Tarleton State University Transition Prof Nurs Practice Sample/Practice Exam (211 Questions and Answers)

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1. An older male client is brought to the Emergency Department by family members who he has become increasingly confused in the last 3 days. Which actions should the nurse (Select all That apply) A. ... Explain that advanced age is associated with confusion B. Evaluate polypharmacy for possible drug interactions C. Obtain a urine specimen for culture and sensitivity D. Discuss nursing home placement with the family E. Determine oxygen saturation rate and breath sounds , C, E 2. A multigravida, full-term, laboring client complains of “back Labor”. Vaginal examination reveals that the client’s 3cm with 50% effacement and the fetal head is at -1 station. What action should the nurse implement? A. Apply counter-pressure to the sacral area B. Turn the client to a lateral position C. Notify the scrub nurse to prepare the OR D. Ambulate the client between contractions 3. An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can this to exhibit? A. Lethargy and a poor suck B. Facial abnormalities and microcephaly C. Irritability and a high-pitched cry D. Low birth weight and intrauterine growth retardation 4. A client with gestational diabetes is undergoing a non-stress test (NST) at 34- weeks gestation; the baby’s heart is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a…. Each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. ???? A. The mother perceives and marks at least four fetal movements B. Fetal movements must be elicited with a vibroacoustic stimulator C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded D. No FHR late decelerations occur in response to fetal movement 5. A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive, the respiration rate of 60 breaths/minute, and a heart rate of 150 beats/minute. What action should the nurse first? A. Obtain a pulse oximeter reading B. Assess the Child’s blood pressure C. Perform a neurological assessment D. Initiate peripheral intravenous access 6. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse ….. Tachypneic, and hypotonic. What is the first action that the nurse should take? A. Notify the healthcare provider immediately B. Increase the temperature of the radiant warmer C. Assess the infant’s heart rate D. Determine the infant’s blood sugar level 7. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important at time the infusion rate is increased? A. Contraction pattern B. Blood pressure C. Infusion site D. Pain level 8. A 6-year old child with acute infectious diarrhea is placed on rehydration therapy regimen. Which action should the nurse instruct the parent to take if the child begins to vomit? A. Continue giving ORS frequently in small amounts B. Withhold all oral intake C. Supplement ORS with gelatin or chicken broth D. Provide only bottled water 9. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. Which is the first nurse priority? A. Clean the perineal area to prevent infection B. Assess the mother’s blood pressure to check for signs of preeclampsia C. Assess the mother’s temperature to check for development of sepsis D. Have a meconium aspirator available at delivery 10. During a 26-week gestation prenatal exam, a client reports occasional dizziness. What intervention is best for the nurse to recommend to this client? A. Elevate the head with two pillows while sleeping B. Lie on the left or right side when sleeping or resting C. Increase intake of foods that are high in iron D. Decrease the amount of carbohydrates in the diet 11. A postpartal client complains that she has the urge to urinate every hour but is only able to a small…. What intervention provides the nurse with the most useful information? A. Initiate a perineal pad count B. Catheterize for residual urine after next voiding C. Assess for a perineal hematoma D. Determine the client’s usual voiding pattern 12. A client is scheduled for a laminectomy to treat lower back pain related to a herniated intervertebral disk. When conducting preoperative teaching, the nurse should teach the client that numbness and tingling in the lower extremities sometimes occurs postoperatively as the result of which condition? A. Effects of intrathecal anesthesia that resolve quickly B. Minor injuries caused by positioning during surgery C. Pressure on the nerves due to prolonged immobility D. Manipulation of nerves and muscles during surgery 13. The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child’s diagnosis? A. “I couldn’t get my son’s socks and shoes on this morning” B. “I couldn’t get my son to calm down and sleep last night” C. “My son has had a red rash over his entire body for the past 4 days” D. “My son has been on Augmentin for 2 days for an ear infection” 14. The nurse is evaluating the home care teaching of a family who has a child with cystic fibrosis. Which parental action indicates correct understanding of the child’s home care? A. Performs postural drainage after meals B. Supplements diet with water-soluble vitamins and fluids C. Plans a diet high in fat and calories D. Gives pancreatic enzymes before every meal and snack 15. Client with mitral stenosis is at 28-weeks gestation. In assessing this client, which observation should the nurse investigate first? A. Edematous feet B. Persistent cough C. Increased fatigue D. Recent sadness 16. A 72-year-old client is admitted to the hospital after falling at home. In taking a nursing history, the nurse notes that the client is taking labetalol HCL (Normodyne) 300mg PO BID and ranitidine (Zantac) 150 mg PO QID. What nursing intervention is most important to include in this client’s nursing care plan? A. Determine gastric pH on admission B. Weigh daily in early morning C. Frequent monitoring of blood pressure D. Daily assessment of WBCs and platelets 17. Captopril (Capoten) is prescribed for an infant admitted 3 days ago with a diagnosis of heart failure. During assessment, which clinical finding indicates to the nurse that the medication is effective? A. Capillary refill is down from 4 seconds on admission to 2 seconds B. Blood pressure decrease from 125/85 on admission to 106/60 C. Heart rate decreased from 200 beats/minute on admission to 140 beats/minute today D. Periorbital adema disappears 18. The client with paranoia and homicidal ideation is brought to Emergency Department…. The client states that her daughter lives her television set and will come the nurse talk to her. What additional finding indicates that the client has a thought disorder? A. Feels lonely and isolated B. Feels very anxious C. Easily changes the subject D. Stays in bed all morning 19. A client with a history of gastroesphageal reflux disease (GERD), who smokes 2 packs of cigarettes and drinks a fifth of liquor daily, had a cholecystectomy. While completing a head to toe assessment, the nurse discovers that the client is tremulous, agitate, febrile, and disoriented. What is the likely indication of this finding? A. Impending delirium tremens B. Post-surgical infection C. Reoccurring reflux D. Nicotine withdrawal 20. Which prescription should the nurse anticipate administering to a client who is experiencing increased intracranial pressure secondary to a head injury? A. Acetazolamide (Diamox) B. Mannitol (Osmitrol) C. Sumatriptan (Imitrex) D. Dobutamine HCI (Dobutrex) 21. The emergency room is alerted that a child is arriving by ambulance with a history of flu-like symptoms for the past week. The reported vital signs are temperature 101 ̊ F, heart rate 168 beats/minute, respirations 16 breaths/minute, and blood pressure 90/60.The child is lethargic with a capillary refill time of 4 seconds. When preparing for the child’s arrival, the nurse should assemble which equipment? A. Mechanical ventilator B. IV infusion pump C. Cooling blanket D. Automated defibrillator 22. A child with heart failure is receiving the diuretic furosemide (Lasix) and has a serum potassium level of 3.0 mEq/L. Which assessment is most important for the nurse to obtain? A. Cardiac rhythm and heart rate B. Daily intake of foods rich in potassium C. Hourly urinary output D. Thirst and skin turgor 23. A male client, who had a total laryngectomy two days ago, is transferred from the intensive care unit to a private room close to the nurse’s station. The nurse recognizes that the client is anxious. Which intervention should the nurse implement? A. Encourage a family member to stay with the client at all times B. Answer the client’s call signal in person quickly after he calls C. Explain the emergency procedure for loss of airway to the client D. Provide the client with a suction catheter to allow for self-suctioning 24. When caring for a client with an acute myocardial infarction, which observation warrants immediate intervention by the nurse? A. Systolic blood pressure of 100 B. Oral temperature of 99.4 ̊ F C. Central venous pressure (CVP) of 4 mHg D. The telemetry displays ventricular bigamy 25. A client is admitted to the emergency center with a possible head injury and spinal cord injury (SCI) after an automobile collision. What is the nurse’s priority assessment? A. Level of consciousness B. Mobility of extremities C. Respiratory status D. Cranial nerve function 26. A school-aged child with juvenile rheumatoid arthritis develops a viral infection with a low grade fever. The child is already taking aspirin for the arthritis. What instruction should the nurse provide to this mother? A. Discontinue the use of all medications to avoid masking the symptoms of the illness B. Discontinue the aspirin, and use another NSAID to control the child’s fever and symptoms C. Continue the aspirin, but add another NSAID to control the child’s fever and symptoms D. Increase the dose of aspirin to control the child’s fever and symptoms 27. A female teacher tells the school nurse that she thinks she is pregnant, but her pregnancy test was negative the previous night. When taking the teacher’s history, the nurse finds that the only medication the teacher is currently taking is tetracycline for acne. Which instruction should the nurse provide? A. Make an appointment with an obstetrician as soon possible B. Increase oral fluid intake to 3 or quarts daily C. Use first voiding of the day for accurate results of a pregnancy test D. Stop taking the acne medication immediately 28. Three days after admission for diabetic ketoacidosis (DKA), a client’s blood glucose levels ranges from 420 to 540 mg/dl. Regular insulin is being administered using a sliding dosage scale. Which intervention is most important for the nurse to implement? A. Confer with the healthcare provider about a continuous IV insulin infusion B. Arrange for a nutritional consult to assist the client with diabetic food choices C. Request the diabetic educator to evaluate the client’s knowledge of diabetes D. Given an additional dose of regular insulin according to sliding scale prescription 29. An adult male who recently returned from a trip to China is diagnosed with severe acute respiratory syndrome (SARS). He is hospitalized and placed in a negative pressure isolation room. Which intervention is most important to include in this client’s plan of care? A. Determine if an advanced directive is signed B. Require use of gown, gloves, and N-95 mask C. Limit visitors to family members only D. Teach how to dispose of used tissues 30. When evaluating the effectiveness of medications administered to a client with Parkinson’s disease, the nurse recognizes that symptom management requires a balance among which neurotransmitters? A. Norepinephrine and acetylcholine B. Epinephrine and dopamine C. Dopamine and norepinephrine D. Acetylcholine and dopamine 31. The nurse is assessing the normal development of a 9-month-old male infant. Which information should the nurse obtain from the mother? A. Is the baby able to lift his head when prone? B. Has the child started to walk? C. Does the baby roll from abdomen to back? D. Can the child sit alone? 32. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nauseas while driving over the bay bridge. What action in the treatment plan should the nurse implement? A. Tell client to drive over the bridge until fear is manageable B. Teach client to listen to music or audio books while driving C. Recommend that the client avoid driving over the bridge D. Encourage client to have spouse drive in stressful places or C 33. When caring for a client with deep partial-thickness burns to the posterior neck, which intervention should the nurse implement during the acute phase to prevent contractures at the site of injury? A. Place a towel roll under the client’s neck or shoulder B. Passively raise arms above the head hourly while awake C. Actively turn head from side to side 90 degrees hourly D. Keep in a supine position without the use of pillow 34. The nurse is conducting an admission assessment and interview of a client who is believed to have Guillain- Barre syndrome. Which comment by the client has the most significance to this diagnosis? A. “I’ve had problems with my sinuses and bad allergies since I was a child” B. “Two years ago, I received immunizations before going to Japan” C. “I’ve lost 5 pounds in the last month by decreasing my fat intake” D. “About two weeks ago, I missed a day of work because I had a bad cold” 35. Which symptom is characteristic of ureteral colic in the client diagnosed with renal calculi? A. Symptoms of irritation associated with urinary tract infection B. Acute, excruciating, wave-like pain radiating to the genitalia C. Intense, deep ache in the costovertebral region D. Chills, fever, and dysuria Correct Answer: 36. When assisting an elderly female client who is bathing herself in bed, the nurse observes that the client has inelastic skin turgor, large pendulous breasts, and a soft flaccid abdomen. To prevent skin maceration, which action should the nurse implement? A. Advice the client to use talcum powder over skin surfaces B. Recommend the use of a blow dryer to dry under the breasts C. Teach the client to dry the skin well between skin folds D. Apply a smooth layer of lotion over areas of loose, inelastic skin 37. A client at the healthcare clinic reports a new onset of pyrosis and dyspepsia to the nurse. Which nursing action has the highest priority? A. Instruct the client about the symptoms of reflux disease B. Provide reassurance that these are common symptoms of reflux disease C. Recommend the use of antacids to control symptoms D. Schedule an appointment for a physical examination 38. A female client with pneumonia and a history of sickle cell anemia begins to complain of pain in her fingers, which indicates to the nurse a possible ensuing sickle cell crisis. What is the underlying pathophysiology for pain in sickle cell crisis? A. Hemolysis of blood cells containing hemoglobin 5 increases cellular debris that results in bone pain B. Production of abnormal red cells in the bone marrow causes extreme pain C. Viscosity of the blood creates sluggish blood flow, leading to blood D. Sickled red blood cells do not flow through small blood vessels, leading to vasocclusion and ischemia 39. A female client with chronic pyelonephritis expresses concern that she may have to undergo dialysis. What is the best initial response by the nurse? A. Offer to introduce the client to a dialysis nurse who can provide teaching about dialysis B. Explain the relationship between chronic kidney infection, real failure, and dialysis C. Provide assurance that dialysis is not the usual treatment for kidney infections D. Assist the client to reduce anxiety and gain control by using guided imagery exercise 40. A male client with bipolar disease reports to the nurse that he has not taken his prescription medication, divalproex (Depakote) for the last 6 months. Assessment of which is most important for the nurse to obtain? A. Mood B. Affect C. Intellect D. Speech 41. A female client with breast cancer who completed her first chemotherapy treatment, out-patient cancer treatment center is preparing for discharge. Which behavior the client understands her care needs for the next week? A. Invited friends and family to visit while she is at home for the next week B. Rented movies and borrowed books to use while passing time at home C. Schedule a lunch date with her best friends for 2 days from now D. Stocked her refrigerator with healthy foods including fruits and vegetables 42. What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A. Assess the client’s ability to use a numeric pain scale B. Initiate the dosage lockout mechanism on the PCA pump C. Instruct the client to use the medication before the pain becomes severe D. Assess the abdomen for bowel sounds 43. A male client with angina pectoris is being discharged from the hospital. What instruction should the nurse plan to indicate in this discharge teaching? A. Engage in physical exercise immediately after eating to help decrease cholesterol levels B. Walk briskly in cold weather to increase cardiac output C. Keep nitroglycerin in a light-colored plastic bottle and readily available D. Avoid all isometric exercises, but walk regularly 44. When assessing a 6 month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A. Crying B. Straining on stool C. Vomiting D. Sitting upright 45. Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity? A. Range motion B. Distal pulse intensity C. Extremity sensation D. Presence of exudate 46. A series of stool guaiac test is prescribed for a client receiving anticoagulant therapy. While obtaining the first specimen, the nurse observes that the client’s stool is clay- colored. What action should the nurse take? A. Implement contact isolation precautions B. Report stool’s appearance to the healthcare provider C. Increase the frequency of guaiac testing D. Assess for signs of bleeding from other orifices Correct Answer: 47. In caring for newborn infant who become cyanotic and start gagging, what action should the nurse implement? A. Give three back blows to clear the airway B. Provide oxygen by resuscitation bag and mask C. Use a bulb syringe to suction nose and mouth D. Request the crash cart be brought to the nursery 48. While transferring a client with a chest tube from the bed to a stretcher, the chest becomes disconnected from the water-seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. What action should the nurse implement next? A. Apply pressure to the chest tube site using a petroleum gauze B. Begin manual ventilation while returning the client to the bed C. Prepare a new water-seal system and reattach the chest tube D. Clamp the chest tube and maintain its distal end in the water 49. While palpating a 6-week old infant’s head, the nurse notes a 0.5 cm wide, soft area at the junction of the coronal and lambdoidal suture lines. Which intervention should the nurse implement? A. Document assessment data in the record B. Assess for presence of the Babinski reflex C. Evaluate infant’s cardinal fields of gaze D. Measure the frontal-occipital circumference 50. A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) A. Give the client 4 ounces of orange juice B. Provide the client with ½ cup diet carbonated soda C. Obtain blood pressure and pulse rate D. Check the client’s current finger stick blood glucose E. Administer a PRN dose of regular insulin C D 51. The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document this sound? (audio) A. High pitched or fire crackles B. Rhonchi C. High pitched wheeze D. Stridor 52. A woman who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. She states that she is pain free. Which intervention should the nurse include in the client’s plan of care? A. Maintain the client on a n NPO status B. Administer daily vitamin supplements C. Determine if the client is over-hydrating to feel satiated D. Encourage positive self-accolades for dietary adherence 53. The nurse knows that several complications can occur the administration of blood. Which finding is an indication of an air emboli? A. Increased blood pressure B. Nausea and vomiting C. Chills and tremors D. Difficult breathing 54. Medical asepsis requires that the nurse include what hand washing technique? A. Use hot water to ensure pathogens are killed B. Hold hands higher than the elbows and scrub vigorously C. Use a circular motion, washing from clean to dirty areas D. Rinse soap off, keeping hands and forearms lower than elbows 55. The nurse brings an oral medication prescribed to be given daily to a male client who tells the nurse that will take the medication later? A. Inform the client that his medication is schedule to be taken now B. Agree upon a time to return to the client room with the medication C. Note the client noncompliance with medication in the nurse note D. Leave the medication on the bed side table with a fresh glass of water 56. Because a client with Bell palsy is at risk for impaired nutrition. What the nurse do or expect? A. Arrange the client to received home delivery meals daily B. Assist the client in choosing low calories, low fat food each meal C. Refers the client to a speech therapist to learn swallowing techniques D. Teach the client to chew food on the unaffected side of the face 57. The nurse is assessing a client with a closed head injury sustained in a motor vehicle collision. Which finding indicates the lowest level of neurologic functioning? A. Withdrawal from painful stimuli B. Localization of a tactile stimulus C. Decorticate posturing during position changes D. Decerebrate posturing during position changes 58. The nurse measuring the output of an infant admitted for vomiting and diarrhea. During a 12 hours shift, the infant drink 4 ounces of pedialyte, vomit 25ml and void twice the dry diaper weighs is 50 grams and one wet diaper weighs 75 grams, and the other weighs 105 grams. What documentation should the nurse include in this infant record? A. Calculate difference in wet and dry diapers and document 80 ml urine output B. Subtract vomitus from 120 ml pedialyte then document 95 ml oral intake C. Document on the flow sheet that the infant voided time 2 and vomited 25ml D. Compared the difference between the infant body weight and admission weight 59. Which class of drugs in the only source of a cure for septic shock? A. Antihypertensives B. Anticholesteremics C. Antihistamines D. Antiinfectives 60. A client with atrial fibrillation receives a new prescription for Dabigatram (Praxada). What instruction should the nurse include in this client teaching plan? A. Continue obtaining schedule lab bleeding test B. Keep an antidote available in the event of hemorrhage C. Avoid use of non-steroid anti-inflammatory drugs (NSAID) D. Eliminate spinach and other green vegetables in the diet 61. A client experiencing withdrawal from the (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? A. Administer Narcan PRN protocol B. Obtain serum drug screen C. Instruct the family about withdrawal symptom D. Initiate seizure precautions 62. In making client care assignments, which client is best to assign to the practical nurse (PN) working on the unit with the nurse? A. An immobile client receiving low molecular weight heparin q12h B. A client who is receiving a continuous infusion of heparin and gets out of bed BID C. A client who is being treated off a heparin infusion and started on PO warfarin (Coumadin) D. An ambulatory client receiving warfarin (Coumadin)with an INR of 5 seconds 63. An older male client arrives at the clinic complaining that his bladder always feels full. He complain of a weak urine flow frequent dribbling after voiding and increasing nocturnal with difficulty initiating his urine stream action should the nurse implement? A. Advice the client to maintain a voiding dairy for one week B. Instruct effective technique to cleanse the glands pennies C. Palpate the client therapeutic area for distention D. Obtain urine specimen for culture and sensitivity 64. The mother of the 7 month- old bring the infant to be clinic because the skin in the diaper area is … and red, but there are no blister or bleeding. The mother reports no evidence of watery stool. Which nursing intervention should the nurse implement? A. Instruct the mother to change the child’s diaper more often B. Tell the mother to cleanse with soap and water at each diaper change C. Encourage the mother to apply lotion with each diaper change D. Ask the mother to decrease the infant’s intake of fruit for 24 hours 65. A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure. His vital signs are temperature 98.8 ̊ , heart rate 118 beats/min, respiration rate 46 breaths/min, blood pressure 176/92. While completing the pulmonary assessment, his oxygen status saturation reading is 78 % and he is difficult to arouse. Which action should the nurse implement? A. Administer PRN nebulizer treatment B. Increase oxygen delivery by 10% C. Complete neurological assessment D. Prepare for rapid sequence intubation 66. A client with pneumonia has arterial blood gases level at pH 7.33, PaCO₂ 49 mm, HCO₃ 25, PaO₂ 95. What intervention should the nurse implement base on these results? A. Instruct the client to breathe into a paper bag B. Prepare to administer sodium chloride fluids C. Initiate oxygen administration at 2 to 3 L per nasal cannula D. Institute coughing and deep breathing protocols 67. A client with a diagnosis of schizophrenia, sits in the day room and fail to interact…. Which intervention is best for the nurse to implement with this client? A. Complete an assessment of social support B. Encourage the client to have lunch off the unit C. Give the client a schedule of planned daily activities D. Engage the client in a game of cards 68. The nurse plans to collect a 24 hrs urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? A. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hrs for the next 24 hrs B. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24hrs C. For the next 24 hrs., notify nurse when the bladder is full, and the nurse will collect catheterized specimen D. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle 69. A child is brought to the clinic complaining of fever and joint pain, and is diagnosed with rheumatic fever. When planning care for this child, what is the primary goal of nursing care? A. Prevent cardiac damage B. Maintain joint mobility and function C. Reduce fever D. Maintain fluid and electrolyte balance 70. The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action first? A. Dry the infant under warming unit B. Determine Apgar score C. Allow the mother to touch the infant D. Perform a physical assessment 71. Following two defibrillation shock, the client ECG continues to indicate ventricular fibrillation. What intervention should the nurse implement next? A. Resume CPR immediately B. Administer an IV bolus of epinephrine C. Perform the third defibrillation shock D. Obtain an arterial blood gas sample 72. During discharge teaching the mother asks why her premature infant should get monthly synagis (Palivizumab) injections the nurse response should be based on what information? A. Monthly injection promote normal neurological and physical development B. This drug protect the premature infant from respiratory syncytial virus C. These injection prevent retinopathy of prematurity caused by high level of oxygen D. This medication provide surfactant, which helps the lungs mature more quickly 73. Using the parkland formula for a patient with burns 4ml x Patients weight in kg which is 76kg x whatever % of burns, which is 40%. SO it is 4ml x 76kg x 40% 74. Mark the Dilaudid dose in a syringe that has to be administering to a patient. (THE IS A SQUARE OF A NUMBER PAD) ANS: Mark the NUMBER 1. (1 MG) 75. A 16-year-old adolescent with Meningococci meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10 million units/liter of normal saline. How many ml/hr. should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 76. A client with general anxiety disorder is pacing the hallway. The client tells the nurse “my heart is just racing and sometimes it feels like it fluttering. I’m feeling short of breath and dizzy”. Nurse first implement? A. Obtain vital signs B. Escort the client to quiet room C. Administer an anti-anxidytic D. Initiate a diversionary activity 77. The nurse notes that a client is experiencing supraventricular tachycardia which action should the nurse implement? A. Place a crash cart at the client bedside B. Prepare to administer adenosine an antidysrrythmic C. Call a code and start CPR immediately D. Assess the client heart sounds and vital signs 78. An infant admitted to the neonatal intensive care is tachypneic, tachycardiac, has bounding brachial pulses. The healthcare provide suspect that the infant coarctaction of the aorta. What intervention is important to include in the plan of care? A. Assess centralized cyanosis 4 times daily B. Monitor congestive heart failure C. Correct respiratory alkalosis related to tachypnea D. Auscultate diastolic murmur daily 79. The nurse is caring for a client admitted in telemetry unit for complications related to a myocardial infarction (MI) occurred 4 days ago. A 12 lead electrocardiogram (ECG) shows right axis deviation and poor R wave progression which assessment suggest that the client is at risk for right ventrical hypertrophy? A. Generalized, fatigue, dizziness, swollen ankles B. Nausea, vomiting and generalized edema C. Severe chest pain and SOB D. Sharp, non-radiating chest pain and nausea 80. In caring for a client with Cushing syndrome, which serum lab value is most important for the nurse to monitor? A. Glucose B. Lactate C. Hemoglobin D. Creatinine 81. A client with a history of recurrent atrial fibrillation is taking Amiodarone (Cordarone) and Warfarin (Coumadin) which meal should the nurse provide for the client? A. Seared tuna steak and stewed squash B. Marinated pork chops and spinach C. Grilled sirloin steak and garden salad D. Bake chicken and steamed broccoli 82. When assessing acuity of a group of clients in the intensive care unit (ICU). The charge nurse determines the staffing matrix requires four nurses for the next shift. Three hour prior to the beginning of the next shift a nurse called sick. Before attempting to obtain staff to cover the sick nurse shift. What action should the nurse take? A. Reevaluate the current client acuity mix B. Complete the absentee sick call form C. Talk to the nurse to see now sick she is D. Notify the administrative supervisor 83. A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client’s admission history, he tells the nurse that he recently received Vancomycin (Vancocin) for methicillin-resistant Staphylococuus aureus (MRSA) wound infection. Which actions should the nurse take? (Select all that apply) A. Collect multiple site screening cultures for MRSA B. Call healthcare provider for a prescription for Linezol (Zyvox) C. Place the client on contact transmission precautions D. Obtain a sputum specimen for culture and sensitivity E. Continue to monitor the client for signs of an infection , C, E 84. A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which intervention should the nurse include in the infant’s plan of care? A. Give O₂ at 6 L/nasal cannula for 3repeated oximetry screens below B. Administer diuretics via secondary infusion in the morning only C. Evaluate heart rate for effectiveness of cardiotonic medication D. Use high energy formula 30calories/ounce at q3 hour feedings via soft nipples E. Ensure uninterrupted and frequent rest periods between procedures , C, D, E 85. Following an esophagogastroduodenoscopy (EGD), a male client is drowsy and difficult to arouse, and his respirations are slow…shallow. Which action should the nurse implement? (Select all that apply) A. Prepare medication reversal agent B. Check oxygen saturation level C. Apply oxygen via nasal cannula D. Initiate bag-valve-mask ventilation E. Begin cardiopulmonary resuscitation , B, C 86. When developing a teaching plan for a client with newly diagnosed Type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Drink electrolyte fluid replacement C. Give a dose of regular insulin per sliding scale D. Measure urine output over the next 24 hours 87. The mother of a school age child tell the school nurse when her daughter can return to school after treatment for pediculosis capitis. What is the best response for the nurse? A. Until all lice are dead B. Until the epidemic in school subside C. Stay in home 88. Client in wrist restraint the nurse frits slides two fingers under the restraint and notes that the ties are secured to the side rail using a quick released tie. What the nurse do? ANS: Reposition the restraint ties, securing them to the bed frame. 89. A newborn infant is diagnosis with developed mental dysplasia of the hip must wear a pavlik harness 23 hours a day. Which behavior by the mother best indicates that discharged teaching was effective? A. The nurse observed the mother removing and replacing the pavlik harness B. The mother described problems that may occur while using the harness C. The nurse report that she has question regarding the care of the harness D. The nurse demonstrate removing the harness and the mother watches closely 90. A client is one day postpartum tells the nurse that her baby cannot catch onto his breast. The nurse determined that the client nipples are inverted. Which action should the nurse implement to provide nutritional to the child? A. Teach about the use of breast pump B. Recommending using breast shield C. Offer supplemental formula feeding D. Encourage the use of ice on the areola 91. The mother of a 24 month old boy tell the clinic nurse that her child avoid eye contact with those how try to interact with him, and he shrieks out in public for no reason. Which intervention is more important for the nurse to screen the child for autism? A. Determine what activities are occurring when this happens B. Inquire about spontaneous make believe play activities C. Evaluate child ability to identify his nose and mouth D. Observe the child for mannerism, such as hand flapping 92. The nurse is planning to teach a male client with type 2 diabetes how to perform blood glucose. Monitoring which action should the nurse implement first? A. Instruct the client to wash his hands before conducting the procedure B. Provide an overwriting of the diabetes mellitus pathology C. Refer the client to the hospital social worker D. Assist the client to selecting a meter to monitoring the blood sugar 93. The nurse is palpating the lymph nodes of a 10 months old. Which findings should the nurse call to the attention of the health care provider? A. Enlarged, warn, tender preauricular node B. Enlarged, non-tender, mobile occipital node C. Small, discrete, mobile, non-tender, inguinal node D. Small, firm, mobile nodules in the axial 94. A young adult female presents at emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? A. History of irritable bowel syndrome (IBS) B. Report white, curdy vaginal discharge C. Last menstrual period was 7 weeks ago D. Pain scale rating of “9” on a 0 -10 scale 95. After reviewing the Braden scale finding of residents at a long term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? A. A woman with osteoporosis who is unable to bear weight B. An older man whose sheets are damp each time he is turned C. An older adult who is unable to communicate elimination needs D. A poorly nourished client who requires liquid supplements 96. A nurse who usually works on a step-down unit is moved to work a 12 hours shift in the critical care unit. Which client is best for the charge nurse to assign to this nurse? A. A client admitted for a narcotic overdose who is ventilated with respiratory alkalosis B. A ventilated client admitted today with respiratory failure and respiratory acidosis C. A ventilator dependent client with chronic obstructive pulmonary disease (COPD) D. A client who has a new onset diabetic ketoacidosis (DKA) and is on insulin drip 97. A toddler 3 years old with laryngotracheobronchitis is experiencing difficulty breathing and his mother is at bed side. What is important for the nurse to implement? A. Allow the mother to stay with the child because separation of anxiety is strefful situation for the child B. Allow the mother to stay with the child because the presence mother help the child to lower the child anxiety C. Allow the mother to stay so staff member can make another task 98. What is earliest sign of intracranial pressure? A. Loss of LOC B. Tremors C. Decerebrate posturing D. Decorticate posturing 99. A young woman is preparing to leave for a 7 day bout trip. She requests a prescription for motion sickness, so the health care provider prescribed meclizine (Antivert) which instruction should the nurse include in this client teaching? A. Suck on hard candy for a dry mouth while taking these drug B. Avoid eating shellfish for 24 h after taking these drug C. Sit up right for at least 30 min after taking these drug D. Do not dink caffeinated beverage while taking these drug 100. A client who recently received a prescription for Ramelteon (rozerem) to treat sleep deprivant reports experiencing several side effects since taking the drug. Which side effects should the nurse report to the healthcare provider? A. Somnambulism B. A charge in the sleep wake cycle C. Mild sedation D. Dizziness reported after initial dose 101. While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? A. Potassium B. Calcium C. Protein D. Hemoglobin 102. A client in the emergency center demonstrates rapid speech, flight of ideas and reports sleeping only three hours during the past 48 hour. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? A. clanzapine (zyprexa) B. divalproex(depakote) C. lorazepan ( ativan) D. fluoxetine (prozac) 103. A client who had a right hip replacement 3 days ago is pale has diminished breath sounds over the left lower lung fields, temp 100.2 ̊F and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for a rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should the nurse give to the healthcare provider? A. Confer with family about home care plans B. Arrange physical therapy for strengthening C. Obtain specimens for culture analysis D. Reassess readiness for SNF transfer 104. A client who had an open cholecystectomy two weeks ago come to the Emergency Department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? A. Auscultate all quadrants of the abdomen B. Perform a digital rectal exam C. Palpate the liver and spleen D. Obtain a hemoccult of the client’s stool 105. An alert, oriented male client is refusing a life-saving surgery because he does not want to live with a colostomy the rest of his life. Hi wife adamantly disagrees and tells her husband that their religious beliefs do not allow him to make such a decision. What explanation should the nurse provide the wife? A. The client’s refusal of treatment constitutes legalized suicide and the family should help him to understand the choice B. The client’s mental competency should be assessed before accepting his decision to ignore medical recommendations C. The chaplain is probably the best person to help the client to understand the religious consequences of his decision D. A competent adult has the right to refuse any treatment for any reason, whether or not it is based on religious beliefs 106. A female client is brought to the community mental health center with complains of headaches, insomnia, and a poor appetite. Her son was killed by a drunk driver 2 years ago and she tells the nurse, “If only has made him stay home that night.” The client is exhibiting symptoms of which condition? A. Denial of the loss B. Displaced anger C. Poor ego strength D. Delayed grief reaction 107. The husband of and older woman, diagnosed with pernicious anemia, calls the client to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobatamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer’s disease. What action should the nurse take? A. Encourage the husband to bring the client to the clinic for a complete blood count B. Explain that memory loss and confusion are common with Vitamin B12 deficiency C. Determine if the client is taking iron and folic acid supplements D. Ask if the client is experiencing any change in bowel habits 108. A male client who weighs 325 pounds (148 kg) is admitted because of ureteral colic and is now complaining of sharp pain radiating toward his genitalia. His has hematuria and is hypertensive. Which intervention is most important for the nurse to include in the client’s plan of care? A. Manage pain B. Monitor hematuria C. Document blood pressures D. Encourage low caloric diet 109. The staff nurse is assigned the care of four clients on the day shift. After receiving report, in what order should the nurse assess the assigned clients? (Arrange the nursing actions with the highest priority first on top, and lowest priority last, on bottom.) A. An adult with leg infection who is scheduled to receive insulin before breakfast B. And older adult who had knee replacement and is scheduled for transfer to rehabilitation later today C. An adult receiving patient controlled analgesia (PCA) whose spinal tumor causes pain and paresthesia D. An adolescent whose left foot was amputated last night after a tree fell on it A C B 110. A combination multidrug cocktail is being considered for an asymptomatic HIV infected client with CD4 cell count of 500. What nursing assessment in determining whether therapy should be initiated? A. State various side effects of retroviral agents B. Willing to comply with complex drug schedules C. Quantities for a prescription program D. Maintained an adequate social support system 111. The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? A. Elevate the presenting part off the cord B. Place the client to a knee chest position C. Administer oxygen by face mask at 6L/min D. Transport the client for a cesarean delivery 112. An unlicensed assistive personnel (UPA) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UPAs behavior? (Place the actions in order from first on top to last on bottom) A. Plan for scheduled break times B. Discuss the issue privately with the UPA C. Evaluate the UPA for signs of improvement D. Note date and time of the behavior , B, A, C 113. Picture Question: BP cuff to client’s thigh where should you place the stethoscope? The picture will be 2 bodies. One will be facing towards you the other facing away. ANS: facing away looking at his ass end and point curser on left leg behind the knee. 114. Discharge instructions to a client with kidney or liver transplant and is on immunosuppressant’s…what does the nurse teach to patient? 115. The electrocardiogram of a patient show a flat T wave and PVCs. What should the nurse know this represent? 116. A client with cirrhosis becomes confused I think ammonia levels are up… 117. An acute care hospital has a disaster something about an outage and a generator. The UAP asks the charge nurse what she can do to help… 118. A patient is in the acute phase of burn to prevent auto contamination when changing dressings how should you do it? 119. A patient with bilateral hearing aids it is ringing loud? 120. A female comes into the clinic stating she is a victim of date rape 2 days ago. What should the nurse ask first? 121. A staff nurse reports to the charge nurse that they suspect thermometers are not working what should the charge nurse do 122. Old client that is being discharge to home with new medication. What teaching should nurse provide the client? 123. Video the nurse hanging a bag of normal saline. The video stop and ask what was missing 124. Question based on these findings and you will have to look in the chart, oxytocin, stadol, and LR what action would the nurse implement? They will give you chart of patient to look through it 125. A combative old man, what nursing diagnosis is best… this is a patient with ad who threatens to be abusive with personnel. 126. Patient receiving warfarin, INR 2.0. What to do? 127. Discharge teaching to a patient with heart failure what parameter is most important for weight monitoring… 128. A patient is in anticoagulant treatment and the nurse is performing some procedure (should be invasive). What intervention should the nurse performed? 129. What is the most important teaching when instructing a parents of a child with sickle cell disease? 130. A patient is bringing to the emergency department with a serum magnesium level of 1.1. Which medication the nurse suspect is going to be administered? 131. Postmortem care what to delegate to UAP before the family see the client? (Select all that apply) Put a clean gown Postmortem care, delegation: assign to UAP. 1. No visitors sing in pt. room door 2. Place pt. in supine flat position 3. Place pillow on head 4. Close patient eyes 5. Remove jewelry and or position that pt. has on 6. Put on clean gloves 7. Place towel under pt. chin for mouth to be closed 8. Remove IV and other tubes 9. Remove all soiled dressing, ex. Ostomy bags, etc. 10. Wash soiled areas of the body 11. Place disposable oats to the perineal area to absorbed any urine, etc., due to sphincter relaxation 12. Remove and discard gloves 13. Put clean gown on the pt. 14. Attach a second ID band to the pt. 15. Replace linens 16. Take off and take care of dentures and glasses 17. At end wash hands 132. A male client on palliative care can’t swallow and is dehydrated but doesn’t want an IV. What should the nurse do? 133. Patient with a past allergy to penicillin 134. Cleft palate lip feeding 135. The nurse is calculating the one-minute Apgar score for a newborn male infant, and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant? A. 7 B. 8 C. 9 D. 10 136. The physician prescribes estrogen 0.625 MG daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication? 137. The nurse is planning care for a newborn with bladder exstrophy. During the preoperative period, which intervention should the nurse implement? 138. A 70-year old man with a history of hypertension and closed angle glaucoma visits the clinic for a routine checkup. Which of the following medications? If ordered by the physician? 139. The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of intestinal obstruction? 140. The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asked the nurse what age is best to start toilet training a child. Which of the following is the best response by the nurse? 141. A child is injured at a sporting event and a nurse attending the event evaluates the child. What is the most accurate method to determine if a fracture has occurred? 142. Which of the following nursing actions has the highest priority and caring for the client with hypoparathyroidism? 143. The nurse knows that which psychosocial stage should be a priority to consider while planning care for the 20-year-old client? 144. After positioning a client on the side to administer a rectal suppository, the nurse observes that the client has been incontinent of a large amount of liquid stool, which has soaked through a gauze pad covering a stage three-pressure ulcer. What action should the nurse take first? 145. A client has an AV graft for hemodialysis in the left forearm and an infiltrated IV in the right arm. After discontinuing the IV, where should the next IV be started? 146. The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? 147. The nurse is preparing to administer a liter of IV solution to a toddler with gastroenteritis who is dehydrated. Which action should the nurse implement to prevent fluid overload? 148. Which of the following types of foods should the nurse encourage in the diet of a client with a hypoparathyroidism? 149. A school-aged child with otitis media receives a prescription for azithromycin (Zithromax) 300 mg once, then 150 mg daily for 4 days. The medication is available in a solution containing 200 mg/5 ml. How many ml should the nurse administer on the first day of the treatment regimen? 150. What area of the body should be palpated to assess for the presence of Heberden’s nodes in the client with osteoarthritis? 151. To determine the effectiveness of a dose of ondansetron (Zofran) administered to a client also receiving chemotherapy, what client data should the nurse obtain? A. White blood cell count B. Current level of pain C. Hemoglobin and hematocrit D. Rating on a nauseas scale 152. The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction following administration of ampicillin (omnipen-N). What instruction is essential for the nurse to provide this client prior discharge? A. Teach the client how to self-administer epinephrine in cases a reaction occur again B. Instruct the client to wear a medic-alert bracelet so penicillin will not be given again C. Tell the client to make medication with food to decrease will not be given again D. Inform the client that it is essential to take all of the prescribed ampicillin 153. To reduce staff the nurse role ambiguity, which strategy should the nurse- manager implement? A. Review the staff nurse job description to ensure that it is clear, accurate, and current B. Assign each staff nurse a turn as the unit charge nurse on a regular, rotating basis C. Analyze the amount of overtime needed by the nursing staff to complete assignments D. Confirm that all of the staff nurses are being assigned to equal numbers of clients 154. The nurse is preparing to administer a formula feeding by nasogastric tube to a 2-month-old. A. Use the syringe plunger to push formula at a rate of 5ml/min B. Microwave refrigerated formula to room temperature C. Measure and discard residual gastric contents before feeding D. Hold the infant with head and shoulders slightly elevated 155. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? A. Bilateral sclera edema B. Pitting peripheral edema C. Jaundice skin tone D. Muffled heart sounds 156. Client was admitted to the cardiac observation unit 2 hour ago complaining of chest pain .On admission the client EKG showed bradycardia ,ST depression ,but no ventricular ectopic .The client reports a sharp pain ,telling the nurse ,I feel like an elephant just stepped on my chest .The EKG now shows Q waves and ST elevations in the anterior leads .What intervention should the nurse perform ? A Administer prescribed morphine sulfate IV and provide oxygen at 2L per minute per nasal cannula B Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels C Notify the HCP of the clients increased chest pain and call for defibrillator crash cart D Increased the peripheral IV rate to 175 ml/hr. to prevent hypotension and shock 157. A female client come to the clinic complaining of fatigue and inability to sleep because he is full time caretaker for a 22 year old son who was paralyzed for a motor vehicle collision. She add that her husband left her because he says that he cannot take her behavior any more since all she does is caring their son .What intervention should the nurse implement? ANS: Acknowledge the client stress and suggest that she consider respite care 158. Esta es la de la pleural working properly? A Reduce pleural lining inflammation. B Relieve pulmonary artery obstruction C Remove air from the thoracic cavity. D Restore airflow through the bronchi. 159. An infant with respiratory rate of 92 b/m and heart rate of 156 b/m .Which drug is the transport team most likely to administer to this infant .? A Instill Beractant (Survanta) 100 mg/kg in the endotracheal tube B Give Ampicillin (Omnipen) 25 mg /kg slow IV C Deliver 1:10, 0000 Epinephrine 0.1 ml/kg per endotracheal tube D Administer digoxin (Lanoxin) 20 mcg /kg IV. 160. The nurse plans to administer 1 teaspoon of liquid medication to a toddler. What is the most accurately way to administer the medication? A Measure the medication in an oral syringe B Use a medicine cup to measure the dose C Give medication using a medication dropper D Administer the medication from teaspoon 161. The nurse identifies which recent event as placing a client for cardiogenic shock? A MI in the right ventricle. B Gunshot wounds in the chest and abdomen. C Multiple bee stings around the head and neck. D Traumatic amputation of the leg at the groin. 162. The nurse is obtaining a blood sample via venipuncture from a preschool age child .Which intervention should the nurse do? A Apply a large colored bandage aid to the puncture site B Explain in very simple terms why the blood is needed C Place the labeled specimen in a paper bag D Encourage the child to talk about this experience 163. The nurse in the outpatient unit is caring for a client who had a right femoral cardiac catherization two hours ago .What assessment findings requires immediate intervention? A The client wants assistance walking to the bathroom B Clients pulse oximeter is 98% C The client right feed is warn to touch D The client B/P is 110/70 and pulse 90 164. A new mother tells the nurse that she does not want her newborn to receive any immunization. It is the hospital policy to routinely administer immunization to all newborns. What intervention should the nurse implement? A Document that the mother has refused the immunization. B Tell the mother to sign out of the hospital AMA if wishing to refuse the immunization C Administer the immunization after first explaining the hospital policy to the mother D Report the immunization status of the infant to the office of child protective services 165. The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate by the nurse? A Sharp pain related to a crushed femur B Burning pain due to mortons neuroma C Stinging pain related to plantar fascitis D Paresthesia of fingers due to carpal tunnel syndrome 166. The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client medical history? A Ingestion of shellfish or fish oil capsules daily B Frequent laxative use for constipation. C Genetically inherited disorders of family members D The length and frequency of the tobacco use 167. A client with a history of upper respiratory symptoms is admitted to the unit with chest tightness, productive cough and difficult breathing. The client ABG is respiratory acidosis. What lab the nurse expect to be high? A pH B Arterial pH C HCO3 D PaCo2 168. A primigravida at 31 weeks of gestation is admitted with a bloody show and contraction every 10 minutes. After administrating betamethasone. Which lab finding should the nurse monitor? A Lecithin sphingomyelin ratio B Arterial blood gas C 24 hr. urine for protein D Hemoglobin level 169. A patient has a living will that said that when he is dying , he wants the physician save his life whenever is possible ,but the family members tell to the nurse that resuscitation is not permitted in their religion so inform to the physician that do not resucited the client. What information provide the nurse to the family member? 170. A client with a wound what diet the nurse teach for healing? A yogurt B Fruit C Green vegetables 171. Which intervention should the nurse include in the plan of care for tetanus....? A Open the window to provide natural light B Encourage coughing and deep breathing. C Minimize the amount of stimuli in the room D Reposition from side to site every hour. 172. A chest x ray reveals that an older adult male fell out of bed has fracture ---right pneumothorax. Two hours ago after the fall, he is anxious and short of breath. The nurse determines that breath sounds on his right are absent, and his trachea is deviated to left. After´paging the rapid response team, which intervention is most important for the nurse to implement? A Set –up chest drainage system. B Obtain portable chest x-ray. C Place the client for comfort. D Place resuscitation cart at bed side 173. The nurse notes that an older adult client has a moist cough that increase in severity during and after meals. Based on this findings, what action should the nurse take? A Encourage client to deep breathing exercises daily B Offer the client additional clear frequently C Collect a sputum specimen immediately D Request a consultation to confirm dysphagia 174. The nurse who is working on surgical unit receives change –of –shift report on a group of clients for the upcoming shift .The client with which description requires the most immediate attention by the nurse? A Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson- Pratt drain B Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. C Abdominal –resection 2 days ago with no drainage on dressing who has fever and chills. D Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container. 175. Suicide precaution are initiated for a client admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarette in the clients room .which intervention is most important for the nurse to implement? A Remove cigarettes from the client room B Screen future visitors for contraband C Assign a sitter for constant observation D Document suicide monitoring frequently 176. The nurse is arranging home care for an older who has a new colostomy following a bowel resection three days ago. The client plans to live with a family member. Which action should the nurse? (Select all that Apply) A Assess the client for self-care abilities. B Provide pain medication instruction C Request home safety inspection D Call home care agency to set up oxygen. E Teach care of ostomy to care provider , B, C 177. The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree .Which finding warrants immediate intervention by the nurse? A Clear fluid leaking from the nose. B Periorbital ecchymosis of right eye. C Complaint of severe headache D Sluggish pupillary response to light. 178. A client has an intravenous fluid infusing in the right forearm. To determine a pulse rate most accurately, which action should the nurse implement? A Palpate at the radial pulse with the pads of two or three fingers. B Turn off the intravenous fluid that is infusing while counting the pulse. C Auscultate directly below the IV site with dropper stethoscope. D Elevate the client upper extremity before counting the pulse. 179. The nurse is preparing a discharge teaching plan for a client who has liver transplant... Which instruction is most important to include in this plan? A Avoid crowds for first two months after surgery. B Notified the healthcare provider if edema occurs. C Limit intake of fatty foods for one months after surgery. D Increase activity and exercise gradually, as tolerated. 180. A male client who has a herniated intervertebral lumbar disc is experiencing severe pain in his right leg .What pathophysiological process explains this client’s pain? A Measure on nerve root moving /rooting the spinal cord. B Inflammation of the surrounding lumbar tissues. C Stresses fractures of the lumbar vertebral bodies. D Nerve signal interruption from involved jounce/joint. 181. In caring for the body of a client who just died, which tasks can be delegated to UAP? (Select all that Apply) A Confirm the client wishes for tissue donation B Follow cultural beliefs in preparing the body C Attach identifying name tags to the body D Place personal religious artifacts on the body E Observed consent for autopsy signature by family , C, D 182. The nursing staff on a medical unit includes register nurse (RN), practical nurse (LPN), and UAP. Which task should the charge nurse assign to the RN? A Supervise a newly hired graduate nurse during admission assessment B Transport a client who is receiving IV fluids to the radiology unit C Administer PRN oral analgesic to a client with a history of chronic pain D Complete ongoing focused assessment on a client with wrist restraints 183. The nurse administer an isotonic intravenous solution to a client in septic shock .Which is most important for the nurse to monitor to determine that treatment is effective? A White blood cell B Blood pressure C Body temperature D Hemoglobin and hematocrit 184. The nurse is interacting with a female client who is diagnostic with postpartum depression. Which findings should the nurse document as an objective signs of depression? (Select all that Apply) A Reports feelings of sad B Has a disheveled appearance C Express suicidal thought D Interacts with felt effect E Avoid eyes contact , D, E 185. The nurse fined a client at 33 weeks of gestation in cardiac arrest. What method of CPR the nurse should perform? 186. An adult male report that the last time he received penicillin he developed a severe maculapapular rash all over his chest. What information should the nurse provide to this client? 187. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that she will be done before administering the medication? A Determine what side of the body is weak. B Auscultate breath sounds C Obtain and record client vital sign D Ask the client about soft food preferences 188. When preparing a client for discharge from the hospital following a cystectomy and urine diversion to treat bladder cancer. Which instruction is most important for the nurse to include in the discharge teaching plan? A Frequent empty the bladder to avoid distention B Follow instruction for self –care toileting C Report any cloudy urine output D Seek counselling for body image concerns. 189. The nurse is teaching a client about prevention of Lyme disease and recommended wearing a long sleeves and pants when hiking outdoors. How should the nurse explain the underlying disease pathology resulting in the need for these precaution? 190. The mother is feeding a client who was admitted this morning with syncope and generalized weakness .The client has a history of aspiration and begins coughing while attempting to drink trough a straw. Which action should the nurse implement? A Elevate the head of bed for 30 minutes after meal B Perform oral care before meals C Allow small amount of liquid with meals D Provide nectar thickened liquids 191. During breath sounds auscultation of a client who is being mechanically ventilated, the nurse hears coarse sounds over the upper anterior chest with clear sounds over the other lung fields. What intervention should the nurse implement at that time? A Continue to assess the client frequently B Begin manual resuscitation who ambu bag C Notify respiratory therapy immediately D Suction the client endotracheal tube 192. Patient with cast in both hands and cannot be put on prone position to check blood pressure? 193. A 5 years old girl had three urinary tract infection in the past 6 months. What information is most important for the nurse to obtain? A If she wear tight – fitting, nylons panties B Amount of fluid intake in the last 24 hrs. C Method used to wipe after urination and defecation D How many times the child urinates during the day. 194. A man with a chest tube. Where to get the draining from? 195. Picture: port needle sizes for chemotherapy 196. Video: Critique what’s wrong while medication giving 197. Calculation: 1ml = 30 oz 1cup = 8oz ANS: 1680 198. Braden Scale risk for skin impairment 199. Syringes to give a med in an IM on deltoid muscle 200. Male patient postoperative after TURP with urinary drainage. Nurse sees a big red bright blood clot. What should nurse do? 201. Child to be given high protein 202. Pt with a paraplegia, paresthesia or both legs bad 203. Huntington disease 204. A newly diagnosed patient with systemic lupus. What information would be accurate to tell this client regarding this disease? 205. Pt with cellulitis where to put IV? 206. Otic gout how you put the child? 207. Patient with metabolic syndrome is going to start exercising what is most important to tell him… 208. Patient c/o pain distal to insertion site, what action should the nurse implements? 209. Which patient at risk for osteoporosis? 210. MATH medication one something about prescribed dose is like 60mg; available is 750mcg/per 2.4ml 211. 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