The nurse would anticipate that the health care provider
(HCP) would add which medication to the regimen of the
client receiving isoniazid?
Pyridoxine
2) A postpartum nurse is caring for a client with an epidural
...
The nurse would anticipate that the health care provider
(HCP) would add which medication to the regimen of the
client receiving isoniazid?
Pyridoxine
2) A postpartum nurse is caring for a client with an epidural
catheter in place for opioid analgesic administration
following cesarean birth. The client develops respiratory
depression and requires naloxone administration. Which
finding should the nurse anticipate as a result of the
naloxone administration?
Increase in pain level
3) The nurse should monitor the client receiving the first dose
of albuterol for which side or adverse effect of this
medication?
Tachycardia
4) The client has a prescription to receive pirbuterol 2 puffs
and beclomethasone dipropionate 2 puffs by metered-dose
inhaler. The nurse plans to give these medications in which
way to ensure effectiveness?
Administering the pirbuterol
before the beclomethasone
5) A client with chronic obstructive pulmonary disease (COPD)
is being changed from an oral glucocorticoid to
triamcinolone by inhalation. The client asks why this change
is necessary. Which statement by the nurse to the client is
accurate?
"Inhaled glucocorticoids are
preferred because of decreased
adverse effects."
6) A client taking theophylline has a serum theophylline level
of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this
laboratory value?
In the middle of the
therapeutic range
7) A client is taking cetirizine. The nurse should inform the
client of which side effect of this medication? Drowsiness
8) A client is scheduled to receive acetylcysteine 20% solution
diluted in 0.9% normal saline by nebulizer. Which outcome
would the nurse expect as a result of the administration of
this medication?
Thinning of respiratory secretions
9) The health care provider prescribes cromolyn for the client
with asthma. The nurse identifies that the client correctly
understands the purpose of this medication when the client
states that the medication will produce which effect?
10) The nurse is teaching a client about the effects of
diphenhydramine, an ingredient in the cough suppressant
prescribed for the client. The nurse should plan to tell the
client to take which measure while taking this medication?
Avoid activities requiring mental
alertness.
11) The health care provider (HCP) has prescribed codeine
sulfate for a client with a nonproductive cough to suppress
the cough reflex. The nurse should teach the client to
monitor for which side effect of the medication?
Constipation
12) A client has begun therapy with a xanthine
bronchodilator. The nurse determines that the client
understands dietary alterations if the client states to
limit which items while taking this medication? Select all
that apply.
Coffee
Chocolate
13) Which supplies should the nurse obtain for the
administration of ribavirin to a hospitalized child with
respiratory syncytial virus (RSV)?
A mask and pair of goggles
14) The nurse is documenting information in a client's
chart when the electrocardiogram telemetry alarm sounds, and
the nurse notes that the client is in ventriculartachycardia (VT). The nurse rushes to the client's bedside
and should perform which assessment first?
Check responsiveness
15) A client is brought into the emergency department in
ventricular fibrillation (VF). The nurse prepares to
defibrillate by placing defibrillation pads on which part of
the chest?
To the right of the sternum and to
the left of the precordium
16) An adult client has been unsuccessfully defibrillated
for ventricular fibrillation, and cardiopulmonary
resuscitation (CPR) is resumed. The nurse confirms that CPR
is being administered effectively by noting which action
The carotid pulse is palpable with
each compression.
17) The nurse is assigned the care of a client who
experienced a myocardial infarction and is being monitored
by cardiac telemetry. The nurse notes the sudden onset of
this cardiac rhythm on the monitor. The nurse should
immediately take which action? Refer to Figure.
View Figure
Initiate cardiopulmonary
resuscitation (CPR).
18) To perform defibrillation, the defibrillator pads
should be placed in which areas of the client's chest?
To the right of the sternum just
below the clavicle and to the left
side, just below and to the left of
the pectoral muscle
19) The nurse is caring for a client who is pulseless and
experiencing this dysrhythmia. Which interventions should
the nurse anticipate implementing in collaboration with the
health care provider (HCP)? Select all that apply. Refer to
Figure.
View Figure
Prepare to administer amiodarone. Prepare to administer epinephrine.
Provide cardiopulmonary resuscitation
(CPR).
20) The nurse is performing cardiopulmonary resuscitation
(CPR) on a client who has had a cardiac arrest. An automatic
external defibrillator (AED) is available to treat the
client. Which activity will allow the nurse to assess the
client's cardiac rhythm?
Apply adhesive patch electrodes to the
chest and move away from the client.
21) The nurse is teaching adult cardiopulmonary
resuscitation (CPR) guidelines to a group of laypeople. The
nurse observes the group correctly demonstrate 2-rescuer CPR
when which ratio of compressions to ventilations is
performed on the mannequin?
30:2
22) The nurse is teaching cardiopulmonary resuscitation
(CPR) to a group of community members. The nurse tells the
group that when chest compressions are performed on infants,
the sternum should be depressed how far?
About 1½ inches (4 cm)
23) The nursing instructor teaches a group of students
about cardiopulmonary resuscitation. The instructor asks a
student to identify the most appropriate location at which
to assess the pulse of an infant younger than 1 year of age.
Which response would indicate that the student understands
the appropriate assessment procedure?
Brachial artery
24) The nurse is conducting a basic life support (BLS)
recertification class and is discussing chest compressions
in a pregnant woman. The nurse should tell the class that
which action should be taken in an advanced pregnancy client
whose fundal height is at or above the umbilicus?
Maintain manual left uterine
displacement during compressions.25) The nurse is initiating 1-rescuer cardiopulmonary
resuscitation on an adult client. The nurse should place the
hands in which position to begin chest compressions?
On the lower half of the
sternum
26) The nurse walking in a downtown business area witnesses
a worker fall from a ladder. The nurse rushes to the victim,
who is unresponsive. A layperson is attempting to perform
resuscitative measures. The nurse should intervene if which
action by the layperson is noted?
Use of the head tilt–chin lift
27) The nurse notes that a 14-year-old child is choking but
is awake and alert at this time. The nurse rushes to perform
the abdominal thrust maneuver. The child becomes
unconscious. What procedure should the nurse perform next?
Start chest compressions.
28) The nurse assigned to the pediatric unit finds an
infant unresponsive and without respirations or a pulse.
What is the nurse's next action after calling for help?
Perform compressions at 100 to
120 times per minute.
29) The nurse is undergoing annual recertification in basic
life support (BLS). The BLS instructor asks the nurse to
identify the pulse point to use when determining
pulselessness on an infant. Which response by the nurse
identifies the most appropriate pulse point?
Brachial
30) External public access defibrillator (PAD) interprets
that the rhythm of a pulseless victim is ventricular
fibrillation and advises defibrillation. Which action should
the rescuer take next?
Order people away from the
client, charge the machine, and
depress the discharge buttons.
31) Cardiopulmonary resuscitation (CPR) is immediately
initiated on a client who is unconscious and has no pulse. A
monitor is attached and it is determined that the rhythm isshockable, and defibrillation with 1 shock is delivered.
Which action should the nurse plan to take next?
Perform CPR for 5 cycles, and
then defibrillate again if the
rhythm is shockable.
32) The nurse has completed 5 cycles of compressions after
beginning cardiopulmonary resuscitation (CPR) on a
hospitalized adult client who experienced unmonitored
cardiac arrest. What should the nurse plan to do next?
Charge the defibrillator.
33) The nurse is teaching chest compressions for
cardiopulmonary resuscitation (CPR) to a group of lay
clients. Which behavior by one of the participants indicates
a need for further teaching?
Letting the right and left
fingers rest on the chest
34) In order of priority, how should the nurse perform
abdominal thrusts on an unconscious adult? Arrange the
actions in the order that they should be performed. All
options must be used.
1,2,3,4,5
35) One unit of packed red blood cells has been prescribed
for a client with severe anemia. The client has received
multiple transfusions in the past, and it is documented that
the client has experienced urticaria-type reactions from the
transfusions. The nurse anticipates that which medication
will be prescribed before administration of the red blood
cells to prevent this type of reaction?
Diphenhydramine
36) The nurse has a prescription to administer whole blood
to a client who does not currently have an intravenous (IV)
line inserted. When obtaining supplies to start the blood
infusion, the nurse should select an angiocatheter of at
least which size?
19 gauge
37) A client has experienced high blood pressure and
crackles in the lungs during previous blood transfusions.The client asks the nurse whether it is safe to receive
another transfusion. The nurse explains that which
medication most likely will be prescribed before the
transfusion is begun?
Furosemide
38) The nurse is told by a health care provider that a
client in hypovolemic shock will require plasma expansion.
The nurse should prepare which supplies for transfusion?
Bottle of albumin with vented
tubing
39) The nurse has discontinued a unit of blood that was
infusing into a client because the client experienced a
transfusion reaction. After documenting the incident
appropriately, the nurse sends the blood bag and tubing to
which department?
Blood bank
40) The nurse has just obtained a unit of blood from the
blood bank to transfuse into a client as prescribed. Before
preparing the blood for transfusion, the nurse looks for
which member of the health care team to assist in checking
the unit of blood?
Registered nurse (RN)
41) The nurse is picking up a unit of packed red blood
cells at the hospital blood bank. After putting the pen
down, the nurse glances at the clock, which reads 1300. The
nurse calculates that the transfusion must be started by
which time?
1330
42) The nurse enters a client's room to assess the client,
who began receiving a blood transfusion 45 minutes earlier,
and notes that the client is flushed and dyspneic. On
assessment, the nurse auscultates the presence of crackles
in the lung bases. The nurse determines that this client
most likely is experiencing which complication of blood
transfusion therapy?
Circulatory overload43) The nurse is monitoring a client who is receiving a
blood transfusion. After 30 minutes of the infusion, the
client begins to have chills and back pain. His temperature
is 100.1°F (37.8°C). What action should the nurse take
first?
Discontinue the infusion and
start an infusion of normal saline
using new tubing.
44) The nurse enters the room of a client who began
receiving a blood transfusion 45 minutes earlier to check on
the client. The client is complaining of "itching all over"
and has a generalized rash. The client's temperature has not
changed from baseline and the lungs are clear to
auscultation. Which complication of blood transfusion
therapy should the nurse determine that this client is most
likely experiencing?
Allergic transfusion reaction
45) A unit of platelets was just received from the blood
bank for transfusion to an assigned client. The nurse should
select tubing with which feature for the transfusion?
An in-line filter
46) The nurse overhears a health care provider (HCP)
stating that a client diagnosed with disseminated
intravascular coagulation (DIC) requires a transfusion.
Which blood product should the nurse anticipate that the HCP
will write a prescription for?
Cryoprecipitate
47) The nurse is assisting in monitoring a client who is
receiving a transfusion of packed red blood cells (PRBCs).
Before leaving the room, the nurse tells the client to
immediately report which symptoms of a transfusion reaction?
Select all that apply.
Chills
Chest pain
Lower back pain
Difficulty breathing48) A child is receiving succimer for the treatment of lead
poisoning. The nurse should monitor which most important
laboratory result?
Blood urea nitrogen level
49) A client with a probable minor head injury resulting
from a motor vehicle crash is admitted to the hospital for
observation. The nurse leaves the cervical collar applied to
the client in place until when?
The results of spinal
radiography are known
50) A client experienced an open pneumothorax (sucking
wound), which has been covered with an occlusive dressing.
The client begins to experience severe dyspnea, and the
blood pressure begins to fall. The nurse should first
perform which action?
Remove the dressing.
51) The nurse is performing an assessment on a client
admitted to the nursing unit who has sustained an extensive
burn injury involving 45% of total body surface area. When
planning for fluid resuscitation, the nurse should consider
that fluid shifting to the interstitial spaces is greatest
during which time period?
Between 18 and 24 hours after
the injury
52) The nurse in the recovery room is caring for a client
who underwent neurosurgery. Sequential compression devices
(SCDs) have been applied to prevent venous stasis. While
awaiting client transfer to the intensive care unit, the
recovery room nurse should perform which critical
assessment?
Monitor vascular status of the
lower extremities.
53) A pulmonary artery catheter is inserted into a client
during cardiac surgery. The nurse is monitoring the right
atrial pressure (RAP). Which finding requires immediate
nursing intervention?
12 mm Hg54) The nursing educator has just completed a lecture to a
group of nurses regarding care of the client with a burn
injury. A major aspect of the lecture was care of the client
at the scene of a fire. Which statement, if made by a nurse,
indicates a need for further instruction?
"The client should be
maintained in a standing position."
55) The community health nurse is providing a teaching
session to firefighters in a small community regarding care
of a burn victim at the scene of injury. The nurse instructs
the firefighters that in the event of a tar burn, which is
the immediate action?
Cooling the injury with water
56) The industrial nurse is providing instructions to a
group of employees regarding care to a client in the event
of a chemical burn injury. The nurse instructs the employees
that which is the first consideration in immediate care?
Removing all clothing,
including gloves, shoes, and any
undergarments
57) A client who sustained an inhalation injury arrives in
the emergency department. On initial assessment, the nurse
notes that the client is very confused and combative. The
nurse determines that the client is most likely experiencing
which condition?
Hypoxia
58) A client is brought to the emergency department
immediately after a smoke inhalation injury. The nurse
initially prepares the client for which treatment?
100% humidified oxygen by face
mask
59) The nurse is caring for a client who sustained a burn
injury to the anterior arms and anterior chest area from a
fire. Which assessment finding would indicate that the
client sustained a respiratory injury as a result of the
burn?
Use of accessory muscles for
breathing60) The nurse is performing an assessment on a client who
sustained circumferential burns of both legs. Which
assessment would be the initial priority in caring for this
client?
Assessing peripheral pulses
61) The nurse is developing a plan of care for a client who
sustained an inhalation burn injury. Which nursing
intervention should the nurse include in the plan of care
for this client?
Elevate the head of the bed.
62) The nurse has developed a nursing care plan for a
client with a burn injury to implement during the emergent
phase. Which priority intervention should the nurse include
in the plan of care?
Monitor mental status every
hour.
63) The nurse is developing a nursing care plan for a
client with a circumferential burn injury of the right arm.
What is the nurse's priority action?
Monitor the radial pulse every
hour.
64) Vasopressin is prescribed for a client with a diagnosis
of bleeding esophageal varices. The nurse should prepare to
administer this medication by which route?
By intravenous infusion
65) Vasopressin therapy is prescribed for a client with a
diagnosis of bleeding esophageal varices. The nurse is
preparing to administer the medication to the client. Which
essential item is needed during the administration of this
medication?
A cardiac monitor
66) The nurse is monitoring a client who required a
Sengstaken-Blakemore tube because other measures for
treating bleeding esophageal varices were unsuccessful. The
client complains of severe pain of abrupt onset. Which
nursing action is most appropriate? Cut the tube.
67) A postpartum client who received an epidural analgesic
after giving birth by cesarean section is lethargic and has
a respiratory rate of 8 breaths per minute. The nurse should
obtain which medication from the emergency cart after
notifying the health care provider?
Naloxone
68) The nurse is reviewing the medical record of a client
transferred to the medical unit from the critical care unit.
The nurse notes that the client received intra-aortic
balloon pump (IABP) therapy while in the critical care unit.
The nurse suspects that the client received this therapy for
which condition?
Cardiogenic shock
69) The nurse is providing care for a client who sustained
burns over 30% of the body from a fire. On assessment, the
nurse notes that the client is edematous in both burned and
unburned body areas. The client's wife asks why her husband
"looks so swollen." What is the nurse's best response?
"Leaking blood vessels have
led to decreased protein amounts in
the blood."
70) The emergency department nurse is monitoring a client
who received treatment for a severe asthma attack. The nurse
determines that the client's respiratory status has worsened
if which is noted on assessment?
Diminished breath sounds
71) The nurse is performing an assessment on a client who
was admitted with a diagnosis of carbon monoxide poisoning.
Which assessment performed by the nurse would primarily
elicit data related to a deterioration of the client's
condition?
Level of consciousness
72) The nurse is reviewing the laboratory test results for
a client admitted to the burn unit 3 hours after an
explosion that occurred at a worksite. The client has a
severe burn injury that covers 35% of the total body surfacearea (TBSA). The nurse is most likely to note which finding
on the laboratory report?
Hematocrit 60% (0.60)
73) The nurse is caring for a client who sustained a
thermal burn caused by the inhalation of steam 24 hours ago.
The nurse determines that the priority nursing action is to
assess which item?
Lung sounds
74) A client with depression receiving phenelzine sulfate
suddenly complains of a severe headache and neck stiffness
and soreness and then begins to vomit. The nurse takes the
client's blood pressure and notes that it is 210/102 mm Hg.
On the basis of the findings, the nurse should obtain which
medication from the emergency drawer of the medication cart?
Phentolamine
75) Acetylcysteine is prescribed for a client in the
hospital emergency department after diagnosis of
acetaminophen overdose. The nurse prepares to administer the
medication using which procedure?
Diluting the medication in
cola and administering it to the
client orally
76) A pregnant client being admitted to the labor room
tells the nurse that she felt a large gush of fluid before
arriving at the hospital. The nurse performs an assessment
on the client and notes that the fetal heart rate is 90
beats/minute and that the umbilical cord is protruding from
the vagina. What is the appropriate nursing action?
Wrap the cord loosely in a
sterile towel saturated with warm,
sterile normal saline.
77) The nurse receives a telephone call from a neighbor,
who states that her 3-year-old child was found sitting on
the kitchen floor with an empty bottle of liquid furniture
polish. The mother of the child tells the nurse that the
bottle was half full, that the child's breath smells like
the polish, and that spilled polish is present on the frontof the child's shirt. What should the nurse tell the mother
to do first?
Call the Poison Control
Center.
78) The nurse is caring for a client who sustained multiple
fractures in a motor vehicle crash 12 hours earlier. The
client now exhibits severe dyspnea, tachycardia, and mental
confusion, and the nurse suspects fat embolism. Which is the
initial nursing action?
Position the client in a
Fowler's position.
79) The home health nurse is visiting an older client whose
family has gone out for the day. During the visit, the
client experiences chest pain that is unrelieved by
sublingual nitroglycerin tablets given by the nurse. Which
action by the nurse would be appropriate at this time?
Call for an ambulance to
transport the client to the
hospital emergency department.
80) The client who has experienced a myocardial infarction
(MI) is recovering from cardiogenic shock. The nurse knows
that which observation of the client's clinical condition is
most favorable?
Urine output of 40 mL/hr
81) A client in cardiogenic shock has a pulmonary artery
catheter (Swan-Ganz type) placed. The nurse would interpret
which cardiac output (CO) and pulmonary capillary wedge
pressure (PCWP) readings as indicating that the client is
most unstable?
CO 3 L/min, PCWP high
82) A client in cardiogenic shock had an intra-aortic
balloon pump inserted 24 hours earlier via the left femoral
approach. The nurse notes that the client's left foot is
cool and mottled and the left pedal pulse is weak. Which
action should the nurse take?
Call the health care provider
immediately.83) The nurse is caring for a client with a chest tube
drainage system. While the client is being assisted to sit
up in bed in preparation for ambulation, the chest tube
accidentally disconnects from the chest drainage system.
Which is the initial nursing action?
Place the end of the chest
tube in a container of sterile
water.
84) The nurse is caring for a client with a chest tube
drainage system. During repositioning of the client, the
chest tube accidentally pulls out of the pleural cavity.
Which is the initial nursing action?
Apply an occlusive dressing.
85) The nurse reviewing the operative record for a client
who has just undergone cardiac surgery notes that the
client's cardiac output immediately after surgery was 3.6
L/min. Which intervention is appropriate based on the
client's cardiac output reading?
Notify the health care
provider (HCP).
86) The nurse has a prescription to administer
acetylcysteine to a client admitted to the emergency
department with acetaminophen overdose. Before giving this
medication, what is the nurse's best action?
Empty the stomach by emesis or
lavage.
87) A client with a history of gastric ulcer complains of a
sudden, sharp, severe pain in the midepigastric area, which
then spreads over the entire abdomen. The client's abdomen
is rigid and boardlike on palpation, and the client obtains
most comfort from lying in the knee-chest position. The
nurse suspects which condition and should perform which
action?
Perforation; notify the health
care provider.
88) A postoperative client receives a dose of naloxone
hydrochloride for respiratory depression shortly after
transfer to the nursing unit from the postanesthesia careunit. After administration of the medication, the nurse
should assess the client for which change?
Sudden increase in pain
89) A new nursing graduate is caring for a client who is
attached to a cardiac monitor. While assisting the client
with bathing, the nurse observes the sudden development of
ventricular tachycardia (VT), but the client remains alert
and oriented and has a pulse. Which interventions would the
nurse take? Select all that apply.
Administer oxygen.
Obtain an electrocardiogram
(ECG).
Contact the health care
provider (HCP).
Assess circulation, airway,
and breathing.
90) An emergency department nurse is caring for a child
with suspected acute epiglottitis. Which nursing
interventions apply in the care of this child? Select all
that apply.
Ensure a patent airway.
Obtain a pediatric-size
tracheostomy tray.
Prepare the child for a chest
radiographic study.
Place the child on an oxygen
saturation monitor.
91) A client with a left arm fracture supported in a cast
complains of loss of sensation in the left fingers. The
nursing assessment identifies pallor in the distal portion
of the arm, poor capillary refill, and a diminished left
radial pulse. On the basis of these findings, the nurse
would take which as a priority action?
Contact the health care
provider (HCP).92) The nurse is caring for a client who is receiving
feedings by nasogastric tube. The client suddenly begins to
vomit, and the nurse quickly repositions the client. The
client is coughing and having difficulty breathing. What is
the nurse's priority action?
Suction the client.
93) A delivery room nurse is caring for a client in labor.
The client tells the nurse that she feels that something is
coming through the vagina. The nurse performs an assessment
and notes the presence of the umbilical cord protruding from
the vagina. The nurse should immediately place the client in
which position?
On the side
94) The nurse witnesses an accident whereby a pedestrian is
hit by an automobile. The nurse stops at the scene and
assesses the victim. The nurse notes that the victim is
responsive and has suffered trauma to the thorax resulting
in a flail chest involving at least 3 ribs. What is the
nurse's priority action for this victim?
Apply firm but gentle pressure
with the hands to the flail
segment.
95) The nurse is assessing a client hospitalized with acute
pericarditis. The nurse monitors the client for cardiac
tamponade, knowing that which signs are associated with this
complication of pericarditis? Select all that apply.
Pulsus paradoxus
Distant heart sounds
Falling blood pressure (BP)
Distended jugular veins
96) A client has frequent runs of ventricular tachycardia.
The health care provider has prescribed flecainide. What is
the best nursing action related to the effects of this
medication while the client is hospitalized?
Monitor vital signs and
cardiac rhythm frequently.97) A postpartum client with femoral thrombophlebitis has
developed sudden shortness of breath and appears very
anxious. What is the nurse's priority action for this
client?
Administer oxygen by face mask
as per protocol at 8 to 10 L/min.
98) The child with croup is being discharged from the
hospital. The nurse provides instructions to the mother and
advises the mother to bring the child to the emergency
department if which occurs?
The child develops stridor.
99) The occupational health nurse is called to care for an
employee who experienced a traumatic amputation of a finger.
Which actions should the nurse take to provide emergency
care and prepare the client for transport to the hospital?
Select all that apply.
Elevate the extremity above
heart level.
Assess the employee for airway
or breathing problems.
Examine the amputation site
and apply direct pressure to the
site using layers of gauze.
100) An emergency department nurse is caring for a conscious
child who was brought to the emergency department after the
ingestion of half a bottle of acetylsalicylic acid
(aspirin). The nurse anticipates that which will be the
initial treatment?
The administration of an
emetic
101) The nurse is providing care for a client with new onset
of a dysrhythmia. The nurse anticipates which prescriptions
from the health care provider? Select all that apply. Refer
to Figure.
View Figure
Oxygen therapy An echocardiogram
An intravenous dose of
metoprolol
A bolus of intravenous heparin
followed by a continuous infusion
102) A depressed client is found unconscious on the floor in
the dayroom of a health care facility. The nurse finds
several empty bottles of a prescribed tricyclic
antidepressant lying near the client. Which is the priority
action of the nurse?
Call the emergency response
team.
103) A client begins experiencing wheezing, anxiety,
swelling, and hives after eating shellfish and is brought to
the emergency department. Which immediate action should the
nurse implement?
Maintain a patent airway.
104) The nurse prepares to administer acetylcysteine to the
client with an overdose of acetaminophen. What is the
appropriate action when administering this antidote?
Mix the medication in a
flavored ice drink, and allow the
client to drink the medication.
105) A client who has just suffered a large flail chest is
experiencing severe pain and dyspnea. The client's central
venous pressure (CVP) is rising, and the arterial blood
pressure is falling. Which condition should the nurse
interpret that the client is experiencing?
`Mediastinal flutter
106) A client develops atrial fibrillation with a
ventricular rate of 140 beats/minute and signs of decreased
cardiac output. Which medication should the nurse anticipate
administering first?
Metoprolol107) A client diagnosed with thrombophlebitis 1 day ago
suddenly complains of chest pain and shortness of breath and
is visibly anxious. Which complication should the nurse
immediately assess the client for?
Pulmonary embolism
108) A client with no history of respiratory disease is
admitted to the hospital with respiratory failure. Which
results on the arterial blood gas report that are consistent
with this disorder should the nurse expect to note?
PaO2 49 mm Hg, PaCO2 52 mm Hg
109) The nurse in the labor room is performing an initial
assessment on a newborn. The infant is exhibiting mild to
moderate respiratory distress, audible bowel sounds in the
chest, and a scaphoid abdomen. The infant is responding
poorly to bag and mask ventilation. The nurse plans for
which actions in the care of this infant? Select all that
apply.
Notify the health care
provider (HCP).
Prepare for endotracheal tube
(ET) placement.
Insert an orogastric tube and
connect it to low suction.
110) A child is admitted to the hospital after being seen in
the emergency department with complaints of right lower
quadrant abdominal pain, nausea and vomiting, fever, and
chills. The health care provider (HCP) suspects
appendicitis. Which assessment finding should the nurse
immediately report to the HCP?
Sudden relief of abdominal
pain
111) The mother of a 3-year-old boy calls the emergency
department and states that she found an empty bottle of
acetaminophen on the floor. She states that she thinks her
child ingested all of the medication. What is the priority
question for the nurse to ask the mother? "Is your child breathing
okay?"
112) A 5-year-old boy is brought by his mother to the
emergency department after ingesting a bottle of
acetylsalicylic acid. Which procedure should be initially
instituted with this child?
Institute a gastric lavage and
administer activated charcoal.
113) A mother brings her child to the emergency department.
Based on the child's sitting position, drooling, and
apparent respiratory distress, a diagnosis of epiglottitis
is suspected. In anticipation of the health care provider's
prescriptions, in which order of priority would the nurse
implement the actions? Arrange the actions in the order that
they should be performed. All options must be used.
1,2,3,4,5,6.
114) The nurse is caring for a client who has overdosed on
phenobarbital. The nurse anticipates which assessment
finding with this client?
Shallow respirations
115) The nurse is caring for a client who has overdosed on
amphetamines. The nurse anticipates noting which assessment
finding in this client?
Hypertension
116) A client experiencing cocaine toxicity is brought to
the emergency department. The nurse should prepare to take
which initial action?
Ensure a patent airway.
117) Which readings obtained from a client's pulmonary
artery catheter suggest that the client is in left-sided
heart failure?
Pulmonary capillary wedge
pressure (PCWP) of 20 mm Hg
118) When creating a mechanically ventilated client's plan
of care for prevention of ventilator-associated pneumonia(VAP), the nurse should include which measures in the plan?
Select all that apply.
Suction the oral cavity
whenever needed.
Practice frequent oral
hygiene, including teeth brushing.
Wear gloves when suctioning or
handling the endotracheal tube.
119) Which step should occur first when using an automated
external defibrillator (AED)?
Apply defibrillator pads on
the client.
120) Which should the nurse do when setting up an arterial
line?
Tighten all tubing
connections.
121) Which interventions would be included in the care of a
client with a head injury and a subarachnoid bolt? Select
all that apply.
Monitor vital signs.
Monitor neurological status.
Monitor the dressing for signs
of infection.
Monitor for signs of increased
intracranial pressure.
122) Which clinical manifestations of a tension pneumothorax
should be of immediate concern to the nurse? Select all that
apply.
Decreased cardiac output
Hyperresonance to percussion
Tracheal deviation to the
opposite side123) A client's arterial blood gas results reveal a PaO2 of
55 mm Hg. The client's admitting diagnosis is acute
respiratory failure secondary to community-acquired
pneumonia. What is the nurse's best action?
Notify the health care
provider (HCP).
124) A client is admitted to the hospital for an acute
episode of angina pectoris. Which parameter is the priority
for the nurse to monitor?
Pulse and blood pressure
125) The nurse is caring for a client in the emergency
department who has sustained a head injury. The client
momentarily lost consciousness at the time of the injury and
then regained it. The client now has lost consciousness
again. The nurse takes quick action, knowing that this
sequence is compatible with which most likely condition?
Epidural hematoma
126) The family of a client with a spinal cord injury rushes
to the nursing station, saying that the client needs
immediate help. On entering the room, the nurse notes that
the client is diaphoretic with a flushed face and neck and
is complaining of a severe headache. The pulse rate is 40
beats/minute, and the blood pressure is 230/100 mm Hg. The
nurse acts quickly, suspecting that the client is
experiencing which condition?
Autonomic dysreflexia
127) A client with a spinal cord injury suddenly experiences
an episode of autonomic dysreflexia. After checking the
client's vital signs, the nurse takes the following actions.
Arrange the actions in the order they should be performed.
All options must be used.
1) Raise the head of the bed.
2) Loosen tight clothing on
the client.
3) Check for bladder
distention. 4) Contact the health care
provider (HCP).
5) Administer an
antihypertensive medication.
6) Document the occurrence,
treatment, and response.
128) A client is admitted to the hospital with a diagnosis
of neurogenic shock after a traumatic motor vehicle
collision. Which manifestation best characterizes this
diagnosis?
Bradycardia
129) The nurse is performing a vaginal assessment of a
pregnant woman who is in labor. The nurse notes that the
umbilical cord is protruding from the vagina. The nurse
would immediately take which action?
Exert upward pressure against
the presenting part.
130) A client in the postpartum unit complains of sudden,
sharp chest pain. The client is tachycardic, and the
respiratory rate is increased. The health care provider
diagnoses a pulmonary embolism. Which actions should the
nurse plan to take? Select all that apply.
Administer oxygen.
Assess the blood pressure.
Start an intravenous (IV)
line.
Prepare to administer morphine
sulfate.
131) A client with angina pectoris is experiencing chest
pain that radiates down the left arm. The nurse administers
a sublingual nitroglycerin tablet to the client. The
client's pain is unrelieved, and the nurse determines that
the client needs another nitroglycerin tablet. Which vital
sign is the most important for the nurse to check before
administering the medication?
Blood pressure132) A client whose cardiac rhythm was normal sinus rhythm
suddenly exhibits a different rhythm on the monitor. The
nurse should take which action? Refer to Figure.
View Figure
Contact the health care
provider (HCP).
133) The nurse is assisting in the care of a client who is
being seen in the clinic with a suspected acetaminophen
overdose. What is the nurse's priority of care?
Administer acetylcysteine.
134) A client who suffered carbon monoxide poisoning from
working on an automobile in a closed garage has a carbon
monoxide level of 15%. The nurse should anticipate observing
which sign or symptom?
Flushing
135) A client presents to the urgent care center with
complaints of abdominal pain and vomits bright red blood.
Which is the priority nursing action?
Take the client's vital signs.
136) The nurse is admitting a young child who arrived from
the emergency department after treatment for acetaminophen
overdose. After administering the antidote, the nurse should
reassess the child, including which priority laboratory
value?
Liver function panel
137) The nurse is monitoring a child who is receiving
ethylenediaminetetraacetic acid (EDTA) with BAL (British
anti-Lewisite) for the treatment of lead poisoning. The
nurse reviews the laboratory results for the child during
treatment with this medication and is particularly concerned
with monitoring which laboratory test result?
Blood urea nitrogen (BUN)
level
138) The nurse is caring for a child who was burned in a
house fire. The nurse develops a plan of care for monitoring
the child during the treatment for burn shock. The nurseidentifies which assessment as providing the most accurate
guide to determine the adequacy of fluid resuscitation?
Level of consciousness
139) A 2-year-old child is being transported to the trauma
center from a local community hospital for treatment of a
burn injury that is estimated as covering more than 40% of
the body. The burns are both partial- and full-thickness
burns. The nurse is asked to prepare for the arrival of the
child and gathers supplies, anticipating that which
treatment will be prescribed initially?
Insertion of a Foley catheter
140) A mother brings her child to the emergency department.
Based on the child's sitting position, drooling, and
apparent respiratory distress, a diagnosis of epiglottitis
is suspected. The nurse should plan for which priority
intervention?
Providing assisted ventilation
and obtaining the necessary
equipment
141) A client had a 1000-mL bag of 5% dextrose in 0.9%
sodium chloride hung at 1500. The nurse, making rounds at
1545, finds that the client is apprehensive, complaining of
a pounding headache, is dyspneic with chills, and has an
increased pulse rate. The intravenous (IV) bag has 400 mL
remaining. The nurse should take which action first?
Shut off the infusion.
142) When performing a surgical dressing change of a
client's abdominal dressing, the nurse notes an increase in
the amount of drainage and separation of the incision line.
The underlying tissue is visible to the nurse. What should
the nurse do next?
Apply a sterile dressing
soaked with normal saline.
143) The nurse is caring for a client with a chest tube who
accidentally disconnects the tube from the drainage system
when trying to get out of bed. The nurse immerses the end of
the tube in sterile water. What immediate action should the
nurse take? Obtain a new drainage system.
144) Which client situation is most appropriate for the
nurse to consult with the Rapid Response Team (RRT)?
A 45-year-old client, 2 years
after kidney transplant, second
hospital day for treatment of
pneumonia, no urine output for 6
hours, temperature 101.4°F
(38.6°C), heart rate 98 beats/min,
respirations 20 breaths/min, blood
pressure 168/94 mm Hg
145) A client who attempted suicide by hanging is brought to
the emergency department by emergency medical services.
Which is the immediate nursing action?
Assess the client's
respiratory status and for the
presence of neck injuries.
146) The nurse has a prescription to hang a 1000-mL
intravenous (IV) bag of 5% dextrose in water with 20 mEq of
potassium chloride and needs to add the medication to the IV
bag. The nurse should plan to take which action immediately
after injecting the potassium chloride into the port of the
IV bag?
Rotate the bag gently.
147) The nurse notes that the client's intravenous (IV) site
is cool, pale, and swollen and that the solution is not
infusing. What is the nurse's priority action?
Remove the IV catheter.
148) The nurse is inserting an intravenous (IV) line into a
client's vein. After the initial stick, the nurse would
continue to advance the catheter in which situation?
A backflash of blood is noted
in the catheter.
149) The nurse notes that the site of a client's peripheral
intravenous (IV) catheter is reddened, warm, painful, and
slightly edematous proximal to the insertion point of the IV
catheter. After taking appropriate steps to care for theclient, the nurse should document in the medical record that
the client experienced which condition?
Phlebitis of the vein
150) The nurse is preparing a continuous intravenous (IV)
infusion at the medication cart. As the nurse goes to insert
the spike end of the IV tubing into the IV bag, the tubing
drops and the spike end hits the top of the medication cart.
The nurse should take which action?
Obtain new IV tubing.
151) A health care provider has written a prescription to
discontinue an intravenous (IV) line. The nurse should
obtain which item from the unit supply area for applying
pressure to the site after removing the IV catheter?
a. Sterile 2 × 2 gauze
152) A client complains of pain at the site of an
intravenous (IV) infusion. The nurse assesses the site and
determines that phlebitis has developed. The nurse should
take which actions in the care of this client? Select all
that apply.
Remove the IV catheter at that site.
Apply warm, moist packs to the site.
Notify the health care provider (HCP).
Document the occurrence, actions taken,
and the client's response.
153)
A client involved in a motor vehicle crash presents to the
emergency department with severe internal bleeding. The
client is severely hypotensive and unresponsive. The nurse
anticipates that which intravenous (IV) solution will most
likely be prescribed?
5% dextrose in lactated Ringer's
154) The nurse provides a list of instructions to a client
being discharged to home with a peripherally inserted
central catheter (PICC). The nurse determines that the
client needs further instruction if the client makes which
statement? "I need to restrict my activity while
this catheter is in place."
155) A client has just undergone insertion of a central
venous catheter at the bedside. The nurse would be sure to
check which results before initiating the flow rate of the
client's intravenous (IV) solution at 100 mL/hour?
Portable chest x-ray film
156) A client with the recent diagnosis of myocardial
infarction and impaired renal function is recuperating on
the cardiac step-down unit. The client's blood pressure has
been borderline low, and intravenous (IV) fluids have been
infusing at 100 mL/hour via a central line catheter in the
right internal jugular vein for approximately 24 hours to
increase renal output and maintain the blood pressure. Upon
entering the client's room, the nurse notes that the client
is breathing rapidly and is coughing. The nurse determines
that the client is most likely experiencing which
complication of IV therapy?
Circulatory overload
157) The nurse in the hospital emergency department is
preparing to administer fomepizole to a client with ethylene
glycol (antifreeze) intoxication. The nurse should plan to
administer this medication by which route?
Intravenous (IV) route
158) The emergency department nurse is preparing to
administer fomepizole to a client suspected of ingesting
antifreeze solution during a suicidal attempt. The nurse
should prepare to administer this medication by which
method?
Diluting the medication in 100 mL of
0.9% normal saline and administering it
over 30 minutes
159) The emergency department nurse is preparing to
administer fomepizole to a client suspected of having
ethylene glycol (antifreeze) intoxication. The nurse obtains
the vial of medication and notes that the medication has
solidified. Which action should the nurse take?
Run the vial under warm water.160) A client in shock is receiving dopamine hydrochloride
by intravenous (IV) infusion. The nurse should have which
medication available for local injection if IV infiltration
and medication extravasation occur?
Phentolamine
161) A client admitted with hypertensive crisis has an
intravenous (IV) infusion of 1000 mL of normal saline with
20 mEq of potassium chloride added. A prescription is
written to administer sodium nitroprusside by continuous IV
infusion. The nurse should plan to do which to administer
this medication?
Protect the sodium nitroprusside from
light with an opaque material.
162) The nurse has a new prescription to administer
verapamil by the intravenous (IV) route. In administering
this medication, the most important nursing action should be
to use what item to monitor the client's response to the
medication?
A cardiac monitor
163) A client with rapid-rate atrial fibrillation has a new
prescription for diltiazem hydrochloride by intravenous (IV)
bolus followed by a continuous IV infusion of the same
medication. What should the nurse plan for with the
administration of this medication?
Discontinuing the infusion after 24
hours
164) A client being admitted to the coronary care unit from
the emergency department has a stat prescription to receive
a dose of intravenous procainamide followed by a continuous
infusion. Based on this prescription, the nurse should
assess for which condition?
Ventricular ectopy
165) The nurse has a prescription to give amiodarone
intravenously to a client. What is the priority assessment
during administration of this medication?
Cardiac rhythm166) The nurse is caring for a client with a diagnosis of
myocardial infarction (MI). The client is experiencing chest
pain that is unrelieved by the administration of
nitroglycerin. The nurse administers morphine sulfate to the
client as prescribed by the health care provider. After
administration of the morphine sulfate, what is the priority
assessment?
Respirations
167) A client hospitalized with a diagnosis of myocardial
infarction calls for the unit nurse because the client is
experiencing chest pain. The nurse administers a sublingual
nitroglycerin tablet as prescribed. The client, who is
receiving oxygen by nasal cannula, reports that her chest
pain is unrelieved by the nitroglycerin. Which is the next
nursing action for this client?
Administer another nitroglycerin tablet.
168) A client is diagnosed with atrial fibrillation, and the
health care provider prescribes medication therapy. Prior to
initiating medication therapy, which cardiac rhythm would
the nurse expect to note on the cardiac monitor? Click on
the image to indicate your answer.
Indication: ✓
169) A client is admitted to the hospital with a diagnosis
of myocardial infarction (MI) and is going to have an
intravenous (IV) nitroglycerin infusion started. Noting that
the client does not have an intra-arterial monitoring line
in place, what piece of equipment should the nurse obtain
for use at the bedside?
Noninvasive blood pressure monitor
170) A client returning to the nursing unit after a cardiac
catheterization procedure has a stat prescription to receive
a dose of intravenous procainamide. Which piece of equipment
would be most appropriate for the nurse to use in
determining the client's response to this medication?
Cardiac monitor
171) A client with heart failure and hypotension has been
started on intravenous medication therapy with inamrinone.The nurse determines which finding, if noted in the client,
is an adverse effect of the medication?
Decreased blood pressure
172) A client sustained a burn injury at 7:00 a.m. The
client's spouse states that before the burn, the client's
body weight was 198 lbs. The health care provider has
estimated that the total body surface area (BSA) burned is
83%. Using the Parkland (Baxter) formula (4 mL × kilograms
of body mass × percent total BSA), the nurse determines that
the total amount of intravenous lactated Ringer's solution
that the client will receive by 3 p.m. of the same day on
which the burn occurred is which value? Fill in the blank.
14,940 mL
173) A client has a closed head injury with increased
intracranial pressure (ICP). The increased ICP is being
managed by mannitol 25 g by the intravenous (IV) route every
2 hours. The nurse is planning to administer this medication
via IV pump in what manner?
Giving it slowly over 30 to 90 minutes
174) The nurse is administering lidocaine hydrochloride by
the intravenous route. Which finding(s) should the nurse
report to the health care provider immediately?
Client complaints of blu
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