1. The nurse shows a teenager how to use a metered dose inhaler of ipratropium
(Atrovent). Which statement, if made by the client to the nurse, indicates... [Show More] teaching is
effective?
1. “I should use this medicine to stop the coughing that leads to an asthma attack”
2. “I should use this medicine if I begin to have an asthma attack”
3. “I should use this medicine right after I have an asthma attack”
4. “I should use this medicine to prevent an asthma attack”
Answer#2
2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of
the following statements, if made by the client to the nurse, should be reported to the
technician before the test?
1. “I take medication to control my blood pressure”
2. “I have had diabetes for about 10 years now”
3. “I had a knee replacement 5 years ago”
4. “I am allergic to penicillin and sulfa medications”
Answer#3
3. The nurse makes the following observations of a 6 hour old newborn: axillary
temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black
sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which
action?
1. Feed the newborn 30mL of infant formula
2. Administer low flow oxygen to the newborn
3. Wrap the newborn in a warmed blanket
4. Perform a guaiac test on the newborns stool
Answer#3
4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The
nurse plans to get the patient out of bed for the first time at 4PM. It is MOST
important for the nurse to take which of the following actions?
1. Turn the patient from side to side at 2 PM
2. Offer pain medication to the patient at 3:30PM
3. Encourage the patient to use the incentive spirometer at 3PM
4. Cough and deep-breathe the patient at 2:30PM
Answer#1
5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The
nurse should intervene with which of the following patients before their departure?
1. A 50 year old female who is having difficulty with sleeping, eating, and social
interaction.
2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20
pounds overweight.
3. A 42 year old female who has problems with decision making who paces
continuously, wringing her hands.
4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a
sundress without a hat or sunglasses.
Answer#4 (photosensitivity;causes sensitivity to sun)
6. A patient experiences skin eruptions due to an allergic reaction to a medication. The
nurse demonstrates the BEST documentation with which of the following?
1. “Patient complains of rash and itching over most of his body. Patient is concerned
about how it looks”
2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch”
3. “Allergic skin reaction to medication experienced by patient. Started several hours
ago”
4. “Vital signs stable. Patient scratching arms and chest area frequently”
Answer#2
7. An older client diagnosed with emphysema is admitted to the psychiatric unit for
treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client
expresses concern to the nurse that someone will come in and change the amount of
oxygen the client is receiving. INITIALLY, the nurse should take which of the following
actions?
1. Schedule an in-service with the staff about emphysema
2. Place a sign above the patient’s bed stating that the oxygen level is not to be
changed
3. Tell the patient she will be well cared for in the hospital
4. Convey the patient’s concern to the nursing staff
Answer#2
8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl
is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus
midway between the symphysis pubis and the umbilicus. Which statement by the nurse
is BEST?
1. “You are 24 weeks pregnant. It is good that you came in for prenatal care”
2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby”
3. “You are 16 weeks pregnant. Let’s talk about what that means”
4. “You are 8 weeks pregnant. Are your periods usually irregular?”
Answer#3
9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to
concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the
prescribed medications, fearing that they are harmful. After the nurse gives the client the
medication, the nurse should take which of the following actions?
1. Instruct the client to open her mouth and move her tongue up and down and to each
side while the nurse looks inside.
2. Ask the client if she has swallowed the medication completely.
3. Watch the client’s behavior to see if the medication is having its desired effect.
4. Observe the clients throat while she swallows several times after putting the
medication in her mouth.
Answer#1
10. The nurse assesses a patient 72 hours after a total joint replacement of the right hip.
Which finding requires an intervention by the nurse?
1. There is a pillow between the patients legs
2. The patient’s legs are internally rotated
3. The patients hip joint is flexed at a 70 degree angle when the patient sits in the chair
4. The patient has not requested pain medication for 12 hours.
Answer#2 (prevent internal or external rotation, that means se safó)
11. A client newly diagnosed with Meniere’s disease plans a trip to an amusement park
with the family. The client asks the clinic nurse which of the following rides is best. The
nurse should suggest which of the following rides?
1. Roller coaster
2. Merry go round
3. Ferris wheel
4. Train
Answer#4
12. A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days
ago. During discharge teaching, the client asks the nurse “When can I resume sexual
intercourse with my wife?” it is best for the nurse to make which of the following
statements?
1. “You can resume sexual activity when you feel strong enough”
2. “You can resume sexual activity when you are able to walk one block without chest
pain or discomfort”
3. “You may have difficulty maintaining an erection because of your recent surgery”
4. “You should abstain from sexual activity because it may be detrimental to your
recovery”
Answer#2 (one block or two flights of stairs without chest pain)
13. A woman complains to the nurse about the care provided to her husband by the nursing
staff the previous night. Initially, the nurse should take which of the following actions?
1. Ask the wife to voice her expectations about a solution to the problem
2. Gain consensus with the woman on the specific steps that will be taken care for her
husband
3. Explain to the wife that the problems she identified will be fixed
4. Notify the wife that everything possible is being done for her husband
Answer#1
14. A patient is restrained bodily by the nursing team. The hands of the nurse assigned to
hold down the patients leg should be placed in which of the following positions?
1. One hand on the patients knee and the other hand on the patients ankle
2. One hand directly above the patient’s knee and the other hand directly above the
patient’s ankle
3. Both hands side by side on the patients thighs
4. One hand at the patients groin and the other hand at the patients mid-calf area
Answer#2
15. The nurse in the community mental health center works with a client who is diagnosed
with depression. Cognitive therapy is initiated. The nurse should take which of the
following actions?
1. Assist the client to review past intellectual achievements
2. Help the client develop more positive thoughts
3. Help the client to identify the source of his depression
4. Change the client’s values and beliefs.
Answer#3
Cognitive Therapy; determined that how individuals feel and behave is determined by how
they think about the world and their place in it.
16. The nurse plans to perform a physical assessment of a young adult who has been deaf
since birth. Although the client indicates using sign language, no interpreter is available.
The nurse should take which action?
1. Face the client and speak slowly using low-pitched voice
2. Write out each question, and ask the client to write out each answer
3. Sit on the clients right side and use gestures and nonverbal clues
4. Show the client pictures of the parts of the body that will be examined
Answer#2
17. A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative
pain. The patient turns on the call light and tells the nurse he has to go to the bathroom.
The patient has bathroom privileges. The nurse should take which of the following actions?
1. Obtain a bedside commode for the patient to use
2. Provide a warmed fracture bedpan for the patient to use
3. Tell the patient to breathe deeply as he walks to the bathroom
4. Ask the patient sit on the side of the bed before proceeding to the bathroom
Answer#4
18. The nurse cares for a patient on the psychiatric unit with a history of drug use and poor
impulse control. After the patient’s mother visits, the patient begins pacing rapidly, with
arms swinging, and kicking at chair legs. The nurse should approach the patient and take
which of the following actions?
1. Sit in a chair several feet away from the patient and lean forward with hands
clasped together
2. Stand facing the patient with legs apart, knees locked, and weight on back leg
3. Sit in a chair next to the patient and lean back with arms folded
4. Stand facing the patient, legs together, knees locked, with weight on both legs
Answer#2 [Show Less]
