1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will
drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is
the best follow-up action by the
...
1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will
drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is
the best follow-up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream
2. A male client with hypertension, who received new antihypertensive prescriptions at his
last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP
is 158/106 and he admits that he has not been taking the prescribed medication because
the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse
should stress that an elevated BP places the client at risk for which pathophysiological
condition?
Stroke secondary to hemorrhage
3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is placing
soft pillows along the side rails. What action should the nurse implement?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up?
Describes life without purpose
5. A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What information should the nurse include
in the client’s teaching plan?
Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client’s respiratory
rate is 14 breaths / minute. What action should the nurse implement?
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the
client’s respiratory rate is within normal limits.
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which client alarm should the nurse investigate firs?
Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What
action should the nurse take first?
Check the client for lacerations or fractures
10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the
client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid
getting a headache. Which action should the nurse take first?
Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is present, what action should the nurse take
first?
Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health insurance through her
place of employment. Which agency should the client be referred to by the employee
health nurse for health insurance needs?
Medicare
13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset.
What snack should the nurse instruct the client to take with the tetracycline?
Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
“I have a headache that gets worse when I sit up”
“I am having pain in my lower back when I move my legs”
“My throat hurts when I swallow”
“I feel sick to my stomach and am going to throw up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with incontinence. Which action should the nurse implement?
Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods
that are in keeping with the child’s dietary restrictions. Which foods are contraindicated
for this child?
Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for
this client. Which response should the circulating nurse provide?
Direct the nurse to continue the surgical hand scrub for a 5 minute duration
18. Which breakfast selection indicates that the client understands the nurse’s instructions
about the dietary management of osteoporosis?
Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the beginning of the shift that less
than the optimal number of registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a
Foley catheter and soft wrist restrains applied
20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the
pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe
and pierced the bottom of the child’s foot. Which action should the nurse implement
first?
Cleanse the foot with soap and water and apply an antibiotic ointment
Provide teaching about the need for a tetanus booster within the next 72 hours.
have the mother check the child's temperature q4h for the next 24 hours
transfer the child to the emergency department to receive a gamma globulin
injection
21. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been
applying triple antibiotic ointment for two days, but there has been no improvement.”
What instruction should the nurse provide?
Stop using the ointment and encourage complete drying of the feet and wearing
clean socks.
22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the
nurse that the prescribed dosage is too high for this client? The client experiences
Bradycardia and constipation
Lethargy and lack of appetite
Muscle cramping and dry, flushed skin
Palpitations and shortness of breath
23. A client with a history of heart failure presents to the clinic with a nausea, vomiting,
yellow vision and palpitations. Which finding is most important for the nurse to assess to
the client?
Obtain a list of medications taken for cardiac history
24. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250
ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how
many ml/hour? (Enter numeric value only.)
75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour /
1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour
25. The pathophysiological mechanism are responsible for ascites related to liver failure?
(Select all that apply)
Fluid shifts from intravascular to interstitial area due to decreased serum protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into
abdomen
Increased circulating aldosterone levels that increase sodium and water retention
26. The nurse is auscultating a client’s heart sounds. Which description should the nurse use
to document this sound? (Please listen to the audio first to select the option that applies)
Murmur
Rationale: A murmur is auscultated as a swishing sound that is associated with the
blood turbulence created by the heart or valvular defect.
27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an
infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a
concentration of 100 mg/ml. How many ml should the nurse administered for each dose?
(Enter numeric value only. If rounding is required, round to the nearest tenth)
0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six
hours for four days. What assessment is most important for the nurse to complete?
Auscultate the client's bowel sounds
Observe for edema around the ankles
Measure the client’s capillary glucose level
Count the apical and radial pulses simultaneously
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently causes constipation, so it is most important to Auscultate the client's
bowel sounds
29. A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants “no heroic
measures” taken if she stops breathing, and she asks the nurse to document this in her
medical record. What action should the nurse implement?
Ask the client to discuss “do not resuscitate” with her healthcare provider
30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has
developed diarrhea. The client has a new prescription to change the feeding to half
strength. What intervention should the nurse implement?
Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
31. A female client reports that her hair is becoming coarse and breaking off, that the outer
part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up
question is best for the nurse to ask?
Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites
and malnutrition. The client is drowsy but responding to verbal stimuli and reports
recently spitting up blood. What assessment finding warrants immediate intervention by
the nurse?
Capillary refill of 8 seconds
bruises on arms and legs
round and tight abdomen
pitting edema in lower legs
33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse
signs the form as a witness. What are the legal implications of the nurse’s signature on
the client’s surgical consent form? (Select all that apply)
The client voluntarily grants permission for the procedure to be done
The client is competent to sign the consent without impairment of judgment
The client understands the risks and benefits associated with the procedure
34. Following surgery, a male client with antisocial personality disorder frequently requests
that a specific nurse be assigned to his care and is belligerent when another nurse is
assigned. What action should the charge nurse implement?
Advise the client that assignments are not based on clients requests
35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical
radiation implant. While providing care, the nurse finds the radiation implant in the bed.
What action should the nurse take?
Place the implant in a lead container using long-handled forceps
36. The client with which type of wound is most likely to need immediate intervention by the
nurse?
Laceration
Abrasion
Contusion
Ulceration
Rationale: A laceration is a wound that is produced by the tearing of soft body
tissue. This type of wound is often irregular and jagged. A laceration wound is
often contaminated with bacteria and debris from whatever object caused the cut.
37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma.
Which intervention has the highest priority for inclusion in this client’s plan of care?
Monitor blood pressure frequently
Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that
may precipitate life-threatening hypertension. The tumor is malignant in 10% of
cases but may be cured completely by surgical removal. Although
pheochromocytoma has classically been associated with 3 syndromes—von
Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2),
and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been
identified as sites of mutations leading to pheochromocytoma.
38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse
elevates the head of the bed 30 degrees. What is the reason for this intervention?
To reduce abdominal pressure on the diaphragm
to promote retraction of the intercostal accessory muscle of respiration
to promote bronchodilation and effective airway clearance
to decrease pressure on the medullary center which stimulates breathing
Rationale: a semi-sitting position is the best position for matching ventilation and
perfusion and for decreasing abdominal pressure on the diaphragm, so that the
client can maximize breathing.
39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the
gallbladder when palpating below the liver margin at the lateral border of the rectus
abdominal muscle. What is the most likely explanation for failure to locate the
gallbladder by palpation?
The client is too obese
Palpating in the wrong abdominal quadrant
Deeper palpation technique is needed
The gallbladder is normal
Rationale: a normal healthy gallbladder is not palpable
[Show More]
