1. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to
the emergency department (ED) with full thickness burns
... [Show More] to all surfaces of both lower
extremities. What percentage of body surface area should the nurse document in the
electronic medical record (EMR)?
9 %
18 %
36 %
45 %
Rational: according to the rule of nines, the anterior and posterior surfaces of one
lower extremity is designated as 18 %of total body surface area (TBSA), so both
extremities equals 36% TBSA, other options are incorrect.
2. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that
the medication is having the desired effect?
Decrease in serum T4 levels
Increase in blood pressure
Decrease in pulse rate
Goiter no longer palpable
3. An older male client with type 2 diabetes mellitus reports that has experiences legs pain
when walking short distances, and that the pain is relieved by rest. Which client behavior
indicates an understanding of healthcare teaching to promote more effective arterial
circulation?
Consistently applies TED hose before getting dressed in the morning.
Frequently elevated legs thorough the day.
Inspect the leg frequently for any irritation or skin breakdown
Completely stop cigarette/ cigar smoking.
Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and
improve arterial circulation to the extremity.
4. A community health nurse is concerned about the spread of communicable diseases among
migrant farm workers in a rural community. What action should the nurse take to promote the
success of a healthcare program designed to address this problem?
Establish trust with community leaders and respect cultural and family
values
5. The nurse performs a prescribed neurological check at the beginning of the shift on a client
who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s
Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to
determine?
The client’s previous GCS score
When the client’s stroke symptoms started
If the client is oriented to time
The client’s blood pressure and respiration rate
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in the
client’s condition
6. The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is
stable enough to be transferred. Which client status report indicates readiness for transfer
from the critical care unit to a medical unit?
Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
7. Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
One inch- border around the edge of the sterile field set up in the operating room
A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
An open sterile Foley catheter kit set up on a table at the nurse waist level
Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
Rationale: A sterile package at or above the waist level is considered sterile. The
edge of sterile field is contaminated which include a 1-inch border (A). A sterile
objects become contaminated by capillary action when sterile objects become in
contact with a wet contaminated surface.
8. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms
when taking the blood pressure using the same arm. After confirming the presence of spams
what action should the nurse take?
Ask the UAP to take the blood pressure in the other arm
Tell the UAP to use a different sphygmomanometer.
Review the client’s serum calcium level
Administer PRN antianxiety medication.
Rationale: Trousseau’s sign is indicated by spasms in the distal portion of an
extremity that is being used to measure blood pressure and is caused by
hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
9. A 56-years-old man shares with the nurse that he is having difficulty making decision about
terminating life support for his wife. What is the best initial action by the nurse?
Provide an opportunity for him to clarify his values related to the decision
Encourage him to share memories about his life with his wife and family
Advise him to seek several opinions before making decision
Offer to contact the hospital chaplain or social worker to offer support.
Rationale: When a client is faced with a decisional conflict, the nurse should first
provide opportunities for the client to clarify values important in the decision. The
rest may also be beneficial once the client as clarified the values that are
important to him in the decision-making process.
10. A client is being discharged home after being treated for heart failure (HF). What instruction
should the nurse include in this client’s discharge teaching plan?
Weigh every morning
Eat a high protein diet
Perform range of motion exercises
Limit fluid intake to 1,500 ml daily
11. A woman just learned that she was infected with Heliobacter pylori. Based on this finding,
which health promotion practice should the nurse suggest?
Encourage screening for a peptic ulcer
12. A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
13. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum
potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?
Cardiac rhythm and heart rate.
Daily intake of foods rich in potassium.
Hourly urinary output
Thirst ad skin turgor.
14. The nurse note a depressed female client has been more withdrawn and non-communicative
during the past two weeks. Which intervention is most important to include in the updated
plan of care for this client?
Encourage the client’s family to visit more often
Schedule a daily conference with the social worker
Encourage the client to participate in group activities
Engage the client in a non-threatening conversation.
Rationale: Consistent attempts to draw the client into conversations which focus
on non-threatening subjects can be an effective means of eliciting a response,
thereby decreasing isolation behaviors. There is not sufficient data to support the
effectiveness of A as an intervention for this client. Although B may be indicated,
nursing interventions can also be used to treat this client. C is too threatening to
this client.
15. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel)
subcutaneously once weekly. The nurse should emphasize the importance of reporting
problem to the healthcare provider?
Headache
Joint stiffness
Persistent fever
Increase hunger and thirst
Rationale: Enbrel decrease immune and inflammatory responses, increasing the
client’s risk of serious infection, so the client should be instructed to report a
persistent fever, or other signs of infection to the healthcare provider.
16. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding
indicates that the client understands long- term control of diabetes?
The fating blood sugar was 120 mg/dl this morning.
Urine ketones have been negative for the past 6 months
The hemoglobin A1C was 6.5g/100 ml last week
No diabetic ketoacidosis has occurred in 6 months.
Rationale: A hemoglobin A1C level reflects he average blood sugar the client had
over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client
understand long-term diabetes control. Normal value in a diabetic patient is up to
6.5 g/100 ml.
17. An older male client is admitted with the medical diagnosis of possible cerebral vascular
accident (CVA). He has facial paralysis and cannot move his left side. When entering the
room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of
water. What action should the nurse take?
Ask the wife to stop and assess the client’s swallowing reflex
18. A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with
osteomyelitis. The healthcare provider collects home aspirate specimens for culture and
sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse
implement next?
Administer antiemetic agents
Bivalve the cast for distal compromise
Provide high- calorie, high-protein diet
Begin parenteral antibiotic therapy
Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and
immobilization. After bond and blood aspirate specimens are obtained for culture
and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.
19. The nurse is preparing a community education program on osteoporosis. Which instruction is
helpful in preventing bone loss and promoting bone formation?
Recommend weigh bearing physical activity
20. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but
has difficulty describing the exact nature and location of the pain to the nurse. What action
should the nurse implement next?
Administer the analgesic as requested
21. A male client receives a thrombolytic medication following a myocardial infarction. When
the client has a bowel movement, what action should the nurse implement?
Send stool sample to the lab for a guaiac test
Observe stool for a day-colored appearance.
Obtain specimen for culture and sensitivity analysis
Asses for fatty yellow streaks in the client’s stool.
Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac
(occult blood test) test of the stool should be evaluated to detect bleeding in the
intestinal tract.
22. The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impaired
movements will worsen as the child grows. Which response provides the best explanation?
Brain damage with CP is not progressive but does have a variable course
23. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which
client alarm should the nurse investigate first?
Respiratory apnea of 30 seconds
24. In early septic shock states, what is the primary cause of hypotension?
Peripheral vasoconstriction
Peripheral vasodilation
Cardiac failure
A vagal response
Rationale: Toxins released by bacteria in septic shock create massive peripheral
vasodilation and increase microvascular permeability at the site of the bacterial
invasion.
25. A client diagnosed with calcium kidney stones has a history of gout. A new prescription for
aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication
should the nurse bring to the healthcare provider’s attention?
Allopurinol (Zyloprim)
Aspirin, low dose
Furosemide (lasix)
Enalapril (vasote)
26. A male client’s laboratory results include a platelet count of 105,000/ mm3 Based on this
finding the nurse should include which action in the client’s plan of care?
Cluster care to conserve energy
Initiate contact isolation
Encourage him to use an electric razor
Asses him for adventitious lung sounds
Rationale: This client is at risk for bleeding based on his platelet count (normal
150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for
shaving, should be encouraged to reduce the risk of bleeding.
27. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as
a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech
therapy if the client exhibits which finding?
Abnormal responses for cranial nerves I and II
Persistent coughing while drinking
Unilateral facial drooping
Inappropriate or exaggerated mood swings
28. At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the
client’s medical record. Based on date contained in the record, what action should the nurse
take before assisting the client with ambulation:
Remove sequential compression devices.
Apply PRN oxygen per nasal cannula.
Administer a PRN dose of an antipyretic.
Reinforce the surgical wound dressing.
Rationale: Sequential compression devices should be removed prior to ambulation
and there is no indication that this action is contraindicated. The client’s oxygen
saturation levels have been within normal limits for the previous four hours, so
supplemental oxygen is not warranted.
29. Which assessment finding for a client who is experiencing pontine myelinolysis should the
nurse report to the healthcare provider?
Sudden dysphagia
Blurred visual field
Gradual weakness
Profuse diarrhea
30. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after
receiving chemotherapy. The client has saline lock and is sleeping quietly without any
restlessness. The nurse caring for the client is not certified in chemotherapy administration.
What action should the nurse take?
Ask a chemotherapy-certified nurse to administer the Zofran
Administer the Zofran after flushing the saline lock with saline
Hold the scheduled dose of Zofran until the client awakens
Awaken the client to assess the need for administration of the Zofran.
Rationale: Zofran is an antiemetic administered before and after chemotherapy to
prevent vomiting. The nurse should administer the antiemetic using the accepter
technique for IV administration via saline lock. Zofran is not a chemotherapy drug
and does not need to be administered by a chemotherapy- certified nurse.
31. When providing diet teaching for a client with cholecystitis, which types of food choices the
nurse recommend to the client?
High protein
Low fat
Low sodium
High carbohydrate.
Rationale: A client with cholecystitis is at risk of gall stones that can be move into
the biliary tract and cause pain or obstruction. Reducing dietary fat decrease
stimulation of the gall bladder, so bile can be expelled, along with possible stones,
into the biliary tract and small intestine.
32. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and
ascites. Which assessment finding warrants immediate intervention by the nurse?
Jaundice skin tone
Muffled heart sounds
Pitting peripheral edema
Bilateral scleral edema
Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium
and is life- threatening. The other one are signs of end stage liver disease related
to alcoholism but are not immediately life- threatening.
33. When entering a client’s room, the nurse discovers that the client is unresponsive and
pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take
next?
Prepare to administer atropine 0.4 mg IVP
Gather emergency tracheostomy equipment
Prepare to administer lidocaine at 100 mg IVP
Place cardiac monitor leads on the client’s chest.
Rationale: Before further interventions can be done, the client’s heart rhythm must
be determined. This can be done by connecting the client to the monitor. A or C
are not a first line drug given for any of the life threatening, pulses dysrhythmias
34. A client with a history of dementia has become increasingly confused at night and is picking
at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The
abdominal dressing is no longer occlusive, and the IV insertion site is pink. What
intervention should the nurse implement?
Replace the IV site with a smaller gauge.
Redress the abdominal incision
Leave the lights on in the room at night.
Apply soft bilateral wrist restraints.
Rationale: The abdominal incision should be redressed using aseptic-techniques.
The IV site should be assessed to ensure that it has not been dislodged and a
dressing reapplied, if need it. Leaving the light on at night may interfere with the
client’s sleep and increase confusion. Restraints are not indicated and should only
be used as a last resort to keep client from self-harm.
35. An adult male client is admitted to the emergency room following an automobile collision in
which he sustained a head injury. What assessment data would provide the earliest that the
client is experiencing increased intracranial pressure (ICP)?
Lethargy
Decorticate posturing
Fixed dilated pupil
Clear drainage from the ear.
Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and
response to verbal commands. The most important indicator of increase ICP is the
client’s level or responsiveness or consciousness. B and C are very late signs of
ICP.
36. In preparing a diabetes education program, which goal should the nurse identify as the
primary emphasis for a class on diabetes self-management?
Prepare the client to independently treat their disease process
Reduce healthcare costs related to diabetic complications
Enable clients to become active participating in controlling the disease
process
Increase client’s knowledge of the diabetic disease process and treatment options.
Rationale: The primary goal of diabetic self- management education is to enable
the client to become an active participant in the care and control of disease
process, matching levels of self- management to the abilities of the individual
client. The goal is to place the client in a cooperative or collaborative role with
healthcare professional rather than (A)
37. To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?
Confirm that all the staff nurses are being assigned to equal number of clients.
Review the staff nurse job description to ensure that it is clear, accurate, and
recurrent.
Assign each staff nurse a turn unit charge nurse on a regular, rotating basis.
Analyze the amount of overtime needed by the nursing staff to complete
assignments.
Rationale: Role ambiguity occurs when there is inadequate explanation of job
descriptions and assigned tasks, as well as the rapid technological changes that
produce uncertainty and frustration. A and D may be implemented if the nurse
manager is concerned about role overload, which is the inability to accomplish the
tasks related to one’s role. C is not related to ambiguity.
38. The nurse is assisting a new mother with infant feeding. Which information should the nurse
provide that is most likely to result in a decrease milk supply for the mother who is
breastfeeding?
Supplemental feedings with formula
Maternal diet high in protein
Maternal intake of increased oral fluid
Breastfeeding every 2 or 3 hours.
Rationale: Infant sucking at the breast increases prolactin release and proceeds a
feedback mechanism for the production of milk, the nurse should explain that
supplemental bottle formula feeding minimizes the infant’s time at the breast and
decreases milk supply. B promotes milk production and healing after delivery. C
support milk production. C is recommended routine for breast feeding that
promote adequate milk supply.
39. Which assessment is more important for the nurse to include in the daily plan of care for a
client with a burned extremity?
Range of Motion
Distal pulse intensity
Extremity sensation
Presence of exudate
Rationale: Distal pulse intensity assesses the blood flow through the extremity
and is the most important assessment because it provides information about
adequate circulation to the extremity. Range of motions evaluates the possibility
of long term contractures sensation. C evaluates neurological involvement, and
exudate. D provides information about wound infection, but this assessment do
not have the priority of determining perfusion to the extremity.
40. An elderly client with degenerative joint disease asks if she should use the rubber jar openers
that are available. The nurse’s response should be based on which information about assistive
devices?
They decrease the risk for joint trauma
41. When assessing a 6-month old infant, the nurse determines that the anterior fontanel is
bulging. In which situation would this finding be most significant?
Crying
Straining on stool
Vomiting
Sitting upright.
Rationale: The anterior fontanel closes at 9 months of age and may bulge when
venous return is reduced from the head, but a bulging anterior fontanel is most
significant if the infant is sitting up and may indicated an increase in
cerebrospinal fluid. Activities that reduce venous return from the head, such as
crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause
a normal transient increase in intracranial pressure.
42. A client with angina pectoris is being discharge from the hospital. What instruction should
the nurse plan to include in this discharge teaching?
Engage in physical exercise immediately after eating to help decrease cholesterol
levels.
Walk briskly in cold weather to increase cardiac output
Keep nitroglycerin in a light-colored plastic bottle and readily available.
Avoid all isometric exercises, but walk regularly.
Rationale: Isometric exercise can raise blood pressure for the duration of the
exercise, which may be dangerous for a client with cardiovascular disease, while
walking provides aerobic conditioning that improves ling, blood vessel, and
muscle function. Client with angina should refrain from physical exercise for 2
hours after meals, but exercising does not decrease cholesterol levels. Cold water
cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily
available and stored in a dark-colored glass bottle not C, to ensure freshness of the
medication.
43. What is the priority nursing action when initiating morphine therapy via an intravenous
patient-controlled analgesia (PCA) pump?
Initiate the dosage lockout mechanism on the PCA pump
Instruct the client to use the medication before the pain becomes severe
Assess the abdomen for bowel sounds.
Assess the client ability to use a numeric pain scale
44. While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert
and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute,
respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the
nurse implement first?
Raise the client’s legs and feet
45. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes
to establish adequate respirations. What priority issue should the nurse address to ensure the
newborn’s survival?
Heat loss
Hypoglycemia
Fluid balance
Bleeding tendencies
46. The fire alarm goes off while the charge nurse is receiving the shift report. What action
should the charge nurse implement first?
Tell the staff to keep all clients and visitors in the client rooms with the doors
closed
47. A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a
means preventing osteoporosis. Which factor in the client’s history is a possible
contraindication for the use of HRT?
Her mother and sister have a history of breast cancer
48. A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that
he is “starving” because he has had no “real food” since before the surgery. Prior to
advancing his diet, which intervention should the nurse implement?
Auscultate bowel sounds in all four quadrants
49. The nurse working in the psychiatric clinic has phone messages from several clients. Which
call should the nurse return first?
A family member of a client with dementia who has been missing for five
hours
50. During change of shift, the nurse reports that a male client who had abdominal surgery
yesterday increasingly confused and disoriented during the night. He wandered into other
clients rooms, saying that there are men in his room trying to hurt him. Because of continuing
disorientation and the client’s multiple attempts to get of bed, soft restrains were applied at
0400. In what order should the nurse who is receiving report implement these interventions?
(Arrange from first action on top to last on the bottom).
1. Assess the client’s skin and circulation for impairment related
to the restrains
2. Evaluate the client’s mentation to determine need to continue
the restrains
3. Assign unlicensed assistive personnel to remove restrains and
remain with client
4. Contact the client’s surgeon and primary healthcare provider
51. A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had
an upper respiratory infection for the past two days. Assessment of the child reveals a rectal
temperature of 102 F. he is drooling and becoming increasingly more restless. What action
should the nurse take first?
Notify the healthcare provider and obtain a tracheostomy tray
52. After receiving the first dose of penicillin, the client begins wheezing and has trouble
breathing. The nurse notifies the healthcare provider immediately and received several
prescriptions. Which medication prescription should the nurse administer first?
Epinephrine Injection, USP IV
53. Two clients ring their call bells simultaneously requesting pain medication. What action
should the nurse implement first?
Evaluate both client’s pain using a standardized pain scale
54. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What
action should the nurse take?
Administer the medication as prescribed with a glass of water
55. Which client should the nurse assess frequently because of the risk for overflow
incontinence? A client
Who is confused and frequently forgets to go to the bathroom
56. While monitoring a client during a seizure, which interventions should the nurse implement?
(Select all that apply)
Move obstacle away from client
Monitor physical movements
Observe for a patent airway
Record the duration of the seizure [Show Less]