1. Which information is a priority for the RN to reinforce to an older client after
intravenous pylegraphy?
2. A client has altered renal function and
... [Show More] is being treated at home. The nurse recognizes
that the most accurate indicator of fluid balance during the weekly visits is
3. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is
most important for the nurse to reinforce with the client?
4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse
determines that the client’s blood pressure is increasing. Which action should the nurse
take first?
5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the
ventricular rate is controlled at 75. Which of the following findings is cause for the most
concern?
6. The client with infective endocarditis must be assessed frequently by the home health
nurse. Which finding suggests that antibiotic therapy is not effective, and must be
reported by the nurse immediately to the healthcare provider?
7. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which
of these points is most important to be reinforced by the nurse?
8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being
would be incorrect about acupuncture?
sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client
9. The nurse is discussing with a group of students the disease Kawasaki. What statement
made by a student about Kawasaki disease is incorrect?
10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best
position to teach the client to lie in every other hour during first 12 hours after admission?
11. A client has an indwelling catheter with continuous bladder irrigation after
at this time should be reported to the health care provider?
undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding
12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest.
Another nurse enters the room in response to the call. After checking the client’s pulse
and respirations, what should
be the function of the second nurse?
13. The nurse assesses a 72 year-old client who was admitted for right sided congestive
heart failure. Which of the following would the nurse anticipate finding?
14. A client with heart failure has a prescription for digoxin. The nurse is aware that
sufficient potassium should be included in the diet because hypokalemia in combination
with this medication
accident. Which of the following neurological signs is of most concern?
15. A nurse assesses a young adult in the emergency room following a motor vehicle
16. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a
diagnosis of vaso-occlusive crisis. Which statements by the client would be most
indicative of the etiology of this crisis?
17. Which these findings would the nurse more closely associate with anemia in a 10
month-old infant?
18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The
priority assessment in the first hour of care is
19. Which of these clients who are all in the terminal stage of cancer is least appropriate
to suggest the use of patient controlled analgesia (PCA) with a pump?
20. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be
21. As the nurse is speaking with a group of teens which of these side effects of
chemotherapy for cancer would the nurse expect this group to be more interested in
during the discussion?
22. While caring for a client who was admitted with myocardial infarction (MI) 2 days
ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees
Celsius). The appropriate
nursing intervention is to
23. A client is admitted for first and second degree burns on the face, neck, anterior chest
and hands. The nurse's priority should be
24. Which of these clients who call the community health clinic would the nurse ask to
come in that day to be seen by the health care provider?
25. A middle aged woman talks to the nurse in the health care provider’s office about
uterine fibroids also called leiomyomas or myomas. What statement by the woman
indicates more education is needed?
26. An elderly client admitted after a fall begins to seize and loses consciousness. What
action by the nurse is appropriate to do next?
27. A nurse is providing care to a primigravida whose membranes spontaneously ruptured
(ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were
T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min.
Which assessment findings taken now may be an early indication that the client is
developing a complication of labor?
28. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago.
During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The
client makes all of these statements during their conversation. Which statement would
alert the nurse to a complication?
29. The nurse is performing an assessment on a client in congestive heart failure.
30. Which of these observations made by the nurse during an excretory urogram indicate
a complicaton?
31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of
a chest tube. What is the best explanation for the nurse to provide this client?
32. The nurse is reviewing laboratory results on a client with acute renal failure. Which
one of the following should be reported immediately?
33. The nurse is caring for a client undergoing the placement of a central venous catheter
line. Which of the following would require the nurse’s immediate attention?
34. The nurse is performing a physical assessment on a client who just had an
endotracheal tube inserted. Which finding would call for immediate action by the nurse?
35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates
that the client may need suctioning?
36. The most effective nursing intervention to prevent atelectasis from developing in a
post operative client is to
37. When caring for a client with a post right thoracotomy who has undergone an upper
lobectomy, the nurse focuses on pain management to promote
38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client.
Which action should the nurse take first?
39. The nurse is caring for a child immediately after surgical correction of a ventricular
septal defect. Which of the following nursing assessments should be a priority?
40. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse
enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed
and his respirations are 8 per minute. What should the nurse do first?
41. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of
a fracture of the right femur. The nurse finds that the child is now crying and the right
foot is pale with the absence of a pulse. What should the nurse do first?
42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal
bypass. The upper leg dressing becomes saturated with blood. The nurse's first action
should be to
43. A client is receiving external beam radiation to the mediastinum for treatment of
bronchial cancer. Which of the following should take priority in planning care?
44. A client has a chest tube in place following a left lower lobectomy inserted after a stab
wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red
fluid flows into the collection chamber of the chest drain. What is the most appropriate
nursing action?
45. A client has returned from a cardiac catheterization. Which one of the following
assessments would indicate the client is experiencing a complication from the procedure?
46. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is
awake and alert, but has not been able to void since he returned from surgery 6 hours ago.
He received 1000 mL of IV fluid. Which action would be most likely to help him void?
47. The nurse is caring for a client who requires a mechanical ventilator for breathing.
The high pressure alarm goes off on the ventilator. What is the first action the nurse
should perform?
48. The nurse is preparing a client who will undergo a myelogram. Which of the
following statements by the client indicates a contraindication for this test?
49. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4
hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the
nurse take?
50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must [Show Less]