A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about
the disease. To research the nurse should identify
... [Show More] that which of the following electronic database has
the most comprehensive collection of nursing (Unable to read)articles?
A. MEDLINE
B. CINAHL.
C. ProQuest.
D. Health Source.
A nurse in an emergency department is assessing newly admitted client who is experiencing drooling
and hoarseness following a burn injury. Which of the following should actions the nurse take first?
A n u r s e is planning care for a client who has unilateral paralysis and dysphagia following a
right hemispheric stroke. Which of the following interventions should the nurse include in the
plan?
nurse iscaring for aclient who is receiving brachytherapyfor treatment of prostate cancer. Which
of the following actionsshould the nurse take?
Limit theclient’s visitorsto 30 minperday.
Discard the client’s linens in a double bag. Discard the
radioactivesource inabiohazard bag
Cleanseequipmentbeforeremoval fromtheclientroom
A nurse is teaching a client about using a 3-point gait for crutch-walking. Which of the following actionsby the
clientunderstanding … teaching ?
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, the
nurse does not speak the same language as the client. The client partner and a 10-year-old child are
accompanying her. Which of the following actions should the nurse take to gather the client’s
information?
Request a female translator interpreter through the facility Aska
student nurse whospeaksthesamelanguagetotranslateHave the
child translate
Allow theclientschildtotranslate
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following
conditions shouldthe nurse recognize asacontraindication totheuseofoxytocin?
A. Diabetes mellitus.
Shoulderpresentation.
Post term withhydramnios.
Chorioamnionitis
A nurse manager is reviewing the steps of the progressive discipline process prior to counseling a staff member
who exhibits unprofessional behavior. Identify the sequence of steps the nurse manager should plan to take in
responseto the staff members conduct
Give the staff member a writing warning about the behavior Verbally
remindthestaffmemberof theexpectedbehaviorchangesSuspendthe
staff member from workfor severaldays
Dismissthestaff memberfrom employmentat thefacility
Setup ameetingtospeak withthestaff memberabout thebehavior
A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the
following actions bythe nurse indicates a break in surgicalaseptictechnique?
Applyingasterilegownafterapplyingasterile mask
Balancing the bottle on the sterile basin while pouring the liquid Placing
thesuppliesonthesterilefiledandleavinga1- inchperimeterPuttingonsterile
glovesafterpreparingthesterile field
A nurse is assessing aclient who has left-sided heart failure. Which of the following should the
nurse identifyas a manifestation of pulmonarycongestion?
A. Frothy,pinksputum.
B. Jugularveindistention.
C. Weightgain.
D..Bradypnea
A nurse isobtainingaclients manualbloodpressureandishavingdifficultyauscultatingsounds .Whichof the
followingactions should the nurse …?
UsethepalpatorymethodtodeterminebioodpressureDeflate
the cuff quickly
. Place the arm above the level of the client's heartApply
the largestcuffavailable.
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?
A. “YourbabyneedsanIVbecausesheisnotproducinganytears”
B. “YourbabyneedsanIVbecauseherfontanels arebudging”
C. “YourbabyneedsanIVbecausesheisbreathingslowerthannormal”
D. “Yourbabyneedsan IVbecauseherheart rateisdecreasing”
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?
“Takingfurosemidecancauseyourpotassium levels tobehigh”
“Eat foodsthatarehighinsodium”
C. “Riseslowlywhengettingoutofbed”
D. “Takingfurosemidecancauseyoutobeoverhydrated”
A nurse iscreating a plan ofcare fora newlyadmitted client who has obsessive-compulsive disorder. Which
of
the following interventions should the nurse take?
A. Allow theclientenoughtimetoperform rituals.
B. Givetheclientautonomyinschedulingactivities.
C. Discouragetheclient from exploringirrational fears.
D. Providenegativereinforcement forritualisticbehaviors
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?
Serotoninsyndrome
Tardive dyskinesia
Pseudoparkinsonism.
Acutedystonia.
A nurse iscaring foraclient who isin aseclusion room following violent behavior.The clientcontinues to
displayaggressive behavior. Which of the following actions should the nurse take?
A. Confront theclientabout thisbehavior.
B. Expresssympathyfortheclient’ssituation.
C. Speakassertivelytotheclient.
D. Stand within 30 cm (1 ft)of theclient whenspeaking withthem.
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?
E. “Takingfurosemidecancauseyourpotassium levels tobehigh”
F. “Eat foodsthatarehighinsodium”
G. “Riseslowlywhengettingoutofbed”
H. “Takingfurosemidecancauseyoutobeoverhydrated”
A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder.
Which ofthe following interventions should the nurse take?
A. Allow theclientenoughtimetoperform rituals.
B. Givetheclientautonomyinschedulingactivities.
C. Discouragetheclient from exploringirrational fears.
D. Providenegativereinforcement forritualisticbehaviors
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?
D. Serotoninsyndrome
E. Tardive dyskinesia
Pseudoparkinsonism.
F. Acutedystonia.
A nurse is caring for a client who is in a seclusion room following violent behavior. The client
continues to displayaggressive behavior. Which of the following actionsshould the nurse take?
A. Confront theclientabout thisbehavior.
C. Expresssympathyfortheclient’ssituation.
C. Speakassertivelytotheclient.
D.Stand within 30 cm (1 ft)of theclient whenspeaking withthem.
A nurse iscalculating aclient's expected date of delivery.The clientsfast menstral period began
April 12 Using Nagele’srule, what date should the nurse determine to be the client’s expected
delivery date?
A nurse is discussing group treatment and therapy with aclient. The nurse should include which
ofthefollowing as being acharacteristic of atherapeutic group?
A. Thegroupisorganizedinanautocraticstructure.
B. The group encourages members to focus on a particular issue. (
C. Thegroup mustbeledbyalicensedpsychiatrist.
D. Thegroupencouragesclientstoform dependentrelationships.
A nurse manger is reviewing documentation with a newly licensed nrse. Which of the following
notations bythe newlylicensed nurse indicates an understanding of the teaching?
UNSURE IF ON THE REPORT
A. “OOBwithassistanceforbreakfast”
B. “Given2mg MSO4IM for reportofpain”
C. “Dressingchangedqd”
D. “Administered 8 uregular insulinsq.”
A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should
take. (Move the steps into the box on the right, placing them in the order of performance. Use all the
steps.)
1. Applypressuretothelacrimalpunctum.5
2. Askthechildtolookupward.2
3. Pull thelowereyeliddownward. 3
4. Instill thedropsof medication.4
5. Placethechildinasittingposition. 1
105. A nurse is caring for a client who speaks a language different from the nrse. Which ofthefollowing
should the nurse take?
A. Requestaninterpreterofadifferentsexfrom theclient.
B. Requestafamily memberorfriendtointerpret informationfortheclient.
C. Directattentiontowardtheinterpreterwhenspeakingtotheclient.
D. Review thefacilitypolicyabout theuseofaninterpreter.
106. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the
following findings indicates that the nurse should increase the rate of infusion?
ON THE REPORTneedsdoublechecking
A. Urineoutput20 ml/hr.
A. Montevideounitsconstantly 300 mm Hg.
B. FHR pattern withabsentvariability.
C. Contractionsevery 5 minthat last 30 seconds.
107. A nurse is planning care for a group of clients and is working with one licensed practical
nurse LPN and one assistive personal AP. Which of the following actions should the nurse
take first to manage her time effectively?
DevelopanhourlytimeframefortasksSchedule
dailyactivities
Determine goals of the day
Delegatetaskstothe AP
108. A public health nurse is managing several projects for the community. Which of the
following interventions should the nurse identifyas a primary prevention strategy?
A. Teachingparentingskillstoexpectant mothersandtheirpartners.
B. Conductingmentalhealthscreeningsat thelocalcommunitycenter.
C. Referringclient whohaveobesitytocommunityexerciseprograms.
D. Providingcrisisinterventionthroughamobilecounselingunit.
109. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which
of the following statements bythe client indicatesan understanding of the teaching?
a. “Iwill takesucralfate with mealsthreetimesperday”
b. “Iwillavoidfood andbeveragesthatcontaincaffeine”
c. “I willdecrease mydailyproteinintaketo15 gramsperday”
d. “Iwilluseibuprofenasneededtocontrolabdominalpain”
110. A n u r s e is assessing a client who is receiving packed RBCs. Which of the
followingfindings indicate fluid overload?
A. Low backpain.
Dyspnea.
Hypotension.
Threadypulse.
111. A nurse is providing teaching about patient-controlled analgesia(PCA) to aclient. Which
ofthe following statements should the nurse include in the teaching?
I. “The PCA willdeliveradoubledoseof medication when youpushthebuttontwice.”
J. “Youcanadjust theamountofpain medication youreceivebypushingonthekeypad.”
K. “Continuous PCA infusionisdesignedtoallow fluctuatingplasma medication levels.”
L. “Youshouldpushthebuttonbeforephysicalactivitytoallow maximumpaincontrol.”
112. A nurse is preparing to administer an autologous blood product to a client. Which
of the following actionsshould the nurse take to identifythe client?
E. Matchtheclient’sbloodtype withthetypeandcross matchspecimens.
F. Confirmtheprovider’sprescription matchesthenumberonthebloodcomponent.
G. Asktheclient tostatethebloodtypeandthedateof theirlastblooddonation.
H. Ensurethat theclient’sidentificationband matches thenumberonthebloodunit.
113. A n u r s e is performing physical therapy for a client who has Parkinson’s disease.
Which of the following statements by the client indicates the need for a referral to physical
therapy?
B. “Inoticedthat Iam havingahardertimeholdingonto mytoothbrush”
C. “Lately, Ifeel like myfeetarefreezingup,astheyarestucktotheground”
D. “Sometimes, I feel Iammakingachewing motion whenI’mnoteating”
114. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which
of the following findings should the nurse expect?
A. Increasedcreatine.
B. Increased
hemoglobin. C.
Increased
bicarbonate.
D. Increasedcalcium.
115. A nurse is teaching at a community health fair about electrical fire prevention. Which
of thefollowing information should the nurse include in the teaching?
A. Usethreepronged groundedplugs.
B. Coverextensioncords witharug.
C. Checkthetinglingsensationsaroundthecordtoensuretheelectricityis working.
D. Removetheplugfrom thesocketbypullingthecord.
116. A charge nurse isrecommending postpartum client discharge following alocal
disaster. Which of the following should the nurse recommend for discharge?
B. A 15-year-oldclient whodelivered viaemergencycesareanbirth1dayago.
C. A client whoreceived 2unitsofpacked RBCs 6 hr.agoforapostpartum hemorrhage.
D. A clientwhodeliveredprecipitously 36 hr.agoandhasasecond-degreeperineal laceration.
E. A 42yoarsoldclient whohaspreeclampsiaand BP of 166/110 mmHG
117. A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take at home. Which of the following responses
should the nurse take?
137 “Irecommendthatyoutakethis medicationasprescribed”
138 “Doyouknow whythismedication isbeingprescribedtoyou?”
139 “Iwillcall thepharmacistnow tocheckonthis medication”
Didthedoctordiscuss withyouthat there wasachangeinthis medication
118. A community health nurse is developing a plan to improve the communitys environmental health.
whichof the followingaction nurse take first?
Establishatimeframeforenvironmental improvements.
EncouragecommunityInvolvement inenvironmental improvementRequest
funding from community organizations
Collect informationabout thecommunity's environmentalstatus
119. 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?
E. Withholdthenextdose.
F. Increasethedosage.
G. Discontinuethe medication.
H. Administerthe medication.
120. A nurs e in a clinic is assessing a 6-month-old infant. Which of the following should the
nurse report to the provider?
Pulse140/min
Closed anterior fontanel
Respiratory rate 26/min
Abdominalbreathing
121. A nurse is reviewing legal issues in health care with a group of newlylicensed nrses. Which of
the following recommendations should the nurse make?
Placecopiesof incidentreports inclient’s medicalrecords
Overestimateclientsacuiltytopreventshortstaffing
Ensurethateachclienthasaliving willonfileprior totreatmentObtain
personalprofessional liabilityinsurancecoverage
122. A nurse is planning care for achild who has neutropenia due to leukemia. Which of the following
Interventionsshould the nurse Include in the plan ofcare?
Screen the child's visitors for active Infections. Initiate
Preparethechildforaplatelet transfusion.Preparethe
childforaplatelet transfusion.
Monitorthechildforindicationsofactivebleeding
123. A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that
he needs to have a bowel movement and the nurse offers a bed pan. The client states. “I’ve always used the
bathroom.“Whichof the followingresponsesshouldthe nurse make?
“Tellme whatconcernsyouhaveaboutusingabedpan.”
“Iwillhavethephysical therapistambulateyoutothebathroom.”
“Youhaveto usethebedpanforyouownsafety.”
“Makesuretousenearbyfurnituretosupportyourself when walkingtothebathroom.
124. A newly licensed nurse isunsureifanassignedtask is withintheirscopeofpractice. whichof the
followingresources shouldthe nurse consult?
Written prescription from the provider
Institutional policies and procedures
Verbaldirectionfrom the nurse manager
State nurse Practice Act
125. A nurse isteachingparticipantsatacommunitycenteraboutadvancedirectives. Whichof thefollowing
informationshouldthe nurse include inthe teaching?
Assigningahealthcaresurrogaterequireslegalconsultation
A clientmustcreateadonot resuscitateorder whencompletingadvancesdirectives.
Advancedirectives cannotbe changedonce implemented.
A healthcaresurrogate makes healthcaredecisions whentheclient isnolongerable.
126. A nurse isreviewing the facility’ssafety protocolsconsidering newborn abduction with the parentof
a newborn. Which ofthe following statements indicates an understanding of the teaching?
I. “Staffwillapplyidentificationbandafterfirstbath”
J. “I willnotpublishpublicannouncementabout mybaby’sbirth”
K. “Icanremove mybaby’sidentificationbandas longassheisin myroom”
L. “Icanleave mybaby in myroom whileI walkinthehallway”
127. A nurse is planning care forfourclients who are atriskforfluid imbalances.The nurse should identity
thatwhich of the following client forfluid volume excess?
A client who has ulcerative colitis
A client who hasan exacerbation of peptic ulcer diseaseA
client who has diabetes insipidus
A client who has advanced stage livercirrhosis
128. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube The high pressure
alarmis beeping and the.. experiencing respiratory distress. the nurse is unable to determine the cause pf the
alarm. Whichofthefollowingactions should the nurse …
Deliver breaths manually with a resuscitation bag
Decreasethe ventilationflow rate
Reevaluate the client for an ET cuff leak
Assess fordisconnected tubing
129. A nurse onamentalhealthunit isadmittingaclient whohas posttraumaticstress,disorder.Whichof thefollowing
shouldthe nurse expect ?
Experiences frequent grandiose
thoughtsTalks continuously about the
event
has difficulty concentrating on a task
Preoccupled withhavingaseriousillness
130. A nurse is verifyingarecordof informedconsent foraclient whoissheduled forsurgery .Whichof thefollowing
actionsshouldthe nurse ….?
Inform the client about the condition that requires
teatmentConfirm theclient'ssignatureIsauthentic
Explaintheproceduretotheclientbeforeverifying informed
ProvideInformationontheinformedconsent form about thebenefitsof thesurgery
131. A nurse in a mental health clinicreceives arequest from aclient who is undergoing psychotherapyto
obtain acopy of the therapist’s notes. Which of the following responses should the nurse make?
Wecanprovideacopyofyourrecords,but thetherapistsnotesarenot includedI don’t
think you will benefit from reviewing your therapists notes right now Whyare you
interested in seeing yourtherapist’snotes?
Areyounothappy withyourtreatment?
132. A nurse is screening food brought in by a family member for a client who takes phenelzine. The nurse
shouldinstruct the family members…of the following foodscancauseaninteraction withthis medication?
Cottage cheese
loeberglettucesalad
bologna sandwich
Orange gelatin
133. A nurse is assessing a client who is in skeletal traction for a fractured left tibia.The nurse should identify
that whichof the following … altered tissueperfusionof the affectedextremity ?
Faintpedalpulseof left leg
Warm sidn temperature distal to pin site
Pain with movement of the left great toe
Purulent drainage at the pin site
134. A nurse iscaringforaclient whohasbipolardisorder.Whichof the followingbehaviorsshouldthe nurse
identifyasindicatingthe client experiencing mania?
The client speaks using echopraxiaThe
clientspeaksusing wordsalad.
Theclient iseasilydistractedbyexternalstimuliThe
client is socially withdrawn
135. A nurse isobtainingaurinespecimenfrom aclient whohas hadanindwellingurinarycatheter for three days.
Whichof thefollowingaction shouldthe nurse takeaftercollectingthespecimens?
Removeglovesafter labelingthespecimen
Place the specimen in a biohazard bag for transport
Obtain the specimen from the drainage collection bag
Wipetheoutsideof thespecimencontainer withalcohol
136. A n u r s e is caring for a toddler who has acute lymphocytic leukemia. In which of
thefollowing should the toddler participate?
M. Lookingatalphabet flashcards.
N. Playing withalargeplastic truck.
O. Usescissorscutoutpaper shapes.
P. Watchingacartooninthedayroom.
137. A nurse is reviewingthecardiac rhythm ofaclient who is …..on indicationventricular
tachycardia?Pwave present with every QRS complex
Sowtooth shaped P waves
PR intervalof 0.24seconds
QRS complexes wider than 0.15 seconds
138. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes
pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions
should the nurse take to address the suspicions of elder abuse?
Informthetransferringagencyof theclient’scondition.
Privatelyinterviewthe clientabout hercondition.
Notifyriskmanagement
Contactthefamilyregardingtheclient’scondition.
139. communityhealth nurse isreviewinglaboratoryreportsforagroupofclient.The nurse shouldidentifythat
whichof the followingdisorderon the CDC's Nationally Notifiable Conditions list!
Bacterial
vaginosisLyme
disease
Respiratory syncytial
virusPediculosiscapitis
140. A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct
in her dietto prevent a neural tube defect?
Folate
Zinc Iron
Calcium
141. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following
manifestationsshould the nurse expect?
Loose stools
Jitteriness Hypertonia
Abdominaldistention
142. A n u rs e is preparing to administer PRN pain medication to a client who has cholelithiasis and
experiencingmoderateabdominalpain.Whichof thefollowing medications shouldthe nurse plan toadminister?
Omeprazole
Ketorolac
Acetaminophen
Metoclopramide
143. A nurse isgivinganintramuscular injectiontoanewborn whohas delivered at 38 weeks ofgestation.Whichof
thefollowing painscale shouldthe nurse usetoassessthe newbornpain?
FACEpainratingscale
PrematureInfant Pain Profile(PIPP)
Visualanalogscale(VAS)
Neonatal Infant Pain Scale(NIPS)
144. A nurse isadmittingaclientwhodoesnotspeakthesamelanguageasthe nurse andscheduledfor
outpatientsurgery. Whichof followingactions shouldthe nurse take?
Request a family member to interpret the information. Explain
theproceduretotheclient throughaninterpreter.
Provideconsent form that is writtenintheclient’sownlanguage.
Helptheclient lookupthe informationabout theprocedureonthe internet
145. A nurse is preparingtoinitiate IVtherapyforanolderadult client.Whichof thefollowingactions shouldthe
nurse plantotake ?
Cleanthesiteusingvigorous friction
Applyatourniquet firmlyabovetheinsertionUse
22-gaugecatheter forinsertion
Select a veinonthebackof the hand
146. A nurse iscaring for aclient who has fibromyalgia and requests pain medication. Which of the
following medications should the nurse administer?
Pregabalin
Lorazepam
Colchicine
Codeine
147. A nurse is providing discharge teaching for a group ofclients. The nurse should recommend a
referral to adietitian
A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I
eat”.
B. A clientwhohasgoutandstates,“Icancontinuetoeatanchovieson mypizza.”
C. A client whohas aprescription for spironolactone andstates “I will reduce my intakeof foods that
containpotassium”.
D. A client whohas (Unabletoread)andstates “I’llplan totake mycalcium carbonate with a full glass
of water”.
148. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat
therapy for afoot injury. Which if the following findingsshould the nurse identifyasacontraindication for
heat therapy?
Phlebitis
AbdominalaorticaneurysmOsteoarthritis
Peripheral neuropathy
149. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the following
informationshouldthe nurse includeabout preventingthespreadinfection?
Clean blood contaminated surfaces with bleach.
Use condoms with a petroleum-based lubricant.
Washsoiledclothes incold water.
Buydisposabledishes fordaily use.
150. A nurse is caring for a client who is receiving continuous enteral feedings. which of the following actions
shouldthe nurse take? Select
Check placement of the feeding tube by x-ray once daily
Maintainthe headof the client's bedata30%angle orhigher
Checkgastric residuals every4 hr.
Changethefeedingcontainer andtubingevery24hr.
Ensuretheformulaiscoldbeforeadministration
151. A nurse isassessingaclient whohasbipolardisorder and is experiencing depressive episode. whichof
thefollowingfindings should the nurse expect?
Clent expresses ilusions of grandeur
Inability to carry out a simple task
Client reports auditory hallucinations
Moves quickly from one idea to the
next
152. A nurse iscaringforaclient whois postoperative immediately followingacardiaccatheterizacion witharight
femoralappro..Whichof the followingactions shouldthe nurse take?
Elevatetheheadof the client's bedto45
Assess the client's peripheral pulses every 15 min.
Change the client's dressing 4 hr following the
procedure.Instruct theclient toflextheright kneeevery
30 min.
153. A nurse isteachingaclient whohaschronic low backpainabout theuseof alternative therapy to manage
pain.Whichof the followingby theclient indicates anunderstandingof theuseof distraction?
Iwillhaveelectrodes inserted in myskin totreat thepainI
should apply myheating blanket to myback toreduce
tensionIshould jogevery morningto improve mycirculation
I will watch myfavorite old movies when Iwant to reducestress
154. A nurse isprovidingdietaryteachingtoaclient whohas hyperlipidemia.The nurse shouldinclude inthe
teachingthat whichobtains she lowestamount ofsaturated fats?
Coconut oil
Olive oil
Canola oil
Palm oil
155. A nurse is reviewing assessment data from several clients. For which of the following clients should
the nurse referral to a dietitian?
Anolderadultclient whohas a BMIof24A
client who has a nonhealing leg ulcer Anolder
adultclient whohaspresbyopia
A client whohasanalbumin levelof 3.7g/Dl
156. A nurse isteachingachildbirtheducationclassandisdiscussingsexual intercourseduringpregnancy.
Whichof the followingstatements shouldthe nurse make?
“Thefemalesuperiorpositioncanbeusedduringthethirdtrimesterofpregnancy.”
“Frequent intercourseincreasestheriskformiscarriage inearlypregnancy.”
“Youshouldlimit thefrequencyof intercourseafterweeksofpregnancy.”
Yoursexualdesiremight increaseduringthefirst trimesterofpregnancy.”
157. A nurse iscaringforanolderadultclient inalong-term carefacility, recently labvaluesshows
increasedhemoglobin,hematocrit, andurine irregularity whichfindings suggest anemia
Anemia.
Dehydration
Hepatic failure
Acuterenal failure
158. A nurse is creating a plan of care for a female client who has recurrent urinary tract infections. Which of
thefollowinginterventions should the nurse include intheplan?
Takeabubblebathafterintercourse
Voidevery 5 to 6 hrduringthe day
Drinkfour240mL(8 oz)glassesof watereachday.
Wear loose-fitting underwear.
159. A charge nurse is planning a staff education and competence session about operating newly acquired
cardiacmonitoringequipment. Whichof the followingactionsshould the nurse plantotake? (Select all that
apply.)
Cautionstaff that theequipment iscomplicatedtouse.
Require a return demonstration using the equipment.
Provide reinforcement of teaching until the skill islearned.
Wait toofferfeedbackonstaffuseof theequipmentuntil theendof thesession.Identifythe
current levelof staff knowledge about the equipment.
160. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
G. “Dehydrationistreated withcalcium supplements”
H. “Dehydrationcanincreasetheriskofpreterm labor”
I. “Dehydrationassociatedgastroesophagealreflux
J. “Dehydrationiscausedbyadecreasedhemoglobin andhematocrit”
161. A nurse is preparing achange of shiftreport for an adult female client who is postoperative. Whichof
the following client information should the nurse include in the report?
CONFIRMED
Hgb 12.8 g/dl - 12- 16
Potassium 4.2 meq/l 3.5 - 5.0 meq
RBC 4.4 million/mm3
Platelets100,000/mm3
162. A nurse iscaringforaclient whotells the nurse thathefeels he is being dischargedfrom the facilitytoosoon
.whichof thefollowingthe nurse demonstrateclientadvocacy?
I willcontact your insurance companytoseeif they willpayfor youtobehavelonger?
Yourproviderunderstandsyour illnessandisactingaccordingtoyourbest interests
I will that theproviderabout yourconcerns
Iknow you willbeabletorecover fasterat home
163. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which of the
followingstatements byaclient indicatedanunderstandingof the teaching?
“Iwillconsume48 ouncesofcarbonatedbeveragesdaily priortothesurgery.”
“I willneedtolose25 percentofmyexcessbody weightprior tosurgery.”
“Ishouldreducemydailycaloricintakeby250 caloriestolose2poundseachweekaftersurgery.”
“Ishould wait 30minutes aftereatingsolid foodstodrinkbeverages followingsurgery.”
164. A nurse is caring for several clients on a medical-surgical unit. For which of the following nursing
activitiesis it required that the nurse use sterile gloves?
Insertingan NG tube
Administeringtotalparenteralnutritional throughacentralvenousaccessdeviceInitiatingIV
access
Performingtracheostomycare
165. A nurse in asurgicalclinic is providing teaching to aclient who is scheduled for a modified radical
mastectomy.Whichof thefollowingstatements bytheclient indicates anunderstandingof theteaching?
“Icanbegintodrive24hoursaftersurgery.”
“Icanshower within48 hoursofmysurgery.”
“Iwillhavemydrainsremoved1hourpriortogoinghome.”‘I
willcomplete myarm exercisesfourtimesaday.”
166. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Whichof the following statements
bythe client indicatesanunderstandingof theteaching?
“Ishouldapplypowertomyskinaftershowering.”
“I willnotabletogo for mydaily walk.”
“I willcleansemyskinusinga mildsoap.”
“Ishouldcheckmyskinonce weeklyfor rashes.”
167. A nurse isprovidingdischargeteachingtoafemaleclient whohastuberculosisandanew prescription
forrifampin.Whichof thefollowinginformationshouldthe nurse include?
“Yoururine willbeorangewhilethis medication.”
Weightgainisanexpectedadverseeffectof thismedication
Youshouldavoidgettingpregnant for 6 monthsafterstoopingthis medication
Youshouldavoidsunexposure while takingthis medication
168. A nurse is providingdischargeInstructionstoaclient whohasanew prescriptionforspironolactone .Which
of the followingthe nurse include in the teaching?
Monitor weightoncea week
Takethemedicationinthemorning
Useasaltsubstitute with meals
Administerapotassium supplementdaily
169. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of the
followingprescriptionsshould the nurse expect theprovider to prescribe?
Atorvastatin
Amoxicillin
Enoxaparin
Interferonbeta-1a
170. A nurse iscaring foraclient who has a history of depression and is experiencing asituationalcrisis.
Which of the following actions should the nurse take first?
A. Confirmtheclient’sperception of theevent
B. Notifytheclient’ssupportsystem
C. Helptheclient identifypersonalstrengths
D. Teachtheclientrelaxationtechniques
171. A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of
the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress
disorder? (Selectall thatapply.)
A client whodescribeshavingpersistent feelingsofangerabout thehurricane.
A client whohas frequentnightmares about thehurricane.
A client whoexpressesarealizationthat life willnot returntothe wayit wasbefore thehurricane.
A client who movedtoanapartment locatedonhighergroundthanherprevioushome.
A client whodescribesfeeling disconnectedfrom thosearoundhim followingthehurricane.
172. A nurse iscaringforaclient whohascancerof thethroatandisreceivingradiationtherapy.The nurse
shouldmonitorfor whichof thefollowing findingasanadverse effectof the radiation?
Excessive salivation
Insomnia
Altered sensation
Elevateplateletcount
173. A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the
followingrecommendations shouldthe nurse include?
Wearatight-fittingunderwirebra.
Applywarm compressesonthebreastsbeforefeedings.
Allow theinfant to nurse onone breastper feeding.
Takeaspirintoreducepainandswelling.
174. A nurse isacommunitycliniciscaringforclient whorequestassistant withsmokingcensationThe nurse
shouldexpectaprescriptionfor whichof the followingmedications?
Bupropion
Chiordiazepoxide
Naltrexone
Clonidine
175. A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag
causing the medication to leak on the counter. Which of the following medications requires the n u r s e
to follow facility procedures in the safe handling of biohazardous material spill?
Doxorubicin hydrochloride
Ampicillin sodium
Metronidazole
Phenytoin
107. A nurse is preparing to assessa 2-week-old newborn. Which of the following actions should the nurse planto
take?
Obtainthenewborn’sbodytemperatureusingatympanicthermometer.Assess
the newbornpain levelusing FACES painscale.
Auscultatethenewborn’sapicalpulsefor 60 seconds.
Measurethenewborn’sheadcircumferenceovertheeyebrowsandbelow theoccipitalprominence.
108. A nurse isreceiving atelephone prescription from a providerforaclient who requires
additional medication for pain control. Which of the following entries should the nurse make in themedical
record?
“Morphine 3 mg SQ every 4 hr. PRN for pain.” “Morphine 3mg
Subcutaneousevery4hr PRN forpain“Morphine 3.0 mg sub q
every 4 hr. PRN for pain.” “Morphine 3 mg SC q4hr. PRN for
pain.”
109. A nurse iscaringforaclientwhohasgestationalhypertensionandisexperiencingtoxiceffectsdueto
magnesiumsulfate therapy.The nurse shouldanticipate administering whichof the medications?
Calcium gluconate
Sodium bicarbonate.
Potassium chloride.
Magnesium citrate
110. A nurse isreviewingtheformulary about NPH insulinbeforeadministeringthe medication toaclient. Whichof the
followinginformationthe nurse expect ?
Administrer NPH Insulin 30minbeforebreakfast.
Give NPH Insulinby IVbolus
Use NPH insulintotreat ketoacidosis
Discardthe NPH insulinvial if the medicationiscloudy
111. A nurse is planningcareforaschoolagechild whois 4hrpostoperative followingappendicitis .Whichof thefollowing
actionshouldthe nurse include inthe planof care?
Administer analgesicsonascheduledbasis forthefirst24hr
Apply a warm compress to the operative site once daily
Offer small amounts of dear liquids 6 hr following surgery
Givecromolynnebulizedsolutionevery8 hr
112. A nurse is preparingtoadmitaclient whois 35 weeksofgestationforevaluationof the fetal wellbeingdue topotencial
preterm labor followingplaces ofequipmentshouldthe nurse usetoevaluatethe fetal heart rate?
Intrauterine pressure
catheterSpiral electrode
Toco transducer
ultrasound
transducer
113. A nurse isreviewingthe medical recordofaclient whohasdelayedhealingofalegulcer. Whichof thefollowing
findings shouldthe nurse identify as acontributing factor?
Theclient takesprednisoneforarthritis.
Theclient isreceivingIVdextrose 5% in waterat 100 mL/hr.
The clienthasatotalcholesterol levelof 190 mg/dL.
The clienthas analbuminlevelof 3.8 g/dL
114. A nurse iscaringforaclient who hashypertensionandanew prescriptionforchlorthalidone.The nurse should
monitorforwhichof the followingadverse effects?
Hypoglycemia
Hypokalemia
Euphoria
Increasedintraocularpressure
115. A nurse isprovidingdischargeinstructionsaboutnewbornsafetytoaclient whois2dayspostpartum.Whichof the
followinginstructions should the nurse include?
Changesmokedetectorbatterieseveryotheryear.
Laythebabyonhisstomachtonapduringthedaytime.
Use acarseat whentraveling by airplane
Placeaplastic waterproofsheetover thecribbedding.
116. A nurse is caring fora client who is 12 hr postoperative followingaortofemoral bypass surgery .which of the
following findingshouldthe nurse impact intheaffectedextremity?
Cool extremities
Pedal pulse of 2+
Throbbing pain
Capillaryrefillof4seconds
117. A home health nurse is teaching a new parent about caring for his 1-week-old-infant. Which of the following statements
by the client indicates anunderstanding of the teaching?
“Ican use a form pillow toprop up the bottle when feeding mybaby.”“I
will avoid picking up my baby too often to keep from spoiling him.”“I
willhangapastel-colored mobile24inchesabove mybaby’scrib.”
“Iwillplaceatickingclocknearlytosoothe mybabythroughout theday.”
118. A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse
take?
Applyzincoxideointment totheirritatedarea.
Wipestool from theskinusingstoreboughtbabywipes.Wipe
urinefrom theskin using acoolcloth
Applytalcum powder totheirritablearea
119. A nurse is assessingaclient who is receivingdailyaspirintherapy .The nurse shouldidentifythat whichof the
followingallergic reactionto this medication ?
Difficulty swallowing
Blurred vision
Weight gain
Highbloodpressure
120. A nurse is preparing to measure a temperature of an infant. Which of the following action should the
nurse take?
Placethetipof thethermometerunderthecenterof theinfant’s axilla.Pull the
pinnaof theinfant’searforwardbeforeinsertingtheprobe.
Insert theprobe 3.8 cm (1.5in) intotheinfant’s rectum.Insert the
thermometer infrontof theinfant’stongue.
121. A nurse iscaring foraclient who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
Q. Coffeewithcreamer.
R. Lettuce withslicedavocados.
S. Broiledskinlesschickenbreast withbrownrice.
T. Warmtoast with margarine.
122. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The
nurse should recommend increasing dietaryintake of which of the following vitamins? (Exhibit) --onlytab
shown isTab 3:
a. Vitamin D
b. VitaminK
c. Vitamin A
d. Vitamin B12
123. A nurse is assessing aclient who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings should the nurse to report?
Chest pain Muscle
spasms.Cool,
moist skin.
Incisionalpain.
124. A nurse is providingteachingtoaclient whoistobeginexternal radiationtherapyforcancer .Whichof the following
informationinclude?
Washyourskinthoroughly witha washclothaftereachtreatment
Wearabinderover theradiationsite
You might experience altered taste sensations
Use rubbingalcohol toremovetheinkmaricings
125. A nurse iscaringforaninfant whohas respiratory svncytial virus .Whichof thefollowinginterventionshouldthe
nurse take ?
Suction nares prior to feeding
Request a prescription for
guaifenesinAdminister palivizumab
intravenouslyInitiate neutropenic
precautions
126. A nurse is interviewingthepartnerofaclient who wasadmittedinthe manicphaseofbipolardisorder. Thepartner
states“I don’t know what to do. Everything has been happening so quickly.” Which of the following by the nurse is
therapeutic?
“Can youtalkabout whathappens withyourpartnerathome?”
“Whydoyouthinkyourpartner’s symptoms areprogressingsoquickly?”“You
should make sure your partner takes the prescribed medication.” “Youdidthe
right thingbybringing yourpartner in fortreatment.”
127. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should
identify that 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. Humanpapillomavirus
C. Candidiasis
D. Herpssimplexvirus
128. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of
thefollowinginformationshould the nurse report totheoccupational therapist?
Theclient’sparent isinaskilled nursingfacilityThe
client is allergictopenicillin
TheclienthastwosmallchildrenathomeThe
client lives inatwo-storyhome
129. A nurse iscaringforaclientwhohasheart failure.The nurse notestheclient’s24-hr-intake is1.750 mLandoutput
is425 mL. Whichof the followingactions shouldthe nurse take first?
Comparetheclient’s wight tothepreviousday.
Reduce the client’ssodium intake.
Encouragetheclient tochangepositionsfrequently.
Administerfurosemide to the client.
130. A nurse ina mentalhealthfacility receiveschange-of-shift report for fourclients. Whichof thefollowingclients
shouldthe nurse planto assess first?
A newlyadmittedclientwhohasahxof4.5 kg(10lb) weight loss inthepast2 monthsA client
who willbe receiving her first ECTtreatment today
A clientplacedinrestraintsduetoaggressivebehavior
A client whoreceiveda PRN doseofhaloperidol2hragofor increased anxiety
131. A nurse iscaringforanewborn whoisexperiencingneonatalabstinencesyndrome. whichof the followingactions
should the nurse take
Decrensethelightinglevelsinthenrsery
Wrapthenewbornloosely inabianket
Encourasefrequenteyecontact withthenewbornduringfeedingProvide
frequentstimulation for the newborn
176. A nurse iscalculating aclient's expected date of delivery.The clientsfast menstral period began
April 12 Using Nagele’srule, what date should the nurse determine to be the client’s expected
delivery date?
A nurse is discussing group treatment and therapy with aclient. The nurse should include which
ofthefollowing as being acharacteristic of atherapeutic group?
A. Thegroupisorganizedinanautocraticstructure.
B. The group encourages members to focus on a particular issue. (
C. Thegroup mustbeledbyalicensedpsychiatrist.
D. Thegroupencouragesclientstoform dependentrelationships.
177. A nurse manger is reviewing documentation with a newly licensed nrse. Which of the following
notations bythe newlylicensed nurse indicates an understanding of the teaching?
UNSURE IF ON THE REPORT
A.“OOB withassistanceforbreakfast”
E. “Given2mg MSO4IM for reportofpain”
F. “Dressingchangedqd”
G. “Administered 8 uregular insulinsq.”
178. A nurse is preparing to administer eye drops to a school-age child. Identify the actions the n u r s e
should take. (Move the steps into the box on the right, placing them in the order of performance. Use all
the steps.)
6. Applypressuretothelacrimalpunctum.5
7. Askthechildtolookupward.2
8. Pull thelowereyeliddownward. 3
9. Instill thedropsof medication.4
10. Placethechildinasittingposition. 1
179. A nurse is caring for a client who speaks a language different from the nrse. Which of
the following should the nurse take?
E. Requestaninterpreterofadifferentsexfrom theclient.
F. Requestafamily memberorfriendtointerpret informationfortheclient.
G. Directattentiontowardtheinterpreterwhenspeakingtotheclient.
H. Review thefacilitypolicyabout theuseofaninterpreter.
180. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the
following findings indicates that the nurse should increase the rate of infusion?
ON THE REPORTneedsdoublechecking
A. Urineoutput20 ml/hr.
D. Montevideounitsconstantly 300 mm Hg.
E. FHR pattern withabsentvariability.
F. Contractionsevery 5 minthat last 30 seconds.
181. A nurse is planning care for a group of clients and is working with one licensed practical
nurse LPN and one assistive personal AP. Which of the following actions should the nurse
take first to manage her time effectively?
DevelopanhourlytimeframefortasksSchedule
dailyactivities
Determine goals of the day
Delegatetaskstothe AP
182. A public health nurse is managing several projects for the community. Which of the
following interventions should the nurse identifyas a primary prevention strategy?
A.Teachingparentingskillstoexpectantmothersandtheirpartners.
C. Conductingmentalhealthscreeningsat thelocalcommunitycenter.
C. Referringclient whohaveobesitytocommunityexerciseprograms.
D. Providingcrisisinterventionthroughamobilecounselingunit.
183. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which
of the following statements bythe client indicatesan understanding of the teaching?
a. “Iwill takesucralfate with mealsthreetimesperday”
b. “Iwillavoidfood andbeveragesthatcontaincaffeine”
c. “I willdecrease mydailyproteinintaketo15 gramsperday”
d. “Iwilluseibuprofenasneededtocontrolabdominalpain”
184. A n u r s e is assessing a client who is receiving packed RBCs. Which of the
followingfindings indicate fluid overload?
A. Low backpain.
Dyspnea.
Hypotension.
Threadypulse.
185. A nurse is providing teaching about patient-controlled analgesia(PCA) to aclient. Which
ofthe following statements should the nurse include in the teaching?
U. “The PCA willdeliveradoubledoseof medication when youpushthebuttontwice.”
V. “Youcanadjust theamountofpain medication youreceivebypushingonthekeypad.”
W. “Continuous PCA infusion isdesignedtoallow fluctuatingplasma medication levels.”
X. “Youshouldpushthebuttonbeforephysicalactivitytoallow maximum paincontrol.”
186. A nurse is preparing to administer an autologous blood product to a client. Which
of the following actionsshould the nurse take to identifythe client?
M. Matchtheclient’sbloodtype withthetypeandcross matchspecimens.
N. Confirmtheprovider’sprescription matchesthenumberonthebloodcomponent.
O. Asktheclient tostatethebloodtypeandthedateof theirlastblooddonation.
P. Ensurethat theclient’sidentificationband matches thenumberonthebloodunit.
187. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of
the following statements bythe client indicates the need for a referral to physical therapy?
E. “Inoticedthat Iam havingahardertimeholdingonto mytoothbrush”
F. “Lately, Ifeel like myfeetarefreezingup,astheyarestucktotheground”
G. “Sometimes, I feel Iammakingachewing motion whenI’mnoteating”
241. A nurse isprovidingdischargeteachingtoafemaleclient whohastuberculosisanda
newprescriptionfor rifampin.Whichof thefollowinginformationshouldthe nurse
include?
“Yoururinewillbeorange whilethismedication.”
Weightgainisanexpectedadverseeffectof this medication
Youshouldavoidgettingpregnant for 6 monthsafterstoopingthis medication
Youshouldavoidsunexposure while taking this medication
242. A nurse is providing discharge Instructions to a client who has a new prescription
forspironolactone .Whichof the followingthe nurse include intheteaching?
Monitor weightonce aweek
TakethemedicationinthemorningUse
asaltsubstitute with meals
Administerapotassium supplementdaily
243. A n u r s e is caring for a client who has acute exacerbation of multiple sclerosis. Which
of thefollowingprescriptions should the nurse expect theprovidertoprescribe?
Atorvastatin
Amoxicillin
Enoxaparin
Interferonbeta-1a
244. A n u r s e is caring for a client who has a history of depression and is experiencing a
situationalcrisis. Which of the following actionsshould the nurse take first?
A. Confirmtheclient’sperceptionof theevent
B. Notifytheclient’ssupportsystem
C. Helptheclient identifypersonalstrengths
D. Teachtheclientrelaxationtechniques
245. A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months
ago. For which of the following clients should the nurse initiate a referral to assess for the presence
of posttraumatic stress disorder?(Selectall thatapply.)
A client whodescribeshavingpersistent feelingsofangerabout thehurricane.A
client whohas frequentnightmares about thehurricane.
A client whoexpressesarealizationthat life willnotreturntothe wayit wasbeforethehurricane.A
client who movedto anapartment locatedonhighergroundthanherprevioushome.
A client whodescribes feelingdisconnectedfrom thosearoundhim followingthehurricane.
246. A nurse iscaringforaclient whohascancerof thethroatandisreceivingradiationtherapy.
The nurse shouldmonitor for whichof thefollowingfindingas anadverseeffectof theradiation?
Excessive salivation
Insomnia
Altered sensation
Elevateplateletcount
247. A nurse is providing teaching to a client who is breastfeeding and experiencing
engorgement.Whichof the followingrecommendations shouldthe nurse include?
Wearatight-fittingunderwirebra.
Applywarm compressesonthebreastsbeforefeedings.
Allow theinfant to nurse ononebreastper feeding.
Takeaspirintoreducepainandswelling.
248. A nurse isacommunitycliniciscaringforclient whorequestassistant withsmokingcensation
The nurse shouldexpecta prescriptionfor whichof thefollowing medications?
Bupropion
Chiordiazepoxide
Naltrexone
Clonidine
249. A nurse is preparing to administer an IV medication to a client and accidently punctures the
IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of biohazardous material
spill?
Doxorubicin hydrochloride
Ampicillin sodium Metronidazole
Phenytoin
132. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should
the nurse plan to take?
Obtainthenewborn’sbodytemperatureusingatympanicthermometer.Assessthe
newbornpainlevelusing FACES pain scale.
Auscultatethenewborn’sapicalpulsefor 60 seconds.
Measure the newborn’s head circumference over the eyebrows and below the occipitalprominence.
133. 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 nrsemakein the
medical record?
“Morphine 3 mg SQ every 4 hr. PRN for pain.” “Morphine 3 mg
Subcutaneousevery4hr PRN forpain“Morphine 3.0 mg sub q
every 4 hr. PRN for pain.” “Morphine 3 mg SC q4hr. PRN for
pain.”
134. A nurse iscaringforaclient whohasgestationalhypertensionandisexperiencingtoxiceffectsdue
tomagnesium sulfatetherapy.The nurse shouldanticipateadministering whichof themedications?
Calcium gluconate
Sodium bicarbonate.
Potassium chloride.
Magnesiumcitrate
135. A nurse isreviewingtheformularyabout NPH insulinbeforeadministeringthe medicationtoaclient.
Whichof thefollowinginformation the nurse expect ?
Administrer NPH Insulin 30minbeforebreakfast.Give
NPH Insulinby IVbolus
Use NPH insulintotreat ketoacidosis
Discardthe NPH insulinvial if the medicationiscloudy [Show Less]