1. A nurse is assessing a client who has a diagnosis on colon cancer which
of the following should the nurse expect?
a) Statorrhea
b) Elevated hemoglobi
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c) Hematochezia
d) Weight gain
2. A nurse is assessing a client admitted with peripheral vascular disease,.
Which of the following findings indicates a venous vascular disorder?
a) An ulcer at the tip of a toe
b) Hair loss distal to the clients calves
c) Leg pain at rest
d) Edema of the ankle
3. A nurse is assessing a client who has pericarditis. In which of the following
areas of the client’s chest should the nurse place the stethoscope to best hear a
pericardial friction rub? (select HOT spot)Answer: D
4. A nurse is caring for a client who has a chest tube. The client asks why
the fluid in the water -seal chamber rises and falls. Which of the following
statements should the nurse make?
a) “ this means your lung is fully expanded “
b) “ this indicates a possible leak”
c) “ suction pressure that is too high causes this”
d) “ Your breathing pattern causes this”
5. A community health nurse is reviewing home care instructions with an
older adult client who has a new diagnosis of heart failure. Which of the following
is the priority topic for the nurse to review with the client?
a) Daily sodium restriction
b) Daily exercise routine
c) Changes in weight
d) Fluid intake record6. A nurse is teaching a client about the use of transcutaneous electrical
nerve stimulation (TENS) unit. Which of the following statements should the
nurse include?
a) “Apply lotion to the site prior to attaching the electrodes”
b) “ this device requires access to a 220 volt outlet”
c) ‘ this device delivers heat via electrodes that are attached to the effected
area”
d) “adjust the dial until you feel a ‘pins and needles’ sensation”
7. A nurse is providing teaching to a client who is postoperative following a
total hip arthroplasty. Which of the following statements should the nurse make?
a) “ use raised toilet seat to maintain your hips above the knees”
b) “ twist at the waist when standing from a seated position”
c) “move your stronger leg first when using a walker”
d) “ apply a heating pad to the operative hip to decrease pain”
8. A nurse finds a client in bed, unresponsive and breathing. Which of the
following action should the nurse take first?
a) Establish IV access
b) Apply blood pressure cuff
c) Palpate for the client’s carotid pulse
d) Initiate cardiac monitoring for the client
9. A nurse is caring who is experiencing a hypertensive crisis. Which of the
following actions should the nurse take?
a) Initiate IV dopamine infusion
b) Perform neurological assessments
c) Place the client supine
d) Begin an IV bolus of lacted ringer’s
10. A nurse is providing discharge teaching about blood sugar monitoring for a
client who has a new diagnosis of type 2 diabetes mellitus. The nurse should
instruct the client to obtain which of the following supplies?
a) Sterile lancets
b) Compression stockings
c) Hand mirrord) Toenail clippers
11. A nurse is completing discharge teaching who has a peripherally inserted
central catheter ( PICC) line in the left arm. Which of the following instructions
should the nurse include in the teaching?
a) Do not elevate the arm above the level of the heart
b) Change the catheter dressing daily
c) Use 10- mL syringe to flush line
d) Clean the insertion site using 20- mL of hydrogen peroxide
12. A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who weights
220 lbs. the amount available is 0.4 mg/mL . how many mL should the nurse
administer? ( round to the nearest tenth)
13. A nurse is caring for a client who has a sealed radiation implant. Which of the
following actions should the nurse take?
a) Remove soiled linens from the room after each change
b) Give the dosimeter badge to the oncoming nurse at the end of the shift
c) Apply a second pair of gloves before touching the client’s implant if it
dislodges
d) Limit family member visits to 30 min per day
14. A nurse is providing teaching to a client and his partner about performing
peritoneal dialysis at home. When discussing peritonitis, which of the following
manifestations should the nurse identify as the earliest indication of this
complication?
a) Generalized abdominal pain
b) Cloudy effluent
c) Increased heart rate
d) Fever
15. A nurse is caring for a client who is receiving a blood transfusion. The nurse
observes that the client has bounding peripheral pulses, hypertension, and
distended jugular veins. The nurse should anticipate administering which of the
following prescribed medications?
a) Pantoprazole
b) Acetaminophen
c) Furosemided) Diphenhydramine
16. A nurse is planning care for a client who has upper gastrointestinal bleeding
due to a peptic ulcer. Which of the following actions should the nurse plan to
take?
a) Provide ketorolac for abdominal pain
b) Administer nitroprusside IV based on the client’s weight
c) Insert a large bore nasogastric tube
d) Ensure that the client has a 22- gauge iv line in place
17. A nurse is caring for a client who has bladder cancer and a WBC count of
900/mm3 . which of the following actions should the nurse take?
a) Instruct client to avoid eating raw fruit
b) Move the client to a negative pressure room
c) Use contact isolation while providing care
d) Apply pressure to venipuncture sites for 10 min
18. A nurse is caring for a patient who has hypotension, cool and clammy skin,
tachycardia and tachypnea. Which of the following positions should the nurse
place the client?
a) Reverse Trendelenburg
b) Feet elevated
c) Side lying
d) High – fowler’s
19. A nurse is caring for a client who weights 190 lb and is receiving Total parenteral Nutrition. if
the RDA Protein is 0.8g/kg Of body weight, how many grams of protein should the client receive
daily ( Round the answer to the nearest whole number. Use a leading zero if it applies. Do not
use a trailing zero)
Answer: 69 grams
20.A nurse is planning care for a client who has a central venous access device for intermittent
infusions. Which of the following actions should the nurse include in the plan of care?
a)Flush a catheter using a 10 mL syringe
b) Use clean technique when changing the dressing
c) Cleanse the site with Provo dine iodine
d) Change the dressing every 24 hours21. A nurse is reviewing the medical record of a client who is to undergo open heart surgery.
Which of the following findings should the nurse report to the provider as a contradiction to
receiving heparin?
a) Thalassemia
b) Rheumatoid arthritis
c) COPD
d) Thrombocytopenia
22. A nurse is caring for an older adult client who has dementia. Which of the following question
should the nurse ask to assess the client's abstract thinking?
a) What is meant by saying “don't beat around the bush?”
b) What do you understand about your condition
c) Can you count backwards from 100 in intervals of 7?
d) Can you state where you were born?
23. A Nurse is completing an assessment of an older adult client and notes reddened areas
over the bony prominences, but the client's skin is intact. Which of the following interventions
should the nurse include in the plan of care?
a) Apply an occlusive dressing
b) turn and reposition the client every 4 hours
c) support bony prominences with pillows
d) massage Tourette in areas three times daily
24. A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter. Which of the
following findings should the nurse expect?
a) Progressively longer PR durations
b) undetectable p waves
c) absent PR intervals with ventricular rate of 40 to 60 / minutes
d) Sawtooth pattern with atrial rate of 252 400 / minutes
25. A nurse is caring for a client who is scheduled for an abdominal paracentesis. The nurse
should plan to take which of the following actions?
a) Administer a stool softener following the procedure
b) ask the client to empty his bladder prior to the procedure
c) instruct the client to take deep breaths and hold them during the procedure
d) assist the client into the left lateral position during the procedure
26. A nurse is assessing a client following the insertion of a central venous catheter. Which of
the following findings indicates a pneumothorax?a) diminished breath sounds
b) itching over the incision
c) distended neck veins
d) irregular heart rate
27. A nurse is providing teaching to a client who is receiving opioids for pain management.
Which of the following information should the nurse include in the teaching?
a) Monitor urinary output for retention
b) avoid taking anti emetics with the medication
c) restrict fluid intake If you experience constipation
d) itching Indicates you are having an allergic reaction to the medication
28. A nurse is providing discharge teaching for a client who has asthma and a new prescription
for a metered dose inhaler. Which of the following client statements indicates an understanding
of the teaching?
a) I should clean the cap of the inhaler once per week
b) I should shake the inhaler before I use it
c) I Should wait 15 seconds between puffs
d) I should inhale the medication quickly
29. A nurse is providing preoperative teaching for a client who is having left-sided cardiac
catheterization. Which of the following information should the nurse include in the teaching?
a) You should plan to remain in bed for 18 hours after the procedure
b) you will have blood pressure measurement every 5 minutes for the first two hours after
the procedure
c) You will receive a general anesthetic during the procedure
d) you should expect warm sensation after the injection of the contrast dye during the
procedure
30. A nurse is caring for a client who has anemia. Which of the following assessment findings
should the nurse anticipate with the client's condition?
a) Bradycardia
b) Headache
c) heat intolerance
d) flushed skin color
31. A nurse is teaching a client who has a new prescription for Warfarin about foods that affect
the INR. The nurse should include in the teaching that which of the following Foods interact with
this medication?
a) Kale
b) beef stewc) Yogurt
d) orange juice
32. A nurse is monitoring an older adult client who has an extrapolation of chronic lymphocytic
leukemia. The nurse notes patikayy on the client's skin which of the following actions should the
nurse take?
a) Determine the client's blood type
b) avoid administering IV pain medication
c) Implement airborne precautions
d) Institute bleeding precautions
33. A nurse is providing discharge teaching for a client who is receiving treatment for genital
herpes. Which of the following statements by the client indicates effectiveness of the teaching?
a) I should expect to take my medication for three weeks
b) I should apply antibiotic ointment to the lesions
c) I should expect my lesions to resolve in 6 weeks
d) I should use natural skin condoms during sexual intercourse
34. A nurse in an emergency department is preparing a client for emergency surgery. The
client's blood alcohol level is 180 mg / DL which of the following action is the nurses priority?
a) Insert an NG Tube
b) obtain consent for surgery
c) apply anti embolic stockings
d) insert an indwelling urinary catheter
35. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia.
Which of the following assessment findings supports this suspicion?
a) Cool, clammy skin
b) kussmaul respirations
c) acetone breath
d) increased urine output
36. A nurse is caring for a client who is receiving radiation. The client reports nausea since the
therapy was initiated. Which of the following considerations should the nurse include when
finding the clients meals?
a) Offer hot beverages with meals
b) offer a snack prior to radiation therapy
c) offer highly seasoned Foods
d) offer frequent High carbohydrate meals37. A charge nurse receives a call from the house supervisor requesting room assignments for
four new clients. Based on the information diagnosis which of the following clients requires a
private room?
a) A client service port reports having fever, night sweats, and call for 2 days
b) an older adult client who was admitted with aspiration pneumonia
c) a client who has diabetes mellitus and is presenting with acute ketoacidosis
d) a client who has a compound fracture of the right femur
38. A nurse in an emergency department is assessing a client who has diabetic ketoacidosis.
Which of the following findings should the nurse expect? (select all the apply)
a) Tremors
b) reports of nausea and vomiting
c) Serum glucose 380 mg / DL
d) serum pH 7.6
e) fruity smelling breath
39. A nurse is planning a staff education session about hepatitis A. Which of the following
information should the nurse include?
a) Immunization for Hepatitis A is recommended prior to travel to high-risk areas
b) the incubation. Of hepatitis A is 5 to 10 days
c) hepatitis A is transmitted is Through Blood to blood exposure
d) clients who have Hepatitis A require a broad-spectrum antibiotic
40. A nurse is caring for a client who has advanced liver disease. Which of the following
laboratory results should the nurse monitor when assessing this client?
a) Phosphate level
b) glucose level
c) serum troponin
d) Serum ammonia
41. A nurse is planning care for a client who has status epilepticus. Which of the following
interventions is the nurses priority to include?
a) Administer phenytoin IV bolus to the client
b) provide the client oxygen at 6 L / min using a nasal cannula
c) turn the client to the lateral position during seizure activity
d) administer diazepam intravenously to the client
42. A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions
should the nurse take to prevent hip dislocation?
a) Elevate the knees higher than the hips when sitting
b) remove the wedge device when turningc) encourage the client to lean forward when attempting to stand
d) place two bed pillows between the legs when in bed
43. A nurse is caring for a client who is receiving Total parenteral Nutrition (TPN) The crane
infusion is almost complete and the new solution is not available which of the following actions
should the nurse take?
a) Infuse dextrose 10% in water
b) decrease that tpn infusion rate
c) disconnect and flush the IV access line
d) administer lactated ringers through the peripheral IV site
44. A nurse is caring for a client who is 6 hours postoperative following application of an
external fixator for a tibial fracture. Which of the following actions should the nurse take?
a) Adjust the clamps on the fixator frame
b) maintain the affected extremity in a dependent position
c) palpate the dorsalis pedis pulse
d) rap sterile gauze on the sharp point of the pins
45. A nurse is caring for a client in the emergency department who experienced a full thickness
burn injury to the lower torso 1 hour ago. Which of the following findings should the nurse
expect?
a) Hypotension
b) Bradycardia
c) decrease respiratory rate
d) urinary diuresis
46. A nurse is planning care for an older adult client who has Meniere's disease. Which of the
following interventions should the nurse include in the plan?
a) Perform range of motion exercises to the client's neck every 4 hours
b) limited clients fluid intake to 1500 ml / day
c) administer aspirin if the client reports a headache
d) encourage the client to change position slowly47. Was not able to take photo of question.. But i remember choosing the second option...
48. A nurse is caring for a client admitted with a skull fracture. which of the following
assessment findings should be of greatest concern to the nurse?
a) Pulse pressure changes from 30 to 20 mmhg
b) bilateral pupil diameter changes from 4 to 2 mm
c) WBC count changes from 9,000 to 16,000 / mm 3
d) Glasgow Coma Scale score changes from 14 to 9
49. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following
actions should the nurse take when performing a close intermittent irrigation?a) Use a 3ml syringe to perform the catheter irrigation
b) Clamp the catheter above the specimen port
c) place the client in Trendelenburg position
d) inject the irrigation solution slowly into the catheter
50. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS.
Which of the following statements by the client indicates an understanding of the teaching?
a) I will need to take my clothes to the dry cleaners to sterilize them
b) I will wipe up areas soiled with body fluids with alcohol and immediately disposed of the
trash (should be cleaned with bleach not alcohol )
c) I will be sure to wear gloves and wash my hands when I change my cat's litter box
d) I will increase the amount of fresh fruits and vegetables I consume
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