Exam (elaborations) NURSING CRITICAL C QUESTIONS AND ANSWERS
Question 1 See full question 20s
Which client is at highest risk for developing a urinary
... [Show More] tract infection?
You Selected:
a man with an indwelling urinary catheter
Correct response:
a man with an indwelling urinary catheter
Explanation:
Remediation:
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Question 2 See full question 6m 8s
A client is recovering from a bacterial infection with intravenous antibiotics. The
healthcare team is planning for the client to be discharged tomorrow. However, the client
wants to leave today because the client’s animals do not have someone to feed them
tomorrow. What is the nurse’s best response to this client?
You Selected:
“You have a right to leave early, but let us make sure you are aware of all the
complications that can occur.”
Correct response:
“You have a right to leave early, but let us make sure you are aware of all the
complications that can occur.”
Explanation:
Remediation:
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Question 3 See full question 2m 3s
A neonate born at 40 weeks' gestation admitted to the nursery is found to be
hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is
reading 75% on room air. What should the nurse do?
You Selected:
Provide supplemental oxygen.
Correct response:
Provide supplemental oxygen.
Explanation:
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Question 4 See full question 2m 22s
A client fears chemotherapy because of the side effects. What is the
nurse's best response to the client's concerns?
You Selected:
“We’ll give you medications to prevent the side effects, so you shouldn’t be too
concerned.”
Correct response:
“Each person responds differently to chemotherapy treatments. We’ll monitor your
responses closely.”
Explanation:
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Question 5 See full question 38s
The nurse teaches the client with chronic cancer pain about optimal pain control. Which
recommendation is most effective for pain control?
You Selected:
Take prescribed analgesics on an around-the-clock schedule to prevent recurrent
pain.
Correct response:
Take prescribed analgesics on an around-the-clock schedule to prevent recurrent
pain.
Explanation:
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Question 6 See full question 30s
A client received chemotherapy 24 hours ago. Which precautions are necessary when
caring for the client?
You Selected:
Wear personal protective equipment when handling blood, body fluids, and feces.
Correct response:
Wear personal protective equipment when handling blood, body fluids, and feces.
Explanation:
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Question 7 See full question 31s
A client with dysphagia is being prepared for discharge. Which outcome indicates that
the client is ready for discharge?
You Selected:
The client is free from esophagitis and achalasia.
Correct response:
The client is free from esophagitis and achalasia.
Explanation:
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Question 8 See full question 9s
A physician orders a loop diuretic for a client. When administering this drug, the nurse
anticipates that the client may develop which electrolyte imbalance?
You Selected:
hypokalemia
Correct response:
hypokalemia
Explanation:
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Question 9 See full question 39s
A hospitalized client with end-stage heart failure does not want to be resuscitated. The
health care provider (HCP) has written the do-not-resuscitate (DNR) prescription on the
client’s record. The client has a cardiac arrest, and the wife tells the nurse she wants the
client to be resuscitated and asks the nurse to “do something.” What should the nurse
do?
You Selected:
Discuss the DNR prescription with the wife.
Correct response:
Discuss the DNR prescription with the wife.
Explanation:
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Question 10 See full question 1m 43s
During the discharge planning teaching process, a client who has been prescribed
tranylocypromine states that he enjoys a beer or two in the evenings. Which of the
following is the nurse's most appropriate response?
You Selected:
“Beer contains tyramine, which must be avoided when on this medication.”
Correct response:
“Beer contains tyramine, which must be avoided when on this medication.”
Explanation:
Remediation:
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Question 11 See full question 46s
The staff of an outpatient clinic has formed a task force to develop new procedures for
swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved,
or shared with all personnel. When a nurse-manager receives word of a bomb threat, the
task force members push for evacuating the unit using the new procedures. Which action
should the nurse-manager take?
You Selected:
Determine that the procedures currently in place must be followed and direct staff
to follow them without question.
Correct response:
Determine that the procedures currently in place must be followed and direct staff
to follow them without question.
Explanation:
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Question 12 See full question 1m 17s
A client with cancer-related pain has been prescribed a narcotic analgesic to be given
around the clock. The client is competent and has been actively involved in decisions
regarding care. What should the nurse do if the client refuses the next dose of analgesia?
You Selected:
Document the client’s choice and re-assess pain in 1 hour.
Correct response:
Document the client’s choice and re-assess pain in 1 hour.
Explanation:
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Question 13 See full question 1m 30s
A client was admitted for a 3-day stay on the psychiatric inpatient unit. At the time of
discharge, the client says to the nurse, "It would nice to go out some time; tell me how I
can reach you outside of the hospital." Which response by the nurse is most appropriate?
You Selected:
"My relationship with you is professional and not social."
Correct response:
"My relationship with you is professional and not social."
Explanation:
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Question 14 See full question 34s
The nurse is caring for an adolescent who has been admitted several times with
uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge.
Which of the following should be the priority focus for the nurse when conducting
discharge teaching?
You Selected:
management of the therapeutic regimen
Correct response:
management of the therapeutic regimen
Explanation:
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Question 15 See full question 17s
The nurse understands that client position is important when treating dyspnea. What
position would be contraindicated for a client who has dyspnea?
You Selected:
supine
Correct response:
supine
Explanation:
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Question 16 See full question 35s
A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed
her neonate. Which instruction should the nurse address as the highest priority in the
teaching plan about preventing nipple soreness?
You Selected:
placing as much of the areola as possible into the baby’s mouth
Correct response:
placing as much of the areola as possible into the baby’s mouth
Explanation:
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Question 17 See full question 35s
Accompanied by her partner, a client seeks admission to the labor and delivery area. She
states that she's in labor and says she attended the facility clinic for prenatal care. Which
question should the nurse ask her first?
You Selected:
"What is your expected due date?"
Correct response:
"What is your expected due date?"
Explanation:
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Question 18 See full question 1m 17s
A first-time mother is concerned that her 6-month-old infant is not gaining enough
weight. What should the nurse tell the mother?
You Selected:
"Birth weight doubles by 6 months of age."
Correct response:
"Birth weight doubles by 6 months of age."
Explanation:
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Question 19 See full question 41s
A nurse is admitting a client to the palliative unit and discussing advanced directives.
Which of the following statements made by the client leads the nurse to believe the
client requires clarification around advanced directives?
You Selected:
“This will stop my daughter-in-law from putting me in a home.”
Correct response:
“This will stop my daughter-in-law from putting me in a home.”
Explanation:
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Question 20 See full question 37s
The nurse preceptor overhears a student nurse talking to a grieving mother, whose child
was stillborn, about her own pregnancy and fears about experiencing a loss. The student
nurse and mother make arrangements for the student to pick up the client’s maternity
clothes and baby furniture on the weekend. What is the preceptor’s most appropriate
action?
You Selected:
Discuss the situation with the nursing student after the visit has ended.
Correct response:
Discuss the situation with the nursing student after the visit has ended.
Explanation:
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Question 21 See full question 29s
The nurse is evaluating a parent’s understanding of measuring one tablespoon of
medication in a medicine cup. At which level on the medicine cup would the nurse
confirm an appropriate dose?
You Selected:
Your selection and the correct area, market by the green box.
Explanation:
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Question 22 See full question 53s
A client has just been admitted with acute delirium of unknown etiology. The client's
daughter states that she is worried about her mom because she has never been this sick
before. Which would be the most helpful statement to make to the daughter?
You Selected:
“The health care provider will prescribe tests to find out what’s causing her
condition.”
Correct response:
“The health care provider will prescribe tests to find out what’s causing her
condition.”
Explanation:
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Question 23 See full question 31s
When performing a postoperative assessment on a client who has undergone surgery to
manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg.
Which action should the nurse perform first?
You Selected:
Check the equipment.
Correct response:
Check the equipment.
Explanation:
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Question 24 See full question 2m
The nurse is assessing a client, who has lung cancer with spinal metastasis, for pain. The
client tells the nurse that the ordered opioid medication helps, but there is still a
shooting pain down the client’s left leg. Identify the best pharmacologic measure to
address this pain.
You Selected:
an adjuvant, such as gabapentin
Correct response:
an adjuvant, such as gabapentin
Explanation:
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Question 25 See full question 2m 38s
A nurse counsels a mother with young children after leaving her abusive husband 6
months ago. The mother says, “My 6-year-old is starting to act just like his father. I just
don’t know how to handle this.” Which response by the nurse is most appropriate?
You Selected:
"Counseling for your son would be helpful."
Correct response:
"Counseling for your son would be helpful."
Explanation:
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Question 26 See full question 32s
A client with Addison's disease comes to the clinic for a follow-up visit. When assessing
this client, the nurse should stay alert for signs and symptoms of:
You Selected:
sodium and potassium abnormalities.
Correct response:
sodium and potassium abnormalities.
Explanation:
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Question 27 See full question 52s
The health care provider (HCP) is calling in a prescription for ampicillin for a neonate.
What should the nurse do? Select all that apply.
You Selected:
Write down the prescription.
Repeat the prescription to the HCP over the telephone.
Ask the HCP to confirm that the prescription is correct.
Correct response:
Write down the prescription.
Repeat the prescription to the HCP over the telephone.
Ask the HCP to confirm that the prescription is correct.
Explanation:
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Question 28 See full question 1m 41s
The nurse is notifying the health care provider via telephone of a change in condition of a
client diagnosed with an exacerbation of asthma. Arrange the nursing statements in
order as they would be communicated using the SBAR method. All options must be used.
You Selected:
Hello. My name is Nurse Jones from Unit D.
I am notifying you because Bob Smith has become increasingly short of breath
with audible wheezing this afternoon.
Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically
controls his asthma with oral medication and inhalers at home. He is ordered
albuterol treatments twice daily. Oxygen is prescribed at 2 liters.
Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal
wheezing in all lung fields. Slight nasal flaring is noted.
I recommend that we increase his oxygen dose and prescribe an extra albuterol
treatment.
Correct response:
Hello. My name is Nurse Jones from Unit D.
I am notifying you because Bob Smith has become increasingly short of breath
with audible wheezing this afternoon.
Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically
controls his asthma with oral medication and inhalers at home. He is ordered
albuterol treatments twice daily. Oxygen is prescribed at 2 liters.
Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal
wheezing in all lung fields. Slight nasal flaring is noted.
I recommend that we increase his oxygen dose and prescribe an extra albuterol
treatment.
Explanation:
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Question 29 See full question 52s
Which type of solution, when administered I.V., would cause fluid to shift from body
tissues to the bloodstream?
You Selected:
hypertonic
Correct response:
hypertonic
Explanation:
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Question 30 See full question 1m 12s
A hospital employee asks the nurse if another hospital employee is a client on the
medical unit. What statements made by the nurse protect client privacy? Select all that
apply.
You Selected:
"Client privacy is part of the hospital code of conduct."
"I am not able to provide that information."
Correct response:
"I am not able to provide that information."
"Client privacy is part of the hospital code of conduct."
Explanation:
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Question 31 See full question 1m 25s
A client who has skeletal traction to stabilize a fractured femur has not had a bowel
movement for 2 days. The nurse should:
You Selected:
increase the client’s fluid intake to 3,000 mL/day.
Correct response:
increase the client’s fluid intake to 3,000 mL/day.
Explanation:
Remediation:
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Question 32 See full question 2m 58s
A client is using an over-the-counter nasal spray containing pseudoephedrine to treat
allergic rhinitis. Which instruction about this medication would be most appropriate for
the nurse to provide for the client?
You Selected:
Overuse of pseudoephedrine can lead to increased nasal congestion.
Correct response:
Overuse of pseudoephedrine can lead to increased nasal congestion.
Explanation:
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Question 33 See full question 44s
The client with a depressive disorder has been consistent with taking 12.5 mg of
paroxetine extended release daily. The nurse judges the client to be benefiting from this
drug therapy when the client demonstrates which behaviors? Select all that apply.
You Selected:
completes homework assignments
decreases pacing
verbalizes feelings
Correct response:
completes homework assignments
decreases pacing
verbalizes feelings
Explanation:
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Question 34 See full question 26s
The nurse is reviewing laboratory values of a client receiving clozapine. Which laboratory
value should the nurse report to the health care provider (HCP)?
You Selected:
WBC of 3,500/μL (3.5 X 109/L)
Correct response:
WBC of 3,500/μL (3.5 X 109/L)
Explanation:
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Question 35 See full question 2m 11s
The nurse conducts a wellness screening on a 9-year-old client Which
finding most suggests that that the client has typical social development?
You Selected:
enjoys active play
Correct response:
has a best friend
Explanation:
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Question 36 See full question 41s
After being examined by a forensic nurse in the emergency department, a rape victim is
prepared for discharge. Because of the nature of the attack, this client is at risk for posttraumatic
stress disorder (PTSD). Which symptoms are associated with PTSD? Select all
that apply.
You Selected:
Sleep disturbances
Recurrent, intrusive recollections or nightmares
Difficulty concentrating
Correct response:
Recurrent, intrusive recollections or nightmares
Sleep disturbances
Difficulty concentrating
Explanation:
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Question 37 See full question 39s
What should the nurse expect to include as a priority in the plan of care for a client with
delirium based on the nurse’s understanding of the disturbances in orientation
associated with this disorder?
You Selected:
identifying self and making sure that the nurse has the client's attention
Correct response:
identifying self and making sure that the nurse has the client's attention
Explanation:
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Question 38 See full question 17s
When caring for a client who has overdosed on phencyclidine (PCP), the nurse should be
especially cautious about which client behavior?
You Selected:
violent behavior
Correct response:
violent behavior
Explanation:
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Question 39 See full question 21s
A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse
expect to see?
You Selected:
Serum potassium level of 6.8 mEq/L (6.8 mmol/L)
Correct response:
Serum potassium level of 6.8 mEq/L (6.8 mmol/L)
Explanation:
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Question 40 See full question 3m 22s
The following clients are in the intermediate care unit. After receiving change of shift
report who should the nurse assess first?
You Selected:
a client with infective endocarditis who has a murmur and a heart rate of 58
Correct response:
a client with aortic stenosis who has a blood pressure of 84/52 mm Hg
Explanation:
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Question 41 See full question 18s
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client
how to care for the neck stoma, the nurse should include which instruction?
You Selected:
"Keep the stoma moist."
Correct response:
"Keep the stoma moist."
Explanation:
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Question 42 See full question 2m 57s
A student nurse is questioning a nursing instructor about the responsibility to have
malpractice insurance. The nursing instructor confirms the safeguard of malpractice
insurance by emphasizing which points regarding student liability? Select all that apply.
You Selected:
The student nurse is held to the same standard of care as a nurse.
The nursing instructor can be liable if the assignment is above the student’s
competency.
The student nurse is responsible for his or her actions.
Correct response:
The student nurse is responsible for his or her actions.
The student nurse is held to the same standard of care as a nurse.
The nursing instructor can be liable if the assignment is above the student’s
competency.
Explanation:
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Question 43 See full question 1m 57s
The family members of a client with mild dementia are asking the nurse about permitting
the elderly father to prepare an advance directive. Which information would be essential
for the nurse to include in a discussion with this family?
You Selected:
Suggest to the family that the client be evaluated psychiatrically to determine if
the client should construct an advance directive.
Correct response:
Explain that the client may have some ideas and some ability to make certain
decisions about what is wanted at end of life.
Explanation:
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Question 44 See full question 1m 28s
In which phase of postpartal psychological adaption would discharge teaching regarding
infant care most likely be successful?
You Selected:
taking hold
Correct response:
taking hold
Explanation:
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Question 45 See full question 21s
An adolescent who is depressed and whose parents report as having difficulty in school is
brought to the community mental health center to be evaluated. Which additional
problem would the nurse expect the client to have?
You Selected:
Behavioral difficulties
Correct response:
Behavioral difficulties
Explanation:
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Question 46 See full question 2m 36s
The nurse is inserting a nasogastric (NG) tube in a child admitted with head trauma. The
nurse should explain to the parents that the NG tube will be used for what purpose?
You Selected:
Decompress the stomach.
Correct response:
Decompress the stomach.
Explanation:
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Question 47 See full question 1m 19s
What occurs during the working phase of the nurse-client relationship?
You Selected:
A nurse and a client discuss their feelings about terminating the relationship.
Correct response:
A nurse and a client evaluate and modify the goals of the relationship.
Explanation:
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Question 48 See full question 30s
A child is diagnosed with pituitary dwarfism. Which pituitary agent will the primary care
provider most likely order to treat this condition?
You Selected:
somatotropin
Correct response:
somatotropin
Explanation:
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Question 49 See full question 17s
A nurse is caring for a client who underwent a skin biopsy and has three stitches in
place. This wound is healing by:
You Selected:
first intention.
Correct response:
first intention.
Explanation:
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Question 50 See full question 4m 36s
An adult client had an abdominal perineal resection with a colostomy 4 days ago and is
ready for discharge. Which is an expected outcome at this point?
You Selected:
The client maintains a high-fiber diet.
Correct response:
The client discusses concerns about sexual functioning.
Explanation:
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Question 51 See full question 4m 14s
A client undergoing a bilateral adrenalectomy has postoperative prescriptions for
hydromorphone hydrochloride 2 mg to be administered subcutaneously every 4 hours as
needed for pain. Why should the nurse administer hydromorphone in small doses?
A small dose is:
You Selected:
as potent as morphine in larger doses.
Correct response:
as potent as morphine in larger doses.
Explanation:
Remediation:
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Question 52 See full question 23s
The client with Addison's disease is taking glucocorticoids at home. Which statement
indicates that the client understands how to take the medication?
You Selected:
"Various circumstances increase the need for glucocorticoids, so I will need to
adjust the dosage."
Correct response:
"Various circumstances increase the need for glucocorticoids, so I will need to
adjust the dosage."
Explanation:
Remediation:
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Question 53 See full question 1m 27s
The nurse is to administer an enteral feeding to an adult client. Prior to initiating the
feeding, the nurse evaluates the gastric residual. What should the nurse determine from
evaluating the gastric residual?
You Selected:
how well nutrients are being absorbed
Correct response:
extent of overdistention of the stomach
Explanation:
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Question 54 See full question 1m 42s
A client who is an Orthodox Jew follows a Kosher diet. To ensure adequate nutritional
intake, the nurse and client work with the dietician to incorporate the client’s nutritional
preferences for meals. Which intervention would be most appropriate?
You Selected:
providing separate eating utensils for meat and dairy items
Correct response:
providing separate eating utensils for meat and dairy items
Explanation:
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Question 55 See full question 1m 37s
Which type of mouth care is most appropriate when the nurse is caring for a client with
dentures who has severe stomatitis?
You Selected:
using a soft toothbrush to provide oral hygiene
Correct response:
using a soft toothbrush to provide oral hygiene
Explanation:
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Question 56 See full question 48s
The nurse is providing discharge teaching for a client who will be taking lithium. Which
condition would necessitate a call to the client’s health care provider?
You Selected:
Persistent gastrointestinal upset.
Correct response:
Persistent gastrointestinal upset.
Explanation:
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Question 57 See full question 19s
Every day for the past 2 weeks, a client with schizophrenia has stood during group
therapy and screamed, "Get out of here right now! The elevator bombs are going to
explode in 3 minutes!" The next time this happens, how should the nurse respond?
You Selected:
"I know you think there are bombs in the elevator, but there aren't."
Correct response:
"I know you think there are bombs in the elevator, but there aren't."
Explanation:
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Question 58 See full question 3m 34s
A client in surgery has an endotracheal tube (ET) in place. The nurse should call a timeout
if which requirements are not in place? Select all that apply.
You Selected:
oxygen administration
an IV line
an identification band
Correct response:
an identification band
an IV line
oxygen administration
an anesthetist/anesthesiologist
Explanation:
Remediation:
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Question 59 See full question 2m 54s
The family member of a client diagnosed with dissociative identity disorder (DID) asks a
nurse if hypnotic therapy might help the client. How should the nurse respond?
You Selected:
“Yes, a client is often not consciously aware of alter personalities.”
Correct response:
“Yes, a client is often not consciously aware of alter personalities.”
Explanation:
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Question 60 See full question 22s
After being treated for minor cuts, a client appears confused and has trouble focusing on
what the nurse is saying. The client reports nausea and dizziness, has tachycardia, and is
hyperventilating during the nursing assessment. The nurse would interpret the level of
anxiety as which of the following?
You Selected:
Severe
Correct response:
Severe
Explanation:
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Question 61 See full question 20s
When developing the plan of care for a newly admitted 2-year-old child with the
diagnosis of Kawasaki disease, which intervention should be the priority?
You Selected:
monitoring intake and output every hour
Correct response:
monitoring intake and output every hour
Explanation:
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Question 62 See full question 25s
The client with an abdominal perineal resection and colostomy had a nasogastric (NG)
tube inserted during surgery. The NG tube will most likely be removed when the client
demonstrates:
You Selected:
passage of flatus from the colostomy
Correct response:
passage of flatus from the colostomy
Explanation:
Remediation:
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Question 63 See full question 5m 40s
The nurse is administering a subcutaneous injection (see accompanying figure). After
releasing the skin, prior to injecting the medication, the needle pulls out of the skin. The
nurse should:
You Selected:
discard the needle and syringe, obtain new needle and syringe, and draw a new
dose of the medication.
Correct response:
discard the needle, attach a new needle to the syringe, and administer the
medication.
Explanation:
Remediation:
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Question 64 See full question 22s
A client is admitted to the oncology unit with an infection. It is suspected that the
infection may be related to the vascular access device (VAD). The nurse should draw the
blood cultures from which site?
You Selected:
a peripheral site and all lumens of the VAD
Correct response:
a peripheral site and all lumens of the VAD
Explanation:
Remediation:
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Question 65 See full question 1m 4s
A registered nurse is mentoring a new graduate nurse. Which action by the new
graduate demonstrates a need for further teaching?
You Selected:
Turns the defibrillator to synchronize before defibrillating a client with ventricular
fibrillation.
Correct response:
Turns the defibrillator to synchronize before defibrillating a client with ventricular
fibrillation.
Explanation:
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Question 66 See full question 1m 5s
Which of the following may occur with respiratory acidosis?
You Selected:
Increased intracranial pressure (ICP)
Correct response:
Increased intracranial pressure (ICP)
Explanation:
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Question 67 See full question 1m 29s
The nurse in a mental health clinic assesses an adolescent client for a suspected eating
disorder. What question by the nurse will gather the most useful information for
designing the treatment plan?
You Selected:
"Do you ever eat to regulate your emotions?"
Correct response:
"What do you think of your body?"
Explanation:
Remediation:
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Question 68 See full question 18s
The nurse is teaching two unlicensed assistive personnel who are new to the inpatient
unit about caring for a client who is suicidal. The nurse determines that additional
teaching is needed when which statement is made?
You Selected:
"I need to check the client precisely at 15-minute intervals."
Correct response:
"I need to check the client precisely at 15-minute intervals."
Explanation:
Remediation:
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Question 69 See full question 18s
A client with decreased urine output refractory to fluid challenges is evaluated for renal
failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure?
You Selected:
Nephrotoxic injury secondary to use of contrast media
Correct response:
Nephrotoxic injury secondary to use of contrast media
Explanation:
Remediation:
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Question 70 See full question 30s
A client comes to the clinic for diagnostic allergy testing. The nurse understands that
intradermal injections are used for such testing based on which principle?
You Selected:
Intradermal drugs diffuse more slowly.
Correct response:
Intradermal drugs diffuse more slowly.
Explanation:
Remediation:
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Question 71 See full question 1m 10s
When magnesium sulfate is administered to a client in labor, its action occurs at which
site?
You Selected:
neural-muscular junctions
Correct response:
neural-muscular junctions
Explanation:
Remediation:
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Question 72 See full question 19s [Show Less]