1. A nurse is assessing a client who has a diagnosis on colon cancer which of the following should the
nurse expect?
a. Steatorrhea
b. Elevated
... [Show More] hemoglobin
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 client‟s 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” – page 111
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 record
6. 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 affected area”
d. “Adjust the dial until you feel a „pins and needles‟ sensation” – page 648
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” – page 455
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 lactated 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 mirror
d. 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 – page 176
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)
2.5 mL
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 Page 605
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 – page 381
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. Furosemide
d. 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 – page 330
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 – page 615
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 – page 397
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 hours
21. 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 [Show Less]