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Question 1

During a coffee break, the nurse notices two coworkers arguing about how to handle a difficult client. Their voices are raised and body postures are tense and defensive. Which would be the most appropriate approach for the nurse to use to address this conflict between staff members?

1. Let it pass because the coworkers probably did not intend to be critical
2. Speak privately to the coworkers, telling them about personal reactions to this public encounter
3. Confront and reprimand the coworkers publicly
4. Inform each coworker privately that it would be most helpful not to display this behavior again.

Answer 1

2 personalizes the discussion between the nurse and the coworkers so it is the best to diffuse the situation.

2. Speak privately to the coworkers, telling them about personal reactions to this public encounter

Question 2

The school nurse is assessing a muscular 17 yr old female who is coming to the high school health service for complains of edema, voice changes, and hair loss. The nurse’s primary analysis based on the subjective and objective data is that the student:

1. Is going through a stage of puberty
2. May be using steroids
3. May be abusing barbiturates
4. Is using marijuana regularly

Answer 2

2. May be using steroids

Question 3

A 4 yr old child has been exposed to chickenpox. After the nurse has provided information about chickenpox, the nurse asks the mother to repeat the information. Which statement by the mother indicates a need for additional information?

1. During the prodromal period, my child will have pox all over his body
2. Chickenpox is a viral infection that can be spread to other children
3. I should monitor my child for Reye syndrome, which is a complication of chickenpox
4. My child should not visit my pregnant sister at this time

Answer 3

1. During the prodromal period, my child will have pox all over his body

Prodromal period refers to the period of time between the initial symptoms and the presence of the full-blown disease.

Question 4

The school health nurse is interested in promoting safety in the high school population. In planning safety education for this age group and their parents, the nurse would recognize that which of the following is a developmental risk factor for adolescents?

1. Substance abuse as a lifestyle means of dealing with stress
2. Feelings of immortality related to perception of being invulnerable to risks that affect others
3. Sports-related injuries that are usually related to not obeying rules and/or intense competition
4. Polypharmacy, which results in mixing of multiple medications

Answer 4

2. Feelings of immortality related to perception of being invulnerable to risks that affect others

Question 5

When giving directions to a 24-year-old female with possible appendicitis who is about to undergo a pelvic sonogram, which statement should the nurse make to the client?

1. “Drink nothing for several hours prior to the exam.”
2. “You will be given an enema to cleanse the bowel.”
3. “Drink plenty of liquids so you will have a full bladder.”
4. Do not take any medications prior to the exam.”

Answer 5

3. “Drink plenty of liquids so you will have a full bladder.”

Question 6

The nurse is conducting an initial interview with a 10 yr old who has been brought to the mental health clinic by his parents. The nurse can establish rapport and credibility with the child by asking the child about his:

1. Behavioral symptoms
2. Interests and hobbies
3. relationships with friends and family members
4. Medical problems in the past

Answer 6

2. Interests and hobbies

Question 7

The nurse is providing medication instructions to a client. The nurse informs the client that persistent gynecomastia can result from taking which of the following newly prescribed diuretics?

1. Hydrochlorothiazide (HCTZ)
2. Furosemide (Lasix)
3. Spironolactone (Aldactone)
4. Indapamide (Lozol)

Answer 7

3. Spironolactone (Aldactone)

Spironolactone is a potassium-sparing diuretic used to treat hypertension. Gynecomastia is one of its adverse reactions. Adverse reactions usually disappear after the drug is discontinued; however, gynecomastia may persist after discontinuing spironolactone.

Question 8

As the nursing unit representative member serving on the hospital quality management committee, the nurse has been asked to evaluate the quality of nursing services on the unit. What would be an appropriate quality improvement activity for the nurse to ask team members to participate in?

1. Tracking the number of accidents or incidents on the unit
2. Documenting nursing time and activities spent on direct client care
3. Administering a client and family satisfaction survey
4. Assessing clients and report acuity to shift managers daily

Answer 8

3. Administering a client and family satisfaction survey

Question 9

When a female client preparing for surgery suddenly bursts into tears, the preoperative holding unit nurse should take which of the following actions?

1. Pull the curtain closed and leave the area to provide privacy.
2. Be silent as a sign of compassion.
3. Ask the client to share what she is feeling.
4. Continue with the physical preparation of the client.

Answer 9

3. Ask the client to share what she is feeling.

Question 10

After reviewing the client’s health history, the nurse concludes that which of the following is the most significant factor related to the development of bronchogenic carcinoma for this client?

1. Asthma
2. Smokeless tobacco
3. Cigarette smoking
4. Air pollution

Answer 10

3. Cigarette smoking

Question 11

The nurse is setting up the breakfast tray for a client with gastroesophageal reflux disease (GERD) and notices one food that the client should not eat. Which food should the nurse remove from the meal tray?

1. Poached egg
2. Dry toast
3. Coffee with cream
4. Skim milk

Answer 11

3. Coffee with cream

Question 12

The nurse is assessing a 30-year-old client with a prior history of smoking who takes theophylline (Theo-Dur) for chronic obstructive pulmonary disease. Additional diagnoses include liver disease and congestive heart failure. The client is experiencing tremors, dizziness, tachycardia, and nausea. The nurse explains to the client that these symptoms may be the result of:

1. A history of smoking cigarettes.
2. Liver disease.
3. The client’s age.
4. The client’s weight.

Answer 12

2. Liver disease.

Question 13

The nurse has admitted to the surgical unit a client who just underwent open reduction and internal fixation of a severely fractured right radius and ulna. Which nursing care activities would be appropriate for the nurse to delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)? Select all that apply.

1. Measure vital signs every 30 minutes.
2. Report drainage on the cast if it appears.
3. Assess neurovascular status of the fingers of the casted arm hourly.
4. Elevate the casted arm above heart level.
5. Administer the prescribed intramuscular analgesic as ordered.

Answer 13

1. Measure vital signs every 30 minutes.
2. Report drainage on the cast if it appears.
3. Elevate the casted arm above heart level.
4. Administer the prescribed intramuscular analgesic as ordered.

Question 14

Which of the following actions would the nurse institute that is specific to the care of the assigned client who has tuberculosis?

1. Wearing a particulate respirator mask when taking vital signs.
2. Instructing the client to cover the mouth with the sheet from the stretcher when transported to other hospital departments.
3. Wearing sterile gloves when collecting a sputum specimen.
4. Keeping the client’s door open to promote ventilation.

Answer 14

1. Wearing a particulate respirator mask when taking vital signs.

Question 15

A client has a potassium level of 6.8 mEq/L. Which sign or symptom would the nurse expect to find when assessing this client?

1. Peaking of T wave on the telemetry monitor
2. The absence of bowel sounds, such as in an ileus
3. Muscle cramping of the lower extremities
4. Somnolence with early changes

Answer 15

1. Peaking of T wave on the telemetry monitor

Question 16

The nurse is preparing to take a client to the electroconvulsive therapy (ECT) treatment suite. The nurse must ensure that which of the following pretreatment processes has been completed?

1. The client’s husband has signed the consent form.
2. The client is wearing snug-fitting clothing.
3. The client is NPO.
4. The client has been given ample liquids before the procedure.

Answer 16

3. The client is NPO.

Question 17

To minimize the pain related to intramuscular injection of 2 mL of penicillin G benzathine (Bicillin LA) in an adult client, the nurse would take which of the following actions?

1. Apply cold compress to site after injection.
2. Divide the dose and inject half into each deltoid.
3. Limit prolonging the time taken to administer the drug by not aspirating.
4. Administer the drug deep IM slowly into a large muscle such as the gluteus.

Answer 17

4. Administer the drug deep IM slowly into a large muscle such as the gluteus.

Administering very thick preparations such as penicillin G with benzathine (Bicillin LA) can be painful. To lessen the pain, intramuscular injection into a larger gluteal muscle should be administered over 12 to 15 seconds to separate the muscle fibers more gradually.

Question 18

The nurse is assigned to the care of an obese client who has gastroesophageal reflux disease (GERD). Which of the following activities could the nurse appropriately delegate to the unlicensed assistant person (UAP)?

1. Teach the client about the need for weight loss.
2. Explore any concerns about the prescribed regimen for managing GERD.
3. Explain why it is important to eat several small meals per day.
4. Instruct the client to remain upright for at least 2 hours after eating.

Answer 18

4. Instruct the client to remain upright for at least 2 hours after eating.

Question 19

The nurse is admitting a client with thermal burns to both arms and anterior trunk. The client asks for a drink of water. What is the most appropriate response for the nurse to make?

1. “I’m sorry, you cannot drink anything right now; let me moisten your mouth instead.”
2. “I can only give you juice to drink, not water.”
3. “I’ll get you a drink as soon as I’m finished.”
4. “Would you also like me to order you a meal tray?”

Answer 19

1. “I’m sorry, you cannot drink anything right now; let me moisten your mouth instead.”

Question 20

A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to the clinic since 6 months of age. The nurse determines that which of the following is the priority of care for this child?

1. Assess growth and development.
2. Begin dental care.
3. Complete hearing screening.
4. Update vaccinations.

Answer 20

4. Update vaccinations.

Every time a child enters the healthcare system, the immunization status should be checked.

Question 21

A client who has pancreatitis is experiencing pain. After administering an analgesic, the nurse should place the client in which of the following positions to promote comfort?

1. Supine
2. Prone
3. Left lateral decubitus
4. Sitting up and leaning forward

Answer 21

4. Sitting up and leaning forward

The pain in pancreatitis is usually aggravated by lying in a recumbent position, but improved by sitting up and leaning forward or in the fetal position with the knees pulled up to the chest. This position reduces pressure caused by contact of the inflamed pancreas with the posterior abdominal wall.

Question 22

The nurse would be most careful to assess for stomatitis in a client receiving which of the following chemotherapeutic agents?

1. Fluorouracil (5-FU)
2. Cisplatin (Platinol)
3. Bleomycin (Blenoxane)
4. Vincristine (Oncovin)

Answer 22

1. Fluorouracil (5-FU)

Although many chemotherapy agents can cause stomatitis, the antimetabolites are commonly known for causing this side effect. Fluorouracil is the only drug listed in this class. Cisplatin is an alkylating agent; bleomycin is an antitumor antibiotic; and vincristine is a plant (vinca) alkaloid.

Question 23

The nurse will be working with an unlicensed assistive person (UAP) for the work shift. Prior to delegating care to the UAP, the nurse places high priority on which of the following?

1. Determining that the UAP is competent to perform the required task
2. Providing written directions to the UAP
3. Making sure all the necessary supplies are available at the client’s bedside
4. Informing clients that an unlicensed staff member will be assigned to them

Answer 23

1. Determining that the UAP is competent to perform the required task

Question 24

The nurse believes a client has slight one-sided weakness and further tests the client’s muscle strength. The nurse asks the client to hold the arms up with hands supinated, as if holding a tray, and then asks the client to close the eyes. The client’s right hand moves downward slightly and turns. The nurse documents and reports that the client has which of the following findings on assessment?

1. Pronator drift
2. Nystagmus
3. Hyperreflexia
4. Ataxia

Answer 24

1. Pronator drift

Question 25

When a client has arterial blood gases drawn from the radial artery, the nurse should plan to do which of the following?

1. Hold the site for up to 1 minute.
2. Transfer the blood sample to a heparinized test tube.
3. Pack the sample in ice for transporting to the laboratory.
4. Obtain a second specimen after 10 minutes for comparison.

Answer 25

3. Pack the sample in ice for transporting to the laboratory.

Question 26

The nurse knows that a client in the long-term care unit suffers from dysthymia. The most important nursing intervention to include in the nursing care plan is:

1. Provide at least 2 hours of quiet time every morning for the client.
2. Encourage the client to eat in the main dining room with other clients.
3. Include at least three regular meals per day and no snacks.
4. Include at least 2 liters of clear liquids per day in the diet regime.

Answer 26

2. Encourage the client to eat in the main dining room with other clients.

For clients with dysthymia, a major concern is social isolation. Option 1 is contraindicated, as is option 3. If the client has a poor appetite, assigning 2 liters of liquid intake (option 4) is not therapeutic, nor is planning three regular meals per day (option 3).

Question 27

A client who is receiving intravenous heparin by protocol orders has an activated partial thromboplastin time (APTT) level of 140 seconds (control time is 36 seconds). What is the priority action that the nurse should institute?

1. Increase the heparin dose as the APTT level is not therapeutic. Obtain a repeat APTT in 6 hours.
2. Stop the heparin therapy for 6 hours, then restart the therapy at the same unit dose and obtain a repeat APTT in 6 hours.
3. Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol and restart the medication in 1 hour. Obtain a repeat APTT in 2 to 3 hours from the restart of the infusion.
4. Obtain an additional APTT in 1 hour and continue to monitor the client.

Answer 27

3. Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol and restart the medication in 1 hour. Obtain a repeat APTT in 2 to 3 hours from the restart of the infusion.

Question 28

The nurse has admitted to the intermediate care unit a client who sustained a spinal cord injury at T1 in a motor vehicle accident. Which of the following nursing care activities can the nurse delegate to the unlicensed assistive person (UAP) when working with this client? Select all that apply.

1. Measure oxygen saturation level every hour.
2. Listen to breath sounds.
3. Provide mouth care.
4. Teach use of incentive spirometer.
5. Assess for Homan’s sign while bathing client.

Answer 28

1. Measure oxygen saturation level every hour.
2. Provide mouth care.

Question 29

The nurse has been instructed to have a surgical consent form signed by a client who will be undergoing a surgical procedure. What is the most essential information to include in the discussion prior to the client signing the permission?

1. The client’s diagnosis
2. Treatment proposed and the cost
3. The technical aspects of the procedure
4. Right to withdraw consent

Answer 29

4. Right to withdraw consent

Question 30

The pregnant client is 7 centimeters, 100% effaced, and at a +1 station. The fetus is in a face presentation. The nurse concludes that teaching has been effective when the client’s husband states:

1. “Our baby will come out face first.”
2. “Our baby will come out facing one hip.”
3. “Our baby will come out buttocks first.”
4. “Our baby will come out with the back of the head first.”

Answer 30

1. “Our baby will come out face first.”