1. A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?
a. The client wants to talk about the diagnosis wi
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1. A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?
a. The client wants to talk about the diagnosis with nursing staff
b. The client has a decreased energy level c. The client makes funeral arrangements d. The client requests a second opinion
2. A nurse is preparing to collect data on a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply)
a. Allows the nurse to touch him on the arm
b. Plays with toys in the examining room c. Answers questions asked by the nurse d. Makes eye contact with the nurse
e. Sits on his parent’s lap when the nurse enters the room
3. A nurse on a mental health unit is planning care for a group of clients. Which of the following clients should the nurse see first?
a. A client who has bipolar disorder and is displaying flights of ideas
b. A client who has ADHD and has an inability to concentrate
c. A client who has schizophrenia and is having command hallucinations
d. A client who has depressive disorder and is withdrawn
4. A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, “ I can’t seem to do anything right. What should I do?” Which of the following responses should the nurse make?
a. “I’ll take him back to the nursery, so you can get some rest.”
b. “Babies need to cry soon after they are born to develop their lungs.”
c. “Let me show you how to swaddle and cuddle him, then you try.”
d. “If I turn him on his side, maybe he’ll go back to sleep.”
5. A nurse is using a glucometer to measure a client’s capillary blood glucose level, Which of the following actions should the nurse take?
a. Test the first drop of blood that forms after the puncture
b. Wear sterile gloves
c. Keep the finger in a dependent position
d. Select the central tip of the finger
6. A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel?
a. Docusate sodium
b. Ranitidine c. Vitamin D3 d. Naproxen
7. A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. The client’s foot is pale with a weak pedal pulse, and the client reports foot numbness. Which of the following actions should the nurse plan to take first?
a. Administer opioid pain medication
b. Apply an ice pack to the affected extremity
c. Check for pain with passive movement of the affected extremity
d. Elevate the affected extremity with several pillows
8. A nurse in a provider’s office is reinforcing teaching about cigarette smoking with a client. Which of the following adverse effects should the nurse include in the teaching?
a. Decreased hemoglobin b. Somnolence c. Bradycardia
d. Decreased blood pressure
9. A nurse is contributing to the development of an in-service program for mental health nursing staff. The nurse should include that the st
aff can medicate a client against his will, without a court hearing, in which of the following situations?
a. A client who has a serious mental illness
b. A client who is having difficulty making decisions about his treatment
c. A client for whom the benefits of the medication outweigh the risks
d. A client who is attempting to hurt himself or others
10. A nurse is reinforcing teaching with a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching?
a. “Monitor for muscle weakness while taking the medication.”
b. “Rotate injection sites when administering the medication.”
c. “Withhold the medication if your pulse rate is above 100 beats per minute.”
d. “Increase your intake of dietary fiber to increase absorption.”
11. A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client’s medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information?
a. A nurse from another unit after a client commits suicide
b. A social worker who is assigned to an involuntary committed school-age client
c. A client’s partner after the client reports intimate partner abuse
d. A client’s employer who is concerned about safety due to substance use
12. A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider?
a. Hgb 13.2 g/dL
b. Urine protein 3 plus c. Fasting blood glucose 72 mg/dL d. BUN 15 mg/dL
13. A nurse is collecting data from a client who is 4 hr postoperative following a hemicolectomy. Which of the following findings is the nurse’s priority, requiring immediate intervention?
a. Pain rating of 9 on a scale from 0 to 10
b. Blood pressure 160/90 mm Hg
c. Oxygen saturation 89%
d. Abdominal dressing with a moderate amount of bright red drainage
14. A nurse in a provider’s office is collecting data from a client who has a history of hypertension during his annual physical examination. Which of the following findings should the nurse report to the provider immediately?
a. A 2 kg (4.4 lb) weight gain b. Blurred vision c. Potassium 3.6 mEq/L
d. Resumption of cigarette smoking
15. A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first?
a. Place the client on bed rest
b. Obtain the clients ABG levels
c. Prepare the client for a ventilation-perfusion scan
d. Elevate the head of the client’s bed
16. A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate of blood glucose effective management?
a. Urine ketones
b. Glucose tolerance test
c. Glycosylated hemoglobin
d. Fasting blood glucose
17. A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene?
a. Requests a client to assist with distributing lunch trays
b. Tells a client he will lose his phone privileges if he does not take his medication
c. Encourages a client to participate in a recreational therapy group
d. Places mechanical restraints on a client who is hitting another staff member
18. A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client’s room?
a. Oral suction equipment b. Wrist restraints c. Tongue depressor d. Tracheostomy tray
19. A nurse is reinforcing discharge teaching with the faculty of a client who has dependent personality disorder. Which of the following instructions should the nurse indicate in the teaching?
a. Maintain a verbal no-harm contract with the client b. Assume responsibility for making the client’s decisions c. Encourage the client to be assertive
d. Limit the client’s social interactions
20. A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse indicate?
a. “You should avoid crossing your legs for 3 months.”
b. “You should avoid putting a pillow between your legs when in bed.”
c. “You should avoid exercising for the next 6 weeks.”
d. “You should avoid lying on your right side.”
21.
22. A nurse is reinforcing dietary teaching with a client who has hyperemesis gravidarum. Which of the following instructions should the nurse include in the teaching?
a. Drink 240 mL ( 8 oz) of water with each meal
b. Eat a small meal every 2 to 3 hr c. Avoid eating dairy products d. Choose foods that are high in fat
23. A nurse is reinforcing teaching with a client who has GERD and a prescription for ranitidine. Which of the following statements by the client indicates an understanding of the teaching?
a. “I have to remain upright for 1 hour after taking the medication.”
b. “I should take this medication in the morning and at night.”
c. “I should expect my tongue to turn black after I take this medication.”
d. “I have to take this medication on an empty stomach.”
24. A nurse is assisting with the admission of a client who has pulmonary tuberculosis. Which of the following types of isolation precautions should the nurse include?
a. Airborne
b. Droplet
c. Protective d. Contact
25. A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?
a. “Self administer oxygen through your nasal cannula at 6 milliliters per minute during meals.”
b. “Perform pulmonary hygiene 1 hour before meals.”
c. “Drink at least 240 milliliters of water during each meal.”
d. “Lie down for 30 minutes after eating.”
26. A nurse is administering pancreatic enzymes to a client who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?
a. Decreased sodium excretion
b. Improved absorption of vitamins B and C
c. Improved respiratory function
d. Reduced fat in the stools
27. A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?
a. “Why do you feel the staff is the FBI?”
b. “What makes you think the staff is following you?”
c. “The psychiatric staff is not FBI. They are here to help you.”
d. “This must be very frightening for you. Let’s talk more about it.”
28. A nurse is assisting in the care of a client who has a fractured femur and is in Buck’s traction, which of the following actions should the nurse take?
a. Clean the pin insertion sites on a daily basis b. Ensure that the weights are hanging freely c. Apply a 9 kg (20 lb) weight to the traction d. Remove the weights while the client is eating
29. A nurse is reviewing the medication record of a client who requires continuous oxygen saturation monitoring. Which of the following should the nurse identify as a factor that can affect the validity of the readings?
a. Calcium level 8.0 mg/dL
b. Peripheral vascular disease
c. Taking anticoagulant medication
d. IV access on the same extremity
30. A nurse is collecting data from a group of clients. Which of the following clients should the nurse identify as having xanthelasma? Lady with eyes closed with nodule on eyelid
31. A nurse is assisting with the admission of a client who has Vancomycin-resistant enterococcus of the urine. Which of the following types of precautions should the nurse implement for this client?
a. Contact precautions b. Droplet precautions c. Airborne precautions d. Protective precautions
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