1Calculate
the IV flow rate for 1200 mL of NS to be infused in 6 hours.
The infusion set is calibrated for a drop factor of 15 gtts/mL.
112gtts/min
, Not Selected
360 gtts/min
, Not Selected
20gtts/min
, Not Selected
Incorrect answer:
50 gtts/min
Correct Answer:
360 gtts/min
Results for item 2.
2
0 / 0.05 points
What is the only solution appropriate for Blood transfusion?
Incorrect answer:
0.9% NaCl
Correct Answer:
D5W
H2O
, Not Selected
D5W
, Not Selected
LR
, Not Selected
Results for item 3.
3
0.05 / 0.05 points
The emergency department nurse is caring for a client in an Addisonian crisis. Which
intervention should the nurse implement FIRST?
Ask the client what medications he or she is taking.
, Not Selected
Administer prednisone p.o. stat
, Not Selected
Correct answer:
Start an 18-gauge catheter with normal saline.
Draw serum electrolyte levels.
, Not Selected
Feedback
Based on answering correctly
Rationale: The nurse must treat an Addisonian crisis as all other shock situations. An IV and
fluid replacement are imperative to prevent or treat shock. This is the first action. The prednisone
is a p.o. dose and will take time to take effect.
Results for item 4.
4
0 / 0.05 points
The nurse is making assignments for the unlicensed assistive personnel (UAP). Which tasks can
be safely assigned to UAP? (Select all that apply.)
Correct answer:
Bathing a client with Alzheimer’s disease
Answer,
Teaching a client how to use a cane
Correct answer:
Turning a client who is poorly nourished
Answer,
Feeding a client with swallowing difficulty
Incorrect answer:
Assisting a client with a chest tube during ambulation
Selected Answer - Incorrect
Feedback
Based on answering incorrectly
Rationale: Unlicensed assistive personnel (UAP) can safely perform bathing and turning a
client. Unstable clients cannot be delegated to UAP. Assisting a client with a chest tube and
feeding a client with swallowing difficulty cannot be assigned to UAP. The registered nurse
should only delegate routine tasks, and tasks with lower priority. Teaching a client how to use a
cane is not within their scope of practice.
Results for item 5.
5
0.05 / 0.05 points
Convert 5,000 mcg to mg
50000
, Not Selected
500
, Not Selected
.5
, Not Selected
Correct answer:
5
Results for item 6.
6
0 / 0.05 points
Potassium chloride is available as 10 mg per tablet. Potassium
Chloride 40 mg is ordered. How many tablets would the nurse
administer?
Incorrect answer:
4
Correct Answer:4 tabs
Results for item 7.
7
0.05 / 0.05 points
A client is hospitalized for open reduction of a fractured femur. During the postoperative
assessment, the nurse notes that the client is restless and observes petechiae on the client's chest.
Which nursing action is indicated first?
Contact the nursing supervisor.
, Not Selected
Correct answer:
Administer oxygen.
Contact the health care provider.
, Not Selected
Elevate the affected extremity.
, Not Selected
Feedback
Based on answering correctly
Rationale: The client is demonstrating clinical manifestations consistent with a fatty embolus.
Administering oxygen is the top priority. Elevating the extremity won't alter the client's
condition. Notifying the nursing supervisor may be indicated by facility policy after other
immediate actions have been taken. The nurse should contact the health care provider after
administering oxygen. Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of
Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 42:
Management of Patients With Musculoskeletal Trauma, Clinical Manifestations, p. 1193.
Results for item 8.
8
0.05 / 0.05 points
The nurse is caring for a client with a suspected pulmonary embolus. What organ is the focus of
care?
Urinary Tract
, Not Selected
Correct answer:
Lungs
Inferior vena Cava
, Not Selected
Lower Extremities
, Not Selected
Feedback
Based on answering correctly
Rationale: An imbalanced or mismatched V/Q scan indicates some type of problem with either
ventilation or perfusion. Further testing is required, especially in the case of suspected PE.
Results for item 9.
9
0 / 0.05 points
The nurse is caring for a client with a prescription for strict intake and output who has had the
following intake throughout the shift.
intravenous fluid 100 ml per hour times 12 hours
oral medication 10 ml
water 800 ml
jello 1 cup
How many milliliters should the nurse document as the client's total intake for the shift? Do not
round your answer. Enter numeric value only.
Incorrect answer:
2250
Correct Answer:2,250 mL
Results for item 10.
10
0.005 / 0.005 points
Which statement below is incorrect about a deep vein thrombosis (DVT)?
A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein
, Not Selected
DVTs tend to mostly occur in the lower extremities but can occur in the upper extremities too
, Not Selected
Correct answer:
A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism.
Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and
superficial femoral.
, Not Selected
Results for item 11.
11
0.05 / 0.05 points
Solumedrol 1.5mg/kg is ordered for a child weighing 74.8 lb.
Solumedrol is available as 125 mg / 2mL. How many mL must the
nurse administer?
Do not give
, Not Selected
Correct answer:
0.82 mL
22.67 mL
, Not Selected
0.79 mL
, Not Selected
Results for item 12.
12
0.05 / 0.05 points
A patient is prescribed Warfarin (Coumadin) for the treatment of a blood clot. What is the
therapeutic INR range for this medication?
2-4
, Not Selected
7-8
, Not Selected
1-2
, Not Selected
Correct answer:
2-3
Results for item 13.
13
0 / 0.05 points
A nurse is caring for a client with a new prescription of digoxin. Which client statement would
require further teaching about digoxin? (Select all that apply.)
Correct answer:
“I will take the digoxin with my antacids at night.”
Incorrect answer:
“I understand that I will need annual blood work to check therapeutic levels.”
Missed Option – Incorrect Answer,
“I will take my pulse before each dose of digoxin.”
Correct answer:
“If I forget a dose, I will catch up by doubling the next dose.”
Answer,
“I will take the digoxin at 9 am daily.”
Answer,
“I will notify my health care provider if experiencing increased fatigue or muscle weakness.”
Feedback
Based on answering incorrectly
Rationale: Digoxin is a cardiac glycoside that slows and strengthens the heart providing a more
regular rhythm. Digoxin has a narrowed therapeutic window requiring every 2 weeks to monthly
serum blood level monitoring initially. It is usually helpful for a client to take digoxin at a
specific time each day to establish its blood level and routine for administration. The nurse
would teach the client to take the pulse before each dose of digoxin and to notify the health care
provider if the rate or rhythm changes, specifically if the rate drops to less than 60 beats/minute.
The client would also be instructed to report increasing fatigue or muscle weakness immediately,
as these are signs of digitalis (digoxin) toxicity. Antacids inhibit the absorption of digoxin, so
digoxin would not be taken with these drugs. If the client forgets to take a dose of digoxin,
he/she may take the missed dose only up to 12 hours later. Lippincott Alternate Format
Results for item 14.
14
0 / 0.05 points
The nurse administers 6 units of regular insulin and 10 units NPH insulin at 7 AM. At what time
does the nurse assess the client for problems related to the NPH insulin?
8 PM
, Not Selected
Incorrect answer:
8 AM
Correct Answer:
4 PM
11 PM
, Not Selected
4 PM
, Not Selected
Feedback
Based on answering incorrectly
Rationale: NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12
hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon;
8:00 PM and 11:00 PM would be too late
Results for item 15.
15
0.05 / 0.05 points
The client has been receiving clonidine 0.1 mg via transdermal patch once every 7 days. The NA
removes the patch during morning care. Eight hours later, the nurse discovers that the clonidine
patch is no longer present. Which assessment finding should be most concerning to the nurse?
The ECG monitor shows a heart rate of 120 bpm.
, Not Selected
Skin tear is noted on the client’s upper chest.
, Not Selected
Client reports having an excruciating headache.
, Not Selected
Correct answer:
Blood pressure is noted to be 182/100 mm Hg.
Feedback
Based on answering correctly
Rationale: Clonidine is an antihypertensive medication. Rebound hypertension occurs from
abrupt withdrawal. Immediate intervention is required to lower BP.
Results for item 16.
16
0.05 / 0.05 points
MD ordered 1000 mL D5W IV to infuse in 10 hours by infusion pump.
If the IV stated at 1700, what time should it be completed?
2200
, Not Selected
Correct answer:
0200
1400
, Not Selected
1730
, Not Selected
Feedback
Based on answering correctly
Rationale: CVP is a useful hemodynamic parameter to observe when managing an unstable
client's fluid volume status. An increasing pressure may be caused by hypervolemia or by a
condition, such as heart failure, that results in decreased myocardial contractility. Stress,
dislodgment of the catheter, and low magnesium levels would not typically result in increased
CVP. Chapter 25: Assessment of Cardiovascular Function - Page 706
Results for item 17.
17
0 / 0.05 points
A mother brings her teenage son to the clinic, where tests show that he has hepatitis A virus
(HAV). They ask the nurse how this could have happened. Which of the following explanations
would the nurse correctly identify as possible causes? (Select all that apply.)
Incorrect answer:
Infection at school
Missed Option - Incorrect
Incorrect answer:
Suboptimal sanitary habits
Missed Option - Incorrect
Correct answer:
Consumption of sewage-contaminated water or shellfish
Answer,
Ingestion of undercooked beef
Correct answer:
Sexual activity
Feedback
Based on answering incorrectly
Rationale: Typically, a child or a young adult acquires the infection at school through poor
hygiene, hand-to-mouth contact, or close contact during play. The virus is carried home, where
haphazard sanitary habits spread it through the family. An infected food handler can spread the
disease, and people can contract it by consuming water or shellfish from sewage-contaminated
waters. Outbreaks have occurred in day care centers and institutions as a result of poor hygiene
among people with developmental disabilities. Hepatitis A can be transmitted during sexual
activity. It is not contracted through the consumption of undercooked beef. Chapter 49:
Assessment and Management of Patients With Hepatic Disorders - Page 1398
Results for item 18.
18
0 / 0.05 points
A client who had cardiac surgery 24 hours ago has had a urine output average 20mL/hour for 2
hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the
subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is
45 mg/dL & the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse
would anticipate that the client is at risk for which problem?
Incorrect answer:
Hypovolemia
Correct Answer:
Acute kidney injury
Graves disease
, Not Selected
Acute kidney injury
, Not Selected
Urinary tract infection
, Not Selected
Feedback
Based on answering incorrectly
Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor
perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is
signaled by decreased urine output & increased blood urea nitrogen & creatinine
levels. The client may need medications to increase renal perfusion.
Results for item 19.
19
0.05 / 0.05 points
A doctor orders 200 mg of Rocephin to be taken by a 15.4 lb infant
every 8 hours. The medication label shows that 75-150 mg/kg per
day is the appropriate dosage range. Is this doctor's order within the
desired range?
True
Correct answer:
False
Results for item 20.
20
0 / 0.05 points
Emergency medical technicians transport a client to the emergency department and inform the
nurse that the client fell from a two-story building. The comatose client has a large contusion on
the left side of the chest, a hematoma in the left parietal area, and a compound fracture of the left
femur. The client was intubated and is maintaining an arterial oxygen saturation of 92% by pulse
oximeter with a manual-resuscitation bag. Which intervention by the nurse has the highest
priority?
Placing the client in Trendelenburg's position
, Not Selected
Assessing level of consciousness (LOC)
, Not Selected
Incorrect answer:
Assessing the pupils
Correct Answer:
Assessing the left leg
Assessing the left leg
, Not Selected
Feedback
Based on answering incorrectly
Rationale: In this scenario, airway and breathing have been established, so the nurse's priority
should be circulation. With a compound fracture of the femur, there is a high risk of profuse
bleeding; therefore, the nurse should assess the left leg. Neurologic assessment of the pupils and
LOC are secondary concerns to airway, breathing, and circulation. The nurse doesn't have
enough data to warrant putting the client in Trendelenburg's position. Chapter 42: Management
of Patients With Musculoskeletal Trauma - Page 1210