1- A nurse admits a client who sustained C3 spinal cord injury. Which finding should the nurse recognize as priority of care?
a) Heart rate
b) Respirations 10/min
c) Temperature 97 F (36 C)
d) Blood pressure 88/54 mm
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1- A nurse admits a client who sustained C3 spinal cord injury. Which finding should the nurse recognize as priority of care?
a) Heart rate
b) Respirations 10/min
c) Temperature 97 F (36 C)
d) Blood pressure 88/54 mmHg
2- A nurse prepares an older adult for a scheduled colonoscopy. Which should be the nurse’s initial action?
a) Chill bowel cleansing solution
b) Monitor frequency of elimination
c) Provide oral intake of clear liquids
d) Place portable commode at bedside.
3- A client presents to the emergency department (ED) and reports a history of Gravida 3 Para 2. Which should be the nurse’s initial action after observing a presenting part?
A) Provide emotional support to the client
B) Notify labor and delivery staff members.
C) Time frequency and duration of contractions
D) Prepare for delivery of the newborn in the emergency department
4- A nurse enters the room of a client who is at the foot of the bed lying on the floor. Which should be the initial nursing action?
a) Examine the client’s injuries.
b) Obtain pulse and blood pressure
c) Assess vital signs and level of consciousness
d) Determine intensity of pain with range of motion.
5- Four days after a ventral hernia repair, a client who is obese and has history of COPD vomits and reports severe abdominal pain. The oxygen saturation is 90%. Which action should the nurse implement first?
a) Administer ondansetron hcl IV.
b) Encourage pursed lip breathing
c) Assess the surgical incision site
d) Apply low dose oxygen via nasal canula
6- A nurse provides care for a client who is 24 hors post-acute myocardial infarction and reports “I can’t breathe now that I am lying down after lunch”. Which should be the nurse’s initial action?
a) Administer IV furosemide
b) Place client in high-fowler’s position
c) Begin oxygen 4-6L/min by nasal cannula
d) Auscultate anterior and posterior lungs bilaterally
7- A nurse arrives at a work site explosion. Which client should the nurse triage first?
a) Fixed pupils and agonal respirations
b) Burns to the face and respiratory stridor
c) Type 2 diabetes mellitus who is disoriented
d) A closed fracture reporting “a pain level of 3”
8- A nurse is coordinating client care. Which client should the nurse delegate to the PN? A client who:
a) Requires insertion of an indwelling urinary catheter.
b) Has a new prescription for patient-controlled analgesia
c) Has a tension pneumothorax and requires a chest tube?
d) Requires intermittent suctioning of a new placed tracheostomy.
9- An adolescent client was admitted 12 hrs ago following a motor vehicle crash. Multiple skeletal fractures were sustained. The client is in balanced-suspension traction. Which assessment finding requires immediate intervention by the nurse?
a) Disorientation
b) Shallow respirations
c) Chest pain with positioning
d) Bloody drainage at the pin site.
10- A nurse provides care for a client who is scheduled for electroconvulsive therapy (ECT). Which medication should the nurse withhold prior to therapy?
a) Atropine sulfate
b) Phenytoin
c) Methohexital
d) Succinylcholine
11- A home health nurse is performing an admission assessment on a client who had a knee arthroplasty one week ago. Which client statements should concern the nurse the most?
a) “I am so glad to be off those blood thinners”
b) “I will keep a pillow under my knee when I am in bed “
c) “I am planning to use a wheelchair to help me get around”
d) “I plan to take ibuprofen instead of the prescribed hydrocodone with acetaminophen for pain control”
12- A client has no voided eight hours following the removal of an indwelling bladder catheter. Which should be the nurse’s initial action?
a) increase fluids
b) perform bladder scan
c) place indwelling catheter
d) provide assistance to the bathroom
13- A nurse provides care for a client who has a chest tube. The nurse notes the chest tube has become disconnected from the chest drainage system. Which action should the nurse take?
a) Increase the suction to the chest drainage system.
b) Reposition the client to a high-fowler’s position
c) Apply to the client low-flow oxygen via nasal cannula.
d) Immerse the end of the chest tube in a bottler of sterile water
14- When an older adult die from complications of a cerebrovascular accident (CVA), the client ‘s partner is present the bedside. Which action should the nurse take?
a) Give the partner time alone
b) Stay with the partner at the bedside
c) Ask the chaplain to come be with the partner
d) Escort the partner to the hallway outside the room
15- A client who has just been diagnoses with rheumatoid arthritis is required to receive 3 months of methotrexate therapy. The nurse recognizes which of the following are adverse effects associated with the therapy? SATA
a) WBC 1,200 mm3
b) Platelets 5,000 mm3
c) Weight gain 2.27 kg (5lb)
d) Urine specific gravity 1,003
e) Oral temperature of 37.2 C (99 F)
16- A nurse is organizing care for a group of clients. Which task should the nurse assign to the assistive personnel (AP)
a) Record a client’s vital signs during a transfusion of blood
b) Assist a client who is requesting a bedpan 1-day post hysterectomy
c) Offer a pamphlet regarding advance directives to a newly admitted client
d) Ask a client if pain was relieved after administration of acetaminophen
17- A nurse is observing a client attempt three-point crutch walking. Which action should be of concern to the nurse?
a) The client kip arms flexed
b) The client moves legs with opposite arm
c) The client backs up to a chair before sitting
d) The client asks for a height adjustment of the crutches.
18- A school nurse observes several children playing on a playground. Which child should concern the nurse most?
a) A child squatting after a game of ball
b) A child arguing with another child
c) A child breathing heavily after running
d) A child climbing on swing set supports
19- A client who is semi-comatose after a cerebrovascular accident (CVA), has an NG tube, and was started on total parenteral nutrition today. Which action should the nurse implement to prevent fluid volume deficit?
a) Administer 120 ml bolus of water
b) Monitor blood glucose every 4-6 hr
c) Determine total fluid intake every 8 hr
d) Increase oral fluid intake to 3 liters per day
LEADERSHIP AND MANAGEMENT INTRODUCTION
1- A nurse prepares a staff in-service on incident reports. Which information should the nurse include? SATA
a) risk management investigates the incident
b) a copy of report is placed in client’s health record.
c) reports include description of incident and actions taken.
d) reports are confidential and not shared with noninvolved staff.
e) completion of report should be documented in the nurse’s notes
2- A nurse is unsure of the proper technique when caring for a client who is prescribed enteral feedings. Which action should the nurse take?
a) Ask the charge nurse for step-by-step directions
b) Call the provider for specific instructions
c) Consult the unit procedure manual for guidance
d) Delegate task to a PN to complete the feedings.
3- A nurse admits a client from a long-term care facility. Which action should be implemented? SATA
a) Verify the admission medications prescribed by the provider
b) Review the current medication regimen with the client
c) Obtain the most recent list of medications from the long-term care facility
d) Locate a list of discharge medications from the most recent hospitalization
e) Discuss any discrepancies with the health care provider
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