1. A nurse is reviewing the laboratory results for
a client who is at 32 gestation. For which of the
following results should the nurse notify the
provider?
a. Hgb 12 g/dL
b. Platelet count 90,000/mm2
c. Hematocrit
...
1. A nurse is reviewing the laboratory results for
a client who is at 32 gestation. For which of the
following results should the nurse notify the
provider?
a. Hgb 12 g/dL
b. Platelet count 90,000/mm2
c. Hematocrit 37%
d. Creatinine 0.7 mg/dL
2. After receiving change-of-shift report, which of
the following clients should the nurse collect data
from first?
a. A client who has a history of pancreatitis
and reports severe abdominal pain
b. A client who has heart failure and reports
severe dyspnea
c. A client who is scheduled for abdominal
surgery in 1 hrs
d. A postoperative client who has diabetes
mellitus and a blood glucose of 280 mg/dK
3. A nurse is preparing a client for surgery. The
client tells the nurse that he is concerned about the
safety of a large sum of money in his wallet.
Which of the following actions is appropriate for
the nurse to take?
a. Place the money in an envelope and lock it
in the client’s medication drawer
b. Contact security personnel to place the
money in the facility safe
c. Hold the money for the client until he
returns from surgery
d. Label the money and leave it with the unit
secretary.
4. A nurse is preparing to instill an otic suspension
into an adult client’ ear. Which of the following
methods should the nurse plan to use?
a. Pull the auricle upward and outward.
b. Pull the auricle downward and backward.
c. Pull the auricle upward and backward.
d. Pull the auricle downward an outward.
5. A nurse is caring for an older adult client who
has pneumonia. When reinforcing teaching about
the diagnosis age- related changes with the client’s
family, which of the following alterations should
the nurse include?
a. Increased inflation of the basilar lungs
b. Increased elasticity of the thoracic cage
c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex
6. A client is participating in an anger
management session explain that his recent
behavior are related to his job loss. Which of the
following mechanism is the client using?
a. Projection
b. Rationalism
c. Repression
d. Sublimation
7. A nurse is reinforcing teaching with the client
who is about to undergo a thoracentesis. Which if
the following statements by the client indicates an
understanding of the information?
a. “I will have general anesthesia during the
procedure.”
b. “I will lie flat for 6 hours before the
procedure.”
c. “I will have the chest x-ray following the
procedure.”
d. “I will breathe deeply through my nose
during the procedure.”
8. A nurse is reviewing the medical record of a
client who is requesting an oral contraceptive.
Which of the following findings should the nurse
identify as a contraindication to the use of oral
contraceptive?
a. History of renal calculi
b. Migraines with aura
c. BMI of 26
d. History of cholecystectomy
9. A nurse is reinforcing discharge teaching about
transmission precautions with a client who has
Hepatitis C. Which of the following information
should the nurse include?
a. Avoid sharing razors with other family
members.
b. Clean toilet surfaces with bleach after each
use
c. Advice family members to receive a
hepatitis c immunization
d. Do not prepare food for other family
member s while infectious.
10. A nurse is preparing to administer an IM
injection to a client. To reduce the risk of a needle
stick injury, the nurse should take which of the
following actions?
a. Place a cap hold securely on the used needle
a before disposal.
b. Recap the needle using a one-handed scoop
approach before proper disposal.
c. Dispose of the used needle immediately in
a puncture proof sharps container.
d. Detach and dispose of the use needle
promptly following injection.
11. A nurse is reinforcing teaching with a client
who has new prescription for levothyroxine.
Which of the following statements indicates
understanding of the instructions?
a. “I should take this medication with meals.”
b. This medication will take 2 weeks to reach
full effectiveness.”
c. “I need to take this medication for the
rest of my life.”
d. “If I forget to take the medication, I can
double the next dose.”
12. A nurse is caring for a client who is receiving
prazosin. The client’s blood pressure is 100/60 mm
Hg. which of the following actions should the nurse
take?
a. Administer a reversal agent
b. Initiate cardiac monitoring
c. Instruct the client to stand up slowly
d. Inform the client to report urinary retention
13. A nurse is reinforcing teaching about
colostomy care with a client. Which of the
following client statements indicate an
understanding of how to care for the colostomy?
a. I will cleanse the stoma site gently with an
antiseptic solution.
b. I will contact my doctor right away if my
stoma is red
c. I will cut the water opening 1 inch bigger
than my stoma.
d. I will empty the colostomy bag when is I
one half full.
14. A nurse is reinforcing teaching with a client
who has a permanent pacemaker in place. Which
of the following statements by the client indicates
an understanding of the teaching?
a. “I should have my doctor replace the battery
in the pacemaker in a year.”
b. “I need to record my pulse rate daily.”
c. “I should avoid taking tub baths.”
d. “I will remove my microwave oven from my
house.”
15. A nurse is collecting data from a parent of a
preschooler at a well-child visit. Which of the
following findings is a contraindication to a
measles, mumps and rubella (MMR)
immunization?
a. Family history of allergies to penicillin
b. Erythema at injection site with previous
immunization.
c. Long-term use of immunosuppressants
d. Current use of antimicrobial therapy.
16. A nurse is reinforcing teaching with a client
who has a vitamin C deficiency. Which of the
following foods should the nurse include as having
the highest vitamin C content?
a. 1 cup yogurt
b. 1 cup raw broccoli
c. 1 large baked potato
d. 1 cup boiled carrot
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