The client’s mother is a Jehovah’s Witness and
refuses to sign the blood permit. What nursing action is most appropriate?
a. Give the blood without permission c. Explain the consequences without treatment
b. Encourage the mother to reconsider d. Notify the physician of the mother’s refusal

40. A client post cholecystectomy has just been given analgesics to have his incentive spirometry exercises. Which
of the following techniques indicates proper use of your incentive spirometry?
a. Place in mouth, exhale normally, and inhale normally
b. Place in mouth, exhale slowly, and inhale slowly
c. Exhale slowly, place in mouth, and inhale normally
d. Place in mouth, inhale slowly, and exhale slowly

41. Prior to surgery, Mr. Rivera was instructed in the use of an incentive spirometer. The primary purpose of this
activity is:
a. To encourage coughing c. To encourage deep breathing
b. To arouse and stimulate the patient d. To measure tidal volume and expiratory reserve volume

42. A client with hepatitis C is scheduled for a liver biopsy. Which would the nurse include in the teaching plan for
this client?
a. The client should lie on the left side after the procedure.
b. Cleansing enemas should be given the morning of the procedure.
c. Blood coagulation studies might be done before the biopsy.
d. The procedure is noninvasive and causes no pain.

43. What is the appropriate nursing action following a liver biopsy?

a. Place the client is supine, in a semi-Fowler’s position c. Check vital signs every 15 minutes for 1 hour
b. Draw blood for a CBC d. Place the client on his left side

44. The physician has ordered a lumbar puncture on a client suspected of having meningitis. Following the
procedure, the nurse should:
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a. Place the collection vials on ice

b. Number the collection vials
c. Rotate the collection vials to prevent settling
d. Carry the second and third vials to the lab after discarding the first vial

45. A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should
be considered normal?
a. Total protein 40 mg/100 mL c. Clear, colorless appearance
b. Glucose 60 mg/100 mL d. White blood cells 100/cu. mm

46. Which finding indicates a need for further assessment of the client scheduled for a magnetic resonance
imaging?
a. The client is an insulin-dependent diabetic c. The client is allergic to shellfish
b. The client refuses a corner bed d. The client has a history of asthma

47. The patient undergoes a purified protein derivative (PPD) test. The test should be read:
a. immediately after the test c. 48 to 72 hours after the test
b. 24 to 48 hours after the test d. anytime after 72 hours

48. A patient traveled out of the country five years ago and has had a purified protein derivative (PPD) test. The
patient returns to the clinic with the site having a raised, reddened area of 5 mm. This PPD test would be read
as:
a. abnormal and need to be repeated in two days. c. negative.
b. positive. d. normal.

49. A nurse assigned to the rural health clinic is to administer Mantoux test to a group of factory workers. The nurse
should administer the vaccine in each client’s:
a. Thigh b. Buttock c. Forearm d. Upper arm

50. The nurse reports that a client with a Mantoux test has an induration of 10mm. The nurse knows that the
induration indicates:
a. Infection with the tubercle bacillus c. Questionable exposure to the tubercle bacillus
b. Exposure to the tubercle bacillus d. No exposure to the tubercle bacillus

51. A client with respiratory failure is on a ventilator. The alarm goes off. The nurse’s intial reaction should be to
a. Notify the physician.
b. Assess the client to determine the cause of the alarm.
c. Turn off the alarm.
d. Disconnect the client and use the ambu bag to ventilate the client.

52. The parents ask the purpose of the CPAP while their child is attached to an apnea monitor. The nurse correctly
states that:
a. “The CPAP will maintain the positive airway pressure”
b. “The CPAP will stimulate the child to breathe during apneic episodes”
c. “The CPAP will permit the child to lengthen its inspiratory and expiratory phase”
d. “The CPAP will allow the child to continuously sleep without any disturbance”

53. The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the
following before initiating the feeding?
a. Assess for tube placement by aspirating stomach content
b. Place the patient in a left-lying position
c. Administer feeding with 50% Dextrose
d. Ensure that the feeding solution has been warmed in a microwave for 2 minutes

54. To best assess for the correct placement of NGT, the nurse should:
a. X-ray confirmation
b. Instill 100mL of saline and check for residual; volume in 1 hour
c. Inject air into the tube and listen for gurgling sound in the styomach
d. Connect the tube to a suction and observe for the drainage

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55. When measuring the length of the nasogastric tube to be inserted, Nurse Angge knows that accurate
measurement includes:
a. The nurse places the tube at the tip of the nose and measures by extending the tube to the earlobe and then
down the xiphoid process
b. The nurse places the tube at the tip of the nose and measures by extending the tube to the earlobe and then
down to the top of the sternum
c. The nurse marks the tube at 10 inches
d. The nurse marks the tube at 32 inches

56. A client is receiving a nasogastric (NG) tube feeding. The nurse knows that:
a. Placement does not need to be checked before feeding
b. A nasogastric tube is for long-term uses
c. The head of the bed must be 30 degrees or greater
d. Feeding the client is not a reason for a nasogastric tube

57. For a client receiving a feeding via a gastrostomy (GT) tube, it is important for the nurse to:
a. Clean it weekly c. Change the GT tube daily
b. Flush it with water before and after feeding d. Do not give the medications through the tube

58. The most important nursing action before gastrostomy feeding is:
a. Check for obstruction c. Measure residual feeding
b. Assess for patency of the tube d. Check the appearance of the tube

59. The client with Cirrhosis is scheduled for a paracentesis. Which instruction should be given to the client before
the exam?
a. “You will need to lay flat during the exam.”
b. “You need to empty your bladder before the procedure.”
c. “You will be asleep during the procedure.”
d. “The doctor will inject a medication to treat your illness during the procedure.”

60. During inspection of the breast for symmetry, which of the following position is necessary for the patient to
assume before the start of the procedure?
a. Supine b. Dorsal recumbent c. Sitting d. Lithotomy

61. A client with ascites is scheduled for a paracentesis. A nurse is assisting the physician in performing the
procedure. Which of the following positions will the nurse assist the client to assume for the procedure?
a. Supine b. Left side-lying c. Right side-lying d. Upright position

62. A patient about to undergo sigmoidoscopy would be appropriately placed in what position?
a. Right side lying with knees flexed c. Recumbent Position
b. Left Lateral with knees flexed d. Prone with foot part elevated by pillow

63. The nurse prepares a client for a colonoscopy and directs the client to move to which position?
a. Prone c. Slight Trendelenburg
b. Sim’s lateral d. Flat with lithotomy stirrups

64. After undergoing a liver biopsy, the client would be placed in which position?
a. Semi-fowler b. Right lateral c. Supine d. Prone

65. The best position for any procedure that involves vaginal and cervical examination is?
a. Dorsal recumbent b. Side lying c. Supine d. Lithotomy

66. A client has labored shortness of breath, and a respiratory rate of 28. The bed is in flat position. The best
nursing intervention includes putting the bed in which of the following positions?
a. Fowler’s b. Semi-Fowler’s c. Trendelenburg d. Reverse Trendelenburg

67. A 55 year old female is admitted to the hospital to rule out pernicious anemia. A Schilling test is ordered. The
nurse recognizes that the primary purpose of the Schilling test is to determine the client’s ability to:
a. Store Vitamin B12 b. Digest Vitamin B12 c. Absorb Vitamin B 12 d. Produce Vitamin B12

68. The doctor orders a sputum culture for Mrs. Sia. When collecting a sputum specimen, the nurse should:
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a. Tell the patient to cough deeply and expectorate into the specimen container.
b. Place the patient in the semi-fowler position and tell her to cough shallowly.
c. Place the patient in the high-fowler position and tell her to expectorate saliva into the specimen container.
d. Tell the patient to breathe deeply, cough shallow, and expectorate into the specimen container.

69. The nurse knows that sputum specimen is best collected:

a. At bedtime b. Early morning c. After lunch d. In the mid-morning
70. The physician has ordered the collection of a sputum specimen for a client suspected of having tuberculosis.
Following collection of the specimen, the nurse should:
a. Perform postural drainage c. Force fluids
b. Provide mouth care d. Provide oxygen via mask
71. Preparation of the client for occult blood examination is:
a. Fluid intake limited only to 1 liter/day
b. NPO for 12 hours prior to obtaining of specimen
c. Increase fluid intake
d. Meatless diet for 48 hours prior to obtaining of specimen
72. In collecting a routine specimen for fecalysis, which of the following, if done by the nurse, indicates inadequate
knowledge and skills about the procedure?
a. The nurse scoop the specimen specifically at the site with blood and mucus
b. She took around 1 inch of specimen or a teaspoonful
c. Asked the client to call her for the specimen after the client wiped off his anus with a tissue
d. Asked the client to defecate in a bed pan, secure a sterile container
73. The physician orders three stool specimens for occult blood from a client who complains of blood-streak stools
and a 10-pound weight loss in one month. To ensure valid test results, the nurse should instruct the client to:
a. Avoid eating red meat before testing
b. Test the specimen while it is still warm
c. Discard the first stool of the day an use the next three stools
d. Take three specimens from different sections of the fecal sample
74. Which statement correctly describes suctioning through an endotracheal tube?
a. The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions
are retrieved; the catheter is then withdrawn.
b. The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed
from the upper airway and inserted into the endotracheal tube to suction the lower airway.
c. With suction applied, the catheter is inserted into the endotraceal tube; when resistance is met, the catheter
is slowly withdrawn.
d. The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is
applied during withdrawal.
75. A nurse is performing oropharyngeal suctioning on an unconscious client. Which of the following actions is
safe?
a. Insert the catheter approximately 20 cm while applying suction.
b. Allow 20- to 30-second intervals between each suction, and limit suctioning to a total of 15 minutes.
c. Gently rotate the catheter while applying suction.
d. Apply suction for 5 seconds while inserting the catheter and continue for another 5 seconds before
withdrawing.
76. To approximate the depth of insertion of the catheter of nasopharygeal suctioning, the nurse measures:
a. An eighth of the length of the suction catheter which is about 16 to 18 cm
b. The circumference of the client’s fist
c. The distance between the client’s mouth to the sternal notch
d. The distance between the tip of the client’s nose and the earlobe or about 13 cm
77. Which of the following are indications for the need for suctioning?
a. Orthopnea, decreased pulse rate, fever, pallor, or petechiae
b. Dyspnea, bubbling or rattling breath sounds, cyanosis, or decreased oxygen saturation levels
c. Presence of bacteria in sputum, adventitious breath sounds, or elevated blood pressure
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d. Elevated temperature, dyspnea, flushing, or restlessness

78. A nurse is assessing the respiratory status of the client following thoracentesis. The nurse would become most
concerned with which of the following assessment findings?
a. Respiratory rate of 22 breaths per minute c. Few scattered wheezes, unchanged from baseline
b. Equal bilateral chest expansion d. Diminished breath sounds on the affected side
79. The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is
receiving TPN?
a. Hemoglobin b. Creatinine c. Blood glucose d. White blood cell count
80. A client has frequent stools, with poor oral intake of both fluids and solids. While administering the ordered
parenteral hyperalimentation, it is important to remember that hyperalimentation solutions are:
a. Hypertonic solutions used primarily to increase osmotic pressure of blood plasma
b. Hypotonic solutions used primarily for hydration when hemoconcentration is present
c. Hyperosmolar solutions used primarily to reverse negative nitrogen balance
d. Alkalyzing solutions used to treat metabolic acidosis, thus reducing cellular swelling
81. Which client is most likely to receive total parenteral nutrition (TPN)?
a. A client hospitalized with dehydration from acute gastroenteritis of two days' duration
b. A client with severe malnutrition due to metastatic cancer who is in a hospice program
c. A client NPO following surgery for repair of gunshot wounds to the gastrointestinal system
d. A client NPO following partial removal of the left lung and insertion of a chest tube
82. A client with a cancer diagnosis returns to the room post-total laryngectomy and having difficulty breathing.
Secretions are noted in the tracheostomy tube. The initial nursing intervention should be to:
a. Obtain the vital signs c. Suction the tube
b. Notify the physician d. Start oxygen via a tracheostomy collar
83. The nurse is suctioning a new post-op laryngectomy client and notices bright red blood streaks in the sputum.
The nurse should:
a. Immediately stop suctioning and call the physician c. Document the finding as normal
b. Flush saline through the tubing and call the physician d. Prepare the client to go back to surgery
84. Which of the following behaviors indicate the client with a laryngectomy has accepted the grief of losing his
voice? The client:
a. Requests only his wife be allowed to visit c. Looks at the tracheostomy tube in a mirror
b. Says the doctor made an incorrect diagnosis d. Asks the nurse to help him with a bath
85. When providing tracheostomy care, the nurse should:
a. wash the suction catheter with soap and water
b. suction the patient using 120 mmHg pressure source
c. wear sterile glo9ves to discard soiled dressing
d. Clean the stoma with saline solution and hydrogen peroxide.
86. An adult has a new tracheostomy in place. he has a small amount of thin, white secretions. The stoma is pink
with no drainage noted. The nurse should expect to provide tracheostomy care every:
a. 4 hours b. 8 hours c. 24 hours d. Hour
87. What nursing observation indicated that the cuff on an endotracheal tube is leaking?
a. An increase in peak pressure on the ventilator. c. Increased swallowing efforts by client.
b. Client is able to speak. d. Increased crackles (rales) over left lung field.
88. The nurse is assessing a client with an endotracheal tube in place. What data confirm that the tube has migrated
too far into the trachea?
a. Decreased breath sounds over the left side of the chest.
b. Increase rhonchi at the lungs bases bilaterally.
c. Client is able to speak and coughs excessively.
d. Ventilator alarm continues to sound, indicating decreased oxygen tension.
89. Nurse Anthony is suctioning a client via a tracheostomy tube. When suctioning, he must limit the suctioning to
a maximum of:
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a. 5 seconds b. 15 seconds c. 10 seconds d. 20 seconds

90. When a client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with
family members, the nurse teaches how to do this without compromising the catheter. Which client action
indicates an accurate understanding of this information?
a. The client sets the drainage bag on the floor while sitting down
b. The client keeps the drainage bag below the bladder at all times
c. The client clamps the catheter drainage tubing while visiting with the family
d. The client loops the drainage tubing below its point of entry into the drainage bag
91. A Foley catheter operates by the principle of
a. Inertia b. Gravity c. Diffusion d. Osmosis
92. When a client with a urinary retention catheter in place complains of discomfort in the bladder and urethra, the
nurse should first:
a. Notify the physician c. Check the patency of the catheter
b. Milk the tubing gently d. Irrigate the catheter with prescribed solutions
93. A client experiences difficulty in voiding after an indwelling urinary catheter is removed. This is probably
related to:
a. Fluid imbalances c. An interruption of the normal voiding habits
b. The client’s recent sedentary lifestyle d. Nervous tension following the procedure
94. The nurse can best prevent the contamination from retention catheters by:
a. Perineal cleansing c. Irrigating the catheter
b. Encouraging fluids d. Cleansing around the meatus periodically
95. A nurse has instructed a nursing aide in the procedure for collecting a 24-hour urine specimen from a client.
The nurse determines that the nursing assistant understand the directions if the nursing aide states to:
a. Save the first urine specimen collected at the start time
b. Keep the specimen at room temperature
c. Discard the last voided specimen at the end of the collection time
d. Ask the client to void, discard the specimen, and note the start time
96. When collecting a 24-hour urine specimen, the nurse should:
a. Check if any preservatives need to be added
b. Weigh the client before starting the collection
c. Discard the last voided specimen of the 24-hour period
d. Check the intake and output for the previous 24-hour period
97. The rationale for refrigerating urine specimens that cannot be analyzed immediately is:
a. Urine becomes more acidic and kills bacteria that might be present
b. Urea breaks down into ammonia, causing urine to become more alkaline and promoting cellular breakdown
c. Components in the urine become consolidated so that the urine cannot be analyzed
d. Red cells appear in stagnant urine
98. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?
a. Collect early in the morning, first voided specimen c. Collect 5 to 10 ml for urine
b. Do perineal care before collection d. Discard the first flow of urine
99. Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?
a. Use a clean container
b. Discard the first flow of urine to ensure that the urine is not contaminated
c. Collect around 30-50 ml of urine
d. Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol
100. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:
a. Empty the bag from the drainage port
b. Wear sterile gloves
c. Cleanse the entry site prior to inserting the needle
d. Drain the bag and wait for a fresh urine sample to send from the drainage bag

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