NUR 339 PREDICTOR VERSION I COMPLETE_LATEST 2021/2022
1. The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should assign the client to a room with which client?
A. A client diagn
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NUR 339 PREDICTOR VERSION I COMPLETE_LATEST 2021/2022
1. The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should assign the client to a room with which client?
A. A client diagnosed with Cushing’s Syndrome.
B. A client Diagnosed with cellulitis of the left leg.
C. A Client diagnosed with acute peritonsillar abscess.
D. A client diagnosed with acute pelvic inflammatory disease. Answer: A
2. The nurse observes client care on a geriatric unit. The nurse should intervene in which situation?
a. A student nurse assist the client out of bed toward the clients strong side.
b. A student nurse assist the client to sit on the side of the bed by lifting the client’s shoulders and swinging the client’s legs over the edge of the bed.
c. A student nurse assists the client to stand from a sitting position by grasping the client’s elbows.
d. Two student nurses use a draw sheet to turn a client in the bed. Answer: C
3. The nurse evaluates the results of the client’s purified protein derivative (PPD) 2 ½ days after the injection. The nurse noted the induration is 4 mm. which action by the nurse is most appropriate?
a. Inform the client the results are negative
b. Obtain the names of the client’s closest contacts.
c. Determine the HIV status of the client.
d. Wait and additional 24 hours to read the results. Answer: A
4. The nurse cores for the client with a history of schizophrenia. The nurse expects to note which speech pattern?
a. Repetition of the words used by the nurse.
b. Rapid, coherent conversation about unrelated topics.
c. Immediately answering questions appropriately.
d. Slow, purposeful answers to the nurses questions. Answer: A
5. The nurse cares for a 6-month-old infant. The parents report that the infant had severe diarrhea for twelve hours. The nurse anticipates which finding?
a. Normal skin elasticity.
b. Depresses anterior fontanel.
c. Pale yellow urine.
d. Absent bowel sounds. Answer: B
6. The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The client reports pain at 1600. The nurse notes that the hydrocodone was last administered at
1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering the error, how should the nurse record the occurrence?
a. “Wrong pain tablet given early. Client will be monitored closely. Asleep now.”
b. “Hydromorphone given instead of hydrocodone. Nursing supervisor aware of error.”
c. Hydrocodone tablet ordered every 6 hours; pain medication given after 4 hours. Health care provider notified.”
d. “Hydromorphone given at 1615; health care provider notified. B/P 122/80, RR 16.” Answer: D
7. The male client asks the nurse, “Why am I experiencing erectile dysfunction (ED)?” The nurse reviews the client’s medications. The nurse recognizes that which classification increases the risk for ED?
a. Non-steroidal anti-inflammatory drugs.
b. Antihypertensive medications.
c. Anticoagulant medications.
d. Histamine H2 inhibitors. Answer: B
8. The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP) discuss the client’s condition. What is the PRIORITY action for the nurse to take?
a. Change the topic of the conversation.
b. Report the employees to their nurse manager.
c. Inform the employees about patient confidentiality and the client’s right to privacy.
d. Meet with the employees at the end of the shift and tell them not to discuss clients in a public place.
Answer: C
9. The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met if which is recorded on the intake and output (I&O) sheet for an eight-hour shift?
a. 360 ml
b. 160 ml
c. 480 ml
d. 240 ml 1 oz=30 ml; 60 oz*8= 480 ml Answer: C
10. The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate which activity to the LPN/LVN?
a. Follow up on the client’s report of chest and back itching two hours after starting a patient controlled analgesia pump.
b. Provide instruction for the client receiving the first nicotine patch.
c. Inform the health care provider of the client’s history of peptic ulcer disease prior to administration of streptokinase.
d. Take the blood pressure and heart rate before administration of enalapril. Answer: D
11. The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne precautions, the nurse must confirm which?
a. The tuberculin skin test is negative
b. No acid-fast bacteria are in the sputum.
c. The client has received anti-tuberculin medication for three days.
d. The client’s temperature has returned to normal. Answer: B
12. The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makes which statement to her husband?
a. I can go back to work tomorrow on a part-time basis
b. I’m sorry to tell you we can’t have sexual relations
c. I will still be able to have a vaginal birth
d. I have to come back in 48 hours for a vaginal exam Answer: B
13. The nurse prepares the client diagnosed with myxedema for discharge. Which action should the nurse teach related to body temperature?
a. “Alternate acetaminophen with ibuprophen every four hours for fever”
b. “Take your temperature and record the results three times a day.”
c. “Put on multiple layers of clothes until you fell comfortably warm.”
d. “Use a heating pad during the day and electric blanket at night.” Answer: C
14. The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a candidate for induction of labor?
a. The client with the fetal face as the presenting part.
b. The client diagnosed with preeclampsia.
c. The client diagnosed with active herpes infection.
d. The client experiencing late decelerations. Answer: B
15. The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST important?
a. Prevent Kaposi’s sarcoma.
b. Prevent depression
c. Prevent infections.
d. Prevent social isolation. Answer: C
16. The nurse educator presents an in-service on acyanotic heart disease. Which is the most common symptom of this disorder that the nurse educator should include?
a. Severe retarded growth.
b. Clubbing of the fingers and toes.
c. Presence of an audible heart murmur.
d. Polycythemia. Answer: C
17. The nurse provides care for the client diagnosed with pneumonia who has postural drainage twice a day. Which client response indicates to the nurse that treatment is effective?
a. “My upset stomach is better.”
b. “I am coughing up more sputum.”
c. “My cough is better.”
d. “I don’t feel feverish anymore.” Answer: B
18. The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration?
a. Failure to follow routine policy and procedures.
b. Caring for too many clients.
c. Responsible for administering numerous medications.
d. Unfamiliar with monk of the new pharmaceuticals ordered. Answer: A
19. The nurse cares for the school-aged child newly diagnosed with type 1 diabetes. The nurse instructs the family that the child’s insulin needs will decrease during which situation?
a. Active exercise
b. Infection
c. Emotional stress.
d. Puberty. Answer: A
20. The nurse cares for the client receiving lactulose. The nurse determines the medication is effective if which is observed?
a. The client’s weight increases by 5 pounds.
b. The client denies shortness of breath.
c. The client’s urinary output is 2000 ml daily.
d. The client is alert and oriented to person, place and time. Answer: D
21. The nurse cares for the three-year-old prior to a surgical procedure. Which behavior indicates that the child is coping with preoperative preparation?
a. The child hops around the room pretending to be a bunny while the nurse attempts to obtain a blood pressure reading.
b. The child talks about the picture of a nurse and client while coloring the picture using a number of bright colored crayons.
c. The child sits quietly reading a story about a boy who is going to have surgery while the nurse reviews the consent from the parents.
d. The child sits on the parent’s lap and sucks the child’s thumb while the nurse uses puppets to demonstrate the use of the pulse oximeter.
Answer: B
22. The nurse instructs the client after a total hip arthroplasty. The client will utilize which assistive devices in the home?
a. Wheelchair
b. A long-handled shoehorn.
c. A reaching device.
d. A raised toilet seat.
e. A trochanter roll.
f. A shower bench. Answer: B,C,D,F
Note: total hip replacement is the same as arthroplasty
23. The client reports vomiting and diarrhea for three days. Which assessment finding does the nurse anticipate?
a. Bradycardia
b. Decreased blood pressure.
c. Peripheral edema.
d. Moist crackles. Answer: B
24. The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion. Which action should the nurse take FIRST after initiating the infusion?
a. Time and record the length and strength of the contractions.
b. Prepare the client for an emergency cesarean birth.
c. Check the client’s perineum for bulging.
d. Monitor the fetal heart rate. Answer: A
25. The intensive care nurse cares for the client two hours after a myocardial infarction is diagnosed. The nurse’s PRIORITY is to focus on which action?
a. Relieve pain.
b. Prevent embolism.
c. Monitor the telemetry.
d. Reduce apprehension. Answer: A
26. The home health nurse instructs the family how to “allergy-proof” their preschooler’s bedroom. The nurse determines teaching is successful if which of the following is observed?
a. There are mini-blinds on the windows without curtains.
b. The feather pillows are enclosed in double pillowcases.
c. The child’s doll collection is displayed high on a shelf.
d. There are no pictures hung on the walls. Answer: D
27. The nurse cares for infants in the newborn nursery. Which observation requires the nurse to contact the physician?
a. The Asian female, 12 hours old, has a large bluish area noted across the sacrum and left hip.
b. An African-American make, 2 hours old, has fine bi-basilar crackles.
c. Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6 hours ago.
d. The anterior fontanel of a Caucasian male born 28 hours ago is moderately firm and flat.
Answer: C
28. The nurse cares for the client diagnosed with partial thickness burns to the entirety of both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage? a. 18%
b. 29%
c. 36%
d. 9%
Answer: A
4.5% front and 4.5 % back, whole arm 9%
29. The home care nurse visits the client diagnosed with late stage Parkinson’s disease. The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective?
a. “My Client should push the hips up from the wheelchair for about 10 seconds every hour or so.”
b. “My client should elevate the knees with a pillow when lying in bed.”
c. “I will limit my client’s time in the wheelchair to 30 minutes each day.”
d. “I will encourage my client to change position every six hours.” Answer: A
30. The home care nurse makes a visit to the client diagnosed with heart failure. The client reports having difficulty sleeping at times. The nurse should take which action FIRST?
a. Recommend taking over-the-counter diphenhydramine (Benadryl)
b. Encourage a half hour of moderate exercise prior to going to bed.
c. Obtain a thorough sleep assessment history.
d. Instruct the client to nap during the day. Answer: C
31. The nurse cares for the client admitted to the critical care unit. The nurse observes splinter hemorrhages in the nails, painful nodules on the fingertips and splenomegaly. It is MOST important for the nurse to take which action?
a. Determine if client can comply with home IV therapy.
b. Auscultate the precordium for murmurs. (ENDOCARDITIS)
c. Instruct the client about the importance of balancing rest and activity.
d. Encourage the client to perform oral hygiene twice a day. Answer: B
32. The nurse instructs the client about stable angina. The nurse determines teaching is effective if the client makes which statement?
a. Angina pain usually feels like being stabbed with a knife
b. Each time I have angina, my heart is damaged.
c. My chest pain can occur if I overexert myself.
d. If I have chest pain, then I’m probably having another heart attack. Answer: C
33. The nurse cares for the client in pain. Which factor is MOST important to determine if the client is a candidate for patient controlled analgesia?
a. The client has a surgical procedure of 30 minutes.
b. Body mass index does not exceed 30 kg/m2
c. The clients has a history of chronic pain.
d. The client is mentally alert. Answer: D
34. The nurse received report from the previous shift. Which client should the nurse see FIRST?
a. The client recently admitted from the operating room who is drowsy and requesting something for pain.
b. The client recently diagnosed with asthma with an O2 saturation of 97%
c. The client scheduled for discharge later in the day and is reporting increased shortness of breath.
d. The client who had an open cholecystectomy 24 hours ago with a temperature of 100 degrees
Answer: C
35. The nurse reviews the arterial blood gas (ABG) report. The PH is 7.50; CO2 is 40mm;
HCO3 is 30 mm. Which is the MOST important question to ask the client? Pg 234
a. Do you smoke?
b. Do you have a history of emphysema?
c. How long have you been vomiting?
d. Do you take insulin for your diabetes? Answer: C
36. The nurse prepares a list of delegated tasks for the nursing assistive personnel (NAP). Which task would be APPROPRIATE?
a. Feed the client diagnosed with dysphagia related to a stroke
b. Assist the client one day postoperatively to ambulate following knee replacement.
c. Turn and reposition the client diagnosed with quadriplegia.
d. Obtain vital signs for the client whose last B/P was 188/104
Answer: C
37. The nurse cares for the client diagnosed with anorexia nervosa. The nurse should include which in the client’s plan of care?
a. Allow as much time as needed for each meal.
b. Observe client during and one hour after each meal.
c. Explain the importance of an adequate diet.
d. Use a random pattern for weigh assessments. Answer: B
38. The nurse cares for the client diagnosed with obsessive-compulsive personality disorder (OCD). Which does the nurse expect the client to demonstrate?
a. Doubts, fears, and indecisiveness
b. Marked emotional maturity.
c. An elaborate delusional system.
d. Rapid, frequent mood swings. Answer: A
39. The nurse prepares to administer medications. Which medication cannot be given directly intravenously?
a. 50%dextrose
b. Potassium chloride (KCI)
c. Furosemide (Lasix)
d. Calcium gluconate. Answer: B
40. The nurse cares for a client diagnosed with pancreatic cancer. When talking to the client about the diagnosis, the nurse anticipates the client will make which statement?
a. How can I have cancer when I don’t hurt anywhere on my entire body?
b. I’ve been feeling fine and didn’t go to the doctor until my skin was kind of yellow.
c. I should have known something was wrong when I gained 10 pounds in six weeks.
d. My last couple of bowel movements have look almost black in color. Answer: B
41. The parent of an adolescent diagnosed with hemophilia calls the nurse to discuss the adolescent’s desire to participate in sports. Which activity should the nurse recommend?
a. Soccer
b. Gymnastics
c. Swimming
d. Snowboarding Answer: C
42. The nurse prepares to administer medications to the following clients. Which medication should the nurse pass FIRST?
a. Cephalexin to the postoperative client with a white blood cell count (WBC of 9.5/mm3
b. Morphine to the postoperative client reporting pain at a 5 on a 0-10 scale.
c. Ipratropium to the newly-admitted client diagnosed with chronic obstructive pulmonary disease.
d. Warfarin tot eh client with a prothrombin (PT) time of 16 seconds and an international normalized ratio (INR) of 3.5.
Answer: C
43. The nurse provides discharge instructions to the client with a tube after traditional cholecystectomy. The nurse determines teaching is effective if the client makes which statement?
a. The tune can be used to administer stone dissolving medications.
b. This tube will stay in for 1-2 weeks and drainage will decrease.
c. If it is this with mucus or blood, I an irrigate the t-tube.
d. I should milk the tube every 4 hours and record the drainage. Answer: B
44. The nurse prepares to administer digoxin for the 5-year-old child. The nurse should withhold the drug and contact the physician for which finding?
a. The one-time dose of furosemide is also due.
b. Child has not eaten in several hours.
c. The nurse notes pallor of the child’s skin.
d. A apical heart rate of 88 assessed. (60 or less adult, 90 or less children) Answer: D
45. The nurse cares for the client with a chest tube. Immediately after the tube is removed, it is MOST important for the nurse to take which action?
a. Cover the section site with a moist saline dressing.
b. Secure the insertion site with several steri-strips.
c. Assist the health care provider to close the insertion site with sutures.
d. Request a STAT portable chest X-ray. Answer: D
46. The home care nurse cares for the client diagnosed with benign prostatic hyperplasia. The client reports not voiding since the previous evening. Assessment reveals a distended bladder. Which action should the nurse take NEXT?
a. Apply gentle pressure over the client’s pubic area.
b. Encourage the client to increase oral intake of fluids.
c. Obtain an order for a straight catheter.
d. Assist the client into a warm shower. Answer: C
47. The nurse assigns the nursing assistive personnel (NAP) to the mother who is first day postpartum following a vaginal birth. Which tasks are appropriate for the nurse to delegate to the NAP?
a. Check the location of the fundus twice a shift.
b. Help the mother to ambulate shortly after delivery.
c. Assist the mother with changing the perineal pad.
d. Inform the mother about appropriate cord cake.
e. Assist the mother with breast-feeding.
f. Instruct the mother about cleansing the perineum. Answer: B,C
48. Two days after a short leg cast was applied for a fractured tibia, the client reports new, severe pain over the calf area. Which action should the nurse take FIRST?
a. Instruct the client to elevate the leg above the heart.
b. Obtain a cast cutter and elastic compression bandages
c. Contact the health care provider.
d. Assess bilateral deep tendon reflexes. Answer: C
49. The nurse counsels the client diagnosed with herpes simplex virus (HSV) infection. Which suggestion by the nurse BEST meet the client’s needs to cope with this diagnosis?
a. Pamphlets about the disease and treatment.
b. Web sites containing sexual transmitted disease (STD) information.
c. Contact information for a local support group.
d. Information about promising drug research. Answer: C
50. The nurse prepares the 3 year old for discharge after a tonsillectomy. The nurse recommends the parents offer the child which food during the first 24 hours?
a. Cherry popsicle
b. Vanilla milkshake
c. Lemon-lime soft drink
d. Cream of tomato soup. Answer: C
51. The client receives enteral nutrition at 50 ml/hour due to dysphagia. Which nursing action diagnosis would be the priority?
a. Risk for fluid volume excess.
b. Risk for electrolyte imbalance.
c. Risk for imbalanced nutrition. Less than body requirements.
d. Risk for aspiration. Answer: D
52. The charge nurse has received change-of-shift report on a medical-surgical unit. Which activity can be delegated to an LPN/LVN?
a. Transfuse platelets for a client.
b. Change a dressing on a client with a stage IV pressure ulcer.
c. Initiate discharge teaching for the client whose B/P was 88/64 an hour ago.
d. Obtain vital signs on a client whose BP was 88/64 an hour ago.
e. Irrigate an urinary catheter.
f. Administer water through a gastrostomy tube. Answer: B,D,E,F
53. The nurse presents information about misuse of medications to the senior citizen group. Which client response indicates a safe medication practice?
a. It is okay to use someone else’s medication if it is similar to my prescription.
b. If I miss a dose of medication, I should not double up on the next dose.
c. Combining prescribed medicines with other the counter ones is cost-saving.
d. Sometimes we have prescriptions from several doctors out of necessity. Answer: B
54. The nurse cares for the client in the emergency department. The client’s friends state the client inhaled varnish remover and passed out. The nurse notices a rash around the client’s nose and mouth, axillary temperature 97.8 degrees, pulse 66, respiration 12, blood pressure 168/88, pulse oximetry 98%. Which action should the nurse take FIRST?
a. Provide oxygen 2L per nasal cannula.
b. Evaluate pupillary response.
c. Listen to heart sounds
d. Place patient in supine position. Answer: B
Increased Intracranial Pressure: opposite of shock; increase BP, decreased Pulse and Decreased Respirations. Pupils don’t respond.
55. Which indicates to the nurse that a 41-year-old woman who is 5’5’’ tall is obese?
a. Waist circumference is 75 cm
b. Wait to hip ratio is 0.7
c. Body mass index is 31 kg/m2
d. Weight is 124 lbs. Answer: C
More than 30, more than 25 overweight. Less than 19 underweight.
56. The nurse cares for the client reporting a burning sensation and itching of the right eye. On examination, the eye is red, with watery yellow discharge. The nurse understands which is the MOST likely cause of the client’s symptoms?
a. Conjunctivitis
b. Foreign body in the eye
c. Allergic reaction
d. Corneal abrasion Answer: A
57. The nurse cares for the infant diagnosed with hydrocephalus immediately after placement of a ventriculoperitoneal (VP) shunt. The nurse should place the infant in which position?
a. High Fowler’s Position
b. Supine lying on the non-operative side
c. Supine lying on the operative side
d. Elevated 30 degrees Answer: B
58. The nurse cares for the teenager recovering from mononucleosis. The teenager is upset and reports feeling too weak to resume normal home and social activates. The friends no longer come visit, and the parent is tired of “doing everything.” Which response by the nurse is MOST appropriate?
a. Medications exist that can boost strength and endurance after mononucleosis.
b. Further diagnostic testing may be necessary to determine the cause of the fatigue.
c. Convalescence is lengthy and people often report fatigue for several months.
d. You need to make more of an effort to participate in normal activities. Answer: C
59. The nurse cares for a client after an involuntary admission to a mental health facility due to threatening to harm self. The family asks the nurse if they can take the client home. Which response by the nurse is MOST appropriate?
a. I will speak to the health care provider about your request.
b. The client is lucky to have a loving family like you.
c. The courts determine how long the client is hospitalized.
d. Why do you want to take the client home? Answer: C
60. The nurse cares for the adolescent diagnosed with Hodgkin’s lymphoma. The adolescent receives nitrogen mustard, vincristine, procarbazine and prednisone. Which adverse effect of the drugs requires early preparation of the adolescent?
a. Constipation
b. Retarded growth in height
c. Alopecia
d. Nausea Answer: C
61. The home care nurse instructs the client receiving long-term prednisone therapy. Which information should the nurse include?
a. There is an increased risk for developing infections.
b. There is a resistance to developing infections.
c. The client should follow a high-protein diet.
d. There are changes in fat distribution over several areas of the body. Answer: D
62. The nurse witnesses a co-worker put one of two narcotic tablets in the co-workers purse twice during the shift. Which action should the nurse take?
a. Confront the co-worker
b. Consult other staff about observation
c. Inform the nursing supervisor
d. Write an incident report
Answer: C
63. The nurse cares for the client with a pacemaker. When monitoring pacemaker functions, which should the nurse assess FIRST?
a. Incision site
b. Apical pulse
c. Blood pressure
d. Electrocardiogram (ECG) Answer: D
64. The adolescent diagnosed with acute mania is started on lithium. Which behavior indicates to the nurse the medication is effective?
a. Decreased euphoria and slower rate of speech noted.
b. Increased interest in sexual activity.
c. Improved appetite and stable weight.
d. Increased social interaction noted during meal times. Answer: A
65. The nurse suspects that the client with severe uterine bleeding is in the early stages of shock. Which is the PRIORITY nursing action?
a. Apply super absorbent perineal pads.
b. Establish intravenous access.
c. Administer oxygen per nasal cannula.
d. Place the client in Trendelenburg position. Answer: C
66. When providing respiratory care for the client with a tracheostomy, it is MOST important for the nurse to take which action?
a. Keep the trach cuff inflated during suctioning.
b. Apply suction as the catheter is being inserted.
c. Instill acetylcysteine just prior to suctioning.
d. Preoxygenate the client prior to suctioning. Answer: D
67. The nurse provides care to a client diagnosed with cirrhosis. Which is the BEST explanation for the development of edema?
a. Decreased concentration of plasma albumin.
b. Decreased production of aldosterone causing sodium and water retention.
c. Shunting of the blood from the portal vessels into the lower pressure vessels.
d. Inadequate formation, use and storage of vitamin K. Answer: A
With cirrhosis there is malnutrition, with malnutrition there is decreased albumin, with decreased albumin there is edema.
68. Nurses working in hospital environments should follow which guideline related to effective hand washing?
a. Use a petroleum-based lotion for prevention of dryness.
b. Have the water temperature as hot as tolerated.
c. Clean under artificial nails prior to starting shift.
d. Wash for at least fifteen seconds covering all surfaces. Answer: D
69. The nurse cares for the primigravida during the transition phase of labor. Which is MOST important for the nurse to include in the client’s plan of care?
a. Provide feedback to reduce client’s anxiety.
b. Assess client’s emotional reaction to impending parenthood.
c. Catheterize client is unable to void for 2 hours.
d. Provide comfort measures including position changes. Answer: D
70. The nurse cares for the client diagnosed with a hearing impairment. Which is a PRIORITY action for the nurse to take?
a. Talk with a raised voice.
b. Utilize more hand gestures.
c. Speak at a slightly slower pace.
d. Use more facial expressions. Answer: C
71. The nurse cares for the newborn with a port wine stain covering the face and half the body. The nurse notes that the mother refuses to look at the newborn. Which response by the nurse is MOST appropriate?
a. Allow the mother to recover from the fatigue of delivery and then bring the newborn to her.
b. Empathetically the mother not to blame herself for the newborn’s appearance.
c. Talk to the family about the situation and encourage the family to comfort the other.
d. Reinforce the health care provider’s explanation of the defect and allow time for the mother to discuss her fears.
Answer: D
72. The nurse reviews a diet containing broiled catfish, baked green beans, a roll, a brownie, and tea. The nurse identifies this diet is most appropriate for which condition?
a. Celiac disease.
b. Type 1 diabetes.
c. Acute pancreatitis.
d. Crohn’s disease. Answer: D
73. The nurse cares for a toddler diagnosed with croup. The nurse notes the toddler’s respiratory and heart rates have increased significantly. Sub sternal and intercostal
retractions are pronounced, and the child is restless. Which action should the nurse take FIRST?
a. Suction the child’s airway.
b. Contact the health care provider.
c. Percuss the child on the back.
d. Increase the oxygen flow rate. Answer: B
74. The client reports dyspnea, sever chest pain, nausea, and increased anxiety. Which lab value would cause the nurse to contact the physician?
a. Creatinine kinase (CK) 155 units/L.
b. Troponin T 0.9 ng/mL.
c. Low-density-lipoproteins (LDL) 175 mg/dL.
d. Total serum lipids 850 mg/dL. Answer: B
75. An adolescent undergoing hemodialysis tells the nurse, “My friends are all going on a big trip over spring break and I can’t go. I don’t think they’ll miss me much anyway.” Which is the BEST response by the nurse?
a. I would not worry about that. You can communicate with them while they are gone.
b. You must be disappointed. Describe what you are feeling right now.
c. I’ve been left out of things before; you’ll feel better when the break is over.
d. Why do you think they won’t miss you? Answer: B
76. The nurse cared for clients diagnosed with AIDS. The nurse recognizes which statement is true regarding therapy?
1. Pneumonia and influenza vaccines are contraindicated.
2. Protease inhibitors affect cell replication and have been successful.
3. Clients respond best when using single antiviral-type of medication.
4. Most of the medications used are administered by the IV route. Answer #2
Termination *vir
77. The nurse instructs the client about a lumbar puncture. In which position will the client be placed?
1. Lateral recumbent position.
2. Tredelenburg position.
3. Prone with the head turned to the left side.
4. High Fowler’s position. Answer#1
78. The nurse assists the client to obtain a sputum specimen. Which action should the nurse take first?
1. The nurse labels the container and places the specimen in a biohazards bag.
2. The nurse assists the client to perform mouth care.
3. The nurse instructs the client to expectorate into a sterile container.
4. The nurse performs hand hygiene and dons clean gloves. Answer#4
79. The nurse cares for a three-year-old child diagnosed with severe anemia. The nurse observes weakness and fatigue. Which will the nurse expect to observe?
1. Cool, clammy skin.
2. Elevated blood pressure.
3. Cyanosis of the nailbeds.
4. Increased heart rate. Answer#4
80. The nurse cares for a child following corrective surgery for tetralogy of Fallot. The nurse should include which in the child’s plan of care?
1. Place the child in a private room near the nursing station.
2. Restrict visitors with exception of the child’s parents.
3. Limit the child’s physical activity to sitting in a chair at bedside.
4. Instruct the child’s parent about food allowed on a 2 gram sodium diet.
Answer#4
(low in sodium high in potassium because they will be on cardiac meds)
81. The nurse cares for a client diagnosed with pneumonia. The client receives intravenous antibiotic therapy twice daily. The client reports three liquid stools the past six hours. Which action should the nurse take FIRST?
1. Obtain an order for loperamide.
2. Encourage increased consumption of fruit juices.
3. Collect a stool sample for Clostridium Difficile.
4. Complete a diet history of the past 3 days. Answer#3
82. A nurse in the pediatric clinic receives a call from a parent stating, “it looks like my 10- year-old has chickenpox, but my child had the immunization”. Which response by the nurse is BEST
1. “You should keep the child home for the next week”.
2. The child will need a booster vaccine once the vesicles have disappeared”.
3. “If your child had the vaccination, it can’t be chickenpox”.
4. Give aspirin every 4 hours for fever or discomfort”. Answer#1
83. After receiving report from the evening shift charge nurse, which client should the nurse see FIRST?
1. A 69-year –old diagnosed with chronic obstructive pulmonary disease requesting a sleeping pill.
2. A 52-year old client diagnosed with pancreatitis reporting abdominal pain.
3. A 67-year old client diagnosed with pneumonia with a pulse oximeter reading of 88%
4. A 78 year old client diagnosed with coronary artery disease with a blood pressure of 155/88.
Answer#3 SAO2 95-99%
84. A nurse in the oncology clinic receives messages from four clients. Which client should the nurse see FIRST?
1. A client diagnosed with testicular cancer requests information about sperm banking prior to starting chemotherapy.
2. A client diagnosed with non-Hodgkin’s lymphoma reports facial swelling.
3. A client diagnosed with colorectal cancer receiving chemotherapy reports tingling in the fingers.
4. A client who had a radical neck dissection notices whitish patches in the mouth. Answer#2
ABC
85. The nurse develops a plan of care for the client diagnosed with osteoporosis. Which is the best description on the PRIORITY goal?
1. Maintenance of body weight.
2. Improved nutritional intake.
3. Knowledge of medication side effects.
4. Prevention of falls and accidents. Answer#4
86. The nurse determines which lunch menu is the BEST choice for a patient diagnosed with fluid volume excess?
1. Turkey on wheat bread, carrot sticks, chocolate cake, 6 oz iced tea.
2. Sit-fry rice with soy sauce, green beans, ice cream, 6 oz water.
3. Pimento cheese with crackers, grapes, cookies, 4 oz diet soda.
4. Grilled cheese sandwich, dill pickle, apple, 4 oz tomato juice. Answer#1
LOW SODIUM DIET, WATER FOLLOWS SALT
87. The nurse teaches the mother of a 3-month-old infant. When planning accident prevention, the nurse emphasizes which goal?
1. Electric outlets will be covered with plugs.
2. All small objects will be removed from the floor.
3. Crib rails will be kept in the highest position.
4. Toxic substances will be moved from lower storage. Answer#3
88. The nurse obtains a health history for the school-age child diagnosed with asthma. It is most important for the nurse to follow up on which statement made by the child?
1. “I use a vaporizer in my room every night”.
2. “I play football and basketball”.
3. “I live in a rural area”.
4. “I snack on fresh fruit and raw vegetables”. Answer#3
89. The nurse cares for the client just admitted to the surgical unit from recovery after a total hip replacement. It is MOST important for the nurse to take which action?
1. Elevate the affected extremity on pillows.
2. Position the client in high Fowler’s position.
3. Place the client in Buck’s traction.
4. Position the client with the legs abducted. Answer#4
ABDUCTION SPLINTER OR TWO PILLOWS BETWEEN LEGS
90. The nurse cares for the school-age child receiving phenytoin. The nurse should observe for which known adverse effect?
1. Hyperactivity several hours after ingestion.
2. Gingival hyperplasia.
3. Flushed face within an hour of ingestion.
4. Pinpoint pupils.
Answer#2 (phenytoin =Dilantin=anticonvulstant)
91. The nurse cares for the child diagnosed with cystic fibrosis. The nurse should intervene if the child is eating which food?
1. Chili.
2. Roasted chicken tenders.
3. A vanilla milkshake.
4. Slice of watermelon. Answer#3
LOW FAT, HIGH PROTEIN, HIGH CARB AND CALORIES
92. The client diagnosed with type 1 diabetes reports to the nurse, “I feel really nervous and jittery all over”. The nurse notes regular insulin was administered two hours ago. Which action should the nurse take FIRST?
1. Review all medications the client has received.
2. Determine the client’s recent dietary intake.
3. Administer a simple carbohydrate.
4. Request laboratory draw serum blood glucose. Answer#2
93. #1
94. #2
95. The nurse cares for the client diagnosed with bipolar disorder. The nurse determines which activity is appropriate for the client during a period of mania?
Select all that apply.
1. Relaxation exercises.
2. Playing board games with other clients.
3. Watching the television.
4. Scheduled rest periods.
5. Aerobic exercises.
6. Listening to soft music. Answers#1,4,5,6
96. The health department nurse cares for the client diagnosed with tuberculosis and positive HIV status, sharing concerns over financial and childcare issues and life expectancy. Which referral is MOST appropriate for this client?
1. A non-denominational chaplain.
2. Financial counselor at a non-profit agency.
3. Social worker from social services department.
4. The director of the local homeless shelter. Answer#3
97. The adolescent tells the school nurse she is planning to start sexual relations with her boyfriend. Which is the BEST response by the nurse?
1. “I can make a referral to a gynecologist for you”.
2. “Have you discussed this decision with your parents?”
3. “Surely you understand I’ll have to let your parents know”.
4. “How do you plan on paying for contraceptives? Answer#2
98. The nurse cares for the client after colostomy surgery. Eight hours after surgery, what observation would the nurse expect?
1. A dusky-red appearance of the stoma.
2. Absence of any output from the colostomy.
3. Bright bloody drainage from the nasogastric tube.
4. Presence of hyperactive bowel sounds. Answer#2
99. The nurse care for the clients in the Sleep Study Unit. The nurse recognizes which client is at GREATEST risk for developing obstructive sleep apnea?
1. 30 year old male, works nightshift as a security guard.
2. 50 year old female, smokes two packs/day.
3. 60 year old male, 55 pounds over ideal weight.
4. 40 year old female, active alcoholic. Answer#3
100. The client after radical prostatectomy expresses concern related to ongoing urinary incontinence. Which response by the nurse is BEST?
1. Have you been doing Kegel exercises?
2. It is important to anticipate leakage and stay close to a bathroom at all times.
3. Drinking more fluids with your meals will decrease the need to void.
4. Avoiding caffeine and alcohol may reduce bladder irritation. Answer#1
101. The client reports severe lower back pain radiating down the left leg. The client identifies the pain as 9 on a 0-10 scale and states, “It feels like I’ve been stuck with a hot poker”. Which order should the nurse anticipate?
1. Opioid analgesic.
2. Nonsteroidal anti-inflammatory drugs.
3. Immunosupressant agent.
4. Topical nonopioid analgesic. Answer#1
102. The nurse on the pediatric unit receives report from the previous shift. Which client should be seen FIRST?
1. The 8 year old newly diagnosed with type 1 diabetes with a blood sugar of 285 mg/dl.
2. The 2 year old diagnosed with asthma whose pulse oximeter reading is 97%.
3. The 6 year old recovering from an appendectomy with a temperature of 100.3 degrees F (37.9 degrees C).
4. The 10 year old with cerebral palsy with a newly placed enteral nutrition Answer#1
RISK FOR DKA
103. The nurse instructs the client receiving enoxaparin (LOVENOX). Which client response indicates teaching is EFFECTIVE?
1. I will inject the medication into the far left or right side of my abdomen every day.
2. I can take ibuprofen if I am feeling pain.
3. The antidote to enoxaparin is Vitamin K.
4. I am taking enoxaparin to dissolve blood cloths. Answer#1 (ANTIDOTE: Protamine sulfate)
104. The nurse cares for the client receiving acyclovir. The nurse knows acyclovir is used to treat which condition?
1. Herpes simplex.
2. Contact dermatitis.
3. Candidiasis.
4. Psoriasis. Answer#1
105. The nurse admits the 6-month old infant diagnosed with hypovolemia secondary to diarrhea. The physician orders KCL 1 mEq per kg/body weight in 250 ml 0.9% saline. Prior to administering the medication, which action should the nurse take FIRST?
1. Validate the baby has wet a diaper.
2. Determine the possible causes for the diarrhea.
3. Offer the electrolyte solution orally.
4. Arrange for a central line catheter placement. Answer#1
No PEE no K!!!!!!
106. The nurse cares for the client diagnosed with spinal cord injury at the level of T1. The nurse notes the client is flushed and sweating profusely. The client reports a headache and nausea. The vital signs are blood pressure 140/98 and heart rate 38 beats per minute. Which action should the nurse take FIRST?
1. Administer antihypertensive medication.
2. Palpate the client’s bladder.
3. Position the client in a supine position.
4. Place the client on a cardiac monitor. Answer#2
ASSESS FIRST ;IPPA (she inspected and now palpate)
107. The nurse cares for the client diagnosed with HIV. The client reports difficulty coping with the diagnosis. The nurse encourages the client to take which action?
1. Attend church services weekly.
2. Obtain a prescription or an anti-depressant medication.
3. Keep a journal recording feelings.
4. Identify successful coping mechanisms used in the past. Answer#4
108. The nurse cares for a client scheduled for a magnetic resonance imaging (MRI) of the back. Which client response required an intervention by the nurse?
1. I am allergic to shellfish and iodine.
2. I use nitroglycerin tablets for angina.
3. I had a total hip replacement three years ago.
4. I am on a blood thinner and bleed easily. Answer# 3
109. The nurse instructs the client diagnosed with vitamin B12 deficiency. The nurse recognizes teaching is effective if the client chooses which menu?
1. Broiled chicken breast, white rice, green beans, and lemonade.
2. Liver and onions, macaroni and cheese, tossed salad, and milk.
3. Medium-rare beef steak, baked sweet potato, boiled carrots, and soda.
4. Baked pork chop, mashed potatoes, creamed corn, and tea. Answer#2
110. The nurse cares for the client diagnosed with advanced cirrhosis. When the client raises both arms, the nurse observes flapping tremors of the hands and wrists. What is the medical term used to describe this?
1. Apraxia.
2. Caput medusa.
3. Fetor hepaticus.
4. Asterixis. Answer#4
111. The nurse cares for the client who returned from overseas having recently lost both lower limbs to a car bomb. The nurse notes the client is increasingly irritable, is unable to
sleep well due to recurring nightmares, and seems hyper vigilant. The nurse recognizes these symptoms are most likely indicative of which condition?
1. Obsessive compulsive disorder (OCD).
2. Bipolar disorder.
3. Regression.
4. Post-traumatic stress disorder (PTSD). Answer#4
112. The nurse cares for the client following a vegan diet. The nurse recognizes which meal selection is BEST?
1. Scrambled eggs, wheat toast, coffee, and cantaloupe.
2. Bagel with peanut butter, strawberries and orange juice.
3. Bran flakes, soy milk, grapefruit and tofu.
4. Fresh fruit, yogurt, blueberry muffin, and tea. Answer#3
ONLY EATS VEGETABLE PRODUCTS.
113. The nurse assists the client to breastfeeding the baby for the first time. Which observation by the nurse indicates that the baby is nursing appropriately?
1. Swallowing noises can be heard.
2. The baby’s head is turned toward the mother’s breast.
3. The client reports a pinching sensation as the baby sucks.
4. The baby’s cheeks are dimpled with each suck. Answer#1
114. At 1500, the nurse begins the infusion of packed red blood cells (PRBC’s). The client asks the nurse when the transfusion will be completed. Which response by the nurse is accurate?
1. The transfusion will be completed by 2000.
2. The transfusion will be completed by 1600
3. The transfusion will be completed by 1800.
4. The transfusion will be completed by 2200. Answer#3 (infuse 3-4 hrs)
115. The community nurse instructs the client receiving isoniazid. The nurse is MOST concerned if the client makes which statement?
1. I will not eat tuna sandwiches.
2. I will frequently wash my hands.
3. I will limit my alcohol intake to 1 beer/day.
4. I will eat small, frequent feedings.
Answer#3 (alcohol increases risk for hepatotoxicity, wrong statement shouldn’t drink)
116. The nurse prepares to administer an intramuscular injection to the one-year-old infant. The infant is in the 70th percentile for height and weight. The nurse determines which injection site is MOST appropriate?
1. Vastus lateralis.
2. Deltoid.
3. Ventrogluteal.
4. Abdomen. Answer#1
117. The nurse plans a burn prevention program for older adults. What is the best description of the cause of burns in the elderly population?
1. Frayed electrical wires.
2. Pots and pans on a stove.
3. A lighted cigarette.
4. A bathtub of hot water. Answer#2
118. Prior to administration of a cleansing enema, the nurse explains the procedure to the client. Which statement, if made by the client to the nurse, indicates further teaching is necessary?
1. I have to lie on my right side while you put the solution in me.
2. You’ll put in about the same amount of fluid that’s in a full IV bag.
3. You want to see the returns in the toilet before I flush.
4. If I feel I can’t hold any more of the fluid, I’ll tell you to stop for a moment. Answer#1 (position on Left Sim’s position to allow the solution to flow by gravity)
119. The nurse cares for the adolescent diagnosed with asthma. Which is the MOST appropriate response by the nurse?
1. The cause of the wheezing is the collapse of the small air sacs in your lungs.
2. There is a narrowing of airways going to your lungs.
3. The wheezing is due to fluid in the space surrounding your lungs.
4. The wheezing is due to inflammation in your nose and throat. Answer#2
120. The nurse cares for the unconscious client after a motor vehicle accident. The nurse does a quick physical assessment and remarks, “He must have a history of chronic emphysema”. The basis for the nurse’s judgment was the presence of which finding?
1. A rounded chest and clubbing of nails.
2. Cyanosis around the patient’s mouth.
3. An ipratropium inhaler in the shirt pocket.
4. Smell of cigarette smoke on the patient’s clothes. Answer#1
121. The school nurse reviews bike safety concerns with elementary school children. Which statement indicates to the nurse teaching is effective?
1. I know my bike is the right size because I can read the pedals.
2. I can ride in the street as long as I ride on the left hand side.
3. I will use a bike helmet and wear light colored clothing when I ride.
4. I will have to buy a horn if I want to ride at night. Answer#3
122. The nurse cares for the client on an NPO status. The client repeatedly asks the nurse for something to drink. Which action by the nurse is MOST appropriate?
1. Frequently explain why fluids are restricted.
2. Offer several ice chips each time the client requests a drink.
3. Turn on the television or radio.
4. Provide oral hygiene care frequently. #4
123. The nurse cares for the client after a near-drowning experience in the Atlantic Ocean. It is MOST important for the nurse to monitor for which complication?
1. Hypernatremia.
2. Hypomagnesemia.
3. Hypocalcemia.
4. Hyperkalemia. Answer#1
124. The newly admitted client tells the nurse, “I have not had a good bowel movement in 10 days”. It is MOST important for the nurse to ask which question.
1. What types of food with fiber do you eat?
2. Have you had small amounts of liquid stool?
3. Do you notice a bad odor to your breath?
4. Are you having any nausea and vomiting? Answer#2
CAN BE OBSTRUCTION OR IMPACTION
125. The nurse cares for the client after percutaneous transluminal coronary angioplasty (PTCA) with stent placement. The nurse determines care is appropriate if which tasks are delegated to the nursing assistive personnel (NAP)?
Select all that apply.
1. Remind the client to remain flat in bed.
2. Obtain vital signs every 15-30 minutes.
3. Assess the distal pulses every 15-30 minutes.
4. Provide the client with fluids to drink.
5. Reinforce the pressure dressing.
6. Immediately call for an electrocardiogram (ECG) if the client has chest pain. Answers#1,2,4
126. The nursing instructor reviews electrolytes and discusses common causes for hypercalcemia. The instructor determines teaching is effective when the student choose which as a common cause of hypercalcemia?
1. Malnutrition.
2. Bone malignancy.
3. Hyperthyroidism.
4. Long-term use of furosemide.
Answer#2 (the bone releases calcium into the bloodstream)
127. The nurse cares for the client two days after surgery. As the nurse hangs a new bag of IV fluids, the client reports sudden chest pain and says. “I can’t breathe”. What would be the nurse’s FIRST action?
1. Insert an intravenous line and obtain an apical heart rate.
2. Place the client in high Fowler’s position and auscultate the lungs.
3. Determine if the client has a history of cardiac problems.
4. Ask the nursing assistant personnel to stay with the client while the nurse calls Respiratory Therapy.
Answer#2
128. The nurse receives a call from a client. The client reports having dark-colored bowel movement. Which action by the nurse is MOST appropriate?
1. Determine if the client is taking ferrous sulfate.
2. Instruct the client to see the health care provider as soon as possible.
3. Tell the client to continue monitoring the bowel movement.
4. Ask if the client as eaten new foods. Answer#1
129. The nurse cares for the client diagnosed with type 2 diabetes and an infection in the left foot. Which observation MOST concerns the nurse?
1. The wound site shows evidence of granulation. 2. WBC 8,300/mm3.
3. Erythrocyte sedimentation rate (ESR) 28.2 mm/h 4. T 99.2 F (37.3 C), P 88, R 18, BP 120/76 Answer#3
NORMAL < 25 : rate at which erythrocytes settle out of anicoagulated blood in 1 hour, detects illness associated with inflammation, necrosis.
130. The nurse cares for the client diagnosed with advanced Parkinson’s disease. Which activity is MOST appropriate to decrease fatigue?
1. Establish a regular bed time.
2. Provide for morning and afternoon naps.
3. Avoid high carbohydrate foods.
4. Schedule alternating periods of rest and activity. Answer #4
131. The client has a 2.5 centimeter abdominal aortic aneurysm (AAA) discovered on X-ray. The nurse determines which goal is MOST appropriate for the client?
1. The client will report pain of no greater than “4” on a 0-10 scale.
2. The client will return for follow-up appointments every 6 months.
3. The client will verbalize understanding of perioperative nursing care.
4. The client will limit activities to bathing, eating, dressing, and toileting. Answer#4
132. The nurse cares for the client diagnosed with diabetes insipidus. Which finding will the nurse expect to observe?
1. Daily fluid intake of 1-2 liters.
2. Urine specific gravity of 1.050.
3. Daily urine output of 10 liter.
4. Serum sodium level of 120 mEq/L.
Answer#3 (Polyuria 2 to 24 L/day, low specific gravity 0.006,)
133. The nursing supervisor observes the staff nurse’s ease and excellence in communicating with new parents and family members. The supervisor recommends the staff nurse for the position teaching childbirth classes. What component of leadership has the supervisor demonstrated?
1. Empowerment.
2. Charismatic leadership.
3. Compassionate leadership.
4. Shared governance. Answer#1
134. The nurse receives report for clients on a Woman’s Health Unit. Which client should the nurse see FIRST?
1. The client post bladder repair reports pain is not fully relieved by medication administered through the PCA pump.
2. The client 6 hours after a right mastectomy reports the sheets under her torso feel wet.
3. The client 12 hours after abdominal hysterectomy with a pulse of 90 and B/P 130/88.
4. The client diagnosed with pelvic inflammatory disease with an oral temperature of
101.8 degrees F (38.8 degrees C). Answer#2
135. The nurse instructs the client after a cataract extraction with a lens implant. The nurse determines further teaching is necessary if the client makes which statement?
1. I need to make every effort to avoid sneezing, coughing, or vomiting.
2. I have to sleep with this eye shield on but can wear my glasses during the day.
3. I should call the doctor if I start seeing double or flashes of light.
4. It’s okay to bend over and pick up my grandchild if I am wearing my eye shield. Answer#4
136. The nurse cares for the client in active labor. The client reports contractions started about 3 hours ago. The contractions occur every 4-5 minutes lasting for about 1 minute. The client’s water broke about an hour ago, and the pains are getting worse. Which action should the nurse take first?
1. Administer oxygen 2 L/min by nasal cannula.
2. Place external uterine and fetal monitors on the client’s abdomen.
3. Assist the client into a high-Fowler’s position.
4. Instruct the partner to model pursed-lipped breathing. Answer#2
137. The client is scheduled for a pelvic ultrasound. Prior to the procedure it is MOST important for the nurse to take which action?
1. Encourage the client to completely empty her bladder.
2. Administer a mild sedative.
3. Instruct the client to drink several glasses of water.
4. Obtain an informed consent. Answer#3
138. The nurse cares for a client diagnosed with amnesia after a motor vehicle accident. The client’s friend was killed in the accident, and the client was arrested for driving while intoxicated and speeding. Which is the MOST likely cause of the amnesia?
1. Repression.
2. Suppression.
3. Projection.
4. Dissociation. Answer#4
139. The nurse teaches the parent of an infant after repair of cleft lip and palate. Which is the BEST solution to remove dried food and drainage from the suture line?
1. Hydrogen peroxide.
2. A mild antiseptic solution.
3. Normal saline.
4. Providone-iodine solution. Answer#3
140. The nurse on a medical-surgical unit received report. Which clients should the nurse see FIRST?
1. The client diagnosed with heart failure and dementia trying to get out of bed.
2. The client two days after a total hip replacement with a hemoglobin of 12.9 gm/dl.
3. The client receiving one unit of packed red blood cells with an IV pump sounding an alarm.
4. The client 12 hours after a laparoscopic cholecystectomy states, “My shoulder hurts”. Answer#1
141. The nurse instructs an adolescent diagnosed with a sprained left ankle. Further teaching is required if the adolescent makes which statement?
1. I will elevate my ankle when I am sitting.
2. I will try to keep weight off the ankle for several days.
3. I will put a heating pad on my ankle as soon as I get home.
4. I will keep my ankle wrapped with an elastic compression bandage. Answer#3
RICE: rest, ice, compression, elevation
142. The client in the psychiatric unit tells the nurse, “I know you are trying to poison me, I’m not taking those pills”, which statement, if made by the nurse is MOST appropriate?
1. It’s alright if you don’t want to take the pills right now. You can take them later.
2. I’m not trying to poison you, why do you say that?
3. It sounds like you are afraid that the staff might hurt you, this is a medication to help you.
4. These pills came straight from the pharmacy just like everyone else’s. Why do you think they are poisonous?
Answer#3
143. The nurse teaches the client diagnosed with Addison’s disease. What is MOST important to include in the instructions?
1. Limit physical exertion.
2. Frequent consultations with the health care provider.
3. Adhere to a low sodium diet.
4. Take hormone replacement therapy as prescribed. Answer#4
144. The nurse identifies which client is at GREATEST risk for developing osteomyelitis?
1. A 75 year old client diagnosed with chronic lymphocytic leukemia with a positive wound culture showing methicillin-resistant Staphylococcus aureus infection.
2. A 35 year old client with a history of smoking being treated for an inguinal hernia and is placed on a nicotine patch.
3. An 82 year old client hospitalized for a compound fracture of the left femur treated with an open reduction 48 hours ago.
4. A 42 year old client diagnosed with cerebral palsy hospitalized with pneumonia and has a Stage II decubitus ulcer on the right heel.
#1
145. The nurse prepared to administer buspirone 15 mg to the client. The nurse recognized this medication is MOST appropriate for which client?
1. The 45 year old woman diagnosed with pancreatitis reporting nausea and vomiting.
2. The 27 year old woman diagnosed with panic attacks.
3. The 60 year old man diagnosed with coronary artery disease with a blood pressure of 172/94.
4. The 38 year old man diagnosed with schizophrenia reporting auditory hallucinations.
Answer#2
Antianxiety Med
146. The nurse records the following intake of the client during an 8 hour shift:
½ liter of oral bowel prep solution (500 ml) 8 ounces of juice 1 oz = 30 ml; (240 ml)
4 tablespoons of medicine through a G-tube 1 tbsp= 15 ml; (60 ml)
2 cups of water 1 cup=8 oz= 16 oz; (480 ml)
0.9% sodium chloride at 125 ml/hour IV 125*8= (1000 ml) Record the patient’s intake in milliliters (ML)
2280 ML
147. The nurse cares for the unconscious client diagnosed with a closed head injury. There is no family present. What is the MOST appropriate action for the nurse to take?
1. Wait until a family member is contacted before treating the client.
2. Request the attending health care provider to sign the consent form.
3. Begin treatment on the client under the doctrine of implied emergency consent.
4. Delegate the unit secretary to call every number listed on the client’s cell phone. Answer#3
148. The nurse and nursing assistive personnel (NAP) care for clients in the postpartum unit. The nurse appropriately delegated which tasks to the NAP?
Select all that apply.
1. Document the amount of food intake at lunch.
2. Assist the father dress a newborn prior to a photograph.
3. Perform an intermittent bladder catheterization.
4. Speak to the health care provider about the results of a client’s complete blood count.
5. Ambulate the mother after cesarean birth to the bathroom.
6. Obtain the vital signs on the client ready for discharge. # 1,2,5,6
149. The nurse cares for the child diagnosed with a closed head injury. It is most important for the nurse to assess which finding?
1. The child’s response to the environment.
2. The child’s intake and output.
3. The child’s vital signs.
4. The child’s motor activity. Answer#1 (level of consciousness)
150. The staff nurse asks for the goals of the Quality Assurance Committee. Which is an example of a goal?
1. Use of an alternate laundry service.
2. Explore an increase of handicap parking spaces.
3. Survey documentation of follow-up after administration of pain medication.
4. Determine the cause for employee’s tardiness. Answer#3
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