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160. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and
asks how she will know that her husband's death is imminent because their two adult children want to be there
when he dies. What is the best response by the nurse?
A. Reassured his paws that the healthcare provider will notify went to call the children
B. Offer to discuss the client’s health status with each of the adult children
C. Gather information regarding how long it will take for the children to arrive
D. Explain that the client will start to lose consciousness and the body system will slow down
Ans: Explain that the client will start to lose consciousness and his body system will slow down.
Rationale: Expected signs of approaching death include noticeable changes in the client's level of consciousness
and a slowing down of body systems. The nurse should answer the spouse's questions about the signs of
imminent death rather than offering reassurance that may or may not be true. Other options listed may be
implemented but the nurse should first answer the spouse's question directly.
159. The nurse is assigned to care for surgical clients. After receiving a report which client should the nurse see
first?
A. An adult one day postoperative laparoscopic cholecystectomy requesting pain medication
B. An older Client who is receiving packed RBCs on the Todd de postoperatively for colon resection
C. An older clients with continuous bladder irrigation who is two days postoperatively for bladder
surgery
D. an adult who is in bucks Traction, and scheduled for hip arthroplasty within the next 12hours
158. The nurse observes an unlicensed assistive personnel [UAP] applying alcohol-based hand rub while leaving
a client room after taking vital signs. What action should the nurse take?
A. Instruct the UAP to return to the clients room to perform and washing
B. Supervise UAP in the next clients room to evaluate hand hygiene
C. Advise the UAP to wear gloves when opting vital signs for all clients
D. remind the UAP to continue rubbing hands together until they are dry
157. The nurse is caring for a client with paralytic ileus who presents with severe, colicky abdominal pain,
nausea, vomiting, and abdominal distention. which pathophysiologic mechanism supports the client's clinical
presentation?
A. Ulceration of protective duodenal mucosal lining.
B. Intestinal volvulus that occurred during surgery.
C. Esophagitis due to reflux of gastric contents.
D. A history of having Helicobacter pylori infection.
The answer is D.
Common signs of H. pylori is distention of the abdomen due to bloating, nausea, vomiting and abdominal pains.
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156. The nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client
complains of paresthesia in the fingers and toes. Which cereal laboratory findings should the nurse expect to
find?
A. Elevated serum potassium.
B. Low serum magnesium.
C. Elevated serum calcium.
D. Low serum calcium.
Rationale
Trousseau's sign is carpal spasms induced by inflating a blood pressure cuff above the systolic pressure for a few
minutes and is an early sign of tetany associated with hypocalcemia (D). Although (A, B, and C) are related to
muscular contractility, a Trousseau's sign supports a low serum calcium level.
155. A client who had a lung biopsy ask the nurse to explain the healthcare provider reports that the lung cancer
is staged as T2N0M0 lung cancer. What information should you not provide.
A. The staging indicates the treatment option for surgery, radiation, or chemotherapy
B. The cancer has spread to other organs which limits the success rate of treatment.
C. The client understanding of the cancer prognosis and quality of life
D. The cancer is within its primary site which no lymph node or metastasis presents.
154. A 41 week gestation primigravida woman is admitted to labor and delivery for induction of Labor. Which
findings should the nurse report to the healthcare provider before initiating the infusion of Oxytocin.
A. fetal heart tones located in upper right quadrant
B. Sterile vaginal exam refill in 3 cm dilatation
C. Well physical profile results showing oligohydramnios
D. Regular contractions or current every 10 minutes
153. The school nurse is screening students for scoliosis and notes that one student has Lordosis. Which finding
should the nurse document in the student screening record?
A. excessive concave curvature of the lumbar spine
B. Posterior curvature that is cortex in the thoracic area
C. Rounded spine from head to hips without concave curves
D. lateral curvature that creates asymmetry of the shoulders
152. An older adult male who had an abdominal cholecystectomy has become increasingly confused and
disoriented over the past 24 hours. He is found wandering into another client room and is returned to his room
by the UAP. Which actions should the nurse take? select all that apply
A. Apply soft upper limb restraints and raise all four bed rails
B. Reports mental status changes to the healthcare provider
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C. Assess the clients breath sounds on oxygen saturation,
D. Assign the UAP to re-assess the client's risk for fall
E. Review the client’s most recent serum electrolyte values
Rationale
The healthcare provider should be informed of changes in the client's condition (B) because this behavior may
indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause
increased confusion in the older adult. Raising all four bed rails (A) may lead to further injury if the client
climbs over the rails and falls and restrains should not be applied until other measures such as re-orientation are
implemented. The nurse should assess the client's increased risk for falls, rather than assigning this to the UAP
(D).
151. A client with eczema is experiencing severe Pruritus. Which PRN prescription should the nose administer
(select all that apply)
A. Transdermal analgesic
B. Topical Scabicide
C. Oral antihistamine
D. Topical alcohol rub
E. Topical corticosteroid
Rationale: anti-inflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe
pruritus (itching). Other options are not indicated.
150. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal Saline at 50ml/hour.
The client's urine specific gravity is 1.035. What action should the nurse implement?
A. Encourage Popsicles and fluids of choice
B. Upton is specimen for urinalysis
C. Evaluate postural blood pressure measurements
D. Assess bowel sound in all quadrants
149. The nurse is caring for a client who had a repair of A bleeding gastric ulcer.
A. Assess skin condition and toggle form breakdown
B. Replace fluid intravenously based on intake and outtake
C. Turn every two hours around the clock from side to side
D. Record the amount of daily wound drainage
148. Which needle should the nurse use to
administer intravenous fluids (IV) via a client's
implanted port?
(The one that does not contain a needle).
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147. What action should the nurse take first when a client is inadvertently given an incorrect dose of the
medication?
A. Document events leading to the error in the nurses notes
B. Assess the client for any adverse effects
C. Notify the healthcare provider
D. Complete an incident report documents in the facts
Similar Questions: The nurse inadvertently administered the wrong medication to a client. Place the tasks to be
completed in order of priority.
1. alert the unit manager
2. complete an incidence report
3. obtain vitals
4. report what happened to the HCP
Ans: 3, 4, 1, 2
146. The nurse is providing care for a client with Severe peripheral arthritis disease [PAD]. The client reports a
history of rest ischemia, with leg pain that occurs during the night. Which action ——A. elevate the leg to assess for Color changes
B. Providing Heating pan for PRN use
C. Suggest dangling the legs when pain begins
D. offer cold packs when the pain occurs
Similar questions: The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms
does the nurse assess?
A.
B.
C.
D.
Reproducible leg pain with exercise
Unilateral swelling of affected leg
Decreased pain when legs are elevated
Pulse oximetry reading of 90%
A.
Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral
swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the
dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results
from atherosclerotic occlusion of peripheral arteries.
145. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse
medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report
immediately to the healthcare provider?
A. Yellowing and itching of the skin
B. Abdominal pain and vomiting
C. Confusion and Tremors
D. Anorexia and abdominal
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144. While a child is hospitalized with Acute glomerulonephritis the Parent asks why blood pressure reading is
taken so often. Which response by the nurse is most accurate?
A. sodium intake with meals and snacks affects the blood pressure
B. Elevated blood pressure must be anticipated and identified quickly
C. hypotension leading to sudden stroke and develop at any time
D. blood pressure fluctuations means that the conditions has become chronic
C. acute hypertension must be anticipated and identified.
Rationale: Vital signs, in particular the blood pressure, provide information about the severity of AGN and
early signs of complications. Acute hypertension is anticipated and requires frequent monitoring for early
intervention. Blood pressure does not commonly fluctuate with antibiotic therapy. Blood pressure fluctuations
are not indicative of chronic disease. Most children with AGN fully recover. Hypertension, not hypotension, is
more likely with AGN.
143. The nurse is planning to implement a tuberculosis screening program at a community health clinic. Which
technician did not use to screen clients who are non-Compromised
A. purified protein derivative [PPD] skin test
B. Stain sputum smears
C. Cultural tubercle bacilli
D. Anterior view of bilateral chest x-ray
142.The nurse prepares to defibrillate a client in ventricular fibrillation. Which intervention should the nurse
Implement during distribution.
A. apply conductive gel on paddles before placing on clients
B. Following the shock, shouts all clear
C. Position the interior of paddle over the mid Sternal area
D. Set synchronizer to deliver shock during the QRS complex
Similar Question: A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority
intervention should the nurse perform prior to defibrillating this client?
a. Make sure the defibrillator is set to the synchronous mode.
b. Administer 1 mg of intravenous epinephrine.
c. Test the equipment by delivering a smaller shock at 100 joules.
d. Ensure that everyone is clear of contact with the client and the bed.
ANS: D
To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures
their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is
available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is
defibrillated because this is an emergency procedure; equipment should be checked on a routine basis.
Epinephrine should be administered after defibrillation.
141. The nurse is caring for a client with chronic bronchitis infection who receives a nebulized bronchodilator
treatment which is chest physiotherapy [CPT]. Which finding indicates to the nurse the interventions was
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effective
A. Absence of coarse crackle
B. Increase in respiratory rate
C. Absence of Coarse crackles
D. Increase in breath sounds
140. The nurse is completing the admission assessment aid a 3-year old is admitted with bacterial meningitis
and hydrocephalus. Which assessment finding is evidence that the child experiencing increased intracranial
pressure (ICP).
A. Sluggish and unequal pupillary responses
B. Blood pressure fluctuations and syncope
C. Tachycardia and tachypnea
D. Increase head circumference bulging fontanels
Similar questions: What finding is consistent with increased ICP in the child?
Ans: Bulging fontanel
Children with increased ICP exhibit bulging fontanels. They typically have a decreased appetite, are restless, and
have trouble sleeping.
131. An older client was discharged from hospital 5 days following surgery for a right total knee arthroplasty.
Three days after discharge, the client arrives to the ED reporting sever pain in the right leg and the nurse observe
edema and erythema below the knee. The nurse recognizes the client is likely exhibiting symptoms of which
condition?
a. fat emboli
b. pulmonary embolism
c. Deep vein thrombosis
d. infection
130. when developing a teaching a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse
should explain that an increase thirst is an early sign of diabetic ketoacidosis, which action
a. give a dose of regular insulin as prescribed
b. measure urine output over the next 24hrs
c. drink electrolyte fluid replacentment
d. Resume normal physical activity
129. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia,
fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric
(discoloration of the eyes and urine) phase?
A. Clay-colored stool
B. Pruritus
C. Icteric sclera
D. Right upper quadrant abdominal pain
The correct answer is c) RUQ abdominal pain
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Step-by-step explanation
Prodromal (pre-icteric) phase: Nonspecific symptoms occur; they include profound anorexia, malaise, nausea
and vomiting, a newly developed distaste for cigarettes (in smokers), and often fever or right upper quadrant
abdominal pain. Right upper quadrant (RUQ) abdominal pain is a common complaint but is usually not severe.
In the pre-icteric phase, patients often have non-specific systemic symptoms together with discomfort in the
right upper quadrant of the abdomen.
Clay-colored stools and pruritus occur in the icteric phase of hepatitis.
Hepatitis A virus (HAV) is a picornavirus with a single-stranded RNA genome. It is the most prevalent cause of
acute viral hepatitis, especially in children and young people. Hepatitis A is caused by an enterically transmitted
RNA virus, which produces classic viral hepatitis symptoms such as anorexia, malaise, and jaundice in older
children and adults. Asymptomatic young children are possible. HAV is disseminated mostly through fecal-oral
contact and may hence arise in regions with inadequate hygiene. Waterborne and food-borne outbreaks are
common, particularly in developing countries. Consuming infected raw shellfish is occasionally to blame.
Sporadic occurrences are also prevalent, mainly as a result of direct contact.
128. In assessing a client's pain, which question or statement is likely to elicit the most information?
A. "Does the pain occur in a specific area?"
B. "Describe what the pain feels like."
C. "Is the pain sharp or dull?"
D. "Tell me how you respond when you feel the pain."
Rationale
An open ended question or request for information such as (B) is likely to elicit the most information about the
client's pain. Cueing or suggesting responses to the client limits the information that will be obtained. (A, C, and
D) gather only limited information.
127. a client with 6cm thoracic aneurysm is being prepared for surgery, the nurse reports to the healthcare
provider that the client's blood pressure is 220/112mmHg in an a ........ which finding warrants immediate
intervention by the nurse?
a. sinus tachycardia with frequent premature ventricular beats (PVC)
B, Rose colored urine drains from the urinary catheter
c. Blood pressure reading of 200/100mmHg 15 min later
D. report a tearing, sharp pain between the shoulder blades
126. The nurse observes a client sleeping with the mouth open with oxygen at 2 L per nasal cannula, the nurse
assess the client's pulse oximetry at 88%, which measure should the nurse implement to improve the clients
oxygenation
a. check the oxygen tubing for kinks or loops
b. Awaken the client to take deep breaths
c. change oxygen delivery to a face mask
d. increase oxygen to 4 liter per nasal cannula
Step-by-step explanation
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The patient is trying to compensate by opening the mouth and increase the airway. even if you increase the flow
rate to 4LPM it will still not increase because the patient is breathing through his mouth. Therefore changing to a
face mask will help with the oxygenation of the patient.
125. An older client who was discharged two weeks ago after hip replacement surgery is brought to the hospital
accompanied by his daughter and admitted with a diagnosis of acute onset of delirium, the daughter is very
worried about her father and tells the nurse that he has been confused for two days and doesn’t recognize her
sometimes. Which information should the nurse provide to the daughter?
A. Delirium is a sign of an underlying mental illness and institutionalization may be needed
B. confusion that suddenly develops may be due to an infection and is potentially reversible
C. Psychiatric evaluation will be needed to determine if the client has developed depression
D. The client is demonstrating symptoms of dementia and because of age, it may be permanent
124. The nurse is caring for a seated client who is experiencing a tonic clonic seizure. Whih action should the
nurse implement (select all that apply)
A.
B.
C.
D.
E.
Note duration of seizure
Insert a bite block
Loosen restrictive clothing
Ease client to the floor
Restrain the client
123 . A middle-aged male client at the outpatient clinic receives a prescription for tetracycline due to folliculitis
of the scalp. Which instruction should the clinic nurse provide?
A. Wash your bed linens in hot water after starting the medication
B. Use a fine toothed comb to remove any nits observed on the scalp
C. Keep the infected area covered until the infection is resolved
D. Take the medication with a glass of water two hours after meals
122. when conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snacks
foods should the nurse encourage the client to eat (select all that apply)
A.
B.
C.
D.
E.
fresh vegetable with mayonnaise dip
Soda crackers and peanut butter
Fresh turkey slices and berries
chicken bouillon soup and toast
Raw unsalted almonds and apples
121. A client is undergoing peritoneal dialysis. After several fluid exchanges the abdomen is distended and blood
pressure is elevated and 6500ml were infused while 5500ml were drained, in response to this finding what action
should the nurse take?
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A. Turn the client from side to side
B. Irrigate the drainage tube with normal saline
C. Lower the head of the bed
D. instruct the client to cough
120.The nurse enters a room where the practical (PN) is positioning a client in a lateral side- lying position with
-Assume care of the client and assign the PN to the care of a different client.
119. A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical
antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved,
but there is no change in cognitive ability. How should the nurse respond to this information?
- Confirm that the desired effect of the medication has been achieved.
118. The nurse is assisting the health care provider with a thoracentesis for a client with empyema. The nurse
will plan to have which precaution available at the bedside during the procedure?
A. A chest tube insertion kit.
B. An intubation kit.
C. Standby ventilator.
D. Morphine.
A
Explanation:
The most important precaution for a thoracenteses is the availability of a chest tube. Empyema will present with
purulent type thick fluid with the needle aspiration and may require a chest tube to drain the purulent effusion.
The question stem does not indicate that the client was unstable, so intubation and ventilator are not priority.
Morphine is not indicated for the procedure.
117.The Home health is assessing an older client who lives alone. The client reportsDaily food and fluid intake, Level of physical activity and exercise, Methods currently used to treat
constipation, Current prescribed and over- the counter medications.
116. A 6-week-old infant with a pyloric stenosis is scheduled for a pyloromyotomy. Which pre- operative nursing
action has the highest priority- Monitor amount of intake and infant’s response to feedings.
Similar questions: Before pyloromyotomy surgery, which of the following should the nurse do? (select all)
1. place patient NPO
2. give clear fluids
3. treat dehydration with IV fluids
4. elevate head of bed (HOB)
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place patient NPO
treat dehydration with IV fluids
elevate head of bed (HOB)
Similar questions: The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative
phase of the child's treatment. What is the highest priority at this time?
a) Maintaining skin integrity
b) Promoting comfort
c) Improving hydration
d) Preparing family for home care
Improving hydration Preoperatively the highest priority for the child with pyloric stenosis is to improve nutrition
and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are
not the priority. The child will not likely have intense pain. Preparing the family for home care would be a
postoperative goal.
115. In assessing a client 12 hours following transurethral resection of the prostate- Ensure that no dependent
loops are present in the tubing.
Similar questions: A nurse is caring for a client who is 12 hours postoperative following a transurethral resection
of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has
not been any urinary output in the last hour. Which of the following actions should the nurse perform first?
Determine the patency of the tubing
114.The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.;
Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What
should the nurse implement?
Determine if Client B has two units of packed cells available in the blood bank.
113. A client taking clopidogrel (Plavix) reports the onset of diarrhea. Which action should the nurse implement
first?
A. Assess the elasticity of the client's skin.
B. Observe the appearance of the stool.
C. Review the clients laboratory values.
D. Auscultate the clients bowel sounds.
Rationale
Clopidogrel can cause GI bleeding, as well as diarrhea, so the nurse should first observe the appearance of any
stool for the presence of blood (B). Continued or severe diarrhea may cause fluid volume deficit, electrolyte
imbalance, or anemia if GI bleeding is present, so assessment of fluid volume status (A) and review of the clients
laboratory values may be indicated (C). The client's over-all GI function should also be assessed (D) for other
possible problems causing diarrhea, but (B) is the priority action to be implemented at this time.
112. A client presents to the emergency department with a gash on the forehead and appears to be dazed and
confused. A family member states the client fell and bumped the forehead on a hard surface. The nurse reviews
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the medication list in the electronic medication record and acknowledges a healthcare power of attorney on
file. When reporting to the healthcare provider user SBAR (Situation, Background, Assessment,
Recommendation) communication, which information should the nurse provide first?
A. Increasing confusion of the client
B. Client's healthcare power of attorney
C. Currently prescribed medications
D. Fall at home as reason for admission
Step-by-step explanation
The client appears confused and dazed. The information will help the nurse assess the healthcare process to
handle the patient to his normal state and communicate background information to the physician who will
provide safe care.
Failure to communicate appropriate information will give the doctor a hard time treating the patient that can
even cause low prescription. SBAR ensures the client's clinical information is safely and transferred from one
health practitioner to another.
111. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum
infection.
A.
B.
C.
D.
Blood Pressure of 122/74 mmHg
Moderate amount of foul-smelling lochia
Oral temperature of 100.2F (37.9)C
White blood count of 19000mm3(19x10^9/L)
110. After administering a proton pump inhibitor ( PPI), which action should the nurse take to evaluate the
effectiveness of the medication?
Ask the client about gastrointestinal pain
109. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the
nurse report to the health care provider?
- Elevated Liver function test
108. A client is receiving heparin sodium 25000 units in 5% dextrose injection 250 ml at 10 ml/hour. the
healthcare provider changes the prescription to 1200 units/hour. the nurse should program the infusion pump to
deliver how many ml/hour? (enter numeric value only).
the answer is 0.48ml/hr
107. The healthcare provider prescribes magnesium sulphate 6 grams intravenously (IV) to be infused over 20
minutes- 150ml
106. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should
the nurse encourage the client to eat?
A. Canned fruit cocktail.
B. Creamy peanut butter.
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C. Vegetable juice.
D. Vanilla frozen yogurt.
E. Clear beef broth.
Rationale
A full liquid diet includes all liquids that are not clear, such as vegetable juice and frozen yogurt, as well as clear
liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not considered liquids.
105. Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic
agent via an IV site in the client's arm?
A.
B.
C.
D.
Explain the temporary burning of the IV site may occur.
Assess IV site frequently for signs of extravasation
Apply a topical anesthetic of the infusion site for burning
Monitor capillary refill distal to the infusion site.
Rationale: Infiltration of a vesicant can cause severe tissue damage and necrosis, so the IV site should be
assessed regularly for extravasation (B) of the chemotherapeutic agent. The client should be instructed to report
any discomfort at the site (A). If pain and burning occur, the IV should be stopped and C is not indicated.
Peripheral pulses, not D, provide the best assessment of perfusion distal to the infusion should the drug
extravasate or infiltrate.
104. When taking a health history, which information collected by the nurse correlates most directly to a
diagnosis of chronic peripheral arterial insufficiency?
A.
B.
C.
D.
A positive brodie-trendelenburg test
Ankle ulceration and edema
History of intermittent claudication
A serum cholesterol level of 250 mg/dl
103. Which assessment is most important for the nurse to include in the daily plan of care for a client with a
burnt extremity?
A.
B.
C.
D.
Distal pulse intensity
Presence of exudate
Range of motion
Extremity sensation
102. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the
nurse complete prior to leaving the delivery room?
A.
B.
C.
D.
Obtain the infant’s vital signs
Observe the infant latching onto the breast
Place the id bands on the infant and mother.
Administer vitamin k injection
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101. An older client is referred to a rehab facility following a cerebrovascular accident.... Is aphasic with left side
paresis and is having difficulty swallowing. Which intervention is most?
A.
B.
C.
D.
Facilitate a consult for speech therapy
Arrange for daily home care assistance
Initiate passive range of motion exercises
Use pictures and gestures to communicate
100. When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete
additional actions in which sequence?
A.
B.
C.
D.
Rub hands palm to palm,
interlace the fingers,
dry hands with paper towel
turn off water