1. A male client who had a transurethral resection of the prostate (TURP) today has a continuous bladder irrigation (CBI). The client requests pain medication for abdominal pain rated at “ 9“on a scale of 1 to 10. What action should the nurse take first?
A. Administer prescribed PRN analgesic medication.
B. Position him on the left side and slow the irrigation rate.
C. Palpate his abdomen and check his urinary output. <
D. Assist him to ambulate to help pass flatus.
2. The mental health nurse takes sever al adolescent clients to the inpatient schoolroom. The teacher asks the nurse to stay and help one of the male clients who has attention deficit hyperactivity disorder with his spelling assignment. Which goal is reasonable for this client to attain during this one hour class?
A. Completes at least one page of spelling. <
B. Follows directions the first time they are given.
C. Sits quietly with peers and completes assignment.
D. Shares his problems with others in the class.
3. A client is receiving a standardized solution of heparin 25,000 units/250 ml of normal saline. The healthcare provider prescribes to increase the client’s current infusion rate of heparin to 700 units/hour. How many ml/hour should the nurse program the infusion pump? Enter the numerical value only.
Using formula, D/H x Q, 700 units/hour 25,000 units x 25o ml = 7 ml/hour
4. A client is receiving the intravenous adrenergic agonist dobutamine (Dobutrex). In evaluating the client’s reaction to the medication, which assessment finding indicates to the nurse that the medication is effective?
A. The client denies chest pain or discomfort.
B. The client had 160 ml urine output in 8 hours.
C. The client’s blood pressure is 110/70 mmHg. <
D. The client’s posterior tibial pulses are 1+.
5. A client misses breakfast because of a two hour hand washing ritual that is performed daily. What plan is most therapeutic for the nurse to implement?
A. Meet with the client daily to discuss motivation for initiating the ritual.
B. Wake the client early so the ritual can be completed before breakfast. <
C. Set limits on amount of time the client is allowed to perform the ritual.
D. Socialize with the client during the ritual to demonstrate acceptance.
6. Which discharge instruction should the nurse provide a client with heart failure who is taking digoxin Lanoxin)?
A. Avoid concurrent use of herbal products. <
B. Take Lanoxin with high fiber foods.
C. Restrict fluid intake to equal urine output.
D. Check blood glucose level weekly.
The charge nurse in the Intensive Care Unit (ICU) needs to transfer a client to the medical unit so that a client from the Emergency Room can be admitted to ICU. Which client is best to consider?
A. A 38 year old with a myocardial infarction who is having multifocal premature ventricular contractions.
B. A 66 year old with congestive heart failure who has 2+ pitting edema and is short of breath on exertion. <
C. A 58 year old diagnosed with Guillain Barre syndrome who is having difficulty breathing.
D. An 80 year old with a bleeding peptic ulcer who has a Hgb of 7 g/dl and coffee ground drainage from NG.
8. The nurse stops to render aid at the scene of a motor vehicle collision and finds a child about 6 months of age strapped into a car seat in the back seat of the car. After calming the infant with a pacifier, what action should the nurse take?
A. Remove the infant from the car seat while stabilizing the neck.
B. Assess the infant’s ability to move arms and legs.
C. Determine if pupils constrict when exposed to light.
D. Lift the car seat out of the car with the infant strapped in it.
9. An unresponsive fem ale victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied bya close friend, but no family members are available. Which intervention should the nurse implement?
A. Obtain an emergency court order for life saving surgery for the client.
B. Prepare the client for surgery without a signed informed consent. <
C. Ask the woman’s friend if the client has an advanced directive.
D. Monitor the client until a family member can be located.
10. A confused and combative male client was placed in bilateral wrist restraints to keep him from pulling out a nasogastric tube. The client developed severe abrasions on both wrists. On the morning that the abrasions were found, the client’s record contained nursing documentation stating that skin and circulation checks were conducted every 6 to 8 hours. How should the nurse manager respond to this
situation?
A. Meet with the client’s nurse to determine why adequate assessment was not performed. <
B. Reassure the staff that skin damage can occur even when the standard of care is met.
C. Provide an in service on the documentation needed for clients with altered skin integrity.
D. Instruct the staff about the correct protocol for the application of bilateral wrist restraints.
11. When the nurse auscultates the anterior chest just above the right nipple, moderate pitched breath sounds are heard that are equal on inspiration and expiration. Which statement best describes t his finding?
A. Bronchial breath sounds that are normal in that location.
B. Bronchovesicular breath sounds that are abnormal in that location.
C. Bronchial breath sounds that are abnormal in that location.
D. Bronchovesicular breath sounds that are normal in that location. <
12. A client is seen in the clinic with an acute episode of acute gastritis. Which nursing diagnosis has the highest priority?
A. Acute pain related to inflammation. <
B. Nausea related to gastric irritation.
C. Knowledge deficit related to diet.
D. Potential for injury related to bleeding.
13. The nurse should encourage males over the age of 45 to obtain which test to screen for prostatic cancer?
A. Prostate specific antigen (PSA). <
B. Serum testosterone level.
C. Alpha fetoprotein radioimmunoassay (AFP).
D. Ultrasound of the scrotum.
14. A male client tells the nurse that he does not want to receive a blood transfusion that was prescribed to treat internal hemorrhaging. What action should the nurse implement?
A. Notify the prescribing healthcare provider of the client’s refusal to receive the blood transfusion.
B. Notify the hospital’s attorney of the client’s wishes and the need to exercise life saving measures.
C. Check the client’s medical record to see if he signed a legal informed consent form.
D. Explain the treatment options available to him if he refuses the prescribed blood transfusion.
15. The nurse is caring for a laboring client whose membranes ruptured 24 hours prior to admission. Based on the laboring client’s record and the current fetal monitor reading, which action should the nurse implement? (Click on each chart for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)
A. Stop the oxytocin infusion.
B. Prepare for Cesarean delivery.
C. Assess the vital signs
D. Apply oxygen 10 L/mask.
16. Which nursing intervention has the highest priority when completing discharge teaching for a client with Helicobacter pylori (H. pylori) induced peptic ulcer diseases (PUD)?
A. Refer the client to a counselor for information on stress reduction and relaxation.
B. Encourage the client to eat regularly scheduled meals to help prevent the pain.
C. Instruct the client to take all the antibiotics, proton pump inhibitors, and Pepto Bismol. <
D. Teach the importance of taking the Carafate medication immediately before meals.
17. A client had a total hip replacement two days ago. She has never been in the hospital before. She has just called for the bedpan. How should the nurse place the pan under this client?
A. Ask her to roll to t he unoperated side and slide the bedpan under her, then roll back onto the pan. <
B. Ask her to roll to the operated side and slide the bedpan under her, then roll her back onto the pan.
C. Ask her to flex her knees, spread her legs, and lift her buttocks with t he flat part of her feet , then push the bedpan under her from the front.
D. Ask her to grab her over bed trapeze, push both heels into the mattress, and raise her buttocks off the bed so the bedpan can be slipped under her.
18. A male client diagnosed with hyper tension has a nursing go al of, “The client will be able to verbalize ways to decrease blood pressure.” What statement by the client indicates that this outcome has been met?
A. “I should have my blood pressure checked monthly to make sure it is within normal limits.”
B. “If I lose weight, quit smoking, and exercise regularly I may not have to take any medication.” <
C. “I should increase my fluid intake and decrease my fiber
D. “If I take my medication every day, I won’t have to worry about my blood
19. On the third day of hospitalization for depression, a male client tells the nurse that he is feeling much better and reports that he believes the antidepressant therapy is working. He participates in all scheduled activities and agrees to take on additional ward assignments. What nursing action is most important for the nurse to implement at this time?
A. Assign an attendant to monitor the client’s whereabouts at all times. <
B. Praise the client’s willingness to take on additional duties.
C. Encourage the client to share his positive attitude with other clients.
D. Monitor the client’s behavior and intake during meals to determine appetite.
20. A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the trauma unit. How should the nurse position this client
A. Totally prone.
B. Right side lying.
C. Completely supine.
D. Elevated head of bed. <
21. The parents of a 4 week old male infant report that he eats well but vomits after each feeding. Which assessment finding should the nurse expect him to exhibit if the baby is receiving inadequate nutrition?
A. Tachypnea.
B. Hypoactive bowel sounds.
C. Sunken fontanels. <
D. Absent Moro reflex.
22. The nurse is planning the discharge teaching for a female client who has frequent urinary tract infections. In teaching the client how to prevent urinary tract infections, which recommendation should the nurse include?
A. Void immediately after intercourse. <
B. Sit in a tub of warm water each evening.
C. Drink a glass of water upon arising each morning.
D. Perform Kegel exercises several times daily.
23. When administering an antibiotic that causes photosensitivity, which instruction is important for the nurse to provide the client?
A. Have hearing checked periodically.
B. Be sure to drink plenty of fluids after activity.
C. Wear long sleeved clothing outdoors. <
D. Get up slowly to avoid dizziness.
24. A client is receiving an infusion of 500 ml D5W with 25,000 units of heparin at 1,000 units/hour has a partial thromboplastin time (PTT) of 110 seconds. The sliding scale prescription reads: “If the PTT is less than 65 seconds, increase the rate by 200 units/hour; and if the PTT is greater than 95 seconds decrease the rate by 200 units/hour.” The nurse should regulate the infusion pump for how many ml/hour? (Enter numeric value only.)
16
25. The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid?
A. Whole grain cereal and milk. <
B. Hard boiled egg and juice.
C. Vanilla milkshake with protein supplement.
D. Toasted white bread with butter.
26. An 8 month old boy who has tetralogy of Fallot experiences periodic “tet spells” with paroxysmal dyspnea. Which nursing intervention is most effective in managing these episodes?
A. Administer digoxin and Lasix as prescribed.
B. Administer oxygen and place the child i n the knee chest position. <
C. Place the child in a prone position and administer chloral hydrate.
D. Elevate the head of the bed and take the child’s vital signs.
27. A 21 year old male client has developed splenomegaly secondary to infection mononucleosis. What factor in the client’s history is most important in developing his discharge teaching plan?
A. He regularly eats at fast food restaurants.
B. On weekends he usually drinks 1 or 2 beers.
C. Lately he has been sleeping 10 to 12 hours every night.
D. He works as a furniture mover. <
28. The nurse is monitoring an infant with pulmonic stenosis. Which finding is most important for the nurse to report to the healthcare provider?
A. Clubbing of the fingers.
B. Systemic cyanosis. <
C. Presence of a thrill.
D. Polycythemia.
29. The nurse is planning care for a newborn with bladder exstrophy. During the preoperative period, which intervention should the nurse implement?
A. Expose the bladder to room air to promote scar formation.
B. Place a dry sterile dressing over the exposed bladder.
C. Apply a sterile non adherent dressing over the bladder. <
D. Use pre weighed large diapers for diapering the infant.
30. After positioning a client on the side to administer a rectal suppository, the nurse observes that the client has been incontinent of a large amount of liquid stool, which has soaked through a gauze pad covering a stage three pressure ulcer. What action should the nurse take first?
A. Administer the rectal suppository.
B. Replace the soiled dressing. <
C. Assess the client’s bowel sound s.
D. Check the client for an impact ion.
31. The nurse is assessing a 48 year old client with Guillain Barre syndrome. What symptom is this client most likely to exhibit?
A. Pill rolling movement of the fingers.
B. Difficulty keeping eyelids open.
C. Pain on one side of the face.
D. Decreased mobility of t he legs. <
32. The emergency department notifies the charge nurse at 3:00 a.m. of the transfer of a client who is being admitted because of multiple lacerations that are a result of self destructive behavior. Agency policy states that this client should be ad mitted to a safe room with window locks, but the only safe room on the unit is currently occupied by a postoperative client. What action should the nurse take?
A. Admit the client to a regular room and provide intensive monito ring.
B. Have the client remain in t he emergency department until morning.
C. Move the postoperative client to another room. <
D. Decline the client because a safe room is unavailable.
33. The nurse is caring for a two day postoperative client. What assessment finding indicates that wound healing is likely?
A. Tolerated a full liquid diet on the second postoperative day.
B. Ambulated in the hallway 24 hours after surgery.
C. Current serum potassium level is 4.9 mEq/L.
D. Total serum protein is 5.4 g/dl. <
34. A client’s arterial blood gases are: pH 7.5, PaO2 94, PaC O2 30, HCO2 24. What action should the nurse take based on these findings?
A. Auscultate the client’s breath sounds for increased secretions.
B. Review the client’s electrolytes and intake/output for fluid balance.
C. Assess the client for nausea, vomiting, or diarrhea.
D. Assess the client for causes of hyperventilation. <
35. A “Code Pink” is announced over the hospital intercom system, indicating that a baby has been abducted from the nursery. What action should the charge nurse on a medical surgical unit implement first?
A. Assign one UAP to report to the nursery to assist with the search.
B. Instruct the nursing staff to check every client’s room, bathroom, and treatment room.
C. Assign one staff member to stay at each of the emergency exits and stairwell doors.
D. Stay alert for further announcements because a code pink primarily affects maternity units.
36. A client who is experiencing paranoid ideation is admitted to the psychiatric unit. During the first 48 hours of treatment, which nursing intervention is best for the nurse to implement?
A. Place the client in group activities with other paranoid clients.
B. Encourage the client to participate in unit social activities.
C. Refer the client to occupational therapy.
D. Allow the client to initiate relationships and activities. <
37. Which surveillance clues are specific potential indicators of a bioterrorism attack? (Select all that apply.)
A. Geographic clustering of client illnesses. <
B. Increased rate of hospital emergency room visits.
C. Emergency room understaffing for six consecutive shifts.
D. Increased prevalence of cases previously not seen in a geographic area. <
E. Increased biosafety practice precautions used by emergency room staff.
F. Unusual age distribution for a common disease. <
38. A client in acute renal failure h as a serum potassium level of 6.3 mEq/L. What medication can the nurse expect the healthcare provider to prescribe?
A. Nitrofurantoin (Macrodantin) orally.
B. Erythropoietin (Epogen) intravenously.
C. Kayexalate retention enema. <
D. Azathioprine (Imuran) orally.
39. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?
A. Position a hip wedge for lateral uterine displacement. <
B. Adjust the ventilation to compression ratio to 3:20.
C. Apply less compression force to r educe aspiration.
D. Apply oxygen mask after opening the airway.
40. A client has produced the first of a series of sputum samples for cytology. What action should the nurse implement?
A. Ensure the client remains NPO until all the samples are collected.
B. Discard the initial sample and document the time it was obtained.
C. Transport the sputum container to the laboratory in a biohazard bag. <
D. Document the time the client last ate or drank on the laboratory slip.
41. In scheduling home visit s, which client is best for the home health charge nurse to assign to the licensed practical nurse (LPN)?
A. A client who needs the first postoperative dressing change following a skin graft to the lower leg.
B. A postoperative client who no longer needs wound care, but has called to report a fever.
C. A client with diabetes who has called to report a newly discovered foot ulceration.
D. A bedfast client who needs daily irrigation of a stage 4 pressure ulcer. <
42. A client is hospitalized for pregnancy induced hypertension (PIH) and is receiving magnesium sulfate 2 g/hour IV. Which medication should the nurse plan to have immediately available for this client?
A. Sodium bicarbonate.
B. Atropine.
C. Epinephrine.
D. Calcium gluconate. <
43. Which statement by the mother of a male toddler with croup indicates to the nurse that the teaching was effective?
A. “I need to take him to the nearest ER immediately if he starts having trouble swallowing.”
B. “The cough makes him sound sicker than he is. I don’t need to
C. “I can give him baby aspirin for the fever and cough.”
D. “Using a steam vaporizer at night in his room will help ease the cough.”
44. The healthcare provider prescribes meperidine (Demerol) 25 mg IV every 3 hours for an older, postoperative client. The nurse prepares the prescribed dose from a cartridge labeled “meperidine 75 mg/ml” and dilutes the medication with 5 ml of normal saline for IV administration. How many ml is the total volume of diluted medication? (Enter numeric value only. If rounding is required, round to the
nearest tenth.)
5.3
45. Which assessment finding indicates to the nurse that resolution of a client’s subcutaneous emphysema has occurred?
A. No crepitus palpated at site. <
B. Client denies pain or tenderness at site.
C. No lymph node enlargement.
D. No redness or inflammation noted.
46. One hour after receiving the initial dose of doxazosin (Cardura), a male client with benign prostatic hypertrophy complains of a rapid heartbeat and dizziness. He is sitting at the side of the bed finishing his bedtime snack. His radial pulse is 144 b eats/minute. What action should t he nurse take first?
A. Assist the client to a recumbent position.
B. Notify the healthcare provider.
C. Obtain his blood pressure and apical pulse rate. <
D. Obtain an electrocardiogram (ECG).
47. When preparing the client for a thoracentesis, it is essential for the nurse to take which action?
A. Have the client lie in the prone position. <
B. Determine if chest x rays have been completed.
C. Encourage the client to cough during the procedure.
D. Ask the client to void prior to the procedure.
48. The nurse is preparing a disaster plan for a community. When planning for a potential bioterrorism attack, which disease should be considered?
A. Shigellosis.
B. West Nile virus.
C. Pertussis.
D. Tularemia. <
49. The nurse has completed discharge teaching with a client who ha d perineal surgery one week ago. Which statement by the client indicates that the teaching was effective?
A. “I will try to avoid eating fruits and
B. “I will limit my fluid intake to about a quart a
C. “I will cleanse the perineum after every bowel movement.” <
D. “I will only use enemas if I do not have a daily bowel movement.”
50. A male client tells the nurse that he has experienced acid reflux for several years. The nurse recognizes that this client has an increased risk for what problem?
A. Cancer. <
B. Cardiac disease.
C. Abdominal aneurysm.
D. Lymphadenopathy.
51. Which equipment should the nurse use to administer iron to an infant with iron deficiency anemia?
A. Rectal suppository.
B. Medicine dropper. <
C. Medicine cup.
D. IV pump.
52. A 25 year old male client with testicular carcinoma is scheduled for a unilateral orchiectomy tomorrow. During the preoperative preparation, he tells the nurse that he is concerned that his scrotum will not look normal after the surgery, even though he knows that a testicular prosthesis will b e inserted during surgery. What immediate response is best for the nurse to provide?
A. Explain that the prosthesis feels and looks natural in the scrotum. <
B. Refer the client to a support group for young adults with cancer.
C. Reassure the client that no one will know just by looking at him.
D. Arrange for a recipient of testicular prosthesis to visit the client.
53. An adult male client presents to the psychiatric clinic accompanied by his mother who is concerned that her child is going to jail because he broke into a jewelry store. The nurse conduct s an intake assessment and determines that the son is using marijuana daily. What information should the nurse provide this mother?
A. Describe the consequences of enabling behaviors. <
B. Suggest to the mother that she allow her son to go to jail.
C. Refer the son to a drug treatment program immediately.
D. Tell the mother to discourage her son’s marijuana use.
54. The nurse plans to frequently monitor the skin color, mucous membranes, and nail beds of a client with acute renal failure (A RF). What is the purpose in carrying out this nursing intervention?
A. Identify early signs of infections.
B. Identify early signs of dietary deficiencies.
C. Detect signs of anemia. <
D. Assess for signs of jaundice.
55. A 7 year old with Guillain Barre syndrome is admitted with ascending paralysis to the C 6 level. In developing a plan to prevent disease until the paralysis subsides, which intervention is most important for the nurse to include in the child’s plan of care?
A. Emotional support and diversional, educational activities.
B. Adequate fluid intake and hygienic care for an indwelling catheter.
C. Bowel incontinent care and skin care to bony prominences.
D. Range of motion and passive exercises of all large muscle groups. <
56. A female client who is being prepared for a hysterosalpingogram (HSG) informs the nurse that she is allergic to shellfish. What action should the nurse implement?
A. Administer an antihistamine before the HSG.
B. Document the client’s allergy.
C. Notify the healthcare provider. <
D. Ensure that a latex free supply c art is available.
57. Returning to t he office after seeing a homebound client, the home health care nurse has many telephone messages from the assigned caseload. Which telephone message should the nurse return first?
A. A young adult who was discharged from the hospital yesterday and is not fee ling well. <
B. An older adult with Type 2 diabetes who complains of intense itching of both feet.
C. An adult client with a peripheral saline lock with redness at the insertion site.
D. A middle aged client with a sigmoid colostomy who has irritation around the stoma.
58. A client with hypertension is scheduled to receive a dose of the alpha beta adrenergic blocking agent carvedilol (Coreg). Which of the client’s vital signs warrants notification of the healthcare provider prior to administering the scheduled dose?
A. Temperature of 101.4 F.
B. Blood pressure of 170/92.
C. Pulse rate of 42 beats/minute. <
D. Respiratory rate of 12 breaths/minute.
59. A 45 year old female client who had a hysterectomy one week ago asks the nurse when she will start to experience hot flashes. Before responding to the client’s question, what information should the nurse obtain?
A. The reason why the hysterectomy was performed.
B. The type of birth control used preoperatively.
C. The type of hysterectomy that was performed.
D. Whether the client’s ovaries were also removed. <
60. After sitting outside, an elderly male who is attending an adult daycare center develops urticaria and a macular rash with raised wheals over most of his trunk. He is slightly dyspneic, and is furiously scratching the rash with both hands. What action should the nurse take first?
A. Call 911 to transport the client to an emergency center. <
B. Assess the vital signs q15 minutes for one hour.
C. Ask the client if there were any fire ants on the patio.
D. Cover the hives with a topical antihistamine cream.
61. A client with an indwelling urinary catheter has developed hematuria in the last four hours. What action should the nurse implement?
A. Assist the client to a right side lying position in the bed.
B. Determine if the client is receiving any anticoagulant medications. <
C. Withhold further oral fluids until the healthcare provider is notified.
D. Remove the client’s indwelling urinary catheter immediately.
62. The charge nurse observes a male healthcare provider viewing his sister’s record on the computer monitor. What action should the nurse take?
A. Remind the healthcare provider that only the treatment team should view the client’s records. <
B. Tell the healthcare provider to maintain confidentiality of the contents in his sister’s record.
C. Allow the healthcare provider to continue viewing the client’s medical record.
D. Ask the client if she gave her brother permission to view her record.
63. While receiving the first of two prescribed units of packed red blood cells, a client develops a low grade fever, flushing, and urticaria, so the nurse stops the transfusion. What action should the nurse implement next?
A. Notify the healthcare provider of the client’s reaction to the transfusion.
B. Obtain the second unit of packed red blood cells from the blood bank.
C. Start a second IV line to administer emergency intravenous medications.
D. Maintain the patency of the IV site by infusing a normal saline solution. <
64. The nurse is working with an unlicensed assistive personnel (UAP) to prepare a client who had hip replacement surgery for transfer to the rehabilitation unit. A practical nurse (PN) enters the room and reports that a client with pneumonia has become confused and combative. What action should the nurse implement?
A. Ask the UAP to continue packing the belongings of t he surgical client while the two nurses return to the room of the combative client. <
B. Continue to prepare the surgical client for the transfer and instruct the PN to apply restraints to the combative client.
C. Assign the UAP to stay with the combative client until the two nurses have transferred the surgical client to the rehabilitation unit.
D. Assess the combative client after asking the PN to help the UAP prepare the surgical client for transfer to the rehabilitation unit.
65. At a 2 year old well child visit, a toddler’s parent tells the nurse that this child, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?
A. Demonstrate games requiring expressive speech.
B. Suggest that the parent read aloud to the child at bed time.
C. Schedule an appointment wit h pediatric audiologist. <
D. Encourage the parent to enroll in preschool classes.
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