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Question 1

A nurse is reviewing the laboratory results for a client who is at 32 gestation. For which of the following results should the nurse notify the provider?

a. Hgb 12 g/dL
b. Platelet count 90,000/mm2
c. Hematocrit 37%
d. Creatinine 0.7 mg/dL

Answer 1

b. Platelet count 90,000/mm2

Question 2

After receiving change-of-shift report, which of the following clients should the nurse collect data from first?

a. A client who has a history of pancreatitis and reports severe abdominal pain
b. A client who has heart failure and reports severe dyspnea
c. A client who is scheduled for abdominal surgery in 1 hrs
d. A postoperative client who has diabetes mellitus and a blood glucose of 280 mg/dK

Answer 2

b. A client who has heart failure and reports severe dyspnea

Question 3

3. A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take?

a. Place the money in an envelope and lock it in the client’s medication drawer
b. Contact security personnel to place the money in the facility safe
c. Hold the money for the client until he returns from surgery
d. Label the money and leave it with the unit secretary.

Answer 3

d. Label the money and leave it with the unit secretary.

Question 4

4. A nurse is preparing to instill an otic suspension into an adult client’ ear. Which of the following methods should the nurse plan to use?
   a. Pull the auricle upward and outward.
   b. Pull the auricle downward and backward.
   c. Pull the auricle upward and backward.
   d. Pull the auricle downward an outward.

Answer 4

c. Pull the auricle upward and backward.

Question 5

5. A nurse is caring for an older adult client who has pneumonia. When reinforcing teaching about the diagnosis age- related changes with the client’s family, which of the following alterations should the nurse include?

a. Increased inflation of the basilar lungs
b. Increased elasticity of the thoracic cage
c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex

Answer 5

b. Increased elasticity of the thoracic cage

Question 6

6. A client is participating in an anger management session explain that his recent behav&ior are related to his job loss. Which of the following mechanism is the client using?
   a. Projection
   b. Rationalism
   c. Repression
   d. Sublimation

Answer 6

d. Sublimation

Question 7

7. A nurse is reinforcing teaching with the client who is about to undergo a thoracentesis. Which if the following statements by the client indicates an understanding of the information?
   a. “I will have general anesthesia during the procedure.”
   b. “I will lie flat for 6 hours before the procedure.”
   c. “I will have the chest x-ray following the procedure.”
   d. “I will breathe deeply through my nose during the procedure.”

Answer 7

c. “I will have the chest x-ray following the procedure.”

Question 8

8. A nurse is reviewing the medical record of a client who is requesting an oral contraceptive. Which of the following findings should the nurse identify as a contraindication to the use of oral contraceptive?
   a. History of renal calculi
   b. Migraines with aura
   c. BMI of 26
   d. History of cholecystectomy

Answer 8

d. History of cholecystectomy

Question 9

9. A nurse is reinforcing discharge teaching about transmission precautions with a client who has Hepatitis C. Which of the following information should the nurse include?
   a. Avoid sharing razors with other family members.
   b. Clean toilet surfaces with bleach after each use
   c. Advice family members to receive a hepatitis c immunization
   d. Do not prepare food for other family member s while infectious.

Answer 9

a. Avoid sharing razors with other family members.

Question 10

10. A nurse is preparing to administer an IM injection to a client. To reduce the risk of a needle stick injury, the nurse should take which of the following actions?
    a. Place a cap hold securely on the used needle a before disposal.
    b. Recap the needle using a one-handed scoop approach before proper disposal.
    c. Dispose of the used needle immediately in a puncture proof sharps container.
    d. Detach and dispose of the use needle
    promptly following injection.

Answer 10

c. Dispose of the used needle immediately in a puncture proof sharps container.

Question 11

11. A nurse is reinforcing teaching with a client who has new prescription for levothyroxine. Which of the following statements indicates understanding of the instructions?
    a. “I should take this medication with meals.” b. This medication will take 2 weeks to reach
    full effectiveness.”
    c. “I need to take this medication for the rest of my life.”
    d. “If I forget to take the medication, I can double the next dose.”

Answer 11

c. “I need to take this medication for the rest of my life.”

Question 12

12. A nurse is caring for a client who is receiving prazosin. The client’s blood pressure is 100/60 mm Hg. which of the following actions should the nurse take?
    a. Administer a reversal agent
    b. Initiate cardiac monitoring
    c. Instruct the client to stand up slowly
    d. Inform the client to report urinary retention

Answer 12

c. Instruct the client to stand up slowly

Question 13

13. A nurse is reinforcing teaching about colostomy care with a client. Which of the following client statements indicate an understanding of how to care for the colostomy?
    a. I will cleanse the stoma site gently with an antiseptic solution.
    b. I will contact my doctor right away if my stoma is red
    c. I will cut the water opening 1 inch bigger than my stoma.
    d. I will empty the colostomy bag when is I one half full.

Answer 13

c. I will cut the water opening 1 inch bigger than my stoma.

Question 14

A nurse is reinforcing teaching with a client who has a permanent pacemaker in place. Which of the following statements by the client indicates an understanding of the teaching?
a. “I should have my doctor replace the battery in the pacemaker in a year.”
b. “I need to record my pulse rate daily.”
c. “I should avoid taking tub baths.”
d. “I will remove my microwave oven from my
house.”

Answer 14

b. “I need to record my pulse rate daily.”

Question 15

15. A nurse is collecting data from a parent of a preschooler at a well-child visit. Which of the following findings is a contraindication to a measles, mumps and rubella (MMR) immunization?
    a. Family history of allergies to penicillin b. Erythema at injection site with previous
    immunization.
    c. Long-term use of immunosuppressants
    d. Current use of antimicrobial therapy.

Answer 15

c. Long-term use of immunosuppressants

Question 16

16. A nurse is reinforcing teaching with a client who has a vitamin C deficiency. Which of the following foods should the nurse include as having the highest vitamin C content?
    a. 1 cup yogurt
    b. 1 cup raw broccoli
    c. 1 large baked potato d. 1 cup boiled carrots

Answer 16

b. 1 cup raw broccoli

Question 17

17. A nurse is checking the home environment of a client for safety hazards. Which of the following items require intervention by the nurse?
    a. The television set is turned to a loud volume
    b. The dining room table has low chairs with no armrests
    c. The bedroom extension cord is placed under a heavy nightstand
    d. The living room contains wall to wall carpeting.

Answer 17

b. The dining room table has low chairs with no armrests

Question 17

18. A nurse is caring for a 17-yr. old client who is admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent?
    a. Have the client’s older sibling give consent if parent is not available.
    b. Delay the procedure if the provider cannot contact the parents.
    c. Witness the signature of the client’s parents when he arrives.
    d. Obtain verbal consent from the client while waiting for the parents to arrive.

Answer 17

a. Have the client’s older sibling give consent if parent is not available.

Question 18

19. A
    about appropriate snacks for a toddler. Which of the following food should the nurse include?
    nurse is reinforcing teaching with a parent
    a. Marshmallows
    b. Graham crackers
    c. Almonds
    d. Carrot sticks

Answer 18

b. Graham crackers

Question 19

20. A nurse is preparing to catheterize a client’s bladder to check for residual urine. The nurse should schedule this procedure at which of the following times?
    a. Right after the client void
    b. When the client feels an urge to void c. While voiding on a bedpan
    d. Before obtaining a bladder scan.

Answer 19

a. Right after the client void

Question 20

21. A nurse is caring for a client who has viral pneumonia. Which of the following actions should the nurse take?
    a. Place the client in a private room
    b. Administer azithromycin
    c. Recommend a pneumococcal immunization.
    d. Limit fluid intake to 1L per day.

Answer 20

a. Place the client in a private room

Question 21

22. A nurse is collecting data from a client who has diabetes mellitus. Which of the following indicates the client might be experiencing diabetic ketoacidosis?
    a. Negative urine ketones
    b. Kussmaul respirations
    c. Hypoglycemia d. Anuria

Answer 21

b. Kussmaul respirations

Question 22

23. A nurse receives a verbal order for a client to receive a stat dose of meperidine 100 mg PO. She administers the medication, charts the administration and then realizes she has administered phenytoin 100 mg. which of the following actions should the nurse take first?
    a. Check client’s vital signs.
    b. Complete an incident report. c. Notify the provider
    d. Administer the meperidine.

Answer 22

a. Check client’s vital signs.

Question 23

24. A nurse is caring for a client and begins to suspect he is experiencing transference. Which of the following client statements should the nurse identify as an indicator of transference?
    a. I’m going to inform my provider that I’m going to quit taking my medication
    b. I don’t want to talk to you about how I’m feeling right now
    c. I feel really close to you because you remind me of my ex-boyfriend.
    d. I feel happy about the progress I have been making in my life.

Answer 23

c. I feel really close to you because you remind me of my ex-boyfriend.

Question 24

26. A nurse is assisting with triaging clients in a mass casualty situation. The nurse should recommend that which of the following clients receive care first?
    a. A client who has a head injury and whose pupils are fixed and dilated.
    b. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10
    c. A client who has 20.3 cm 8 in scalp laceration with inter mitten bleeding.
    d. A client who has diminished breath sounds and paradoxical chest movement.

Answer 24

d. A client who has diminished breath sounds and paradoxical chest movement.

Question 24

25.
administration of nasal drops with a client. Which of the following position should the nurse recommend for installation of the drops?
a. Sims’
b. Prone
c. Supine
d. Orthopneic

Answer 24

c. Supine

Question 25

27. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions should the nurse plan to take?
    a. Place the client in a negative-pressure airflow room.
    b. Wear a mask when working within 3 feet of the client.
    c. Limit visitors to family members.
    d. Don a gown and gloves when providing perineal care.

Answer 25

d. Don a gown and gloves when providing perineal care.

Question 26

28. A nurse in the newborn nursery is collecting data about a newborn’s Moro reflex. Which of the following actions should the nurse take to elicit this reflex?
    a. Turn the newborn’s head quickly to one side while he is sleeping.
    b. Place a finger in the newborn’s palm
    c. Strike the crib surface on which the newborn is lying
    d. Hold the newborn upright with one foot touching the crib surface.

Answer 26

c. Strike the crib surface on which the newborn is lying

Question 27

29. A nurse working in an inpatient mental health facility is assisting with the plan of care for a client who has anorexia nervosa. Which of the following should the nurse recommend including in the plan of care?
    a. encourage the client to gain 3 lb per week
    b. initiate 3500 calories/day diet
    c. maintain continuity of staff members
    d. admister an antiemetic before meals

Answer 27

c. maintain continuity of staff members

Question 28

30. A nurse is caring for a client who has chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem-solving skills?
    a. Preinteraction phase
    b. Working phase
    c. Orientation phase
    d. Termination phase

Answer 28

b. Working phase

Question 29

31. A nurse is collecting data from a client who has Hepatitis A. Which of the following findings should the nurse expect?
    a. Splenomegaly
    b. Abdominal pain
    c. Irregular heart rate d. Tarry stools

Answer 29

b. Abdominal pain

Question 30

32. A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin, for which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?
    a. Constipation
    b. Elevated skin patches
    c. Ringing in the ears
    d. Depression

Answer 30

b. Elevated skin patches

Question 31

33. A nurse is assisting with the client admission of a client who has mononucleosis. Which of the following precaution should the nurse initiate?
    a. Airborne
    b. Droplet
    c. Contact
    d. Protective environment

Answer 31

c. Contact

Question 32

34. A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain, swelling a stiffness. Which of the following client statement indicates understanding of the teaching?
    I will sleep on a soft mattress.

I will apply a heating pad to make my hands feel better.

I will take aspirin on an empty stomach.

I will exercise my joint as much as I can when they are inflamed.

Answer 32

I will apply a heating pad to make my hands feel better.

Question 33

35. A nurse is caring for a toddler who is admitted to the patient unit and is 2 hours postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage?
    a. Dark brown emesis.
    b. Temperature of 37.7 degree Celsius (99.8 F)
    c. Frequent swallowing
    d. Respiratory rate of 24/min

Answer 33

c. Frequent swallowing

Question 34

36. A nurse in a mental health facility is reviewing the laboratory report for four clients. Which of the following results should the nurse report to the provider immediately?
    a. WBC count of 8.000/mm3 for. A client who has schizophrenia and takes clozapine.
    b. BUN levels of 14 mg/dl level for a client who has anorexia nervosa.
    c. Sodium level of 130 mEq/L for a client who has bipolar disorder and takes lithium.
    d. Potassium level of 3.8 mEq/L for a client who has bulimia nervosa.

Answer 34

c. Sodium level of 130 mEq/L for a client who has bipolar disorder and takes lithium.

Question 35

37. A nurse is reinforcing discharge teaching with an older adult client’s family about safety precautions when administering a tap water enema to the clients. Which of the following should the nurse include in the instructions?
    a. Instruct the client to bear down during rectal tube insertion.
    b. Administer a second enema if result is not clear.
    c. Assist the client to a right sim’s position.
    d. Insert the rectal tube in the direction of
    the client’s umbilicus

Answer 35

d. Insert the rectal tube in the direction of
the client’s umbilicus

Question 36

38. A nurse is reinforcing teaching with a client who plans to bottle feed her newborn. Which of the following statements indicate an understand of the instructions?
    a. If my baby doesn’t finish a bottle of formula, I will let him finish it at the next feeding.
    b. I will position my baby on his stomach after feeding.
    c. I will feed my baby six to eight times a day.
    d. If my baby doesn’t seem satisfied after a feeding, I will add rice cereal to his next bottle.

Answer 36

c. I will feed my baby six to eight times a day.

Question 37

39. A nurse is expressing concern about his assignment with the charge nurse. The nurse states that, he has more work to do than anyone else. Which of the following statements by the charge nurse demonstrates the conflict resolution strategy of competing?

“There is no one else available to design that task, so you have to complete them.”

“Let’s just focus for now on the task of administering the clients’ morning medications on time.”

“We will take a look at the assignments together and attempt to modify the workload you are concerned about.

” I’m sure you’re capable of handling the workload because you have been a nurse for a long time.”

Answer 37

“We will take a look at the assignments together and attempt to modify the workload you are concerned about.

Question 38

40. A nurse us reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates to the nurse a need for further teaching?
    a. “I will soak me feet in warm water every night”
    b. “I will visit a podiatrist for nail care”
    c. “I will be sure to wear cotton socks”
    d. “I will apply lanolin to prevent cracked
    heels”

Answer 38

a. “I will soak me feet in warm water every night”

Question 39

41. A nurse is collecting data from a client who has substance use disorder and reports recently taking opioids. Which of the following findings should the nurse identify as a manifestation of opioid intoxication?
    a. Tachycardia
    b. Mental alertness
    c. Hyperreflexia
    d. Pinpoint pupils

Answer 39

d. Pinpoint pupils

Question 40

42. A nurse is collecting data from a client who is receiving a continuous IV infusion of 0.9% sodium chloride. The nurse discovers the IV infusion pump was set incorrectly and the client received 200mL more than the prescribed. Data collection reveals that the client is stable. The nurse recognizes that this incident is not considered malpractice for which of the following reasons?
    a. The client was not harmed as a result of the incident
    b. The nurse did not intentionally make this error
    c. The nurse completed an incident report immediately
    d. The charge nurse set up the infusion pump.

Answer 40

a. The client was not harmed as a result of the incident

Question 41

43. A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible message from the central intelligence agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?
    a. Depersonalization
    b. Hallucination
    c. Illusion
    d. Derealization

Answer 41

b. Hallucination

Question 42

44. A nurse is caring for four clients. Which of the following client statements should the nurse attend to first?
    a. “My heartburn pain is going into my jaw now.”
    b. “I almost fell on my way to the bathroom.”
    c. “I now have pain in both legs.”
    d. “My headache pain is now a 7.”

Answer 42

a. “My heartburn pain is going into my jaw now.”

Question 43

45. A nurse in a mental health unit asks a client who has schizophrenia, “How are you?” Which of the following responses should the nurse identify as the speech alteration of echolalia?
    a. “I am levitated.”
    b. Super, trooper, and duper.”
    c. “How are you?”
    d. “Pink spots in Africa.”

Answer 43

c. “How are you?”

Question 44

46. A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellites. Which of the following actions should the nurse take first?
    a. Inject 20 units of air into the vial of NPH insulin
    b. Inject 5 units of air into the vial of regular insulin
    c. Withdraw 20 units of NPH insulin from the vial
    d. Withdraw 5 units of regular insulin from the vial.

Answer 44

a. Inject 20 units of air into the vial of NPH insulin

Question 45

47. A nurse is preparing to administer cefaclor to a preschooler who weighs 20 kg. The child is to receive cefaclor 30mg/kg/day to divide equally every 8 hours available is cefaclor 125mg/5ml. How many mL should the nurse administer for one dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

Answer 45

8 ML

Question 46

48. A nurse is caring for a client who has heart failure and reports difficulty limiting sodium in his diet. Which of the following recommendations should the nurse provide?

Eat more prepared frozen dinners to minimize cooking with salt
Add salt when preparing the meal instead of the table
Use imitation crab and lobster product for salad at home
Replace bottled salad dressing with homemade vinegar and oil dressing

Answer 46

Replace bottled salad dressing with homemade vinegar and oil dressing

Question 47

49. A client’s daughter calls the nurse requesting information about her mother’s condition. The client’s chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse?
    a. “Your mother has slept well, and her condition has not changed.”
    b. “You should talk with the doctor about your mother’s condition.”
    c. “You will need to contact your mother directly about her condition.”
    d. “You need to come to the hospital to talk with someone about your mother’s condition

Answer 47

b. “You should talk with the doctor about your mother’s condition.”

Question 48

50. A nurse is caring for a client in a provider office. The client asks about the purpose of a living will. Which of the following in the appropriate response by the nurse?

a. It expresses your wishes regarding health care when you can no longer communicate.
b. It appoints a person to server as your durable power to attorney for health care.
c. It specifies your choices regarding after death arrangements.
d. It defines the criteria for distribution of your assets.

Answer 48

a. It expresses your wishes regarding health care when you can no longer communicate.

Question 49

51. A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have treatment. Which of the following is an appropriate response by the nurse?
    a. “You have the right to refuse the recommended treatment plan.”
    b. “I will have to tell your provider right away that you are considering this.”
    c. “You have to consider the medical consequences of not treating this cancer.”
    d. “In cases like yours it is best to talk with your clergyperson before deciding this.”

Answer 49

a. “You have the right to refuse the recommended treatment plan.”

Question 50

53. A nurse is caring for a client who in 3 days postoperative following abdominal surgery and has a Penrose drain. Which of the following actions should the nurse take?
    a. Apply a barrier cream to the wound
    b. Reposition the sterile safety pin when the surgeon advances the drains
    c. Trim the external portion of the drains to 10 cm (4 in)
    d. Leave the drain insertion site open to the air

Answer 50

b. Reposition the sterile safety pin when the surgeon advances the drains

Question 51

54. A nurse is reinforcing teaching with a client who is about to undergo an upper gastrointestinal series with fluoroscopy. Which of the following information should the nurse provide?
    a. “You will receive an injection of contrast dye during the test.”
    b. “Consume a clear liquid breakfast on the day of the procedure.”
    c. “Someone should drive you home after the procedure.”
    d. “You will have to drink a contrast medium before the test.”

Answer 51

d. “You will have to drink a contrast medium before the test.”

Question 52

55. A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?
    a. Hypernatremia
    b. Hypercalcemia
    c. Hypermagnesemia
    d. Hyperkalemia

Answer 52

d. Hyperkalemia

Question 53

56. A nurse is admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?
    a. Place the client in a room that is ventilated to the outside
    b. Wear a gown when delivering the client’s food tray
    c. Prohibit visitors while the client’s infection is active
    d. Administer a tuberculin skin test prior to discharge

Answer 53

a. Place the client in a room that is ventilated to the outside

Question 54

57. A nurse is assisting with the admission of the older adult client, which of the following subjective finding suggest findings suggests that the client may have cataracts?
    a. Sudden dimmed vision.
    b. Cloudy vision.
    c. Intermittent flashes of light.
    d. Pain in the eyes.

Answer 54

b. Cloudy vision.

Question 55

58. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which of the following situations requires completion of an incident report?

a. A client’s MAR indicates 0800 dose of morphine was withheld because the client refused to take the medication.
b. A client’s MAR indicates the 0800 dose of furosemide 20 mg was administered at 0830.
c. A nurse collects data from a client who reports severe pain and finds a dose of hydromorphone in the client’s bed.
d. A nurse finds a secondary infusion bag of an antibiotic that infused 1 hr ago that is still hanging at the client’s bedside

Answer 55

c. A nurse collects data from a client who reports severe pain and finds a dose of hydromorphone in the client’s bed.

Question 55

61. A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty and has deep- vein thrombosis. Which of the following findings should the nurse expect in the affected extremity?
    a. Absent dorsal pedal pain
    b. Shiny, hairless skin
    c. Irregular, bulging veins
    d. Dull, aching pain

Answer 55

d. Dull, aching pain

Question 55

59. A nurse in a long-term care facility has received change-of-shift report about four clients. Which of the following clients should the nurse attend to first?
    a. A client who has heart failure and is incontinent of urine
    b. A client which COPD and dementia and was agitated during the night shift
    c. A client who has a hip arthroplasty 10 days ago, and report pain with ambulation
    d. A client who has a cerebrovascular accident 6 months ago and reports constipation

Answer 55

b. A client which COPD and dementia and was agitated during the night shift

Question 55

62. A nurse is caring for a client who has a new colostomy. He voices a reluctance about resuming sexual relations. Which of the following is an appropriate response by the nurse?
    a. “Most people in your situation have similar feeling.”
    b. “I think you should join a support group”
    c. “You should discuss this with your partner”
    d. “I’m available if you’d like to talk about
    your concerns”

Answer 55

d. “I’m available if you’d like to talk about
your concerns”

Question 56

63. A nurse is reinforcing teaching with a client who is scheduled for a monogram. Which of the following instruction should the nurse include in the coaching?
    a. Refrain from using deodorant in the morning of the test.
    b. Shower with an antimicrobial solution before the test.
    c. Avoid takin aspirin for 1 week prior to the test.
    d. Do not eat or drink midnight the night before the test.

Answer 56

a. Refrain from using deodorant in the morning of the test.

Question 57

64. A nurse is planning to administer an ophthalmic medication to a client. Which of the following action will minimize systemic absorption of the medication?

a. Apply light pressure to the inner canthus just after instilling the eye drops.
b. Wipe the eye from the inner to the outer canthus with a sterile saline-moistened cotton ball
c. Administer the medication drops directly into the lower conjunctival sacs of each eye
d. Wait 5 min after instillation before instilling the drops in the other eye.

Answer 57

a. Apply light pressure to the inner canthus just after instilling the eye drops.

Question 58

65. A
    client who has a potassium level of 3.2 mEq/L. For which of the following statement medications should the nurse withhold administration and notify the provider?
    a. Atenolol
    b. Omeprazole
    c. Furosemide
    d. Potassium chloride

Answer 58

c. Furosemide

Question 59

66. A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the following laboratory values should the nurse check prior to administering the medication. (select all that apply.)
    a. PT
    b. Serum potassium
    c. INR
    d. Serum sodium
    e. BUN

Answer 59

PT. INR

Question 60

7. A nurse collecting data frm a client who has
   preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following finding should the nurse report to the provider?
   a. 2+ deep tendon reflex
   b. Facial flushing
   c. Respiratory rate 13/min
   d. Urine output 20 mL/hr

Answer 60

d. Urine output 20 mL/hr

Question 61

68. A nurse working at a crisis hotline call center receives a call from a client who states, I can’t take it. my life is over. Which of the following is the priority response by the nurse?
    a. Are you thinking of harming yourself?
    b. You made the right decision by calling the hotline.
    c. Tell me more about what is going on in your life
    d. Is there anyone with your right now?

Answer 61

a. Are you thinking of harming yourself?

Question 62

69. A nurse is contributing to the plan of care for a school-age child who has sickle-cell disease and is experiencing a vaso-occlusive crisis. Which of the following should the nurse recommend to include in the plan of care?
    a. Provide a low-protein diet
    b. Apply cold compresses to painful area
    c. Perform passive range-of-motion exercise
    d. Limit fluid intake during the evening

Answer 62

b. Apply cold compresses to painful area

Question 63

70. A nurse on a medical-surgical unit is planning care for a group of clients. Which of the following tasks is appropriate to delegate to assistive personnel?
    a. Change the dressing on a client’s IV site
    b. Suction a client’s new tracheostomy
    c. Evaluate a client’s risk of developing
    pressure ulcers
    d. Administer a large-volume enema to a client

Answer 63

. Administer a large-volume enema to a client

Question 64

71. A nurse in a provider’s office is collecting data from a client who was discharged from the hospital 7 days ago following treatment for deep- vein thrombosis. Which of the following findings is the nurse’s priority? (click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)
    a. The client takes ibuprofen daily to treat musculoskeletal pain.
    b. The client depends on friends for transportation to the clinic.
    c. The clients have difficulty applying his compression stocking.
    d. The client consumes 15 g of fiber daily.

Answer 64

a. The client takes ibuprofen daily to treat musculoskeletal pain.

Question 65

72. A nurse is collecting data from the guardian of a toddlers during a well-child visit. The guardian expresses concern to the nurse because his child has a poor appetite but drinks a quart of milk each day. The nurse should identify that this practice places the toddler at risk for which of the of the following condition?
    a. Celiac disease
    b. Lactose intolerance
    c. Acute renal failure
    d. Iron deficiency anemia

Answer 65

d. Iron deficiency anemia

Question 66

73. A nurse in a urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia?
    a. Pitting edema.
    b. Diplopia.
    c. Muscle weakness.
    d. Hyperactive bowel sounds.

Answer 66

c. Muscle weakness.

Question 67

74. A nurse is working in an urgent care clinic when a client who does not speak the same language arrives with a laceration that will require suturing. Which of the following actions is appropriate for the nurse to take?
    a. Have a family member who speaks the same language as the nurse explain the procedure to the client.
    b. Contact a medical interpreter to assist in obtaining informed consent.
    c. Ask assistive personnel who speaks the same language as the client to assist in obtaining informed consent.
    d. Request that the provider draw a diagram to explain the procedure to the client.

Answer 67

b. Contact a medical interpreter to assist in obtaining informed consent.

Question 68

75. A nurse is participating in a performance improvement process to decrease the rate of health care-associated infections within the facility. The nurse should recognize that which of the following is an appropriate performance improvement outcome indicator?
    a. Staff members complete an in-service about hand hygiene.
    b. Client rooms each have a wall-mounted hand sanitizer
    c. Client data indicates a decreased rate of infection
    d. Client surveys show increased satisfaction

Answer 68

c. Client data indicates a decreased rate of infection

Question 69

76. A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client’s right leg should be of the most concern to the nurse?
    a. The client’s foot feels cooler than in the previous assessment
    b. The client’s pedal pulse in the right foot is not palpable
    c. The client’s capillary refill time is 5 seconds in the toes
    d. The client reports a pain level of 8 on a scale from 0 to 10.

Answer 69

b. The client’s pedal pulse in the right foot is not palpable

Question 70

77. A nurse is reinforcing teaching with a postpartum client about bathing her newborn. Which of the following statements should the nurse include?
    a. “Wash your newborn’s head under a stream of running water.”
    b. “Bathe your newborn with 30 minutes after a feeding.”
    c. “Start the bath by washing the newborn’s diaper are first.”
    d. “The bath water should be 100 to 103 degrees Fahrenheit.”

Answer 70

d. “The bath water should be 100 to 103 degrees Fahrenheit.”

Question 71

78. A nurse is caring for a school-age child whose family adheres to a vegan diet in the home. The nurse should recognize the child is at the risk for the deficiency of which of the following?
    a. Vitamin C
    b. Potassium
    c. Vitamin D
    d. Magnesium

Answer 71

c. Vitamin D

Question 72

79. A nurse is reinforcing teaching with a postpartum client. Which of the following should the nurse explain as the most important reason for staff to wear identification?
    a. Recognizing a nurse’s name
    b. Reducing the risk of newborn abduction
    c. Identifying staff position
    d. Improving staff-client communication

Answer 72

b. Reducing the risk of newborn abduction

Question 73

80. A nurse is assisting with the discharge planning for a client following a myocardial infarction. Which of the following is an appropriate referral for the client?
    a. Physical therapist for range-of-motion
    exercise. a.
    b. Respiratory therapist for breathing exercise
    c. Dietitian for nutritional modifications.
    d. Pharmacist for pain management guidelines

Answer 73

c. Dietitian for nutritional modifications.

Question 74

81. A nurse is reinforcing teaching with a client who has new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?
    a. Improves muscle strength.
    b. Destroys the antibodies that cause MG. c. Enhances immune system function.
    d. Prevents excessive coughing.

Answer 74

a. Improves muscle strength.

Question 75

82. A nurse discovers a fire in a trash can in a client’s room. Which of the following actions should the nurse take first?
    a. Extinguish the fire.
    b. Shut the door to the client’s room.
    c. Pull the alarm.
    d. Walk the client to the waiting room.

Answer 75

d. Walk the client to the waiting room.

Question 76

83. A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of a car seat. Which of the following statements by a parent indicates an understanding of the teaching?
    a. “I will secure the seatbelt across my newborn’s lap.”
    b. “I can move my child to a booster seat when she weighs 20 pounds.”
    c. “I will turn the car seat forward-facing when my child is 10 months old.”
    d. “I can place a rolled towel on each side of my newborn’s head until he can hold his head up.”

Answer 76

d. “I can place a rolled towel on each side of my newborn’s head until he can hold his head up.”

Question 77

84. A home health nurse is reinforcing teaching with a client about kitchen safety. Which of the following instructions should the nurse reinforce
    about
    using a fire extinguisher?
    Store the fire extinguisher in a closed cabinet.
    b. Aim the extinguisher at the top of the fire and move download.
    c. Sweep the extinguisher from side to side put out the fire.
    d. If the extinguisher does not put out the fir call the fire department.

Answer 77

c. Sweep the extinguisher from side to side put out the fire.

Question 78

85. A nurse in a provider’s office is reinforcing teaching with the parents of a school-age child who has an active case of Pediculosis humanus capitis. Which of the following should the nurse include in the teaching?
    a. Apply a topical corticosteroid ointment to the scalp.
    b. Soak hairbrushes and combs in soapy water.
    c. Wash the bed lines in hot water.
    d. Clean the child’s toys with 1:10 bleach solution.

Answer 78

c. Wash the bed lines in hot water.

Question 79

86. A nurse is removing a female client’s indwelling urinary catheter. Which of the following actions should the nurse take?
    a. Irrigate the catheter before removal
    b. Withdraw the fluid from the catheter balloon.
    c. Wear sterile gloves while removing the catheter.
    d. Place the client in high-fowler’s position

Answer 79

b. Withdraw the fluid from the catheter balloon.

Question 80

87. A nurse is observing the mother of a 12-hr old newborn. Which of the following actions by the mother requires intervention by the nurse?
    a. The mother takes the newborn o nursery before showering.
    b. The mother places the newborn in prone position
    c. The mother feeds the newborn on demand. d. The mother swaddles the newborn.

Answer 80

b. The mother places the newborn in prone position

Question 81

88. A nurse on a mental health unit is discussing client rights with a group of coworkers. Which of the following statements should the nurse include?
    a. a client must withdraw consent for treatment in writing if he is competent to do so
    b. a client who is an immediate danger to herself or others cannot refuse antipsychotic medications
    c. a client who is voluntarily committed loses the right the right to refuse treatment
    d. a client who refuses to go to group therapy can be discharged for noncompliance

Answer 81

c. a client who is voluntarily committed loses the right the right to refuse treatment

Question 82

89. A nurse is reviewing standard precautions with an assistive personnel (AP) who is new to the newborn nursery. For which of the following newborn care procedures should the nurse remind the AP to wear clean gloves?
    a. Removing a mask after phototherapy
    b. Applying an identification bracelet
    c. Measuring axillary temperature
    d. Changing wet diapers

Answer 82

d. Changing wet diapers

Question 83

90. A nurse is preparing a client’s insulin regimen. Which of the following insulins can be mixed? (Select all the apply.)
    a. Insulin aspart
    b. Regular insulin
    c. Insulin glargine
    d. Insulin detemir
    e. Insulin lispro

Answer 83

a. Insulin aspart
b. Regular insulin
e. Insulin lispro

Question 84

91. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?
    a. A client who has a cesarean delivery 24 hr ago
    b. A client who is receiving oxytocin for uterine atony
    c. A client who will be breastfeeding for the first time
    d. A client who underwent removal of retained placenta

Answer 84

a. A client who has a cesarean delivery 24 hr ago

Question 85

92. A nurse is caring for a client who is in
    mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?
    a.
    Documents in the client’s medical record every 15 min
    Offer toileting to the client every 4 hr. Remove the restraint when the client falls asleep
    Request the provider write an as-needed prescription for restraints.

Answer 85

a.
Documents in the client’s medical record every 15 min

Question 86

93. A nurse is collecting data from a 3 month- old infant who is 6 hr postoperative following a cleft palate repair. Which of the following pain rating tools should the nurses use?
    a. FACES Scale
    b. FLACC scale
    c. Color tool
    d. Numeric scale

Answer 86

b. FLACC scale

Question 87

94. A nurse is reinforcing teaching with the family of a client who is receiving palliative care for a terminal cancer. Which of the following guidelines should the nurse emphasize about appropriate pain control measure?
    a. Administer pain medication on a regular schedule
    b. Administer pain medication with caution to avoid addiction
    c. Administer a placebo if it is not time for pain medication
    d. Administer scheduled doses of medication from a patient-controlled analgesia (PCA) pump

Answer 87

a. Administer pain medication on a regular schedule

Question 88

95. A nurse is assisting with a group therapy session in which a client begins to monopolize the group time. Which of the interventions is appropriate?
    a. Allow the client to continue expressing feelings until finished
    b. Schedule one on one discussion time with the client.
    c. Assign the client a leadership role within the group.
    d. refer the client to a different group.

Answer 88

b. Schedule one on one discussion time with the client.

Question 89

96. A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?
    a. “You should follow the label directions based on your child’s weight.”
    b. “You should avoid administering aspirin to your child.”
    c. “Your child will require an antibiotic if she develops a fever.”
    d. “Your child can have two baby aspirins every 4 hours.

Answer 89

b. “You should avoid administering aspirin to your child.”

Question 90

97. A nurse is collection data from a client whose Hgb is 8.8 mg/dl. Which of the following statements should the nurse expect?
    a. “I feel tired all the time.”
    b. “I have noticed that my fingernails are becoming thicker.”
    c. “I have to go to the bathroom all the time.” d. “I notice that my hands are always shaky.”

Answer 90

a. “I feel tired all the time.”

Question 91

98. A nurse preparing to administer a liquid medication to a 6 months-old infant who is crying. Which of the following actions should the nurse take to reduce the risk of aspiration?

Pinch the infant’s nares during administration.

Administration the whole dose as once.

Hold the infant in a side-lying position.

Administer using a needless syringe in the buccal cavity.

Answer 91

Administer using a needless syringe in the buccal cavity.

Question 92

99. A nurse is reinforcing teaching with a client who is 12 hours postpartum and has an episiotomy. Which of the following instruction should the nurse include?
    a. Cleanse the perineal area from back to front.
    b. Use a cool size bath for 60 min once per
    day.
    c. Change the perineal pad with each void.
    d. Wipe the perineal area with a soft towel.

Answer 92

c. Change the perineal pad with each void.

Question 93

100. A nurse is caring for a school-age child who has epistaxis. Which of the following action should the nurse take?
     a. Position the child so his head is tilted back.
     b. Apply a cold compress to the child’s neck.
     c. Apply pressure at the bridge of the child’s
     nose.
     d. Instruct the child to clear his nose by blowing

Answer 93

c. Apply pressure at the bridge of the child’s
nose.

Question 94

101. A charge nurse in a long-term care unit is planning care for a group of clients. Which of the following care tasks should the nurse plan to delegate to assistive personnel?
     a. Evaluate the effectiveness of acetaminophen administered 30 min ago to a client who reported headache.
     b. Discussing upcoming dietary changes with a client who has a new prescription for a low cholesterol diet.
     c. Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection.
     d. Inserting a temporary nasogastric tube for a client who has a prescription for a laboratory analysis of stomach contents

Answer 94

c. Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection.

Question 95

103. A nurse is reinforcing teaching with the parents of a preschool-age child who has a new diagnosis of celiac disease. Which of the following foods should the nurse recommend?
     a. Wheat toast and jelly
     b. Graham crackers with peanut butter
     c. Beef barley soup.
     d. Corn tortillas with black beans

Answer 95

d. Corn tortillas with black beans

Question 96

104. A nurse is administering a cleansing enema to a client who reports mild camping during instillation of the solution. Which of the following actions should the nurse take?
     a. Discontinue the enema.
     b. Slow the rate of instillation
     c. Ask the client to hold his breath until the
     cramping passes.
     d. Pause the enema to administer pain
     medication to the client.

Answer 96

b. Slow the rate of instillation

Question 97

105. A nurse is assisting with the admission of an older adult client who has impaired mobility and is at the risk for falls. Which of the following actions should the nurse plan to perform first?
     a. Check the client’s ability to use the call light.
     b. Document the client’s risk in the medical record.
     c. Request a referral for physical therapy. d. Place a gait belt in the client’s room.

Answer 97

a. Check the client’s ability to use the call light.

Question 98

106. A nurse is assisting in the development of an in-service for staff members about physical abuse of children. Which of the following children are at an increased risk for physical abuse?
     a. Children whose parents have college degrees
     b. Children who were born after 38 weeks of gestation
     c. Children whose parents are married d. Children who live in crowed homes.

Answer 98

a. Children whose parents have college degrees

Question 99

107. A nurse in the newborn nursery is planning to obtain blood from a newborn by a heel stick. Which of the following actions should the nurse
     take?
     Puncture the heel 3 mm to obtain the specimen.

Wear sterile gloves to collect the specimen.

Apply a heat pack 5 to 10 min prior to the procedure.

Elevate the newborn’s food for 15 min following the procedure.

Answer 99

Apply a heat pack 5 to 10 min prior to the procedure.

Question 100

108. A
     has dehydration and is receiving continuous IV therapy. Which of the following findings indicates effectiveness of the IV therapy?
     a. Hematocrit 55%
     b. BUN 16 mg/dL
     c. Urine specific gravity 1.038
     d. Urine output 25 mL/hr

Answer 100

b. BUN 16 mg/dL

Question 101

109. A nurse is caring for a client who is 5 days postoperative following abdominal surgery. The client tells the nurse that he was coughing and “felt a pop” at the incision site. The nurse examines the incision and finds wound dehiscence and evisceration. Which of the following actions should the nurse take?

Don sterile gloves to reinsert the protruding organs.

Apply an abdominal binder to the client.

Cover the wound with moist sterile gauze

Place the client in a side-lying position.

Answer 101

Cover the wound with moist sterile gauze

Question 103

110. A
     nurse on a medical unit is observing an assistive personnel (AP) delivering food trays. Which of the following action by the AP requires intervention?

Provide a ham and cheese sandwich to a client who follows a Kosher diet

Giving peanut butter to a client who was prescribed a mechanical soft diet

Offering ginger ale to a client who is a member of the Mormon faith.

Serving ice cream to a client who was prescribed a full-liquid diet.

Answer 103

Provide a ham and cheese sandwich to a client who follows a Kosher diet

Question 104

111. nurse caring for a client who attempted
     suicide. Which of the following actions should the nurse take?

Serve meal with plastic utensils.

Assign another client to accompany the client to therapy sessions.

Assign the client to private room.

Check on the client every 4 hr

Answer 104

Serve meal with plastic utensils.

Question 105

112. A
     adult client who has a new prescription for digoxin for heart failure. Which of the following effects should the nurse include as an expected outcome of this medication?
     a. Increased heart rate
     b. Increased cardiac output
     c. Decreased urinary output
     d. Decreased serum potassium

Answer 105

b. Increased cardiac output

Question 106

nurse caring for postop client and obtains pulse oximeter reading of 89%. which of the
following interventions should the nurse take?

Notify the primary care provider of the result

Documents the finding in the medical record

Repeat the test on another figure

Consult the respiratory therapist.

Answer 106

Repeat the test on another figure

Question 107

nurse is assisting with the admission of the client who has Hodgkin’s disease and is receiving chemotherapy. Because a private room is not available, the nurse should recommend that the client share a room with a client who has which of the following diagnosis?

a. Sickle-cell anemia
b. Herpes zoster
c. Community-acquired pneumonia
d. Viral meningitis

Answer 107

a. Sickle-cell anemia

Question 108

115. A nurse is caring for a child who has a terminal cancer. Which of the following responses by the child’s siblings should the nurse expect?
     a. The adolescent brother criticizes the parents plan to have a funeral service
     b. The school-age sister views death as being a type of temporary sleep
     c. The adolescent brother fears the terminal illness is contagious
     d. The school-age sister is concerned about the impact of her sibling’s death on herself

Answer 108

b. The school-age sister views death as being a type of temporary sleep

Question 109

116. A nurse working in a long erm care facility is assisting with the plan of care for a client who has Alzheimer’s disease. The nurse notes that the client wanders the halls at night and says she is looking for the bathroom. Which of the following intervention should the nurse recommend including in the plan of care?
     a. Turn off the lights in the client’s room at bedtime.
     b. Limit physical activity during the day
     c. Have the client wear an incontinence brief
     after dinner
     d. Label the client’s bathroom door.

Answer 109

d. Label the client’s bathroom door.

Question 110

117. A nurse is setting up a sterile field prior to preforming a dressing change. Which of the following action should the nurse take?
     a. Pour liquid by holding the bottle with the label facing the sterile field.
     b. Prepare the sterile field 5 cm 2 in below the level of the waist.
     c. Pour liquid from 10 to 15 cm 4 to 6 in about the sterile filed
     d. Open the outermost flap of the wrapper toward the body.

Answer 110

c. Pour liquid from 10 to 15 cm 4 to 6 in about the sterile filed

Question 111

118. A nurse is caring for a client who was diagnosed with hyperemesis gravidarum. Which of the following findings should the nurse anticipate?
     a. Poor skin turgor
     b. Increased blood pressure
     c. Decreased pulse rate
     d. Absence of ketones in urine

Answer 111

a. Poor skin turgor

Question 112

119. A nurse is caring for a client who has been placed in restraints, which of the following is appropriate?
     a. Attach the restraints to the side rails
     b. Ask assistive personnel to assess the safety
     of the restraints every 2 hrs.
     c. Monitor the client skin integrity on a regular schedule
     d. Secure the restraints so that four fingers can be placed between the client and the restraints

Answer 112

c. Monitor the client skin integrity on a regular schedule

Question 113

120. A nurse is reinforcing teaching with a client about the importance of a low- sodium diet. Which of the following foods should the nurse recommend as the best choice to include in a low sodium diet?
     a. 1 medium baked potato
     b. 1 oz of cheddar cheese
     c. 2 tbsp of peanut butter
     d. 1 slice of turkey bologna

Answer 113

a. 1 medium baked potato

Question 114

121. A nurse is caring for a client who is receiving total parental nutrition. Which of the following laboratory result indicate a possible complication of the therapy?
     a. Serum calcium 12.5 mg/dl
     b. BUN 16 mg/dl
     c. Serum potassium 4.6 meq/l
     d. WBC count 8000/mm3

Answer 114

a. Serum calcium 12.5 mg/dl

Question 115

122. A nurse is caring for a client who is asking about the technique of effleurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique?
     a. “It should be used in the second stage of labor”
     b. “It is an effective method to relieve perineal pressure”
     c. “It is a type of relaxation technique which focuses on a pleasant memory”
     d. “It is a light stroking of the skin stage during a uterine contraction”

Answer 115

d. “It is a light stroking of the skin stage during a uterine contraction”

Question 116

123. A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a combination contraceptive transdermal patch. Which of the following should the nurse include in the teaching?
     a. “The contraceptive effect will continues for 5 months following discontinuation of the medication.”
     b. “Start the first patch on the seventh day of the menstrual cycle.”
     c. “Apply the patch to the lower abdomen.”
     d. “Expect to have a headache during the first month.”

Answer 116

c. “Apply the patch to the lower abdomen.”

Question 117

124. A nurse is escorting a client to his car following from an acute mental health facility. The client states intentions to harm a friend when he leaves the facility. Which of the following actions should the nurse take?
     a. Ask for the client’s consent to notify the friend.
     b. Maintain confidentiality about the client’s statement.
     c. Prevent the client from leaving the facility
     d. Notify local law enforcement about the client’s threat.

Answer 117

d. Notify local law enforcement about the client’s threat.

Question 118

125. A nurse is evaluating a client who just attended a breastfeeding class. Which of the following statements by the client demonstrates thta she understood the teaching

“I will make sure that my baby has at least six wet diapers a day.”
“I can reuse any breast milk my baby does not drink for the next feeding.”
“I will feed my baby each time he cries.”
“I can give my baby water following each feeding.

Answer 118

“I will make sure that my baby has at least six wet diapers a day.”

Question 119

126. A nurse collecting data from 18 month
     old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?
     a. The toddler can remove her own socks
     b. The toddler has a security blanket
     c. The toddler can say four words
     d. The toddler throws a ball without falling

Answer 119

c. The toddler can say four words

Question 120

127. A nurse is assisting with the admission of a client who attempted suicide. When the nurse processes the client’s belongings. Which of the following items should the nurse remove from the client’s suitcase?
     a. Hairbrush
     b. Photo album
     c. Emery boards
     d. Perfume

Answer 120

d. Perfume

Question 121

128. A nurse is reinforcing teaching with the parent of a toddler who has difficulty falling asleep. Which of the following instructions should the nurse include:
     a. Establish a bedtime routine.
     b. Allow the child to fall asleep in a rocking chair.
     c. Lie with the child until she falls asleep.
     d. Discourage napping during the day

Answer 121

a. Establish a bedtime routine.

Question 122

129. A nurse in a prenatal clinic is reinforcing teaching with a client about nonstress treatment. Which of the following statements should the nurse include?
     a. “A nurse will insert an IV prior to starting the test.”
     b. “You should have nothing to eat or drink for 4 hours prior to the test.”
     c. “You should expect the test to take a minimum of 2 hours.”
     d. “You will be asked to press a button when feel your baby move.”

Answer 122

d. “You will be asked to press a button when feel your baby move.”

Question 123

130. A nurse is caring for a client who is experiencing chest pain. The client states, “I am really afraid because my brother died a year ago of a heart attack.” Which of the following responses is appropriate?
     a. “Were you brother’s symptoms similar to yours?”
     b. “There are reasons chest pain not related to your heart.”
     c. “Being afraid will only make the pain worse, so try to stay calm.”
     d. “This must be frightening experience for you.”

Answer 123

d. “This must be frightening experience for you.”

Question 124

131. A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?
     a. Call EMS if a seizure lasts 5 min or more.
     b. Restrain the child at the onset of a seizure.
     c. Offer the child a bubble bath every morning.
     d. Place the child in a prone position during the
     seizure.

Answer 124

a. Call EMS if a seizure lasts 5 min or more.

Question 125

132. A nurse in an acute mental health facility observes a client having a panic attack. Which of the following interventions should the nurse implement first?

Discuss the client’s feeling prior to the panic attack.

Encourage the use of positive self-talk strategies.

Instruct the client to use abdominal breathing

Administer an antianxiety medication

Answer 125

Instruct the client to use abdominal breathing

Question 126

133. A nurse collecting data from a client who
     has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (select all that apply)
     a. Pallor in the exposed portion to the left foot
     b. Inability to move the left foot
     c. Increased warmth of the exposed portion of the left foot.
     d. Ecchymosis in the exposed portion of the left foot
     e. Paresthesia in the left foot.

Answer 126

a. Pallor in the exposed portion to the left foot
b. Inability to move the left foot
e. Paresthesia in the left foot.

Question 127

134. a nurse in a provider’s office is talking on the phone with the parents of a school age child who has varicella. The patent asks the nurse when the child can return to school. The nurse should tell the parent that which of the following is an indication that the child is no longer contagious?
     a. The itching has subsided.
     b. All vesicles have crusted over.
     c. The fever is less than 37.8 (100 f) d. All lesions are healed

Answer 127

b. All vesicles have crusted over.

Question 128

135. A nurse is assisting in the car of a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse plan to administer?
     a. Terbutaline
     b. Methylergonovine
     c. Magnesium sulfate
     d. Nifedipine

Answer 128

b. methylergonovine

Question 129

136. A nurse is caring for a client who is postoperative following a hemicolectomy. Which of the following is the best indication that the client needs PRN pain medication?
     a. The client’s heart rate is 110/min.
     b. The client is guarding his abdominal
     incision.
     c. The client exhibits facial grimacing.
     d. The client reports pain.

Answer 129

c. The client exhibits facial grimacing.

Question 130

137. A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For which of the following results should the nurse notify the provider?
     a. Nitrites negative
     b. Ketones positive
     c. Uric acid 475 mg/24 hr
     d. Specific gravity 1.020

Answer 130

b. Ketones positive

Question 131

138. A nurse is reinforcing healthy eating habits for an older adult client to ensure adequate dietary intake. Which of the following is an appropriate recommendation?
     a. Consume a diet high in fat
     b. Drink 1 L (32 oz) of water each day
     c. Snack between meals
     d. Eat three large meals each day

Answer 131

c. Snack between meals

Question 132

139. A nurse is caring for a client who has a new prescription for a protective safety restraint. Which of the following actions should the nurse take?
     a. Choose the most restrictive type of restraint that will fit the client.
     b. Assess skin integrity under the restraint once per day.
     c. Attach the restraint securely to the side rail when the client is in bed.
     d. Secure the restraint with an easy-to- release tie.

Answer 132

d. Secure the restraint with an easy-to- release tie.

Question 133

141. A nurse is reinforcing teaching about nonpharmacological pain relief with a client who is 6 hr. postpartum following a vaginal delivery. The client has an episiotomy and swelling of the labia. Which of the following instructions should the nurse include?
     a. Apply cold packs to the affected area.
     b. Cleanse the site with antibacterial
     c. Take warm sitz bath every 2 hr.
     d. Sit on soft pillow throughout the day.

Answer 133

a. Apply cold packs to the affected area.

Question 133

140. A nurse is reinforcing with a client who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?
     a. “I should skip meals when I’m having pain” b. “I will take a dose of aspirin each morning
     with breakfast.”
     c. “I will plan to have my meals at regular intervals.”
     d. “I will eat a diet low in iron.”

Answer 133

c. “I will plan to have my meals at regular intervals.”

Question 134

142. A nurse is caring for a client who has a new prescription for furosemide. The client asks the nurse about the purpose of the medication. The nurse tells the client, “This medication is a diuretic, and you should monitor your weight while taking it,” Which of the following ethical concepts is the nurse exhibiting?
     a. Accountability
     b. Autonomy
     c. Veracity
     d. Justice

Answer 134

a. Accountability

Question 135

143. A nurse is reinforcing discharge teaching with a client who is postoperative following laser surgery for open-angle glaucoma. Which of the following statements by the client indicates an understanding of the instructions?
     a. “I will take a stool softener to prevent constipation.”
     b. “I will ask to work the night shift, so I will not be driving in bright sunlight.”
     c. “I will need to use my eye drops for 1 year.” d. “I will need to follow a low-protein diet.”

Answer 135

a. “I will take a stool softener to prevent constipation.”

Question 136

144. A nurse is caring for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take?
     a. Frequently remind the client of the expectations for her behavior
     b. Encourage the client to participate in a group activity in the dayroom
     c. Allow the client to pick her own choice of clothing
     d. Encourage the client to increase physical activity during the day

Answer 136

d. Encourage the client to increase physical activity during the day

Question 137

145. A client who is prescribed metoprolol for hypertension tells the nurse, “I don’t want to take this medication because it makes me tired all the times.” which of the following is the appropriate response?
     a. “I know the fatigue is difficult, but you must control your hypertension”.
     b. “Limiting sodium intake will minimize the side effects.”
     c. “The side effect usually decreases within one to two days.”
     d. “Let’s talk with your doctor about other option.”

Answer 137

d. “Let’s talk with your doctor about other option.”

Question 138

146. A nurse is reinforcing teaching with a client who has rheumatoid arthritis and is using a straight legged cane for ambulation. Which of the following instructions should the nurse include?
     a. “Maintain your elbow flexed at a 90-degree angle”
     b. “Keep the cane on the stronger side of the body”
     c. “Place the cane forward 5 to 10 cm (2 to 4 inch)”
     d. “Move the stronger leg forward first.

Answer 138

b. “Keep the cane on the stronger side of the body”

Question 139

147. A nurse is assisting with the plan of care for a client who has Alzheimer’s disease. Which of the following actions should the nurse recommend for the plan of care?

Encourage the client to talk about current events.
Give directions using simple phrases
Orient the client to time and place twice per day
Rotate assistive personnel to help the client with ADLs

Answer 139

Give directions using simple phrases

Question 140

148. A nurse is an impatient mental health facility is caring for a client who has bipolar disorder and is in an acute manic episode. Which of the following activities should the nurse suggest for the client?
     a. Participate in group therapy sessions
     b. Play basketball with other clients
     c. Take a walk with a staff member
     d. Avoid napping during the day

Answer 140

c. Take a walk with a staff member

Question 141

149. A nurse who is orienting to a medical surgical unit is having difficulty finishing client care tasks during his shift. Which of the following suggestions should the nurse’ preceptor make to help the nurse with time management?
     a. Delegate complicate task to RN.
     b. Document all client care at the end of the
     shift.
     c. Perform quick tasks before time consuming
     tasks.
     d. Try to complete a task before moving on the next.

Answer 141

d. Try to complete a task before moving on the next.

Question 142

150. A nurse is orienting a newly licensed nurse to a medical-surgical unit. Which of the following actions should the nurse take to verify that the newly licensed nurse understands the procedure for measuring a client’s blood glucose level?
     a. Have the nurse perform a return demonstration
     b. Administer a written quiz to the nurse
     c. Ask the nurse to verbalize the steps of the
     procedure
     d. Review the nurse’s documentation of the
     procedure

Answer 142

a. Have the nurse perform a return demonstration

Question 143

151. A nurse in a long-term care facility is observing an assistive personal who is performing hand hygiene. Which of the following actions by the AP requires intervention?

a. Holding his hands up and elbows down while washing his hands
b. Washing his hands with warm water and soap
c. Using 4 to 5 mL (1 tsp) of liquid hand soap.
d. Pushing his watch up above his wrist prior
to performing hand hygiene.

Answer 143

a. Holding his hands up and elbows down while washing his hands

Question 144

152. A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?
     a. Document the client’s respiratory rate in 1 hr.
     b. Monitor the client for an allergic reaction for 30 min
     c. Check the client’s response to the medication in 1 hr.
     d. Evaluate the client for therapeutic effect in 30 min

Answer 144

a. Document the client’s respiratory rate in 1 hr.

Question 145

153. A nurse is speaking to a client who called the provider’s office to report chest pain and requests clarification on how to take his sublingual nitroglycerin tables. Which of the following instructions should the nurse give the client?
     a. Wait 5 min in between doses
     b. Swallow two tablets together
     c. Take up to four tablets
     d. Drink with a full glass of water

Answer 145

a. Wait 5 min in between doses

Question 146

154. A nurse is contributing to the plan of care for a client who has bulimia nervosa which of the
     following interventions should the nurse
     recommend?
     a. Administer bupropion 1 hour before meals.
     b. Allow the client access to food throughout
     the day
     c. Weigh the client once weekly.
     d. Observe the client for 1 hour after meals.

Answer 146

d. Observe the client for 1 hour after meals.

Question 147

155. A nurse is preparing to administer morphine IM to a client using the Z-track method. Identify the order of the steps the nurse should take to administer the medication using this method. (Move the steps into the box on the right placing them in the order of performance. Use all the steps.)

Answer 147

Answer: The correct order is:
Cleanse the Skin

Use the Ulnar side of the nondominant hand to pull the skin approximately 2.5 cm (1 inch) to the side.

Insert the needle at a 90-degree angle using the dominant hand

Aspirate for blood return

Inject the medication slowly

Question 148

156. A nurse is caring for a client who is receiving
     morphine 2 mg subcutaneously every 4 hr. for a plan. The medication is available in a vial containing 10 mg/ml. how many mL should the nurse administer? round the answer to the nearest tenth. Use a leading zero.

Answer 148

0.2 mL

Question 149

157. A nurse is caring for a client who is undergoing evaluation for a thoracic aortic aneurysm. Which of the following findings should make the nurse suspect an impending rupture of the aneurysm?
     a. A cough with hemoptysis.
     b. Report of sharp pain in the back.
     c. Bounding peripheral pulses.
     d. Facial flushing.

Answer 149

b. Report of sharp pain in the back.

Question 150

158. A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client’s dressing sensitivity to age-related changes?

Ask the client to help with the dressing change.

Wait for the client to approach the nurse for assistance.

Use paper tape for securing the new dressing.

Apply the dressing loosely over the incision.

Answer 150

ask the client to help with the dressing change

Question 151

159. A nurse is reinforcing discharge teaching with an older adult client who has osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching?
     a. “I will apply cold compression when my joints are painful.”
     b. “I will limit purine intake in my diet.”
     c. “I plan to take water aerobics classes at the
     gym near my house.”
     d. “I will avoid the use of ibuprofen for pain
     control.”

Answer 151

c. “I plan to take water aerobics classes at the
gym near my house.”

Question 152

160. A nurse is caring for a client who has COPD. The client tells the nurse, “I get short of breath during meals. It is too much trouble to eat.” Which of the following instructions should the nursing suggest?
     a. “Have several small meals during the day.”
     b. “Limiting snacking between meals.”
     c. “Eat one food at a time during meals.”
     d. “Consume a full-liquid diet.”

Answer 152

a. “Have several small meals during the day.”

Question 153

161. A nurse is caring for a client who has urolithiasis. Which of the following actions should the nurse take?
     a. Implement NPO status.
     b. Place the client on bedrest.
     c. Monitor the client liver function.
     d. Strain the client’s urine.

Answer 153

a. Implement NPO status.

Question 154

162. A nurse is preparing to administer purified protein derivative (PPD) to a client. The nurse should use which of the following routes?
     a. Subcutaneous
     b. Intramuscular
     c. Intradermal
     d. Oral

Answer 154

c. Intradermal

Question 155

163. A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicate the client experiencing allergic reaction?
     a. Headache
     b. Distended neck veins
     c. Marked hypertension
     d. Urticaria (Aka: Hives)

Answer 155

d. Urticaria (Aka: Hives)

Question 156

164. A nurse is reinforcing teaching with a client who has new prescription for lithium carbonate. Which of the following client statements indicates an understanding of the teaching?

“I will notify my provider if I develop a tremor.”
“I will drink less than 1 liter of fluid per day.”
“I should take ibuprofen when I get a headache.”
“I should expect to follow a high potassium diet.”

Answer 156

“I will notify my provider if I develop a tremor.”

Question 157

165. A nurse colleecting from child who has acute glomerulonephritis. Which of the following finding should the nurse expect?
     nurse is collecting from child who has acute
     a. Decreased blood pressure
     b. Pale yellow urine
     c. Periorbital edema
     d. Increased urination

Answer 157

c. Periorbital edema

Question 158

166. A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse see first?

A client who is exhibiting flight of ideas.

A client who refuses to attend group therapy.

A client who is experiencing a moderate level of anxiety.

A client who is having command hallucinations.

Answer 158

A client who is exhibiting flight of ideas.

Question 159

167. A nurse is caring for a client who is
     postoperative following a femoral cardiac catheterization. Which of the following actions should the nurse take during the first 30 min?
     a. Ambulate the client.
     b. Elevate the lower extremities with pillows. c. Remove the pressure dressing.
     d. Compare the bilateral peripheral pulses.

Answer 159

compare the bilateral peripheral pulses

Question 160

168. A nurse is caring for a client who was recently admitted to an inpatient mental health unit. The client tells the nurse that, he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?
     a. “I think you should just ignore the others.”
     b. “You feel upset by the responses of others.”
     c. “Let’s keep the focus of our discussion on you needs.”
     d. “Everything will get better once you get to know everyone.”

Answer 160

b. “You feel upset by the responses of others.”

Question 161

169. A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client does which of the following?
     a. Draws up regular insulin before NPH when demonstrating injection technique
     b. Says that he will see a primary care provider treat corns on his feet
     c. States that he will treat hypoglycemic reactions with 15 g of carbohydrates
     d. Lists sweating, shaking, and palpitations as symptoms of hyperglycemia

Answer 161

d. Lists sweating, shaking, and palpitations as symptoms of hyperglycemia

Question 162

170. a nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse include in the plan of care?
     a. Decrease the client’s daily fiber intake.
     b. Limit the amount of fluid the client drinks
     per day
     c. Decrease the level of environmental stimuli
     d. Allow the client to give the possessions to others.

Answer 162

c. Decrease the level of environmental stimuli

Question 163

171. A nurse is contributing to the discharge plans for 4 clients. The nurse should identify that which of the following clients requires an interdisciplinary care conference?
     A client who had surgery for cataract removal and lives in a rural location

A client who has hemiparesis and lives alone

A client who requires assistance to pay for dressing supplies.

A client who requires instruction regarding medication administration.

Answer 163

A client who has hemiparesis and lives alone

Question 164

nurse is applying a condom catheter to a male incontinent client. which of the following is an appropriate technique to use?

Apply sterile gloves after performing hand hygiene

Unroll the catheter before applying it to the penis

Leave space between the tip of the penis and the end of the condom catheter.

Tape the condom catheter to the penis using waterproof adhesive tape

Answer 164

Leave space between the tip of the penis and the end of the condom catheter.

Question 165

173. A nurse is assisting in the preparation of an in service for a group of unit nurses about ethical principles. Which of the following nursing actions should the nurse include as an example of fidelity?
     A nurse shares her time fairly among clients
     A nurse tells a client the truth
     A nurse allows a client to make her own choice
     A nurse keeps a promise made to a client.

Answer 165

A nurse keeps a promise made to a client.

Question 166

a nurse is reinforcing teaching with the parents of a newborn who has a circumcision. Which of the following client statement indicates understanding of the teaching?

a. “I will keep the penis clean of yellow exudate.”
b. “I will apply petroleum jelly to the penis with each diaper change.”
c. “I will make sure my baby’s diaper fits snugly.”
d. “I will use soap to wash the penis until it heals.”

Answer 166

b. “I will apply petroleum jelly to the penis with each diaper change.”

Question 167

175. A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?
     a. A decreased level of consciousness and vomiting
     b. Cellulitis accompanied by a low-grade fever c. A pain rating of 7 on a scale from 0 to 10
     after receiving analgesia 30 min ago d. Type 2 diabetes mellitus and a blood
     glucose level of 160 mg/dL

Answer 167

a. A decreased level of consciousness and vomiting

Question 168

176. A nurse is caring for a client who had a stroke and is having difficulty swallowing. The nurse should recommend a referral to which of the following members of the interprofessional team?

Dentist
Speech therapist
Physical therapist
Social worker

Answer 168

Speech therapist

Question 169

177. A nurse is caring for a school age child who is scheduled for a bone marrow aspiration biopsy. The child asks the nurse. “Will this be painful?” which of the following is an appropriate response by the nurse?
     a. “Do not worry about the pain right now. You need to try and relax.”
     b. “The pain will be worth it because this test will help us give you the best possible treatment.”
     c. “Let’s talk about your favorite activities at school.”
     d. “There will be some pain, but i can give you medicine to make you more comfortable.”

Answer 169

d. “There will be some pain, but i can give you medicine to make you more comfortable.”

Question 170

178. A nurse is planning to reinforce teaching with a preschooler who is about to undergo an incision and drainage for cellulitis on the left arm. Which of the following techniques should the nurse use?
     a. Plan for a 30-min instructional session
     b. Schedule the instructional session for 24 to
     36 hr before the procedure
     c. Take the child on a tour of the surgery and
     recovery areas.
     nurse is caring for a school-age child who is
     d. Help the child put a dressing on a doll.

Answer 170

d. Help the child put a dressing on a doll.

Question 171

179. A nurse is contributing to the discharge plan of an older adult client who had a total hip arthroplasty. The client is unable to ambulate independently and lives alone. Which of the following care settings should the nurse recommend for this client?
     a. Skilled nursing facility
     b. Adult day care center
     c. Respite care
     d. Home health nurse visits

Answer 171

a. Skilled nursing facility

Question 172

180. A nurse working on a mental health unit is meeting with a client who has been on the unit for 2 days. The nurse greets the clients and asks.” What has been happening with you today?” which of the following therapeutic techniques is the nurse doing?
     a. Giving broad openings
     b. Focusing
     c. Reflecting
     d. Seeking clarification

Answer 172

a. Giving broad openings