Practice Exam 1 Flashcards
1
Q
A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?
A. N/a
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure.
A
B. Tell the child they will feel discomfort during the catheter insertion.
2
Q
A nurse is caring for a client who has an arteriovenous fistula. Which of the following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit
C. Distended blood vessels
D. Swishing sound upon auscultation
A
B. Absence of a bruit
3
Q
A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator. Which of the following statements demonstrates an understanding of the teaching?
A. I will soak in the tub rather than showering
B. I will wear loose clothing around my ICD
C. I will stop using my microwave oven at home because of my ICD
D. I can hold my cellphone on the same side of my body as the ICD
A
B. I will wear loose clothing around my ICD
4
Q
A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
A. Describe your feelings to me about being pregnant
B. You should discuss your feelings about being pregnant with your provider
C. Have you discussed these feelings with your partner?
D. When did you start having these feelings.
A
A. Describe your feelings to me about being pregnant
5
Q
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500ml per day
B. Increase the amount of refined grains in the client’s diet
C. Provide the client with a cold drink prior to defecation
D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
A
D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
6
Q
A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position.
A
B. Place the client in a warm shower.
7
Q
A nurse in an emergency department is performing triage for multiple clients following a disaster
in the community. To which of the following types of injuries should the nurse assign the highest priority?
A. Below-the-knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm(4in) laceration to the forearm
A
A. Below-the knee amputation
8
Q
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?
1. Remove the client’s restraint every 4hr
2. Document the client’s condition every 15 min
3. Attach the restrain to the bed’s side rails
4. Request a PRN restrain prescription for clients who are aggressive
A
- Document the client’s condition every 15 min
9
Q
A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader?
1. Acts as an advocate for the nursing unit.
2. (Unable to read) for the unit
3. Priorities staff request over client needs.
4. Provides routine client care and documentation.
A
- Acts as an advocate for the nursing unit.
10
Q
A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care.
1. Serum sodium 144mEq/
2. Unable to read)
3. Hba1c 10 %
4. Random serum glucose 190 mg/dl.
A
- Hba1c 10 %
11
Q
A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The
the nurse should identify which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department.
A. Chlamydia
B. Human papillomavirus
C. Candidiasis
D. Herps simplex virus
A
A.Chlamydia
12
Q
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?
A. Share personal opinions to help influence the group’s values
B. Measure the accomplishments of the group against a previous group
C. Yield situations of conflicts to maintain group harmony
D. Use modeling to help the clients improve their interpersonal skills
A
D.Use modeling to help the clients improve their interpersonal skills
13
Q
A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse that (Unable to read) the Passover holiday. Which of the following action should the nurse include in the plan of care?
1. Provide chicken with cream sauce.
2. Avoid serving fish with fins and scales.
3. Provide unleavened bread.
4. A void serving of foods containing lamb.
A
Provide unleavened bread.
14
Q
A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment
1. A chest x-ray reveals increased density in all fields.
2. The client reports feeling less anxious.
3. Diminished breath sounds are auscultated bilaterally
4. ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg.
A
The client reports feeling less anxious.
15
Q
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway and initiating an IV, which of the following actions should the nurse do next?
1. Monitor the client’s IV site for thrombophlebitis.
2. Administer flumazenil to the client.
3. Evaluate the client for further suicidal behavior.
4. Initiate seizure precautions for the client.
A
Administer flumazenil to the client.
16
Q
A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect?
A. Hypotension
B. Memory loss
C. Slurred speech
D. Elevated temperature
A
D.Elevated temperature
17
Q
A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect?
A. Loose stools
B. Jitteriness
C. Hypertonia
D. Abdominal distention
A
B.Jitteriness
18
Q
A nurse in a pediatric clinic is reviewing the laboratory test results of a school-age child. Which of the following findings should the nurse report to the provider?
A. Hgb 12.5 g/dl
B. Platelets 250,000/mm3
C. Hct 40%
D. WBC 14,000/mm3
A
D.WBC 14,000/mm3
19
Q
A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the following information should the charge nurse include?
1. “The proxy should make health care decisions for the client regardless of the client’s ability to do so.”
2. “The proxy can make financial decisions if the need arises.”
3. “The proxy can make treatment decisions if the client is under anesthesia.”
4. “The proxy should manage legal issues for the client.”
A
“The proxy can make treatment decisions if the client is under anesthesia.”
20
Q
A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?
1. Turn the client on their side.
2. Administer an analgesic
3. Administer antiemetic
4. Monitor the client’s vital signs.
A
Turn the client on their side.
21
Q
A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
1. Confirm the client’s perception of the event
2. Notify the client’ s support system
3. Help the client identify personal strengths
4. Teach the client relaxation techniques
A
Confirm the client’s perception of the event
22
Q
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions should the nurse take?
1. Request a renewal of the prescription every 8 hr.
2. Check the client’s peripheral pulse rate every 30 min
3. Obtain a prescription for restraint within 4hr.
4. Document the client’s condition every 15 minutes.
A
Document the client’s condition every 15 minutes.
23
Q
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the (Unable to read) unit due to a staffing shortage. Which of the
following clients should the nurse delegate to the LPN?
1. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
2. A client who sustained a concussion and has unequal pupils.
3. A client who is postoperative following a bowel resection with an NG tube set to continuous suction.
4. A client who fractured his femur yesterday and is experiencing shortness of breath.
A
A client who is postoperative following a bowel resection with an NG tube set to continuous suction.
24
Q
A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia.The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?
1. Place the client upright on a donut-shaped cushion
2. Teach the client to shift his weight every 15 min while sitting
3. Turn and reposition the client every 3 hr while in bed
4. Assess pressure points every 24 hr
A
Place the client upright on a donut-shaped cushion
25
A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following pain-
management (Unable to read) a safe option for the client?
A. Naloxone hydrochloride.
B. Spinal anesthesia.
C. Pudendal block.
D. Butorphanol tartrate.
C. Pudendal block.
26
A nurse is assessing a client who has a major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?)
A. The client changes the subject when future plans are mentioned.
B. The client talks about being in pain constantly.
C. The client sleeps over 12 hr. each day.
D. The client reports giving away personal items.
D. The client reports giving away personal items.
27
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse should inform the client that she can receive which of the following immunizations during pregnancy? (Select all that apply)
1. Varicella vaccine.
2. Inactivated polio vaccine.
3. Tetanus diphtheria and acellular pertussis vaccine
4. Rubella vaccine.
5. Inactivated influenza vaccine.
3. Tetanus diphtheria and acellular pertussis vaccine
5. Inactivated influenza vaccine.
28
A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child’s medical history should the nurse identify as a contraindication to the procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary glaucoma
C. Hypertension
29
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian
1. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”.
2. A client who has gout and states, “I can continue to eat anchovies on my pizza.”
3. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”.
4. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”.
A client who has gout and states, “I can continue to eat anchovies on my pizza.”
30
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
A. “I can give you information about respite care if you are interested.”
B. “You should consider taking a sleeping pill before bed each night”
C. “It must be difficult taking care of someone who is terminally ill”
D. “You are doing a great job taking care of your mother”
A. “I can give you information about respite care if you are interested.”
31
A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an
increase in the child’s glucose. The nurse should identify this finding as an adverse effect of which
of the following medications
A. Methylprednisolone.
B. Ondansetron.
C. Guaifenesin.
D. Amoxicillin.
A. Methylprednisolone.
32
The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching?
A. “You should take folic acid to decrease the risk of transmitting infections to your baby”
B. “You should consume a maximum of 300 micrograms of folic acid everyday”.
C. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”.
C. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”.
33
A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse’s priority?
A. Social relationships with peers.
B. Plans for attending school while pregnant.
C. (Unabletoread) (Picked this one) Medicaid?
D. Understanding of infant care.
C. (Unabletoread) (Picked this one) Medicaid?
34
A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include?
1. Critical pathways have an unlimited time frame for completion
2. (Unable to read) decrease healthcare costs.
3. (Unable to read) critical pathway if variances (Unable to read)
4. (Unable to read) are used to create the critical pathway
(Unable to read) decrease healthcare costs.
35
A nurse is reviewing the medical record of a client who has schizophrenia. Which of the
following should the nurse report to the provider?
**Exhibit 1**
Blood pressure: 102/56 mm Hg. Heart rate: 95/min
Respiratory rate: 18/min Temperature: 37.4C (99.3F)
**Exhibit 2**
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors. **Exhibit 3** Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heartrate. C. Sore throat. D. Blood pressure.
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors. **Exhibit 3** Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. A. Dietary intake B. Heartrate. C. Sore throat. D. Blood pressure.
C. Sore throat.
36
A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel. Which of the following statements is correct?
1. “The nurse is legally responsible for the actions of the AP”.
2. “An AP can perform tasks outside of his range if he has been trained”.
3. An experienced AP can delegate to another AP”.
4. An RN evaluates the client needs to determine tasks to delegate”
“An RN evaluates the client needs to determine tasks to delegate”
37
A nurse is assessing a client who is in active labor. Which of the following findings should the
nurse report to the provider?
A. Contractions lasting 80 seconds
B. FHR baseline 170/min
C. Early decelerations in the FHR
D. Temperature 37.4C (99.3)
B. FHR baseline 170/min
38
A nurse working in a rehabilitation facility is developing a discharge plan for a client who has
left-sided hemiplegia the following actions is the nurse’s priority?
A. Consult with a case manager about insurance coverage.
B. Counsel caregivers about respite care options.
C. Ensure that the client has a referral for physical therapy.
D. Refer the client to a local stroke support group.
C. Ensure that the client has a referral for physical therapy.
39
A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse’s station?
1. A client who has an anxiety disorder and is experiencing moderate anxiety.
2. A client who has somatic symptom disorder and reports chronic pain.
3. A client who has depressive disorder and reports feeling hopeless.
4. A client who has bipolar disorder and impaired social interactions.
A client who has depressive disorder and reports feeling hopeless.
40
A nurse is preparing to measure a temperature of an infant. Which of the following action
should the nurse take?
A. Place the tip of the thermometer under the center of the infant’s axilla.
B. Pull the pinna of the infant’s ear forward before inserting the probe.
C. Insert the probe 3.8cm (1.5in) into the infant’s rectum.
D. Insert the thermometer in front of the infant’s tongue.
A. Place the tip of the thermometer under the center of the infant’s axilla.
41
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
1. Encourage the client to spend time in the day room
2. Withdraw the client’s TV privileges is the does not attend group therapy
3. Encourage the client to take frequent rest periods
4. Place the cline in seclusion when he exhibits signs of anxiety
Encourage the client to take frequent rest periods
42
A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report?
1. A client receives his antibiotics 2hr late
2. A client vomits within 20min of taking his morning medications
3. A client requests his statin to be administered at 2100
4. A client asks for pain medication 1hr early
A client receives his antibiotics 2hr late
43
A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The
client asks the nurse to warm up seaweed soup that the client’s partner brought for her. Which of
the following responses should the nurse make?
A. “Does the doctor know you are eating that?”
B. “Why are you eating seaweed soup?”
C. “Of course I will heat that up for you”
D. “The hospital good is more nutritious”
A. “Does the doctor know you are eating that?”
44
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?
1. Leaving a nasogastric tube clamped after administering oral medication
2. Documenting communication with a provider in the progress notes of the client’s medical records
3. Administering potassium via IV bolus
4. Placing a yellow bracelet on a client who is at risk for falls
Administering potassium via IV bolus
45
A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?
1. Establish a toileting schedule for the client
2. Use clothing with buttons and sippers
3. Discourage physical activity during the day
4. Engage the client in activities that increase sensory stimulation
Establish a toileting schedule for the client
46
The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction to the
use of oral contraceptives?
A. Hyperthyroidism.
B. Thrombophlebitis.
C. Diverticulosis.
D. Hypocalcemia.
B. Thrombophlebitis.
47
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the
nurse ask the client?
1. “Do you understand that the voices are not real?”
2. “Why do you think the voices are talking to you?”
3. “Have you tried going to a private place when this occurs?”
4. “What helps you ignore what you are hearing?”
“What helps you ignore what you are hearing?”
48
A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching?
1. Placing a belt restraint on a school-age child who has seizures.
2. Securing wrist restraints to the bed rails for an adolescent.
3. Applying elbow immobilizers of an infant receiving cleft lip injury
4. Keeping the side rails of a toddler’s crib elevated.
Applying elbow immobilizers of an infant receiving cleft lip injury
49
A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following
A. Inject air into the NPH insulin vial.
B. (Unable to read)
C. Withdraw the prescribed dose of regular insulin
D. Withdraw the prescribed dose of NPH insulin
A. Inject air into the NPH insulin vial.
50
A nurse is working with a client who has an anxiety disorder and is in the orientation phase ofthe therapeutic relationship. Which of the following statements should the nurse make during this phase?
1.“Let’s talk about how you can change your response to stress.”
2. “We should establish our roles in the initial session.”
3. “Let me show you simple relaxation
4. “We should discuss resources to implement in your daily life.”
“We should establish our roles in the initial session"
51
A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information
should the nurse include?
1. Children who have varicella are contagious until vesicles are crusted.
2. Children who have varicella should receive the herpes zoster vaccination.
3. Children who have varicella should be placed in droplet precaution.
4. Children who have varicella are contagious 4 days before the first vesicle eruption.
Children who have varicella are contagious until vesicles are crusted.
52
A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following requires intervention by the staff nurse?
1. Waits 2 minutes between suctions.
2. Encourages the client to cough during suctioning.
3. Apply suctioning for 15 seconds.
4. Inserts the catheter without applying suction.
Waits 2 minutes between suctions.
53
A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?
2. Cover extension cords with a rug.
3. Check the tingling sensations around the cord to ensure the electricity is working.
4. Remove the plug from the socket by pulling the cord
Use three pronged grounded plugs.
54
A nurse is providing care for a group of clients. Which of the following client’s should the nurse identify as having the highest risk for developing a pressure injury?
1. A client who has a T-tube following an open cholecystectomy.
2. A client who had a knee 2 days ago following a sports injury.
3. A client who has dementia and is incontinent of urine and feces
4. A client who has a myocardial infarction and is receiving thrombolytic therapy.
A client who has a T-tube following an open cholecystectomy.
55
A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops.
Which of the following statements indicates an understanding of the teaching?
A. “I will place the eye drops in the center of my eye”
B. “I will place pressure on the corner of my eye after using the eye drops”
C. “I should expect my tears to turn a red color after using the eye drops.”
D. “I should expect the eye drops to appear cloudy.”
B. “I will place pressure on the corner of my eye after using the eye drops”
56
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report
to the provider. Which of the following findings should the nurse include in the teaching?
A. Bleeding gums
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
C. Swelling of the face
57
A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make?
1. “I would recommend sharing your feelings with a psychologist”.
2. I can give you information about making 3. “You should discuss your end life decisions with your family”
4. Everyone feels this way at first.You will start feeling better soon”.
“I can give you information about making end of life decisions”.
58
A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
1. Keep client’ s calcium gluconate at the client’ s bedside
2. Monitor blood pressure every 2 hr.
3. (Limit or remove?) IV bag from exposure to light.
4. Attach tan inline filter to the IV tubing.
(Limit or remove?) IV bag from exposure to light.
59
A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings
should the nurse expect?
A. Feelings of dread
B. Heightened perceptual field
C. Rapid speech
D. Purposeless activity
B. Heightened perceptual field
60
A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for
the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders
from the provider should the nurse expect?
A. Withhold the next dose.
B. Increase the dosage.
C. Discontinue the medication.
D. Administer the medication.
D. Administer the medication.
61
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
1. Stay in bed at least 1hr if unable to fall asleep
2. Take 1 hr nap during the day
3. Perform exercise prior to bed
4. Eat a light snack before bedtime
Eat a light snack before bedtime
62
A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the
following medications should the nurse administer?
A. Pregabalin
B. Lorazepam
C. Colchicine
D. Codeine.
A. Pregabalin
63
A nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to read) following actions should the nurse take?
1. Assess the amount of drainage in the collection chamber.
2. Clamp the chest tube during ambulation.
3. Report continuous bubbling in the water seal chamber.
4. Strip the chest tube every 4 hr. to maintain patency.
Report continuous bubbling in the water seal chamber.
64
A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN.
The nurse should monitor for which of the following adverse effects?
A. Productive cough.
B. Urinary retention.
C. Rhinitis
D. Fever.
B. Urinary retention.
65
A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar
disorder. The partner states “I don’t know what to do. Everything has been happening so quickly.”
Which of the following by the nurse is therapeutic?
A. “Can you talk about what happens with your partner at home?”
B. “Why do you think your partner’s symptoms are progressing so quickly?”
C. “You should make sure your partner takes the prescribed medication.”
D. “You did the right thing by bringing your partner in for treatment.”
A. “Can you talk about what happens with your partner at home?”
66
A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the
teaching?
1. “I will put my child on a gluten-free diet”.
2. “I will administer digestive enzymes with meals and snacks”.
3. “Provide my child with some high-fiber foods.”
4. “I will give my child whole wheat toast and milk for breakfast”.
“I will put my child on a gluten-free diet”.
67
A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
1. Prime IV tubing with 0.9% sodium chloride.
2. Use a 24-gauge IV catheter
3. Obtain filterless IV tubing.
4. Place blood in the warmer for 1 hr.
Prime IV tubing with 0.9% sodium chloride.
68
A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of
continuous infusions should the nurse initiate?
A. 0.9% normal saline.
B. NPH insulin.
C. Glargine insulin.
D. 0.45% saline.
A. 0.9% normal saline.
69
A nurse is teaching who has chronic pain about avoiding constipation from opioid medications.
Which of the following should the nurse include in the teaching?
A. Drink 1.5L fluids each day.
B. Take mineral oil at bedtime.
C. Increase exercise activity
D. Decrease insoluble fiber.
C. Increase exercise activity
70
A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching?
A.“Drink 2 liters of warm water per day”.
B. “Empty your bladder every 6 weeks.”
C. “Soak in a warm bath everyday”.
D. “Take an oral estrogen tablet”.
A.“Drink 2 liters of warm water per day”.
71
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving monitoring
B. A client who has a hip fracture and a new onset of tachypnea
C. A client who has epidural analgesia and weakness in the lower extremities
D. A client who has diabetes and a hemoglobin A1C of 6.8%
B. A client who has a hip fracture and a new onset of tachypnea
72
A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?
1. Consume food high in bran fiber
2. Increase intake of milk products
3. Sweeten foods with fructose corn syrup
4. Increase foods high in gluten
Consume food high in bran fiber
73
A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?
1. The infant 30 ml (1 oz) glucose water every 2 hr.
2. Keep the infants head covered with a cap.
3. Ensure that the newborn wears a diaper.
4. Apply lotion to the newborn every 4 hr.
Ensure that the newborn wears a diaper.
74
A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
1. “(Unable to read) I feel to be in his best health care decision”
2. “I will intervene if there is conflict between a client and his provider”
3. I should not advocate for a client unless he is able to ask me himself”
4. I will inform a client that his family should help make his health care decisions.”
“I will intervene if there is conflict between a client and his provider”
75
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
1. Raise the side rails on both sides of the client’s bed during repositioning.
2. Reposition the client without assistive devices.
3. Discuss the client’s preferences for determining are position schedule.
4. Evaluate the client’s ability to help with repositioning.
Evaluate the client’s ability to help with repositioning.
76
A nurse is caring for an infant who has coaction of the aorta. Which of the following should the
nurse identify as an expected finding?
A. Weak femoral pulses
B. Frequent nosebleeds
C. Upper extremity hypotension
D. Increased intracranial pressure
A. Weak femoral pulses
77
A nurse is assisting with the development of an informed document for participation in a
research study. Which of the following information should the nurse include?
1. A statement that participants can leave the study at will.
2. An assignment of the participant to either the experimental or control group.
3. A list of the clients participating in the study.
4. A description of the framework the researchers will use to evaluate the data.
A statement that participants can leave the study at will.
78
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?
1. Excessive sweating
2. Increased urinary frequency
3. Drycough
4. Metallic taste in mouth
Excessive sweating
79
A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the
following should the nurse report to the provider?
A. The client’s pulse oximetry level is 96%.
B. (Unabletoread)
C. The client develops hiccups.
D. The ECG shows pacing spikes after the QRS complex.
C. The client develops hiccups.
80
A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which
of the following resources should the nurse provide to the client?
A. Personal blogs about managing the adverse effects of diabetes medications
B. Food label recommendations from the Institute of Medicine
C. Diabetes medication information from the Physicians’ Desk Reference
D. Food exchange lists for meal planning from the American Diabetes Association
D. Food exchange lists for meal planning from the American Diabetes Association
81
A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?
1. “The PCA will deliver a double dose of medication when you push the button twice.”
2. “You can adjust the amount of pain medication you receive by pushing on the keypad.”
3. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”
4. “You should push the button before physical activity to allow maximum pain control.”
“You should push the button before physical activity to allow maximum pain control.”
82
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following
types of insulin?
A. Glargine insulin.
B. Regular insulin.
C. NPH insulin.
D. Insulin aspart.
A. Glargine insulin.
83
A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate?
1. Looking at alphabet flashcards.
2. Playing with a large plastic truck.
3. Use scissors cutout paper shapes.
4. Watching a cartoon in the dayroom.
Playing with a large plastic truck.
84
A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take?
1. Administer a refrigerated feeding.
2. Increased the amount of water use to flush the tubing.
3. (Unabletoread) rate of the client’s feedings.
4. Instruct the client to move onto their right side.
(Unabletoread) rate of the client’s feedings.
85
A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse’s priority?
1. Monitor the client’ s ECG
2. Take the client’ s vital signs.
3. Administer oxygen
4. Insert an IV line.
Administer oxygen
86
A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take?
1. Provide information about stress management.
2. Maintain a cool temperature in the client’s 3. Administer epinephrine for acute episodes.
4. Give glucocorticoid steroid twice per day.
Provide information about stress management.
87
A nurse is reviewing the medical history of a client who has angina. Which of the following
findings in the client’s medical history should identify as a risk factor for angina?
A. Hyperlipidemia.
B. COPD
C. Seizuredisorder
D. Hyponatremia.
A. Hyperlipidemia.
88
A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal
laceration. The client reports not having a bowel movement for 4 days. Which of the following
medications should the nurse administer?
A. Bisacodyl 10mg rectal suppository.
B. Magnesium hydroxide 30ml PO.
C. Famotidine 20mg PO.
D. Loperamide 4 mg PO.
B. Magnesium hydroxide 30ml PO.
89
A nurse overhears two assistive personnel (AP) discussing care for a client while in the
elevator. Which of the following actions should the nurse take?
A. Contact the client’s family about the incident.
B. Notify the client’s provider about the incident.
C. File a complaint with the facility’s ethics committee.
D. Report the incident to the AP’s charge nurse.
D. Report the incident to the AP’s charge nurse.
90
A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include
1. Withhold all medications until after dialysis
2. Rehydrate with dextrose 5% in water for orthostatic hypotension.
3. Check the vascular access site for bleeding after dialysis.
4. Give an antibiotic 30 min before dialysis.
Check the vascular access site for bleeding after dialysis.
91
A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse’s priority?
1. Develop a safety plan with the client
2. Unable) options for reporting the incident.
3. Refer the client to a community support group.
4. Determine if the client has any injuries
Determine if the client has any injuries.
92
A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min
for the past 15 min. The nurse should identify which of the following conditions as a possible cause
of fetal bradycardia?
A. Maternal fever
B. Fetal anemia
C. Maternal hypoglycemia
D. Chorioamnionitis
C. Maternal hypoglycemia
93
A nurse is assessing a school-age child who has a urinary tract infection. Which of the
following findings should the nurse expect?
A. Periorbital edema.
B. Decreased frequency of urination.
C. Enuresis.
D. Diarrhea.
C. Enuresis.
94
A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
1. A client who has COPD and a respiratory rate of 44/min
2. A client who has cancer with a sealed implant for radiation therapy
3. A client who is receiving heparin for deep-vein thrombosis
4. A client who is 1 day postoperative following a vertebroplasty
A client who is 1 day postoperative following a vertebroplasty
95
A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round the answer to the nearest whole number)
6 mL/hr
96
A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching?
1. “This test should be performed after your baby is 24 hours old.”
2. “A nurse will draw blood from your baby’s inner elbow.”
3. Your baby will be given 2 ounces of water to drink prior to the test.”
4. “This test will be repeated when your baby is 2 months old.”
“This test should be performed after your baby is 24 hours old.”
97
A nurse is providing discharge teaching to a client who is postoperative following a colon
resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching?
1. “My stool will become fully formed within 3 weeks”
2. “My skin will need to be cleaned with alcohol before I apply a new pouch”
3. “I should avoid eating popcorn and fresh pineapple”
4. “I should expect bruising around the stoma”
“I should avoid eating popcorn and fresh pineapple”
98
A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse’s priority?
1. Refer the client to a speech language pathologist.
2. Monitor the client’ s prealbumin levels
3. Measure the client’ s weight.
4. Place the client on NPO status.
Place the client on NPO status.
99
A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
1. “Taking furosemide can cause your potassium levels to be high”
2. “Eat foods that are high in sodium”
3. Rise slowly when getting out of bed”
4. “Taking furosemide can cause you to be over hydrated”
“Rise slowly when getting out of bed”
100
A nurse is planning a teaching session for a client who is postoperative following a colon
resection. Which of the following actions should the nurse take first?
A. Providing written material for the client to read
B. Plan a short instruction about coughing and deep breathing.
C. Determine the client’ s current pain level.
D. Instruct the client about dietary restrictions.
Determine the client’ s current pain level.
101
A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make?
A. Coffee with creamer.
B. Lettuce with sliced avocados.
C. Broiled skinless chicken breast with brown rice.
D. Warm toast with margarine.
C. Broiled skinless chicken breast with brown rice.
102
A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make?
1. “I cannot be a witness for your consent to donate.”
2. Your name cannot be removed once you are listed on the organ donor list.”
3. Your desire to be an organ donor must be documented in writing.”
4. “You must be at least 21 years of age to become an organ donor.”
“Your desire to be an organ donor must be documented in writing.”
103
A nurse is teaching a female client about personal hygiene. Which of the client's actions indicates an understanding of the teaching?
1. The client takes a hot bubble bath every day.
2. The client wipes back to front when toileting.
3. The client washes her perineum first when bathing.
4. The client brushes her teeth twice daily.
The client brushes her teeth twice daily.
104
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
1. Obtain the newborn’s body temperature using a tympanic thermometer.
2. (Unabletoread) FACES pain scale.
3. Auscultate the newborn’s apical pulse for 60 seconds.
4. Measure the newborn’s head circumference over the eyebrows and below the occipitalvprominence. (NOT)
Auscultate the newborn’s apical pulse for 60 seconds.
105
A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days.
The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these findings to which of the following members of the interdisciplinary team?
A. Dietitian
B. Infection control nurse
C. Nephrologist
D. Cardiologist
C. Nephrologist
106
A nurse is caring for an infant who is in contact isolation and received a blood transfusion.
Which of the following actions is appropriate for the nurse to take to provide cost-effective care?
A. Return unopened equipment to the supply center
B. Leave the unused infusion pump in the room until discharge
C. Stock the room with a 2-day supply of disposable diapers
D. Being formula as needed
A. Return unopened equipment to the supply center
107
A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider?
1. Heart rate100/min
2. Temperature 37.8C (100F)
3. Albumin level 4.0 g/dL.
4. WBC count 14,000 mm3
WBC count 14,000 mm3
108
A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material?
1. Emphasize important information using bold lettering.
2. Use 7th grade reading level.
3. Avoid using cartoons in the teaching material.
4. Use words with three or four syllables.
Emphasize important information using bold lettering.
109
A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?
A. “Add salt to season”
B. “Ice chips”
C. “Rinse yourmouth with an alcohol-based mouthwash”
D. “Eat foods served at hot temperatures”
B. “Ice chips”
110
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
D. Contractions
111
A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take?
1. Insert an indwelling urinary catheter.
2. Apply fetal heart rate monitor.
3. Initiate fundal massage.
4. Initiate an oxytocin IV infusion.
Apply fetal heart rate monitor.
112
A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance).
1. Identify family needs interventions using the nursing process.
2. Record information about the home visit according to agency policy.
3. Contact the family to determine availability and readiness to make an appointment
4. Discuss plans for future visits with the family.
5. Clarify the reason for the referral with the provider’s office.
5, 3, 1, 2, 4.
113
A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The Guardian asks, “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make?
1. Your baby needs an IV because she is not producing any tears”
2. “Your baby needs an IV because her fontanels are budging”
3. “Your baby needs an IV because she is breathing slower than normal”
4. “Your baby needs an IV because her heart rate is decreasing”
“Your baby needs an IV because she is not producing any tears”
114
A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration?
1. A residual of 65mL 1hr post prandial
2. History of gastroesophageal reflux disease
3. Sitting in a high-Fowler’s position during the feeding
4. Receiving a high osmolarity formula
A History of gastroesophageal reflux disease
115
A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the teaching?
A. Take magnesium hydroxide for indigestion
B. Drink at least 3L of fluid daily
C. Eat 1g/kg of protein per day
D. Consume foods high in potassium
C. Eat 1g/kg of protein per day
116
A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac
monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms?
A. First degree AV block
B. Premature ventricula contraction.
C. Sinus bradycardia.
D. Atrial fibrillation.
A. First degree AV block
117
A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next?
1. Provide the client with an instructional handout about swallowing exercises.
2. Ask a speech therapist to evaluate the client’s ability to swallow.
3. Discuss the manifestations of impaired swallowing with the AP.
4. Listens to the client’s lung sounds.
Listens to the client’ s lung sounds.
118
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
1. Ask the client directly what he is hearing
2. Encourage the client to lie down in a quiet room
3. A void eye contact with the client
4. Refer to the hallucinations as if the are real
Ask the client directly what he is hearing
119
The nurse is teaching a group of clients at a community health fair about genetic diseases. Which of the following statements by a client indicates an understanding of the teaching?
1. “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease”
2. “There is no need to have genetic counseling if I know that I have a family history of
mental illness.”
3. My family has a genetic risk for breast cancer, so I am considering a total mastectomy”
4. Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments.”
“My family has genetic risk for breast cancer, so I am considering a total mastectomy”
120
A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching?
1. “The cord stump will fall off in 5 days.”
2. “Contact the provider if the cord stump turns black.”
3. “Clean the base of the cord with hydrogen peroxide daily.”
4. “Keep the cord stump dry until it falls off.”
“Keep the cord stump dry until it falls off.”
121
A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the
following statements by the client indicates an understanding of the teaching?
1. I have my eyes examines annually”
2. “I take a calcium vitamin supplement daily”
3. “I limit my intake of foods with potassium”
4. “I constantly take my medication between 8 and 9 each evening”
“I take a calcium vitamin supplement daily”
122
A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the
following actions by a newly licensed nurse indicates an understanding of the teaching?
A. Stands with feet together when lifting a client up in bed.
B. Raises the client’s head of bed before pulling the cline up.
C. Uses a mechanical lift to move client from bed to chair.
D. Places a gait belt around the client’s upper chest before assisting a client to stand.
C. Uses a mechanical lift to move client from bed to chair.
123
A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make?
A. “Your bladder should be full prior to me performing this test
B.“If this test is positive you will be required to have a non-stress test.
C.“This test will determine if there is leaking amniotic fluid”
D. “I will be taking a blood sample to test for changes in your hormones levels”
C.“This test will determine if there is leaking amniotic fluid”
124
A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which
of the following findings indicate the client is developing a complication of therapy?
A. Peripheral edema
B. Increased thirst.
C. Flattened neck veins.
D. Hypotension
A. Peripheral edema
125
A nurse is conducting a home visit for a family who has two young children. The nurse notes
several welts across the backs of the legs of one of the children. Which of the following actions
should the nurse take first?
A. Document clinical findings.
B. Contact child protective services.
C. Refer the parents to a self-help group.
D.Instruct the parents about methods of discipline.
B. Contact child protective services.
126
A nurse is planning care for a client who has thrombocytopenia. Which of the following
actions should the nurse include?
1. Encourage the client to floss daily.
2. Remove fresh flowers from the client’s room.
3. Provide the client with a stool softener.
4. Avoid serving the client raw vegetable.
Provide the client with a stool softener.
127
A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy.
Which of the following findings should the nurse to report?
A. Chest pain
B. Muscles pasms.
C. Cool, moist skin.
D. Incisional pain
A. Chest pain
128
(Unable to read)
1. Use NPH insulin to treat ketoacidosis.
2. Administer NPH insulin 30 minutes before breakfast.
3. (Unabletoread) I think this answer was 0.9% sodium chloride
4. Discard the NPH insulin vial if the medication is cloudy.
(Unabletoread) I think this answer was 0.9% sodium chloride
129
A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take?
A. Maintain the client’s oxygen saturation level at 89%.
B. Place the client’s lower extremities on two pillows.
C. Recommended that the client follow a 3g sodium diet.
D. Place the client in high fowler’s position.
D. Place the client in a high Fowler’s position.
130
A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following should the charge nurse include?
A. “You will need to monitor the client's electrolytes daily”
B. “You will need to change the IV dressing site once per week”
C. “You will need to warm the solution in the microwave before administration”
D. “You need to weigh the client twice per week”
A. “You will need to monitor the client’ s electrolytes daily”
131
A nurse is teaching a prenatal class about infection at a community center. Which of the following statements by a client indicates an understanding of the teaching?
A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
B. “I can clean my cat’s litter box during my pregnancy.”
C. “I should take antibiotics when I have a virus.”
D. “I should wash my hands for 10 seconds with hot after working in the garden.”
A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
132
A nurse is caring for a client who has end-stage liver cancer. Which of the following
statements should the nurse make to support the client’s right to autonomy?
1. “You should trust that your care team has your best interest at heart”
2. “I will not share any personal information without your permission
3. “The health care team will do their best to keep any promise we make to you”
4. We encourage you to participate in all decisions about your treatment”
“We encourage you to participate in all decisions about your treatment”
133
A nurse is completing an incident report after a client fall. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
A. Quality improvement.
B. Patient (Unable to read)
C. Evidence based practice.
D. Informatics
A. Quality improvement.
134
A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take?
1. Confront the nurse about the suspected alcohol use.
2. Inform another nurse on the unit about the suspected alcohol use.
3. Ask the nurse to finish administering medications and then go home.
4. Notify the nursing manager about the suspected alcohol use.
Notify the nursing manager about the suspected alcohol use.
135
A charge nurse is teaching new staff members about factors that increase a client’s risk to become violet. Which of the following risk factors should the nurse include as the best predictor of future violence?
1. Previous violent behavior
2. A history of being in prison
3. Experiencing delusions
4. Male gender
Previous violent behavior
136
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
1. Inform clients about the action of each medication prior to administration.
2. (Unabletoread) two times prior to administration.
3. Complete an incident report if a client vomits after taking a medication.
4. Avoid preparing medications for more than two clients at one time.
Avoid preparing medications for more than two clients at one time.
137
A charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
A. Takes assigned breaks at regular intervals
B. Documents the clients care tasks at the end of the shift.
C. Assisting with ADLs to perform time sensitive activities
D. Gather necessary supplies before beginning a dressing change.
B. Documents the clients care tasks at the end of the shift.
138
A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take?
1. Apply zinc oxide ointment to the irritated area.
2. (Unabletoread)
3. Wipe stool from the skin using store bought baby wipes.
4. Apply talcum powder to the irritated area.
Apply zinc oxide ointment to the irritated area.
139
A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client’s fundus?
C
140
A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?
A. “The client might act seductively.”
B. “The client is overly concentrated about minor details.”
C. “The client exhibits impulsive behaviors.”
D. “The client is exceptionally clingy to others.”
C. “The client exhibits impulsive behaviors.”
141
A nurse is caring for a client who has a prescription for warfarin. When reviewing the client’s current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply).
A. Aspirin
B. Magnesiumsulfate
C. Gingkobiloba.
D. Cetirizine
E. Ibuprofen.
A, C, E
142
A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?
1. Ritual behavior
2. Suspicious of others
3. Exhibits separation anxiety
4. Preoccupied with aging
Preoccupied with aging
143
A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb) and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client’s BMI value as which of the following?
A. 23
B. 42
C. 32
D. 8
A. 23
144
A nurse is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding?1. The child expresses curiosity about the death process.
2. The child refuses to talk about death.
3. The child believes the person will return.
4. The child focuses on his own mortality.
The child believes the person will return.
145
A nurse is assessing a client in the emergency department. Which of the following actions
should the nurse take first?
**Exhibit 1**
*Laboratory Results *
Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl
Glucose 35 mg/dl Cloudy in appearance
**Exhibit 2**
*History and Physical*
Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic.
**Exhibit 3**
*Vital Signs*
BP 166/96 mm Hg
Respiratory rate 24/min
Pulse rate 112/min
Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9
1. Place the client on a cooling blanket.
2. Administer an analgesic.
3. Obtain arterial blood gas levels.
4. Elevate the head of the client’s bed 30 degrees.
Obtain arterial blood gas levels.
146
A client is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication?
1. Decreased hematocrit.
2. Increased blood pressure.
3. Tachycardia.
4. Hypothermia.
Tachycardia.
147
A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching?
1. “Use a vein in the middle of the lower arm to insert a PICC.”
2. Flush a PICC using a 3-milliliter syringe.”
3. “Informed consent is required prior to PICC placement.”
4. “Position the client’s arm in adduction for PICC placement.”
“Informed consent is required prior to PICC placement.”
148
A nurse is reviewing admission prescriptions for a group of clients. Which of the following
prescriptions should the nurse identify as complete?
1. Furosemide 20 mg BID
2. Nitroglycerin transdermal patch.
3. Aspirin 1 tablet daily.
4. Metoprolol 5mg IV now.
Metoprolol 5mg IV now.
149
A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
1. Hold hand flat to perform percussion on the child
2. Perform the procedure twice a day
3. Administer a bronchodilator after the procedure
4. Perform the procedure prior to meals
Perform the procedure prior to meals
150
A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?
1. A client who received a Mantoux test 48hr ago and has an induration
2. A client who is schedule for a colonoscopy and is taking sodium phosphate
3. A client who is taking warfarin and has an INR of 1.8
4. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L
A client who is taking warfarin and has an INR of 1.8
151
A nurse is caring for a client who is postpartum and requests information about contraception.
Which of the following instructions should the nurse include?
A. “The lactation amenorrhea method is effective for your first year postpartum”
B.“You can continue to use the diaphragm used before your pregnancy”
C. “Place transdermal birth control patch on your upper arm”
D. “I should avoid vaginal spermicides while breastfeeding.”
C. “Place transdermal birth control patch on your upper arm”
152
A nurse is reviewing the facility's safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?
1. “Staff will apply identification band after first bath”
2. “I will not publish a public announcement about my baby’s birth”
3. “I can remove my baby’s identification band as long as she is in my room”
4. “I can leave my baby in my room while I walk in the hallway”
“I will not publish public announcement about my baby’s birth”
153
A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?
1. Restrict the client’s total fluid intake to 250mL/hr
2. Give the protamine if signs of magnesium sulfate toxicity occur
3. Monitor the FHR via Doppler every 30min
4. Measure the client’s urine output every hour
Measure the client’s urine output every hour
154
A nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make in the medical record?
1. “Morphine 3 mg SQ every 4 hr. PRN for pain.”
2. “Morphine 3mg Subcutaneous (Unable to read)
3. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.”
4. “Morphine 3 mg SC q 4 hr. PRN for pain.”
“Morphine 3mg Subcutaneous (Unable to read)
155
A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect?
A. Metabolic acidosis.
B. Metabolic alkalosis.
C. Respiratory acidosis.
D. Respiratory alkalosis.
A. Metabolic acidosis.
156
A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
1. Notify the provider.
2. Report the incident to the nurse manager.
3. Monitor vital signs.
4. Fill out an incident report.
Monitor vital signs.
157
A nurse receives a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider?
1. “Have your child lie down and turn their head to their side for 10 minutes”
2. “Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s nose”
3. “Place a warm wet washcloth over your child’s forehead and the bridge of their nose”
4. “Tell your child to blow their nose gently and then sit down and tilt your head back” <
“Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s
158
A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?
1. Match the client’s blood type with the type and cross-match specimens.
2. Confirm the provider’s prescription matches the number on the blood component.
3. Ask the client to state the blood type and the date of their last blood donation.
4. Ensure that the client’s identification band matches the number on the blood unit.
Ensure that the client’s identification band matches the number on the blood unit.
159
A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications?
1. Zolpidem 10mg PO one tablet at bedtime
2. Hydrochlorothiazide12.5mg PO BID
3. Triamcinolone acetonide 100 mcg/inhalation two puffs TID
4. Lorazepam .5mg PO one tablet daily
Lorazepam .5mg PO one tablet daily
160
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
A. Offer fluids every 2hr.
B. Document the client’s behavior prior to being placed in seclusion.
C. Discuss with the client his inappropriate behavior prior to seclusion.
D. Assess the client’s behavior once every hour.
A. Offer fluids every 2hr.
161
A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
1. “Dehydration is treated with calcium supplements”
2. “Dehydration can increase the risk of preterm labor”
3. “Dehydration associated gastroesophageal reflux
4. “Dehydration is caused by a decreased hemoglobin and hematocrit”
“Dehydration can increase the risk of preterm labor”
162
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following interventions should 1. Clamp the (Unable to read)
2. Administer fluid bolus.
3. Obtain a urine specimen for culture and sensitivity
4. Initiate continuous bladder irrigation.
Obtain a urine specimen for culture and sensitivity
163
A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?
1. Heartrate58/min
2. Fasting blood glucose 100mg/dL
3. Hgb 14 g/dL
4. WBC count 2,900/mm3
WBC count 2,900/mm3
164
A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report?
1. (Unabletoread)
2. (Unabletoread)
3. Answer might be lower platelets.
4. (Unabletoread)
Answer might be lower platelets.
165
A nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?
A. Serotonin syndrome
B. Tardive dyskinesia
C. Pseudo parkinsonism.
D. Acute dystonia.
A. Serotonin syndrome
166
A client who sustained a major burn over 20% of the body. Which of the following
interventions should the nurse nutritional requirements?
A. (Unabletoread) (Chose this one)
B. Keep a calorie count for food and beverages.
C. Schedule meals at 6hr .intervals
D. Provide low-protein high carbohydrate diet
A. (Unabletoread) (Chose this one)
167
A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine. The nurse should collect additional (Unable to read) for which of the following client prior to administering the vaccine?
1. (Unable to read)
2. Client has (Unable to read) HIV/AIDS
3. Client has a sensitivity to eggs.
4. Client is experiencing seasonal allergies.
Client has a sensitivity to eggs.
168
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?
A. “Limit your child’s potassium intake while she is taking this medication.”
B. “You can add the medication to a half-cup of your child’s favorite juice.”
C. “Repeat the dose if your child vomits within 1 hour after taking the medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
169
A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
A. Obtain the specimen immediately upon the client waking up.
B. Wait 1 day to collect the specimen if the client cannot provide sputum.
C. Ask the client to provide 15 to 20 ml of sputum in the container.
D. Wear sterile gloves to collect specimen from the client.
A. Obtain the specimen immediately upon the client waking up.
170
A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider?
A. Digoxin 0.8ng/ml
B. Sodium (Was out of range)
C. BUN15
D. Potassium 3.1mEq/L.
D. Potassium 3.1mEq/L.
171
A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take?
A. Store the glasses in a labeled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.
A. Store the glasses in a labeled case.
172
A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include?
1. “This type of seizure can be mistaken for daydreaming.”
2. “This type of seizure lasts 30 to 60 seconds.”
3. “The child usually has an aura prior to onset.”
4. “This type of seizure has a gradual onset.”
“This type of seizure can be mistaken for day dreaming.”
173
A nurse is planning care for a client who has cancer and is about to receive low-dose
brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care?
1. Removal of vaginal packing
2. Insertion of an indwelling urinary catheter
3. Ambulation four times daily
4. Maintenance of NPO status until therapy is complete
Insertion of an indwelling urinary catheter
174
A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications?
1. aPTT.
2. Pyro (Unsure if that’s the writing)
3. Platelet count.
4. INR.
aPTT.
175
A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation?
A. Identify solutions prior to negotiation
B. Focus on how the conflict occurred
C. Attempts to understand both sides of the issue
D. Personalize the conflict
C. Attempts to understand both sides of the issue
176
A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as the clinical staff. Which of the following instructions should the nurse include?
A. Use the client's children to provide interpretation
B. (Answer was the nurse was going to do the interpretation)
C. Offer client's translation services for a nominal fee
D. Evaluate the client's understanding at regular intervals
B. (Answer was the nurse was going to do the interpretation)
177
A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of increased intracranial pressure?
A. Tachycardia
B. Narrowed pulse pressure
C. Hypotension
D. Increasingly severe headache
D. Increasingly severe headache
