1. The nurse performs an assessment on a full-term newborn. Which finding does the nurse report to the health care provider?
1. The client's blood pressure of 70/44 mm Hg.
2. The umbilical cord is whitish gray in color
...
1. The nurse performs an assessment on a full-term newborn. Which finding does the nurse report to the health care provider?
1. The client's blood pressure of 70/44 mm Hg.
2. The umbilical cord is whitish gray in color.
3. Bowel sounds cannot be auscultated in the abdomen.
4. The big toe dorsiflexes when the side of the foot is stroked.
Ans: 3
2. The nurse in an antepartum clinic has several phone messages from clients. Which client does the nurse call first?
1. The client who is 10 weeks pregnant and reports vomiting after dinner for the past 5
days.
2 days.
2. The client who is 18 weeks pregnant and reports a headache in the evening for the past
3. The client who is 32 weeks pregnant and reports that her feet are swollen in the
morning.
4. The client who is 37 weeks pregnant and reports that her membranes have ruptured.
Ans: 4
3. The nurse prepares a medication in a prefilled syringe and notes that the syringe does not have a label with the client's name. What action will the nurse take?
1. Notify the pharmacy.
2. Call the health care provider.
3. Label the syringe.
4. Administer the medication.
Ans: 1
4. The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.)
1. Uncontrolled COPD can lead to cardiac disease.
2. Asthma in childhood leads to COPD later in life.
3. Cigarette smoking is the leading COPD risk factor.
4. More females are affected by COPD than males.
5. Co-existing illness may cause COPD exacerbation.
Ans: 1, 3,5
5. The nurse notes that a client requires protective isolation. Which additional client will the nurse safely pair with the client in protective isolation?
1. Client with a urinary tract infection.
2. Client with a stage 3 sacral pressure ulcer.
3. Client with unstable diabetes mellitus.
4. Client recovering from surgery for a perforated bowel.
Ans: 3
6. A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother?
1. Gestational diabetes.
2. A neural tube defects.
3. Trisomy 21 (Down syndrome).
4. Lack of lung maturity.
Ans: 1
7. The nurse notes that a toddler-age client has burn marks in various stages of healing and is fearful of male health care professionals. Which action will the nurse take next?
1. Document the findings in the chart.
2. Talk to the nursing supervisor.
3. Ask the client what happened.
4. Discuss the findings with the health care provider.
Ans: 1
8. The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct?
1. The National Council of State Boards of Nursing (NCSBN).
2. The American Nursing Association (ANA).
3. The Joint Commission.
4. The National League of Nursing (NLN).
Ans: 3
9. The nurse provides care for several clients. Which task does the nurse delegate to the nursing assistive personnel (NAP)? (Select all that apply.)
1. Determine client’s pain level.
2. Perform walker use training.
3. Assist with meal trays.
4. Bathe a client with wounds.
5. Obtain routine vital signs.
Ans: 3, 4, 5
10. A client receives an antibiotic every 8 hours. The antibiotic has an onset of action of 2 hours and a duration of action of 8 hours. The client is prescribed a peak blood level. If the medication is provided at 1000, at which time will the nurse schedule the peak level to be drawn?
1. 1100.
2. 1200.
3. 1400.
4. 1800.
Ans: 3
11. The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take?
1. Encourage strict bed rest.
2. Limit dietary fiber.
3. Encourage oral fluids.
4. Hold prescribed zoledronate.
Ans: 3
12. The nurse provides care for several clients in Buck traction. Which client is at greatest risk for skin breakdown?
1. An elderly client with severe Alzheimer disease.
2. An elderly client with a history of atrial fibrillation.
3. An elderly client with chronic bronchitis.
4. An elderly client with diverticulosis.
Ans: 1
13. The charge nurse reviews the medical records of several clients. Which documentation from a staff nurse requires the charge nurse to follow-up?
1. “Returned from radiology department following a chest X-ray. Requesting lunch but remains nothing by mouth until seen by the health care provider as prescribed.”
2. “Late – entry. Ambulated from bed to doorway without assistance. No shortness of breath or diaphoresis noted. Vital signs remained within baseline after ambulating.”
3. “Intravenous catheter site in left antecubital space is red and warm to touch. Intravenous solution infusing slowly. Catheter removed intact. New catheter placed in right forearm.”
4. “Found client sitting on floor. All four side rails were in upright position. Client reports no pain. No abrasions or bleeding noted. Health care provider notified. Incident report completed.”
Ans: 4
14. The nurse delegates vital sign measurement to the nursing assistive personnel (NAP). Which statement provides the best information for the nurse to give when delegating this task?
1. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), or pulse oximetry <95%."
2. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Report any readings outside the normal ranges."
3. “Please obtain blood pressure, heart rate, respiratory rate, temperature, pain rating, and pulse oximetry. Let me know if anyone’s systolic blood pressure is <100 or >160, heart rate <60 or >100, respiratory rate <12 or >20, temperature >100.50F (40.60C), pain level >5/10, or pulse oximetry <95%."
4. “Please obtain blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry. Let me know if anyone’s blood pressure is <100 or >160, heart rate <50, respiratory rate <12, temperature >100.50F (45.60C), or pulse oximetry <93%."
Ans: 1
15. A client takes a beta 2 afrenergic agonist. Which finding indicates to mthe nurse that the client is experiencing and adverse reaction?
1. Drowsiness
2. Dysphagia
3. Palpitation
4. Paresthesias Ans: 3
16. The nurse notes that a client's laboratory values are blood urea nitrogen (BUN) 55 mg/dL (19.64 mmol/L) and creatinine 3.5 mg/dL (309.4 µmol/L). For which acid-base imbalance will the nurse assess the client?
1. Respiratory acidosis.
2. Respiratory alkalosis.
3. Metabolic acidosis.
4. Metabolic alkalosis.
Ans: 3
17. The nurse performs a nitrazine test on a client at 38 weeks' gestation. Which color change indicates that membranes have likely ruptured?
1. Yellow.
2. Olive-green.
3. Olive-yellow.
4. Blue green.
Ans: 4
18. A client develops ventricular tachycardia (VT). Which action does the nurse take next when providing care to this client?
1. Auscultate breath sounds.
2. Check pulse for a full minute.
3. Establish responsiveness.
4. Start cardiac compressions.
Ans: 3
19. The nurse notes that a client who follows Judaism has roast beef and whole milk on the dinner tray. Which action will the nurse take first?
1. Ask the nutrition department to replace the roast beef with pork.
2. Deliver the food tray to the client.
3. Ask the nutrition department for a new tray.
4. Replace the whole milk with skim milk.
Ans: 3
20. The nurse provides care for a client with face, ear, and neck burns. Which is the best position for the client?
1. Prone with a small pillow under the head.
2. Supine with padding on the affected side.
3. Supine without pillows or padding.
4. Prone without extra padding around the head.
Ans: 3
21. The nurse provides care for a client who requests testing for human immunodeficiency virus infection (HIV). Which intervention is most important for the nurse to perform before administering testing?
1. Discuss prevention practices to prevent the transmission of HIV to others.
2. Explain that all tests must be repeated twice to be valid.
3. Ask the client to identify all sexual partners.
4. Determine when the client thinks the exposure to HIV occurred.
Ans: 4
22. The nurse provides care to a client diagnosed with a clostridium difficile (C. diff) infection. Which precaution will the nurse take? (Select all that apply.)
1. Wear a protective gown when entering the client’s room.
2. Put on a particulate respirator mask when administering medications to the client.
3. Wear gloves when feeding the client a meal.
4. Ask the client’s visitors to wear a surgical mask when in the client’s room.
5. Wear sterile gloves when removing the client’s wound dressing.
Ans: 1, 3
23. The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication?
1. Twice a day within 1 hour before morning and evening meals.
2. Once a day before bedtime.
3. Twice a day within 2 hours before morning and evening meals.
4. Twice a day within 1 hour after morning and evening meals.
Ans: 1
24. The nurse provides care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding indicates that the treatment has been effective?
1. Serum osmolality is decreased.
2. Serum sodium is decreased.
3. Urinary output is increased.
4. Urine osmolality is increased.
Ans: 3
25. The nurse provides care for four clients. Which client will benefit the most from a multidisciplinary conference?
1. A 3-month-old client with intussusception who is vomiting, has colicky abdominal pain, and is having jelly-like stools.
2. A 2-month-old client with respiratory syncytial virus (RSV), who is wheezing and has moderate subcostal retractions and copious nasal discharge.
3. A 3-day-old client with developmental dysplasia of the hip, who has unequal leg length, limited abduction of the left hip, and asymmetry of the gluteal folds.
4. A 2-day-old client with body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant.
Ans: 4
26. The nurse provides care to a client who is unconscious. Which form of medication will the nurse safely administer to this client? (Select all that apply.)
1. Topical cream.
2. Subcutaneous injection.
3. Oral liquid.
4. Rectal suppository.
5. Intravenous infusion.
Ans: 1, 2, 4, 5
27. A client says, “I promise not to touch the intravenous catheter anymore because I don’t want to be slapped again.” Which action does the nurse take first?
1. Complete a neurological assessment.
2. Ask the nursing assistive personnel (NAP) if the client was slapped when providing care.
3. Ask the client where the slap occurred and under what conditions.
4. Document the client’s statement and report it to the nurse manager.
Ans: 3
28. The nurse provides care for a client who reports waking up with heartburn every night. Which client statement requires the nurse to provide further education to the client?
1. “I eat 3 meals a day.”
2. “I do not eat 2 hours before going to bed.”
3. “I will work on losing weight.”
4. “I will elevate the head of my bed 6 to 12 inches.”
Ans: 1
29. The nurse provides for a client who is being evaluated for possible thrombolytic therapy. Which lab value would cause the nurse the most concern?
1. Blood glucose of 160 mg/dL (8.88 mmol/L).
2. International normalized ratio (INR) of 1.2. 3. Platelets of 90,000/mm3 (90 X 109/L).
4. Hemoglobin of 9 g/dL (90 g/L).
Ans: 3
30. The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes that the lesions are open and draining small amounts of serous fluid. Which personal protective equipment (PPE) does the nurse use when bathing and changing the linens for this client?
1. Gloves.
2. Gown and gloves.
3. Gown, gloves, and mask.
4. Gown and gloves to change the linens; gloves when bathing.
Ans: 2
31. A client in her third trimester of pregnancy asks the nurse how to differentiate between true labor and false labor. Which is the best explanation by the nurse to describe false labor to the client?
1. The intensity, frequency, and duration of contractions do not change.
2. Discomfort begins in the back and radiates to the abdomen.
3. Contractions are accompanied by pink mucus from the vagina.
4. Progressive effacement and dilation of the cervix begin to occur.
Ans: 1
32. The nurse provides an older client, who was recently widowed, with a list of activities available at a local library. For which nursing diagnosis is this action most appropriate?
1. Risk for loneliness.
2. Risk for ineffective coping.
3. Risk for complicated grieving.
4. Risk for situational low self-esteem.
Ans: 1
33. The nurse provides care for a client that reports difficulty falling asleep several nights a week. The nurse reviews the client’s bedtime pattern. Which client statement requires an intervention by the nurse?
1. “I turn the TV off about an hour before bed and try to read.”
2. “I will go to bed when I am wide awake and relax in bed.”
3. “I will drink some herbal tea to help me wind down for the night.”
4. “I will limit my naps to 20 minutes a day.”
Ans: 2
34. The nurse prepares a client for surgery. Which task is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.)
1. Performing a clean catch urinalysis.
2. Collecting vital signs.
3. Monitoring lung sounds.
4. Applying compression stockings.
5. Educating on incentive spirometer use. Ans: 1, 2, 4
35. The nurse is teaching the parent of a 2-year-old client on how to correctly administer ear drops. Which action by the parent indicates to the nurse a need for further education?
1. Pulls the pinna up and back.
2. Directs the drops along the side of the ear canal.
3. Removes the ear drops from the fridge 30 minutes before giving.
4. Keeps the child lying down for 5 to 10 minutes before administering drops in the other
ear. Ans: 1
36. The nurse provides care to a client with severe hypothermia. Which assessment will the nurse perform first?
1. Determine presence of shivering.
2. Assess the skin for mottling.
3. Examine cardiac monitor for dysrhythmias.
4. Review laboratory values for a low calcium level.
Ans: 3
37. A client with transient confusion coughs constantly while being fed by nursing assistive personnel (NAP). Which action will the nurse take first?
1. Auscultate breath sounds.
2. Offer the client sips of water.
3. Direct the NAP to stop feeding the client.
4. Assess the oral cavity for pocketing of food.
Ans: 3
38. A client experiences a fever, headache, photophobia, and neck stiffness. Which transmission-based precaution will the nurse implement for this client?
1. Contact.
2. Airborne.
3. Droplet.
4. Standard.
Ans: 3
39. An older client with Medicare insurance asks the nurse to explain the “donut hole” in prescription drug coverage. Which response by the nurse is best?
1. It is a $20 co-payment for all prescriptions.
2. It is a temporary limit on what the drug plan will pay for covered drugs.
3. There is 20% decrease in prescription payment after six prescriptions per year.
4. There is no prescription drug coverage after age 85.
Ans: 2
40. The nurse provides care to a client diagnosed with asthma who suddenly develops wheezing. Which class of medications does the nurse give first?
1. Methylxanthines.
2. Corticosteroids.
3. ß2-adrenergic agonist.
4. Anticholinergics.
Ans: 3
41. The nurse provides care for a client experiencing acute anxiety. It is most important for the nurse to assess the client for which acid-base imbalance?
1. Respiratory alkalosis.
2. Respiratory acidosis.
3. Metabolic alkalosis.
4. Metabolic acidosis.
Ans: 1
42. The nurse assesses a newborn’s penis 2 days after a circumcision. The nurse notes a yellow exudate around the head of the penis. Which is the appropriate nursing intervention?
1. Wash the penis with soap and a warm washcloth.
2. Take the newborn’s temperature to determine if an infection is present.
3. Leave the area alone, as this is a normal finding.
4. Report the finding to the health care provider.
Ans: 3
43. The nurse plans to delegate a task to a new nursing assistive personnel (NAP). The nurse discovers that the NAP has never performed the task and changes the assignment. Which right of delegation does the nurse follow in this scenario?
1. Right supervision.
2. Right person.
3. Right circumstance.
4. Right direction.
Ans: 2
44. A client claims to feel ugly because of hair lost after receiving chemotherapy for breast cancer. Which statement does the nurse make to help the client cope with these feelings?
1. “Let’s see how you look with a scarf or hat.”
2. “Your hair will grow back after your treatments are over.”
3. “Many women choose to shave their head when this starts to happen.”
4. “Just think how much easier it will be to not have to do your hair every day.”
Ans: 1
45. The nurse provides care for an unconscious client. The nurse finds a stage 2 pressure injury on the client’s elbow. Which statement indicates the best understanding of the client’s perception of pain?
1. There will be a behavioral response if pain is perceived.
2. The client is not able to perceive pain.
3. The area will be treated as a painful lesion, using gentle cleaning and dressing.
4. The client will be medicated with an opioid before a dressing change.
Ans: 3
46. The nurse provides preoperative teaching for a client having surgery. Which type of anesthesia does the nurse explain as altering the level of consciousness? (Select all that apply.)
1. General anesthesia.
2. Regional anesthesia.
3. Local anesthesia.
4. Conscious sedation.
5. Topical anesthesia.
Ans: 1, 4
47. While changing a client's bed linen, the nurse sustains a needlestick injury from a syringe left in the bed. After washing the injury with soap and water, which action does the nurse take next?
1. Send the needle to the laboratory for testing.
2. Interview the client about infection status.
3. File an incident report according to protocol.
4. Notify the nurse manager as soon as possible.
Ans: 4
48. A nurse prepares to administer medication to a client. Which information should the nurse use as client identifiers? (Select all that apply.)
1. The client’s birth date.
2. The client’s room number.
3. The client’s provider’s name.
4. The client’s medical record number.
5. The client’s first and last name.
Ans: 1, 4, 5
49. The nurse provides care for a client who sustained a burn injury. The nurse notes that the client has absent bowel sounds, abdominal distention, belching, mild nausea, and a reduced appetite. Which complication should the nurse suspect the client has developed?
1. Curling ulcer.
2. Paralytic ileus.
3. Large bowel obstruction.
4. Translocation of bacteria.
Ans: 2
50. The nurse delegates care of a stable client to nursing assistive personnel (NAP). Which right of delegation is the nurse following?
1. Right supervision.
2. Right circumstance.
3. Right person.
4. Right direction/communication.
Ans: 2
51. The nurse provides care for a client who takes potassium chloride 40 mEq by mouth twice daily. The client’s serum creatinine level is 1.9 mg/dL. Which action is the priority for the nurse?
1. Obtain an order for a renal consultation.
2. Administer the potassium as prescribed.
3. Monitor the client’s intake and output.
4. Notify the client’s health care provider (HCP).
Ans: 4
52. The nurse overhears an argument between a client and the nursing assistive personnel (NAP). Which action will the nurse take to resolve this conflict? (Select all that apply.)
1. Listen to the NAP’s issue.
2. Listen to the client’s issue.
3. Change the NAP’s assignment.
4. Offer approaches to eliminate the issue.
5. Reprimand the NAP for aggressive behavior.
Ans:
53. The nurse provides care for a client reporting crushing chest pain. Which electrocardiogram (ECG) changes support the current nursing diagnosis of cardiac tissue injury?
1. ST segment depression of 2 mm or more.
2. ST segment elevation of 2 mm or more.
3. QRS duration greater than 0.12 seconds.
4. PR interval greater than 0.20 seconds.
Ans: 2
54. The nurse notes that four clients have returned from surgery within the last 24 hours. Which client is at the highest risk for developing a post-operative infection?
1. A school-age client recovering from a tonsillectomy.
2. An adolescent client who had an unruptured appendectomy.
3. An older adult client with gastric tube placement.
4. A middle-age client with a coronary artery by-pass graft.
Ans: 3
55. Prior to the beginning of a site survey, the charge nurse advises the nurse to deny any knowledge of a recent sentinel event if asked by the surveyor. Which action will the nurse take?
1. Notify the unit manager.
2. Notify the medical director.
3. Tell the charge nurse about being uncomfortable lying to the surveyor.
4. Tell the surveyor the nurse is not allowed to talk to them.
Ans: 1
56. The parent of a 22-month-old toddler plans to begin toilet training the child. Which is the most important factor for the nurse to stress to the mother?
1. Consistency in method.
2. Maintain a positive attitude.
3. Developmental readiness of the child.
4. Avoid comparing the child to peers.
Ans: 3
57. The nurse prepares a school-age client diagnosed with a fractured humerus to be discharged home with the parents. Which observation requires the nurse to make a referral to home health?
1. The child does not play with toys during the hospital stay.
2. One parent is working the night shift.
3. The mother has bruises around the wrists.
4. The father is anxious to leave the hospital.
Ans: 3
58. The nurse observes a student nurse perform closed urinary catheter irrigation on a client with decreased urinary output. Which observation indicates that the student requires additional teaching to perform the procedure correctly?
1. Clamps the urinary drainage tubing below the irrigation port.
2. Draws up 50 mL of sterile saline into a syringe.
3. Cleanses the irrigation port with alcohol.
4. Quickly instills the sterile saline.
Ans: 4
59. A nurse from a pediatric unit works a shift on an adult surgical unit. The charge nurse makes client assignments. Which client is most appropriate for the charge nurse to assign to the pediatric nurse? (Select all that apply.)
1. A preschool-age client who had a tonsillectomy.
2. A young adult client who had a pilonidal cyst removed.
3. An adult client diagnosed with Stage 3 cancer who had a partial removal of the colon.
4. An older adult client who had a right total hip arthroplasty.
5. An adolescent client who had an appendectomy.
Ans: 1, 2, 5
60. The nurse provides teaching for a client who has a medication delivered via the use of a transdermal patch. Which client statement requires the nurse to provide additional teaching?
1. “I will remove the old patch before applying the new patch.”
2. “I will avoid putting the patch on any sites that have bruises.”
3. “I will shave the skin area before applying the patch.”
4. “I will place the patch on areas that are hairless.”
Ans: 3
61. The nurse provides care for a client dying from cervical cancer. The client states that the pain is “excruciating.” Which is the best strategy for the nurse to add to the client’s plan of care?”
1. Administer increased opioids as needed.
2. Dim the lights and perform guided imagery.
3. Use distraction such as music and crossword puzzles.
4. Obtain a prescription to deliver analgesics on a schedule.
Ans: 4
62. The nurse provides care for a group of clients. Which condition puts the client at risk for metabolic acidosis? (Select all that apply.)
1. Pneumonia.
2. Diabetes mellitus.
3. Asthma.
4. Renal failure.
5. Malnourishment.
Ans: 2, 4, 5
63. The nurse teaches a parent actions for home safety during the second half of infancy. Which parent statement causes the nurse to be most concerned?
1. “I avoid giving my baby carrot sticks.”
2. “My baby loves to be in the walker.”
3. “I keep the bathroom door closed.”
4. “I lay my baby on the back to sleep.”
Ans: 2
64. The nurse provides care to several clients. Which client will the nurse assess first?
1. Client with heart failure and reports substernal pain.
2. Client who had laparoscopic bariatric surgery 1 hour ago and is sleeping in a semi-Fowler position.
3. Client who had a left pneumonectomy 14 hours ago and is positioned on the left side.
4. Client who had an appendectomy 10 hours ago and has vesicular breath sounds over peripheral lung fields.
Ans: 1
65. The health care provider prescribes isoniazid for a client with active tuberculosis. Which statement is most important for the nurse to include when teaching the client about the medication?
1. “You should begin to feel better in 2 to 3 days. If you don’t, notify your health care provider.”
2. “You can safely have one to two glasses of wine daily while taking the medication.”
3. “You should always take the medication with food, even if it upsets your stomach.”
4. “Vitamin B6 prevents leg tingling and numbness that can occur with isoniazid.”
Ans: 4
66. The nurse provides care for a pediatric client experiencing an acute episode of croup. It is most important for the nurse to assess the client for which acid-base imbalance?
1. Respiratory alkalosis.
2. Respiratory acidosis.
3. Metabolic alkalosis.
4. Metabolic acidosis.
Ans: 2
67. The nurse provides care for a client who has mild pre-eclampsia. Which evaluation data indicate that the nursing interventions to help control mild pre-eclampsia have been effective?
1. The client’s blood pressure is 145/95 mm Hg.
2. Edema is noticed around the client’s eyes.
3. The client’s patella reflexes are 2+.
4. The client’s urine protein is 3+.
Ans: 3
68. The nurse provides home care to a client receiving intravenous therapy and enteral nutrition. Which care objective will the nurse identify as a priority for this client?
1. Screening.
2. Counseling.
3. Education.
4. Case management.
Ans: 3
69. The nurse provides care to an adolescent client with a history of frequent urinary tract infections (UTIs). Upon assessment the nurse learns that the client has symptoms of a UTI , is having difficulty in school, and does not want to be at home alone with the parent’s spouse. Which action will the nurse take first?
1. Ask the client to use the bathroom and obtain a urinalysis.
2. Discuss the client’s concerns with the health care provider.
3. Ask the parent to leave the room so the nurse can ask the client assessment questions privately.
4. Call the social worker to come and talk to the client.
Ans: 3
70. The nurse administers an enema to a client with an impaction. As the nurse begins the procedure, the client’s heart rate goes from 70 to 40 beats per minute, and the client reports nausea. Which action does the nurse take first?
1. Remove the tube from the rectum.
2. Slow down the enema rate.
3. Stop the enema.
4. Place the client in a supine position.
Ans: 3
71. The nurse provides care for a client diagnosed with a stage 2 pressure injury. The nurse assigns the client a Braden scale score of 9. Which action does the nurse take next?
1. Reassess the Braden scale within 12 hours.
2. Increase the client’s daily oral fluid intake.
3. Obtain a prescription for an indwelling catheter.
4. Consult with health team on the care plan.
Ans: 3
72. The nurse provides discharge instructions to an adult client hospitalized for pneumococcal pneumonia. Which instruction does the nurse include in the teaching plan? (Select all that apply.)
1. “Finish all of the antibiotics, even if you start to feel better.”
2. “Continue doing your breathing exercises and using the spirometer.”
3. “Report any cough or mucous production to your health care provider.”
4. “Avoid large crowds because your immune system is weakened.”
5. “Report any increase in shortness of breath to your health care provider.” Ans: 1, 2, 4, 5
73. The nurse provides care for a client who takes a cyclobenzaprine hydrochloride extended release capsule once a day. Which finding indicates to the nurse that this medication is effective?
1. Experiences patchy hair loss.
2. Bends over to tie shoes.
3. Demonstrates hyperactive bowel sounds.
4. Experiences a 2 kg weight loss in 3 weeks.
Ans: 2
74. The nurse assists the health care provider with cardioversion for a client with uncontrolled atrial fibrillation. Which step does the nurse take during cardioversion that is omitted during defibrillation?
1. Ensure the defibrillator is set in the synchronized mode when delivering the charge.
2. Use a conduction medium between the paddles and the client’s skin if paddles are used.
3. Apply 20 to 25 pounds of pressure when using paddles to deliver the charge.
4. Record the delivered energy and resulting rhythm.
Ans: 1
75. The nurse caring for a client with an acute myocardial infarction and chest pain delegates 5-minute vital sign assessments to nursing assistive personnel (NAP). The charge nurse intervenes and changes the assignment. Which right of delegation does the charge nurse following in this situation?
1. Right direction.
2. Right communication.
3. Right circumstance.
4. Right supervision.
Ans: 3
76. Which action will the nurse take to maintain safety when providing a client with a blood product? (Select all that apply.)
1. Verify client’s identification according to institutional policy.
2. Administer blood product as soon as it arrives on the care area.
3. Transfuse blood products in less than 2 hours for maximum effect.
4. Stay with the client during the first 15 minutes of the transfusion.
5. Obtain an order for oxygen 2 L via nasal cannula during transfusion.
Ans: 1, 2, 4
77. The nurse teaches a group of nursing assistive personnel (NAP) about preventing venous thromboembolism (VTE). Which action does the nurse delegate to the NAP? (Select all that apply.)
1. Reposition the client at least every 2 hours.
2. Assist the client with ambulation as needed.
3. Provide the client with teaching materials on VTE.
4. Apply sequential compression devices (SCDs).
5. Help the client in putting on compression stockings.
Ans: 1, 2, 4, 5
78. The nurse plans to teach an adolescent female, newly diagnosed with systemic lupus erythematosus (SLE), about measures to prevent complications. Which information does the nurse include in the teaching session?
1. Apply sunscreen daily.
2. Protect against warm weather by wearing light clothing.
3. Take aspirin to control joint pain.
4. Avoid intake of calcium-rich foods.
Ans: 1
79. The nurse provides care for a client after an above the knee amputation (AKA) 2 days ago. The nurse places the client in which position?
1. Reverse Trendelenburg position.
2. Prone position.
3. Lithotomy position.
4. High Fowler position.
Ans: 2
80. The nurse provides care to a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation will the nurse implement for this client?
1. Contact.
2. Droplet.
3. Airborne.
4. Reverse.
Ans: 1
81. The parents of a young preschool-age client report that their child becomes easily frustrated and acts out. Which suggestion does the nurse offer to help the parents with their child’s behavior?
1. “Use positive redirection to guide the child toward a positive action.”
2. “Ignore the behavior. A 3-year-old child is too young for discipline.”
3. “Use a 10-minute time-out to allow your child time to cool down.”
4. “Encourage your child to verbalize feelings to you.”
Ans: 1
82. The nurse provides care for a client in the end stages of dying. The family asks the nurse how they can provide comfort to the client in the client’s final hours. Which intervention will the nurse recommend the family implement? (Select all that apply.)
1. Reading to the client.
2. Encouraging the intake of fluid.
3. Giving a gentle massage.
4. Holding the client’s hand.
5. Talking to the client.
Ans: 1, 3, 4, 5
83. The nurse screens a client for sleep apnea. Which question is most important for the nurse to ask the client?
1. Do you have difficulty staying asleep?
2. What time do you wake up in the morning?
3. Has anyone told you that you snore loudly?
4. Do you fall asleep at the wrong times?
Ans: 3
84. The nurse learns that a client was not prescribed a treatment for a disease process because of age. For which principle violation will the nurse bring this issue to the organization’s ethics committee?
1. Justice.
2. Veracity.
3. Beneficence.
4. Nonmaleficence
Ans: 1
85. The nurse provides care for a client who comes to the clinic for follow-up blood pressure monitoring. The nurse auscultates the client’s breath sounds. The nurse hears wheezing over all lung fields. Which medication in the client’s current medication list does the nurse suspect as a cause of the wheezing?
1. Atenolol.
2. Indapamide.
3. Metformin.
4. Atorvastatin.
Ans: 1
86. The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which finding indicates to the nurse that the client is experiencing cor pulmonale?
1. Jugular vein distension.
2. Whitish frothy sputum.
3. Finger clubbing.
4. Chest tightness.
Ans: 1
87. The nurse provides care to a client with an epidural catheter for pain control with fentanyl after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client? (Select all that apply.)
1. Perform peripheral neurovascular checks every 2 hours.
2. Ambulate the client around the hallway.
3. Assess for bowel and bladder distention.
4. Keep the client at nothing by mouth status.
5. Monitor client for nausea and vomiting.
Ans: 1, 3, 5
88. The nurse plans care for an older adult client. Which intervention does the nurse implement to reduce this client’s risk for falls?
1. Elevate bed to waist height.
2. Ensure socks are worn when ambulating.
3. Position commode close to the bed.
4. Place a chair and overbed table close to the commode.
Ans: 3
89. The nurse reviews care needs for assigned clients. Which client will the nurse assess first?
1. Client who had a vaginal hysterectomy 2 days ago and is reporting that the right calf is warm to touch.
2. Client who received a dose of prescribed warfarin while receiving a heparin infusion.
3. Client with chronic obstructive pulmonary disease who is using pursed-lip breathing.
4. Client who had an abdominal aortic aneurysm repaired 10 hours ago and has bronchial breath sounds over the trachea.
Ans: 1
90. The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication?
1. “Take the medication at bedtime with a snack.”
2. “Take the medication in the morning after breakfast.”
3. “Lie down for 30 minutes after taking the medication.”
4. “Take the medication with a full glass of water.”
Ans: 4
91. The nurse is assessing a newly admitted client. Which observation leads the nurse to suspect that the client has a respiratory health problem?
1. The client appears to be whistling during activity.
2. The client uses one pillow when lying in bed.
3. The client walks slowly and deliberately.
4. The client dangles legs before stepping out of bed.
Ans: 1
92. The nurse teaches a client about complications of venous insufficiency. Which complication will the nurse include as the most serious complication?
1. Varicose veins.
2. Stasis pruritus.
3. Venous ulcerations.
4. Neuropathic ulcers.
Ans: 3
93. Before delegating tasks to nursing assistive personnel (NAP), a new nurse asks the manager to explain "the right circumstance" of delegation. Which response will the manager make to the nurse?
1. “Delegating the right circumstance is ensuring the person you delegate to is capable of handling the delegated task.”
2. “Delegating the right circumstance is ensuring the client is stable.”
3. “Delegating the right circumstance is intervening when the person the task was delegated to is not doing the delegated task correctly.”
4. “Delegating the right circumstance is asking the person delegated if they completed the task assigned.”
Ans: 2
94. After being told the diagnosis of terminal cancer, a client says “Why is God doing this to me?” Which nursing diagnosis does the nurse include in the plan of care for this client?
1. Spiritual distress.
2. Ineffective coping.
3. Anticipatory grieving.
4. Readiness for enhanced spiritual well-being.
Ans: 1
95. A client reports having difficulty falling asleep at night. With which statement will the nurse respond to this client? (Select all that apply.)
1. “Exercising immediately before bed will reduce stress.”
2. “Reading or watching television in bed will help you relax.”
3. “Eating a heavy meal before bedtime can interfere with sleep.”
4. “Maintaining a regular sleep/wake schedule promotes sleep.”
5. “Napping during the day can interfere with sleep at night.” Ans: 3, 4, 5
96. The nurse provides care for a client undergoing an exercise stress test. The cardiologist is suddenly called away for an emergency. Which action should the nurse take next?
1. Continue the test, as the client was almost finished.
2. Stop the test and reschedule for another day.
3. Ask the client to stay until the doctor returns.
4. Inform the client that the test is finished.
Ans: 2
97. A client receives treatment with internal radiation for cervical cancer. Which observation by the charge nurse poses the greatest risk to the person involved?
1. Housekeeper leaves the client’s room with full trash bags for disposal.
2. Food service worker who is pregnant delivers a breakfast tray into the room.
3. Client’s spouse visits for 1 hour and brings flowers into the room.
4. Client’s nurse enters the room without the dosimeter badge during shift report.
Ans: 2
98. The nurse plans a teaching session for a client with iron deficiency anemia. Which teaching point will the nurse include? (Select all that apply.)
1. Take iron supplements 1 hour before or 2 hours after meals.
2. Take iron supplements with dairy products.
3. Consume foods that are low in fiber.
4. Consume beans, leafy green vegetable, and organ meats.
5. Continue iron supplements as prescribed, even if no longer feeling fatigued.
Ans: 1, 4, 5
99. The nurse teaches the client diagnosed with anal-rectal cancer about the side effects of external radiation therapy. Which side effect is most important for the nurse to include in this teaching plan?
1. Alopecia occurrence is reduced by the use of a cooling cap during therapy.
2. Stomatitis is prevented by using salt and soda mouth rinses after meals.
3. Fatigue is managed by incorporating frequent rest periods during activity.
4. Thrombocytopenia can be treated with platelet infusions for bleeding.
Ans: 3
100. The client’s health care provider advises the client to undergo chemotherapy. The client, who has not yet signed the consent form, requests more information about the chemotherapy medications and the side effects. The nurse answers all the client’s questions honestly, even though the client may decide not to proceed with the chemotherapy. Which ethical principle is guiding the nurse’s practice?
1. Beneficence.
2. Fidelity.
3. Veracity.
4. Justice.
Ans: 3
101. The nurse reviews medications prescribed for a client with a gastric feeding tube. For which medication will the nurse need to contact the health care provider?
1. Potassium chloride oral solution.
2. Phenytoin oral elixir.
3. Enalapril tablet.
4. Aspirin E.
Ans: 4
102. The nurse teaches a group of nursing students about managed care. Which information will the nurse include in the teaching session?
1. Provides full coverage of health care costs.
2. Allows providers to focus on illness care.
3. Assumes the financial risk involved.
4. Encourages providers to focus on prevention.
Ans: 4
103. The nurse assesses a client’s sleep patterns. The client tells the nurse, “I am so tired in the morning. How do I know if I have sleep apnea?” Which clinical manifestation does the nurse explain to the client as indicative of sleep apnea? (Select all that apply.)
1. Awakening at night.
2. Snoring.
3. Irritability.
4. Vivid dreams.
5. Hyperactivity.
Ans: 1, 2, 3
104. The nurse provides care for a client experiencing status epilepticus. Which action is most appropriate for the nurse to take?
1. Place a tongue blade in the client’s mouth.
2. Prevent the client from flailing the arms.
3. Remove all pillows and raise the bed rails.
4. Maintain the client’s head in a midline position.
Ans: 3
105. The nurse delegates care of a client diagnosed with osteoporosis to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include?
1. “Monitor the urinary output.”
2. “Clean up clutter in the room.”
3. “Encourage the client to bathe independently.”
4. “Perform passive range-of-motion exercises.”
Ans: 2
106. The nurse is assessing a neonate born at 44 weeks' gestation. Which finding does the nurse document as consistent with the newborn’s gestational age?
1. Slow recoil of the pinna.
2. Absence of plantar creases.
3. Cracked, peeling skin.
4. Abundant vernix.
Ans: 3
107. The nurse provides care for an alcohol-dependent client diagnosed with pancreatitis. Which sign leads the nurse to determine that the client is experiencing alcohol withdrawal? (Select all that apply.)
1. Hallucinations.
2. Apathy.
3. Depression.
4. Seizures.
5. Gross tremors.
Ans: 1, 4, 5
108. The nurse provides care for a client diagnosed with vitamin A deficiency. Which menu selection is most appropriate for the nurse to recommend to the client?
1. Legumes, grains, fish.
2. Tomatoes, potatoes, fruit juice.
3. Leafy vegetables, eggs, cheese.
4. Liver, sweet potato, carrots.
Ans: 4
109. The nurse makes an error when administering a medication to a client. It is unlikely that anyone else will find out about the error. Which principle does the nurse follow to uphold ethical standards of nursing practice?
1. Fidelity.
2. Justice.
3. Veracity.
4. Confidentiality.
Ans: 3
110. The hospice client receives 10 mg of oral oxycodone every 4 hours around the clock for 1 week. The client has become unable to swallow and exhibits moderate restlessness. Which action does the nurse take?
1. Hold the oxycodone, noting in the client’s record the inability to swallow.
2. Ask the health care provider (HCP) to prescribe an alternative pain medication.
3. Dissolve the oxycodone in water and deliver it as a sublingual dose.
4. Discontinue the oxycodone and administer a reversal agent for the overdose.
Ans: 2
111. The nurse provides care for a child who ingested an unknown substance. The client is unconscious with a respiratory rate of 10 breaths/min, pulse oximeter reading is 88%, and the heart rate is 160 beats/min. The nurse determines which nursing diagnosis is the highest priority for this client?
1. Decreased cardiac output.
2. Ineffective breathing pattern.
3. Ineffective tissue perfusion.
4. Impaired cerebral tissue perfusion.
Ans: 2
112. The nurse, caring for a client diagnosed with a postoperative ileus, inserts a nasogastric (NG) tube. (Please arrange the steps in the correct order. All options must be used.)
1. Asses the client ability to follow directions
2. Gently insert the NG tube into the nares
3. Prepare the equipment at bedside
4. Instruct the client to extend the neck backward against the pillow
5. Mark the length of the tube to be inserted Ans: 1 - 3 - 5 - 4 - 2
113. The nurse is providing care to a client diagnosed with measles. Which transmission-based precaution does the nurse implement when caring for this client?
1. Airborne.
2. Droplet.
3. Contact.
4. Neutropenic.
Ans: 1
114. The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.)
1. Place respiratory equipment at the bedside.
2. Remove harmful objects from the client’s reach.
3. Apply foam padding around the bed rails.
4. Time the duration of seizure activity.
5. Teach the client about antiseizure medications.
Ans: 1, 2, 3
115. A client receiving a blood transfusion experiences a febrile reaction. Once the transfusion is discontinued, which action will the nurse take next?
1. Flush the blood tubing with normal saline.
2. Place tubing and bag in a red biohazard bag and discard.
3. Keep the blood bag and tubing hung in case the health care provider wants to restart the transfusion.
4. Place the bag and tubing in a biohazard container to send back to the blood bank.
Ans: 4
116. The graduate nurse attends an orientation to the oncology unit. Which statement indicates that the graduate nurse understands the teaching?
1. “Angiogenesis is only accomplished by malignant cells.”
2. “Everyone diagnosed with cancer will die from it.”
3. “Cancers metastasize through lymphatic spread to organs.”
4. “Cell mutations cannot be managed by the body’s immune system.”
Ans: 3
117. The nurse assess a pregnant client at 10 weeks gestation. Which finding is consistent with the gestational age of the fetus?
1. A ballottement occurs during a pelvic examination.
2. A fetal heartbeat can be heard with a Doppler.
3. The systolic blood pressure has increased 15 mm Hg above baseline.
4. The client reports feeling quickening in the lower abdomen.
Ans: 2
118. The nurse reviews care required for assigned clients. Which task will the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.)
1. Empty a client’s indwelling urinary catheter bag.
2. Adding up intake and output for each client.
3. Adding ‘acute pain’ nursing diagnosis to the care plan.
4. Check and document vital signs.
5. Set up a client’s supper tray.
Ans: 1, 2, 4, 5
119. The client says to the nurse, “I’m so upset! I’ve tried my hardest to give my children everything, but they still hate me.” Which response by the nurse is appropriate?
1. “I’m sure they don’t hate you.”
2. “Children say things they don’t mean.”
3. “What would make them feel that way?”
4. “You think your children hate you?”
Ans: 4
120. The nurse provides care for a client with an enteral feeding tube. The nurse discovers that the client’s continuous enteral tube feeding is 100 mL behind the prescribed infusion schedule. Which action should the nurse take first?
1. Flush the tube.
2. Reposition the tube.
3. Increase the flow rate.
4. Measure residual volume.
Ans: 4
121. The nurse evaluates laboratory values for a client experiencing diaphoresis and weight loss. Which value will the nurse immediately report to the health care professional?
1. Calcium 9.0 mg/dL (2.25 mmol/L).
2. Hemoglobin A1C 8% (0.08).
3. Magnesium 2.2 mg/dL (1.10 mmol/L).
4. Blood glucose 118 mg/dL (6.55 mmol/L).
Ans: 2
122. The nurse provides cares for a client with a wound. The client’s wound culture is positive for vancomycin-resistant Staphylococcus aureus (VRSA). Which personal protective equipment (PPE) does the nurse don before entering the client’s room? (Select all that apply.)
1. Mask.
2. Gown.
3. Gloves.
4. Face shield.
5. N-95 respirator mask.
Ans: 2, 3
123. The nurse provides care for a client diagnosed with cervical cancer and spinal metastasis. The client is prescribed dexamethasone three times daily. Which client statement would indicate to the nurse that treatment has been effective?
1. “The pain in my pelvic area is less.”
2. “My appetite seems to be better.”
3. “I have more energy now.”
4. “I’m not as nauseated as I was before.”
Ans: 1
124. The nurse assesses a client diagnosed with gestational hypertension (GH). Which finding is the priority for the nurse to report to the health care provider?
1. 1+ protein in the urine.
2. A continuous headache.
3. 2+ ankle edema.
4. A weight gain of 2 lb. (0.9 kg) in the past week.
Ans: 2
125. The nurse uses research findings to improve client care. Which technique of care is the nurse using?
1. Nurse-sensitive indicators.
2. Care management.
3. Performance improvement.
4. Utilization review.
Ans: 3
126. The nurse receives a prescription to provide aspirin to a client with an emergent acute myocardial infarction. What is the best method to administer aspirin to this client?
1. Administer as a rectal suppository.
2. Administer with a glass of milk or antacid.
3. Give sublingually, times three doses.
4. Have the client chew non-enteric coated ASA.
Ans: 4
127. The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act?
1. “A client needs to complete an advance directive and identify a health care proxy to become an organ donor.”
2. “The health care provider is the person who requests organ donation from a client’s family members.”
3. “The health care provider who signs the client’s death certificate must supervise the removal of the client’s donated organs.”
4. “Family members can consent to organ donation after the client’s death, even if the client had not expressed a desire to have organs donated.”
Ans: 4
128. The nurse provides care for a client experiencing a sickle cell crisis. Which nursing diagnosis is the priority for the nurse to include in the plan of care?
1. Risk for infection.
2. Risk for ineffective cerebral tissue perfusion.
3. Activity intolerance.
4. Ineffective peripheral tissue perfusion.
Ans: 4
129. The nurse provides care for a client diagnosed with a stage 2 sacral pressure injury. The nurse educates the client’s family members about proper positioning. Which statement by the family members indicates a need for further teaching?
1. “We will not keep our parent sitting on the bedpan for too long.”
2. “We will encourage our parent to change position every few hours.”
3. “We will use a draw sheet to help position our parent when in bed.”
4. “We will put our parent on a rubber ring cushion when he is sitting up.”
Ans: 4
130. The nurse provides care for a hospitalized client receiving ethambutol, isoniazid, pyrazinamide, and rifampin for active tuberculosis (TB). The client states, “I want to go home! I refuse to stay here another day!” Which statement by the nurse is most appropriate?
1. “You must remain in the hospital until you have finished the antibiotics.”
2. “I will notify the health care provider of your request.”
3. “You will have to wear a mask around sick people.”
4. “Let’s test your sputum again for the presence of tuberculosis.”
Ans: 2
131. The nurse teaches a class about birth control. Which client statement about the use of a male condom requires follow-up by the nurse?
1. "Condoms are the only birth control method that prevents the spread of sexually transmitted infections.”
2. "I will put the condom on before I have an erection to collect all sperm.
3. "I will leave a space at the tip for the condom to collect the ejaculate."
4. "I will hold the condom firmly at the base of the penis and withdraw the penis before the erection ends."
Ans: 2
132. The nurse provides care for a client with a small bowel obstruction and stage 4 stomach cancer. The client verbalizes an interest in palliative care and the spouse does not agree. Which statement by the nurse to the client is appropriate?
1. “We need to insert a nasogastric tube.”
2. “Would you two like to speak in private?”
3. “What are your treatment goals?”
4. “I know this process is very stressful.”
Ans: 3
133. The nurse provides care for a client that has difficulty getting comfortable at night. The client remains awake until the client requests acetaminophen. The client is able to fall asleep about an hour after taking the acetaminophen. Which nursing intervention should the nurse add to the client’s plan of care?
1. Talk with the health care provider about prescribing a sleep medication for the client.
2. Talk with the health care provider about prescribing a stronger pain medication for the
client. effects.
3. Instruct the client to avoid using acetaminophen routinely because of the adverse
4. Administer the acetaminophen about an hour before the client goes to sleep.
Ans: 4
134. The nurse receives report for a group of adult clients. Which client will the nurse see first?
1. The client receiving treatment for osteomyelitis of the lumbar spine, with a white blood cell count of 22,000/mm3 (22 x 109/L).
2. The client diagnosed with right-sided heart failure and 4+ pitting edema of the legs, ankles, and feet.
3. The adult client with a pneumonia diagnosis, rhonchi clear with coughing, and oxygen saturation level of 93%.
4. The client diagnosed with failure to thrive lying supine with a nasogastric tube feeding infusing.
Ans: 4
135. After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and toes. Which electrolyte imbalance does the nurse suspect the client is experiencing?
1. Hypocalcemia.
2. Hypercalcemia.
3. Hyponatremia.
4. Hypernatremia.
Ans: 1
136. The nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care?
1. Risk for impaired cognition.
2. Risk for cardiac dysrhythmia.
3. Risk for acid-base imbalance.
4. Risk for shivering and spasm.
Ans: 2
137. The nurse evaluates care provided to a client diagnosed with anorexia nervosa. Which laboratory result indicates to the nurse that further treatment is needed?
1. Arterial pH 7.37.
2. Arterial pH 7.48.
3. Arterial bicarbonate 24 mEq/L.
4. Arterial bicarbonate 19 mEq/L.
Ans: 4
138. An older client is discharged from the hospital to home following treatment for a fall. The nurse makes a home safety survey. Which findings does the nurse report as fall safety risks? (Select all that apply.)
1. Bathroom is located on the second floor.
2. Meals are prepared using a gas stove.
3. Bilateral hearing aids are used regularly.
4. Throw rugs are in the pathway to the kitchen.
5. Mailbox is located at the end of the driveway.
Ans: 1, 4, 5
139. The nurse plans for the discharge of a client with Parkinson disease. Which outcome is appropriate for collaboration between the nurse and the physical therapist? (Select all that apply.)
1. Maintain physical strength and mobility.
2. Bladder training to increase bladder capacity.
3. Optimal use of extremities in performing activities.
4. Proper use of ambulatory assistive devices.
5. Monitor skin for alterations in integrity.
Ans: 1, 3, 4
140. The nurse assesses a client being considered for thrombolytic therapy. Which question is most appropriate for the nurse to ask? (Select all that apply.)
1. “When was the last time you had a bowel movement?”
2. “Can you tell me the exact time your chest pain began?”
3. “Are you taking any medications to thin your blood?”
4. “Did you have the flu and pneumonia vaccination?”
5. “When was the last time you ate?” Ans: 2, 3
141. The nurse provides care for a client who reports severe right shoulder pain. Which abdominal organ should the nurse suspect is causing this client’s discomfort?
1. Spleen.
2. Pancreas.
3. Stomach.
4. Gall bladder.
Ans: 4
142. The parents bring their 4-month-old infant to the clinic for a wellness visit. They report trying to give the infant prepackaged baby food a couple of weeks ago, but the infant stuck out the tongue and would not take the food. Which response by the nurse is appropriate?
1. “That’s a natural reflex; it will soon disappear and then your baby will be ready for solid
foods.” tried.”
2. “Try introducing another food. Your baby probably doesn’t like the taste of what you
3. “Keep introducing foods, as it may be the texture of the food you tried.”
4. “Try pureeing your own food instead of giving the prepackaged baby food.”
Ans: 1
143. The new graduate nurse notices that one of the other nurses has been sleeping on the unit during the night shift. The other staff members seem to have seen this nurse asleep, but they have said nothing. Which action does the new graduate nurse take?
1. Tell the nurse manager in the morning.
2. Contact the nursing supervisor.
3. Tell the nurse you have seen the sleeping and it needs to stop.
4. Tell the nurse if you see the sleeping again, you will report it.
Ans: 2
144. The nurse provides care to a client of Asian descent having surgery later in the day. Which action will be most appropriate for the nurse to take when assessing this client?
1. Observe the client’s use of eye contact.
2. Look directly at the client when interacting.
3. Avoid eye contact with the client.
4. Ask a family member about the client’s cultural beliefs.
Ans: 1
145. The nurse provides care to a client who is unconscious. In which position will the nurse place the client to provide oral care?
1. Dorsal recumbent.
2. Orthopneic.
3. Side-lying.
4. High Fowler.
Ans: 3
146. A client with diabetes returns from the post-anesthesia care unit (PACU) after a transurethral resection of the prostate (TURP). Which intervention will the nurse perform first?
1. Perform a bedside bladder scan.
2. Collect a specimen for urine culture.
3. Check patency of the indwelling urinary catheter.
4. Obtain a capillary blood glucose level.
Ans: 3
147. A client with a history of intravenous drug abuse experiences a low-grade fever, cough, night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum. Which transmission- based precaution will the nurse use for this client?
1. Airborne.
2. Contact.
3. Droplet.
4. Standard.
Ans: 1
148. The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). The nurse receives a prescription to transition the client from a regular insulin infusion to insulin glargine. Which action does the nurse take first?
1. Continue the insulin infusion for 1 to 2 hours after the glargine is started.
2. Check the client’s blood glucose every 30 minutes for 24 hours.
3. Discontinue the insulin infusion as soon as the glargine is administered.
4. Monitor the client closely for signs of seizure activity.
Ans: 1
149. The nurse provides care for a client diagnosed with emphysema. The client becomes anxious and confused. What is the first action the nurse should take?
1. Increase the client’s oxygen flow rate to 4 liters per minute.
2. Encourage the client to do pursed-lip breathing.
3. Assess the client’s sodium level.
4. Take the client’s blood pressure.
Ans: 2
150. The nurse works with an LPN/LVN on a team nursing unit. Which task is most appropriate for the nurse to delegate to the LPN/LVN? (Select all that apply.)
1. Administering an intramuscular injection.
2. Administering a blood pressure medication intravenously.
3. Administering oral medications.
4. Referring a client to a long-term care facility.
5. Obtaining a capillary blood glucose.
Ans: 1, 3, 5
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