1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy
products, suchas milk, to help coat a... [Show More] nd protect his ulcer. What is the best follow-up action by the nurse?
a- Remind the client that it is also important to switch to decaffeinated coffee and tea.
b- Suggest that the client also plan to eat frequent small meals to reduce discomfort
c- Review with the client the need to avoid foods that are rich in milk and cream.
d- Reinforce this teaching by asking the client to list a dairy food that he might select.
2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the
clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been
taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension
control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological
condition?
a- Blindness secondary to cataracts
b- Acute kidney injury due to glomerular damage
c- Stroke secondary to hemorrhage
d- Heart block due to myocardial damage
3.The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure
disorder.The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse
implement?
a- Ensure that the UAP has placed the pillows effectively to protect the client.
b- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.a- Assume responsibility for placing the pillows while the UAP
completes another task.
b- Ask the UAP to use some of the pillows to prop the client in a side lying position.
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which
assessmentfinding requires immediate follow-up?
a- Describes life without purpose
b- Complains of nausea and loss of appetite
c- States is often fatigued and drowsy
d- Exhibits an increase in sweating.
5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass
and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What
information should the nurse include in the client’s teaching plan?
a- Further evaluation involving surgery may be needed
b- A pelvic exam is also needed before cancer is ruled out
c- Pap smear evaluation should be continued every six month
d- One additional negative pap smear in six months is needed.
6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions
is mostimportant for the nurse to include in the discharge plan?
a- Explain how to use communication tools.
b- Teach tracheal suctioning techniques
c- Encourage self-care and independence.
d- Demonstrate how to clean tracheostomy site.
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7.In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not
deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the
nurse implement?a- Encourage the client to take deep breaths
b- Remove the mask to deflate the bag
c- Increase the liter flow of oxygen
d- Document the assessment data
8. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse
take first?
a- Give the client 4 ounces of orange juice
b- Call 911 to summon emergency assistance
c- Check the client for lacerations or fractures
d- Asses clients blood sugar level
9. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that
she dranka cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take
first?
a- Ensure preoperative lab results are available
b- Start prescribed IV with lactated Ringer’s
c- Inform the anesthesia care provider
d- Contact the client’s obstetrician.
10.After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an
S3 heartsound is present, what action should the nurse take first?
a- Side the stethoscope across the sternum.
b- Move the stethoscope to the mitral site
c- Listen with the bell at the same location
d- Observe the cardiac telemetry monitor
11.A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment.
Which agencyshould the client be referred to by the employee health nurse for health insurance needs?
a- Woman, Infant, and Children program
b- Medicaid
c- Medicare
d- Consolidated Omnibus Budget Reconciliation Act provision.
12.A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should
the nurseinstruct the client to take with the tetracycline?
a- Fruit-flavored yogurt.
b- Cheese and crackers.
c- Cold cereal with skim milk.
d- Toasted wheat bread and jelly
13.Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that
the clientis experiencing a complication?
a- “I am having pain in my lower back when I move my legs”
b- “My throat hurts when I swallow”
c- “I feel sick to my stomach and am going to throw up”
d- I have a headache that gets worse when I sit up”
14.An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence.
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Which actionshould the nurse implement?
a- Auscultate for renal bruits
b- Obtain a clean catch mid-stream specimen
c- Use a dipstick to measure for urinary ketone
d- Begin to strain the client’s urine.
15.The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in
keeping withthe child’s dietary restrictions. Which foods are contraindicated for this child?
a- Wheat products
b- Foods sweetened with aspartame.
c- High fat foods
d- High calories foods.
16.Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a
3-minutesurgical hand scrub is adequate preparation for this client. Which response should the circulating nurse
provide?
a- Ask a more experience nurse to perform that scrub since it is the first time of the day
b- Validate the nurse is implementing the OR policy for surgical hand scrub
c- Inform the nurse that hand scrubs should be 3 minutes between cases.
d- Direct the nurse to continue the surgical hand scrub for a 5-minute duration.
17.Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary
management ofosteoporosis?
a- Egg whites, toast and coffee.
b- Bran muffin, mixed fruits, and orange juice.
c- Granola and grapefruit juice
d- Bagel with jelly and skim milk.
18.The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should receive the
most care hours by aregistered nurse (RN)?
a- A 34-year -old admitted today after an emergency appendendectomy who has a peripheral intravenous catheter and
a Foleycatheter.
b- A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to
electrolytedisturbance following a race.
c- A 63-year-old chain smoker admitted with chronic bronchitis who receiving oxygen via nasal cannula and has a
saline-lockedperipheral intravenous catheter.
d- An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft wrist
restrainsapplied
19.Z
a- Cleanse the foot with soap and water and apply an antibiotic ointment
b- Provide teaching about the need for a tetanus booster within the next 72 hours.
c- have the mother check the child's temperature q4h for the next 24 hours
d- transfer the child to the emergency department to receive a gamma globulin injection
20.The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple
antibioticointment for two days, but there has been no improvement.” What instruction should the nurse
provide?
a- Antibiotics take two weeks to become effective against infections such as athlete’s foot.
b- Continue using the ointment for a full week, even after the symptoms disappear.
c- Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.
d- Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
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21.A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium
(Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
The clientexperiences
a- Palpitations and shortness of breath
b- Bradycardia and constipation
c- Lethargy and lack of appetite
d- Muscle cramping and dry, flushed skin
22.A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and
palpitations. Whichfinding is most important for the nurse to assess to the client?
a- Determine the client’s level of orientation and cognition
b- Assess distal pulses and signs of peripheral edema
c- Obtain a list of medications taken for cardiac history.
d- Ask the client about exposure to environmental heat.
23.The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300
mcg/hour.The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value
only.)
a- 75
24.The pathophysiological mechanisms are responsible for ascites related to liver failure? (Select all
that apply)a- Bleeding that results from a decreased production of the body’s clotting factors
b- Fluid shifts from intravascular to interstitial area due to decreased serum protein
c- Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
d- Increased circulating aldosterone levels that increase sodium and water retention
e- Decreased absorption of fatty acids in the duodenum leading to abdominal distention.
25.The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound?
(Pleaselisten to the audio first to select the option that applies)
a- S1 S2
b- S1 S2 S3
c- Murmur
d- Pericardial friction rub.
26.The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial
is labeledwith the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml
should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the
nearest tenth)
a- 0.4
27.The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four
days. Whatassessment is most important for the nurse to complete?
a- Auscultate the client's bowel sounds
b- Observe for edema around the ankles
c- Measure the client’s capillary glucose level
d- Count the apical and radial pulses simultaneously
28.A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of
breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the
nurse to document thisin her medical record. What action should the nurse implement?
a- Ask the client to discuss “do not resuscitate” with her healthcare provider
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29.A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea.
The clienthas a new prescription to change the feeding to half strength. What intervention should the nurse
implement?
a- Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
b- Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr.
c- Maintain the present feeding until diarrhea subsides and the begin the next new prescription.
d- Withhold any further feeding until clarifying the prescription with healthcare provides.
30.A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows havedisappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to
ask?
a- “Is there a history of female baldness in your family?”
b- “Are you under any unusual stress at home or work?”
c- “Do you work with hazardous chemicals?”
d- “Have you noticed any changes in your fingernails?”
31.After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The
client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding
warrants immediateintervention by the nurse?
a- Bruises on arms and legs
b- Round and tight abdomen
c- Pitting edema in lower legs
d- Capillary refill of 8 seconds
32.After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a
witness. Whatare the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that
apply)
a- The client voluntarily grants permission for the procedure to be done
b- The surgeon has explained to the client why the surgery is necessary.
c- The client is competent to sign the consent without impairment of judgement
d- The client understands the risks and benefits associated with the procedure
e- After considering alternatives to surgery, the client elects to have the procedure.
33.Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be
assigned tohis care and is belligerent when another nurse is assigned. What action should the charge nurse
implement?
a- Ask the client to explain why he constantly request the nurse
b- Encourage the client to verbalize his feelings about the nurse
c- Reassure the client that his request will be met whenever possible.
d- Advise the client that assignments are not based on client requests
34.A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While
providing care,the nurse finds the radiation implant in the bed. What action should the nurse take?
a- Call the radiology department
b- Reinsert the implant into the vagina
c- Apply double gloves to retrieve the implant for disposal.
d- Place the implant in a lead container using long-handled forceps
35.The client with which type of wound is most likely to need immediate intervention by the
nurse?a- Laceration
b- Abrasion
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c- Contusion
d- Ulceration
36.The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which
intervention has thehighest priority for inclusion in this client’s plan of care?
a- Record urine output every hour
b- Monitor blood pressure frequently
c- Evaluate neurological status
d- Maintain seizure precautions
37.When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of
the bed 30degrees. What is the reason for this intervention?
a- To reduce abdominal pressure on the diaphragm
b- to promote retraction of the intercostal accessory muscle of respiration
c- to promote bronchodilation and effective airway clearance
d- to decrease pressure on the medullary center which stimulates breathing
38.When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when
palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely
explanation for failure tolocate the gallbladder by palpation?
a- The client is too obese
b- Palpating in the wrong abdominal quadrant
c- The gallbladder is normal
d- Deeper palpation technique is needed
39.A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since
the normalvaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her
antianxiety medications,
but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse
toprovide this woman?
a- Describe the transmission of drugs to the infant through breast milk
b- Encourage her to use stress relieving alternatives, such as deep breathing exercises
c- Inform her that some antianxiety medications are safe to take while breastfeeding
d- Explain that anxiety is a normal response for the mother of a 3-weekold.
40.An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic
with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took
his last dose ofinsulin or ate last. What action should the nurse implement first?
a- obtain a serum potassium level
b- administer the client's usual dose of insulin
c- assess pupillary response to light
d- Start an intravenous (IV) infusion of normal saline
41.A client who received multiple antihypertensive medications experiences syncope due to a drop-in blood pressure
to 70/40.What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication?
a- Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
b- The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
c- The additive effect of multiple medications has caused the blood pressure to drop too low.
d- The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
42.Which client is at the greatest risk for developing
delirium?a- An adult client who cannot sleep due to
constant pain.
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b- an older client who attempted 1 month ago
c- a young adult who takes antipsychotic medications twice a day
d- a middle-aged woman who uses a tank for supplemental oxygen
43.Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive
PulmonaryDisease (COPD)?
a- Reduce risks factors for infection
b- Administer high flow oxygen during sleep
c- Limit fluid intake to reduce secretions
d- Use diaphragmatic breathing to achieve better exhalation
44.Which location should the nurse choose as the best for beginning a screening program for
hypothyroidism?a- A business and professional women's group.
b- An African-American senior citizens center
c- A daycare center in a Hispanic neighborhood
d- An after-school center for Native-American teens
45.A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After
stopping the medication abruptly, the client reports feeling “very tired”. Which nursing intervention is most
important for the nurse toimplement?
a- Measure vital signs
b- Auscultate breath sounds
c- Palpate the abdomen
d- Observe the skin for bruising
46.A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is
important for thenurse to review before contacting the health care provider?
a- capillary glucose
b- urine specific gravity
c- Serum calcium
d- white blood cell count
47.What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling
technique forturning?
a- working together can decrease the risk for back injury
b- The technique is intended to maintain straight spinal alignment.
c- Using two or three people increases client safety.
d- turning instead of pulling reduces the likelihood of skin damage
48.A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the
client?a- Plain yogurt with sweetened with raw honey
b- Peanuts in the shell, roasted or un-roasted.
c- Aged farmer’s cheese with celery sticks
d- Baked apples topped with dried raisins
49.Which action should the school nurse take first when conducting a screening for
scoliosis?a- Compare dorsal measurement of trunk
b- Extend arms over head for visualization
c- Inspect for symmetrical shoulder height.
d- Observe weight-bearing on each leg.
50.An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a
client has aweak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?
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a- Instruct the UAP to count the client apical pulse rate for sixty seconds
b- Determine if the UAP also measured the client’s capillary refill time.
c- Assign a practical nurse (LPN) to determine if an apical radial deficit is present.
d- Notify the health care provider of the abnormal pulse rate and pulse volume. [Show Less]
