A nurse is teaching a client who has a new prescription for metformin extended release tablets. Which
of the following statements by the client
... [Show More] indicates
an understanding of the teaching?
I will avoid crushing this
medication I'll switch to a lactosefree formula
2. A nurse is assessing a client who is receiving
enteral feeding via an NG tube. The client has
developed hyperosmolar dehydration. Which of the
following ac- tions should the nurse take when
administering the client's findings?
Empty your ostomy pouch when it is half
full Switch to a lactose-free formula.
3. A nurse is teaching the parents of a school-age
child who has sickle cell anemia about managing
the dis- ease at home which of the following
instructions should the nurse include?
Apply cold compresses too painful areas
I should boil tap water for 2 minutes and call it
before I mix it with powdered formula
4. A nurse is teaching about Safe Handling of formula
to a client who is postpartum and chooses to bottle
feed her newborn. Which of the following statements
by the client indicates an understanding of the teaching?
I should boil tap water for 2 minutes before I mix
it with powdered formula
I should use sterile water when I mix it with powdered
formula
5. A nurse is assessing a child who is post-operative
following a tonsillectomy. Which of the following findI will avoid crushing this medication
Switch to a lactose-free
formula.
Apply cold compresses too
painful areas
I should boil tap
water for 2 minutes before I mix
it with powdered
for- mula
Frequent swallowing
2 / 51
ings should the nurse identify as the priority?
During this test, I will punch a button if the
baby moves
Frequent swallowing
6. A nurse is teaching a client who is pregnant about
non-stress testing. Which of the following statements
by the client indicates an understanding of the teaching?
During this test, I will punch a button if the
baby moves
During this test, I will punch a button if I feel stressed
7. A nurse is monitoring a client who is receiving a
transfusion of packed RBC's.The client reports chills,
headaches, low back pain, and a feeling of tightness
in his chest. The nurse should identify that the
client has developed which of the following types of
trans- fusion reactions?
Pudendal nerve
block Acute
hemolytic
8. A nurse is caring for a client who is in the latent
phase of Labor and reports severe back pain. The
vaginal examination reveals that the cervix is
dilated two centimeters, 25% effaced and -2 station.
Which of the following interventions should the
nurse implement?
You should wear a snug fitting bra continuously
for 72 hours
Request the provider prescribe a pudendal
nerve block
9. A nurse is teaching about how to suppress lactation
2
During this test, I
will punch a button
if the baby moves
Acute hemolytic
Request the
provider prescribe
a pudendal nerve
block
You should wear
with a client who is postpartum and bottle feeding her a snug fitting bra
3 / 51
newborn. Which of the following instructions should
the nurse include in the teaching?
continuously for
72 hours
3
You should wear a snug fitting bra continuously
for 72 hours
Room number
10. A nurse is preparing to administer medication to a
client. What are the following identifiers should
the nurse use to identify the client?
Room number
MRN
11. A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine
to a seated position. Which of the following
findings should indicate to the nurse that the client
is experi- encing orthostatic hypotension?
The clients systolic blood pressure decreases by
25 mmHg
The clients systolic blood pressure increases by
35 mmHg
12. While a nurse is caring for a client who is receiving
mechanical ventilation via an endotracheal tube,
the high-pressure alarm of the ventilator sounds.
Which of the following actions should the nurse
take?
Look for a block in the tubes
cuff Look for a leak in the tubes
cuff
13. A nurse is preparing to insert an indwelling urinary
catheter for a client. Which of the following actions
should the nurse take first?
Monitor Vital Signs every hour throughout the
trans- fusion
Position
the sterile
drape
leaving the
perineum
ex- posed
Room number
The clients sys- tolic blood pres- sure decreases by 25
mmHg
Look for a leak in the tubes cuff
Position the ster- ile drape leaving the perineum ex- posed
4
14.A nurse is planning to administer packed RBC's to Monitor Vital
an older adult client who has a low hemoglobin level. Signs every hour
to take? Which of the following actions should the nurse plan throughout the
Monitor Vital Signs every hour throughout the
trans- fusion
Monitor RR every hour throughout the transfusion
15. A new nurse in an acute mental health facility is
teaching a client about potential adverse effects of
transcranial magnetic stimulation. The nurse tells
the client that he might feel light-headed but that it
should not affect his memory. The nurse is
demonstrating which of the following ethical
principles?
Beneficence
Restrictive
16. A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses.
The nurse should include that which of the
following procedures is outside the legal scope of
practice for an RN?
Irrigation of the external ear
canal Irrigation of the inferior ear
canal
17. A nurse in an acute care facility is caring for a client
who has anorexia nervosa. During the first week of
care, which of the following actions should the
nurse take?
Observe the client for 1 hour after meals
Observe the client for 6 hours after
meals
18. A nurse is
planning
care for a
client who
has sciatica and a
prescription
for a
transcutane
ous
electrical
nerve
stimulation
(TENS) unit.
Which of the
following
referral
should the
nurse
anticipate
for the
client?
transfusion
Beneficence
Irrigation of the ex- ternal ear canal
Observe the client for 1 hour after meals
Physical therapist
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8 / 51
Primary Care Provider
Physical therapist
19. A nurse is teaching a client who has generalized
anxiety disorder about ways to help manage stress.
Which of the following instructions should the
nurse give the client about using Progressive
relaxation?
Tighten the muscle group, then release tension
and move to the next one
Rest the muscle group, then release tension
and move to the next one
20. A nurse is assessing a client who is at 37 weeks
of gestation and reports sudden, severe abdominal
pain with moderate vaginal bleeding and persistent
uterine contraction. The client's blood pressure is 88
over 50 mmhg and her abdomen is rigid. The nurse
should identify these findings as indicating which
of the following complications?
Placenta discharge
Placenta abruption
21. A home health nurse is planning care for an older
adult client who has a vision loss and takes medication throughout the day. Which of the following
actions should the nurse include in the plan?
Use container Lids of different shapes to
indicate times of Administration
Use container Lids of different colors to
indicate times of Administration
22. A nurse at an acute care facility is teaching a client
about fall risk prevention strategies for use during
their stay at the facility. Which of the following
state- ments by the client indicates an understanding
of the
teaching?
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Tighten the mus- cle group, then re- lease tension and
move to the next one
Placenta abrup- tion
Use container Lids of different shapes to indicate times of
Administration
I will wear a yel- low wristband, so everyone knows I'm at
risk for falling
I will wear a yellow wristband, so everyone knows I'm
at risk for falling
I will wear call for help, so everyone knows I'm at
risk for falling
23. A nurse is caring for a client who is taking disulfiram for alcohol-use disorder and reports ingestion
of alcohol. For which of the following adverse effects
should the nurse monitor?
Headache
Hypertension
24. A nurse at the health department is providing anticipatory guidance to a parent of a one month or a
year-old infant. The nurse should inform the parent
that the infant should receive which of the
following immunizations at the age of two months?
C. Diff
Rotavirus
25. A Nurse is assisting in the selection of foods for a
client who has dysphagia caused by a stroke.
Which of the following foods should the nurse
recommend?
Scrambled eggs
Fish
26. A community health nurse is providing education to
a group of older adults about immunizations. Which
of the following immunizations should the nurse
rec- ommend?
Tdap
HIV
27. A nurse is
caring for a
client who is
postoperativ
e following a
mitral
balloon
valvuloplasty
. Which of
the
Headache
Rotavirus
Scrambled eggs
Tdap
Mitral
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following areas should the nurse auscultate to assess for mitral areas of the heart? (you will find hot
spots to select in the artwork below. Select only
the hot spot that corresponds to your answer.)
See picture
28. A nurse is planning care for a client who is experiencFlumazenil ing benzodiazepine toxicity. The nurse should plan
to administer which of the following medications?
Flumazenil
Furosemide
29. A nurse is admitting a client to the medical-surgical
unit. The patient self-determination act requires the
nurse to perform which of the following actions
dur- ing the admission process?
Document in the client's medical record if a client
has advance directives
Document in the client's medical record if a client
has PCP directives
30. A nurse is assessing a client who is postoperative
following orthopedic surgery. Which of the
following findings should the nurse identify as an
indication of paralytic Ileus?
Abdominal dissection
Abdominal distension [Show Less]