1. A nurse is assessing a client who has a diagnosis on colon
cancer whichof the following should the nurse expect?
a) Statorrhea
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 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 apericardial friction rub? (select HOT spot)
Answer: D
4. A nurse is caring for a client who has a chest tube. The
client asks whythe 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 followingis 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 electricalnerve 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 effectedarea”
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 thefollowing 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 thefollowing 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 aclient 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
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 weights220 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 thefollowing 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 itdislodges
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 followingmanifestations 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 nurseobserves 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 bleedingdue 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 of900/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 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
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 / minutesd) 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 stew
c) 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
precautionsd) 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 weeksb) 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 meals
37. 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
vomitingc) 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 highrisk 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 cannulac) 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 turning
c) encourage the client to lean forward when
attempting to standd) 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 anexternal 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 positionc) 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
headached) encourage the client to
change position slowly
47. 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 3d) 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
51. A nurse is caring for a client who is post-operative following an
endoscopy with moderate (conscious) Sedation. Which of the following
assessment findings is the nurse’s priority?
a) Level of
painb) gag
reflex
c) warmth of extremities
d) temperature
52. Nurse is caring for an older adult client who is suspected of having
septicemia. Which of the following actions is the nurses priority?
a) Obtain a history to determine recent injuries
b) obtain a broad-spectrum antibiotic for Rapid Administration
c) obtain a WBC count with differential
d) obtain a blood specimen for culture and sensitivity testing
53. A nurse is caring for a client who has just undergone a total
laryngectomy. Which of the following findings is the nurses priority for
immediate intervention?
a) Blood-tinged
secretionsb)
tachypnea
c) Fever
d) IV infiltration
54. A nurse is admitting a client to the emergency department after a
gunshot wound to the abdomen. Which of the following actions should
the nurse take to help prevent the onset ofacute kidney failure?
a) Administer IV fluids to the client
b) insert a urinary catheter
c) initiate beta-blocker therapy
d) prepare the client for an intravenous pyelogram
55. A nurse is caring for a client who has just returned from surgery with
an external fixator to the left tibia. Which of the following assessment
finding requires immediate intervention by the nurse?
a) a client has 100 ml blood in the closed
suction drainb) the client's capillary
refill in the left toe is 6 seconds
c) the client has an oral temperature of 38.3 C (100.9 Fahrenheit)
d) the client reports a pain level of 7 on a scale from 0 to 10 at the
operative site
56. A nurse is an emergency department is reviewing a client's ECG
reading. Which of the following findings should the nurse identify as an
indication that the client has a first degree heart block?
a) more p waves than QRS
complexesb) prolonged PR
intervals
c) non discernible P waves
d) no correlation between P and QRS waves
57. A nurse is reviewing the medication list of a client who is being
admitted with diabetes insipidus. Which of the following medication places
the client at an increased risk for developing diabetes insipidus?
a) Ranitidine
b) Atorvastatin
c) Propran
olold)
lithium
58. A nurse is planning care for a client who has left-sided hemiplegia
following a stroke which of the following actions should the nurse include
in the plan of care?
a) Place a plate guard on the clients meal tray
b) position the bedside table on the client's left side
c) remind the client to use a cane on his left side while ambulating
d) provide the client with a short handled Reacher
59. A nurse is administering potassium chloride via IV infusion to a
client who has severehypokalemia. Which of the following actions
should the nurse take?
a) Start the infusion at 30 meq /hr
b) assess the client for a positive chvostek's sign
c) Monitor the client for adequate urine output
d) check infusion site at least every 4 hours
60. A nurse in the PACU is caring for a client. Which of the following
assessment is the nurses priority?
a) Surgical site
b) level of
consciousnessc)
respiratory status
d) pain level
61. A nurse is reviewing the medical record of a client who is scheduled
for a CT scan with contrast media. Which of the following medication
should the nurse instruct the client to withhold for 48 hours following the
procedure?
a) Carvedilol
b) Furosemi
dec)
Metformi
n
d) Clopidrogel
62. Nurse is caring for a client who has pancreatitis and has been
receiving Total parenteral Nutrition. Which of the following Laboratory test
should the nurse monitor for overall nutritional status?
a) creatini
neb)
Prealbumin
c) Lipase
d) C-reactive protein
63. A nurse is teaching a client who has endometriosis about the
adverse effects of leuprolide. Which of the following manifestations should
the nurse include in the teaching?
a) Pallor
b) increased
appetitec)
bone loss
d) hypoglycemia
64. A nurse is caring for a client who had an arterial revascularization of
the right lower extremity which of the following is the priority action the
nurse should plan to take after contacting the provider? ( Click on the “
exhibit” button for additional information about the client) [Show Less]