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B.

1. An older male client is brought to the Emergency Department by family members


who he has become increasingly confused in the last 3 days. Which actions should
the nurse (Select all That apply)
A. Explain that advanced age is associated with confusion
Evaluate polypharmacy for possible drug interactions
C. Obtain a urine specimen for culture and sensitivity
D. Discuss nursing home placement with the family
E. Determine oxygen saturation rate and breath sounds
Correct Answer: B, C, E
2.

A multigravida, full-term, laboring client complains of back Labor. Vaginal


examination reveals that the clients 3cm with 50% effacement and the fetal head
is at -1 station. What action should the nurse implement?
A. Apply counter-pressure to the sacral area
B. Turn the client to a lateral position
C. Notify the scrub nurse to prepare the OR
D. Ambulate the client between contractions

Correct Answer: A
3. An infant born to a heroin-addicted mother is admitted to the neonatal care unit.
What behaviors can this to exhibit?
A. Lethargy and a poor suck
B. Facial abnormalities and microcephaly
C. Irritability and a high-pitched cry
D. Low birth weight and intrauterine growth retardation
Correct Answer: C
4. A client with gestational diabetes is undergoing a non-stress test (NST) at 34weeks gestation; the babys heart is 144 beats/minute. The client is instructed to
mark the fetal monitor paper by pressing a. Each time the baby moves. After 20
minutes, the nurse evaluates the fetal monitor strip. ????
A. The mother perceives and marks at least four fetal movements
B. Fetal movements must be elicited with a vibroacoustic stimulator
C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded
D. No FHR late decelerations occur in response to fetal movement
Correct Answer: C
5. A toddler with a history of an acyanotic heart defect is admitted to the pediatric
intensive, the respiration rate of 60 breaths/minute, and a heart rate of 150
beats/minute. What action should the nurse first?
A. Obtain a pulse oximeter reading
B. Assess the Childs blood pressure
C. Perform a neurological assessment
D. Initiate peripheral intravenous access

Correct Answer: A
6. An infant is placed in a radiant warmer immediately after birth. At one hour of age,
the nurse .. Tachypneic, and hypotonic. What is the first action that the nurse
should take?
A. Notify the healthcare provider immediately
B. Increase the temperature of the radiant warmer
C. Assess the infants heart rate
D. Determine the infants blood sugar level
Correct Answer: D
7. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is
most important at time the infusion rate is increased?
A. Contraction pattern
B. Blood pressure
C. Infusion site
D. Pain level
Correct Answer: A
8. A 6-year old child with acute infectious diarrhea is placed on rehydration therapy
regimen. Which action should the nurse instruct the parent to take if the child
begins to vomit?
A. Continue giving ORS frequently in small amounts
B. Withhold all oral intake
C. Supplement ORS with gelatin or chicken broth
D. Provide only bottled water
Correct Answer: A
9. Artificial rupture of the membranes of a laboring client reveals meconium-stained
fluid. Which is the first nurse priority?
A. Clean the perineal area to prevent infection
B. Assess the mothers blood pressure to check for signs of preeclampsia
C. Assess the mothers temperature to check for development of sepsis
D. Have a meconium aspirator available at delivery
Correct Answer: D
10.
During a 26-week gestation prenatal exam, a client reports occasional
dizziness. What intervention is best for the nurse to recommend to this client?
A. Elevate the head with two pillows while sleeping
B. Lie on the left or right side when sleeping or resting
C. Increase intake of foods that are high in iron
D. Decrease the amount of carbohydrates in the diet
Correct Answer: B

11.
A postpartal client complains that she has the urge to urinate every hour but
is only able to a small. What intervention provides the nurse with the most useful
information?
A. Initiate a perineal pad count
B. Catheterize for residual urine after next voiding
C. Assess for a perineal hematoma
D. Determine the clients usual voiding pattern
Correct Answer: B
12.
A client is scheduled for a laminectomy to treat lower back pain related to a
herniated intervertebral disk. When conducting preoperative teaching, the nurse
should teach the client that numbness and tingling in the lower extremities
sometimes occurs postoperatively as the result of which condition?
A. Effects of intrathecal anesthesia that resolve quickly
B. Minor injuries caused by positioning during surgery
C. Pressure on the nerves due to prolonged immobility
D. Manipulation of nerves and muscles during surgery
Correct Answer: D
13.
The nurse is assessing a 4-year-old boy admitted to the hospital with the
diagnosis of possible nephrotic syndrome. Which statement by the parents
indicates a likely correlation to the childs diagnosis?
A. I couldnt get my sons socks and shoes on this morning
B. I couldnt get my son to calm down and sleep last night
C. My son has had a red rash over his entire body for the past 4 days
D. My son has been on Augmentin for 2 days for an ear infection
Correct Answer: A
14.
The nurse is evaluating the home care teaching of a family who has a child
with cystic fibrosis. Which parental action indicates correct understanding of the
childs home care?
A. Performs postural drainage after meals
B. Supplements diet with water-soluble vitamins and fluids
C. Plans a diet high in fat and calories
D. Gives pancreatic enzymes before every meal and snack
Correct Answer: D
15.
Client with mitral stenosis is at 28-weeks gestation. In assessing this client,
which observation should the nurse investigate first?
A. Edematous feet
B. Persistent cough
C. Increased fatigue
D. Recent sadness

Correct Answer: B
16.
A 72-year-old client is admitted to the hospital after falling at home. In taking
a nursing history, the nurse notes that the client is taking labetalol HCL
(Normodyne) 300mg PO BID and ranitidine (Zantac) 150 mg PO QID. What nursing
intervention is most important to include in this clients nursing care plan?
A. Determine gastric pH on admission
B. Weigh daily in early morning
C. Frequent monitoring of blood pressure
D. Daily assessment of WBCs and platelets
Correct Answer: C
17.
Captopril (Capoten) is prescribed for an infant admitted 3 days ago with a
diagnosis of heart failure. During assessment, which clinical finding indicates to the
nurse that the medication is effective?
A. Capillary refill is down from 4 seconds on admission to 2 seconds
B. Blood pressure decrease from 125/85 on admission to 106/60
C. Heart rate decreased from 200 beats/minute on admission to 140
beats/minute today
D. Periorbital adema disappears
Correct Answer: B
18.
The client with paranoia and homicidal ideation is brought to Emergency
Department. The client states that her daughter lives her television set and will
come the nurse talk to her. What additional finding indicates that the client has a
thought disorder?
A. Feels lonely and isolated
B. Feels very anxious
C. Easily changes the subject
D. Stays in bed all morning
Correct Answer: C
19.
A client with a history of gastroesphageal reflux disease (GERD), who smokes
2 packs of cigarettes and drinks a fifth of liquor daily, had a cholecystectomy. While
completing a head to toe assessment, the nurse discovers that the client is
tremulous, agitate, febrile, and disoriented. What is the likely indication of this
finding?
A. Impending delirium tremens
B. Post-surgical infection
C. Reoccurring reflux
D. Nicotine withdrawal
Correct Answer: A

20.
Which prescription should the nurse anticipate administering to a client who
is experiencing increased intracranial pressure secondary to a head injury?
A. Acetazolamide (Diamox)
B. Mannitol (Osmitrol)
C. Sumatriptan (Imitrex)
D. Dobutamine HCI (Dobutrex)
Correct Answer: B
21.
The emergency room is alerted that a child is arriving by ambulance with a
history of flu-like symptoms for the past week. The reported vital signs are
temperature 101 F, heart rate 168 beats/minute, respirations 16 breaths/minute,
and blood pressure 90/60.The child is lethargic with a capillary refill time of 4
seconds. When preparing for the childs arrival, the nurse should assemble which
equipment?
A. Mechanical ventilator
B. IV infusion pump
C. Cooling blanket
D. Automated defibrillator
Correct Answer: B
22.
A child with heart failure is receiving the diuretic furosemide (Lasix) and has
a serum potassium level of 3.0 mEq/L. Which assessment is most important for the
nurse to obtain?
A. Cardiac rhythm and heart rate
B. Daily intake of foods rich in potassium
C. Hourly urinary output
D. Thirst and skin turgor
Correct Answer: A
23.
A male client, who had a total laryngectomy two days ago, is transferred
from the intensive care unit to a private room close to the nurses station. The
nurse recognizes that the client is anxious. Which intervention should the nurse
implement?
A. Encourage a family member to stay with the client at all times
B. Answer the clients call signal in person quickly after he calls
C. Explain the emergency procedure for loss of airway to the client
D. Provide the client with a suction catheter to allow for self-suctioning
Correct Answer: B
24.
When caring for a client with an acute myocardial infarction, which
observation warrants immediate intervention by the nurse?
A. Systolic blood pressure of 100
B. Oral temperature of 99.4 F
C. Central venous pressure (CVP) of 4 mm Hg

D. The telemetry displays ventricular bigamy


Correct Answer: D
25.
A client is admitted to the emergency center with a possible head injury and
spinal cord injury (SCI) after an automobile collision. What is the nurses priority
assessment?
A. Level of consciousness
B. Mobility of extremities
C. Respiratory status
D. Cranial nerve function
Correct Answer: C
26.
A school-aged child with juvenile rheumatoid arthritis develops a viral
infection with a low grade fever. The child is already taking aspirin for the arthritis.
What instruction should the nurse provide to this mother?
A. Discontinue the use of all medications to avoid masking the symptoms of the
illness
B. Discontinue the aspirin, and use another NSAID to control the childs fever
and symptoms
C. Continue the aspirin, but add another NSAID to control the childs fever and
symptoms
D. Increase the dose of aspirin to control the childs fever and symptoms
Correct Answer: B
27.
A female teacher tells the school nurse that she thinks she is pregnant, but
her pregnancy test was negative the previous night. When taking the teachers
history, the nurse finds that the only medication the teacher is currently taking is
tetracycline for acne. Which instruction should the nurse provide?
A. Make an appointment with an obstetrician as soon possible
B. Increase oral fluid intake to 3 or quarts daily
C. Use first voiding of the day for accurate results of a pregnancy test
D. Stop taking the acne medication immediately
Correct Answer: D
28.
Three days after admission for diabetic ketoacidosis (DKA), a clients blood
glucose levels ranges from 420 to 540 mg/dl. Regular insulin is being administered
using a sliding dosage scale. Which intervention is most important for the nurse to
implement?
A. Confer with the healthcare provider about a continuous IV insulin infusion
B. Arrange for a nutritional consult to assist the client with diabetic food choices
C. Request the diabetic educator to evaluate the clients knowledge of diabetes
D. Given an additional dose of regular insulin according to sliding scale
prescription

Correct Answer: A
29.
An adult male who recently returned from a trip to China is diagnosed with
severe acute respiratory syndrome (SARS). He is hospitalized and placed in a
negative pressure isolation room. Which intervention is most important to include
in this clients plan of care?
A. Determine if an advanced directive is signed
B. Require use of gown, gloves, and N-95 mask
C. Limit visitors to family members only
D. Teach how to dispose of used tissues
Correct Answer: B
30.
When evaluating the effectiveness of medications administered to a client
with Parkinsons disease, the nurse recognizes that symptom management
requires a balance among which neurotransmitters?
A. Norepinephrine and acetylcholine
B. Epinephrine and dopamine
C. Dopamine and norepinephrine
D. Acetylcholine and dopamine
Correct Answer: D
31.
The nurse is assessing the normal development of a 9-month-old male infant.
Which information should the nurse obtain from the mother?
A. Is the baby able to lift his head when prone?
B. Has the child started to walk?
C. Does the baby roll from abdomen to back?
D. Can the child sit alone?
Correct Answer: D
32.
A male client returns to the mental health clinic for assistance with his
anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and
nauseas while driving over the bay bridge. What action in the treatment plan
should the nurse implement?
A. Tell client to drive over the bridge until fear is manageable
B. Teach client to listen to music or audio books while driving
C. Recommend that the client avoid driving over the bridge
D. Encourage client to have spouse drive in stressful places
Correct Answer: B or C
33.
When caring for a client with deep partial-thickness burns to the posterior
neck, which intervention should the nurse implement during the acute phase to
prevent contractures at the site of injury?
A. Place a towel roll under the clients neck or shoulder
B. Passively raise arms above the head hourly while awake

C. Actively turn head from side to side 90 degrees hourly


D. Keep in a supine position without the use of pillow
Correct Answer: A
34.
The nurse is conducting an admission assessment and interview of a client
who is believed to have Guillain- Barre syndrome. Which comment by the client
has the most significance to this diagnosis?
A. Ive had problems with my sinuses and bad allergies since I was a child
B. Two years ago, I received immunizations before going to Japan
C. Ive lost 5 pounds in the last month by decreasing my fat intake
D. About two weeks ago, I missed a day of work because I had a bad cold
Correct Answer: D
35.
Which symptom is characteristic of ureteral colic in the client diagnosed with
renal calculi?
A. Symptoms of irritation associated with urinary tract infection
B. Acute, excruciating, wave-like pain radiating to the genitalia
C. Intense, deep ache in the costovertebral region
D. Chills, fever, and dysuria
Correct Answer:
36.
When assisting an elderly female client who is bathing herself in bed, the
nurse observes that the client has inelastic skin turgor, large pendulous breasts,
and a soft flaccid abdomen. To prevent skin maceration, which action should the
nurse implement?
A. Advice the client to use talcum powder over skin surfaces
B. Recommend the use of a blow dryer to dry under the breasts
C. Teach the client to dry the skin well between skin folds
D. Apply a smooth layer of lotion over areas of loose, inelastic skin
Correct Answer: C
37.
A client at the healthcare clinic reports a new onset of pyrosis and dyspepsia
to the nurse. Which nursing action has the highest priority?
A. Instruct the client about the symptoms of reflux disease
B. Provide reassurance that these are common symptoms of reflux disease
C. Recommend the use of antacids to control symptoms
D. Schedule an appointment for a physical examination
Correct Answer: D
38.
A female client with pneumonia and a history of sickle cell anemia begins to
complain of pain in her fingers, which indicates to the nurse a possible ensuing
sickle cell crisis. What is the underlying pathophysiology for pain in sickle cell
crisis?

A. Hemolysis of blood cells containing hemoglobin 5 increases cellular debris


that results in bone pain
B. Production of abnormal red cells in the bone marrow causes extreme pain
C. Viscosity of the blood creates sluggish blood flow, leading to blood
D. Sickled red blood cells do not flow through small blood vessels, leading to
vasocclusion and ischemia
Correct Answer: D
39.
A female client with chronic pyelonephritis expresses concern that she may
have to undergo dialysis. What is the best initial response by the nurse?
A. Offer to introduce the client to a dialysis nurse who can provide teaching
about dialysis
B. Explain the relationship between chronic kidney infection, real failure, and
dialysis
C. Provide assurance that dialysis is not the usual treatment for kidney
infections
D. Assist the client to reduce anxiety and gain control by using guided imagery
exercise
Correct Answer: B
40.
A male client with bipolar disease reports to the nurse that he has not taken
his prescription medication, divalproex (Depakote) for the last 6 months.
Assessment of which is most important for the nurse to obtain?
A. Mood
B. Affect
C. Intellect
D. Speech
Correct Answer: A
41.
A female client with breast cancer who completed her first chemotherapy
treatment, out-patient cancer treatment center is preparing for discharge. Which
behavior the client understands her care needs for the next week?
A. Invited friends and family to visit while she is at home for the next week
B. Rented movies and borrowed books to use while passing time at home
C. Schedule a lunch date with her best friends for 2 days from now
D. Stocked her refrigerator with healthy foods including fruits and vegetables
Correct Answer: B
42.
What is the priority nursing action when initiating morphine therapy via an
intravenous patient-controlled analgesia (PCA) pump?
A. Assess the clients ability to use a numeric pain scale
B. Initiate the dosage lockout mechanism on the PCA pump
C. Instruct the client to use the medication before the pain becomes severe
D. Assess the abdomen for bowel sounds

Correct Answer: B
43.
A male client with angina pectoris is being discharged from the hospital.
What instruction should the nurse plan to indicate in this discharge teaching?
A. Engage in physical exercise immediately after eating to help decrease
cholesterol levels
B. Walk briskly in cold weather to increase cardiac output
C. Keep nitroglycerin in a light-colored plastic bottle and readily available
D. Avoid all isometric exercises, but walk regularly
Correct Answer: D
44.
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?
A. Crying
B. Straining on stool
C. Vomiting
D. Sitting upright
Correct Answer: D
45.
Which assessment is most important for the nurse to include in the daily plan
of care for a client with a burned extremity?
A. Range motion
B. Distal pulse intensity
C. Extremity sensation
D. Presence of exudate
Correct Answer: B
46.
A series of stool guaiac test is prescribed for a client receiving anticoagulant
therapy. While obtaining the first specimen, the nurse observes that the clients
stool is clay- colored. What action should the nurse take?
A. Implement contact isolation precautions
B. Report stools appearance to the healthcare provider
C. Increase the frequency of guaiac testing
D. Assess for signs of bleeding from other orifices
Correct Answer:
47.
In caring for newborn infant who become cyanotic and start gagging, what
action should the nurse implement?
A. Give three back blows to clear the airway
B. Provide oxygen by resuscitation bag and mask
C. Use a bulb syringe to suction nose and mouth
D. Request the crash cart be brought to the nursery
Correct Answer: C

48.
While transferring a client with a chest tube from the bed to a stretcher, the
chest becomes disconnected from the water-seal drainage container. The nurse
immediately immerses the end of the tube in a container of sterile water. What
action should the nurse implement next?
A. Apply pressure to the chest tube site using a petroleum gauze
B. Begin manual ventilation while returning the client to the bed
C. Prepare a new water-seal system and reattach the chest tube
D. Clamp the chest tube and maintain its distal end in the water
Correct Answer: C
49.
While palpating a 6-week old infants head, the nurse notes a 0.5 cm wide,
soft area at the junction of the coronal and lambdoidal suture lines. Which
intervention should the nurse implement?
A. Document assessment data in the record
B. Assess for presence of the Babinski reflex
C. Evaluate infants cardinal fields of gaze
D. Measure the frontal-occipital circumference
Correct Answer: A
50.
A client newly diagnosed with diabetes mellitus suddenly becomes confused
and weak. Which interventions should the nurse implement? (Select all that apply)
A. Give the client 4 ounces of orange juice
B. Provide the client with cup diet carbonated soda
C. Obtain blood pressure and pulse rate
D. Check the clients current finger stick blood glucose
E. Administer a PRN dose of regular insulin
Correct Answer: A C D
51.
The nurse is auscultating a clients lung sounds. Which description should the
nurse use to document this sound? (audio)
A. High pitched or fire crackles
B. Rhonchi
C. High pitched wheeze
D. Stridor
Correct Answer: C
52.
A woman who had bariatric surgery 2 months ago is admitted because of
vomiting and inability to tolerate food and liquids. She states that she is pain free.
Which intervention should the nurse include in the clients plan of care?
A. Maintain the client on a n NPO status
B. Administer daily vitamin supplements
C. Determine if the client is over-hydrating to feel satiated
D. Encourage positive self-accolades for dietary adherence
Correct Answer: A

53.
The nurse knows that several complications can occur the administration of
blood. Which finding is an indication of an air emboli?
A. Increased blood pressure
B. Nausea and vomiting
C. Chills and tremors
D. Difficult breathing
Correct Answer: D
54.
Medical asepsis requires that the nurse include what hand washing
technique?
A. Use hot water to ensure pathogens are killed
B. Hold hands higher than the elbows and scrub vigorously
C. Use a circular motion, washing from clean to dirty areas
D. Rinse soap off, keeping hands and forearms lower than elbows
Correct Answer: D
55.
The nurse brings an oral medication prescribed to be given daily to a male
client who tells the nurse that will take the medication later?
A. Inform the client that his medication is schedule to be taken now
B. Agree upon a time to return to the client room with the medication
C. Note the client noncompliance with medication in the nurse note
D. Leave the medication on the bed side table with a fresh glass of water
Correct Answer: B
56.
Because a client with Bell palsy is at risk for impaired nutrition. What the
nurse do or expect?
A. Arrange the client to received home delivery meals daily
B. Assist the client in choosing low calories, low fat food each meal
C. Refers the client to a speech therapist to learn swallowing techniques
D. Teach the client to chew food on the unaffected side of the face
Correct Answer: D
57.
The nurse is assessing a client with a closed head injury sustained in a motor
vehicle collision. Which finding indicates the lowest level of neurologic functioning?
A. Withdrawal from painful stimuli
B. Localization of a tactile stimulus
C. Decorticate posturing during position changes
D. Decerebrate posturing during position changes
Correct Answer: D
58.
The nurse measuring the output of an infant admitted for vomiting and
diarrhea. During a 12 hours shift, the infant drink 4 ounces of pedialyte, vomit
25ml and void twice the dry diaper weighs is 50 grams and one wet diaper weighs

75 grams, and the other weighs 105 grams. What documentation should the nurse
include in this infant record?
A. Calculate difference in wet and dry diapers and document 80 ml urine
output
B. Subtract vomitus from 120 ml pedialyte then document 95 ml oral intake
C. Document on the flow sheet that the infant voided time 2 and vomited
25ml
D. Compared the difference between the infant body weight and admission
weight
Correct Answer: A
59.

Which class of drugs in the only source of a cure for septic shock?
A. Antihypertensives
B. Anticholesteremics
C. Antihistamines
D. Antiinfectives

Correct Answer: D
60.
A client with atrial fibrillation receives a new prescription for Dabigatram
(Praxada). What instruction should the nurse include in this client teaching plan?
A. Continue obtaining schedule lab bleeding test
B. Keep an antidote available in the event of hemorrhage
C. Avoid use of non-steroid anti-inflammatory drugs (NSAID)
D. Eliminate spinach and other green vegetables in the diet
Correct Answer: C
61.
A client experiencing withdrawal from the (Xanax) is demonstrating severe
agitation and tremors. What is the best initial nursing action?
A. Administer Narcan PRN protocol
B. Obtain serum drug screen
C. Instruct the family about withdrawal symptom
D. Initiate seizure precautions
Correct Answer: D
62.
In making client care assignments, which client is best to assign to the
practical nurse (PN) working on the unit with the nurse?
A. An immobile client receiving low molecular weight heparin q12h
B. A client who is receiving a continuous infusion of heparin and gets out of
bed BID
C. A client who is being treated off a heparin infusion and started on PO
warfarin (Coumadin)
D. An ambulatory client receiving warfarin (Coumadin)with an INR of 5
seconds

Correct Answer: A
63.
An older male client arrives at the clinic complaining that his bladder always
feels full. He complain of a weak urine flow frequent dribbling after voiding and
increasing nocturnal with difficulty initiating his urine stream action should the
nurse implement?
A. Advice the client to maintain a voiding dairy for one week
B. Instruct effective technique to cleanse the glands pennies
C. Palpate the client therapeutic area for distention
D. Obtain urine specimen for culture and sensitivity
Correct Answer: C
64.
The mother of the 7 month- old bring the infant to be clinic because the skin
in the diaper area is and red, but there are no blister or bleeding. The mother
reports no evidence of watery stool. Which nursing intervention should the nurse
implement?
A. Instruct the mother to change the childs diaper more often
B. Tell the mother to cleanse with soap and water at each diaper change
C. Encourage the mother to apply lotion with each diaper change
D. Ask the mother to decrease the infants intake of fruit for 24 hours
Correct Answer: A
65.
A male client admitted with chronic pulmonary obstruction disease (COPD)
exacerbation is receiving assisted ventilation with continuous positive airway
pressure. His vital signs are temperature 98.8 , heart rate 118 beats/min,
respiration rate 46 breaths/min, blood pressure 176/92. While completing the
pulmonary assessment, his oxygen status saturation reading is 78 % and he is
difficult to arouse. Which action should the nurse implement?
A. Administer PRN nebulizer treatment
B. Increase oxygen delivery by 10%
C. Complete neurological assessment
D. Prepare for rapid sequence intubation
Correct Answer: B
66.
A client with pneumonia has arterial blood gases level at pH 7.33, PaCO 49
mm, HCO 25, PaO 95. What intervention should the nurse implement base on
these results?
A. Instruct the client to breathe into a paper bag
B. Prepare to administer sodium chloride fluids
C. Initiate oxygen administration at 2 to 3 L per nasal cannula
D. Institute coughing and deep breathing protocols
Correct Answer: D

67.
A client with a diagnosis of schizophrenia, sits in the day room and fail to
interact. Which intervention is best for the nurse to implement with this client?
A. Complete an assessment of social support
B. Encourage the client to have lunch off the unit
C. Give the client a schedule of planned daily activities
D. Engage the client in a game of cards
Correct Answer: D
68.
The nurse plans to collect a 24 hrs urine specimen for a creatinine clearance
test. Which instruction should the nurse provide to the adult male client?
A. Urinate immediately into a urinal, and the lab will collect the specimen
every 6 hrs for the next 24 hrs
B. Urinate at a specified time, discard this urine, and collect all subsequent
urine during the next 24hrs
C. For the next 24 hrs., notify nurse when the bladder is full, and the nurse
will collect catheterized specimen
D. Cleanse around the meatus, discard first portion of voiding, and collect
the rest in a sterile bottle
Correct Answer: B
69.
A child is brought to the clinic complaining of fever and joint pain, and is
diagnosed with rheumatic fever. When planning care for this child, what is the
primary goal of nursing care?
A. Prevent cardiac damage
B. Maintain joint mobility and function
C. Reduce fever
D. Maintain fluid and electrolyte balance
Correct Answer: A
70.
The healthcare provider hands a newborn to the circulating nurse during a
cesarean delivery. What action first?
A. Dry the infant under warming unit
B. Determine Apgar score
C. Allow the mother to touch the infant
D. Perform a physical assessment
Correct Answer: A
71.
Following two defibrillation shock, the client ECG continues to indicate
ventricular fibrillation. What intervention should the nurse implement next?
A. Resume CPR immediately
B. Administer an IV bolus of epinephrine
C. Perform the third defibrillation shock
D. Obtain an arterial blood gas sample

Correct Answer: A
72.
During discharge teaching the mother asks why her premature infant should
get monthly synagis (Palivizumab) injections the nurse response should be based
on what information?
A. Monthly injection promote normal neurological and physical development
B. This drug protect the premature infant from respiratory syncytial virus
C. These injection prevent retinopathy of prematurity caused by high level of
oxygen
D. This medication provide surfactant, which helps the lungs mature more
quickly
Correct Answer: B
73.
Using the parkland formula for a patient with burns 4ml x Patients weight in
kg which is 76kg x whatever % of burns, which is 40%. SO it is 4ml x 76kg x 40%
12160

74.
Mark the Dilaudid dose in a syringe that has to be administering to a patient.
(THE IS A SQUARE OF A NUMBER PAD)
ANS: Mark the NUMBER 1. (1 MG)

75.
A 16-year-old adolescent with Meningococci meningitis is receiving a
continuous IV infusion of penicillin G, which is prescribed as 20 million units in a
total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10
million units/liter of normal saline. How many ml/hr. should the nurse program the
infusion pump? (Enter numeric value only. If rounding is required, round to the
nearest whole number.)
83

76.
A client with general anxiety disorder is pacing the hallway. The client tells
the nurse my heart is just racing and sometimes it feels like it fluttering. Im
feeling short of breath and dizzy. Nurse first implement?
A. Obtain vital signs
B. Escort the client to quiet room
C. Administer an anti-anxidytic
D. Initiate a diversionary activity

Correct Answer: A
77.
The nurse notes that a client is experiencing supraventricular tachycardia
which action should the nurse implement?
A. Place a crash cart at the client bedside
B. Prepare to administer adenosine an antidysrrythmic
C. Call a code and start CPR immediately
D. Assess the client heart sounds and vital signs
Correct Answer: B
78.
An infant admitted to the neonatal intensive care is tachypneic,
tachycardiac, has bounding brachial pulses. The healthcare provide suspect that
the infant coarctaction of the aorta. What intervention is important to include in
the plan of care?
A. Assess centralized cyanosis 4 times daily
B. Monitor congestive heart failure
C. Correct respiratory alkalosis related to tachypnea
D. Auscultate diastolic murmur daily
Correct Answer: B
79.
The nurse is caring for a client admitted in telemetry unit for complications
related to a myocardial infarction (MI) occurred 4 days ago. A 12 lead
electrocardiogram (ECG) shows right axis deviation and poor R wave progression
which assessment suggest that the client is at risk for right ventrical hypertrophy?
A. Generalized, fatigue, dizziness, swollen ankles
B. Nausea, vomiting and generalized edema
C. Severe chest pain and SOB
D. Sharp, non-radiating chest pain and nausea
Correct Answer: A
80.
In caring for a client with Cushing syndrome, which serum lab value is most
important for the nurse to monitor?
A. Glucose
B. Lactate
C. Hemoglobin
D. Creatinine
Correct Answer: A
81.
A client with a history of recurrent atrial fibrillation is taking Amiodarone
(Cordarone) and Warfarin (Coumadin) which meal should the nurse provide for the
client?
A. Seared tuna steak and stewed squash
B. Marinated pork chops and spinach
C. Grilled sirloin steak and garden salad

D. Bake chicken and steamed broccoli


Correct Answer: A
82.
When assessing acuity of a group of clients in the intensive care unit (ICU).
The charge nurse determines the staffing matrix requires four nurses for the next
shift. Three hour prior to the beginning of the next shift a nurse called sick. Before
attempting to obtain staff to cover the sick nurse shift. What action should the
nurse take?
A. Reevaluate the current client acuity mix
B. Complete the absentee sick call form
C. Talk to the nurse to see now sick she is
D. Notify the administrative supervisor
Correct Answer: A
83.
A male client is admitted for the removal of an internal fixation device that
was inserted for a fractured ankle. During the clients admission history, he tells
the nurse that he recently received Vancomycin (Vancocin) for methicillin-resistant
Staphylococuus aureus (MRSA) wound infection. Which actions should the nurse
take? (Select all that apply)
A. Collect multiple site screening cultures for MRSA
B. Call healthcare provider for a prescription for Linezol (Zyvox)
C. Place the client on contact transmission precautions
D. Obtain a sputum specimen for culture and sensitivity
E. Continue to monitor the client for signs of an infection
Correct Answer: A, C, E
84.
A neonate with a congenital heart defect (CHD) is demonstrating symptoms
of heart failure (HF). Which intervention should the nurse include in the infants
plan of care?
A. Give O at 6 L/nasal cannula for 3repeated oximetry screens below
B. Administer diuretics via secondary infusion in the morning only
C. Evaluate heart rate for effectiveness of cardiotonic medication
D. Use high energy formula 30calories/ounce at q3 hour feedings via soft
nipples
E. Ensure uninterrupted and frequent rest periods between procedures
Correct Answer: A, C, D, E
85.
Following an esophagogastroduodenoscopy (EGD), a male client is drowsy
and difficult to arouse, and his respirations are slowshallow. Which action should
the nurse implement? (Select all that apply)
A. Prepare medication reversal agent
B. Check oxygen saturation level
C. Apply oxygen via nasal cannula
D. Initiate bag-valve-mask ventilation

E. Begin cardiopulmonary resuscitation


Correct Answer: A, B, C
86.
When developing a teaching plan for a client with newly diagnosed Type 1
diabetes, the nurse should explain that an increased thirst is an early sign of
diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to
implement if this sign of DKA occurs?
A. Resume normal physical activity
B. Drink electrolyte fluid replacement
C. Give a dose of regular insulin per sliding scale
D. Measure urine output over the next 24 hours
Correct Answer: C
87.
The mother of a school age child tell the school nurse when her daughter can
return to school after treatment for pediculosis capitis. What is the best response
for the nurse?
A. Until all lice are dead
B. Until the epidemic in school subside
C. Stay in home
Correct Answer: A
88.
Client in wrist restraint the nurse frits slides two fingers under the restraint
and notes that the ties are secured to the side rail using a quick released tie. What
the nurse do?
ANS: Reposition the restraint ties, securing them to the bed frame.
89.
A newborn infant is diagnosis with developed mental dysplasia of the hip
must wear a pavlik harness 23 hours a day. Which behavior by the mother best
indicates that discharged teaching was effective?
A. The nurse observed the mother removing and replacing the pavlik
harness
B. The mother described problems that may occur while using the harness
C. The nurse report that she has question regarding the care of the harness
D. The nurse demonstrate removing the harness and the mother watches
closely
Correct Answer: A
90.
A client is one day postpartum tells the nurse that her baby cannot catch
onto his breast. The nurse determined that the client nipples are inverted. Which
action should the nurse implement to provide nutritional to the child?
A. Teach about the use of breast pump
B. Recommending using breast shield

C. Offer supplemental formula feeding


D. Encourage the use of ice on the areola
Correct Answer: B
91.
The mother of a 24 month old boy tell the clinic nurse that her child avoid
eye contact with those how try to interact with him, and he shrieks out in public for
no reason. Which intervention is more important for the nurse to screen the child
for autism?
A. Determine what activities are occurring when this happens
B. Inquire about spontaneous make believe play activities
C. Evaluate child ability to identify his nose and mouth
D. Observe the child for mannerism, such as hand flapping
Correct Answer: D
92.
The nurse is planning to teach a male client with type 2 diabetes how to
perform blood glucose. Monitoring which action should the nurse implement first?
A. Instruct the client to wash his hands before conducting the procedure
B. Provide an overwriting of the diabetes mellitus pathology
C. Refer the client to the hospital social worker
D. Assist the client to selecting a meter to monitoring the blood sugar
Correct Answer: A
93.
The nurse is palpating the lymph nodes of a 10 months old. Which findings
should the nurse call to the attention of the health care provider?
A. Enlarged, warn, tender preauricular node
B. Enlarged, non-tender, mobile occipital node
C. Small, discrete, mobile, non-tender, inguinal node
D. Small, firm, mobile nodules in the axial
Correct Answer: A
94.
A young adult female presents at emergency center with acute lower
abdominal pain. Which assessment finding is most important for the nurse to
report to the healthcare provider?
A. History of irritable bowel syndrome (IBS)
B. Report white, curdy vaginal discharge
C. Last menstrual period was 7 weeks ago
D. Pain scale rating of 9 on a 0 -10 scale
Correct Answer: C
95.
After reviewing the Braden scale finding of residents at a long term facility,
the charge nurse should to tell the unlicensed assistive personnel (UAP) to
prioritize skin care for which client?
A. A woman with osteoporosis who is unable to bear weight
B. An older man whose sheets are damp each time he is turned

C. An older adult who is unable to communicate elimination needs


D. A poorly nourished client who requires liquid supplements
Correct Answer: C
96.
A nurse who usually works on a step-down unit is moved to work a 12 hours
shift in the critical care unit. Which client is best for the charge nurse to assign to
this nurse?
A. A client admitted for a narcotic overdose who is ventilated with
respiratory alkalosis
B. A ventilated client admitted today with respiratory failure and respiratory
acidosis
C. A ventilator dependent client with chronic obstructive pulmonary disease
(COPD)
D. A client who has a new onset diabetic ketoacidosis (DKA) and is on insulin
drip
Correct Answer: C
97.
A toddler 3 years old with laryngotracheobronchitis is experiencing difficulty
breathing and his mother is at bed side. What is important for the nurse to
implement?
A. Allow the mother to stay with the child because separation of anxiety is
strefful situation for the child
B. Allow the mother to stay with the child because the presence mother
help the child to lower the child anxiety
C. Allow the mother to stay so staff member can make another task
Correct Answer: B
98.

What is earliest sign of intracranial pressure?


A. Loss of LOC
B. Tremors
C. Decerebrate posturing
D. Decorticate posturing

Correct Answer: A
99.
A young woman is preparing to leave for a 7 day bout trip. She requests a
prescription for motion sickness, so the health care provider prescribed meclizine
(Antivert) which instruction should the nurse include in this client teaching?
A. Suck on hard candy for a dry mouth while taking these drug
B. Avoid eating shellfish for 24 h after taking these drug
C. Sit up right for at least 30 min after taking these drug
D. Do not dink caffeinated beverage while taking these drug
Correct Answer: A

100.
A client who recently received a prescription for Ramelteon (rozerem) to treat
sleep deprivant reports experiencing several side effects since taking the drug.
Which side effects should the nurse report to the healthcare provider?
A. Somnambulism
B. A charge in the sleep wake cycle
C. Mild sedation
D. Dizziness reported after initial dose
Correct Answer: A
101.
While administering a continuous insulin infusion to a client with diabetic
ketoacidosis, it is essential for the nurse to monitor which serum lab value?
A. Potassium
B. Calcium
C. Protein
D. Hemoglobin
Correct Answer: A
102. A client in the emergency center demonstrates rapid speech, flight of ideas and
reports sleeping only three hours during the past 48 hour.
Based on these finding, it is
most important for the nurse to review the laboratory value for which medication?
A.
B.
C.
D.

clanzapine (zyprexa)
divalproex(depakote)
lorazepan ( ativan)
fluoxetine (prozac)

Correct Answer: B
103. A client who had a right hip replacement 3 days ago is pale has diminished breath
sounds over the left lower lung fields, temp 100.2 F and an oxygen saturation rate of
90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow
for a rehabilitative critical pathway. Based on the clients symptoms, what
recommendation should the nurse give to the healthcare provider?
A.
B.
C.
D.

Confer with family about home care plans


Arrange physical therapy for strengthening
Obtain specimens for culture analysis
Reassess readiness for SNF transfer

Correct Answer: D
104. A client who had an open cholecystectomy two weeks ago come to the Emergency
Department with complaints of nausea, abdominal distention, and pain. Which
assessment should the nurse implement?
A. Auscultate all quadrants of the abdomen
B. Perform a digital rectal exam

C. Palpate the liver and spleen


D. Obtain a hemoccult of the clients stool
Correct Answer: A
105.
An alert, oriented male client is refusing a life-saving surgery because he
does not want to live with a colostomy the rest of his life. Hi wife adamantly
disagrees and tells her husband that their religious beliefs do not allow him to
make such a decision. What explanation should the nurse provide the wife?
A. The clients refusal of treatment constitutes legalized suicide and the
family should help him to understand the choice
B. The clients mental competency should be assessed before accepting
his decision to ignore medical recommendations
C. The chaplain is probably the best person to help the client to
understand the religious consequences of his decision
D. A competent adult has the right to refuse any treatment for any
reason, whether or not it is based on religious beliefs
Correct Answer: D
106.
A female client is brought to the community mental health center with
complains of headaches, insomnia, and a poor appetite. Her son was killed by a
drunk driver 2 years ago and she tells the nurse, If only has made him stay
home that night. The client is exhibiting symptoms of which condition?
A. Denial of the loss
B. Displaced anger
C. Poor ego strength
D. Delayed grief reaction
Correct Answer: D
107.
The husband of and older woman, diagnosed with pernicious anemia, calls
the client to report that his wife still has memory loss and some confusion since
she received the first dose of nasal cyanocobatamin two days ago. He tells the
nurse that he is worried that she may be getting Alzheimers disease. What action
should the nurse take?
A. Encourage the husband to bring the client to the clinic for a complete
blood count
B. Explain that memory loss and confusion are common with Vitamin B12
deficiency
C. Determine if the client is taking iron and folic acid supplements
D. Ask if the client is experiencing any change in bowel habits
Correct Answer: B
108.
A male client who weighs 325 pounds (148 kg) is admitted because of
ureteral colic and is now complaining of sharp pain radiating toward his genitalia.

His has hematuria and is hypertensive. Which intervention is most important for
the nurse to include in the clients plan of care?
A. Manage pain
B. Monitor hematuria
C. Document blood pressures
D. Encourage low caloric diet
Correct Answer: A
109.
The staff nurse is assigned the care of four clients on the day shift. After
receiving report, in what order should the nurse assess the assigned clients?
(Arrange the nursing actions with the highest priority first on top, and lowest
priority last, on bottom.)
A. An adult with leg infection who is scheduled to receive insulin before
breakfast
B. And older adult who had knee replacement and is scheduled for
transfer to rehabilitation later today
C. An adult receiving patient controlled analgesia (PCA) whose spinal
tumor causes pain and paresthesia
D. An adolescent whose left foot was amputated last night after a tree fell
on it
Correct Answer: D A C B
110.
A combination multidrug cocktail is being considered for an asymptomatic
HIV infected client with CD4 cell count of 500. What nursing assessment in
determining whether therapy should be initiated?
A. State various side effects of retroviral agents
B. Willing to comply with complex drug schedules
C. Quantities for a prescription program
D. Maintained an adequate social support system
Correct Answer: B
111.
The nurse notes a visible prolapse of the umbilical cord after a client
experiences spontaneous rupture of the membranes during labor. What
intervention should the nurse implement immediately?
A. Elevate the presenting part off the cord
B. Place the client to a knee chest position
C. Administer oxygen by face mask at 6L/min
D. Transport the client for a cesarean delivery
Correct Answer: A
112.
An unlicensed assistive personnel (UPA) leaves the unit without notifying the
staff. In what order should the unit manager implement these interventions to
address the UPAs behavior? (Place the actions in order from first on top to last on
bottom)

A.
B.
C.
D.

Plan for scheduled break times


Discuss the issue privately with the UPA
Evaluate the UPA for signs of improvement
Note date and time of the behavior

Correct Answer: D, B, A, C
113.
Picture Question: BP cuff to clients thigh where should you place the
stethoscope? The picture will be 2 bodies. One will be facing towards you the
other facing away.
ANS: facing away looking at his ass end and point curser on left leg
behind the knee.

114.
Discharge instructions to a client with kidney or liver transplant and is on
immunosuppressantswhat does the nurse teach to patient?
ANS: Avoid large crowds for 2 months
115.
The electrocardiogram of a patient show a flat T wave and PVCs. What
should the nurse know this represent?
ANS: repolarization
116.
A client with cirrhosis becomes confused I think ammonia levels are up
ANS: Lactulose
117.
An acute care hospital has a disaster something about an outage and a
generator. The UAP asks the charge nurse what she can do to help
ANS: Tell clients to stay in their rooms
118.
A patient is in the acute phase of burn to prevent auto contamination when
changing dressings how should you do it?
ANS: Change each dressing separately
119.
A patient with bilateral hearing aids it is ringing loud?
ANS: Reinsert hearing aid
120.
A female comes into the clinic stating she is a victim of date rape 2 days ago.
What should the nurse ask first?
ANS: find out if she had any consensual sex in the last couple days
121.
A staff nurse reports to the charge nurse that they suspect thermometers are
not working what should the charge nurse do
ANS: use another machine and compare
122.
Old client that is being discharge to home with new medication. What
teaching should nurse provide the client?

ANS: tell to the client that he cannot share the medication with friends or
family
123.
Video the nurse hanging a bag of normal saline. The video stop and ask what
was missing
ANS: Open the clamp
124.
Question based on these findings and you will have to look in the chart,
oxytocin, stadol, and LR what action would the nurse implement? They will give
you chart of patient to look through it
ANS: STOP OXITOCIN** (I pick this one)
meds, no change.

OR/Not Sure

Leave same

125.
A combative old man, what nursing diagnosis is best this is a patient with
ad who threatens to be abusive with personnel.
ANS: Risk for others self-direct harm or violence
126.

Patient receiving warfarin, INR 2.0. What to do?

ANS: Administer next warfarin dose.


127.
Discharge teaching to a patient with heart failure what parameter is most
important for weight monitoring
ANS: Weigh themselves at the same time everyday
128.
A patient is in anticoagulant treatment and the nurse is performing some
procedure (should be invasive). What intervention should the nurse performed?
ANS: Apply pression at the insertion site when the needle is removed
129.
What is the most important teaching when instructing a parents of a child
with sickle cell disease?
ANS: If Hydration or fluid replacement appear in the choices get it,
because it is the most important in this disease
130.
A patient is bringing to the emergency department with a serum magnesium
level of 1.1. Which medication the nurse suspect is going to be administered?
ANS: Magnesium
131.
Postmortem care what to delegate to UAP before the family see the client?
(Select all that apply)
ANS: Change the bed lines

Put a clean gown


Postmortem care, delegation: assign to UAP.
1.
No visitors sing in pt. room door
2.
Place pt. in supine flat position
3.
Place pillow on head
4.
Close patient eyes
5.
Remove jewelry and or position that pt. has on
6.
Put on clean gloves
7.
Place towel under pt. chin for mouth to be closed
8.
Remove IV and other tubes
9.
Remove all soiled dressing, ex. Ostomy bags, etc.
10. Wash soiled areas of the body
11. Place disposable oats to the perineal area to absorbed any urine, etc., due to
sphincter relaxation
12. Remove and discard gloves
13. Put clean gown on the pt.
14. Attach a second ID band to the pt.
15. Replace linens
16. Take off and take care of dentures and glasses
17. At end wash hands
132.
A male client on palliative care cant swallow and is dehydrated but doesnt
want an IV. What should the nurse do?
ANS: Keep him comfortable
133.

Patient with a past allergy to penicillin

ANS: Check for further cross allergy to cephalosporin antibiotics


134.

Cleft palate lip feeding

ANS: Special soft large nipple for feeding. (Lamb nipple for feeding)
135.
The nurse is calculating the one-minute Apgar score for a newborn male
infant, and determines that his heart rate is 150 beats/minute, he has a vigorous
cry, his muscle tone is good with total flexion, he has quick reflex irritability, and
his color is dusky and cyanotic. What Apgar score should the nurse assign to the
infant?
A. 7
B. 8
C. 9
D. 10
Correct Answer: B

136.
The physician prescribes estrogen 0.625 MG daily for a 43-year-old woman.
The nurse knows which of the following symptoms is a common initial side effect
of this medication?
ANS: Ataxia.
137.
The nurse is planning care for a newborn with bladder exstrophy. During the
preoperative period, which intervention should the nurse implement?
ANS: Apply a sterile non-adherent dressing over the bladder.
138.
A 70-year old man with a history of hypertension and closed angle glaucoma
visits the clinic for a routine checkup. Which of the following medications? If
ordered by the physician?
ANS: Tetrahydrozoline (visine), 2 gtts OU TID.
139.
The nurse is assessing a client immediately after an exploratory laparotomy.
Which of the following nursing observations would relate to the complication of
intestinal obstruction?
ANS: Distended abdomen with complaints of pain
140.
The school nurse conducts a class on childcare at the local high school.
During the class, one of the participants asked the nurse what age is best to start
toilet training a child. Which of the following is the best response by the nurse?
ANS: twenty months of age
141.
A child is injured at a sporting event and a nurse attending the event
evaluates the child. What is the most accurate method to determine if a fracture
has occurred?
ANS: Send the child for a radiological exam.
142.
Which of the following nursing actions has the highest priority and caring for
the client with hypoparathyroidism?
ANS: Plan measures to deal with cardiac dysthymias
143.
The nurse knows that which psychosocial stage should be a priority to
consider while planning care for the 20-year-old client?
ANS: Identity versus diffusion
144.
After positioning a client on the side to administer a rectal suppository, the
nurse observes that the client has been incontinent of a large amount of liquid

stool, which has soaked through a gauze pad covering a stage three-pressure
ulcer. What action should the nurse take first?
ANS: Replace the soiled dressing.
145.
A client has an AV graft for hemodialysis in the left forearm and an infiltrated
IV in the right arm. After discontinuing the IV, where should the next IV be
started?
ANS: Right arm proximal to the former IV.
146.
The nurse in the emergency department is using the simple triage and rapid
transport (START) system to assess victims of a hurricane. Which statement
correctly describes a yellow disaster tag?
ANS: A yellow disaster tag means critical injuries and require
immediate intervention.
147.
The nurse is preparing to administer a liter of IV solution to a toddler with
gastroenteritis who is dehydrated. Which action should the nurse implement to
prevent fluid overload?
ANS: Attach a volume-control device below the primary infusion.
148.
Which of the following types of foods should the nurse encourage in the diet
of
a client with a hypoparathyroidism?
ANS: Low in sodium.
149.
A school-aged child with otitis media receives a prescription for azithromycin
(Zithromax) 300 mg once, then 150 mg daily for 4 days. The medication is
available in a solution containing 200 mg/5 ml. How many ml should the nurse
administer on the first day of the treatment regimen?
7.5

150.
What area of the body should be palpated to assess for the presence of
Heberdens nodes in the client with osteoarthritis?
ANS: Distal fingers.
151.
To determine the effectiveness of a dose of ondansetron (Zofran)
administered to a client also receiving chemotherapy, what client data should the
nurse obtain?
A. White blood cell count
B. Current level of pain
C. Hemoglobin and hematocrit
D. Rating on a nauseas scale

Correct Answer: D
152.
The nurse is preparing to conduct discharge teaching for a client who had an
anaphylactic reaction following administration of ampicillin (omnipen-N). What
instruction is essential for the nurse to provide this client prior discharge?
A. Teach the client how to self-administer epinephrine in cases a reaction
occur again
B. Instruct the client to wear a medic-alert bracelet so penicillin will not be
given again
C. Tell the client to make medication with food to decrease will not be given
again
D. Inform the client that it is essential to take all of the prescribed ampicillin
Correct Answer: B
153.
To reduce staff the nurse role ambiguity, which strategy should the nursemanager implement?
A. Review the staff nurse job description to ensure that it is clear, accurate,
and current
B. Assign each staff nurse a turn as the unit charge nurse on a regular,
rotating basis
C. Analyze the amount of overtime needed by the nursing staff to complete
assignments
D. Confirm that all of the staff nurses are being assigned to equal numbers of
clients
Correct Answer: A
154.
The nurse is preparing to administer a formula feeding by nasogastric tube
to a 2-month-old.
A.
B.
C.
D.

Use the syringe plunger to push formula at a rate of 5ml/min


Microwave refrigerated formula to room temperature
Measure and discard residual gastric contents before feeding
Hold the infant with head and shoulders slightly elevated

Correct Answer: D
155.
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?
A. Bilateral sclera edema
B. Pitting peripheral edema
C. Jaundice skin tone
D. Muffled heart sounds

Correct Answer: D
156.
Client was admitted to the cardiac observation unit 2 hour ago
complaining of chest pain .On admission the client EKG showed bradycardia ,ST
depression ,but no ventricular ectopic .The client reports a sharp pain ,telling the
nurse ,I feel like an elephant just stepped on my chest .The EKG now shows Q
waves and ST elevations in the anterior leads .What intervention should the nurse
perform ?
A Administer prescribed morphine sulfate IV and provide oxygen at 2L per
minute per nasal cannula
B Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac
enzyme levels
C Notify the HCP of the clients increased chest pain and call for defibrillator
crash cart
D Increased the peripheral IV rate to 175 ml/hr. to prevent hypotension and
shock
Correct Answer: A
157. A female client come to the clinic complaining of fatigue and inability to sleep
because he is full time caretaker for a 22 year old son who was paralyzed for a motor
vehicle collision. She add that her husband left her because he says that he cannot take
her behavior any more since all she does is caring their son .What intervention should
the nurse implement?
ANS: Acknowledge the client stress and suggest that she consider respite care
158.
A
B
C
D

Esta es la de la pleural working properly?


Reduce pleural lining inflammation.
Relieve pulmonary artery obstruction
Remove air from the thoracic cavity.
Restore airflow through the bronchi.

Correct Answer: C
159. An infant with respiratory rate of 92 b/m and heart rate of 156 b/m .Which drug
is the transport team most likely to administer to this infant .?
A Instill Beractant (Survanta) 100 mg/kg in the endotracheal tube
B Give Ampicillin (Omnipen) 25 mg /kg slow IV
C Deliver 1:10, 0000 Epinephrine 0.1 ml/kg per endotracheal tube
D Administer digoxin (Lanoxin) 20 mcg /kg IV.
Correct Answer: A
160. The nurse plans to administer 1 teaspoon of liquid medication to a toddler. What is
the most accurately way to administer the medication?
A Measure the medication in an oral syringe
B Use a medicine cup to measure the dose

C Give medication using a medication dropper


D Administer the medication from teaspoon
Correct Answer: A
161. The nurse identifies which recent event as placing a client for cardiogenic shock?
A MI in the right ventricle.
B Gunshot wounds in the chest and abdomen.
C Multiple bee stings around the head and neck.
D Traumatic amputation of the leg at the groin.
Correct Answer: A
162. The nurse is obtaining a blood sample via venipuncture from a preschool age
child .Which intervention should the nurse do?
A Apply a large colored bandage aid to the puncture site
B Explain in very simple terms why the blood is needed
C Place the labeled specimen in a paper bag
D Encourage the child to talk about this experience
Correct Answer: A
163. The nurse in the outpatient unit is caring for a client who had a right femoral
cardiac catherization two hours ago .What assessment findings requires immediate
intervention?
A The client wants assistance walking to the bathroom
B Clients pulse oximeter is 98%
C The client right feed is warn to touch
D The client B/P is 110/70 and pulse 90
Correct Answer: A
164. A new mother tells the nurse that she does not want her newborn to receive any
immunization. It is the hospital policy to routinely administer immunization to all
newborns. What intervention should the nurse implement?
A Document that the mother has refused the immunization.
B Tell the mother to sign out of the hospital AMA if wishing to refuse the
immunization
C Administer the immunization after first explaining the hospital policy to the
mother
D Report the immunization status of the infant to the office of child protective
services
Correct Answer: A
165. The nurse receives report on four clients who are complaining of increased pain.
Which client requires immediate by the nurse?
A Sharp pain related to a crushed femur
B Burning pain due to mortons neuroma
C Stinging pain related to plantar fascitis
D Paresthesia of fingers due to carpal tunnel syndrome

Correct Answer: A
166. The nurse discovers that an elderly client with no history of cardiac or renal
disease has an elevated serum magnesium level. To further investigate the cause of this
electrolyte imbalance, what information is most important for the nurse to obtain from
the client medical history?
A Ingestion of shellfish or fish oil capsules daily
B Frequent laxative use for constipation.
C Genetically inherited disorders of family members
D The length and frequency of the tobacco use
Correct Answer: B
167. A client with a history of upper respiratory symptoms is admitted to the unit with
chest tightness, productive cough and difficult breathing. The client ABG is respiratory
acidosis. What lab the nurse expect to be high?
A pH
B Arterial pH
C HCO3
D PaCo2
Correct Answer: D
168. A primigravida at 31 weeks of gestation is admitted with a bloody show and
contraction every 10 minutes. After administrating betamethasone. Which lab finding
should the nurse monitor?
A Lecithin sphingomyelin ratio
B Arterial blood gas
C 24 hr. urine for protein
D Hemoglobin level
Correct Answer: A
169. A patient has a living will that said that when he is dying , he wants the physician
save his life
whenever is possible ,but the family members
tell to the nurse that resuscitation is not permitted in their religion so inform to the
physician that do not resucited the client. What information provide the nurse to the
family member?
ANS: Inform to the family that the physician follows that the living
report.
170.
A
B
C

A client with a wound what diet the nurse teach for healing?
yogurt
Fruit
Green vegetables

Correct Answer: A
171. Which intervention should the nurse include in the plan of care for tetanus....?
A Open the window to provide natural light
B Encourage coughing and deep breathing.

C Minimize the amount of stimuli in the room


D Reposition from side to site every hour.
Correct Answer: C
172. A chest x ray reveals that an older adult male fell out of bed has fracture ---right
pneumothorax. Two hours ago after the fall, he is anxious and short of breath. The nurse
determines that breath sounds on his right are absent, and his trachea is deviated to left.
Afterpaging the rapid response team, which intervention is most important for the nurse
to implement?
A Set up chest drainage system.
B Obtain portable chest x-ray.
C Place the client for comfort.
D Place resuscitation cart at bed side
Correct Answer: A
173. The nurse notes that an older adult client has a moist cough that increase in
severity during and after meals. Based on this findings, what action should the nurse
take?
A Encourage client to deep breathing exercises daily
B Offer the client additional clear frequently
C Collect a sputum specimen immediately
D Request a consultation to confirm dysphagia
Correct Answer: D
174. The nurse who is working on surgical unit receives change of shift report on a
group of clients for the upcoming shift .The client with which description requires the
most immediate attention by the nurse?
A Mastectomy 2 days ago with 50 ml bloody drainage noted in the JacksonPratt drain
B Gunshot wound three hours ago with dark drainage of 2 cm noted on the
dressing.
C Abdominal resection 2 days ago with no drainage on dressing who has
fever and chills.
D Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube
collection container.
Correct Answer: C
175. Suicide precaution are initiated for a client admitted to the mental health unit
following an intentional narcotic overdose. After a visitor leaves, the nurse finds a
package of cigarette in the clients room .which intervention is most important for the
nurse to implement?
A Remove cigarettes from the client room
B Screen future visitors for contraband
C Assign a sitter for constant observation
D Document suicide monitoring frequently
Correct Answer: C
176. The nurse is arranging home care for an older who has a new colostomy following a
bowel resection three days ago. The client plans to live with a family member. Which
action should the nurse? (Select all that Apply)

A
B
C
D
E

Assess the client for self-care abilities.


Provide pain medication instruction
Request home safety inspection
Call home care agency to set up oxygen.
Teach care of ostomy to care provider

Correct Answer: A, B, C
177. The nurse is completing a head to toe assessment for a client admitted for
observation after falling out of a tree .Which finding warrants immediate intervention by
the nurse?
A Clear fluid leaking from the nose.
B Periorbital ecchymosis of right eye.
C Complaint of severe headache
D Sluggish pupillary response to light.
Correct Answer: A
178. A client has an intravenous fluid infusing in the right forearm. To determine a pulse
rate most accurately, which action should the nurse implement?
A Palpate at the radial pulse with the pads of two or three fingers.
B Turn off the intravenous fluid that is infusing while counting the pulse.
C Auscultate directly below the IV site with dropper stethoscope.
D Elevate the client upper extremity before counting the pulse.
Correct Answer: A
179. The nurse is preparing a discharge teaching plan for a client who has liver
transplant... Which instruction is most important to include in this plan?
A Avoid crowds for first two months after surgery.
B Notified the healthcare provider if edema occurs.
C Limit intake of fatty foods for one months after surgery.
D Increase activity and exercise gradually, as tolerated.
Correct Answer: A
180. A male client who has a herniated intervertebral lumbar disc is experiencing severe
pain in his right leg .What pathophysiological process explains this clients pain?
A Measure on nerve root moving /rooting the spinal cord.
B Inflammation of the surrounding lumbar tissues.
C Stresses fractures of the lumbar vertebral bodies.
D Nerve signal interruption from involved jounce/joint.
Correct Answer: A
181. In caring for the body of a client who just died, which tasks can be delegated to
UAP? (Select all that Apply)
A Confirm the client wishes for tissue donation
B Follow cultural beliefs in preparing the body

C Attach identifying name tags to the body


D Place personal religious artifacts on the body
E Observed consent for autopsy signature by family
Correct Answer: B, C, D
182. The nursing staff on a medical unit includes register nurse (RN), practical nurse
(LPN), and UAP. Which task should the charge nurse assign to the RN?
A Supervise a newly hired graduate nurse during admission assessment
B Transport a client who is receiving IV fluids to the radiology unit
C Administer PRN oral analgesic to a client with a history of chronic pain
D Complete ongoing focused assessment on a client with wrist restraints
Correct Answer: A
183. The nurse administer an isotonic intravenous solution to a client in septic shock
.Which is most important for the nurse to monitor to determine that treatment is
effective?
A White blood cell
B Blood pressure
C Body temperature
D Hemoglobin and hematocrit
Correct Answer: B
184. The nurse is interacting with a female client who is diagnostic with postpartum
depression. Which findings should the nurse document as an objective signs of
depression? (Select all that Apply)
A Reports feelings of sad
B Has a disheveled appearance
C Express suicidal thought
D Interacts with felt effect
E Avoid eyes contact
Correct Answer: B, D, E
185. The nurse fined a client at 33 weeks of gestation in cardiac arrest. What method of
CPR the nurse should perform?
ANS: Position a firm wedge to support pelvis and thorax at 30 degree tilt
186. An adult male report that the last time he received penicillin he developed a severe
maculapapular rash all over his chest. What information should the nurse provide to this
client?
ANS: Be alert for possible cross-sensitivity to cephalosporin agents.
187. The nurse is preparing to administer an oral antibiotic to a client with unilateral
weakness, mouth drooping, and aspiration pneumonia. What is the priority nursing
assessment that she will be done before administering the medication?
A Determine what side of the body is weak.

B Auscultate breath sounds


C Obtain and record client vital sign
D Ask the client about soft food preferences
Correct Answer: A
188. When preparing a client for discharge from the hospital following a cystectomy and
urine diversion to treat bladder cancer. Which instruction is most important for the nurse
to include in the discharge teaching plan?
A Frequent empty the bladder to avoid distention
B Follow instruction for self care toileting
C Report any cloudy urine output
D Seek counselling for body image concerns.
Correct Answer: C
189. The nurse is teaching a client about prevention of Lyme disease and recommended
wearing a long sleeves and pants when hiking outdoors. How should the nurse explain
the underlying disease pathology resulting in the need for these precaution?
ANS: The infectious organism is transmitted by ticks that become attached to
the skin
190. The mother is feeding a client who was admitted this morning with syncope and
generalized weakness .The client has a history of aspiration and begins coughing while
attempting to drink trough a straw. Which action should the nurse implement?
A Elevate the head of bed for 30 minutes after meal
B Perform oral care before meals
C Allow small amount of liquid with meals
D Provide nectar thickened liquids
Correct Answer: D
191. During breath sounds auscultation of a client who is being mechanically ventilated,
the nurse hears coarse sounds over the upper anterior chest with clear sounds over the
other lung fields. What intervention should the nurse implement at that time?
A Continue to assess the client frequently
B Begin manual resuscitation who ambu bag
C Notify respiratory therapy immediately
D Suction the client endotracheal tube
Correct Answer: D
192. Patient with cast in both hands and cannot be put on prone position to check blood
pressure?
ANS: Show UAO how to check pulse flexing knee on the popliteal area

193. A 5 years old girl had three urinary tract infection in the past 6 months. What
information is most important for the nurse to obtain?
A If she wear tight fitting, nylons panties
B Amount of fluid intake in the last 24 hrs.
C Method used to wipe after urination and defecation
D How many times the child urinates during the day.
Correct Answer: C
194. A man with a chest tube. Where to get the draining from?
ANS: Port of the upper draining chamber.
195. Picture: port needle sizes for chemotherapy

196. Video: Critique whats wrong while medication giving


ANS: Nurse did wrong was that she left the syringe on and she left
Or if not dispose the needle
197. Calculation: 1ml = 30 oz

1cup = 8oz

ANS: 1680

198. Braden Scale risk for skin impairment


ANS: Urinary Incontinent
199. Syringes to give a med in an IM on deltoid muscle
ANS: 2 cc/ 22 in size (no more than 1 in deltoid muscle)
200. Male patient postoperative after TURP with urinary drainage. Nurse sees a big red
bright blood clot. What should nurse do?
ANS: Assess catheter for urine output or Irrigate
201. Child to be given high protein
ANS: Scrambled eggs and bacon
202. Pt with a paraplegia, paresthesia or both legs bad
ANS: 4 point crutches

203. Huntington disease


ANS: take the patient to the cafeteria
204. A newly diagnosed patient with systemic lupus. What information would be
accurate to tell this client regarding this disease?
ANS: disease is characterized by periods of flare-ups and remission
205. Pt with cellulitis where to put IV?
ANS: Place the IV opposite site
206. Otic gout how you put the child?
ANS: Side lie on unaffected site and rest for 5 min (med should be warm)
207. Patient with metabolic syndrome is going to start exercising what is most important
to tell him
ANS: Monitor BP as exercise increases
208. Patient c/o pain distal to insertion site, what action should the nurse implements?
ANS: remove IV
209. Which patient at risk for osteoporosis?
ANS: Smoking 2 packs a day has COPD
210. MATH medication one something about prescribed dose is like 60mg; available is
750mcg/per 2.4ml
ANS: 0.19, round to the nearest 10th so it is 0.2
211. Foods low in Na menu choice
ANS: turkey salad sandwich.