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Exit Exam File A B C D E F - final
Nursing integration (Miami Regional University)
Studocu is not sponsored or endorsed by any college or university
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RN Comprehensive Predictor 2019 Form A
1.
A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of
the following actions should the nurse take?
A.
B.
C.
D.
(Unable to read)
Tell the child they will feel discomfort during the catheter insertion.
Use a mummy restraint to hold the child during the catheter insertion.
Require the parents to leave the room during the procedure.
2.
A nurse is caring for a client who has arteriovenous fistula Which of the following
findings should the nurse report?
A.
B.
C.
D.
Thrill upon palpation.
Absence of a bruit.
Distended blood vessels
Swishing sound upon auscultation.
3.
A nurse is providing discharge teaching for a client who has an implantable cardioverter
defibrillator which of the following statements demonstrates understanding of the teaching?
A.
B.
C.
D.
"I will soak in the tub rather and showering"
"I will wear loose clothing around my ICD"
"I will stop using my microwave oven at home because of my ICD"
"I can hold my cellphone on the same side of my body as the ICD"
4.
A nurse is caring for a client who is at 14 weeks gestation and reports feelings of
ambivalence about being pregnant. Which of the following responses should the nurse make?
A.
B.
C.
D.
"Describe your feelings to me about being pregnant"
"You should discuss your feelings about being pregnant with your provider"
"Have you discussed these feelings with your partner?"
"When did you start having these feelings?"
5.
A nurse is planning care for a client who has a prescription for a bowel- training program
following a spinal cord injury. Which of the following actions should the nurse include in the
plan of care?
A.
B.
C.
D.
Encourage a maximum fluid intake of 1,500 ml per day.
Increase the amount of refined grains in the client's diet.
Provide the client with a cold drink prior to defecation.
Administer a rectal suppository 30 minutes prior to scheduled defecation times.
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6.
A nurse is caring for a client who is in active labor and requests pain management.
Which of the following actions should the nurse take?
A.
B.
C.
D.
Administer ondansetron.
Place the client in a warm shower.
Apply fundal pressure during contractions.
Assist the client to a supine position.
7.
a nurse in an emergency department is performing triage for multiple clients following a
disaster in the community. To which of the following types of injuries should the nurse assign
the highest priority?
A.
B.
C.
D.
Below-the knee amputation
Fractured tibia
95% full-thickness body burn
10cm (4in) laceration to the forearm
8.
a nurse manager is updating protocols for the use of belt restraints. Which of the
following guidelines should the nurse include?
A.
B.
C.
D.
Remove the client's restraint every 4hr
Document the client's condition every 15 min
Attach the restrain to the bed's side rails
Request a PRN restrain prescription for clients who are aggressive
9.
A nurse is teaching an in-service about nursing leadership. Which of the following
information should the nurse include about an effective leader?
A.
B.
C.
D.
Acts as an advocate for the nursing unit.
(Unable to read) for the unit
Priorities staff request over client needs.
Provides routine client care and documentation.
10.
A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and
reports that she has been following her (unable to read) care. The nurse should identify which
of the following findings indicates a need to revise the client's plan of care.
A.
B.
C.
D.
Serum sodium 144 mEq/
(Unable to read)
Hba1c 10 %
Random serum glucose 190 mg/dl.
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11.
A nurse in a provider's office is reviewing the laboratory results of a group of clients. The
nurse should identify that which of the following sexually transmitted infections is a nationally
notifiable infectious disease that should be reported to the state health department?
A.
B.
C.
D.
Chlamydia
Human papillomavirus
Candidiasis
Herps simplex virus
12.
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when
leading a group on a mental health unit. Which of the following group facilitation techniques
should the nurse include in the teaching?
A.
B.
C.
D.
Share personal opinions to help influence the group's values
Measure the accomplishments of the group against a previous group
Yield in situations of conflicts to maintain group harmony
Use modeling to help the clients improve their interpersonal skills
1 3.
A nurse is planning for a client who practices Orthodox Judaism. The client tells the
nurse that (Unable to read) Passover holiday. Which of the following action should the nurse
include in the plan of care?
A.
B.
C.
D.
Provide chicken with cream sauce.
Avoid serving fish with fins and scales.
Provide unleavened bread.
Avoid serving foods containing lamb.
14.
A nurse is caring for a client who has a pulmonary embolism. The nurse should identify
the effectiveness of the treatment
A.
B.
C.
D.
A chest x-ray reveals increased density in all fields.
The client reports feeling less anxious.
Diminished breath sounds are auscultated bilaterally
ABG results include Ph 7.48 PaO2 77 mm Hg and PaCO2 47 mm Hg.
15.
A nurse in an emergency department is assessing a client who reports ingesting thirty
diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client's airway
and initiating an IV, which of the following actions should the nurse do next.
A.
B.
C.
D.
Monitor the client's IV site for thrombophlebitis.
Administer flumazenil to the client.
Evaluate the client for further suicidal behavior.
Initiate seizure precautions for the client.
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16.
A nurse in an emergency department is caring for a client who reports cocaine use 1hr
ago. Which of the following findings should the nurse expect?
A.
B.
C.
D.
Hypotension
Memory loss
Slurred speech
Elevated temperature
17.
A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the
following manifestations should the nurse expect?
A.
B.
C.
D.
Loose stools
Jitteriness
Hypertonia
Abdominal distention
18.
A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child.
Which of the following findings should the nurse report to the provider?
A.
B.
C.
D.
Hgb 12.5 g/dl
Platelets 250,000/mm3
Hct 40%
WBC 14,000/mm3
19.
A charge nurse is teaching a newly licensed nurse about clients designating a health care
proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the
following information should the charge nurse include?
A.
"The proxy should make health care decisions for the client regardless of the client's
ability to do so."
B.
"The proxy can make financial decisions if the need arises."
C.
"The proxy can make treatment decisions if the client is under anesthesia."
D.
"The proxy should manage legal issues for the client."
20.
A nurse in the PACU is caring for a client who reports nausea. Which of the following
actions should the nurse take first?
A.
B.
C.
D.
Turn the client on their side.
Administer an analgesic
Administer antiemetic
Monitor the client's vital signs.
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21.
A nurse is caring for a client who has a history of depression and is experiencing a
situational crisis. Which of the following actions should the nurse take first?
A.
B.
C.
D.
Confirm the client's perception of the event
Notify the client's support system
Help the client identify personal strengths
Teach the client relaxation techniques
22.
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania.
The nurse obtained a verbal prescription for restraints. Which of the following actions should
the nurse take?
A.
B.
C.
d.
Request a renewal of the prescription every 8 hr.
Check the client's peripheral pulse rate every 30 min
Obtain a prescription for restraint within 4 hr.
Document the client's condition every 15 minutes.
23.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child
asks the nurse about becoming a living kidney donor for her father. Which of the following
condition in the child's medical history should the nurse identify as a contraindication to the
procedure?
A.
Amputation
B.
Osteoarthritis
C.
Hypertension
D.
Primary glaucoma
24.
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical
nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift.
Which of the following client should the nurse delegate to the LPN?
A.
A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
B.
A client who sustained a concussion and has unequal pupils.
C.
A client who is postoperative following a bowel resection with an NG tube set to
continuous suction.
D.
A client who fractured his femur yesterday and is experiencing shortness of breath.
25.
A nurse is working on a surgical unit is developing a care plan for a client who has
paraplegia. The client has an area of no blanchable erythema over his ischium. Which of the
following interventions should the nurse include in the care plan?
A.
B.
C.
D.
Place the client upright on a donut-shaped cushion
Teach the client to shift his weight every 15 min while sitting
Turn and reposition the client every 3 hr while in bed
Assess pressure points every
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26.
A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following
pain-management (Unable to read) a safe option for the client?
E.
F.
G.
H.
Naloxone hydrochloride.
Spinal anesthesia.
Pudendal block.
Butorphanol tartrate.
26.
A nurse is caring for a client who has left homonymous hemianopsia. Which of the
following is an appropriate nursing intervention?
a.
Teach the client to scan the right to see objects on the right side of her body.
b.
Place the bedside table on the right side of the bed.
c.
Orient the client to the food on her plate using the clock method.
d.
Place the wheelchair on the client's left side.
27.
A nurse is assessing a client who has major depressive disorder. Which of the following
findings should the nurse identify as the (Unable to read) (Most important?)
A.
B.
C.
D.
The client changes the subject when future plans are mentioned.
The client talks about being in pain constantly.
The client sleeping over 12 hr. each day.
The client reports giving away personal items.
28.
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse
should inform the client that she can receive which of the following immunizations during
pregnancy? (Select all that apply)
A.
B.
C.
D.
E.
Varicella vaccine.
Inactivated polio vaccine.
Tetanus diphtheria and acellular pertussis vaccine
Rubella vaccine.
Inactivated influenza vaccine.
29.
A nurse is providing discharge teaching for a group of clients. The nurse should
recommend a referral to a dietitian
A.
A client who has a prescription for warfarin and states "I will need to limit how much
spinach I eat".
B.
A client who has gout and states, "I can continue to eat anchovies on my pizza."
C.
A client who has a prescription for spironolactone and states "I will reduce my intake of
foods that contain potassium".
D.
A client who has (Unable to read) and states "I'll plan to take my calcium carbonate with
a full glass of water".
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30.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son
reports sleeping very little during the past week due to caring for his mother. Which of the
following responses should the nurse make?
A.
B.
C.
D.
"I can give you information about respite care if you are interested."
"You should consider taking a sleeping pill before bed each night"
"It must be difficult taking care of someone who is terminally ill"
"You are doing a great job taking care of your mother"
31.
A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse
notes an increase in the child's glucose. The nurse should identify this finding as an adverse
effect of which of the following medications?
A.
B.
C.
D.
Methylprednisolone.
Ondansetron.
Guaifenesin.
Amoxicillin.
32.
The nurse is providing teaching about folic acid to a client who is prima gravida. Which
of the following information should the nurse include in the teaching?
A.
B.
C.
D.
"You should take folic acid to decrease the risk of transmitting infections to your baby"
"You should consume a maximum of 300 micrograms of folic acid every day".
"You can increase your dietary intake of folic acid by eating cereals and citrus fruits".
"You can expect your urine to appear red-tingled while taking folic acid supplements".
33.
A community health nurse is assessing an adolescent who is pregnant. Which of the
following assessments is the nurse's priority?
A.
B.
C.
D.
Social relationship with peers.
Plans for attending school while pregnant.
(Unable to read) (Picked this one) Medicaid?
Understanding of infant care.
34.
A nurse manager is planning to teach staff about critical pathways. Which of the
following information should the nurse include?
A.
Critical pathways have unlimited timeframe for completion
B.
(Unable to read) decrease health care costs.
C.
(Unable to read) critical pathway if variances (Unable to read)
D.
(Unable to read) are used to create the critical pathway.
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35.
A nurse is reviewing the medical record of a client who has schizophrenia. Which of the
following should the nurse report to the provider?
Exhibit 1
Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature:
37.4C (99.3F) Exhibit 2
Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO
twice daily as needed for tremors.
Exhibit 3 Nurse's notes:
Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the
past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of
breakfast and reports slightly nauseous.
A.
B.
C.
D.
Dietary intake
Heart rate.
Sore throat.
Blood pressure
36.
A charge nurse is educating a group of unit nurses about delegating client tasks to
assistive personnel
A.
B.
C.
D.
"The nurse is legally responsible for the actions of the AP".
"An AP can perform tasks outside of his range if he has been trained".
"An experienced AP can delegate to another AP".
"An RN evaluates the client needs to determine tasks to delegate
37.
A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
A.
B.
C.
C.
Contractions lasting 80 seconds
FHR baseline 170/min
Early decelerations in the FHR
Temperature 37.4C (99.3)
38.
A nurse working in a rehabilitation facility is developing a discharge plan for a client who
has left-sided hemiplegia. Which of the following actions is the nurse's priority?
A.
B.
C.
D.
Consult with a case manager about insurance coverage.
Counsel caregivers about respite care options.
Ensure that the client has a referral for physical therapy.
Refer the client to a local stroke support group.
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39.
A nurse in a mental health unit is planning room assignments for four clients. Which of
the following client should be closest to the nurse's station?
A.
B.
C.
D.
A client who has an anxiety disorder and is experiencing moderate anxiety.
A client who has somatic symptom disorder and reports chronic pain.
A client who has depressive disorder and reports feeling hopeless.
A client who has bipolar disorder and impaired social interactions.
40.
A nurse is preparing to measure a temperature of an infant. Which of the following
action should the nurse take?
A.
Place the tip of the thermometer under the center of the infant's axilla.
B.
Pull the pinna of the infant's ear forward before inserting the probe.
C.
Insert the probe 3.8 cm (1.5in) into the infant's rectum.
D.
Insert the thermometer in front of the infant's tongue.
41.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A.
B.
C.
D.
Encourage the client to spend time in the day room
Withdraw the client's TV privileges is the does not attend group therapy
Encourage the client to take frequent rest periods
Place the cllient in seclusion when he exhibits signs of anxiety
42.
A nurse is admitting medications to a group of clients. Which of the following
occurrences requires the completion of an incident report?
A.
B.
C.
D.
A client receives his antibiotics 2hr late
A client vomits within 20min of taking his morning medications
A client requests his statin to be administered at 2100
A client asks for pain medication 1hr early
43.
A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her
newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought
for her. Which of the following responses should the nurse make?
A.
B.
C.
D.
"Does the doctor know you are eating that?"
"Why are you eating seaweed soup?"
"Of course, I will heat that up for you"
"The hospital good is more nutritious"
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44.
A nurse is preparing an in-service for a group of nurses about malpractice issues in
nursing. Which of the following examples should the nurse include in the teaching?
A.
Leaving a nasogastric tube clamped after administering oral medication
B.
Documenting communication with a provider in the progress notes of the client's
medical records
C.
Administering potassium via IV bolus
D.
Placing a yellow bracelet on a client who is at risk for falls
45.
A nurse is providing teaching to family members of a client who has dementia. Which of
the following instructions should the nurse include in the teaching?
A.
B.
C.
D.
Establish a toileting schedule for the client
Use clothing with buttons and sippers
Discourage physical activity during the day
Engage the client in activities that increase sensory stimulation
46.
The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client's history is a contradiction to the
use of oral contraceptives?
A.
B.
C.
D.
Hyperthyroidism.
Thrombophlebitis.
Diverticulosis.
Hypocalcemia.
47.
A nurse is admitting a client who has schizophrenia and experiences auditory
hallucinations. The client states, "It's hard not to listen to the voices." Which of the following
questions should the nurse ask the client?
A.
B.
C.
D.
"Do you understand that the voices are not real?"
"Why do you think the voices are talking to you?"
"Have you tried going to a private place when this occurs?"
"What helps you ignore what you are hearing?
48.
A charge nurse is teaching a group of newly licensed nurses about the correct use of
restraints. Which of the following should the nurse include in the teaching?
A.
B.
C.
D.
Placing a belt restraint on a school-age child who has seizures.
Securing wrist restraints to the bed rails for an adolescent.
Applying elbow immobilizers of an infant receiving cleft lip injury
Keeping the side rails of a toddler's crib elevated.
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49.
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The
results are pH 7.47, PaCo2 32 mm Hg. HCO3 22 mm Hg. The nurse should recognize that the
client is experiencing which of the following acid-base imbalances?
a.
b.
c.
d.
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
50.
A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the
following
A.
Inject air into the NPH insulin vial.
B.
(Unable to read)
C.
Withdraw the prescribed dose of regular insulin
D.
Withdraw the prescribed dose of NPH insulin
51.
A Nurse is working with a client who has an anxiety disorder and is in the orientation
phase of the therapeutic relationship. Which of the following statements should the nurse make
during this phase?
A.
B.
C.
D.
"Let's talk about how you can change your response to stress."
"We should establish our roles in the initial session."
"Let me show you simple relaxation exercises to manage stress."
"We should discuss resources to implement in your daily life."
51.
A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella zoster.
Which of the following information should the nurse include?
A.
B.
C.
D.
Children who have varicella are contagious until vesicles are crusted.
Children who have varicella should receive the herpes zoster vaccination.
Children who have varicella should be placed in droplet precaution.
Children who have varicella are contagious 4 days before the first vesicle eruption.
52.
A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which
of the following requires intervention by the staff nurse?
A.
B.
C.
D.
Waits 2 minutes between suctions.
Encourages the client to cough during suctioning.
Apply suctioning for 15 seconds.
Inserts the catheter without applying suction.
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53.
A nurse is teaching at a community health fair about electrical fire prevention. Which of
the following information should the nurse include in the teaching?
A.
B.
C.
D.
Use three pronged grounded plugs.
Cover extension cords with a rug.
Check the tingling sensations around the cord to ensure the electricity is working.
Remove the plug from the socket by pulling the cord.
54.
A nurse is providing care for a group of clients. Which of the following client's should the
nurse identify as having the highest risk for developing a pressure injury?
A.
B.
C.
D.
A client who has a T-tube following an open cholecystectomy.
A client who had a knee 2 days ago following a sports injury.
A client who has dementia and is incontinent of urine and feces
A client who has a myocardial infarction and is receiving thrombolytic therapy.
55.
A nurse is teaching a client who has glaucoma and a new prescription for timolol
eyedrops. Which of the following statements indicates an understanding of the teaching?
A.
B.
C.
D.
"I will place the eye drops in the center of my eye"
"I will place pressure on the corner of my eye after using he eye drops"
"I should expect my tears to turn a red color after using the eye drops."
"I should expect the eye drops to appear cloudy."
56.
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the teaching?
A.
B.
C.
D.
Bleeding gums
Faintness upon rising
Swelling of the face
Urinary frequency
57.
A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of
the following responses should the nurse make?
A.
B.
C.
D.
"I would recommend sharing your feelings with a psychologist".
"I can give you information about making end of life decisions".
"You should discuss your end life decisions with your family"
"Everyone feels this way at first. You will start feeling better soon".
58.
A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside
via continuous IV infusion. Which of the following actions should the nurse plan to take?
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A.
B.
C.
D.
Keep client's calcium gluconate at the client's bedside
Monitor blood pressure every 2 hr.
(Limit or remove?) IV bag from exposure to light.
Attach tan inline filter to the IV tubing.
59.
A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
A.
B.
C.
D.
Feelings of dread
Heightened perceptual field
Rapid speech
Purposeless activity
60.
A nurse is reviewing the laboratory report of a client who has been having lithium
carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the
following orders from the provider should the nurse expect?
A.
B.
C.
D.
Withhold the next dose.
Increase the dosage.
Discontinue the medication.
Administer the medication
61.
A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
A.
B.
C.
D.
Stay in bed at least 1hr if unable to fall asleep
Take 1 hr nap during the day
Perform exercise prior to bed
Eat a light snack before bedtime
62.
A nurse is caring for a client who has fibromyalgia and requests pain medication. Which
of the following medications should the nurse administer?
A.
B.
C.
D.
Pregabalin
Lorazepam
Colchicine
Codeine.
63.
A nurse is caring for a client following insertion of a chest tube 12 hr. ago. The (Unable to
read) following actions should the nurse take?
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A.
B.
C.
D.
Assess the amount of drainage in the collection chamber.
Clamp the chest tube during ambulation.
Report continuous bubbling in the water seal chamber.
Strip the chest tube every 4 hr. to maintain patency.
64.
A nurse is caring for a client who is receiving morphine 4 mg via IV bolus every 4 hr. PRN.
The nurse should monitor for which of the following adverse effects?
A.
Productive cough.
B.
Urinary retention.
C.
Rhinitis
D.
Fever.
65.
A nurse is interviewing the partner of a client who was admitted in the manic phase of
bipolar disorder. The partner states "I don't know what to do. Everything has been happening so
quickly." Which of the following by the nurse is therapeutic?
A.
B.
C.
D.
"Can you talk about what happens with your partner at home?"
"Why do you think your partner's symptoms are progressing so quickly?"
"You should make sure your partner takes the prescribed medication."
"You did the right thing by bringing your partner in for treatment."
66.
A nurse is providing dietary teaching to a guardian of a preschooler who has a new
diagnosis of celiac disease. Which of the following statements by the guardian indicates an
understanding of the teaching?
A.
B.
C.
D.
"I will put my child on a gluten-free diet".
"I will administer digestive enzymes with meals and snacks".
"Provide my child with some high fiber foods."
"I will give my child whole wheat toast and milk for breakfast".
67.
A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the
following actions should the nurse take?
A.
B.
C.
D.
Prime IV tubing with 0.9% sodium chloride.
Use a 24-gauge IV catheter
Obtain filter less IV tubing.
Place blood in the warmer for 1 hr.
68.
A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types
of continuous infusions should the nurse initiate?
A.
0.9% normal saline.
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B.
C.
D.
NPH insulin.
Glargine insulin.
0.45% saline.
69.
A nurse is teaching a patient who has chronic pain about avoiding constipation from
opioid medications. Which of the following should the nurse include in the teaching?
A.
B.
C.
D.
Drink 1.5L fluids each day.
Take mineral oil at bedtime.
Increase exercise activity
Decrease insoluble fiber.
70.
A nurse is teaching about preventative measures to a female client who has chronic
urinary tract infections. Which of the following interventions should the nurse include in the
teaching?
A.
B.
C.
D.
"Drink 2 liters of warm water per day".
"Empty your bladder every 6 weeks.".
"Soak in a warm bath everyday".
"Take an oral estrogen tablet".
71.
A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A.
B.
C.
D.
A client who has sinus arrhythmia and is receiving monitoring
A client who has a hip fracture and a new onset of tachypnea
A client who has epidural analgesia and weakness in the lower extremities
A client who has diabetes and a hemoglobin A1C of 6.8%
72.
A nurse is providing dietary teaching to a client who has a new diagnosis of irritable
bowel syndrome. Which of the following recommendations should the nurse include?
A.
B.
C.
D.
Consume food high in bran fiber
Increase intake of milk products
Sweeten foods with fructose corn syrup
Increase foods high in gluten
73.
A nurse is caring for a 1-day-old newborns who has jaundice and is receiving
phototherapy. Which of the following actions should the nurse take?
A.
B.
the infant 30 ml (1 oz) glucose water every 2 hr.
Keep the infants head covered with a cap.
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C.
D.
Ensure that the newborn wears a diaper.
Apply lotion to the newborn every 4 hr.
74.
A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the
following statements by a newly licensed nurse indicates an understanding of the teaching?
A.
B.
C.
D.
"(Unable to read) I feel to be in his best health care decision"
"I will intervene if there is conflict between a client and his provider"
"I should not advocate for a client unless he is able to ask me himself"
"I will inform a client that his family should help make his health care decisions."
75.
A nurse is preparing to reposition a client who had a stroke. Which of the following
actions should the nurse take?
A.
B.
C.
D.
Raise the side rails on both sides of the client's bed during repositioning.
Reposition the client without assistive devices.
Discuss the client's preferences for determining a reposition schedule.
Evaluate the client's ability to help with repositioning.
76.
A nurse is orientation a newly licensed nurse who is caring for a client who is receiving
mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the
following statements by the newly licensed nurse indicates and understanding of PSV?
A.
B.
C.
D.
"It keeps the alveoli open and prevents atelectasis."
"It allows preset pressure delivered during spontaneous ventilation."
"It guarantees minimal minute ventilator."
"It delivers a preset ventilatory rate and tidal volume to the client
77.
A nurse is caring for an infant who has coaction of the aorta. Which of the following
should the nurse identify as an expected finding?
A.
B.
C.
D.
Weak femoral pulses
Frequent nosebleeds
Upper extremity hypotension
Increased intracranial pressure\
78.
A nurse is auscultating for crackles on a client who has pneumonia. Which of the
following anterior chest wall locations should the nurse auscultate?
D
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79.
A nurse is assisting with the development of an informed document for participation in a
research study. Which of the following information should the nurse include?
A.
B.
C.
D.
A statement that participants can leave the study at will.
An assignment of the participant to either the experimental or control group.
A list of the clients participating in the study.
A description of the framework the researchers will use to evaluate the data.
80.
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of
the following adverse effects should the nurse include?
A.
B.
C.
D.
Excessive sweating
Increased urinary frequency
Dry cough
Metallic taste in mouth
81.
A nurse is caring for a client who has a new temporary synchronous pacemaker. Which
of the following should the nurse report to the provider?
A.
The client's pulse oximetry level is 96%.
B.
(Unable to read)
C.
The client develops hiccups.
D.
The ECG shows pacing spikes after the QRS complex.
82.
A nurse is preparing discharge information for a client who has type 2 diabetes mellitus.
Which of the following resources should the nurse provide to the client?
A.
B.
C.
D.
Personal blogs about managing the adverse effects of diabetes medications
Food label recommendations from the Institute of Medicine
Diabetes medication information from the Physicians' Desk Reference
Food exchange lists for meal planning from the American Diabetes Association
83.
A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which
of the following statements should the nurse include in the teaching?
A.
B.
C.
D.
"The PCA will deliver a double dose of medication when you push the button twice."
"You can adjust the amount of pain medication you receive by pushing on the keypad."
"Continuous PCA infusion is designed to allow fluctuating plasma medication levels."
"You should push the button before physical activity to allow maximum pain control."
84.
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting
insulin for blood glucose management. The nurse should anticipate administering which of the
following types of insulin?
E.
Glargine insulin.
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F.
G.
H.
Regular insulin.
NPH insulin.
Insulin aspart.
83.
A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the
following should the toddler participate?
A.
B.
C.
D.
Looking at alphabet flashcards.
Playing with a large plastic truck.
Use scissors cut out paper shapes.
Watching a cartoon in the dayroom.
84.
A nurse is caring for a client who is receiving intermittent feedings via a feeding pump
and is experiencing dumping syndrome. Which of the following actions should the nurse take?
A.
B.
C.
D.
Administer a refrigerated feeding.
Increased the amount of water use to flush the tubing.
Monitor the rate of the client's feedings.
Instruct the client to move onto their right side.
85.
A nurse in an emergency department is caring for a client who received a dose of
penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the
following actions is the nurse's priority?
A.
B.
C.
D.
Monitor the client's ECG
Take the client's vital signs.
Administer oxygen
Insert an IV line.
86.
A nurse is caring for a client who has Raynaud's disease. Which of the following actions
should the nurse take?
A.
B.
C.
D.
Provide information about stress management.
Maintain a cool temperature in the client's room.
Administer epinephrine for acute episodes.
Give glucocorticoid steroid twice per day.
87.
A nurse is reviewing the medical history of a client who has angina. Which of the
following findings in the client's medical history should identify as a risk factor for angina?
A.
B.
C.
Hyperlipidemia.
COPD
Seizure disorder
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D.
Hyponatremia.
88.
A nurse is caring for a client who is 12 hr. postpartum and has a third-degree perineal
laceration. The client reports not having a bowel movement for 4 days. Which of the following
medications should the nurse administer?
A.
B.
C.
D.
Bisacodyl 10 mg rectal suppository.
Magnesium hydroxide 30 ml PO.
Famotidine 20 mg PO.
Loperamide 4 mg PO.
89.
A nurse overhears two assistive personnel (AP) discussing care for a client while in the
elevator. Which of the following actions should the nurse take?
A.
B.
C.
D.
Contact the client's family about the incident.
Notify the client's provider about the incident.
File a complaint with the facility's ethics committee.
Report the incident to the AP's charge nurse.
90.
A nurse is planning care for a client who is receiving hemodialysis. Which of the
following actions should the nurse include in the plan of care?
A.
B.
C.
D.
Withhold all medications until after dialysis
Rehydrate with dextrose 5% in water for orthostatic hypotension.
Check the vascular access site for bleeding after dialysis.
Give an antibiotic 30 min before dialysis.
91.
A nurse in the emergency department is caring for a client who reports intimate partner
violence. Which of the following interventions is the nurse's priority?
A.
B.
C.
D.
Develop a safety plan with the client
(Unable) options for reporting the incident.
Refer the client to a community support group.
Determine if the client has any injuries.
92.
A nurse is caring for a client who is in active labor and note the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause of fetal bradycardia?
A.
B.
C.
Maternal fever
Fetal anemia
Maternal hypoglycemia
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D.
Chorioamnionitis
93.
A nurse is assessing a school-age child who has a urinary tract infection. Which of the
following findings should the nurse expect?
A.
B.
C.
D.
Periorbital edema.
Decreased frequency of urination.
Enuresis.
Diarrhea.
94.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A.
B.
C.
D.
A client who has COPD and a respiratory rate of 44/min
A client who has cancer with a sealed implant for radiation therapy
A client who is receiving heparin for deep-vein thrombosis
A client who is 1 day postoperative following a vertebroplasty
95.
A nurse is preparing to administer dopamine hydrochloride 4 mcg/kg/min via
continuous infusion. Available is dopamine hydrochloride in a solution of 800 mg in a 250 ml
bag. The
client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round
the answer to the nearest whole number)
6 mL/hr
96.
A nurse is providing teaching to the parents of a newborn genetic screening. Which of
the following statement should the nurse include in the teaching?
A.
B.
C.
D.
"This test should be performed after your baby is 24 hours old."
"A nurse will draw blood from your baby's inner elbow."
"Your baby will be given 2 ounces of water to drink prior to the test."
"This test will be repeated when your baby is 2 months old."
97.
A nurse is providing discharge teaching to a client who is postoperative following a colon
resection and has a new ascending colostomy. Which of the following statements by the client
indicates an understanding of the teaching?
A.
B.
C.
D.
"My stool will become fully formed within 3 weeks"
"My skin will need to be cleaned with alcohol before I apply a new pouch"
"I should avoid eating popcorn and fresh pineapple"
"I should expect bruising around the stoma"
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98.
A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and
hoarseness. Which of the following is the nurse's priority?
A.
B.
C.
D.
Refer the client to a speech language pathologist.
Monitor the client's prealbumin levels
Measure the client's weight.
Place the client on NPO status.
99.
A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
A.
B.
C.
D.
"Taking furosemide can cause your potassium levels to be high"
"Eat foods that are high in sodium"
"Rise slowly when getting out of bed"
"Taking furosemide can cause you to be overhydrated"
100. A nurse is planning a teaching session for a client who is postoperative following a colon
resection. Which of the following actions should the nurse take first?
A.
B.
C.
D.
Providing written material for the client to read
Plan a short instruction about coughing and deep breathing.
Determine the client's current pain level.
Instruct the client about dietary restrictions.
101. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
A.
B.
C.
D.
Coffee with creamer.
Lettuce with sliced avocados.
Broiled skinless chicken breast with brown rice.
Warm toast with margarine.
102. A nurse is caring for a client who asks for information regarding organ donation. Which
of the following should the nurse make?
A.
B.
C.
D.
"I cannot be a witness for your consent to donate."
"Your name cannot be removed once you are listed on the organ donor list."
"Your desire to be an organ donor must be documented in writing."
"You must be at least 21 years of age to become an organ donor."
103. A nurse is teaching a female client about personal hygiene. Which of the client actions
indicates an understanding go the teaching?
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A.
B.
C.
D.
The client takes a hot bubble bath every day.
The client wipes back to front when toileting.
The client washes her perineum first when bathing.
The client brushes her teeth twice daily.
107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions
should the nurse plan to take?
A.
Obtain the newborn's body temperature using a tympanic thermometer.
B.
(Unable to read) FACES pain scale.
C.
Auscultate the newborn's apical pulse for 60 seconds.
D.
Measure the newborn's head circumference over the eyebrows and below the occipital
prominence.
108. A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the
last 5 days. The client's laboratory values this morning are the following: WBC 10,000/mm3, RBC
5.2
million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse
should report these finding to which of the following members of the interdisciplinary team?
A.
B.
C.
D.
Dietitian
Infection control nurse
Nephrologist
Cardiologist
109. A nurse is caring for an infant who is in contact isolation and received a blood
transfusion. Which of the following actions is appropriate for the nurse to take to provide costeffective care?
A.
Return unopened equipment to the supply center
B.
Leave the unused infusion pump in the room until discharge
C.
Stock the room with a 2-day supply of disposable diapers
D.
Being in formula as needed
108. A nurse is reviewing the medical record of a client who is postoperative following a total
hip arthroplasty. For which of the following findings should the nurse contact the provider?
A.
B.
C.
D.
Hear rate 100/min
Temperature 37.8C (100F)
Albumin level 4.0 g/dL.
WBC count 14,000 mm3
109. A nurse is preparing education material for a client. Which of the following techniques
should the nurse use in creating material?
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A.
B.
C.
D.
Emphasize important information using bold lettering.
Use 7th grade reading level.
Avoid using cartoons in the teaching material.
Use words with three or four syllables.
110. A nurse is creating for a client who has aids. The client states, "My mouth is sore when I
eat." Which of the following instructions should the nurse provide?
A.
B.
C.
D.
"Add salt to season"
"Ice chips"
"Rinse your mouth with an alcohol-based mouthwash"
"Eat foods served at hot temperatures"
111. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications?
A.
B.
C.
D.
Vomiting
Hypertension
Epigastric pain
Contractions
112. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has
ruptured membrane. Which of the following actions should the nurse take?
A.
B.
C.
D.
Insert an indwelling urinary catheter.
Apply fetal heart rate monitor.
Initiate fundal massage.
Initiate an oxytocin IV infusion.
113. A home health nurse is preparing to make an initial visit to a family following a referral
from a local provider. Identify the sequence of steps the nurse should take when conducting a
home visit. (Move the steps into the box on the right. Placing them in the order of performance)
A.
B.
C.
3. Identify family needs interventions using the nursing process.
4. Record information about the home visit according to agency policy.
2.Contact the family to determine availability and readiness to make an appointment D.
5. Discuss plans for future visits with the family.
E.
1.Clarify the reason for the referral with the provider's office.
E C A B D (My choice)
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114. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration
and a prescription for paternal fluid therapy. The guardian asks. "What are the indications that
my baby needs an IV?" Which of the following responses should the nurse make?
A.
B.
C.
D.
"Your baby needs an IV because she is not producing any tears"
"Your baby needs an IV because her fontanels are budging"
"Your baby needs an IV because she is breathing slower than normal"
"Your baby needs an IV because her heart rate is decreasing"
115. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of
the following places the client at risk for aspiration?
A.
B.
C.
D.
A residual of 65mL 1 hr postprandial
A History of gastroesophageal reflux disease
Sitting in a high-Fowler's position during the feeding
Receiving a high osmolarity formula
116. A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
A.
B.
C.
D.
Take magnesium hydroxide for indigestion
Drink at least 3L of fluid daily
Eat 1g/kg of protein per day
Consume foods high in potassium
118. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac
monitoring. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse
should interpret this finding as which of the following cardiac rhythms?
A.
B.
C.
D.
First degree AV block
Premature ventricular contraction.
Sinus bradycardia.
Atrial fibrillation.
119. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse
observes that the client coughs after each bite. After asking the AP to stop feeding the client,
which of the following actions should the nurse take next?
A.
Provide the client with an instructional handout about swallowing exercises.
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B.
C.
D.
Ask a speech therapist to evaluate the client's ability to swallow.
Discuss the manifestations of impaired swallowing with the AP.
Listens to the client's lung sounds.
120. A nurse is developing a plan of care for a client who has schizophrenia and is
experiencing auditory hallucinations. Which of the following actions should the nurse include in
the plan?
A.
B.
C.
D.
Ask the client directly what he is hearing
Encourage the client to lie down in a quiet room
Avoid eye contact with the client
Refer to the hallucinations as if the are real
120. The nurse is teaching a group of clients at a community health fair about genetic
disease. Which of the following statements by a client indicates an understanding of the
teaching?
A.
"If there is a genetic risk for future pregnancies, we can get treatment now to prevent
the disease"
B.
"There is no need to have genetic counseling if I know that I have a family history of
mental illness."
C.
"My family has genetic risk for breast cancer, so I am considering a total mastectomy"
D.
"Even if I have a genetic risk for a disease the chance, I will get the disease is probably
low due to current medical treatments."
121. A nurse is planning discharge teaching about cord care for the parents of a newborn.
Which of the following instructions should the nurse plan to include in the teaching?
A.
B.
C.
D.
"The cord stump will fall off in 5 days."
"Contact the provider if the cord stump turns black."
"Clean the base of the cord with hydrogen peroxide daily."
"Keep the cord stump dry until it falls off."
122. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the
following statements by the client indicates an understanding of the teaching?
A.
B.
C.
D.
"I have my eyes examines annually"
"I take a calcium vitamin supplement daily"
"I limit my intake of foods with potassium"
"I constantly take my medication between 8 and 9 each evening"
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123. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the
following actions by a newly licensed nurse indicates an understanding of the teaching?
A.
B.
C.
D.
Stands with feet together when lifting a client up in bed.
Raises the client's head of bed before pulling the cline up.
Uses a mechanical lift to move client from bed to chair.
Places a gait belt around the client's upper chest before assisting a client to stand.
124. A client is requesting information from a nurse about a nitrazine test. Which of the
following statements should the nurse make?
A.
B.
C.
D.
"Your bladder should be full prior to me performing this test
"If this test is positive you will be required to have a non-stress test.
"This test will determine if there is leaking amniotic fluid"
"I will be taking a blood sample to test for changes in your hormones levels"
125. A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy.
Which of the following findings indicate the client is developing a complication of therapy?
A.
B.
C.
D.
Peripheral edema
Increased thirst.
Flattened neck veins.
Hypotension
126. A nurse is conducting a home visit for a family who has two young children. The nurse
notes several welts across the backs of the legs of one of the children. Which of the following
actions should the nurse take first?
A.
B.
C.
D.
Document clinical findings.
Contact child protective services.
Refer the parents to a self-help group.
Instruct the parents about methods of discipline.
127. A nurse is planning care for a client who has thrombocytopenia. Which of the following
actions should the nurse include?
A.
B.
C.
D.
Encourage the client to floss daily.
Remove fresh flowers from the client's room.
Provide the client what a stool softener.
Avoid serving the client raw vegetable.
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128. A nurse is assessing a client who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings should the nurse to report?
A.
B.
C.
D.
Chest pain
Muscle spasms.
Cool, moist skin.
Incisional pain.
129.
(Unable to read)
A.
B.
C.
D.
Use NPH insulin to treat ketoacidosis.
Administer NPH insulin 30 minutes before breakfast.
(Unable to read) I think this answer was 0.9% sodium chloride
Discard the NPH insulin vial if the medication is cloudy.
131. A nurse is caring for a client who has left-sided heart failure, and the provider is
concerned that the client might develop (Unable to read) Which of the following actions should
the nurse take?
A.
B.
C.
D.
Maintain the client's oxygen saturation level at 89%.
Place the client's lower extremities on two pillows.
Recommended that the client follow a 3g sodium diet.
Place the client in high fowler's position.
132. A charge nurse is teaching a newly licensed nurse about the administration of total
parenteral nutrition. Which of the following should the charge nurse include?
A.
B.
C.
D.
"You will need to monitor the client's electrolytes daily"
"You will need to change the IV dressing site once per week"
"You will need to warm the solution in the microwave before administration"
"You need to weigh the client twice per week"
133. A nurse is teaching a prenatal class about infection at a community center. Which of the
following statements by a client indicates an understanding of the teaching?
A.
B.
C.
D.
"I can visit my nephew who has chickenpox 5 days after the sores have crusted."
"I can clean my cat's litter box during my pregnancy."
"I should take antibiotics when I have a virus."
"I should wash my hands for 10 seconds with hot after working in the garden."
133. A nurse is caring for a client who has end-stage liver cancer. Which of the following
statements should the nurse make to support the client's right to autonomy?
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A.
B.
C.
D.
"You should trust that your care team has your best interest at heart"
"I will not share any personal information without your permission
"The health care team will do their best to keep any promise we make to you"
"We encourage you to participate in all decisions about your treatment"
134. A nurse is completing an incident report after a client fall. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
A.
B.
C.
D.
Quality improvement.
Patient (Unable to read)
Evidence based practice.
Informatics.
136. A nurse is talking with another nurse on the unit and smells alcohol on her breath.
Which of the following actions should the nurse take?
A.
B.
C.
D.
Confront the nurse about the suspected alcohol use.
Inform another nurse on the unit about the suspected alcohol use.
Ask the nurse to finish administering medications and then go home.
Notify the nursing manager about the suspected alcohol use.
137. A charge nurse is teaching new staff members about factors that increase a client's risk
to become violent. Which of the following risk factors should the nurse include as the best
predictor of future violence?
A.
B.
C.
D.
Previous violent behavior
A history of being in prison
Experiencing delusions
Male gender
137. A charge nurse is teaching a newly licensed nurse about medication administration.
Which of the following information should the charge nurse include?
A.
B.
C.
D.
Inform clients about the action of each medication prior to administration.
(Unable to read) two times prior to administration.
Complete an incident report if a client vomits after taking a medication.
Avoid preparing medications for more than two clients at one time.
138. A charge nurse is evaluating the time management skills of a newly licensed nurse. For
which of the following actions by the newly licensed nurse should the charge nurse intervene?
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A.
B.
C.
D.
Takes assigned breaks at regular intervals
Documents the clients care tasks at the end of the shift.
assisting with ADLs to perform time sensitive activities
Gather necessary supplies before beginning a dressing change.
139. A nurse is caring for a client who has diaper dermatitis. Which of the following actions
should the nurse take?
A.
B.
C.
D.
Apply zinc oxide ointment to the irritated area.
(Unable to read)
Wipe stool from the skin using store bought baby wipes.
Apply talcum powder to the irritated area.
140. A nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which
of the following locations should the nurse expect to palpate the client's fundus?
C
142. A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
A.
"The client might act seductively."
B.
"The client is overly concentrated about minor details."
C.
"The client exhibits impulsive behaviors."
D.
"The client is exceptionally clingy to others."
142. A nurse is caring for a client who has a prescription for warfarin. When reviewing the
client's current medications, which of the following medications should the nurse identify as
contraindicated for use with warfarin? (Select all that apply)
A.
B.
C.
D.
E.
Aspirin
Magnesium sulfate
Gingko biloba.
Cetirizine
Ibuprofen.
143. A nurse is completing an admission assessment for a client who has narcissistic
personality disorder. Which of the following findings should the nurse expect?
A.
B.
C.
D.
Ritual behavior
Suspicious of others
Exhibits separation anxiety
Preoccupied with aging
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144. A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb)
and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client's BMI value as which of the
following?
A.
B.
C.
D.
23
42
32
8
145. A nurse is assessing a preschooler who has recently experienced an unexpected death in
the family. Which of the following should the nurse recognize as an expected finding?
A.
B.
C.
D.
The child expresses curiosity about the death process.
The child refuses to talk about death.
The child believes the person will return.
The child focuses on his own mortality.
146. A nurse is assessing a client in the emergency department. Which of the following
actions should the nurse take first?
Exhibit 1
Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl
Glucose 35 mg/dl Cloudy in appearance
Exhibit 2
History and Physical
Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic.
Exhibit 3 Vital Signs BP 166/96 mm Hg
Respiratory rate 24/min Pulse rate 112/min
Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9
A.
B.
C.
D.
Place the client on a cooling blanket.
Administer an analgesic.
Obtain arterial blood gas levels.
Elevate the head of the client's bed 30 degrees.
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147. A nurse is caring for a client following a paracentesis. Which of the following findings
should the nurse identify as an indication of a complication?
A.
B.
C.
D.
Decreased hematocrit.
Increased blood pressure.
Tachycardia.
Hypothermia.
148. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to
a newly licensed nurse. Which of the following statements by the newly licensed nurse
indicated an understanding of the teaching?
A.
B.
C.
D.
"Use a vein in the middle of the lower arm to insert a PICC."
"Flush a PICC using a 3-milliliter syringe."
"Informed consent is required prior to PICC placement."
"Position the client's arm in adduction for PICC placement."
149. A nurse is reviewing admission prescriptions for a group of clients. Which of the
following prescriptions should the nurse identify as complete?
A.
Furosemide 20 mg BID
B.
Nitroglycerin transdermal patch.
C.
Aspirin 1 tablet daily.
D.
Metoprolol 5mg IV now.
150. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
A.
B.
C.
D.
Hold hand flat to perform percussion on the child
Perform the procedure twice a day
Administer a bronchodilator after the procedure
Perform the procedure prior to meals
AVOID Before or AFTER meals
151. A nurse is reviewing the medical records of four clients. The nurse should identify that
which of the following client findings requires follow up care?
A.
B.
C.
D.
A client who received a Mantoux test 48hr ago and has an induration
A client who is schedule for a colonoscopy and is taking sodium phosphate
A client who is taking warfarin and has an INR of 1.8
A client who is takin bumetanide and has a potassium level of 3.6 mEq/L
152. A nurse is caring for a client who is postpartum and request information about
contraception. Which of the following instructions should the nurse include?
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A.
B.
C.
D.
"The lactation amenorrhea method is effective for your first year postpartum"
"You can continue to use the diaphragm used before your pregnancy"
"Place transdermal birth control patch on your upper arm"
"I should avoid vaginal spermicides while breast feeding."
153. A nurse is reviewing the facility's safety protocols considering newborn abduction with
the parent of a newborn. Which of the following statements indicates an understanding of the
teaching?
A.
B.
C.
D.
"Staff will apply identification band after first bath"
"I will not publish public announcement about my baby's birth"
"I can remove my baby's identification band as long as she is in my room"
"I can leave my baby in my room while I walk in the hallway"
154. A nurse is developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
A.
B.
Restrict the client's total fluid intake to 250 mL/hr
Give the protamine if signs of magnesium sulfate toxicity occur
C.
D.
Monitor the FHR via Doppler every 30min
Measure the client's urine output every hour
155. A nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make in
the medical record?
A.
B.
C.
D.
"Morphine 3 mg SQ every 4 hr. PRN for pain."
"Morphine 3 mg Subcutaneous (Unable to read)
"Morphine 3.0 mg sub q every 4 hr. PRN for pain."
"Morphine 3 mg SC q 4 hr. PRN for pain."
156. A nurse is assessing a client who has acute kidney injury and a respiratory rate of
34/min. The client's ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg.
Which of the following conditions should the nurse expect?
A.
Metabolic acidosis.
B.
Metabolic alkalosis.
C.
Respiratory acidosis.
D.
Respiratory alkalosis.
157. A nurse realizes that the wrong medication has been administered to a client. Which of
the following actions should the nurse take first?
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A.
B.
C.
D.
Notify the provider.
Report the incident to the nurse manager.
Monitor vital signs.
Fill out an incident report.
158. A nurse received a telephone call from a parent reporting that their school-age child has
a nosebleed and that they cannot stop the bleeding. Which of the following instructions should
the nurse provide to the provider?
A.
B.
nose"
C.
D.
"Have your child lie down and turn their head to their side for 10 minutes"
"Use your thumb and forefinger to apply pressure to the (Unable to read) of your child's
"Place a warm wet washcloth over your child's forehead and the bridge of their nose"
"Tell your child to blow their nose gently and then sit down and tilt your head back"
159. A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
A.
B.
C.
D.
Match the client's blood type with the type and cross match specimens.
Confirm the provider's prescription matches the number on the blood component.
Ask the client to state the blood type and the date of their last blood donation.
Ensure that the client's identification band matches the number on the blood unit.
160. A nurse is transcribing new medication prescriptions for a group of clients. For which of
the following prescriptions should the nurse contact the provider for clarifications?
A.
B.
C.
D.
Zolpidem 10mg PO one tablet at bedtime
Hydrochlorothiazide 12.5 mg PO BID
Triamcinolone acetonide 100 mcg/inhalation two puffs TID
Lorazepam .5mg PO one tablet daily
161. A nurse is caring for a client who requires seclusion to prevent harm to others on the
unit. Which of the following is an appropriate action for the nurse to take?
A.
Offer fluids every 2hr.
B.
C.
D.
Document the client's behavior prior to being placed in seclusion.
Discuss with the client his inappropriate behavior prior to seclusion.
Assess the client's behavior once every hour.
162. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
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A.
B.
C.
D.
"Dehydration is treated with calcium supplements"
"Dehydration can increase the risk of preterm labor"
"Dehydration associated gastroesophageal reflux
"Dehydration is caused by a decreased hemoglobin and hematocrit"
163. A nurse is using an IV pump for a newly admitted client. Which of the following actions
should the nurse take?
A.
B.
C.
D.
Ensure that the electric outlet has two prolongs for the IV pump
Check the clouds of the IV pump for fraying
Grasp the IV pump cord when unplugging it from the electrical outlet
Remove the safety inspection sticker before plugging in the IV pump
164. A nurse is assessing a client who is postoperative following abdominal surgery and has
an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the
following interventions should the nurse anticipate?
A.
B.
C.
D.
Clamp the (Unable to read)
Administer fluid bolus.
Obtain a urine specimen for culture and sensitivity
Initiate continuous bladder irrigation.
165. A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine?
A.
B.
C.
D.
Heart rate 58/min
Fasting blood glucose 100 mg/dL
Hgb 14 g/dL
WBC count 2,900/mm3
AGRANULOCYTOSIS - 4,800- 15,000 is normal range
166. A nurse is receiving a change-of-shift report for an adult female client who is
postoperative. Which of the following client information should the nurse report?
A.
B.
C.
D.
(Unable to read)
(Unable to read)
Answer might be lower platelets.
(Unable to read)
167. A nurse is caring for a client who has depression and reports taking ST. John's wort along
with citalopram. The nurse should monitor the client for which of the following conditions as a
result of an interaction between these substances?
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A.
B.
C.
D.
Serotonin syndrome
Tardive dyskinesia
Pseudo parkinsonism.
Acute dystonia.
168. A client who sustained a major burn over 20% of the body. Which of the following
interventions should the nurse nutritional requirements?
A.
B.
C.
D.
(Unable to read) (Chose this one)
Keep a calorie count for food and beverages.
Schedule meals at 6 hr. intervals
Provide low-protein high carbohydrate diet
169.
D
170. A nurse in a provider's office is preparing to administer the inactivated influenza vaccine.
The nurse should collect additional (Unable to read) for which of the following client prior to
administering the vaccine?
A.
(Unable to read
B.
Client has (Unable to read) HIV/AIDS
C.
Client has a sensitivity to eggs.
D.
Client is experiencing seasonal allergies.
171. A nurse is providing teaching about digoxin administration to the parents of a toddler
which as heart failure. Which of the following statements should the nurse include in the
teaching?
A.
B.
C.
D.
"Limit your child's potassium intake while she is taking this medication."
"You can add the medication to a half-cup of your child's favorite juice."
"Repeat the does if your child vomits within 1 hour after taking the medication."
"Have your child drink a small glass of water after swallowing the medication."
171. A nurse is teaching about preventing sudden infant syndrome (SIDS) to parent of a
1-month-old infant. Which of the following indicates that the parent understands how to place
the infant in the crib at bedtime?
B
172. A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of
the following actions should the nurse take?
A.
B.
Obtain the specimen immediately upon the client waking up.
Wait 1 day to collect the specimen if the client cannot provide sputum.
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C.
D.
Ask the client to provide 15 to 20 ml of sputum in the container.
Wear sterile gloves to collect specimen from the client.
173. A nurse is reviewing the laboratory report of a client who has a prescription for digoxin.
For which of the following laboratory results should the nurse withhold the medication and
notify the provider?
Digoxin 0.8 ng/ml
Sodium (Was out of range)
BUN 15
Potassium 3.1 mEq/L.
174. A nurse is caring for a client who wears glasses. Which of the following actions should
the nurse take?
A.
B.
C.
D.
Store the glasses in a labeled case.
Clean the glasses with hot water.
Clean the glasses with a paper towel.
Store the glasses on the bedside table.
175. A school nurse is teaching a parent about absent seizures. Which of the following
information should the nurse include?
A.
B.
C.
D.
"This type of seizure can be mistaken for daydreaming."
"This type of seizure lasts 30 to 60 seconds."
"The child usually has an aura prior to onset."
"This type of seizure has a gradual onset."
176. A nurse is planning care for a client who has cancer and is about to receive low dose
brachytherapy via a vaginal implant applicator. Which of the following interventions should the
nurse include in the plan of care?
A.
B.
C.
D.
Removal of vaginal packing
Insertion of an indwelling urinary catheter
Ambulation four times daily
Maintenance of NPO status until therapy is complete
177. A nurse is caring for a client who has deep vein thrombosis and is receiving heparin
therapy. Which of the following tests should the nurse use to monitor and regulate the dosage
of the medications?
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A.
B.
C.
D.
aPTT.
Pyro (Unsure if that's the writing)
Platelet count.
INR.
178. A charge nurse is preparing to lead negotiations among nursing staff due to conflict
about overtime requirements. Which of the following strategies should the nurse use to
promote effective negotiation?
A.
B.
C.
D.
Identify solutions prior to negotiation
Focus on how the conflict occurred
Attempts to understand both sides of the issue
Personalize the conflict
179. A nurse manager is developing a protocol for an urgent care clinic that often cares for
clients who do not speak the same language as clinical staff. Which of the following instructions
should the nurse include?
A.
B.
C.
D.
Use the client's children to provide interpretation.
(Answer was the nurse was going to do the interpretation)
Offer client's translation services for a nominal fee.
Evaluate the clients' understanding at regular intervals.
180. A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which
of the following findings should the nurse identify as an indication of intercranial pressure?
A.
B.
C.
D.
Tachycardia.
Narrowed pulse pressure.
Hypotension.
Increasingly severe headache.
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RN Comprehensive Predictor 2019 Form B
1.
A nurse is providing teaching about the gastrostomy tube feedings to the parents of a
school age child. Which of the following instructions should the nurse take?
A.
Administer the feeding over 30 min.
B.
Place the child in as supine position after the feeding.
C.
Charge the feeding bag and tubing every 3 days.
D.
Warm the formula in the microwave prior to administration.
2.
A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the
following findings should the nurse report to the provider?
A.
Potassium level 4.2 mEq/L.
B.
Apical pulse 58/min.
C.
Digoxin level 1 ng/ml.
D.
Constipation for 2 days.
3.
A nurse is caring for a client who is comatose and has advance directives that indicate
the client does not want life-sustaining measures. The client's family want the client to have lifesustaining measures. Which of the following action should the nurse take?
A.
Arrange for an ethics committee meeting to address the family's concerns.
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B.
C.
D.
Support the family's decision and initiate life-sustaining measures.
Complete an incident report.
Encourage the family to contact an attorney.
4.
A nurse is teaching a group of newly licensed nurses about measures to take when
caring for a client who is on contact precautions. Which of the following should the nurse
include in the teaching?
B.
Place the client in a room with negative pressure.
C.
Wear gloves when providing care to the client.
D.
Wear a mask when changing the linens in the client's room.
5.
A nurse is planning on care for a client who is recovering from an acute myocardial
infarction that occurred 3 days ago. Which of the following instructions should the nurse
include?
A.
B.
C.
D.
Perform an ECG every 12 hr.
Place the client in a supine position while resting.
Draw a troponin level every 4hr.
Obtain a cardiac rehabilitation consultation.
6.
A nurse is caring for a client who request the creation of a living will. Which of the
following actions
should the nurse take?
A.
Schedule a meeting between the hospital ethics committee and the client.
B.
Evaluate the client's understanding of life-sustaining measures.
C.
Determine the client's preferences about postmortem care.
D.
Request a conference with the client's family.
9.
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following
manifestations indicates acute chest syndrome and should be immediately reported to the
provider?
A.
Substernal retractions.
B.
Hematuria.
C.
Temperature 37.9 C (100.2 F).
D.
Sneezing
10.
A nurse is preforming a gastric lavage for a client who has upper gastrointestinal
bleeding. Which of the following action should the nurse take?
A.
Instill 500 ml of solution through the NG tube.
B.
Insert a large-bore NG tube.
C.
Use a cold irrigation solution.
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D.
Instruct the client to lie on his right side.
11.
A nurse is providing care for a client who is in the advance stage of amyotrophic lateral
sclerosis.
(ALS). Which of the following referrals is the nurse's priority?
A.
Psychologist.
B.
Social worker.
C.
Occupational therapist.
D.
Speech-language pathologist.
12.
A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis.
Which of the following findings should the nurse report to the provider?
A.
B.
C.
D.
WBC count 8,000/mm3.
Platelets 150,000/mm3.
Aspartate aminotransferase 10 units/L. rate 5 a 40 units/L
Erythrocyte sedimentation rate 75 mm/hr
13.
A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse
should expect a prescription for which of the following laboratory tests?
A.
B.
C.
D.
Platelet count.
Potassium level.
Creatine clearance.
Prealbumin.
14.
A nurse is caring for a client following application of a cast. Which of the following
actions should the nurse take first?
A.
B.
C.
D.
Place an ice pack over the cast.
Palpate the pulse distal to the cast.
Teach the client to keep the cast clean and dry.
Position the casted extremity on a pillow.
15.
A nurse is caring for a client who has vision loss. Which of the following actions should
the nurse take? (Select all that apply)
A.
B.
Keep objects in the client's room in the same place.
Ensure there is high-wattage lighting in the client's room.
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C.
D.
E.
Approach the client from the side.
Allow extra time for the client to perform tasks.
Touch the client gently to announce presence.
16.
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has
questions about the disease. To research the nurse should identify that which of the following
electronic database has the most comprehensive collection of nursing (Unable to read) articles?
A.
MEDLINE
B.
CINAHL.
C.
ProQuest.
D.
Health Source.
17.
A nurse in an emergency department is assessing newly admitted client who is
experiencing drooling and hoarseness following a burn injury. Which of the following should
actions the nurse take first?
A.
Obtain a baseline ECG.
B.
Obtain a blood specimen for ABG analysis.
C.
Insert an 18-gauge IV catheter.
D.
Administer 100% humidified oxygen.
18.
A nurse is planning care for a client who has unilateral paralysis and dysphagia following
a right hemispheric stroke. Which of the following interventions should the nurse include in the
plan?
A.
Place food on the left side of the client's mouth when he is ready to eat.
B.
Provide total care in performing the client's ADLs.
C.
Maintain the client on bed rest.
D.
Place the client's left arm on a pillow while he is sitting.
19.
A nurse is caring for a client who is in a seclusion room following violent behavior. The
client continues to display aggressive behavior. Which of the following actions should the nurse
take?
A.
B.
C.
D.
Confront the client about this behavior.
Express sympathy for the client's situation.
Speak assertively to the client.
Stand within 30 cm (1 ft) of the client when speaking with them.
20.
A nurse is caring for a client who is receiving brachytherapy for treatment of prostate
cancer. Which of the following actions should the nurse take?
B.
C.
D.
Limit the client's visitors to 30 min per day.
Discard the client's linens in a double bag.
Discard the radioactive source in a biohazard bag
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21.
A nurse is assessing a client who has left-sided heart failure. Which of the following
should the nurse identify as a manifestation of pulmonary congestion?
A.
B.
C.
D.
Frothy, pink sputum.
Jugular vein distention.
Weight gain.
.Bradypnea
22.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of
the following conditions should the nurse recognize as a contraindication to the use of
oxytocin?
A.
B.
C.
D.
Diabetes mellitus.
Shoulder presentation.
Post term with hydramnios.
Chorioamnionitis
23.
A nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder. Which of the following interventions should the nurse take?
A.
B.
C.
D.
Allow the client enough time to perform rituals.
Give the client autonomy in scheduling activities.
Discourage the client from exploring irrational fears.
Provide negative reinforcement for ritualistic behaviors
24.A nurse is assessing a client who is receiving packed RBCs. Which of the following findings
indicate fluid overload?
A.
Low back pain.
B.
Dyspnea.
C.
Hypotension.
D.
Thready pulse.
25.
A nurse is calculating a client's expected date of delivery. The client's last menstrual
period began on April 12. Using Nagele's rule, what date should the nurse determine to be the
client's expected delivery date? (Use mmdd format.)
0119
26.
A nurse is discussing group treatment and therapy with a client. The nurse should
include which of the following as being a characteristic of a therapeutic group?
A.
The group is organized in an autocratic structure.
B.
The group encourages members to focus on a particular issue.
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C.
D.
The group must be led by a licensed psychiatrist.
The group encourages clients to form dependent relationships.
27.A nurse manger is reviewing documentation with a newly licensed nurse. Which of the
following notations by the newly licensed nurse indicates an understanding of the teaching?
A.
B.
C.
D.
"OOB with assistance for breakfast"
"Given 2 mg MSO4 IM for report of pain"
"Dressing changed qd"
"Administered 8 u regular insulin sq."
27.A nurse is preparing to administer eye drops to a school-age child. Identify the actions the
nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
1.
Apply pressure to the lacrimal punctum.
2.
Ask the child to look upward.
3.
Pull the lower eyelid downward.
4.
Instill the drops of medication.
5.
Place the child in a sitting position.
52341
28.A nurse is caring for a client who speaks a language different from the nurse. Which of the
following should the nurse take?
A.
B.
C.
D.
Request an interpreter of a different sex from the client.
Request a family member or friend to interpret information for the client.
Direct attention toward the interpreter when speaking to the client.
Review the facility policy about the use of an interpreter.
29.A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following
findings indicates that the nurse should increase the rate of infusion?
A.
B.
C.
D.
Urine output 20 ml/hr.
Montevideo units constantly 300 mm Hg.
FHR pattern with absent variability.
Contractions every 5 min that last 30 seconds.
30.A public health nurse is managing several projects for the community. Which of the
following interventions should the nurse identify as a primary prevention strategy?
A.
B.
C.
D.
Teaching parenting skills to expectant mothers and their partners.
Conducting mental health screenings at the local community center.
Referring client who have obesity to community exercise programs.
Providing crisis intervention through a mobile counseling unit.
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31. A nurse is performing physical therapy for a client who has Parkinson's disease. Which of the
following statements by the client indicates the need for a referral to physical therapy?
B.
C.
D.
"I noticed that I am having a harder time holding on to my toothbrush"
"Lately, I feel like my feet are freezing up, as they are stuck to the ground"
"Sometimes, I feel I am making a chewing motion when I'm not eating"
33.A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of
the following findings should the nurse expect?
A.
Increased creatine.
B.
Increased hemoglobin.
C.
Increased bicarbonate.
D.
Increased calcium.
34.A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take at home. Which of the following responses
should the nurse take?
B.
C.
D.
"I recommend that you take this medication as prescribed"
"Do you know why this medication is being prescribed to you?
"I will call the pharmacist now to check on this medication"
35.A charge nurse is recommending postpartum client discharge following a local disaster.
Which of the following should the nurse recommend for discharge?
B.
A 15-year-old client who delivered via emergency cesarean birth 1 day ago.
C.
A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.
D.
A client who delivered precipitously 36 hr. ago and has a second-degree perineal
laceration.
36.
A nurse in a provider's office is reviewing the laboratory results of a group of clients.
Which to report?
A.
Herpes simplex.
B.
Human papillomavirus
C.
Candidiasis
D.
Chlamydia
37.
A nurse is providing discharge teaching to a client who has a new prescription for
phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods
while taking this medication?
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A.
b.
c.
d.
Avocados
Whole grain bread
Pepperoni pizza
Smoked salmon
38.
A nurse is preparing to perform a sterile wound irrigation and dressing change for a
client. Which of the following actions by the nurse indicates a break in surgical aseptic
technique?
A.
B.
C.
D.
Applying a sterile gown after applying a sterile mask
Balancing the bottle on the sterile basin while pouring the liquid
Placing the supplies on the sterile filed and leaving a 1- inch perimeter Putting on sterile
gloves after preparing the sterile field
39.
A nurse is planning care for a group of clients and is working with one licensed practical
nurse LPN and one assistive personal AP. Which of the following actions should the nurse take
first to manage her time effectively?
A.
B.
C.
Develop an hourly time frame for tasks Schedule daily activities
Determine goals of the day
Delegate tasks to the AP
40.
A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of
the following statements by the client indicates an understanding of the teaching?
a.
"I will take sucralfate with meals three times per day"
b.
"I will avoid food and beverages that contain caffeine"
c.
"I will decrease my daily protein intake to 15 grams per day"
d.
"I will use ibuprofen as needed to control abdominal pain"
41.
A nurse is reviewing legal issues in health care with a group of newly licensed nurses.
Which of the following recommendations should the nurse make?
A.
B.
C.
D.
Place copies of incident reports in client's medical records
Overestimate clients aculty to prevent short staffing
Ensure that each client has a living will on file prior to treatment
Obtain personal professional liability insurance coverage (N0)
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42.
Respuesta Figure C
43.
A nurse is teaching a client who is trying to conceive. Which of the following should the
nurse instruct in her diet to prevent a neural tube defect?
A.
B.
C.
D.
Folate
Zinc
Iron
Calcium
44.
A nurse is caring for a client who is experiencing acute mania. Which of the following
foods should the nurse provide for this client?
A.
B.
C.
D.
Peanut butter sandwich
Oatmeal with butter
Chicken noodle soup
Celery sticks
45.
A nurse is preparing to administer an IV medication to a client and accidently punctures
the IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of biohazardous material
spill?
A. Doxorubicin hydrochloride
B. Ampicillin sodium
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C. Metronidazole
D. Phenytoin
46.
A nurse in a provider's office is reviewing a female client's medical record during a
routine visit. The nurse should recommend increasing dietary intake of which of the following
vitamins?
(Exhibit) --only tab shown is Tab 3:
A.
B.
C.
D.
Vitamin D
Vitamin K
Vitamin A
Vitamin B12
47.
A nurse is reviewing assessment data from several clients. For which of the following
clients should the nurse referral to a dietitian?
A.
B.
C.
D.
An older adult client who has a BMI of 24
A client who has a nonhealing leg ulcer
An older adult client who has presbyopia
A client who has an albumin level of 3.7g/Dl
48.
A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse use sterile gloves?
A.
B.
C.
D.
Inserting an NG tube
Administering total parenteral nutritional through a central venous access device
Initiating IV access
Performing tracheostomy care
49.
A nurse in a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist's notes. Which of the following responses
should the nurse make?
A.
B.
C.
D.
We can provide a copy of your records, but the therapists notes are not included
I don't think you will benefit from reviewing your therapists notes right now
Why are you interested in seeing your therapist's notes?
Are you not happy with your treatment?
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50.
A nurse is caring for a client who is in labor and has received an epidural. Which of the
following actions should the nurse take?
A.
B.
C.
D.
Decrease the maintenance infusion rate of IV fluid
Have protamine sulfate available at the bedside
Reposition the client side-to side each hour
Monitor the client for hypertension
51.
A nurse is building a therapeutic relationship with a new admitted client. Which of the
following actions should the nurse plan to take during the orientation phase of the relationship?
A.
B.
C.
D.
Determine previous coping skills used by the client
Establish the responsibilities of the nurse and client
Facilitate the clients problem-solving skills
Assist the client in expressing alternative behaviors
52.
A nurse is caring for a client who is 2 hr postoperative following a cardiac
catheterization. Which of the following is the priority assessment finding?
A.
B.
C.
D.
Report of burning sensation at the insertion site
Absence of pedal pulse in the affected extremity
Urinary output 25 Ml/hr
Oxygen saturation 91 %
53.
A nurse in a mental health facility receives change-of-shift report for four clients. Which
of the following clients should the nurse plan to assess first?
A.
B.
C.
D.
A client placed in restrain due to aggressive behavior
A client who will be receiving her first ECT treatment today
A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
A newly admitted client who has a history of 4.5 kg (10 lb.) weight loss in the past 2
months
54.
A nurse is providing teaching about car seat safety to a parent of a newborn. Which of
the following statements by the parent indicates an understanding of the teaching?
A.
B.
C.
D.
I can turn my baby's car seat around when she weighs 15 pounds
I can place my baby in the front seat with the airbag turned off
I will place my baby in a forward-facing car seat in my back seat
I will position my baby at a 45-degree angle in the car seat
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55.
A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the
nurse report to the provider?
A.
B.
C.
D.
Pulse 140/min
Close anterior fontanel
Respiratory rate 26/min
Abdominal breathing
56.
A nurse is caring for a client following a cardiac catheterization through the left groin.
Which of the following actions should the nurse take?
A.
B.
C.
D.
Monitor the dorsalis pedis pulse every 15 min
Keep the client NPO for 24 hr.
Place the client in fowlers position
Maintain strict bedrest for the first 12 hr.
57.
A nurse is reviewing the medical record of a client who has a prescription for
intermittent heat therapy for a foot injury. Which if the following findings should the nurse
identify as a contraindication for heat therapy?
A.
B.
C.
D.
Phlebitis
Abdominal aortic aneurysm
Osteoarthritis
Peripheral neuropathy
58.
A nurse in an emergency department is caring for a toddler who has burns following a
house fire. Which of the following actions should the nurse take first?
A.
B.
C.
D.
Calculate the fluid replacement based on vital signs and urinary output
Determine the location and depth of burns
Administer antibiotics to prevent sepsis.
Check the mouth for smooth and smoky breath
59.
A nurse is caring for a client following a stroke. The client has right-sided weakness and
facial drooping. Which of the following nursing actions is the priority?
A.
B.
C.
D.
Maintain NPO status for client
Change client's position every 2 hours
Perform range-of-motion exercises to client's extremities.
Place the client's right hand in supination position.
60.
A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a
transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
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A. Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
B. Check the client's vital signs from the previous shift prior to the initiation of the
transfusion
C. Set the IV infusion pump to administer the blood over 6 hr
D. Administer the blood via a 21-gauge IV needle
61.
A.
B.
C.
Intradermal Injection areas
Buttocks.
Upper back.
Hamstring area
62.
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of
the following are expected findings? (Select all that apply.)
A.
B.
C.
D.
E.
Impulse control difficulty
Left hemiplegia
Loss of depth perception
Aphasia
Lack of situational awareness
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63.
A nurse is planning care for a client who has dysphagia and a new dietary prescription.
Which of the following should the nurse include in the plan of care? (Select all that apply.)
A.
B.
C.
D.
E.
Have suction equipment available for use.
Feed the client thickened liquids.
Place food on the unaffected side of the client's mouth.
Assign an assistive personnel to feed the client slowly.
Teach the client to swallow with her neck flexed.
64.
A nurse is caring for a client who has global aphasia (both receptive and expressive.).
Which of the following should the nurse include in the client's plan of care? (Select all that
apply.)
A. Speak to the client at a slower rate.
B. Assist the client to use flash cards with pictures.
C. Speak to the client in a loud voice.
D. Complete sentences that the client cannot finish.
E. Give instructions one step at a time.
65.
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the
following is an expected finding?
A.
B.
C.
D.
Impulse control difficulty
Poor judgement
Inability to recognize familiar objects
Loss of depth perception
66.A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure,
which of the following actions should the nurse take?
A. Position the client in an upright position, leaning over the bedside table.
B. Explain the procedure.
C. Obtain ABG's.
D. Administer benzocaine spray.
67.
A nurse is assessing a client following bronchoscopy. Which of the following findings
should the nurse report to the provider?
A.
B.
C.
D.
Blood-tinged sputum
Dry, nonproductive cough
Sore throat
Bronchospasms
68.
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following
supplies should the nurse ensure are in the client's room? (Select all that apply.)
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A.
B.
C.
D.
E.
Oxygen equipment
Incentive spirometer
Pulse oximeter
Sterile dressing
Suture removal kit
69.
A nurse is caring for a client following a thoracentesis. Which of the following
manifestations should the nurse recognize as risks for complications? (Select all that apply.)
A. Dyspnea
B. Localized bloody drainage on the dressing
C. Fever
D. Hypotension
E. Report of pain at the puncture site
70.
A nurse is preparing to care for a client following chest tube placement. Which of the
following items should be available in the client's room? (Select all that apply.)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing
71.
A nurse is caring for a client who has a chest tube and drainage system in place. The
nurse observes that
the chest tube was accidentally removed. Which of the following actions should the nurse take
first?
A. Obtain a chest x-ray
B. Apply sterile gauze to the insertion site.
C. Place tape around the insertion site.
D. Assess respiratory status.
72.
A nurse is assessing a client who has a chest tube and drainage system in place. Which of
the following are expected findings? (Select all that apply.)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and
expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level
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73.
A nurse is assisting a provider with the removal of a chest tube. Which of the following
should the nurse instruct the client to do?
A. Lie on it left side.
B. Use the incentive spirometer.
C. Cough at regular intervals.
D. Perform the Valsalva maneuver.
74.
A nurse is planning care for a client following the insertion of a chest tube and drainage
system. Which of the following should be included in the plan of care? (Select all that apply.)
A. Encourage the client to cough every 2 hours.
B. Check the continuous bubbling in the suction chamber.
C. Strip the drainage tubing every 4 hours.
D. Clamp the tube once a day.
E. Obtain a chest x-ray.
75.
A nurse is caring for a client who is experiencing respiratory distress. Which of the
following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevation blood pressure.
76.
A nurse is orienting a newly licensed nurse on performing routine assessment of a client
who is receiving mechanical ventilation via an endotracheal tube. Which of the following
information should the nurse include in the teaching?
A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings ever 8 hours.
C. Document tube placement in centimeters at the angle of jaw.
D. Assess breath sounds every 1 to 2 hour
77.
A nurse is caring for a client who has dyspnea and will receive oxygen continuously.
Which of the following oxygen devices should the nurse use to deliver a precise amount of
oxygen to the client?
A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask
78.
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the
following modes of ventilation that increase the effort of the client's respiratory muscles should
the nurse include in the plan of care? (Select all that apply.)
A. Assist-control
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B.
C.
D.
E.
Synchronized intermittent mandatory ventilation
Continuous positive airway pressure
Pressure support ventilation
Independent lung ventilation
79.
A nurse is monitoring a group of clients for increased risk for developing pneumonia.
Which of the following clients should the nurse expect to be at risk? (Select all that apply.)
A. Client who has dysphagia
B. Client who has AIDS
C. Client who was vaccinated for pneumococcus and influenza 6 months ago
D. Client who is postoperative and received local anesthesia.
E. Client who has a closed head injury and is receiving ventilation
F. Client who has myasthenia gravis
80.A nurse in a clinic is caring for a client whose partner states the client woke up this morning,
did not recognize him, and did not know where she was. The client reports chills and chest pain
that is worse upon inspiration. Which of the following actions is the nurse's priority?
A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide a pneumococcal vaccine.
81.
A nurse is caring for a client who has pneumonia. Assessment findings include
temperature 37.8 C (100 F), respirations 30/min, blood pressure 130/76, heart rate 100/min,
and SaO2 91% on room air. Prioritize the following nursing interventions.
Administer antibiotics.
Administer oxygen therapy.
Perform a sputum culture.
Administer an antipyretic medication to promote client comfort.
82.
A nurse in a clinic is assessing a client who has sinusitis. Which of the following
techniques should the nurse use to identify manifestations of this disorder?
A. Percussion of posterior lobes of lungs
B. Auscultation of the trachea
C. Inspection of the conjunctiva
D. Palpation of the orbital areas
83.
A nurse is teaching a group of clients about influenza. Which of the following client
statements indicates an understanding of the teaching?
A. "I should wash my hands after blowing my nose to prevent spreading the virus."
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B. "I need to avoid drinking fluids if I develop symptoms."
C. "I need a flu shot every 2 years because of the different flu strains."
D. "I should cover my mouth with my hand when I sneeze."
84.
A nurse in the emergency department is caring for a client who is having an acute
asthma attack. Which of the following assessments indicates that the respiratory status is
declining? (Select all that apply.)
A. SaO2 95%
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVC's)
85.
A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%,
exhibits audible wheezes, and is using accessory muscles when breathing. Which of the
following classes of medication should the nurse expect to administer?
A. Antibiotic
B. Beta-blocker
C. Antiviral
D. Beta2 agonist
86.
A nurse is providing discharge teaching to a client who has a new prescription for
prednisone for asthma. Which of the following client statements indicates an understanding in
teaching?
A.
B.
C.
D.
"I will decrease my fluid intake while taking this medication."
"I will expected to have black, tarry stools."
"I will take my medication with meals."
"I will monitor for weight loss while on this medication."
87.
A nurse is assessing a client who has a history of asthma. Which of the following factors
should the nurse identify as a risk for asthma?
A.
B.
C.
D.
Gender
Environmental allergies
Alcohol use
Race
88.
A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator.
Which of the following client statements indicates an understanding of the teaching?
A. "This medication can decrease my immune response."
B. "I take this medication to prevent asthma attacks."
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C. "I need to take this medication with food."
D. "This medication has a slow onset to treat my symptoms."
89.
A nurse is providing discharge teaching to a client who has COPD and a new prescription
for albuterol. Which of the following statements by the client indicates and understanding of
the teaching?
A. "This medication can increase my blood sugar levels."
B. "This medication can decrease my immune response."
C. "I can have an increase in my heart rate while taking this medication."
D. "I can have mouth sores while taking this medication."
90.
A nurse is preparing to administer a dose of a new prescription of prednisone to a client
who has COPD. The nurse should monitor for which of the following adverse effects of this
medication? (Select all that apply.)
A. Hypokalemia
B. Tachycardia
C. Fluid retention
D. Nausea
E. Black, tarry stools
91.
A nurse is discharging a client who has COPD. Upon discharge, the client is concerned
that he will never be able to leave his house now that he is on continuous oxygen. Which of the
following is an appropriate response by the nurse?
A. "There are portable oxygen delivery systems that you can take with you."
B. "When you go out, you can remove the oxygen and then reapply it when you get home."
C. "You probably will not be able to go out at much as you used to."
D. "Home health services will come to see you so you will not need to get out."
92.
A nurse is instructing a client on the use of an incentive spirometer. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will place the adapter on my finger to read my blood oxygen saturation level."
B. "I will lie on my back with my knees bent."
C. "I will rest my hand over my abdomen to create resistance."
D. "I will take in a deep breath and hold it before exhaling."
93.A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of
the following should the nurse include in the plan of care?
A. Take quick breaths upon inhalation.
B. Place you hand over your stomach.
C. Take a deep breath in through your nose.
D. Puff your cheeks upon exhalation.
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94.A home health nurse is teaching a client who has active tuberculosis. The provider has
prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO
daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following
client statements indicate the client understands the teaching? (Select all that apply.)
A. "I can substitute one medication for another if I run out because that all fight infection."
B. "I will wash my hands each time I cough."
C. "I will wear a mask when I am in a public area."
D. "I am glad I don't have to have any more sputum specimens."
E. "I don't need to worry where I go once I start taking my medications."
95.A nurse is teaching a client who has tuberculosis. Which of the following statements
should the nurse include in the teaching?
A. "You will need to continue to take the multi-medication regimen for 4 months."
B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of
the medication."
C. "You will need to remain hospitalized for treatment."
D. "You will need to wear a mask at all times."
96.A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed
on a multi-medication regimen. Which of the following instructions should the nurse give the
client related to ethambutol?
A. "Your urine can turn a dark orange."
B. "Watch for a change in the sclera of your eyes."
C. "Watch for any changes in vision."
D. "Take vitamin B6 daily."
97.A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who
has tuberculosis. The nurse should instruct the client to report which of the following findings
as an adverse effect of the medication?
A. "You might notice yellowing of your skin."
B. "You might experience pain in your joints."
C. "You might notice tingling of your hands."
D. "You might experience loss of appetite."
98.
A nurse is providing information about tuberculosis to a group of clients at a local
community center. Which of the following manifestations should the nurse include in the
teaching? (Select all that apply.)
A. Persistent cough
B. Weight gain
C. Fatigue
D. Night sweats
E. Purulent sputum
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99.
A nurse is caring for a group of clients. Which of the following clients are at risk for
pulmonary embolism? (Select all that apply.)
A. A client who has a BMI of 30
B. A female client who is postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic atrial fibrillation
100. A nurse is assessing a client who has a pulmonary embolism. Which of the following
information should the nurse expect to find? (Select all that apply.)
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
101. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis.
The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min,
respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of
the following nursing actions is the priority?
A. Notify the provider.
B. Administer heparin via IV infusion.
C. Administer oxygen therapy.
D. Obtain a spiral CT scan.
102. A nurse is caring for a client who has a new prescription for heparin therapy. Which of
the following statements by the client should indicate and immediate concern for the nurse?
A. "I am allergic to morphine."
B. "I take antacids several times a day."
C. "I had a blood clot in my leg several years ago."
D. "It hurts to take a deep breath."
103. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the
following factors should the nurse recognize as a contraindication to the therapy?
A. Hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count
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104. A nurse is assessing a client following a gunshot wound to the chest. For which of the
following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.)
A. Tachypnea
B. Deviation of the trachea
C. Bradycardia
D. Decreased use of accessory muscles
E. Pleuritic pain
105.A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the
following actions should the nurse perform first?
A. Assess the client's pain.
B. Obtain a large-bore IV needle for decompression.
C. Administer lorazepam.
D. Prepare for chest tube insertion.
106.A nurse is reviewing discharge instructions for a client who experienced a pneumothorax.
Which for the following statement should the nurse use when teaching the client?
A. "Notify the provider if you experience weakness."
B. "You should be able to return to work in 1 week."
C. "You need to wear a mask when in crowded areas."
D. "Notify your provider if you experience a productive cough."
107.A nurse in the emergency department is assessing a client who has a suspected flail chest.
Which of the following findings should the nurse expect? (Select all that apply.)
A. Bradycardia
B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement
108.A nurse in the emergency department is assessing a client who was in a motor vehicle
crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure
118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and
SaO2 92% on room air. Which of the following actions should the nurse take first?
A.
B.
C.
D.
Obtain a chest ex-ray.
Prepare for chest tube insertion.
Administer oxygen via high-flow mask.
Initiate IV access.
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109. A nurse is orientation a newly licensed nurse on the purpose of administering
vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the
following statements by the newly licensed nurse indicates understanding of the teaching?
A. "This medication is given to treat infection."
B. "This medication is given to facilitate ventilation."
C. "This medication is given to decrease inflammation."
D. "This medication is given to reduce anxiety."
110. A nurse is reviewing the health records of five clients. Which of the following clients
are at risk for developing acute respiratory distress syndrome? (Select all that apply.)
A. A client who experienced a near-drowning incident
B. A client following coronary artery bypass graft surgery
C. A client who has a hemoglobin of 15.1 mg/dL
D. A client who has dysphagia
E. A client who experienced a drug overdose
111.A nurse is planning care for a client who has severe respiratory distress system (SARS).
Which of the following actions should be included in the plan of care for this client? (Select all
that apply.)
A. Administer antibiotics.
B. Provide supplemental oxygen.
C. Administer antiviral medications.
D. Administer bronchodilators.
E. Maintain ventilatory support.
112. A nurse is caring for a client who is receiving vecuronium for acute respiratory distress
syndrome. Which of the following medications should the nurse anticipate administering with
this medication? (Select all that apply.)
A. Fentanyl
B. Furosemide
C. Midazolam
D. Famotidine
E. Dexamethasone
113.A nurse is orienting a newly licensed nurse on the care of a client who is to have a line
placed for hemodynamic monitoring. Which of the following statements by the newly licensed
nurse indicates effectiveness of the teaching?
A. "Air should be instilled into the monitoring system prior to the procedure."
B. "The client should be positioned on the left side during the procedure."
C. "The transducer should be level with the second intercostal spaced after the line is
placed."
D. "A chest x-ray is needed to verify placement after the procedure."
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114. A nurse is assessing a client who is immediately post-operative following hip
arthroplasty, which of the following considerations should the nurse take when positioning the
client?
A.
B.
C.
D.
Place the client's heels directly against the bed mattress
Ensure that the client's hips remain in an abducted position.
Maintain the client in a supine position for the first 24 hr. after surgery.
Flex the client's hip up to 120° when sitting in a chair.
115. A nurse is assessing a client who is immediately postoperative following a subtotal
thyroidectomy. Which of the following should the nurse expect to administer?
A.
B.
C.
D.
Calcium gluconate.
Sodium bicarbonate.
Potassium chloride.
Sodium phosphate.
116. A nurse is caring for an adult client who has prescriptions for multiple medications.
Which of the following (Unable to read) as an age-related change that increases the risk for
adverse effects from this medication?
A.
B.
C.
D.
Rapid gastric emptying.
Prolonged medication half-life.
Increased medication elimination.
Decreased medication sensitivity.
117. A nurse manager is planning to promote client advocacy among staff in a medical unit.
Which of the following actions should the nurse take?
A. Encourage staff to implement the principle of paternalism when a client is having
difficulty making a choice.
B. Tell staff explain procedures to clients before obtaining informed consent.
C. Instruct unit staff to share personal experiences to help clients make decisions.
D. Develop a system for staff members to report safety concerns in the client care
environment.
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RN Comprehensive Predictor 2019 Form C
1.
A nursing planning care for a school-age child who is 4 hr postoperative following
perforated appendicitis. Which of the following actions should the nurse include in the plan of
care?
a.
Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
b.
Give cromolyn nebulizer solution every 6 hr (for asthma)
c.
Apply a warm compress to the operative site every 4 hr d.
2.
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the
following
actions should the nurse take?
a.
Shave hairy areas of skin prior to application ( apply to hairless, clean & dry areas to
promote absorption; avoid oily or broken skin)
b.
Wear gloves to apply the patch to the client's skin
c.
Apply the patch within 1 hr of removing it from the protective pouch (apply
immediately)
d.
Remove the previous patch and place it in a tissue (fold patch in half with sticky sides
pressed together)
3.
A nurse has just received change-of-shift report for four clients. Which of the following
clients
should the nurse assess first?
b.
c.
d.
A client who is schedule for a procedure in 1 hr (can wait)
A client who has 100 mL fluid remaining in his IV bag (can wait)
A client who received a pain medication 30 min ago for postoperative pain
4.
A nurse is reviewing the laboratory results for a client who has Cushing's disease. The
nurse
should expect the client to have an increase in which of the following laboratory values?
a.
b.
c.
d.
Serum glucose level- increased
Serum calcium level-decreased
Lymphocyte count- decreased immune system.
Serum potassium level- decreased
5.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium
sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displaces
toxicity. Which of the following actions should the nurse take?
+
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a.
b.
c.
d.
Position the client supine
Prepare an IV bolus of dextrose 5% in water
Administer methylergonovine IM
Administer calcium gluconate IV
6.A nurse is preparing to perform a sterile dressing change. Which of the following actions
should
the nurse take when setting up the sterile field?
a.
Place the cap from the solution sterile side up on clean surface
b.
Open the outermost flap of the sterile kit toward the body� flap AWAY from the body's
first Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field � 2.5 cm (1inch) border around any sterile drape or wrap that is considered contaminated.
d.
Set up the sterile field 5 cm (2 in) below waist level� it says BELOW waist level; should
be ABOVE waist level
7.A home health nurse is preparing for an initial visit with an older adult client who lives
alone. Which of the following actions should the nurse take first?
a.
Educate the client about current medical diagnosis
b.
Refer the client to a meal delivery program
c.
d.
Arrange for client transportation to follow-up appointments Rationale Priority: Assess
first.
8.
A nurse is assessing the remote memory of an older adult client who has mild dementia.
Which of the following questions should the nurse ask the client?
a.
"Can you tell me who visited you today?"
"Can you list your current medications?" "What did you have for breakfast yesterday?"
9.
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which
of the
following goals should the nurse include in the teaching?
a.
HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
b.
Blood glucose level greater than 200 mg/dL at bedtime
c.
Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC
d.
10.
A nurse is caring for a client who is receiving phenytoin for management of grand mal
seizures and has a new prescription for isoniazid and rifampin. Which of the following should
the nurse concludes if the client develops ataxia and incoordination?
a.
The client is experiencing an adverse reaction to rifampin
b.
The client's seizure disorder is no longer under control
d.
The client is having adverse effects due to combination antimicrobial therapy
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11.
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of
the
following manifestations requires immediate action by the nurse?
a.
Increase in frequency of swallowing � may indicate bleeding
b.
Moderate sanguineous drainage on the drip pad
c.
Bruising to the face� side effect
d.
Absent gag reflex� possibly due to anesthesia given. (1 hour postoperative) Rationale
"Requires immediate action" choose the worst possibility that could lead to. ABC
12.A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki
disease. Which of the following interventions should the nurse include in the plan of care?
a.
Give scheduled doses of acetaminophen every 6 hr
Administer antibiotics via intermittent IV bolus for 24 hr
Provide stimulation with children of the same age in the playroom
12.A nurse is planning an educational program for high school students about cigarette
smoking. Which of the following potential consequences of smoking is most likely to discourage
adolescents from using tobacco?
a.
Use of tobacco might lead to alcohol and drug abuse
b.
Smoking in adolescence increases the risk of developing lung cancer later in life
c.
d.
Smoking in adolescence increases the risk of lifelong addiction
13.A nurse is assessing a client who is prescribed spironolactone. Which of the following
laboratory values should the nurse monitor for this client?
a.
Total bilirubin
b.
Urine ketones
c.
d.
Platelet count
14.A nurse has agreed to serve as an interpreter for an older adult client who is assigned to
another
nurse. Which of the following statements by the nurse indicates an understanding of this role?
"I will receive a small fee for interpreting for this client."
c.
"I am glad I'm available today, but when I'm not, you can use a family member."
d.
"I will let the client know that an interpreter is unavailable during the night shift."
15.A nurse is performing assessments on newborns in the nursery. Which of the following
findings
should the nurse report to the provider?
a.
A two-day old newborn who has a respiratory rate of 70 --> 30 - 60 is normal
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b.
stool
c.
d.
A 16-hour old new newborn who has yet to pass meconium- you got 24 hours to pass
A 2-day old newborn who has a small amount of blood tinged vaginal discharge
A 16 hr old newborn whose blood glucose is 45 mg/dl- 40 - 60 is normal
16. A nurse on an acute unit has received change of shift report for 4 clients which of the
following clients should the nurse assess first? Pain pallor pulselessness paresthesia
a.
A client who is 1 hr postoperative and has hypoactive bowel sounds
A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses
d.
A client who has a elevated AST level following administration of azithromycin
17.A nurse is providing discharge instructions to a client who has a new prescription for
haloperidol which of the following adverse effects should the nurse instruct the client to report
to the provider?
a.
Weight gain
b.
Dry mouth� anticholinergic effects
c.
d.
Sedation
� s/s neuroleptic malignant syndrome??>> life threatening
Shuffling gait -+A/E EPS: is an indication of parkinsonism and should be reported to t
18. A nurse is teaching dietary guidelines to a client who has celiac disease which of the
following
food choices is appropriate for the client?
a.
White flour tortillas
Wheat crackers
d.
Canned barley soup
19.A nurse is working in acute care mental health facility is assessing a client who has
schizophrenia. Which of the following findings should the nurse expect?
a.
All or nothing thinking
b.
Euphoric mood
c.
Disorganized speech
d.
Hypochondriasis (anxiety disorder)
20.A nurse is caring for a client who is immobile which of the following interventions is
appropriate
to prevent contracture?
a.
Align a trochanter wedge between the client's legs
b.
Place a towel roll under the client's neck
c.
Apply an orthotic to the client's foot
d.
Position a pillow under the client's knees
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21.A public health nurse working in a rural area is developing a program to improve health for
the
local population. Which of the following actions should the nurse plan to take?
a.
b.
Have a nurse from the outside the community provide health lectures at the county
hospital
c.
Encourage rural residents to focus health spending on tertiary health interventions
d.
Launch a media campaign to increase awareness about industrial pollution
22.
A nurse is preparing a change of shift report for an adult female client who is
postoperative.
Which of the following client information should the nurse include in the report?
CONFIRMED
a.
Hgb 12.8 g/dl - 12- 16
b.
Potassium 4.2 meq/l 3.5 - 5.0 meq
c.
RBC 4.4 million/mm3
d.
Platelets 100,000/mm3 - 150,000 - 300,000 risk for bleeding
23.
A nurse is admitting a client who has anorexia nervosa. Which of the following is an
expected
finding?
a.
Iron 90 mcg/dl
b.
c.
Serum creatinine 0.8 mg/dl
d.
Calcium 9.5 mg/dl
a.
Continue the monitor the fetal heart rate- - Not a problem- absent or late are a
problem however CONFIRMED
24.A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor
induction. The nurse notes early deceleration on the fetal heart rate monitor. Which of the
following nursing actions should the nurse take? p . 88 ch 13 maternity
b.
Stop the oxytocin infusion
c.
Perform a vaginal examination
d.
Initiate an amnioinfusion
25.A nurse is conducting an initial assessment of a client and noticed a discrepancy between the
clients current IV infusion and the information received during the shift report. Which of the
following actions should the nurse take?
a.
Complete an incident report and place it in the client's medical record.
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b.
Compare the current infusion with the prescription in the client's medication
record.
c.
Contact the charge nurse to see if the prescription was changed.
d.
Submit a written warning for the nurse involved in the incident.
26. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C.
The client asks the nurse if she will be able to breastfeed. Which of the following responses by
the nurse is appropriate?
You must use a breast pump to provide breast milk.
c.
You must use nipple shield when breastfeeding.
You may breastfeed after your baby develops his antibiotics.
27.A nurse is caring for a client who has returned to the medical-surgical unit following a
transurethral resection of the prostate. Which of the following should the nurse identify as
priority nursing assessment after reviewing the client's information? Exhibit .
a.
Level of consciousness . (priority)- decreased LOC can mean less o2 going to the
brain ?
b.
Skin turgor
c.
Deep tender Reflex
d.
Bowel sounds
28.A nurse is caring for a client who has hyperthermia. Which of the following actions for the
nurse
to take?
a.
Submerge the adolescent feet in ice water
b.
Cover the adolescent with a thermal blanket � if hypothermia.
c.
Administer oral acetaminophen
Initiate seizure precautions
d.
29.
A nurse in emergency department is caring for a client who has full thickness burn of the
thorax and upper torso. After securing the client's airway, which of the following is the nurse's
priority intervention?
P. 482 ch 75 CONFIRMED
a.
Providing pain management
b.
Offering emotional support
c.
Preventing infection
d spacing
30.
A nurse is caring for a client who has cancer and is being transferred to hospice care. The
client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about
dying." which of the following responses by the nurse is appropriate? (SATA)
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A.
Hospice will take good care of your mom, so I wouldn't worry about that.
D.
Tell her not to worry. She still has plenty of time left.
E.
You sound like you have questions about your mom dying. Let's talk about it.
Rationale: Therapeutic communication
32. A community health nurse receives a referral for a family home visit. Which of the following
tasks should the nurse perform first?
b.
c.
d.
Implement the nursing process
Schedule a time for the home visit
Contact the family by phone
33.A nurse is caring for a client who will undergo a procedure. The client states he does not
want the provider to discuss the results with his partner. Which of the following is an
appropriate response for the nurse to make?
a.
You have right to decide who receives information
b.
You partner can be source of support for at this time
c.
d.
Is there a reason you don't want your partner to know about your procedure?
The provider will be tactful when talking to your partner
34.
A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg
(15lb) from an original weight of 90.7 (200 lb). The nurse should identify the weight of the
following total percentage.
b.
15%
c.
8.1%
d.
13.3%
15lb/200lb = 0.075 x 100 = 7.5% weight loss percentage
35.
A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate.
Which of the following interventions should the nurse implement?
a.
Perform fundal massage (massage if fundus is boggy)
b.
Pour water from a squeeze bottle over the client's perineal area.
c.
Insert an indwelling urinary catheter.
d.
Apply cold therapy to the client's perineal area. (warm)
36.
A nurse is providing discharge teaching to a client who has cancer and a prescription for
a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse
include in the teaching?
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a.
b.
c.
d.
Avoid hot tub while wearing the patch
Apply patch to your forearm
Avoid high-fiber foods while taking this medication
Remove the patch for 8 hours every day to reduce the risk for tolerance.
37.
A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the
sequence of steps the nurse should take. (Move the steps into the box on the right, placing
them in the selected order of performance. Use all steps)
a.
b.
c.
d.
(4)
a.
Tremors
38.
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she
is not feeling well. Which of the following findings should indicate to the nurse that the client is
hypoglycemic? (Select all that apply.)
b.
Polydipsia = hyperglycemia
c.
Acetone Breath odor = DKA
39.
A community health nurse is planning primary prevention activities to reduce the
occurrence of abuse. Which of the following strategies should the nurse include in the plan?
a.
Instruct healthcare professionals to identify abusive situations (screening=secondary
prevention)
b.
Locate financial support to open a shelter for abuse survivors (3rd)
d.
Connect abuse survivors with legal counsel (3rd)
40.A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the
following tasks is appropriate for the nurse to delegate to the AP?
a.
Documenting the report of pain for a client who is postoperative
b.
Administering oral fluids to a client who has dysphagia-
Reviewing active range-of-motion exercise with a client who had a stroke
41.
A nurse is caring for a client who reports xerostomia following radiation therapy to the
mandible. Which of the following is an appropriate action by the nurse?
a.
b.
Offer the client saltine crackers between meals
Suggest rinsing his mouth with an alcohol-based mouthwash
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c.
d.
Instruct the client on the use of esophageal speech
42.
A nurse is caring for four clients. Which of the following tasks can the nurse delegate to
an
assistive personnel?
a.
Assess effectiveness of antiemetic medicationb.
c.
Perform a dressing change for a new amputeed.
Apply a transdermal nicotine patch43.
A nurse is caring for a client who states he recently purchased lavender oil to use when
he gets the flu. The nurse should recognize which of the following findings as a potential
contraindication for using lavender?
a.
The client takes vitamin C daily
b.
The client has a history of alcohol use disorder
c.
The client has a history of asthma
d.The client takes furosemide twice daily
44.
A nurse is caring for a client who has major depressive disorder and a new prescription
for
amitriptyline. The nurse should monitor for which of the following adverse effects?
a.
Increased salivation- dry it will cause - anticholinergic effects
b.
Weight loss
d.
Hypertension- orthostatic hypotension it will cause instead
45.
A nurse is conducting a health promotion class about the use of oral contraceptives.
Which of
the following disorders is a contraindication for oral contraceptive use?
a.
Asthma
c.
d.
Fibromyalgia
Fibrocystic breast condition
46.
A nurse is preparing to witness a client's signature on a consent form for a colon
resection. The nurse should recognize that which of the following information should be
provided to the client by the provider before signing the form? (SATA)
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e.
Cost of the procedure
47.
A nurse is providing teaching to a client who will undergo a magnetic resonance imaging
(MRI)
scan. Which of the following statements is appropriate to include in the teaching?
a.
"You should not have this procedure if you are allergic to iodine."
b.
"You should not have this procedure if you have a tattoo."
c.
"The nurse will ask you to wear protective eyewear during this procedure."
d.
"The nurse will ask you to remove any transdermal patches prior to the procedure."
48.
A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive
crisis.
Which of the following actions should the nurse include in the plan of care?
b.
Start a 24-hr urine collection- not the priority
c.
Give aspirin to reduce pain- acetaminophen or ibuprofen. Asa might lead to reye's
disease
d.
Encourage ambulation- we want to promote rest to decrease 02 consumption
49.
A nurse is teaching a parent about safety securing her 3-month-old infant in a car seat.
Which of
the following images indicates that the parent understands the teaching? B
50.A nurse is caring for a client who is dissatisfied with the care from the provider and decides
to leave the facility against medical advice. After notifying the provider, which of the following
actions is appropriate for the nurse to take?
a.
Summon a security guard
c.
d.
Complete an incident report
Notify a social worker
51.A nurse is making an initial postpartum home visit. Which of the following client statements
should the nurse
identify as a manifestation of increased risk for child abuse?
a.
"I try to respond to the baby quickly."
b.
c.
"I have several friends who come by to help out with the baby."
d.
"I want to meet other parents to see if they are going through the same thing."
52.A nurse is caring for an infant who has gastroenteritis. Which of the following assessments
should the nurse
report to the provider?
a.
Temperature 38 C(100.4 F) and pulse rate 124/min p
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b.
c.
d.
Decreased appetite and irritability
Pale and 24-hour fluid deficit of 30 mL
Sunken fontanels and dry mucous membranes
53.A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding, the nurse does not speak the same language as the client. The client partner and a 10year-old child are accompanying her. Which of the following actions should the nurse take to
gather the client's information?
b.
c.
d.
Ask a student nurse who speaks the same language to translate
Have the child translate
Allow the clients partner to translate
54. A nurse is caring for a client who has pernicious anemia, Which of the following laboratory
values should the
nurse evaluate effectiveness of the treatment?
A.
Folate level
B.
INR level
C.
Vitamin b12 level
D.
Creatinine level
74.
A nurse is assigning tasks to assistive personnel (AP). Which of the following tasks should
the nurse assign to the
AP?
a.
Suction a new tracheostomy
b.
Remove an NG tube
c.
Perform post mortem care
d. Change the dressing on an implanted central venous access device
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75.
A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of
the following findings
should indicate to the nurse that the client's ability to eliminate urine from the bladder is
restored?
Fundus 2 fingerbreadths above the umbilicus (needs to be below or at the umbilicus)
c.
Uterine atony (fundus not firm which means possible hemorrhage)
d.
Fundus firm and to the right of the abdominal midline (fundus not midline, bladder may
cause shifting if patient not voiding properly)
76.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following
should the nurse expect?
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a.
b.
B
C
D
Polyuria- oliguria
Hypotension- hypertension
Ketoacidosis
Hepatotoxicity
Thyroid storm
95.A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which
of the following
action should nurse take? (SATA)
A.
Place the client in a semi-private room
B.
Wear a lead apron when providing care
C.
Limit visitors to 30 mins
D.
Instruct visitors who are pregnant to remain 3 ft from the client
E.
96.A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving
process. Which of the
following information should the CN include in the teaching?
A.
Client can expect to have feeling of hopelessness
B.
C.
Client will experience anhedonia
D.
Client will experience low self-esteem
97. A client who is pregnant voice her concern that her 3y/o son will feel left out one the
newborn arrives. Which of
the following statements by the nurse is appropriate?
Offer your son a gift when the baby receives one Move your son to a toddler bed when the baby
arrives Tell your son to kiss the baby
D.
Teach your son to change the baby diapers
A nurse is obtaining a nutritional health hx on a client who reports problems with constipation.
Which of the following should the nurse identify as a cause of constipation?
A.
Following high-fiber diet
B.
Currently taking probioticsC.
D.
Intolerance to lactose
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99. A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following
findings should the
nurse except?
A.
Increase PaO2
B.
Hypoglycemia
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C.
D.
Board-like abdomen
Bounding pulse
100.A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight.
The client
experiences shortness of breath when eating. Which of the following actions should the nurse
take?
a.
Administer a bronchodilator following meals.
b.
Request non gas forming foods from the dietary department
c.
Limit the client's food consumption between meals.
d.
Arrange for a low protein diet. HIGH PROTEIN.
101.A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of
insulin. The client's lab
findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1
mg/dL. Which of the
Stop the IV infusion of insulin
c.
Administer oral potassium to the client- potassium is already high
d.
Initiate a 24 hr urine collection
.
102.A nurse is providing discharge teaching to a client who is postoperative following the
surgical repair of a
detached retina. Which of the following statements by the client indicates an understanding of
the teaching?
a.
I can go jogging after 2 weeks. -Avoid vigorous activities.
b.
I can lift objects that are less than 10 seconds. -avoid lifting more than 5pounds.
c.
d.
I should bend at the waist when putting on my shoes. -Avoid bending at the waist level.
103.A nurse is planning to administer vancomycin IV to a client. Which of the following actions
should the nurse
take to reduce the risk of an adverse reaction to the vancomycin?
b.
Administer the medication undiluted
c.
Obtain trough level 30 min after the medication infusion
d.
Inject 1% lidocaine prior to each dose
104.A nurse is delegating tasks to an assistive personnel group of clients. Which of the following
statements should
the nurse make?
a.
Take the client in room 106 to radiologyb.
Take the vital signs of the clients on the side of the unit
c.
d.
The client in room 109 has spilled his water pitcher
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Rationale: right direction/communication. Leadership.
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105.A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion
of low dose
dopamine. Which of the following findings is the highest priority?
a.
Erythema 5 cm (2in) above the IV site
b.
Blood pressure 92/68 mm Hg c.
Urine output 35mL/hr
d.
Pedal pulse of +1 bilaterally
106. A nurse is providing teaching about the use of crutches using a three-point gait to a
client who has tibia fracture.
Which of the following actions by the client indicates an understanding of the teaching?
A.
Positioning both hands on the grips with his elbows slightly flexed
Supporting his body weight while leaning on the axillary crutch pads (Support body weight using
both Crutches when shifting weight)
Stepping with his affected leg first when going up stairs (Unaffected First) Moving both crutches
with the stronger leg forward
107. A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the
following developmental
tasks should the toddler be able to perform?
A.
B.
C.
D.
Hop on one foot
Kick a ball forward
Climb Stairs with alternate feet
Ride a tricycle
108. A case manager is meeting with a client who asks about using alternative therapies to
manage her rheumatoid
arthritis. Which of the following statements should the nurse make?
A.
I'm sure you can find alternative remedies through an online support group
B.
If there are therapies available to you, your provider will tell you about them
C.
Feel free to try whatever therapies that fit within your personal belief system
D.
109.A nurse is assessing a client following a ischemic stroke. Which of the following findings is
the priority for the
nurse to report to the provider?
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A.
B.
C.
D.
The client reports a metallic taste in his mouth
A client reports a decreased appetite
The client coughs after swallowing
The client has poor fitting dentures
1.
A nurse is caring for a client who has end-stage liver disease and is undergoing a
paracentesis. Which of the
following actions should the nurse take to evaluate effectiveness of the procedure?
A.
B.
C.
D.
4
Check the client's serum albumin levels
Examine for leakage at this site of the procedure
Confirm that the client is able to urinate
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111.A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A.
B.
C.
D.
•
Swaddle the newborn with this leg extended.
Maintain eye contact with the newborn during feedings.
Minimize noise in the newborn environment
Administer naloxone to the newborn
Reduce environmental stimuli (decrease lights, lower noise level).
112.A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity
a nurse should engage in to assist in disaster preparedness?
A.
B.
C.
D.
Participate in community drills and mock events .
Vaccinate susceptible children and adults against smallpox
Assess types, levels and scopes of disasters.
Make quarantine preparations for those exposed to anthrax Rationale: Assess First
113. A nurse is obtaining a client's medical history before initiating 1000 ml of 0.9% NaCl with
20 mEq/L KCl IV to
correct hypokalemia. Which of the following findings is a contraindication to the client receiving
this IV solution?
A.
Chronic alcohol use disorder Multiple sclerosis
Advanced cardiac disease.
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114. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse
hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal
space. Which of the following is an appropriate documentation of the findings?
a.
Fourth heart sound at the aortic area
b.
Murmur at the mitral area
c.
Third heart sound at the tricuspid area
d.
Pericardial friction rub at the pulmonic area
113. A nurse is teaching a client who has a newly documented latex allergy. Which of the
following statements by the
clients indicates an understanding of the teaching?
a.
I will remove dairy products from my diet
b.
I will remove peanuts from my diet
d.
I will remove gluten from my diet
•
People allergic to latex also allergic to avocado, banana, chestnut, kiwi, passion fruit,
plum, strawberry, tomato
114. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2
diabetes mellitus. The
nurse should report which of the following conditions is a contraindication for the use of
metformin?
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a.
b.
c.
d.
Seizure disorder
Polycystic ovary syndrome
Renal insufficiency
Gluten intolerance
115. A nurse on a surgical pediatric care unit receives report prior to providing care for a
group of clients. Which of
the following clients should the nurse assess first?
a.
A 15-year-old who is 6 hr postop following a herniorrhaphy and reports pain at the IV
site
b.
3-month-old who is 1 day postop following cleft lip repair and has a pulse of 120
c.
12-year-old who is 2 days postop following an appendectomy and is refusing to
ambulate
d.
8-year-old client who is 12 hr postop following a tonsillectomy and is
experiencing
frequent swallowing - bleeding
116.A nurse is teaching a client how to perform Kegel exercises. Which of the following client
statements indicates
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understanding of the teaching?
a.
I will alternately contract and relax my gluteal muscles
b.
I will perform the exercises once each day before bed
c.
I will try to hold my urine for a little after i first feel the urge to urinate
d.
I will determine which muscles to contract by stopping and starting my stream of
urine
117.A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis.
Which of the following
statements indicates that the client understands the teaching?
I need to have an enema before the test
I will lie on my left side during the test
I will drink an oral glucose solution during the test
118.A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the
following clinical
manifestations is an expected finding for this client?
Report of occipital headache
ECG demonstrates a depressed ST segment White, diffuse peritonsillar pustules
119. A nurse is admitting an older adult client who is transferring from another facility. The
nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the
following actions should the nurse take to address the suspicions of elder abuse?
Inform the transferring agency of the client's condition.
Notify risk management
Contact the family regarding the client's condition.
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120.A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10
weeks of gestation about managing diabetes during pregnancy. Which of the following
statements by the client indicates an understanding of the teaching?
a.
"I will decrease my protein intake during the third trimester" (increase protein for basic
growth)
b.
"I will need to increase my insulin doses later in my pregnancy "
c.
"I will increase my carbs at breakfast and limit them the rest of the day"
d.
"I will decrease my calorie consumption during the first trimester" (increase calorie)
121.A home health nurse is preparing to assess a client who reports tingling around the mouth
and laxative use at
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least once daily. Which of the following assessments should the nurse perform first?
Assess the client's skin turgor Check the client's motor strength Measure the client's pupil size
122.A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of
the following
statements by the client requires further teaching?
a.
"I should clean my stoma with warm water" (can use low ph soap and water)
b.
"My stoma should be bright pink or red" (pink,red and moist)
c.
"I should change the stoma pouch every day"
d.
"I should cut my pouch opening ½ inch larger than my stoma" (allow expansion)
Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at ¼ or ½ full.
123.A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion.
Which of the
following findings should the nurse recognize as a result of magnesium sulfate toxicity?
a.
b.
c.
d.
Hyporeflexia
Tachypnea (bradypnea, less than 12/min)
Pruritus (sign of allergic reaction)
Polyuria (oliguria, less than 30 ml/hr)
124.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours
to a newborn who weighs 4.34 kg (9.5 lbs). Available is ampicillin 125mg/ml. How many
milliliters should the nurse administer per dose? (Round the answer to the nearest tenth. Use a
leading zero if it applies. Do not use a trailing zero )
1.7
mL per dose Rationale:
100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736
A nurse is admitting a client who has acute heart failure. Which of the following prescriptions
from the provider
should the nurse anticipate?
a.
Administer enalapril 2.5 mg PO twice daily
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b.
c.
d.
Ambulate the client every 4 hr while awake(bedrest)
Provide the client with 4 g sodium diet(
Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr
126. A nurse is collecting a specimen for urinalysis and culture from a client who has an
indwelling urinary catheter.
Which of the following actions should the nurse take during collection?
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a.
b.
c.
d.
Drain the specimen from the drainage bag (not sterile use the port for culture and UA)
Clamp the catheter distal to the injection port
Collect 2 mL of urine for each specimen
Obtain the urinalysis specimen before the culture specimen
127.A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the
client for which of
the following manifestations?
A.
Orthostatic Hypertension
B.
Dependent Edema
C.
Decreased Hematocrit
D.
Neck Vein Distension
A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings
should the nurse
report to the provider?
A. 3+ deep tendon reflexes
(common finding in women with preeclampsia and does not require action unless there are
symptoms of magnesium toxicity.)
B.
C. Urinary Frequency (expected)
D. Supine Hypotension Rationale:
129.A nurse is administering an analgesic to a client who has a chest tube. The provider is
preparing to discontinue the chest tube before the medication has taken affect. Which of the
following actions should the nurse prepare to take first?
A.
Inform the provider of the time of the last dose of pain medication.
B.
Document the sequence of events as they occur.
C.
Provide non-pharmacological pain management interventions.
D.
Instruct the client about the steps of the procedure.
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which
of the
following statements should the nurse include in the hand-off report?
A.
B.
C.
D.
8
The client was intubated without complications.
The estimated blood loss was 250 milliliters.
There was a total of 10 sponges used during the procedures.
The client is a member of the board of directors.
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131.A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should
recognize that an
elevated PAWP indicates which of the following complications?
A.
B.
Left ventricular failure
Cardiogenic shock
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C.
Hypovolemia D. Hypotension
132.A nurse is caring for four clients who are scheduled for surgery the same day. Which of the
following laboratory
values indicates the need for intervention before surgery?
A.
Fasting blood glucose 108 mg/dl (WNL)
B.
WBC 9,800/mm (WNL)
C.
Creatinine 0.9 mg/dl (WNL)
D.
Potassium 5.2 mEq/L
133.A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at
the peripheral IV
site. Which of the following actions should the nurse plan to take?
a.
Insert a new IV catheter distal to the discontinued IV site
b.
apply pressure dressing at the IV site
c.
Please a warm moist compress on the site
d.
Express drainage from the IV site and send it to be cultured
Phlebitis is characterized by pain, increased skin temperature, and redness along the vein. It is
commonly treated by
discontinuing the IV line and applying a moist, warm compress over the area.
135.A nurse is preparing to administer three medications to a client who is receiving continuous
enteral tube feeding
through an NG tube. Which of the following actions is appropriate for the nurse to take?
a.
ADD medication directly to enteral feeding - not without crushing them first
b.
Dissolve the medications together- some medications can mix others can't
c.
Use a syringe to allow the medications to Flow by gravity
d.
Flush the NG tube with 5 ml water- 10ml
136.The nurse is caring for a client who has histrionic personality disorder. Which of the
following findings should
the nurse expect?
a.
Repeated acts of unlawful Behavior
b.
Suspicious demeanor
c.
Seductive Behavior
d.
Lack of remorse
137.A nurse in a prenatal Clinic is teaching a client about nonpharmacological pain
management during labor.
Which of the following statements by the client indicates an understanding of the teaching?
a.
My nurse can teach me biofeedback at the beginning of labor- biofeedback would be
taught earlier to control other pain, not pain of labor
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b.
A transcutaneous electrical nerve stimulator will help with pelvic pressure- This would
mess with the readings of the pt and baby
c.
The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no.
d.
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138.A nurse is assessing a client Telemetry strip. Which of the following findings should the
nurse report to the
provider?
a.
c.
b.
d.
Heart rate 98 per minute
2 PVCs per minute
ST segment elevations
Widened P wave
139.A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition
tpn to a client.
Which of the following actions by the newly licensed nurse indicates a need for the nurse to
intervene
a.
Plans for a check of the clients fingerstick glucose every 6 hours
b.
Schedules a bag and tubing change for 24 hours after the start of the infusion- ok
c.
Uses the tpn IV tubing to administer the clients next dose of antibiotic
d.
Increases the tpn infusion rate each hour until the prescribed rate is achieved
140.A nurse is assessing a client's respirations which of the following actions should the nurse
take?
a.
Assess respirations before counting radial pulsations -either or is fine
b.
Multiply the number of respirations in 15 seconds by 4 - short way to do it, not
necessarily the right way
c.
Inform the client that has breaths will be counted- may raise or lower breath rate due to
fear
d.
Count respirations for 1 minute if the rhythm is irregular
141.A client's partner tells a staff nurse that he overhears laboratory staff discussing the result
of the client's biopsy
report while on the elevator. Which of the following actions should the nurse take?
a.
Report the information to the charge nurse
b.
Review confidentiality policies with laboratory employees- would be the job of the
Facility manager or someone who audits or teaches HIPAA stuff
c.
Contact the laboratory manager regarding the situation - you are not high enough up the
chain to do that
d.
Notify the facilities legal department - no need to go that far
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142.A nurse is assessing a client who requests an oral contraceptive. Which of the following
findings in the client's medical history should the nurse identify as a contraindication for the use
of a combination oral contraceptive?
a.
Concurrent use of levothyroxine
b.
Allergy to penicillin
c.
Recurrent urinary tract infections
d.
Migraines with aura
Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as
migraine, epilepsy, asthma, kidney, or heart disease.
143.A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the
following clients should the
nurse see first?
a.
A client who is at 36 weeks of gestation and has a biophysical profile score of 8
b.
A client who has pregestational diabetes mellitus and an HbA1c of 6.2%
c.
A client who is at 28 weeks of gestation and reports leukorrhea
d.
A client who has preeclampsia and reports a persistent headache
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144. A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the
following actions
should the nurse include in the plan of care?
a.
Instruct the client to empty her bladder prior to the procedure.
b.
Position the client over an overbed table prior to the procedure.
c.
Administer 1 L dextrose 5% in water IV bolus prior to the procedure.
d.
Initiate NPO status 4 hr prior to the procedure.
.
145.A nurse is assessing a client who is prescribed valproic acid. Which of the following
laboratory tests
should the nurse monitor?
a.
Arterial blood gas
b.
Serum potassium
c.
Liver Function Test
d.
Serum creatinine
146.A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an
appropriate action
for the nurse to take?
a.
Discard the first 10 mL of urine.
b.
Apply EMLA cream prior to the procedure.
c.
Obtain a 12 French catheter.
d.
Don sterile gloves prior to the procedure.
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147.A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which
of the following levels
should the nurse report to the provider? a. Potassium 3.2 mEq/L
b.
BUN 16 mg/dL (Normal 10-20)
c.
PT 12.2 seconds (Normal 11-14)
d.
Fasting blood glucose 103 mg/dL
148.A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices."
Which of the
following responses is the priority for the nurse to state?
a.
"How long have you been hearing the voices?"
b.
"What are the voices telling you?"
c.
"Have you taken your medication today?"
d.
"I realize the voices are real to you, but I don't hear anything."-
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RN Comprehensive Predictor 2019 Form D
1.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an
assistive personnel (AP) telling the client, "I f you don't eat, I'll put restraints on your wrists and
feed you." The nurse should intervene and explain to the AP that this statement constitutes
which of the following torts? a. Malpractice
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b.
c.
d.
Battery- physical
Assault- verbal
Negligence
2.
A nurse is providing discharge instructions to the parent of a newborn. Which of the
following statement by the parent indicates an understanding of the teaching?
a.
b.
c.
d.
I will suction my baby's mouth before I suction his nose.
I will lubricate the tip of the syringe with water prior to suction his nose.
I should insert the syringe into the center of his mouth.
I should compress the bulb after inserting it into the mouth.
3.
A nurse is providing discharge teaching about car seat safety to a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
I will place my baby in a forward- facing car seat in my back seat (facing the rear)
I can place my baby in the front seat with the airbag turned off. (dont put newborn in
front)
I will position my baby at a 45 degrees angle in the car seat.
d. I can turn my baby car seat around when she weighs 15 pounds.
4.
A nurse is planning care for a client who is in labor and has gonorrhea. Which of the
following actions should the nurse include in the plan for delivery?
Instill erythromycin ointment into the newborn's eye
Apply miconazole vaginal cream to the mother prior to delivery Give oral sulfadiazine to the
mother prior to delivery
d. Administer penicillin G procaine IM to the newborn
5.
A nurse is planning care for a client who has small-bore NG feeding tube in the jejenum.
Which of the following is an appropriate action for the nurse to take to confirm placement?
Instill two drops of blue food coloring formula Review an abdominal x-ray report.
Verify the glucose level aspirated content.
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d. Auscultate for bubbling sound while injecting air through the tube.??? - i chose this but ima
doble
check , i thought about verifying the placement at the moment
6.
A charge nurse delegates to an AP the task of ambulating a client. At the end of the shift,
the nurse discovers the client has not been ambulated. Which of the following actions should
the nurse take first?
a.
Supervise the AP performing the task
b.
Remind the AP of her assigned tasks.
c.
d. Ambulate the client on behalf of the AP.
Asses the situation first. Y es. assess first
Rationale: Care for the client comes first, so ambulate the patient because AP did not. Then you
can investigate why AP did not do the task.
7.
A nurse is caring for a client who has prescription for lactated ringer's IV 4080/mL24hr.
The nurse should set the IV infusion pump to deliver how many mL/hr to administer half of the
total volume in the first 8 hr?
Half = 2040 which need to be administered in 8hrs. So 2040ml/8hr = 255ml/hr
8.
A nurse is providing teaching to a client who DM about glycosylated hemoglobin blood
test. Which of the following statement by the client indicated an understanding of this test?
I will need to drink a glucose solution to get an accurate result I will need to fast prior to taking
this test
not necessary
I will use the result of this test daily to modify my insulin dosage. I will use this test to monitor
how well I control my blood glucose.
9.
A nurse is caring for a client who has CVC and develops an air embolism. Which of the
following actions should the nurse take?
a.
Prepare the client for chest tube insertion (I put this one. -Jackie) Instruct the client to perform
valsalva maneuver
Remove the client catheter.
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Rationale: Page 98 ATI Med Surg Book.
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10.
A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following
finding is priority?
a.
The client reports a pain level of 6
b.
The stoma appears dark purple in color
c.
The colostomy has had no output
d.
The client refuses to look at the colostomy
Rationale: Says notify provider when you see dark purple color which may indicate blood supply
is compromised.
http://www.atitesting.com/ati_next_gen/skillsmodules/content/ostomycare/equipment/stoma
_and
_peristo mal_skin_care.html
11.
A nurse is caring for a client who has new prescription for enalapril. The client report
tingling and swelling around the mouth 1hr after receiving the medication. Which of the
following actions should the nurse take first?
a.
Notify the rapid response team
Obtain IV access.? ???- whats that drug that dilates bronchioles that are constricted in case of
an anaphylactic RXN ? i thought about that thats why i chose this.
Document findings
d. Elevate the lower extremity.
12.
A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid.
Which of the following actions should the nurse take?
Ensure the client has a full bladder just prior to the procedure Weight the client before and after
the procedure
c.
Administer a low-volume hypertonic enema the night before the procedure
d.
Place the client in a side-lying position for the procedure
Rationale: Paracentesis is a procedure done to drain ascites fluid in the abdominal wall using a
trocar and a needle. Decrease in weight can be a data to assess if procedure has been effective
to reduce weight and remove ascites fluid in the abdominal wall.
13.
A nurse is admitting a client who tells the nurse he has brought a copy of his advance
directives. Which of the following actions should the nurse take?
Place a copy of the document in the client's medical record.
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b.
Request a social worker to review the document with the client (social worker does not
need to review this)
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c.
d.
Ask the client to keep the document in his bedside table. (store it in a safe place)
D. Have the provider approve the document. (does not need to be approved by MD)
14.
A nurse is providing preoperative teaching to a client who is scheduled for uterine
surgery and asks about the reason for the indwelling urinary catheter. Which of the following
responses should the nurse make?
a.
The catheter will be used to administer pain medication after surgery. (not used for pain
medication)
b.
The catheter will decompress your bladder during surgery.
c.
The catheter will decrease the risk for UTI from surgery. (risk for UTI)
The catheter will immobilization after surgery.
15.
A nurse is discharging a client who has a colostomy. The client states that she would like
to use her moisturizing soap to clean around the stoma. Which of the following responses by
the nurse is appropriate?
It is acceptable to use this soap if it makes you comfortable.
Lubricants in moisturizing soaps can interfere with adhesion of the appliance
You may want to try other soaps to determine what is the best to clean around the stoma Use
of moisturizing soaps can contribute to skin infections. (I put this one -Jackie)
Rationale: Page 240 of Funds ATI book Moisturizing soap can interfere with adherence of pouch.
16.
A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings
should the nurse report to the provider?
RR 26/min- (30 - 60 is normal they can be is respiratory distress ABCS) Pulse 140/min
Abdominal breathing- they are normally abdominal breathers
Closed anterior fontanel (front closed 18 months, back 2 to 3 months) Rationale: page 7 peds
2016 Newborn to 1 year old: RR= 30-35/min
17.
A school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
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a.
t
b.
c.
"The child usually has an aura prior to onset"
This type of seizure last 30-60 sec" ( begin and end abruptly)
d.
"This type of seizure has a gradual onset" ( generalized onset)
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18.
A nurse is providing teaching about crutch safety to a client. Which of the following
client actions indicates an understanding of the teaching?
a.
The client leans on both crutches to support body weight. (no)
b.
The client places the crutches 30cm (12in) to the front and side of each foot while
standing (6in)
c.
The client flexes her elbows 10 degree when supporting weight by using the handgrips.
(30deg)
The client keeps her axillae free of pressure. (yes use your hand for pressure)
19.
A nurse is assessing a client who received a Mantoux skin test 72hr ago for TB screening.
Which of the following findings indicates a positive test?
An area of ecchymosis A blister like area
An elevated hardened area. A cool, blanched area.
Rationale: Page 136 of MEDSURG ATI BOOK. An induration (palpable, raised, hardened area) of
10 mm or greater in diameter indicates a positive skin test.
20.
A nurse is caring for a client who has a chest tube drainage. Which of the following
findings indicates the nurse the presence of an air leak?
Gentle bubbling in the suction chamber Continuous bubbling in the water seal chamber
Fluid rising with inspiration and falling with expiration in the water seal chamber
D. Serosanguineous fluid in the drainage collection chamber.
Rationale:ATI Med Surg book page 106. Monitor the water seal chamber for continuous
bubbling (air leak finding). If observed, locate the source of the air leak, and intervene
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accordingly (tighten the connection, replace drainage system).
21.
A nurse is admitting a client to a med-surg unit. When performing medication
reconciliation for the client. Which of the following actions should the nurse take?
a.
Compare new prescription with the list of medications the clients reports.
Encourage the client to make his own list after he returns to his home. Exclude nutritional
supplements from the list of medication the client reports. Include any adverse effects of the
medication the client might develop.
22.
A nurse is caring for a toddler who has cancer and is experiencing stomatitis from
chemotherapy. Which of the following intervention should nurse implement?
Apply viscous lidocaine. Provide soft, nonacidic food Give peroxide mouth washes. Administer
antiemetics
23.
A nurse is teaching the family of an infant who has decreased cardiac output to
congenital heart disease. Which of the following instruction should the nurse include in the
teaching?
keep
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crying to a minimum, crying increases workload of heart
Bathe the infant and change the bed linens daily to reduce the risk of infection. maintain the
infant in supine position when sleeping.
Perform infant care activities frequently and intermittently throughout the day.
24.
A nurse is providing teaching to a parent of a child who has varicella. Which of the
following statements should the nurse include in the teaching?
"Your child can return to school after a negative titer result."
"Your child can return to school 24 hours after beginning antibiotics." Your child can return to
school once the lesions have crusted over."
d. "Your child can return to school once the fever has subsided."
25.
A nurse is providing an in-service about client evacuation during a fire. Which of the
following clients should the nurse instruct the staff to evacuate first?
A client who has a fracture and is in balanced suspension traction A client who uses a
wheelchair and is confused
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c.
d.
A client who is bedridden and wears a hearing aid
A client who is ambulatory and receiving oxygen � RESCUE
26.
A nurse is caring for four clients. Which of the following client data should the nurse
report to the provider?
a.
A client who is 4 hr postoperative and has a heart rate of 98/min
b.
A client who has a total of 110 mL of serosanguineous fluid from a Jackson-Pratt drain
within the first 24 hr following surgery
A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
d. A client who has pleurisy and reports pain of a 6 on a scale of 0 to 10 when coughing
27.
A community health nurse is working with a family that is struggling to adapt following
the loss of a family member. Which of the following actions should the nurse take first?
Encourage the family to assign specific tasks to individual family members. Determine the roles
of individual family members.
Assist the family to establish a daily routine
Refer the family to a grief support group.
Rationale: Assess first.
28.
A nurse is planning to delegate tasks to an A P. Which of the following tasks should the
nurse assign to the AP?
Record the client's BP reading by 1000- documenting VS is RNS job
Obtain a client temp prior to surgery- this CT is unstable since they are going to surgery
Reposition a client- i didn't choose this because certain disease require clients to be in certain
positions.
Measure a client's urine output
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29.
A community health nurse is planning a program to address substance use in the
adolescent population. Which of the following interventions should the nurse include as a
method of secondary prevention?
Facilitate referrals to substance use treatment programs (tertiary) Create anti-substance use
media messages
Establish an early detection program for substance use
Provide education about the danger of substance abuse. (Primary)
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Rationale: Secondary preventions: Includes screening such as early detection.
30.
A nurse in an ER is planning care for a client who has abdominal trauma from a MVC.
Which of the following provider prescription should the nurse implement first?
a.
Administer RBC
b.
Place a large bore IV catheter in an upper extremity- IV FLUID REPLACEMENT IS
c.
d.
Insert an indwelling urinary catheter
Obtain a specimen for ABG analysis
31.
A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing
treatment prescribed by a wound care consultant. For which of the following findings should
the nurse contact the consultant to revise the plan of care?
a.
Weight loss of 5% in 10 days
B.
Appearance of pink tissue under eschar
c.
Hgb 15 g/dL
d.
Albumin level 4.0 g/dL
32.
A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia which
of the following is the nurse's priority?
a.
U rinary output 35 ml/hr> 30 ml is normal
2 + deep tendon reflexes
+2 is normal 3 or 4 is ABNORMAL d't hyperreflexia.
3 + pedal edema
d.
Respiratory rate 10/min-
normal rate 12 -20 ATI PHARM
33.
A nurse is developing a plan of care for an older adult client who has hearing loss. Which
of the following instructions the nurse include in the plan?
A.
Increase the pitch of voice when speaking to the client l ow pitch
B.
Avoid using hand motions when speaking to the client
C.
Rephrase statements that the client misunderstands ESTA NO
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D.
Ask the client to confirm an understanding of the instructions by nodding. (I put this one
- Jackie)
34 A nurse is collaborating with social services in the discharge planning for a young adult client
who is below the poverty income level and will require home IV therapy. Which of the following
resources the nurse recommend? (SATA)
A.
Medicare Part A � must be 65 older (A; hospital care, home care, hospice, and skilled)
B.
Medicaid
C.
Adult day care
D.
Food stamps
E.
Respite care � Maybe? No. LOL. sorry paul. (yeah, no)
Young Adult- 20-39
Medicaid � low socioeconomic status and children.
35.
A nurse is reviewing legal issues in health care with a group of newly licensed nurses.
Which of the following recommendations should the nurse make?
A.
Overestimate client acuity to prevent short staffing
B.
Obtain personal professional liability insurance coverage
C.
Ensure that each client has a living will on file prior to treatment.
D.
Place copies of incident reports in client's medical records.
36.
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which
of the following places the client at risk for aspiration?
a.
b.
Receiving a high osmolarity formula
c.
Sitting in a high-Fowler's position during the feeding
d.
A residual of 65 mL 1hr postprandial
Rationale AT/ MS p309: Complications: Aspiration of gastric secretion Causes: Reflux of gastric
fluids into the esophagus can be aspirated into the trachea.
37.
A charge nurse is observing a conflict between two nurses who both insist that the
charge nurse favors the other when making assignments. Which of the following conflictresolution strategies
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should the charge nurse use?
Arrange for the nurses to have as few shifts together as possible
Tell the nurses that the assignments will be more equitable in the future Ask each nurse to take
turns making the assignments
ATI Leadership 15 Open communication among staff & b/w staff and clients can help defray the
need for conflict resolution.
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38.
A nurse is caring for a client who has received a first dose of losartan. Which of the
following adverse effects should the nurse report to the provider immediately?
A.
Angioedema airway; AIE
B.
Cough
C.
Hypotension
D.
Itching
Pharm 252 for HTN, HF. (Cozaar)
39.
A nurse is caring for a client who has Crohn's disease. Which of the following should the
nurse recommend for the client?
Navy beans Bacon Banana
Hard-boiled egg
40.
A nurse is evaluating a client's understanding of food nutrition labels. Which of
the following statements by the client indicate an understanding of the teaching?
b.Food manufacturers provide nutrition information voluntarily.
C.
Item serving size is consistent from one manufacturer to the next
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d.The daily values relate to a 1,500 calorie diet
(2 ,000)
http://www.mindfulbody.com/food/nutrition/nutritional-labels
41.A nurse is caring for a preschool-age child who has injuries due to abuse by her father's
partner. Which of the following actions by the nurse is appropriate?
A.
Limit visits by the father's partner to 30 min
B.
Restrict the child's interaction with other children on the unit
C.
Allow the father unlimited visitation with the child i assume father still has the right to
see his child. He didn't abuse him (I put this one -Jackie)
D.
Interview the child about the abuse with the father present.
42.A nurse is reviewing a client's medical record. Which of the following findings places the
client at increased for the development of heart failure? (SATA)
A.
Alcohol use disorder
B.
Osteoarthritis
C.
Sleep apnea
D.
E. BMI 23
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43.A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
A. Teach the client relaxation techniques
C. Help the client identify personal strengths.
D. Notify the client's support person.
44.A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The
nurse should recognize which of the following findings as an indication that the medication has
been effective?
A.
Increased blood pressure- Loop diuretics decrease BP via making you PEE ALOt
B.
Decreased inflammation- loops are not pain meds they are for BP C.
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D. Decreased pain - Loops are for BP
45.A nurse in an emergency department is assessing an adolescent who has conduct disorder.
Which of the following questions is the priority for the nurse to ask the client?
A.
"How do you get along with your peers at school?"
B.
"Do you have thoughts of harming yourself" - safety is number 1 when it comes to
priority
C.
"How do you manage your behavior?"
D.
"Do you have a criminal record?"
46.A nurse is planning care for a client who has cancer and is about to receive low dose
brachytherapy via a vaginal implant applicator. Which of the following interventions should the
nurse include in the plan of care?
A.
Ambulation four times daily
B.
Removal of vaginal packing
C.
restroom
so you will not have to get up and use the
D. Maintenance of NPO status until therapy is complete
https://cancer.stonybrookmedicine.edu/diagnosis-treatment/radiationoncology/info/brachytherapy
47.A nurse is providing care for a client following a thoracentesis. If the client develops a
pneumothorax, which of the following assessment findings should the nurse expect?
A.
Stridor
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B.
Pain on inhalation c hest pain that worsens when you breathe or pleuritic pain (I put this
one -Jackie)
C.
Friction rub
D.
Bradycardia
48.A charge nurse is delegating care for a group of clients. Which of the following tasks should
the charge nurse assign to a licensed practical nurse?
A.
Complete a discharge teaching for a client who has a new diagnosis of diabetes mellitus
B.
Perform a sterile dressing change for a client who has an abdominal wound
C.
Perform an admission assessment for a client who is scheduled for surgery
D.
Complete the Glasgow Coma Scale for a client who has an evolving stroke
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49.A nurse is caring for a client who has bipolar disorder. Which of the following client
findings is
an indication that the client is about to experience a manic phase?
A.
The client is restless and has changes in his sleep pattern
B.
The client laughs out loud and is overly cheerful
C.
The client has disorganized thoughts and is easily distracted
D.
The client shows poor judgment and demands attention ( I put this one -Jackie)
50.A nurse is caring for a client who has a spinal cord injury. Which of the following support
devices should the nurse plan to use to prevent plantar flexion contractures?
A.
Sheepskin heel pad
B.
Trochanter roll
C.
Abduction pillow
D.
Footboard prevents plantar flexion contractures due to immobility (I put this one -Jackie)
51.A nurse is caring for a client who speaks a different language than the nurse and is using
an interpreter. Which of the following actions should the nurse take when working with an
interpreter?
A.
Pause in the middle of sentences
B.
Use gestures when speaking with the client
C.
Direct statements to the interpreter
D.
Speak in a normal voice at a natural pace
52.A charge nurse is providing teaching to a newly licensed nurse about acceptable client
identifiers before administering medications. Which of the following statements by the newly
licensed nurse requires intervention?
A.
"I will check the client's hospital arm band before administering medication"
B.
"I will ask the client for his hospital assigned number prior to giving medication"
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C.
D.
"I should check the client's room number prior to giving medication"
"I should ask the client to state his name before administering medication"
53.A nurse is providing discharge teaching to a client who has hyperlipidemia and is to start
treatment with atorvastatin. The nurse should instruct the client to avoid taking the medication
with which of the following?
A.
Aged cheese
B.
Caffeinated beverages
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C.
D.
Green, leafy vegetables
Grapefruit juice
54.A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving
monitoring for dehydration. For which of the following findings should the nurse monitor?
A.
Weight loss
B.
Bradycardia
C.
Bulging fontanel
D.
Distended jugular vein
55.
A nurse is teaching a parent of a school-age child who is to begin a daily dose of
methylphenidate. Which of the following should the nurse include in the teaching?
A.
"Your child should avoid foods containing tyramine"
B.
"Your child should avoid excess sodium intake"
C.
"You should administer the medication at bedtime"
D.
administer med immediately
during or after meals (I put this one -Jackie; it is a ADHD medication)
56.A charge nurse is teaching a newly licensed nurse about clients designating a health care
proxy in situations that require a durable power of attorney for healthcare (DPAHC). Which of
the following information should the charge nurse include?
A.
"The proxy can make financial decisions if the need arises"
B.
"The proxy should manage legal issues for the client"
C.
"The proxy should make healthcare decisions for the client regardless of the client's
ability to do so"
D.
"The proxy can make treatment decisions if the client is under anesthesia"
57.A nurse is admitting a client who has been taking prednisone 10 mg PO daily for 10
months. Which of the following assessment findings should the nurse identify as an adverse
effect of this medication therapy?
A.
Absence of hair on legs below the knees
B.
Swelling and decreased range of motion of the joints ( I put this one -Jackie)
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C.
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D.
Bradycardia and postural hypotension
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58.A nurse is caring for a client who had gastric bypass surgery 1 week ago and has
manifestations of early dumping syndrome. Which of the following findings should the nurse
expect? (Select all that apply)
A.
Hypertension
B.
Diaphoresis
C.
Syncope
D.
Fever
E.
Dizziness
Early manifestations: Feeling of fullness, weakness, dizziness, palpitations, sweating, abdominal
cramping, and diarrhea
59.A nurse is caring for a male client who has a spinal cord injury. Which of the following
techniques should the nurse use when providing perineal care?
A.
Wash the penis from the scrotum to the tip using a spiral motion
B.
Discard the washcloth after cleansing the urethral meatus
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C.
D.
Don sterile gloves to prevent infection
Use water with no soap to prevent skin irritation
60.A nurse is assessing a toddler whose parent is concerned about the child's hearing ability.
Which of the following findings indicates the need for further hearing evaluation?
A.
Lack of response to facial expressions
B.
Uses gestures to communicate
C.
Exaggerated startle response to sounds
D.
Prefers group over solitary play
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61.A surgeon is obtaining informed consent from a client. When a nurse witnesses the client
sign the consent form, which of the following legal requirements is the nurse confirming?
a.
The nurse explained the risks and benefits of the surgery- PROVIDERS JOB
b.
The nurse explained the surgical procedure in detail- PROVIDERS JOB
c.
The client knows she may not longer refuse the procedure- Client has the right to refuse
even if its seconds prior to the surgery.
d.
The client agreed to the procedure voluntarily. - meaning she wasn't forced to sign .
62.A nurse providing teaching about nutritional needs to an adolescent client. Which of the
following statements by the client indicates an understanding of the teaching?
a.
I should consume about 1,300 milligrams of calcium a day
b.
Protein should be my main source of caloric intake
c.
I should limit my daily fat intake to 40 percent
d.
I should consume about 8 milligrams of iron a day
63.A nurse manager on an interprofessional team is creating a disaster plan. The nurse should
include in the plan that which of the following actions is the responsibility of the unit nurse
during a disaster?
a.
Determine the need for additional providers
b.
Act as a spokesperson to provider info to the media
c.
Decided which client should be transported for a higher level of care.
d.
Recommend to the provider a list of clients for early discharge
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64.A nurse is caring for a client who is 2 hr postpartum. The client states, " I'm having
difficulty emptying my bladder." which of the following actions should the nurse take?
a.
Pour warm water from a squeeze bottle over the client's perineum
b.
Hold analgesic medication until the client voids
c.
Place a transcutaneous electrical nerve stimulation (TENS) unit over the client's bladder
area
d.
Immerse the client's hands in cool water
65.A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching? I dk the answer
a.
Eat 1g/kg of protein per day (I put this one -Jackie)
b.
Drink at least 3L of fluid daily ???? i picked this one but ima double check
c.
Consume foods high in potassium
d.
Take magnesium hydroxide for indigestion
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66.A nurse is reviewing a client's cardiac rhythm strips and notes a constant P -R interval of
0.35 sec. Which of the following dysrhythmia is the client displaying?
a.
Premature atrial complexes?????????????
b.
Complete heart block
c.
Atrial fibrillation
d.
First degree atrioventricular block (I put this one -Jackie)
67.A nurse is reviewing laboratory values for a client who has bipolar disorder and takes
lithium carbonate. Which of the following values should the nurse report to the provider?
a.
Sodium 137 meq/L
b.
Lithium 1.0 meq/L
c.
WBC count 5,600 mm
(I put this one -Jackie) : lithium can cause hypothyroidism and goiter, T4 normal range is 4.6-12
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68.A nurse is planning teaching for a client who has a newly implantable
cardioverter/defibrillator. Which of the following information should the nurse include?
a.
Return in two weeks for a follow up MRI - MRI should be avoided
b.
Expect to have a rapid pulse rate for the first few weeks?
c.
Resume tub baths and swimming after 24hr
d.
Wear loose fitting clothing (I put this one -Jackie)
69.A nurse is caring for a 2 yr old toddler. Which of the following food choices should the
nurse recommend to promote independence in eating?
a.
Grapes- choking hazard
b.
Banana slices
c.
Hot dogs- choking hazards
d.
Popcorn- choking hazard
70.A nurse is caring for a client who has a 22 gauge IV inserted 2 days ago and a new
prescription for 2 packed RBCs. Which of the following actions should the nurse take?
a.
Transfuse each unit of packed RBCs over 5 hrs
b.
Replace the current IV site dressing prior to RBC infusion
c.
Start a new IV distal to the current IV site
d.
Place a larger gauge IV in the opposite extremity- RBC administration needs to have at
least an 18 -20 bore gauge needle to administer.
71.A nurse is providing information for a client who has a new prescription for simvastatin.
For which of the following should the nurse instruct the client to monitor and report to the
provider?
a.
Fever
b.
Muscle weakness- statin drugs = RHABDOMYLOSIS
c.
Weight loss edema
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72.A nurse is positioning a client for a cesarean birth. To prevent a compromise in placental
blood flow during the intraoperative period, which of the following actions should the nurse
take?
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a.
b.
c.
d.
Place a wedge under one of the client's hips
Assist the client into the lithotomy position
Position the client in reverse trendelenburg
Insert a pillow under the client's knees
73.A nurse is planning to delegate the fasting blood glucose testing for a client who has DM to
an assistive personnel. Which of the following actions should the nurse take?
a.
Determine if the AP has the skills to perform the test
b.
Assign the AP to ask the client if she has taken her antidiabetic meds today
c.
Help the AP perform the blood glucose test
d.
Have the AP check the medical record for the prior blood glucose test results
74.A nurse is teaching an adolescent who has a type 1 diabetes mellitus and his parents how
to dispose of his insulin syringes and needles at home. Which of the following instructions is
appropriate?
a.
Seal the needles in zipper lock plastic bags and place them in a metal trash can
b.
Place the needles in a plastic container and then pour alcohol into the container
c.
Recap the needles and wrap them and the syringes in paper towels
d.
Place the needles in an aluminum coffee can and store them on a high shelf
75.A nurse in a long term care facility is caring for an older adult who has a dementia. The
client believes he needs to get ready for work and is becoming increasingly agitated. Which of
the following actions should the nurse take?
a.
Assist the client in selecting clothing for the day
b.
Tell the client that his behavior is unacceptable
c.
Administer an anti anxiety medication
d.
Inform the client that he no longer has a job to go to
76.A nurse is assessing a young adult male client having an unusual rash on the palms of
hands and bottom of his feet. The nurse should further assess for which of the following
infections?
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1.
2.
3.
Syphilis
Herpes simplex virus 2
Gonorrhea
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4.
Hepatitis B
77.A nurse is providing teaching about digoxin administration to the parents of a toddler who
has heart failure. Which of the following statements should the nurse include in the teaching ?
1.
"Repeat the dose if your child vomits w/in 1 hr taking the medication"
2.
"Have your child drink a small glass of water after swallowing the medication" I put this
one -Jackie
3.
"You can add the medication to a half cup of your child's favorite juice"
4.
"Limit your child's potassium intake while she is taking this medication"
78.A nurse in a family health clinic is caring for a client who requests information regarding the
correct use of condoms. Which of the following statements should the nurse make?
When using implanted contraceptive methods, condoms should also be used to protect against
STDs
Use of petroleum based lubricant with a condom increases the condom's effectiveness Ensure
that the condom fits snugly over the tip of the penis
Condoms are equally effective for birth control with or without the use of vaginal spermicides
79.A nurse is assessing a client who is receiving a unit of packed RBCs. Which of the following
findings should indicate to the nurse that the client is experiencing a hemolytic reaction
reaction?
1.
Bradycardia
2.
Urticaria (hives) - allergic rxn (I put this one -Jackie)
3.
Low blood pressure
4.
Jugular vein distention - fluid overload
Rationale: Hemolytic reactions: chills, headache, backache, dsypnea , hypotension, fever
(KAPLAN)
80.A nurse is providing teaching to the parents of a newborn about newborn genetic
screening. Which of the following statements should the nurse include in the teaching?
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1.
2.
3.
4.
A nurse will draw blood from your baby's inner elbow
This test should be performed after your baby is 24 hrs old
This test will be repeated when your baby is 2 months old
Your baby will be given 2 ounces of water to drink prior to the test
81.A nurse is evaluating the outcomes for a client who had an amnioinfusion for
oligohydramnios. Which of the following findings indicates an adverse response to this
treatment?
1.
Fetal cord compression
2.
Placental insufficiency (OB p 102) - this CAUSES oligohydramnios, but the question is
asking "adverse response" to amnioinfusion..
3.
Meconium aspiration
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4.
Uterine contractions - monitor the client to prevent uterine overdistention and
increased uterine tone = can initiate/accelerate/intensify UTERINE CONTRACTIONS and cause
nonreassuring FHR changes; (I put this one -Jackie)
82.A nurse has received clearance to go back to work after an occupational injury to her back.
To reduce the risk of future lifting injuries, which of the following principles should the nurse
use when lifting objects?
1.
Bend at the waist to pick up the object
2.
3.
4.
Keep the object close to her body as she lifts it
Twist at the waist when moving the object to her side
Stand with her feet close together when lifting the object
83.A nurse is teaching a client about a variety of stress management techniques. Which of the
following instructions by the nurse is appropriate?
Tighten your muscles before relaxing them when using muscle relaxation techniques Breathe in
through your mouth and out through your nose when using deep breathing exercises
Imagine a situation that has been stimulating for you when practicing guided imagery
Talk to someone who you admire as the first step in using mindfulness techniques to relax
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84.A nurse is caring for a client who has a prescription for a peripheral IV catheter. After
puncturing the skin with the vascular access device and noting a blood return in the flashback
chamber, which of the following actions should the nurse perform next?
1.
Release the tourniquet
2.
Retract the stylet
3.
Advance the catheter into the vein
4.
Flush the catheter with saline
85.A nurse is caring for a client who has a vented NG tube set to low intermittent suction and
has vomited. Which of the following actions should the nurse perform first?
1.
Administer an antiemetic medication
2.
Replace the NG tube
3.
Provide functioning of the suction device
4.
Evaluate function of the suction device
86.A nurse is administering medications to a group of clients. Which of the following
occurrences requires the completion of an incident report?
1.
A client requests his statin to be administered at 2100
2.
A client asks for pain medication 1 hr early
3.
A client vomits within 20mints of taking morning medications
4.
A client receives his antibiotic 2 hrs late
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87.A nurse is caring for a client who has prescriptions for furosemide and gentamicin. For
which of the following complications should the nurse monitor the client? P .143 pharm
1.
Ototoxicity
2.
Liver toxicity
3.
Hyperkalemia
4.
Hypoglycemia
Always remember for those two meds - OTOTOXICITY is always the complication
88.A nurse is caring for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding?
1.
Increased intracranial pressure
2.
Upper extremity hypotension
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3.
4.
Weak femoral pulses ( peds. P 112)
Frequent nosebleeds
89.A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the
following should the charge nurse identify as the purpose of telemetry monitoring?
1.
To measure cardiac perfusion
2.
To measure cardiac output
3.
To identify dysrhythmias
4.
To identify valve insufficiency
90.A nurse is caring for a client who is at 20 weeks of gestation and reports urinary frequency.
Which of the following actions is appropriate?
1.
Advise the client to limit her evening fluid intake ( Esta no)
2.
Obtain a specimen for culture and sensitivity
(ESTA SI)
3.
Check the client for rupture membranes
4.
Assure the client that this is an expected finding during this trimester
(urinary
frequency is common in pregnancy) - ESTA NO. occurs during first and third trimester
106. A nurse is providing discharge teaching to a client who has undergone bowel surgery with
placement of a colostomy. Which of the following information should the nurse include in the
teaching?
a.
Eat a low-fiber diet if constipation occurs.
b.
Apply a skin sealant around the stoma before applying the pouch. (I put this one -Jackie)
c.
Make a pinhole in the pouch to allow for gasses to vent.
d.
Cut the opening of the wafer 2 cm (0.8in) wider than the stoma
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108. A home health nurse is teaching the caregiver of a client who has AIDS about infection
control in the home. Which of the following information the nurse include in the teaching?
a.
Dispose of recapped needles and syringes in biohazard bag.
b.
Wash clothing twice in cold water and laundry detergent.
c.
Designate a separate bathroom in the home for the clients use.
d.
Make a new solution of bleach and water each day for disinfection.
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109. A nurse is planning care for a group of clients and is working with one licensed practical
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse
take first to manage her time effectively?
a.
Delegate tasks to the AP.
b.
Determine goals of the day (I put this
one Jackie)
C.
Schedule daily activities.
d. Develop an hourly time frame for tasks.
110. A nurse is assessing a client who has antisocial personality disorder. Which of the
following characteristics should the nurse expect?
a.
Exaggerated expression of emotion
b.
Sensitive to criticism
C. Needs continues reassurance
d. Lack of remorse (I put this one -Jackie)
111. A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine?
a.
Hgb 14 g/dL
b.
WBC count 2,900/mm (I put this one -Jackie) me too!! AGRANULOCYTOSIS
C. Fasting blood glucose 100 mg/dL
d. Heart rate 58/min
112. A nurse is performing a dietary assessment for a client. Which of the following questions
should the nurse ask when assessing the client's dietary acculturation?
a.
"Are there any foods that you are allergic to?"
b.
"How do you feel about your current body weight?"
C. "What questions do you have about reading food labels?"
d. " Do you have special customs that you follow for meals?" (I put this one -Jackie)
113. A nurse is preparing to document care in a client's electronic health record. Which of the
following entries by the nurse demonstrates appropriate documentation?
a.
"Client drank orange juice at HS."
b.
"Client has a heart rate of 102/min" (I put this one -Jackie) ME TOO I CHOSE THIS
ONE
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C. "Client is demanding of nurse's attention."
d. "Client appears nervous."
114. A nurse manager is planning a staff in-service to address advocacy in client care. The
nurse should promote which of the following practices during the in-service? (select all that
apply)
a.
Addressing client needs when providing resources *
b.
Making decisions about health care on client's behalf
C. Promoting health care access*
d. Encouraging clients to seek further information from the provider *
e. Honoring family requests to withhold medical information *(I put this one -Jackie)
115. A nurse is providing teaching to a client about risk factors for breast cancer. Which of the
following factors should the nurse include as placing the client at an increased risk for
developing breast cancer?
a.
A BMI less than 25
b.
Use of hormone replacement therapy (I put this one -Jackie)
C. Early menopause
d. Fibrocystic breast disease
116. A charge nurse is concerned about a recent increase in facility-acquired catheter
infections. Which of the following actions should the nurse take first?
a.
Schedule nursing staff training for infection control procedures
b.
Identify possible precipitating factors related to the infections (I put this one -Jackie)
C. Meet with providers to discuss measure to decrease the infections
d. Revise the current policy for catheter care
117. A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of
the following responses by the client is the priority for the nurse to evaluate?
a.
"My throat feels tight." (I put this one -Jackie)- THS ONE I CHOSE! THIS CAN BE
ANAPYLACTIC RXN
!!!
b.
" I don't understand why I am getting this antibiotic."
C. "My arms burn each time that medication is running."
d. "This medication bag is still full."
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118. A nurse is teaching a group of newly licensed nurses caring for a client who has a
Clostridium difficile infection. Which of the following instructions should the nurse include in
the teaching?
a.
Apply a mask when providing care.
b.
Wear a gown while providing personal hygiene. (I put this one -Jackie)
C. Place the client in a room with negative airflow.
d. Wipe the stethoscope with alcohol after leaving the client's room.
119. A nurse is caring for a client who is alert and oriented and is receiving continuous ECG
monitoring. The cardiac rhythm strips show a wavy baseline, no distinguishable P waves, and an
increased heart rate. The nurse should identify the cardiac rhythm as which of the following?
a.
Ventricular asystole
b.
Second-degree heart block
C. Sinus Tachycard
d. Atrial fibrillation (I put this one -Jackie) me too!!!!!
A fib has no p waves and HIGH
HEART RATE
120. A nurse is assessing a client who has type 1 diabetes mellitus and a blood glucose level
of 52 mg/dL. Which of the following findings should the nurse expect?
a.
Deep respirations- this is KUSSMAUALS
b.
Hot, dry skin- HYPO is COOL and CLAMMY
C. Bradycardia HYPO is TACHY
d. Blurred vision (I put this one -Jackie) me too!!!!!!!
The rest is HYPERGYLCEMIA
121. A nurse is preparing to perform a sterile wound irrigation and dressing change for a
client. Which of the following actions by the nurse indicates a break in surgical aseptic
technique?
a.
Placing the supplies on the sterile field and leaving a 1-inch perimeter
b.
Applying a sterile gown after applying a sterile mask
C. Balancing the bottle on the sterile basin while pouring the liquid
d. Putting on sterile gloves after preparing the sterile field
122. A nurse is preparing to administer several medications through a client's nasointestinal
tube. The nurse should ask the pharmacist about the availability of a different form for which
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of the following medications?
a.
Oral anticoagulant
b.
Statin tablet
C. Antibiotic suspension
d. Enteric-coated aspirin
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123. A nurse is caring for a client who has a new prescription for clozapine. Which of the
following should the nurse recognize as an adverse effect of this medication?
a.
Diarrhea
b.
Hypoglycemia
C. Urinary frequency
d. agranulocytosis
124. A nurse is planning care for a client who follows Buddhist dietary practices. Which of the
following food selections should the nurse recommend for the client's meal tray?
a.
Vegetable beef soup
b.
Spinach and strawberry salad
C. Ham and cheese sandwhich
d. Baked fish
125. A nurse in a mental health facility receives change-of-shift report for four clients. Which
of the following clients should the nurse plan to assess first?
a.
A newly admitted client who has a hx of 4.5 kg (1Olb) weight loss in the past 2 months
b.
A client who will be receiving her first ECT treatment today
C. A client placed in restraints due to aggressive behavior
d. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
126. A nurse is providing teaching about immunizations to a client who is pregnant. Which of
the following statements should the nurse include in the teaching?
a.
You can receive the immunization for influenza at any time during your pregnancy
b.
The immunization for varicella should be given at least 1 month prior to delivery
C. The hepatitis B immunization should not be obtained until after you finish breastfeeding
d. You can receive the rubella immunization during the third trimester of pregnancy
127. A public health nurse is teaching a group of new parents about SIDS. Which of the
following statements by the parents indicates an understanding of the teaching
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a.
"I will make sure the mattress in my baby's crib is firm" <???
b.
"My baby will no longer be at risk for SIDS when he reaches 6 months
C. I can keep my newborn in bed with me at night to make bottle feeding easier
d. I will avoid giving my baby a pacifier during naptimes
128. A nurse is planning care for a child during admission to the facility. Which of the
following actions should the nurse take first? (Exhibit)
Tab 1: H&P - 6 years old, vomited 3x in past 24h, irritable behavior for past 24h, respiratory
infection started
3 days ago, Brudzinski's and Kernig's signs positive
Tab 2: VS - RR 28/min, HR 12O/min, BP 1O8/64, pain 6/1O
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Tab 3: Meds - vancomycin 3OO mg IV q6h following blood cultures, Acetaminophen 24O mg PO
6hr PRN fever
a.
Initiate seizure precautions<<<meningitis
b.
Collect blood cultures
C. Transport the child to obtain a CT scan
d. Obtain a prescription for pain medication
129. A nurse in the ED is caring for an adolescent who has acute appendicitis and reports pain
at McBurney's point. The nurse should identify which of the following areas as McBurney's
point?
130. A nurse is developing a plan of care for a client who has preeclampsia and is to receive
magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
a.
Give the client protamine if the signs of magnesium sulfate toxicity occur
b.
Monitor the FHR via doppler q3O min
C. Restrict the client's total fluid intake to 25O mL/hr
d.
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retaiing the MAG SULFATE
131. A nurse is providing teaching to a client about the adverse effects of Sertraline. Which of
the following adverse effects should the nurse include?
a.
Excessive sweating - serotonin syndrome = ch 8 p 53 pharm
b.
Metallic taste in mouth
C. Increased urinary frequency
d. Dry cough
132. A nurse is caring for a client who has tuberculosis. The client tells the nurse he has not
been taking his medication because he can no longer afford to purchase it. Which of the
following statements should the nurse make?
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a.
I will ask the social worker to come speak with you about this situation
b.
I will tell your provider that you do not want take the medication
C. You should budget your money to be able to purchase this medication
d. You should ask your family to purchase the medication for you
133. A nurse in an ED is caring for a client who is having manifestations of an ischemic stroke
that began 2 hr ago. Which of the following actions should the nurse take? P . 84 ch 15
a.
Place the client in high-fowler's position
b.
Prepare the client for a chest x-ray
C. Initiate fibrinolytic therapyyou got a window of 6 hours! Its contraindicates for
HEMORRHAGIC STROKE
d. Insert an indwelling urinary catheter
134. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus.
Which of the following resources should the nurse provide to the client?
a.
Food label recommendations from the institute of medicine
b.
Personal blogs about managing the adverse effects of diabetes medications
C. Food exchange lists for meal planning from the american diabetes association
d. Diabetes medication information from the physicians' desk reference
135. A nurse is receiving report on four postpartum clients. Which of the following clients
should the nurse plan to attend to first.
a.
A client who has hyporeflexia while receiving magnesium sulfate
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b.
A client who reports abdominal pain during breastfeeding- normal, since your
stimulating oxytocin
C. A client who reports changing her perineal pad every 2 hr.
q 15 minutes would be a
problem
d. A client who has a output of 25O mL in 6hr= 3O x 6 = 18O
136. A nurse is preparing to administer methylprednisone sodium succinate to a client who
has chronic inflammatory disorder. The nurse should plan to monitor which of the following
laboratory tests while the client is taking this medication?
a.
INR
b.
PaO2
C. Troponin T
d. Serum glucose (I put this one -Jackie)
137. A nurse is teaching a client who has a new prescription for an MAOI. Which of the
following foods is contraindicated for this medication?
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a.
Eggs
b.
Cheese (I put this one -Jackie) Is high in Tyramine, avoid with MAOI.
C. Grapefruit
d. Potatoes
138. A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac
disease. Into which of the following positions should the nurse place the client to best promote
optimal cardiac output?
a.
High-Fowler's
b.
Left-lateral (I put this one -Jackie)
C. Supine
d. Standing
139. A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription
for an antipsychotic medication. The nurse should recognize that which of the following
indicates an adverse effect that must be reported to the provider?
a.
b.
The client states, "Being in the sun seems to really hurt my eyes."
The client is observed displaying a shuffling gait while walking in the hall.
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C. The client is observed mumbling quietly while alone in the day room.
d. The client states, "I feel light-headed when i stand up quickly."
140. A nurse is reviewing laboratory findings for a client who is to receive a dose of
enoxaparin. For which of the following laboratory values should the nurse withhold the dose
and notify the provider?
a.
WBC 15,OOO/mm3
b.
Urine specific gravity 1.O35
C. Platelets 8O,OOO/mm3- GIVEN
d. BUN 25 mg/dL
141. A nurse manager is confronted by a staff nurse who complains that her assignment is
unfair. Which of the following responses should the nurse manager make?
a.
"You are being unreasonable about your assignment."
b.
"You seem to be upset about your assignment."
C. "I will always try to be fair when i make assignments."
d. "I can't believe you think this assignment is unfair."
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142. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following indicates that the child maybe experiencing hemmorrhage?
a.
Diminished breath sounds
b.
Elevated pain level
C. Frequent swallowing- they can indicate bleeding.
d. Increased drowsiness
143. A nurse is caring for a client who states that the first day of her last menstrual cycle was
June 14. Using Nagele's rule, the nurse should calculate the client's estimated date of delivery as
which of the following?
a.
April 14
b.
March 21 - 3 months and
C. March 14
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+ 7 months
d. February 14
144. A nurse on a medical-surgical unit is receiving report for four client. Which of the
following clients should the nurse assess first?
a.
A client who is scheduled for chemotherapy and has an RBC count of 4 million/mm3
b.
A client who is 24hr postoperative following a transurethral resection of the prostate
and has small blood clots in the drainage tubing
C. A client who is receiving a blood transfusion and reports low-back pain
d. A client who is 2 days postoperative following placement of an ascending colostomy and has
shreds of bloody mucus in the bag
145. A nurse is admitting a client who has dementia to a long-term facility. The client tells the
nurse that she lived in this facility years ago and took care of all the residents by herself. The
nurse should document this as which of the following findings?
a.
Confabulation
b.
Perseveration
C. Agnosia
d. Projection
146. A nurse is completing an admission assessment for a client who is scheduled for surgery.
Which of the following client allergies should the nurse report to the provider?
a.
Eggs
b.
Peanuts
C. Wheat
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d. Shellfish
147. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag
has 2O mL remaining to infuse but the new bag is not readily available. Which of the following
actions should the nurse take?
a.
Administer dextrose 1O% in water
b.
Slow the infusion rate
C. Temporarily discontinue the infusion
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d. Give 5OO mL of lactated Ringer's solution
148. A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which
of the following actions should the nurse take?
a.
Report the infection to the state department of health
b.
Schedule the client for retesting in 1 week
C. Administer ceftriaxone via intermittent IV bolus
d. Instruct the client to abstain from abstain from sexual intercourse for 1 month
149. A nurse is providing discharge teaching to the provider who has a tracheostomy. Which
of the following information should the nurse include in the teaching?
a.
How to change the tracheostomy dressing using clean technique
b.
How to operate the portable suction machine
C. How to change the non disposable tracheostomy tube daily
d. How to secure the tracheostomy tube with ties at the back of the neck
150. A nurse is planning care for a group of clients. Which of the following methods should
the nurse use to manage time effectively?
a.
Complete partial assessments on all clients before planning the day
b.
Prioritize activities based on the nurse's needs
C. Use the break time to perform documentation
d. Gather supplies prior to completing a dressing change
151. A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran.
Which of the following statements by the client indicates an understanding of the teaching?
a.
b.
"I can store the medication in the refrigerator."
"I should keep the medication in the original container."
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C. "I can crush the medication and mix with applesauce."
d. "I should replace any unused medication every 6 months."
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152. A nurse is providing discharge instructions to a client who is 1-day postoperative
following a vertical banded gastroplasty for morbid obesity. Which of the following statements
demonstrates an understanding of the dietary teaching?
a.
"I will be limited to pureed foods for the next 6 months."
b.
"I should eat three meals per day."
C. "It should take me 3O to 6O minutes to eat a meal."
d. "Vomiting is common ant I will have to learn to live with it."
153. A nurse in the intensive care unit is planning care for a client who has a closed head
injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter.
Which of the following actions should the nurse include in the plan of care?
a.
Keep the client in a supine position
b.
Maintain ICP at 2Omm Hg
C. Suction the client every 2 hr
d. Avoid overstimulation of the client
154. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the
following interventions should the nurse include in the plan of care?
a.
Prepare the child for a platelet transfusion
b.
Initiate a low-protein diet for the child
C. Screen the child's visitors for active infections
d. Monitor the child for indications of active bleeding
155. A nurse is caring for an older adult client who has hemiparesis following a stroke. Which
of the following actions should the nurse take to prevent falls? (SATA)
a.
Leave the client's bathroom light on
b.
Have the client wear shoes while ambulating to the bathroom
C. PLace a nonskid mat on the shower floor
d. Place the client's bedside table at the foot of the bed
e. Keep the client's bed in the lowest position
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156. A nurse is providing prenatal teaching for a client who has herpes simplex virus. Which
of the following client statements indicates an understanding of the teaching?
a.
"I won't pass herpes on to my baby if I've only had an outbreak for a week"
b.
"I can't take acyclovir during pregnancy because it might hurt my baby."
C. "My herpes infection has to be reported to the Centers for Disease Control and Prevention."
d. "I should have a cesarean delivery if I'm having an outbreak."
157. A nurse receiving change-of-shift report from the nurse on the previous shift. Which of
the following information should the nurse include in the report?
a.
"Client in room 3O2 has visitors."
b.
"Client in room 3O3 needs his 8am blood glucose before his scheduled insulin."
C. "Client in room 3O1 is in the cardiac catheterization lab."
d. "Client in room 3O4 is doing poorly."
158. A nurse is caring for a client who is recovering from an amputation of her right arm
below the elbow. Which of the following information should the nurse report to the
occupational therapist?
a.
The client's parent is in a skilled nursing facility
b.
The client is allergic to penicillin
C. The client has two small children at home
d. The client lives in a two-story home i picked this one, OT's help out with ADL's, maybe
hell have a hard time walking up stairs or carrying himself or objects up stairs.
159. A nurse is obtaining a blood specimen from a client who has a peripherally inserted
central catheter. Which of the following actions should the nurse take?
a.
Use a 3mL syringe to flush the catheter
b.
Instruct the client to perform the Valsalva maneuver during the blood draw
C. Cleanse the port with povidone-iodine prior to obtaining the specimen
d. Flush with 2OmL of O.9% sodium chloride after obtaining the blood sample
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160. A nurse is providing dietary teaching to a client who has heart failure. Which of the
following recommendations is appropriate for this client?
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a.
Encourage seasoning with dry herbs
b.
Increase fluids to 2L/day (NO puede ser)
C. Use saturated oils when cooking
d. Increase consumption of dairy products
161. A Nurse is developing a plan of care for a newborn whose mother tested positive for
heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of
the following actions should the nurse include in the plan?
a.
Maintain eye contact with the newborn during feedings
b.
Minimize noise in the newborn's environment
C. Administer naloxone to the newborn.
d. Swaddle the newborn with his legs extended
162. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the
following statements by a newly "I should advise a client about what I feel to be his best
licensed nurse indicates an
a."
health care decision. (Creo que esta no puede ser)
understanding of the teaching?
b.
"I will inform a client that his family should help make his health care decisions."
C. "I will intervene if there is a conflict between a client and his provider."
d. "I should not advocate for a client unless he is able to ask me himself."
163. A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP).
Which of the following client care tasks is within the scope of practice for the AP?
a.
Performing postmortem care
b.
Explaining the steps for a 24-hr urine collection
C. Assisting with low-carbohydrate diet selections
d. Interpreting blood glucose values
164. A nurse is planning discharge care for an older adult client who tells the nurse he does
not like living alone because he is afraid of falling. Which of the following resources should the
nurse assist the client to explore prior to discharge?
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a.
Ambulatory care center
b.
Assisted living center
C. Skilled nursing facility
d. Hospice care
165. A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis.
Which of the following assessments should the nurse perform as part of this screening?
a.
Observe for sacral dimpling
b.
Observe for a positive Romberg sign
C. Measure the anteroposterior diameter of the chest
d. Measure the truncal rotation
166. A nurse is providing discharge teaching about oxycodone to a client who had an
appendectomy. Which of the following information should the nurse include in the teaching?
a.
Decrease fiber intake while taking his medication to prevent diarrhea.
b.
Urinary frequency is an adverse effect of this medication.
C. Slow respirations can occur when taking this medication.
d. Pain relief should occur 5 min after taking this medication.
167. A nurse is preparing information about skin care for a client who has cancer of the
prostate and is receiving radiation therapy. Which of the following information should the nurse
include?
a.
Clean the perineal area using a washcloth.
b.
Dry the perineal area by using a patting motion
C. Apply heat packs to the affected area as needed (No puede ser en radiation no se puede dar
mas calor)
d. Wear snug-fitting underwear
168. A nurse is providing preoperative teaching to an older adult female client who is
scheduled for a laminectomy and uses supplements. Which of the following supplements
should the nurse identify as increasing the client's risk for hypotension during surgery?
a.
Soy
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b.
Flaxseed
C. Probiotics
d. Black cohosh
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169. A nurse is assessing a client who is preoperative for abdominal surgery. Which of the
following findings should the nurse identify as the priority?
a.
WBC 11,OOO/mm3
b.
Temperature 38.1 C (1OO.5 F)
C. Potassium 3.4 mEq/L
d. Heart Rate 13O/min
170. A nurse is teaching a group of parents about expected development of gross motor skills
during infancy, The nurse should teach that the following developmental tasks are expected to
occur in what order?
Rolls from back to side 1
Rolls from back to abdomen 2
Changes from prone to sitting 3
Sits steadily unsupported. 4
171. A nurse is planning care for a client who has stage II Parkinson's Disease. Which of the
following actions should the nurse include in the plan of care?
a.
Offer clear liquids with and between meals
b.
Offer high-calorie nutrition supplements
C. Encourage the client to concentrate on looking at his feet while walking.
d. Encourage the client to participate in small muscle dexterity activities.
172. A nurse is assessing a client who has been taking oral contraceptives for the past 6
months. Which of the following findings should the nurse immediately report to the provider?
a.
Frequent nausea
b.
Breast tenderness
C. Weight Gain 2.3kg (5lb)
d. Persistent Headache
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173. A nurse in the emergency department is assessing a client who has major depressive
disorder. Which of the following actions should the nurse take first ? (click on the "Exhibit"
button for additional information about the client. There are three tabs that contain separate
categories of data.)
a.
Encourage the client to verbalize feelings. (Asess for hopelessness)
b.
Implement seizure precautions for the client.
C. Administer ondansetron to the client for nausea.
d. Obtain the client's weight.
174. A nurse is planning care for a client who is receiving internal radiation therapy to treat
uterine cancer. Which of the following interventions should the nurse include in the plan?
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a.
Tell visitors to remain at least 1.8 m(6 feet) away from the client.
b.
Place the client in a semi-private room with a roommate who is noninfectious.
C. Instruct the client that she can ambulate to the bathroom.
d. Allow children younger than 16 years of age to visit for up to 1 hr per day.
175. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care.
Which of the following instructions should the nurse include in the teaching?
a.
Round the edges of toenails when trimming.
b.
Use moisturizing lotion between the toes
C. Wear clean cotton socks every day.
d. Soak feet twice daily.
176. A nurse is preparing to administer cefpodoxime 1O mg/kg/day PO divided equally every
12 hr to a child who weighs 66 lbs. Available is cefpodoxime 2O mg/ml oral solution. How many
ml should the nurse administer per dose? (Round the answer to the nearest tenth. Usea leading
zero if applicable. Do not use a trailing zero.)
66 lbs. /2.2= 3O kg
3Okg x 1O mg=3OO mg/day 3OO mg/2 doses= 15O mg/dose
15O mg/2Omg x 1ml= 7 .5 ml/dose
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177. A nurse on a medical-surgical unit is planning care for a group of clients. Which of the
following clients should the nurse plan to see first?
a.
A client who has diabetes mellitus and a morning blood glucose level of 12O mg/dL.
b.
A client who has heart failure and an oxygen saturation level of 89%
C. A client who has atrial fibrillation and a ventricular heart rate of 1O5/min
d. A client who has polycystic kidney disease and a blood pressure of 13O/85 mmHg
178. A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which
of the following actions should the nurse take?
a.
Perform the procedure prior to meals
b.
Administer a bronchodilator after the procedure
C. Hold hand flat to perform percussions on the child.
d. Perform the procedure twice a day.
179. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications
a.
Contractions
b.
Hypertension
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C. Vomiting
d. Epigastric pain ( Esta no)
180. A nurse is providing care for a group of clients. Which of the following client's should the
nurse assess first?
a.
A client who has pneumonia with a productive cough
b.
A client who has a NG tube in place and reports nausea
C. A client who received an opioid for pain following an appendectomy and has an SaO2 of
94%
d. A client who has a fracture tibia and reports shortness of breath
18O. A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices."
Which of the following responses is the priority for the nurse to state?
a.
"How long have you been hearing the voices?"
b.
"What are the voices telling you?"
c.
"Have you taken your medication today?"
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d.
"I realize the voices are real to you, but I don't hear anything."-
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RN Comprehensive Predictor 2019 Form E
1)
A nurse in an emergency department completes an assessment on an adolescent client
that has conduct
disorder. The client threatened suicide to teacher at school. Which of the following statements
should the
nurse include in the assessment?
a)
Tell me about your siblings
b)
Tell me what kind of music you like
c)
c) Tell me how often do you drink alcohol
d)
Tell me about your school schedule
2)
*A nurse is observing bonding to the client her newborn. Which of following actions by
the client requires
the nurse to intervene ?
a)
Holding the newborn in an en face position
b)
Asking the father to change the newborn's diaper
c)
Requesting the nurse take the newborn nursery so she can rest
d)
d) Viewing the newborn's actions to be uncooperative
3)
A nurse is caring for client who is taking levothyroxin. Which of the following findings
should indicate that
the medication is effective?
a)
Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism)
b)
Decreased blood pressure
c)
Absence of seizures
d)
Decrease inflammation
4)
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which
instructions would
you include in the teaching?
a)
Contact provider if the cord still turns black (it's going to turn black)
b)
Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH
cleanser ) c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent
infection)
d) The cord stump will fall off in five days (cord falls off in 10-14 days)
5)
A nurse is assessing a client in the PACU. Which of the following findings indicates
decreased cardiac
output?
a)
Shivering
b)
b) Oliguria
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c)
d)
Bradypnea
Constricted pupils
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6)
A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the
following client
should the nurse identify as the priority?
a)
A client that has massive head trauma
b)
A client has full thickness burns to face and trunk
c)
c) A client with indications of hypovolemic shock
d)
A client with open fracture of the lower extremity
7)
A nurse is a receiving report on four clients. Which of the following clients should the
nurse assess first?
a)
A client who has illeal conduit and mucus in the pouch
b)
Client pleasant arteriovenous additional vibration palpated
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c)
d)
A client whose chronic kidney disease with cloudy diasylate outflow
A client was transurethral resection of the prostate with a red tinged urine in the bag
8)
A nurse is caring for a client just received the first dose of lisinopril. The following is an
appropriate nursing
intervention?
a)
Place's cardiac monitoring
b)
Monitor the clients oxygen saturation level
c)
c) Provide standby assist with the client from bed
d)
Encourage foods high in potassium
9)
A nurse is caring for a client who is in labor and his seat is receiving electronic fetal
monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the
following should the nurse
expect?
a)
Feta hypoxia
b)
Abrupto placentae
c)
Post maturity
d)
Head Compression
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1O) A nurse is caring for a client who has chronic kidney disease. The nurse should identify
which of the
following laboratory values as in an indication for hemodialysis?
a)
glomerular filtration rate of 14 mL/ minute
b)
BUN 16 mg/DL
c)
serum magnesium 1.8 mg mg/dl
d)
Serum phosphorus 4.O mg/dL
11)
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The
following is an
appropriate action for the nurse to take?
a)
Placed infant under radiant warmer
b)
Move the probe site every 3 hours
c)
Heat the skin one minute prior to placing the program
d)
Placed a sensor on the index finger
12)
A nurse in a mental health facility receives a change of shift report on for clients. Which
of the following
clients should the nurse plan to assess first?
a)
Client placed in restraints to the aggressive behavior
b)
A new limited client pleasures history of 4.5 kg weight loss in the past two months
c)
Client is receiving a PRN dose of health heard all two hours ago for increased anxiety
d)
Applied he'll be receiving his first ECT treatment today
13)
A nurse working at the clinic is teaching a group of clients who are pregnant on the use
of
nonpharmacological pain management. Which of the following statements by the nurse is an
appropriate
description of the use of hypnosis during labor?
a)
Hypnosis focuses on the biofeedback as a relaxation technique
b)
Hypnosis promotes increased control of her pain perception during contractions
c)
Hypnosis uses therapeutic touch to reduce anxiety during labor
d)
Hypnosis provides instruction to minimize pain
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of
14)
A nurse in a County Jail health clinic is leading group therapy session. A client who was
incarcerated for theft is addressing the group. Which of the following is an example of reaction
formation? (rxn formation is when you use opposite feelings; ex: being super nice to someone
you dislike)
a)
I steal things because it's the only way I can keep my mind off my bad marriage
b)
I can't believe I was accused of something I didn't do
c)
I don't want talk about my feelings right now. We will talk more next time
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d)
I think that people just you're just lazy and should earn money honestly
15)
A nurse is obtaining the medical history of a client who has a new prescription for
isosorbide monotitrate.
Which of the following should the nurse identify as a contraindication to medication?
a)
Glaucoma
b)
Hypertension
c)
Polycythemia
d)
Migraine headaches
16) ?
17)
The nurses is caring for a client recovering from an acute myocardial infarction. Which
following intervention should the nurse include in the point of care?
a)
Draw a troponin level every four hours
b)
Performance EKG every 12 hours
c)
Plant oxygen tent fell over minutes via rebreather mask
d)
Obtain a cardiac rehabilitation consult
18)
A Nurses caring for client who has breast cancer and has been covering receiving
chemotherapy. Which of
the following laboratory values should nurse report to provider?
a)
WBC 3,OOO/mm3
b)
Hemoglobin 14 g/dl
c)
Platelet 25O,OOO/mm3
d)
aPTT 3O seconds
19)
Home health nurse is carefully planned for Alzheimer's disease. To the following action
should the nurse
include in the plan of care
a)
Place a daily calendar in the kitchen
b)
Replace button clothing with zippered items
c)
Replace the carpet with hardwood floors
d)
Create variation in daily routine
2O) Nurse is performing change of shift assessments on 4 clients. Which of the following
findings should the
nurse report to provider first?
a)
The client was cystic fibrosis and has a thick productive clock and reports thirst
b)
Client who has gastroenteritis and is lethargic and confused
c)
The Client has diabetes mellitus has morning fasting Legal cost of 185 mg over deal
d)
The client was sick of signing it reports pain 15 minutes after receiving oral analgesic
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21)
A nurse is caring for a client was in the second trimester of pregnancy and asks how to
treat constipation.
Which of the following statements by the nurse is appropriate?
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a)
Decrease taking vitamins and supplements to every other day
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of
b)
c)
d)
Eat 15 g of fiber per day
Consume 48 ounces of water each day (need at least 64 oz)
Drink hot water with lemon juice each morning when you wake up
22) ?
23)
A nurse is caring for a client who is preparing his advance directives. Which is the
following statements by
the client indicates an understanding of advanced directives? select all that apply
a)
I can't change my instructions once a minute
b)
My doctor will need to approve my advance directives
c)
I need an attorney to witness my signature on the advance directives d) I have the right
to refuse treatment
e) My health care proxy can make medical decisions for me
24)
A nurse is caring for a client who is at 32 weeks gestation and has a history of cardiac
disease. Which of
the following positions should the nurse place the client to best promote optimal cardiac
output?
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a)
b)
c)
d)
The chest
Standing
Supine
Left lateral
25)
A nurse is caring for a group of clients. Which of the following clients should the nurse
assign to an AP?
a)
Client who has chronic obstructive pulmonary disease and needs guidance on incentive
spirometry
b)
Client who has awoken following a bronchoscopy and requests a drink
c)
Client who had a myocardial infarction 3 days ago reports chest discomfort
d)
Client who had a cerebrovascular accident two days ago and needs help toileting
26)
Nurse providing discharge teaching to the client who has schizophrenia and is starting
therapy with
clozapine. Which of the following is the highest priority for the client to report to the provider?
a)
Constipation
b)
blurred vision
c)
Fever
d)
Dry Mouth
27)
A nurse observes an AP providing care to a child who is in skeletal traction. Which of the
following action
requires intervention?
a)
Providing a high protein snack
b)
Assisting the child to reposition
c)
Placing weights as a child's bed
d)
Massaging pressure points-causes skin breakdown
28)
A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who
has diabetes
mellitus. Which of the following action should the nurse take?
a)
Determine if the AP is qualified to perform the test.
b)
Help the AP performed the blood glucose test
c)
Assign the AP to ask the client is taking his diabetic medication today
d)
Have AP check the medical record for prior blood glucose test results
123 of
29)
A nurse is assessing client brought to the hospital psychiatric emergency services by a
law enforcement officer. The client has disorganized, incoherent speech with loose associations
and religious content. You should recognize the signs and symptoms as being consistent with
which of the following?
a)
Alzheimer's disease
b)
Schizophrenia
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c)
d)
Substance intoxication
Depression
3O) A nurse is caring for a child who has infectious mononucleosis.. Which of the following
findings are
associated with this diagnosis? Select all that apply
a)
splenomegaly
b)
Koplik spots (this is associated with measles)
c)
Malaise
d)
Vertigo
e)
e) Sore throat
31)
Nurse is performing dressing change for client was a sacral wound using negative
pressure wound
therapy. Which The following actions should the nurse take first?
a)
Apply skin preparation to wound edges.
b)
Normal saline
c)
Don sterile gloves
d)
Determine pain level
32)
A nurses caring for client recovery from the bowel surgery who has nasogastric tube
connected to low intermittent suction. Which the following assessment findings should indicate
to the nurse that the NG tube
may not be functioning properly?
a)
Drainage fluid is greenish-yellow
b)
aspirate pH of 3
c)
Abdominal rigidity
d)
air bubbles noted in the NG tube
33)
A nurse is preparing to administer TPN with added fat supplements to a client who has
malnutrition.
Which of the following action should the nurse take?
a)
Piggyback O.9 sodium chloride with TPN solution
b)
Check for an allergy to eggs
c)
Discuss the TPS solution for 12 hours
d)
Monitor for hypoglycemia
34)
A charge nurse is discussing the use of applying ice to a client's injured knee with a
newly licensed nurse.
Which of the following should the nurse identify as a benefit? (A/C?)
a)
Systemic analgesic effect
b)
increase in your metabolism
c)
Decreased capillary permeability
d)
Vasodilation
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35)
Nurse is developing discharge care plans for client has osteoporosis. To prevent injury
the nurse should
instruct the client to
124 of
a)
Perform weight bearing exercises
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28
of
b)
c)
d)
Avoid crossing the legs beyond the midline
Avoid sitting in one position for prolonged periods
Split affected area
36)
A nurse on acute med-surgical unit is performing assessments on a group of clients.
Which is highest
priority?
a)
The client has surgical hypoparathyroidism and positive Trousseau's sign
b)
A client who was Clostridium difficile with acute diarrhea
c)
A client who is acute kidney injury and urine with a low specific gravity
d)
The client who has oral cancer and reports a sore on his gums
37)
Nurses caring for a client was congestive heart failure. Which of the following
prescriptions for the
provider should the nurse anticipate?
a)
Call the provider to clients respiratory rate is less 18/min
b)
Give the client 5OO mL IV bolus of O.9 sodium chloride over 1 hr
c)
Give the client enalapril 2.5 mg PO twice daily
d)
Call the provider if the clients pulse rate is less than 8O/min
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38)
A nurse is caring for a client who has a prescription for sertraline to treat depression.
Which of the
following statements by the client indicates an understanding of the medication treatment
plan?
a)
I will be able starting this medication with feel better
b)
I can expect to urinate frequently while on this medication
c)
I understand I may experience difficulty sleeping on this medication
d)
I should decrease my sodium intake while on this medication
39)
A nurse has been caring for a female client who has bruises on her arms that she
explains are a result of physical abuse by her husband. The client states, "I don't know how
much longer I can take this, but I'm afraid he'll really hurt me if I leave. "Which of the following
is an appropriate nursing intervention?"
a)
Offer to speak to the client's husband regarding his abuse behavior.
b)
b) Help the client to recognize the signs of escalation of abuse behavior
c)
Assist the client to identify personal behaviors that trigger abusive behavior
d)
Assist the client to Reports abusive behavior to the proper authority
4O) A client was having suicidal thoughts tells the nurse "It just does not seem worth it
anymore. Why not end
my misery?" Which of the following responses for the nurses appropriate?
a)
Why do you think your life is not worth it anymore? b) Do you have a plan to end your
life?
c)
I need to know what you mean my misery
d)
You can trust me and tell me what you're thinking
41)
A nurse is caring for a client who has schizophrenia. Which of the following assessment
findings should
the nurse expect?
a)
Decreased level consciousness
b)
Unable to identify common objects
c)
Poor problem solving ability
d)
Preoccupation was somatic disturbances
126
of
42)
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity.
Which of the
following action should nurse take? There are 3 tabs that contain separate categories of data.
a)
Position the client with the affected extremity lower than the heart
b)
Administration of acetaminophen
c)
Massage the affected extremity every 4 hrs. d) Withhold heparin IV infusion
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43)
Is caring for clients was a new prescription for enoxaparin for the prevention of DVT.
Which of the
following is an appropriate action by the nurse?
a)
Expel air bubble at the top of the prefilled syringe
b)
Massage the injection site to evenly distribute the medication c)
Inject the medication the lateral abdominal wall
d) Administer an NSAID for injection site discomfort
44)
Nurses caring for four clients. Which of the following client data should the nurse report
to the provider?
a)
A client who has a pleurisy and reports pain of 6 on a scale of O to 1O when coughing
b)
Client was a total of 11O mL of serosanguineous fluid from the Jackson Pratt drain within
the first 24
hour following surgery
c)
Client who is 4 hrs postoperative and has a heart rate of 98 per minute
d)
The client was a prescription for chemotherapy and an absolute neutrophil count of
75/mm3
45)
Nurses caring for client was in end-stage osteoporosis and is reporting severe pain.
Clients respiratory
rate is 14 per minute. Which of the following medications should the nurse expect to be the
highest
priority to administer to the client?
a)
Promethazine b)
Hydromorphone
c)
Ketorolac
d)
Amitriptyline
46)
A nurse is caring for a client who has DVT. Which of the following instructions the nurse
include in the
plan of care?
a)
Live with the clients fluid intake to 15OO mL per day
b)
Massage place affected extremity to relieve pain
c)
Apply cold packs of clients affected extremity
d)
Elevate the client's affected extremity when in bed
47)
A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The
client's contractions are occurring every 45 seconds with a nine seconds duration in the fetal
heart rate is 17O to
18O/minute. Which of the following actions should nurse take?
a)
Discontinue oxytocin infusion
b)
Increased oxytocin infusion
c)
Decreased oxytocin infusion
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d)
Maintain oxytocin infusion
48)
A nurse is admitting a client who is in labor and at 38 wks of gestatio n to the maternal
newborn unit. The client has a history of herpes simplex virus 2 . Which of the following
questions is most
appropriate for the nurse to ask the client?
127 of
a)
Have your membranes ruptured?
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28
of
b)
How far apart are your contractions? c) Do you have any active lesions?
d) Are you positive for beta strap?
49)
Nurse is providing teaching for child prescribed ferrous sulfate. Which of the following
instructions should
the nurse include?
a)
Take with meals
b)
Take at bedtime
c)
Take with a glass of milk
d)
Take with a glass of orange juice
5O) Four clients present to the emergency department. The nurse should plan to see which of
the following
clients first?
a)
A 6 year old client whose left shoulder is dislocated
b)
A 26 year old client for sickle cell disease and a severe joint pain
c)
A 76 year old client was confused, febrile and has foul smelling urine - uti
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d)
A 50- year old client who has slurred speech, is disoriented, and reports a headache stroke
51)
A nurse is completing a dietary assessment for client who is Jewish and observes kosher
dietary practices.
Which of the following behaviors should the nurse expect to find?
a)
Leavened bread maybe eaten during Passover.
b)
Shellfish is commonly consumed in the diet. c) Meat and dairy products are eaten
separately.
d) Fasting from meat occurs during Hanukkah.
52) ?
53)
A nurse is in an ER caring for client of multiple wounds due to a motor vehicle crash.
Which of the
following interventions are appropriate? Select all that apply
a)
Apply direct pressure to bleeding wounds
b)
Clean rest last rations and abrasions with hydrogen peroxide c)
Cover wounds with a sterile dressing
d) Administer 65O mg aspirin PO as needed for pain e) Determine date of last tetanus toxoid
vaccination.
54)
The nurses reviewing clients admission laboratory results. Which of the findings required
further
evaluation?
a)
Sodium 138 b)
Creatinine 1.8
c)
Hemoglobin 15
d)
Potassium 4.2
55)
A nurse is providing teaching for a client has a new prescription for methadone. Which
of the phone
following client statements indicates need for further teaching?
a)
I understand the methadone tends to slow my breathing
b)
I understand the methadone may cause me to have difficulty sleeping
c)
I will avoid alcohol while I'm taking this medication
d)
I'll change positions gradually especially from lying down to standing
129
of
56)
Which of the following client is appropriate for the nurse to refer to speech therapy for
swallowing
evaluation?
a)
Premature infant with a poor suck reflex and failure to thrive
b)
An older adults who has difficulty taking in fluids
c)
Adolescent who anorexia who is cachectic
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d)
A middle aged adults was gastroesophageal reflux disease
57)
first?
a)
b)
c)
d)
A nurse is caring for a group of clients. Which of the following client should nurse assess
A client whose benign prostatic hyperplasia and is unable to urinate
The client was heart failure and report shortness of breath while ambulating
A client who is open cholecystectomy and has green drainage from the T-tube
A client whose abdominal pain and is vomiting coffee ground emesis
58)
A nurse is taking a medication history from client was type II diabetes mellitus is
scheduled for an
arteriogram. Which of the following medications to the nurses instruct the client to discontinue
48 hrs
prior to the procedure?
a)
Atorvastatin
b)
Digoxin
c)
Nifedipine
d)
d) Metformin
59)
The nurses assessing client with posttraumatic stress disorder. Which of the following
findings to the
nurse expect to find?
a)
Dependence on family and friends
b)
Loss of interest in usual activities
c)
Ritualistic behavior
d)
Passive aggressive behavior
6O) A nurse working in a long-term care facility is caring for an older adult client has dementia.
The clients
often agitated and frequently wanders the halls. Which of the following intervention should the
nurse
include in the plan of care?
a)
Give the client several choices when scheduling activities.
b)
Confront the client regarding unacceptable behavior
c)
Maintain Nutritional requirements by offering finger foods
d)
Stimulate the client by leaving the television on throughout the day
61)
A nurse on a mental health unit receives report on four clients. Which of the following
client should the
nurse attend to first?
a)
A client who has begun to demonstrate catatonic behavior
b)
The client was compulsive behavior and is frequently drinking from the water fountain c)
Client was having auditory hallucinations is becoming agitated
d) A client was making sexual comments to clients of the opposite sex
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62)
A nurse is caring for the full term newborn immediately following birth. Which of the
following actions
should the nurse take first?
a)
Instill erythromycin ophthalmic ointment and the newborn's eyes.
b)
Place identification bracelets on the newborn.
130
of
c)
Weigh the newborn.
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28
of
d)
Dry the newborn
63)
A nurse receives report on a group of clients. Which of the following client should the
nurse attend to first?
a)
A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at
1 L per
minute via nasal cannula
b)
A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10
c)
The client was type II diabetes mellitus in his blood with glucose level is at 8O mg/dL
d)
A client who had a gastric endoscopy and whose nasogastric tube is draining 3O mL per
hour of green
fluid
64)
A client at 38 weeks of gestation enters the emergency department. The nurse should
recognize that which
of the following indicates that the client is in the latent phase of labor?
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a)
b)
c)
d)
The client reports the urge to push
b) The cervix is dilated 2 cm
Contractions are 2 to 3 minutes apart
The client reports nausea and vomiting
65)
The charge nurse for medical surgical units discovers client care assignments that should
be reassigned.
Which of the following delegated tasks should be reassigned?
a)
An AP is to calculate intake and output every two hours for client in acute renal failure.
b)
An AP is to collect vital signs every 3O minutes for client who had a cholecystectomy
c)
A licensed practical nurse is to check nasogastric tube placement for client list had a
bowel resection. d) A licensed practical nurses to provide initial feeding for client who had a
cerebrovascular accident.
66)
A nurse caring for the client who has a cast due to a compound fracture to the right
ankle. Which of the
following findings requires immediate intervention?
a)
pruiritus under the cast
b)
Localized stabbing pain upon movement
c)
c) paresthesia of the distal extremity
d)
Edema present when leg is in the dependent position
67)
The nurses providing care for preschoolers with acute gastroenteritis. Basing information
below which of
the following is an appropriate nursing action? Click on the links of this below for additional
client
information
a)
Offer the child a cup of chicken broth.
b)
Encourage the child's intake of gelatin.
c)
Administer oral rehydration solutions.
d)
Institute a banana, Rice, applesauce, and toast diet.
68)
The nurses caring for a client whose taking allopurinol. The nurse should monitor which
of the following
laboratory findings to determine the effectiveness of the medication?
a)
Serum chloride b)
Uric acid level
c)
Serum albumin
d)
Magnesium level
132
of
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69)
A nurse is caring for a client on the cardiac care unit who is hemodynamically unstable.
Which of the
following dysrhythmias should the nurse plan for cardioversion?
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28
of
a)
Ventricular asystole
b)
Third-degree AV block c)
Atrial fibrillation
d) Ventricular fibrillation
7O) Nurse managers preparing an educational program on infection control measures. Which of
the following
should the nurse include when discussing contact precautions?
a)
Scarlet fever b) Herpes simplex
c)
Varicella
d)
Streptococcal pharyngitis
71)
A nurse assesses an older adult client with the decrease caloric intake and weight loss.
Which of the
following findings should the nurse report to the provider immediately?
a)
The clinic experiences coughing and wheezing after eating.
b)
The client reports abdominal pain at a five on a scale of O to 1O.
c)
The client experience is a drop in oxygen saturation to 91% while eating.
d)
The client reports a burning sensation in epigastric area.
72)
A nurse and an assistive personnel are caring for a group of clients. Which of the
following tasks is
appropriate for the nurse to delegate an AP?
a)
Applying condom catheter for client for spinal cord injury
b)
Administrative oral fluids to client was dysphasia
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c)
d)
Documenting the report of pain from client who is postoperative
Reviewing active range of motion exercises with a client who is had a stroke
73)
A nurse from the state health department this is instructing a group nurses regarding
reportable infections.
Which of the following infections should the nurse report to the CDC?
a)
Candida albicans
b)
Herpes simplex virus 2
c)
staphylococcus aureus d) Lyme disease
74)
The nurse is assessing an adolescent client for sickle cell anemia. Which of the following
is a priority
finding by the nurse?
a)
A pain score 7 on a scale of O to 1O b)
Shortness of breath
c)
New onset of a new enuresis
d)
Priapism
75)
Nurses caring for a client whose 1 day postop following a Hypophysectomy for the
removal of the
pituitary tumor. Which of the following findings requires further assessment by nurse?
a)
Glascow scale score a 15
b)
Blood drainage on initial dressing measuring 3 cm
c)
Report of dry mouth
d)
Urinary output greater than fluid intake
134
of
76)
A client with the left leg cast is using crutches for ambulation. The nurse recognizes
client needs further
instruction of the client
a)
Flexes elbows at 3O degrees when using the handgrips
b)
Maintains 3 to 4 finger width between the crutch pad and axilla
c)
Places the crutches 6 inches in front and side of each foot when standing.
d)
Pushes up from a chair with crutches on the unaffected side.
77)
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following
actions should
the nurse plan to take?
a)
Use a designated stethoscope when caring for the toddler.
b)
Wear an N95 respiratory mask while caring for the toddler.
c)
Remove the disposable gown after leaving the toddler's room
d)
Place the toddler in a room with negative air pressure.
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78)
A nurse is admitting to a client to emergency department and initiates continuous
cardiac
monitoring. Which of the following ECG with strips indicates sinus tachycardia?
b)
79)
A nurse is planning care for client to prevent complications of immobility. With the
following
actions should the nurse including the plan of care?
a)
Massage lower extremities daily to prevent DVT
b)
Limit intake of Food high in calcium to prevent renal calculi.
c)
Encourage client to lie supine prevent constipation.
d)
Remove anti embolism stockings for 3 hours each day to decreased skin breakdown.
8O) A nurse discovers that the wrong dosage of medication was given to client . When
determining what action to take your should recognize that which of the following ethical
principles should be applied?
a)
Utility
b)
Paternalism
c)
Veracity
d)
Fidelity
81)
?
82)
A nurse is review in the prescription for doxazosin with a client. Which of the following
should be
included in the teaching?
a)
Decrease caloric intake to reduce weight gain.
b)
Increased dietary fiber to prevent constipation.
c)
Rise slowly when sitting up from bed.
135
of
d)
Take this medication each morning.
83)
the
Addresses planning to provide teaching to young adult client who is insomnia. Which of
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following should the nurse include in the teaching?
a)
Exercising an hour before bedtime
b)
Take a short nap today
c)
Keep bedroom cool at night
d)
Consume a high carbohydrate snack at bedtime.
84)
A nurse is caring for client who has a stool culture that is positive for Clostridium difficile.
Which of the following infection control precautions is appropriate?
a)
Wear a face shield prior into entering the room.
b)
Place the client private room.
c)
Place the client in a negative pressure room.
d)
Use alcohol based hand rub following client care.
85)
A nurse is planning care for a child who has increased intracranial pressure with a
decreased level of
consciousness. Which of the following intervention should the nurse including the plan of care?
a)
Perform active range of motion exercises.
b)
Perform neurological checks every 4 hours.
c)
Suction the airway frequently.
d)
Maintain the head at a midline position.
86)
The nurse assessing a client is receiving radiation therapy. Which of the following
findings should the nurse expect?
a)
White blood cell count at 12,5OO mm3
b)
Excessive salivation
c) +3 pitting edema
d) Platelets 95,000 mm3
87)
A nurse is caring for a client who has preeclampsia and is experiencing postpartum
hemorrhage. The nurse should identify that which of the following medications is
contraindicated?
a)
Methylergonovine.
b)
Misoprostol
c)
Dinoprostone
d)
Oxytocin
88)
A nurse is caring for client was GERD. Which of the following assessment findings the
nurse expect to find?
a)
Shortness of breath
b)
Rebound tenderness
c)
Atypical chest pain
d)
Vomiting blood
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89)
A nurse is caring for a newborn who is under phototherapy lights. Which of the following
is an
appropriate nursing action?
a)
Ensure eye shield is covering the eyes.
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of
b)
Apply lotion to expose skin.
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137
28
of
c)
d)
Offer glucose water between feedings.
Discontinue breast-feeding during treatment.
90)
This is assessing clients as had a long arm cast. Which of the following findings of the
dress
moderate and when assessing for acute compartment syndrome?
a)
Shortness of breath
b)
Petechiae
c)
Change in mental status
d)
Edema
91)
I Just came from client is receiving IV moderate (Conscious) sedation with midazolam.
The client has a respiratory rate of 9/min and is not responding to commands. Which of the
following is an appropriate action by the nurse?
a)
Placed the client in a prone position.
b)
Implement Positive pressure ventilation.
c)
Perform nasopharyngeal suctioning. d) administer flumazenil
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92)
A nurses in a hospital cafeteria overhears two assistive personnel (AP) discussing a client.
They are using the clients name and discussing details of his diagnosis. Which of following
actions should the nurse take first?
a)
Report the AP's behavior to the supervisor.
b)
Completed instant report regarding the Aps conversation.
c)
Provide the AP with written documentation regarding client confidentiality
d)
d) Tell the AP to discontinue their conversation
93)
A community health nurse is teaching a group of adults about the importance of health
screenings. The nurse should include African American males almost twice as likely as caucasian
males to experience which of the following?
a)
testicular Cancer
b)
Obesity
c)
Stroke
d)
Melanoma
94)
A nurse is caring for a client who sprained his left ankle 12 hrs ago . Which of the
following prescription is given by the provider should the nurse clarify?
a)
Over the fact that extremities and two pillows.
b)
Apply heat to affect extremity for 45 minutes on the 45 is off.
c)
wrap the affected extremity with a compression dressing.
d)
Assess the affected extremity for sensation movement impulse every four hours
95)
A nurse is providing dietary teachings for client who has hepatic encephalopathy. Which
the
following food selections indicates that client understands teaching?
a)
A sandwich and milkshake b) Rice with black beans
c)
Cottage cheese and tuna lettuce
d)
Three egg omelette with low-sodium ham
138
of
96)
A nurse is planning care for client sealed radiation implant and is to remain in the
hospital for 1 week. Which of the following should the nurse include in the plan of care?
a)
Remove dirty linens from the room after double bagging. b) Wear a dosimeter film
badge while in the client's room
c)
Limit each of the clients is yours to one hour per day.
d)
Ensure family members remain at least 3 feet from the client.
97)
first?
a)
b)
c)
A nurses is Caring for four clients. Which of the following client should the nurse care
A client to receive a chemotherapy treatment or first national
A client who has an appendectomy to these don't has diminished all sounds
A client is hypothyroidism and his stuporous
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d)
A client who is a burn requiring a sterile dressing change
98)
The nurses planning care for newly admitted adolescent who has bacterial meningitis.
Which the
following instructions is appropriate for the nurse to include in the plan of care?
a)
Initiate droplet precautions for the client
b)
Assisted client to supine position
c)
Performing Glasgow coma scale every 24 hrs
d)
Recommend prophylactic acyclovir there for the clients family.
99)
Nurse is giving discharge instructions to client has new ileostomy. The nurse should
recognize that the teaching has been effective when the client states.
a)
I want sure that my medications are enteric coated
b)
My stoma will drain liquid fluid continuously
c)
I will change my pump system every two weeks
d)
My stoma size will stay the same even after healed
100) A nurse in a provider's office is interviewing a client who is requesting an oral
contraceptive. Which of the following findings in the client's history is a contraindication to use
in combination oral contraceptives?
a)
thyroid disease
b)
Allergy to penicillin
c)
impaired liver function
d)
abnormal blood glucose
1O1) The nurses providing teaching to a client who has mild persistent asthma has been
prescribed
montelukast. Which of the following statements to the nursing put in teaching?
a)
This medication can be used to help you when have an acute asthma attack
b)
This medication should be taken before exercise and physical activity
c)
This medication can be taken for 1O days and then gradually discontinued
d)
This medication helps decrease swelling and mucus production
1O2) A nurse on the medical surgical unit is receiving reports on four clients. Which of the
following client should the nurse assess first?
a)
A client who is receiving warfarin and has and INR of 3.3
b)
A client who has an acute kidney injury, a creatinine of 4 mg/dL, and a BUN 52 mg/dL
c)
A client who had a NG tube inserted 6 hr ago and has abdominal distention
139 of
d)
A client who is 4 hr postoperative following a thyroidectomy and reports fullness in the
back of the
throat
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1O3) A nurse is assessing a client who has pericarditis. Which of the following findings is
priority
a)
Paradoxical pulse
b)
dependent edema
c)
Pericardial friction rub
d)
Substernal chest pain
1O4) A charge nurse is providing teaching to a new licensed nurse on how to cleanup surfaces
contaminated with blood. Which of the following agents said the nurse include in the teaching?
a)
Hydrogen peroxide
b)
Chlorhexidine
c)
Isopropyl alcohol
d)
Chlorine bleach
1O5) *A nurse is preparing to feed a newly admitted patient with dysphagia. Which of the
following actions in response take?
a)
instruct the client to lift her chin when swallowing
b)
discourage the client from coughing during feedings
c)
Sit at or below the client eye level during feedings.
d)
Talk with the client during her feeding.
1O6) A nurse caring for a client who repeatedly refuses meals. The nurse overhears an
assistive personnel telling the client. "If you don't eat, I'll put restraints on your wrists and feed
you." The nurse should intervene and explain to the AP that this statement constitutes which of
the following torts?
a)
Assault
b)
Battery
c)
Malpractice
d)
Negligence
1O7) A charge nurse is evaluating the time management skills for new licensed nurse. The
charge nurse should intervene when a newly licensed nurse does which of the following?
a)
Re-Evaluate priorities halfway through the shift
b)
Delegate changing sterile dressing for licensed practical nurse
c)
Groups activities for the Same client d) Works on several tasks simultaneously
1O8) A nurse is monitoring the client during an IV urography procedure. Which of the
following client reports is the priority finding?
a)
Feeling flushed and warm
b)
Abdominal fullness
c)
Swollen lips
d)
Metallic taste in mouth
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1O9) A nurse is planning to delegate client assignments to the assistive personnel. which of
the following task is appropriate for the nurse to delegate?
a)
Just the flow rate of the clients oxygen tank
140 of
b)
c)
d)
Collecting urine sample
Measuring the clients pain level
Monitoring blood glucose levels
11O) A nurse is assessing a client wasn't following vital signs: Oral temperature of 37.2°C (99 F).
Apical pulse rate of 8O/min, radial pulse rate 62/min, respiratory rate of 16/min, and blood
pressure of 132/4O mm Hg. What is the clients pulse pressure?
a) Systolic presssure subtracted by diastolic pressure (132 - 4O) = 92
111) A nurse if caring for a group of clients in a medical surgical unit. Which of the following
situations requires completion of an incident report?
a)
A client who is absent gag reflex following a bronchoscopy b) A client whose IV pump
has malfunctioned
c)
A client who requires insertion of NG tube due to a bowel obstruction
d)
A client who is absent bell sounds following a gastrectomy
112) A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin.
Which of the following should nurse monitor?
a)
Fasting blood glucose
b)
Carbohydrate intake
c)
Hematocrit
d)
Weight
113) The nurses providing discharge instructions about engorgement for client has decided
not to breastfeed. Which of the following statements by the client indicates a need for further
instruction by the nurse?
a)
I can wear support bra
b)
I will play cold compression my breasts
c)
I will manually express breastmilk
d)
I can take a mild analgesic
114) A nurses caring for client in preterm labor who is receiving magnesium sulfate by
continuous IV
infusion. Which of the following client findings indicates medication toxicity?
a)
Blood glucose of 15O mg/dL
b)
Urine output of 20 mL per hour
c)
Systolic blood pressure at 14O mm Hg
d)
BUN 2O mg/dL
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115) The nurse is completing an assessment for newborn who is 2 hrs old . Which of the
following findings are indicative of cold stress?
a)
Respiratory rate of 6O per minute b) Jitteriness of the hands
c)
Diaphoretic
d)
Bounding peripheral pulses in all extremities
116. A nurse is planning care for four clients. Which of the following clients is the highest
priority?
a.
A client who is dry, black eschar on the heel
b.
A client who is wearing an arm cast and reports numb fingers
141
of
c.
d.
The client was reddened skin area with blanching around the coccyx
The client who has frequent incontinence
117. A nurse is caring for a male adolescent client who has heart failure. Based on the client's
chart
finds. Which of the following actions should the nurse plan to take?
a.
Withholds spironolactone
b.
Administer ferrous sulfate
c.
Administer furosemide
d.
Withhold digoxin (O.8-2.O)
118. The nurses assessing a client plus blood glucose level of 25O mg/dl. Which of the
following clinical
manifestations are associated with this finding?
a.
Confusion (hypoglycemia)
b.
Thirst
c.
Diaphoresis (hypoglycemia)
d.
Shakiness (hypoglycemia)
119. A nurse is assessing for allergies before administering Propofol to a client placed on the
mechanical ventilator. Which of the following allergies is a contraindication to the medication?
a.
Eggs
b.
Milk
c.
Shrimp
d.
Peanuts
12O. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to
interpret the following statement, "When the cat's away, the mice will play". The client
response was, "The mice come out when the cat is not around". The nurse should document
this finding which of the following in the client's chart?
a.
Echolalia
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b.
c.
d.
Associative looseness
Neologisms
Concrete thinking
121. A nurse caring for a client who is receiving total parental nutrition. Which of the
following assessment findings required immediate intervention by the nurse?
a.
prealbumin level of 2O mg/dL b. Weight increase of two kg/day
c.
Temperature of 37.6°C
d.
Blood glucose level of 12O mg/dL
122. A nurse in the telemetry unit is receiving the laboratory findings for adult male client
who's been
treated for myocardial function. The following is an expected finding for the client?
a.
Troponin 1 (TNI) 8 ng/ml
b.
Brain natriuretic peptide (BNP) 1O ng/L
c.
Alanine aminotransferase (ALT 45 unit/L
d.
High density lipoprotein (HDL) 75 mg/dl
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123. A nurse is reviewing the results of an ABG performed on a client with chronic
emphysema. Which
of the following results suggests the need for further treatment?
a.
paO2 level of 89 mm Hg b. PaCO2 level of 55 mm Hg
c.
HCO2 level of 25 mEq/L
d.
pH level of 7.37
124. A nurse is teaching a client about nutritional intake. The nurse should include which of
the
following in the teaching?
a.
"Carbohydrates should be at least 45% of your caloric intake."
b.
"Protein should be at least 55% of your calorie intake."
c.
"Carbohydrates should be at least 3O% of your caloric intake."
d.
"Protein should be at least 6O% of your caloric intake."
125. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr .
The client is scheduled to have the morning dose at O7OO. The nurse should schedule the
trough level to be drawn at which of the following times?
a.
21OO
b.
O9OO
c.
13OO
d.
18OO
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126. A nurse is planning an education session for a client who has type 1 diabetes mellitus .
Which of the
following should the nurse plan to include when teaching the client to monitor for
hypoglycemia?
a.
diaphoresis
b.
polyuria
c.
abdominal pain
d.
thirst
127. A nurse in an urgent-care clinic is collecting admission history from a client who is 16
weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the
following clinical findings are associated with this infection?
a.
Frequency and dysuria
b.
Profuse milky white discharge
c.
Hematuria
d.
Low grade fever
128. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the
following foods should be included when initiating feeding?
a.
beef broth
b.
oatmeal
c.
apple juice
d.
toast
129. A nurse receives a change-of-shift report. Which of the following clients should the nurse
attend to
first?
a.
A client who reports tingling in the fingers following a thyroidectorny
143
of
b.
A client who has dark, foul-smelling urine with a urine output of 32O mL in the last 8 hr
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144
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of
c.
d.
A client who is in a long leg cast and reports cool feet bilaterally
A client who has a productive cough and an oral temperature of 36° C (96.8O F)
13O. A nurse is caring for a client who has lactose intolerance and has eliminated dairy
products from his diet. The nurse should instruct the client to increase consumption of which of
the following foods?
a.
spinach
b.
peanut butter
c.
ground beef
d.
carrots
131. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune
globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood
type is B positive. Which of the following statements is appropriate?
a.
You only need to receive Rh immune globulin if you have a positive blood type."
b.
You should receive Rh immune globulin within 72 hours of delivery."
c.
"Both you and your baby should receive Rh immune globulin at your -week
appointment."
d.
"immune globulin is not necessary since this is your second pregnancy."
132. A nurse is caring for the mother of an adolescent who was killed in a motor-vehicle crash
after a school event. The mother states, I never should have let him take the car. Its all my
fault!" Which of the following responses by the nurse is appropriate?
a.
You had no way of knowing this would happen."
b.
Most parents blame themselves when losing a child."
c.
Tell me why you feel this is your fault."
d.
You appear to be feeling overwhelmed"
133. A nurse is educating a client about caloric intake and weight reduction. Which of the
following client statements indicates an understanding of the teaching?
a.
"If I eat 5OO fewer calories per day, I should lose 1 pound per week."
b.
" If I eat 5OO fewer calories per day, I should lose 1 pound per week."
c.
"If I eat 45O fewer calories per day, I should lose 2 pounds per week."
d.
"If I eat 25O fewer calories per day, I should lose 2 pounds per week."
e.
"If I eat 3OO fewer calories per day, I should lose 1 pound per week."
134. A nurse is teaching post-operative care with the parents of a toddler following a cleft
palate
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repair. Which of the following should be included in the teaching?
a.
Provide an orthodontic pacifier for comfort.
b.
Offer fluids by using a straw.
c.
Cleanse suture line with a cotton tip swab.
d.
Remove elbow splints periodically to perform range of motion.
135. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to
an assistive personnel?
a.
Perform chest compressions during cardiac resuscitation.
b.
Perform a dressing change for a new amputee.
c.
Assess effectiveness of antiemetic medication.
d.
Provide discharge instructions
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136. A nurse in an emergency department is serving on a committee that is reviewing the
facility protocol for disaster readiness. The nurse should recommend that the protocol include
which of the following as a clinical manifestation of smallpox?
a.
Bloody diarrhea
b.
Ptosis of the eyelids
c.
Descending paralysis
d.
Rash in the mouth
137. A nurse is preparing to perform closed intermittent bladder irrigation for a client
following a transurethral resection of the prostate (TURP). Which of the following actions is
appropriate by the nurse?
a.
Aspirate the irrigation solution from the bladder.
b.
Insert the tip of the irrigation syringe into the catheter opening.
c.
Apply sterile gloves. 1296 in med surgical book
d.
open the flow clamp to the irrigating fluid infusion tubing.
138. A nurse is caring for a client who has been taking haloperidol for several years. Which of
the following assessment findings should the nurse recognize as a long-term side effect of this
medication?
a.
b.
c.
d.
Lipsmacking
Agranulocytosis
Clang association
Alopecia
139. A nurse is planning care for a client who has Alzheimers disease and demonstrates
confusion and
wandering behavior. Which of the following should the nurse include in the plan of care?
a.
Place the client in seclusion when she is confused.
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b.
c.
d.
Request a prescription for PRN restraints when the client is wandering.
Dim the lighting in the clients room.
Leave one side rail up on the clients bed.
14O. A nurse is reviewing the laboratory data of a client who has diabetes mellitus. Which of
the
following laboratory tests is an indicator of long-term disease management?
a.
Postorandial blood glucose
b.
Glycosylated hemoglobin - Ha1c
c.
Glucose tolerance test
d.
Fasting blood glucose
141. A nurse on a pediatric care unit is delegating client care. Which of the following tasks
should the
nurse delegate to an assistive personnel?
a.
Initiate a dietary consult for a toddler.
b.
Administer a glycerin suppository to a preschool-age child.
c.
Evaluate gastric residual following intermittent feeding of an adolescent. d. Transport a
school-age child to x-ray.
142. A nurse is caring for a client who has been taking propranolol. Which of the following
findings
indicates a need to withhold the medication?
a.
sodium 13O mEq/L
146 of
b.
c.
d.
Blood pressure 156/9O mm Hg
Potassium 5.2 mEq/L
Pulse 54/min
143. A nurse working in a mental health facility observes a client who has bipolar disorder
walk over to a table occupied by other clients and knock their game off the table. Which of the
following is an a ppropriate response by the nurse?
a.
Apologize to the others for your behavior."
b.
I am disappointed that you continue to act out when you are angry."
c.
Come outside with me for a walk."
d.
If you dont calm down, you will have to go into seclusion."
144. A nurse is caring for a client who has human immunodeficiency virus (HIV) with
neutropenia.
Which of the following precautions should the nurse take while caring for this client
a.
Wear an N95 respirator while caring for the client.
b.
Use a dedicated stethoscope for the client.
c.
Insert an indwelling urinary catheter to monitor urinary output.
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d.
Monitor the client's vital signs every 8 hr.
145. A nurse is checking laboratory results for a client. Which of the following laboratory
findings
indicates hypervolemia?
a.
serum sodium 138 mEq/L b. Urine specific gravity 1.OO1
c.
serum calcium 1O mg/dL
d.
Urine pH 6
146. A nurse is caring for a group of clients in a long-term care facility. Which of the following
situations should the nurse recognize as a safety hazard?
a.
A client's wrist restraints tied to the bed rails
b.
A clients bedside table placed across the foot of the bed
c.
A meal tray left at the bedside from breakfast
d.
A call light extension cord pinned to the bedspread
147. A nurse is caring for a client in a mental health facility. The clients daughter is crying and
tells the nurse that she feels guilty for leaving her father in the hospital. Which of the following
is an appropriate response?
a.
I'd like to know more about what's bothering you."
b.
"Why are you feeling this way"
c.
"You did the right thing by bringing him here."
d.
"I'm sure your father doesn't blame you."
148. A nurse is planning care for a client following gastric bypass surgery. The nurse should
include
which of the following dietary instructions when preparing the client for discharge?
a.
start each meal with a protein source.
b.
Consume at least 25 g of fiber daily.
c.
Check your blood glucose level before each meal.
d.
Limit your meals to three times per day.
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149. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the
following findings requires intervention by the nurse?
a.
Tidaling with spontaneous respirations
b.
Drainage collection chamber is 1/3 full
c.
1 cm of water present in the water seal chamber
d.
Suction chamber pressure of -2O cm H2O
15O. A provider has written a do not resuscitate order for a client who is comatose and does
not have advance directives. A member of the clients family says to the nurse, "I wonder when
the doctor will tell us what's going on" Which of the following actions should the nurse take first
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a.
b.
c.
d.
Request that the provider provide more information to the family.
Refer the family to a support group for grief counseling.
Offer to answer questions that family members have.
Ask the family what the provider has discussed with them.
151. A nurse is performing a skin assessment on a client who has risk factors for development
of skin
cancer. The nurse should understand that a suspicious lesion is
a.
scaly and red
b.
asymmetric, with variegated coloring
c.
firm and rubbery
d.
brown with a wart-like texture
152. A nurse is interviewing an older adult client about the physiological changes he has been
experiencing. Which of the following changes should the nurse recognize is normally associated
with the aging process?
a.
Decreased sense of taste
b.
Decreased blood pressure
c.
Increased gastric secretions
d.
Increased accommodation to near vision
153. A nurse in an intensive care unit is planning care for a client who has alcohol withdrawal
syndrome. Which of the following should the nurse include in the plan of care?
a.
Administer disulfiram.
b.
Provide frequent orientation to time and place.
c.
Engage the client in group therapy.
d.
Perform gastric lavage.
154. A nurse is assessing a client's cardiovascular system. Identify where the nurse should
place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve.
(Selectable areas or Hot Spots" can be found by moving your cursor over the artwork until the
cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds to
your answer.)
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a.
Top left site
155. A nurse manager is planning an audit to measure the quality of care on the unit. Which
of the
following is the most appropriate source for the nurse to consult?
a.
Nursing manager colleagues b. Evidence-based practice data
c.
Hospital administrators
d.
Protocols in other hospitals
156. A nurse is caring for a client who had gastric bypass surgery 1 week ago and has signs of
early
dumping syndrome. Which of the following findings should the nurse expect? (Select all that
apply)
a.
b.
c.
d.
e.
Facial flushing
Syncope
Diaphoresis
Vertigo
Bradycardia
157. A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings
should the nurse expect?
a.
feelings of dread
b.
rapid speech
c.
purposeless activity
d.
heightened perceptual field
158. A nurse is delegating tasks to an assistive personnel. Which of the following instructions
demonstrates appropriate communication of the task?
a.
"Take a blood glucose fingerstick on the client in room 1O2 before breakfast and then
place the
glucometer into the docking station."
b.
"Obtain a blood pressure reading from the client in room 116 after lunch and
report a systolic level less than 9O."
c.
"Assist the client in room 11O to ambulate once around the unit and stop if she gets
short of
breath."
d.
"Turn the client in room 126 to prevent pressure areas on his hip bones."
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159. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased
blood pressure. The nurse should recognize that these findings are potential manifestations of
which of the following?
a.
Nicotine withdrawal b. Heroin intoxication
c.
Alcohol withdrawal
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d.
Amphetamine intoxication
16O. A nurse is assessing an older adult client who had a stroke. Which of the following
findings should
the nurse recognize as an indication of dysphagia?
a.
Abnormal movements of the mouth
b.
Inability to stand without assistance
c.
Paralysis of the right arm
d.
Loss of appetite
161. *A nurse is providing preoperative teaching to a client who will use PCA morphine
sulfate
following surgery. Which of the following information should the nurse include?
a.
The client should notify the nurse when administering a dose of the medication.
b.
The client can administer a dose of medication every 6 to 8 min.
c.
The client should be cautious to avoid overmedication (OD).
d.
Family members can administer a dose the client.
162. A nurse is assisting the provider with a paracentesis for a client who has ascites.
Following
collection of the specimen , which of the following actions should the nurse take next
a.
Document the procedure.
b.
Measure the drainage.
c.
Record the color of the drainage. d. Label the specimen.
163. A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving
because
the facility policy prohibits smoking inside. Which of the following actions should the nurse
take?
a.
Notify security to monitor the facility exits.
b.
Place the client in seclusion.
c.
Inform the client of the risks involved if she leaves.
d.
Call the provider for a discharge prescription.
164. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a
child.
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Which of the following is a contraindication for administration?
a.
Recent blood transfusion
b.
Allergy to penicillin
c.
Minor acute illness
d.
Low-grade fever
165. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult
client. Which
of the following is the safest site for the nurse to use?
a.
Ventrogluteal
b.
Dorsogluteal
c.
Vastus lateralis
d.
Rectus femoris
166. A nurse is teaching a female client how to reduce the risk of urinary tract infections
(UTIs). Which
of the following should the nurse include as a risk factor for developing a UTI?
a.
Wearing underwear with a cotton crotch
b.
Wiping from front to back
150 of
c.
d.
Using perfumed toilet paper
Urinating immediately after intercourse
167. A nurse is providing discharge instructions for a client who has a new prescription for
furosemide. Which of the following client statements indicates a need for further teaching?
a.
"I will take my morning pills with food or milk."
b.
"I will weigh myself every day."
c.
"I will notify the nurse if I have muscle cramps."
d.
"I will limit my intake of fish."
168. A nurse is caring for a client who has a prescription for atorvastatin. Which of the
following client
conditions is a contraindication to this medication? a. hepatits C
b.
peptic ulcer disease
c.
bronchitis
d.
chrohn's disease
169. A nurse is planning care for an adolescent who has chronic renal failure. Which of the
following actions should the nurse include in the plan of care?
a.
Encourage a diet high in calcium.
b.
Provide a diet high in potassium.
c.
Ensure increased fluid intake.
d.
Restrict protein intake to the RDA.
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17O. A nurse is assessing a client 1 hr following birth and notes that her uterus is boggy and
located 2
cm above the umbilicus . Which of the following actions should the nurse take first?
a.
Take vital signs.
b.
Assess lochia.
c.
Massage the fundus.
d.
Give oxytocin IV bolus.
171. A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which
of the
following interventions should the nurse perform
a.
Give 1OO mL of water with every feeding.
b.
Obtain gastric residuals every 24 hr.
c.
Position the head of bed at 3O degrees during feeding.
d.
Mix the clients medications with the tube feedings.
172. A nurse is caring for a 7 month-old infant who is being treated for severe dehydration.
Which of
the following assessment findings indicates treatment has been effective?
a.
Skin turgor displays tenting
b.
Flat anterior fontanel
c.
Cool, mottled skin
d.
hyperpnea
173. A nurse is providing teaching to a client who has esophageal cancer and is scheduled to
start
radiation therapy. Which of the following should the nurse include in the teaching?
151
of
a.
Remove dye markings after each radiation treatment.
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152
28
of
b.
c.
d.
Apply a warm compress to the irradiated site.
Wear clothing over the area of radiation treatment.
Use a washcloth to bathe the treatment area.
174. A nurse in a provider's office is providing education to a client who is 16 weeks of
gestation and has a new prescription for ferrous sulfate. Which of the following instructions
should the nurse provide
a.
Avoid strawberries, citrus fruit, and melon to ensure that your iron medication is
effective."
b.
"Take your iron medication with fluids other than coffee or tea."
c.
"It is important to take your iron medication on a full stomach."
d.
"If you miss a dose one day, take two doses the next day."
175. A nurse receives a change-of-shift report on four clients. Based on the shift report
information,
which of the following clients should the nurse plan to assess
a.
A client who had a hip arthroplasty reports pain and erythema in his calf
b.
A client who has anorexia and peripheral edema
c.
A client who has Addison's disease with a blood glucose level of 75 mg/dL
d.
A client who had a barium enema 2 days ago and reports constipation
176. A nurse administers a dose of metoclopramide to a client prior to chemotherapy
treatment. Which
of the following medications should the nurse administer?
a.
Albuterol sulfate
b.
Hydromorphone
c.
Diphenhydramine
d.
Amitriptyline
177. A client who does not speak English arrives at the emergency department accompanied
by a child.
Which of the following actions should the nurse take?
a.
Ask the assistive personnel to assist the client in signing consent for treatment
b.
Ask the child to interpret for the client.
c.
Ascertain what language the client speaks and get an interpreter.
d.
Try to find an adult relative to help the client communicate.
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178. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium
sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays
toxicity. Which of the following actions should the nurse take?
a.
Position the client supine.
b.
Prepare an IV bolus of dextrose 5% in water
c.
Administer calcium gluconate IV.
d.
Administer methylergonovine IM.
179. A nurse is using Naegeles rule to calculate the expected delivery date for a newly
pregnant primigravida. The first day of the clients last period was October. What is the expected
delivery date? (Provide the date using four numerals, the first two for the month and the
second two for the day. For example, January 2 O1O2)
a. O711 (July 7, 2O11)
Formula: +1 year, -3 months, +7 days
153
of
18O. A nurse on a medical-surgical unit is receiving report on four clients. Which of the
following
clients should the nurse assess first?
a.
A client who is scheduled for chemotherapy and has a hemoglobin of 9
b.
A client who is 24 hr postoperative following a transurethral resection of the prostate
(TURP) and has small blood clots in the urinary catheter
c.
A client who is receiving a blood transfusion and reports low-back pain
d.
A client who has a new colostomy with a reddish-pink stoma
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RN Comprehensive Predictor 2019 Form F
1.
A nurse is caring for a client who has compartment syndrome following the application
of a tast to the leg. Which of the following.. nurse take?
Check the client's pedal pulses
Administer a dose of antlemetic medication Position the client's leg above the level of the heart
.Apply ice to the extremity
2.
A nurse is preparing to administer levothyroxine 50 micrograms to a client .Aavailable
levothyroxine 0.025 mg/tablet .How many table to the nurse administer per dose?
3.
A nurse is providing teaching about home safety to the adult child of an older adult
client who is postoperative following knee replacement surgery.Which of the following
instructions should the nurse include
Place a throw rug over electrical cords
Encourag the client to avoid wearing shoes at home Mark the edges of the doorway to the
house with tape Ensure that area rugs have rubber backs
4.
A nurse manager is reviewing the steps of the progressive discipline process prior to
counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps
the nurse manager should plan to take in response to the staff member's conduct. (Move the
steps into the box on the right, placing them in order of performance. Use all the steps.)
2- Give the staff member a written earning about the behavior.
1- Verbally remind the staff member of the expected behavior changes.
4- Suspend the staff member from employment at the facility 5- Dismiss the staff member from
employment at the facility.
3- Set up a meeting to speak with the staff member about the behavior.
5.
A nurse is providing teaching to a client who has a multiple sclerosis . Which of the
following statement should the nurse include
Limit your daily intake of high fiber foods
Establish a voiding schedule by urinating exercises every 4 hours Avoid exercises that increase
your body temperature
Wear an eye patch over one eye for an entire day before switching
6.
A nurse in an emergency department is caring for a toddler who has burns following a
house fire. Which of the following actions should the nurse take first?
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Calculate the fluid replacement based on vital signs and urinary output Determine the location
and depth of burns
Administer antibiotics to prevent sepsis.
Check the mouth for smooth and smoky breath
7.
A nurse is caring for a client who has a pressure injury on the coccyx .Which of the
following should indicateto the nurse that… a stage III pressure injury ?
Bone is exposed within the wound Shough and eschar is present Subcutaneous fat is visible
The skin is reddened and intact
8.
(OJO) A newly licensed nurse is unsure if an assigned task is within their scope of
practice. which of the following resources should the nurse consult?
Written prescription from the provider Institutional policies and procedures Verbal direction
from the nurse manager State Nurse Practice Act
9.
A nurse is caring for a client who has a prescription for 1 unit of packed RBCS. Flve
minutes after beginning the transfusion… with chills. After stopping the transfusion, which of
the following actions should the nurse taket?
Infuse 500 mL lactated Ringer's Iv. Adininister epinephrine subcutaneously.
Document the reaction in the medical record.
Place the blood bag in a biohazard bag before discarding
10.
A Nurse is teaching participants at a community center about advance directives. Which
of the following information should the nurse include in the teaching?
Assigning a health care surrogate requires legal consultation
A client must create a do not resuscitate order when completing advances directives. Advance
directives cannot be changed once implemented.
A health care surrogate makes health care decisions when the client is no longer able.
11.
A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which
of the following Information should the nurse
Limit Intake of nuts and legumes. Choose foods high in vitamin B12
Choose high-fat cheese as a meal substitute. Limit Intake of foods high in vitamin C
12.
OJO A nurse in an emergency department is assesing
depressive disorder. Which of t nurse take first? Exhibit
a client with
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Obtain the clients weight
Administer ondansetron to the client for ma Obtain a blood glucose level
Implement seizure precaution for the client
13.
A nurse is assessing the grief response of a client whose child died 6 mONTHS age Which
of the following client statement should.. the provider as an Indication of major depressive
disorder?
I am unable to feel any joy since my child died. I feel guilty because my child died
I now that will be reunited with my child someday I am angry that my child died.
14.
A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the
following is an activity a nurse should engage in to assist in disaster preparedness?
Participate in community drills and mock events. Vaccinate susceptible children and adults
against smallpox Assess types, levels and scopes of disasters.
Make quarantine preparations for those exposed to anthrax Rationale: Assess First
15.
A nurse is caring for a client who is experiencing acute mania. Which of the following
foods should the nurse provide for this client?
Peanut butter sandwich Oatmeal with butter Chicken noodle soup Celery sticks
16.
A nurse is admitting a client who has dementia to a long-term care facility. The client
tells the nurse that she lived in this facility years ago and took care of all the residents by
herself. The nurse should document this as which of the following findings?
Agnosia Projection Perseveration Confabulation
17.
A nurse is providing dietary teaching to a client who had an exacerbation of COPD. which
of the following information should the nurse including in the teaching?
You should eat hot foods to reduce your sense of fulness during a meal. While eating, you
should drink liquids frequently.
Lunch should be your largest meal of the day
During meals, you should eat foods with a high-calorie content first
18.
A nurse is caring for four clients on a medical-surgical unit For which of the following
clients should the nurse complete a medication conciciliation ?
A client who has a prescription for a gallbladder sonogram
A client who transfers from a private room Into a semi-private room A client who received twice
the prescribed dose of a medication
A client who returns to the unit from the PACU following surgery
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19.
A nurse is Initiating bladder retraining for a client who has urge urinary incontinence.
Which of the following instruction should the nurse…the client ?
Take your diuretic medication with your evening meal Decrease your intake of cranberry juice
Pan to urinate every 3 hours while you are awake Limit your fluid Intake to 500 milliters per day.
"
20.
A nurse realizes that the wrong medication has been administered to a client. Which of
the following actions should the nurse take first?
A.
B.
C.
D.
Notify the provider.
Report the incident to the nurse manager.
Measure the client vital signs.
Fill out an incident report.
21.
A nurse is teaching a client who had a left below-the-knee amputation 3 days ago. The
nurse should identity that which of the following statement by the client Indicates an
understanding of the teaching?
I will change the wrapping on my left leg once a day at home I Should avoid moving the joints in
my left leg
I might still experience the feeling of numbness and brigling in my left
I can elevate my left leg on a pillow while lying in bed.
22.
A nurse and an assistive personnel (AP) are assigned a group of clients on the unit.
Which of the Following clients should the nurse report to the nurse ?
A client who has a prescription for compression stockings and did not receive them A client who
consumes all the food from their meal tray
A client who requests assistance to use the bedside commode
A client who requests to sit in the bedside chair while watching TV
23.
A nurse is preparing to obtain a client signature on an informed consent form. Which of
the following actions should the nurse…
Notify the provider if the client has questions about the procedure Ask the client to explain his
understanding of the procedure.
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Inform the client of his right to change his mind witness the client signing the informed consent
form
24.
A nurse is updating the plan of care for a client who has an exacerbation of psoriasis.
Which of the following intervention should the nurse include in the plan ?
Cover lesions with an occlusive dressing after applying a corticosteroid Discontinue ultraviolet
light therapy If lesions itchy
Scrub external lesions with a pumice stone
Instruct the client to add rubbing alcohol to bath water.
25.
A nurse is caring for a client who received a large amount of heparin IV in error. Which of
the following laboratory should the nurse
aPTT INR
Ferritin level Albumin level
26.
(OJO) A nurse in an emergency department is caring for a client following a motor
vehicle crash . The client Glasgow coma scale,, following findings should the nurse expects?
The client opens eyes to sound The client withdraws from pain. The client Is oriented times
three
The client is unable to obey commands
27.
A client’s partner tells a staff nurse that he overhears laboratory staff discussing the
result of
the client’s biopsy report while on the elevator. Which of the following actions
should the nurse take?
Report the information to the charge nurse
review confidentiality policies with laboratory employees- would be the job of the Facility
manager or someone who audits or teaches HIPAA stuff
contact the laboratory manager regarding the situation - you are not high enough up the chain
to do that
Notify the facilities legal department - no need to go that far
28.
(OJO)A nurse is assessing a client who has a prescription for hydrocodone PRN . Which of
the following adverse effects should the nurse identify priority for withholding this medication
and notifying the provider ?
Constipation Hypotension Urinary retention Nausea
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29.
A nurse is performing initial assessment of a newborn. Which of the following actions
should the nurse take to prevent any heat lost thro.. production?
Place the newborns crib away from of on air went to perform the assessment Evaluate
respirations by observing the newborn's uncovered chest for 1 min Perform the assessment
inmediately after bith before removing amniotic fluid Cover the scale with a warmed blanket
before weighing the baby.
30.
A nurse is completing an incident report after a client fall. Which of the following
competencies of Quality and Safety Education for Nurse is the use demonstrating?
A.
B.
C.
Quality improvement.
Patient centered care
Evidence based practice.
D.
Informatics.
31.
A nurse is consulting a pharmacological reference about medication compatibility prior
to administering warfarin a client. Which of should the nurse identify as being incompatible
with warfarin?
Propranolol Lisinopril
Magnesium hydroxide Naproxen
32.
A nurse is preparing to administer a blood transfusion to a client , Which of the following
actions should the nurse take ?
Use an IV catheter that is at least 24-gauge. Prime the tubing with 0.9% sodium chloride. Attach
a single-line administration set.
Use tubing that does not have a filter in the drip chamber
33.
A nurse is providing teaching to a client who has a new prescription for warfarin. The
nurse should include that which of following medications can increase the effects of warfarin ?
Nafcilin
Vitamin K
Oral contraceptives
34.
A charge nurse is planning a staff education and competence session about operating
newly acquired cardiac monitoring equipment. Which of the following actions should the nurse
plan to take? (Select all that apply.)
Caution staff that the equipment is complicated to use.
Wait to offer feedback on staff use of the equipment until the end of the session. Identify the
current level of staff knowledge about the equipment.
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35.
A nurse is creating a plan of care for a female client who has recurrent urinary tract
infections. Which of the following interventions should the nurse include in the plan?
Take a bubble bath after intercourse Void every 5 to 6 hr during the day
Drink four 240 mL (8 oz) glasses of water each day. Wear loose-fitting underwear.
36.
A nurse is providing teaching to a client who is scheduled for radiation therapy to treat
esophageal cancer. Which of the following the nurse make?
Drink mostly clear liquids.
"Use commercial mouthwashes to rinse your mouth. Soften foods with gravy and sauces
Warm up foods before eating.
37.
(OJO) A nurse is assessing a client who has heart failure and is prescribed a 2,000 m / 24
hr fluid restriction .Which of the following fluid should the nurse report to the provider?
Watery stools of 400 ml in 8 hr Oral intake of 300 ml in 8 hr Urinary output of 420 ml in 8 hr
Intravenous intake of 240 ml in 8 hr
38.
A nurse is helping to prepare a client in the operating room prior to a surgical procedure.
which of the following action should
Leave the client's arms and legs uncovered until after the induction of anesthesia Remove the
client eyeglasses upon arrival to the operating room
Provide padding to the pressure point areas when positioning the client Minimize conversation
with the client to reduce anxiety
39.
A nurse manager is reviewing the steps of the progressive discipline process prior to
counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps
the nurse manager should plan to take in response to the staff member’s conduct. (Move the
steps into the box on the right, placing them in order of performance. Use all the steps.)
Give the staff member a written earning about the behavior. (3) Verbally remind the staff
member of the expected behavior changes. (2)
Suspend the staff member from work for several day employment at the facility. (4) Dismiss the
staff member from employment at the facility. (5)
Set up a meeting to speak with the staff member about the behavior. (1)
40.
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding, the nurse does not speak the same language as the client. The client partner and a 10year-old child are accompanying her. Which of the following actions should the nurse take to
gather the client’s information?
Request a female translator interpreter through the facility
Ask a student nurse who speaks the same language to translate Have the child translate
Allow the clients child to translate
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41.
A nurse in an emergency department is caring for a toddler who has burns following a
house fire. Which of the following actions should the nurse take first?
Calculate the fluid replacement based on vital signs and urinary output Determine the location
and depth of burns
Administer antibiotics prophylactically to prevent sepsis. Check the mouth for smooth and
smoky breath
42.
OJO A nurse is caring for a client who has heart failure. The nurse notes the client’s 24hr- intake is 1.750 mL and output is 425 mL. Which of the following actions should the nurse
take first?
Compare the client’s wight to the previous day. Reduce the client’s sodium intake.
Encourage the client to change positions frequently. Administer furosemide to the client.
43.
A nurse is caring for a school-age child who has sickie cell anemia and is in vaso-acclusive
crisis. Which of the following action the nurse….
Increase oral fluid intake
Promote active range of motion exercises Apply cold compresses to the affected areas Prepare
for a transfusion of platelets
44.
A nurse is talking with another nurse on the unit and smells alcohol on her breath.
Which of the following actions should the nurse take?
A.
B.
C.
D.
Confront the nurse about the suspected alcohol use.
Inform another nurse on the unit about the suspected alcohol use.
Ask the nurse to finish administering medications and then go home.
Notify the nursing manager about the suspected alcohol use.
45.
A nurse is assessing a client who is immediately post-operative following hip
arthroplasty, which of the following considerations should the nurse take when positioning the
client?
A.
Place the client’s heels directly against the bed mattress.
B.
Ensure that the client’s hips remain in an abducted position.
C.
Maintain the client in a supine position for the first 24 hr. after surgery.
D.
Flex the client’s hip up to 120° when sitting in a chair.
46.
OJO P[access device .Which of the following …. the child's family member Indicates an
understanding of the teaching?
I can expect my child to resume playing sports within 48 hours "Twill replace the dressing in 24
hours with an occlusive dressing" If my child develops an elevated temperature. I will contact
you " I should encourage a dally shower to keep the insertion site clean.
47.
A nurse is caring for a client who wears glasses. Which of the following actions should
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the nurse take?
A.
B.
C.
D.
Store the glasses in a labeled case.
Clean the glasses with hot water.
Clean the glasses with a paper towel.
Store the glasses on the bedside table.
48.
A nurse is teaching a group of newly licensed nurses about measures to take when
caring for a client who is on contact precautions. Which of the following should the nurse
include in the teaching?
Remove the protective gown after leaving the client
Wear a mask when changing the linens in the client’s room. Place the client in a room with
negative air pressure
Wear gloves when providing care to the client.
49.
A nurse is assessing a client who is immediately postoperative following a subtotal
thyroidectomy. Which of the following should the nurse expect to administer?
A.
Calcium gluconate.
B.
Sodium bicarbonate.
C.
Potassium chloride.
D.
Sodium phosphate.
50.
The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction to the
use of oral contraceptives?
A.
Hyperthyroidism.
Thrombophlebitis.
C.
Diverticulosis.
D.
Hypocalcemia. E.
51.
A nurse is planning on care for a client who is recovering from an acute myocardial
infarction that occurred 3 days ago. Which of the following instructions should the nurse
include?
A.
Perform an ECG every 12 hr.
B.
Place the client in a supine position while resting.
C.
Draw a troponin level every 4hr.
D.
Obtain a cardiac rehabilitation consultation.
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52.
A nurse is assessing a client who is immediately post-operative following hip
arthroplasty, which of the following considerations should the nurse take when positioning the
client?
A.
Place the client’s heels directly against the bed mattress.
B.
Ensure that the client’s hips remain in an abducted position.
C.
Maintain the client in a supine position for the first 24 hr. after surgery.
D.
Flex the client’s hip up to 120° when sitting in a chair.
53.
A nurse is assessing a client who is immediately postoperative following a subtotal
thyroidectomy. Which of the following should the nurse expect to administer?
A.
Calcium gluconate.
B.
Sodium bicarbonate.
C.
Potassium chloride.
D.
Sodium phosphate.
54.
A nurse is caring for an adult client who has prescriptions for multiple medications.
Which of the following (Unable to read) as an age-related change that increases the risk for
adverse effects from this medication?
A.
Rapid gastric emptying.
B.
Prolonged medication half-life.
C.
Increased medication elimination.
D.
Decreased medication sensitivity.
55.
(Ojo) A nurse manager is planning to promote client advocacy among staff in a medical
unit. Which of the following actions should the nurse take?
A.
Encourage staf f to implement the principle of paternalism when a client is having
difficulty making a choice.
B.
C.
Tell
staff explain procedures to
clients before obtaining
informed
consent.
Instruct unit staff to share personal experiences to help clients make decisions.
56.
A nurse is providing teaching to a client who has a new prescription for warfarin. The
nurse should include that which of the following medications can increase the effects of
warfarin.
Nafcillin Aspirin Vitamin k
Oral contraceptives
57.
101. A nurse is consulting a pharmacological reference about medication compatibility
prior to administering warfarin to a client. Which of the following medications should the nurse
identify as being incompatible with warfarin?
Propranolol Lisinopril
Magnesium hydroxide Naprox…
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58.
A charge nurse is planning a staff education and competency session about operating
newly acquired cardiac monitoring equal. Which of the following actions should the nurse plan?
(Select all that apply.)
Wait to offer feedback on staff use of the equipment until the end of the session Require a
return demonstration using the equipment
Caution staff that the equipment is complicated to use Provide reinforcement of teaching until
the skill is learned
Identify the current level os staff knowledge about the equipment
59.
A nurse is caring for a client who is experiencing expressive aphasia and right
hemiparesis following a cerebrovascular accident. Which of the following actions by the nurse
best promotes communications among staff caring for the client?
Noting changes in the treatment plan in the client’s medical record Recording the client’s
progress in the nurses’ notes
Posting swallowing precautions at the head of the client’s bed
Having interdisciplinary team meetings for the client on a regular basis
60.
A nurse is providing teaching about the gastrostomy tube feedings to the parents of a
school age child. Which of the following instructions should the nurse take?
A.
Administer the feeding over 30 min.
Place the child in as supine position after the feeding. Charge the feeding bag and tubing every
3 days.
Warm the formula in the microwave prior to administration.
61.
A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the
following findings should the nurse report to the provider?
A. Potassium level 4.2 mEq/L. B. Apical pulse
58/min.
C.
Digoxin level 1 ng/ml. nivel
D.
Constipation for 2 days.
62.
A nurse is talking with another nurse on the unit and smells alcohol on her breath.
Which of the following actions should the nurse take?
E.
F.
G.
Confront the nurse about the suspected alcohol use.
Inform another nurse on the unit about the suspected alcohol use.
Ask the nurse to finish administering medications and then go home.
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63.
A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following
manifestations indicates acute chest syndrome and should be immediately reported to the
provider?
A.
Substernal retractions.
B.
Hematuria.
C.
Temperature 37.9 C (100.2 F).
D.
Sneezing.
64.
A nurse is evaluating the response to the plan of care for a client who is grieving the
death of a partner. Which of the following nurse identify as indicating that the client is
experiencing maladaptive grieving ?
The client openly expresses anger when discussing the partner death The client has joined a
support group
The client reports having good and bed days
The client reports feelings of guilt about the partner death
65.
A nurse is helping to prepare a client in the operating room prior to a surgical procedure.
Which of the following actions should the nurse take?
Leave the client's arms and legs uncovered until after the induction of anesthesia. Remove the
cent's eyeglasses upon to the operating room
Provide padding to the pressure point areas when positioning the client Minimize conversation
with the client to reduce anxiety
66.
A nurse is providing care for a client who is in the advance stage of amyotrophic lateral
sclerosis. (ALS). Which of the following referrals is the nurse’s priority?
A.
Psychologist.
B.
Social worker.
C.
Occupational therapist.
D.
Speech-language pathologist.
67.
A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis.
Which of the following findings should the nurse report to the provider?
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A.
WBC count 8,000/mm3.
B.
Platelets 150,000/mm3.
C.
Aspartate aminotransferase 10 units/L. rate 5 a 40 units/L
D.
29
Erythrocyte sedimentation rate 75 mm/hr
para los hombres 0 a 22 y las mujeres de o a
68.
A nurse is preforming a gastric lavage for a client who has upper gastrointestinal
bleeding. Which of the following action should the nurse take?
A.
Instill 500 ml of solution through the NG tube.
B.
Insert a large-bore NG tube.
C.
Use a cold irrigation solution.
D.
Instruct the client to lie on his right side.
69.
A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol
nurse take to assist the client… the nurse take to assist the client in maintaining self-control of
the behavior?
Provide the client with periods of alone time for reflection on their behavior Discuss strategies
with the client to reduce alcohol consumption gradually Give positive feedback to the client for
using adaptive coping strategies
Have the client's partner assume responsibility for monitoring the clients alcohol intake
70.
A nurse is caring for a client who is comatose and has advance directives that indicate
the client does not want life-sustaining measures. The client’s family want the client to have lifesustaining measures. Which of the following action should the nurse take?
Arrange for an ethics committee meeting to address the family’s concerns. Support the family’s
decision and initiate life-sustaining measures.
Complete an incident report.
Encourage the family to contact an attorney.
71.
A nurse is caring for a client who wears glasses. Which of the following actions should
the nurse take?
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Store the glasses in a labeled case. Clean the glasses with hot water. Clean the glasses with a
paper towel. Store the glasses on the bedside table.
72.
A nurse is providing discharge teaching to a client who has a new prescription for
phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods
while taking this medication?
A.
b.
c.
d.
Avocados
Whole grain bread
Pepperoni pizza
Smoked salmon
73.
A nurse is planning on care for a client who is recovering from an acute myocardial
infarction that occurred 3 days ago. Which of the following instructions should the nurse
include?
A. Perform an ECG every 12 hr.
E.
Place the client in a supine position while resting.
F.
Draw a troponin level every 4hr.
G.
Obtain a cardiac rehabilitation consultation.
74.
The nurse is reviewing the medical record of a client who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction to the
use of oral contraceptives?
F.
Hyperthyroidism.
Thrombophlebitis.
H.
Diverticulosis.
I.
Hypocalcemia.
75.
A nurse is caring for a client who request the creation of a living will. Which of the
following actions should the nurse take?
A.
Schedule a meeting between the hospital ethics committee and the client.
B.
Evaluate the client’s understanding of life-sustaining measures.
C.
Determine the client’s preferences about postmortem care.
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D.
Request a conference with the client’s family.
76.
A nurse is providing teaching to a client who is scheduled for radiation therapy to treat
esophageal cancer. Which of the following should the nurse make?
Drink mostly clear liquids
Use commercial mouthwashes to rinse your mouth Soften foods with gravy and sauces
Warm up foods before eating
77.
A nurse is assessing a client who has heart failure and is prescribed a 2,000 Ml/ hr fluid
restriction. Which of the following fluids should the nurse report to the provider?
Water stools of 400Ml in 8 hr Oral intake of 300 ml in 8 hr Urinary output of 420 ml in 8 hr
Intravenous intake of 240 ml in 8 hr
78.
A nurse is caring for a client who has colon cancer and is terminality III. The client states I
can believe going to die .Which of the following statement should the nurse make?
Tell me what is Important to you right now
Your doctor will make sure you wont be in much pain
I felt the same way you re feeling when my mother died It might be comforting to pray for
spiritual assistance
79.
A nurse is caring for a client following application of a cast. Which of the following
actions should the nurse take first ?
Palpate the pulse distal to the cast Position the casted extremity on a pillow Place an ice pack
over the cast
Teach the client to keep the cast clean and dry
80.
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding, the
nurse does not speak the same language as the client. The client partner and a 10-year-old child
are accompanying her. Which of the following actions should the nurse take to gather the
client’s information?
a.
b.
c.
d.
Request a female translator interpreter through the facility
Ask a student nurse who speaks the same language to translate
Have the child translate
Allow the clients partner to translate
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81.
A nurse is caring for a client who has vision loss. Which of the following actions should
the nurse take? (Select all that apply)
A.
Keep objects in the client’s room in the same place.
B.
Ensure there is high-wattage lighting in the client’s room.
C.
Approach the client from the side.
D.
Allow extra time for the client to perform tasks.
E.
Touch the client gently to announce presence.
82.
A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has
questions about the disease. To research the nurse should identify that which of the following
electronic database has the most comprehensive collection of nursing (Unable to read) articles?
A.
MEDLINE
B.
CINAHL.
C.
ProQuest.
D.
Health Source.
83.
A nurse in an emergency department is assessing newly admitted client who is
experiencing drooling and hoarseness following a burn injury. Which of the following should
actions the nurse take first?
A.
Obtain a baseline ECG.
B.
C.
D.
Obtain a blood specimen for ABG analysis.
Insert an 18-gauge IV catheter.
Administer 100% humidified oxygen.
84.
A nurse is planning care for a client who has unilateral paralysis and dysphagia following
a right hemispheric stroke. Which of the following interventions should the nurse include in the
plan?
A.
B.
Place food on the left side of the client’s mouth when he is ready to eat.
Provide total care in performing the client’s ADLs.
C.
Maintain the client on bed rest.
D.
Place the client’s left arm on a pillow while he is sitting.
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85.
A nurse is caring for a client who is receiving brachytherapy for treatment of prostate
cancer. Which of the following actions should the nurse take?
Limit the client’s visitors to 30 min per day. Discard the client’s linens in a double bag. Discard
the radioactive source in a biohazard bag
Cleanse equipment before removal from the client room
86.
A nurse is teaching a client about using a 3-point gait for crutch-walking. Which of the
following actions by the client understanding … teaching ?
Advances the affected leg first prior to the nonaffected leg Uses both crutches when advancing
the affected leg
Applies full weight on the affected side when advancing crutches Planes weight on the axilla
when advancing crutches
87.
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal
bleeding, the nurse does not speak the same language as the client. The client partner and a 10year-old child are accompanying her. Which of the following actions should the nurse take to
gather the client’s information?
Request a female translator interpreter through the facility
Ask a student nurse who speaks the same language to translate Have the child translate
Allow the clients child to translate
88.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of
the following conditions should the nurse recognize as a contraindication to the use of
oxytocin?
A. Diabetes mellitus.
Shoulder presentation.
Post term withhydramnios.
Chorioamnionitis
89.
A nurse manager is reviewing the steps of the progressive discipline process prior to
counseling a staff member who exhibits unprofessional behavior. Identify the sequence of steps
the nurse manager should plan to take in response to the staff members conduct
Give the staff member a writing warning about the behavior Verbally remind the staff member
of the expected behavior changes Suspend the staff member from work for several days
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Dismiss the staff member from employment at the facility
Set up a meeting to speak with the staff member about the behavior
90.
A nurse is preparing to perform a sterile wound irrigation and dressing change for a
client. Which of the following actions by the nurse indicates a break in surgical aseptic
technique?
Applying a sterile gown after applying a sterile mask
Balancing the bottle on the sterile basin while pouring the liquid Placing the supplies on the
sterile filed and leaving a 1- inch perimeter Putting on sterile gloves after preparing the sterile
field
91.
A nurse is assessing a client who has left-sided heart failure. Which of the following
should the nurse identify as a manifestation of pulmonary congestion?
A.
Frothy, pink sputum.
B.
Jugular vein distention.
C.
Weight gain.
D..Bradypnea
92.
A nurse is obtaining a clients manual blood pressure and is having difficulty auscultating
sounds .Which of the following actions should the nurse …?
Use the palpatory method to determine biood pressure Deflate the cuff quickly
. Place the arm above the level of the client's heart Apply the largest cuff available.
93.
A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration
and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that
my baby needs an IV?” Which of the following responses should the nurse make?
B.
“Your baby needs an IV because her fontanels are budging”
C.
D.
“Your baby needs an IV because she is breathing slower than normal”
“Your baby needs an IV because her heart rate is decreasing”
94.
A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
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A.
“Taking furosemide can cause your potassium levels to be high”
B.
“Eat foods that are high in sodium”
D. “Taking furosemide can cause you to be overhydrated”
95.
A nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder. Which of the following interventions should the nurse take?
A.
Allow the client enough time to perform rituals.
B.
C.
D.
Give the client autonomy in scheduling activities.
Discourage the client from exploring irrational fears.
Provide negative reinforcement for ritualistic behaviors
96.
A nurse is caring for a client who has depression and reports taking ST. John’s wort along
with citalopram. The nurse should monitor the client for which of the following conditions as a
result of an interaction between these substances?
A.
B.
Serotonin syndrome
Tardive dyskinesia
Pseudo parkinsonism.
C.
Acute dystonia.
97.
A nurse is caring for a client who is in a seclusion room following violent behavior. The
client continues to display aggressive behavior. Which of the following actions should the nurse
take?
A.
Confront the client about this behavior.
B.
Express sympathy for the client’s situation.
C.
Speak assertively to the client.
D.
Stand within 30 cm (1 ft) of the client when speaking with them.
98.
A nurse is providing teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
E.
F.
“Taking furosemide can cause your potassium levels to be high”
“Eat foods that are high in sodium”
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G.
H.
“Rise slowly when getting out of bed”
“Taking furosemide can cause you to be overhydrated”
99.
A nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder. Which of the following interventions should the nurse take?
A.
Allow the client enough time to perform rituals.
B.
C.
D.
Give the client autonomy in scheduling activities.
Discourage the client from exploring irrational fears.
Provide negative reinforcement for ritualistic behaviors
100. A nurse is caring for a client who has depression and reports taking ST. John’s wort along
with citalopram. The nurse should monitor the client for which of the following conditions as a
result of an interaction between these substances?
D.
E.
F.
Serotonin syndrome
Tardive dyskinesia Pseudo parkinsonism.
Acute dystonia.
101. A nurse is caring for a client who is in a seclusion room following violent behavior. The
client continues to display aggressive behavior. Which of the following actions should the nurse
take?
A. Confront the client about this behavior.
C. Express sympathy for the client’s situation.
C. Speak assertively to the client.
D.Stand within 30 cm (1 ft) of the client when speaking with them.
102. A nurse is calculating a client's expected date of delivery. The clients fast menstral period
began April 12
Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery
date?
A nurse is discussing group treatment and therapy with a client. The nurse should include which
of the following as being a characteristic of a therapeutic group?
A.
The group is organized in an autocratic structure.
B.
The group encourages members to focus on a particular issue. (
C.
The group must be led by a licensed psychiatrist.
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D.
The group encourages clients to form dependent relationships.
103. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the
following notations by the newly licensed nurse indicates an understanding of the teaching?
UNSURE IF ON THE REPORT
A.
“OOB with assistance for breakfast”
B.
“Given 2 mg MSO4 IM for report of pain”
C.
“Dressing changed qd”
D.
“Administered 8 u regular insulin sq.”
104. A nurse is preparing to administer eye drops to a school-age child. Identify the actions
the nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
1.
Apply pressure to the lacrimal punctum.5
2.
Ask the child to look upward. 2
3.
Pull the lower eyelid downward. 3
4.
Instill the drops of medication. 4
5.
Place the child in a sitting position. 1
105. A nurse is caring for a client who speaks a language different from the nurse. Which of the
following should the nurse take?
A.
Request an interpreter of a different sex from the client.
B.
Request a family member or friend to interpret information for the client.
C.
Direct attention toward the interpreter when speaking to the client.
D.
Review the facility policy about the use of an interpreter.
106. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the
following findings indicates that the nurse should increase the rate of infusion?
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ON THE REPORT needs double checking
A. Urine output 20 ml/hr.
A.
Montevideo units constantly 300 mm Hg.
B.
FHR pattern with absent variability.
C.
Contractions every 5 min that last 30 seconds.
107. A nurse is planning care for a group of clients and is working with one licensed practical
nurse LPN and one assistive personal AP. Which of the following actions should the nurse take
first to manage her time effectively?
Develop an hourly time frame for tasks Schedule daily activities
Determine goals of the day
Delegate tasks to the AP
108. A public health nurse is managing several projects for the community. Which of the
following interventions should the nurse identify as a primary prevention strategy?
A.
Teaching parenting skills to expectant mothers and their partners.
B.
C.
Conducting mental health screenings at the local community center.
Referring client who have obesity to community exercise programs.
D.
Providing crisis intervention through a mobile counseling unit.
109. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of
the following statements by the client indicates an understanding of the teaching?
a.
“I will take sucralfate with meals three times per day”
b.
“I will avoid food and beverages that contain caffeine”
c.
“I will decrease my daily protein intake to 15 grams per day”
d.
“I will use ibuprofen as needed to control abdominal pain”
110. A nurse is assessing a client who is receiving packed RBCs. Which of the following
findings indicate fluid overload?
A.
Low back pain.
Dyspnea. Hypotension. Thready pulse.
111. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which
of the following statements should the nurse include in the teaching?
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I.
“The PCA will deliver a double dose of medication when you push the button twice.”
J.
“You can adjust the amount of pain medication you receive by pushing on the keypad.”
K.
“Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” L.
“You should push the button before physical activity to allow maximum pain control.”
112. A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
E.
F.
G.
H.
Match the client’s blood type with the type and cross match specimens.
Confirm the provider’s prescription matches the number on the blood component.
Ask the client to state the blood type and the date of their last blood donation.
Ensure that the client’s identification band matches the number on the blood unit.
113. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of
the following statements by the client indicates the need for a referral to physical therapy?
B.
“I noticed that I am having a harder time holding on to my toothbrush”
C.
“Lately, I feel like my feet are freezing up, as they are stuck to the ground”
D.
“Sometimes, I feel I am making a chewing motion when I’m not eating”
114. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which
of the following findings should the nurse expect?
A.
Increased creatine.
B.
Increased hemoglobin.
C. Increased bicarbonate.
D. Increased calcium.
115. A nurse is teaching at a community health fair about electrical fire prevention. Which of
the following information should the nurse include in the teaching?
A.
B.
C.
D.
Use three pronged grounded plugs.
Cover extension cords with a rug.
Check the tingling sensations around the cord to ensure the electricity is working.
Remove the plug from the socket by pulling the cord.
116. A charge nurse is recommending postpartum client discharge following a local disaster.
Which of the following should the nurse recommend for discharge?
B.
A 15-year-old client who delivered via emergency cesarean birth 1 day ago.
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C.
A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.
D.
A client who delivered precipitously 36 hr. ago and has a second-degree perineal
laceration.
E.
A 42 yoars old client who has preeclampsia and BP of 166/110 mmHG
117. A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take at home. Which of the following responses
should the nurse take?
137
“I recommend that you take this medication as prescribed”
138
“Do you know why this medication is being prescribed to you?”
139
“I will call the pharmacist now to check on this medication”
Did the doctor discuss with you that there was a change in this medication
118. A community health nurse is developing a plan to improve the communitys
environmental health. which of the following action nurse take first?
Establish a timeframe for environmental improvements.
Encourage community Involvement in environmental improvement Request funding from
community organizations
Collect information about the community's environmental status
119. A nurse is reviewing the laboratory report of a client who has been having lithium
carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the
following orders from the provider should the nurse expect?
E.
Withhold the next dose.
F.
G.
H.
Increase the dosage.
Discontinue the medication.
Administer the medication.
120. A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the
nurse report to the provider?
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Pulse 140/min
Closed anterior fontanel Respiratory rate 26/min Abdominal breathing
121. A nurse is reviewing legal issues in health care with a group of newly licensed nurses.
Which of the following recommendations should the nurse make?
Place copies of incident reports in client’s medical records Overestimate clients acuilty to
prevent short staffing
Ensure that each client has a living will on file prior to treatment Obtain personal professional
liability insurance coverage
122. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the
following Interventions should the nurse Include in the plan of care?
Screen the child's visitors for active Infections. Initiate Prepare the child for a platelet
transfusion. Prepare the child for a platelet transfusion.
Monitor the child for indications of active bleeding
123. A nurse is caring for a client who is near the end of life and is on complete bed rest. The
client states that he needs to have a bowel movement and the nurse offers a bed pan. The client
states. “I’ve always used the bathroom. “Which of the following responses should the nurse
make?
“Tell me what concerns you have about using a bed pan.”
“I will have the physical therapist ambulate you to the bathroom.” “You have to use the bed pan
for you own safety.”
“Make sure to use nearby furniture to support yourself when walking to the bathroom.
124. A newly licensed nurse is unsure if an assigned task is within their scope of practice.
which of the following resources should the nurse consult?
Written prescription from the provider Institutional policies and procedures Verbal direction
from the nurse manager State Nurse Practice Act
125. A Nurse is teaching participants at a community center about advance directives. Which
of the following information should the nurse include in the teaching?
Assigning a health care surrogate requires legal consultation
A client must create a do not resuscitate order when completing advances directives. Advance
directives cannot be changed once implemented.
A health care surrogate makes health care decisions when the client is no longer able.
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126. A nurse is reviewing the facility’s safety protocols considering newborn abduction with
the parent of a newborn. Which of the following statements indicates an understanding of the
teaching?
I. “Staff will apply identification band after first bath”
“I will not publish public announcement about my baby’s birth”
K.
“I can remove my baby’s identification band as long as she is in my room”
L.
“I can leave my baby in my room while I walk in the hallway”
127. A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse
should identity that which of the following client for fluid volume excess?
A client who has ulcerative colitis
A client who has an exacerbation of peptic ulcer disease A client who has diabetes insipidus
A client who has advanced stage liver cirrhosis
128. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube
The high pressure alarmis beeping and the.. experiencing respiratory distress. the nurse is
unable to determine the cause pf the alarm. Which of the following actions should the nurse …
Deliver breaths manually with a resuscitation bag Decrease the ventilation flow rate
Reevaluate the client for an ET cuff leak Assess for disconnected tubing
129. A nurse on a mental health unit is admitting a client who has posttraumatic stress,
disorder.Which of the following should the nurse expect ?
Experiences frequent grandiose thoughts Talks continuously about the event
has difficulty concentrating on a task Preoccupled with having a serious illness
130. A nurse is verifying a record of informed consent for a client who is sheduled for
surgery .Which of the following actions should the nurse ….?
Inform the client about the condition that requires teatment Confirm the client's signature Is
authentic
Explain the procedure to the client before verifying informed
Provide Information on the informed consent form about the benefits of the surgery
131. A nurse in a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist’s notes. Which of the following responses
should the nurse make?
We can provide a copy of your records, but the therapists notes are not included I don’t think
you will benefit from reviewing your therapists notes right now Why are you interested in
seeing your therapist’s notes?
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Are you not happy with your treatment?
132. A nurse is screening food brought in by a family member for a client who takes
phenelzine. The nurse should instruct the family members…of the following foods can cause an
interaction with this medication ?
Cottage cheese loeberg lettuce salad bologna sandwich Orange gelatin
133. A nurse is assessing a client who is in skeletal traction for a fractured left tibia.The nurse
should identify that which of the following … altered tissue perfusion of the affected extremity ?
Faint pedal pulse of left leg
Warm sidn temperature distal to pin site Pain with movement of the left great toe Purulent
drainage at the pin site
134. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors
should the nurse identify as indicating the client experiencing mania ?
The client speaks using echopraxia The client speaks using word salad.
The client is easily distracted by external stimuli The client is socially withdrawn
135. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary
catheter for three days. Which of the following action should the nurse take after collecting the
specimens?
Remove gloves after labeling the specimen
Place the specimen in a biohazard bag for transport Obtain the specimen from the drainage
collection bag Wipe the outside of the specimen container with alcohol
136. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the
following should the toddler participate?
M.
Looking at alphabet flashcards. Playing with a large plastic truck.
O. Use scissors cut out paper shapes.
P.
Watching a cartoon in the dayroom.
137. A nurse is reviewing the cardiac rhythm of a client who is ….. on indication ventricular
tachycardia? P wave present with every QRS complex
Sowtooth shaped P waves PR interval of 0.24 seconds
QRS complexes wider than 0.15 seconds
138. A nurse is admitting an older adult client who is transferring from another facility. The
nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the
following actions should the nurse take to address the suspicions of elder abuse?
Inform the transferring agency of the client’s condition.
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Privately interview the client about her condition.
Notify risk management
Contact the family regarding the client’s condition.
139. community health nurse is reviewing laboratory reports for a group of client. The nurse
should identify that which of the following disorder on the CDC's Nationally Notifiable
Conditions list!
Bacterial vaginosis Lyme disease
Respiratory syncytial virus Pediculosis capitis
140. A nurse is teaching a client who is trying to conceive. Which of the following should the
nurse instruct in her diet to prevent a neural tube defect?
Folate Zinc Iron Calcium
141. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the
following
manifestations should the nurse expect?
Loose stools Jitteriness Hypertonia Abdominal distention
142. A Nurse is preparing to administer PRN pain medication to a client who has cholelithiasis
and experiencing moderate abdominal pain. Which of the following medications should the
nurse plan to administer?
Omeprazole Ketorolac Acetaminophen Metoclopramide
143. A nurse is giving an intramuscular injection to a newborn who has delivered at 38 weeks
of gestation .Which of the following pain scale should the nurse use to assess the newborn
pain ?
FACE pain rating scale
Premature Infant Pain Profile (PIPP) Visual analog scale (VAS)
Neonatal Infant Pain Scale (NIPS)
144. A nurse is admitting a client who does not speak the same language as the nurse and
scheduled for outpatient surgery. Which of following actions should the nurse take?
Request a family member to interpret the information. Explain the procedure to the client
through an interpreter.
Provide consent form that is written in the client’s own language.
Help the client look up the information about the procedure on the internet
145. A nurse is preparing to initiate IV therapy for an older adult client. Which of the
following actions should the nurse plan to take ?
Clean the site using vigorous friction
Apply a tourniquet firmly above the insertion Use 22-gauge catheter for insertion
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Select a vein on the back of the hand
146. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which
of the following medications should the nurse administer?
Pregabalin Lorazepam Colchicine Codeine
147. A nurse is providing discharge teaching for a group of clients. The nurse should
recommend a referral to a dietitian
A.
A client who has a prescription for warfarin and states “I will need to limit how much
spinach I
eat”.
A client who has gout and states, “I can continue to eat anchovies on my pizza.”
C.
A client who has a prescription for spironolactone and states “I will reduce my intake of
foods that contain potassium”.
D.
A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with
a full glass of water”.
148. A nurse is reviewing the medical record of a client who has a prescription for
intermittent heat therapy for a foot injury. Which if the following findings should the nurse
identify as a contraindication for heat therapy?
Phlebitis
Abdominal aortic aneurysm Osteoarthritis
Peripheral neuropathy
149. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the
following information should the nurse include about preventing the spread infection?
Clean blood contaminated surfaces with bleach. Use condoms with a petroleum-based
lubricant. Wash soiled clothes in cold water.
Buy disposable dishes for daily use.
150. A nurse is caring for a client who is receiving continuous enteral feedings. which of the
following actions should the nurse take? Select
Check placement of the feeding tube by x-ray once daily Maintain the head of the client's bed at
a30% angle or higher Check gastric residuals every 4 hr.
Change the feeding container and tubing every 24 hr. Ensure the formula is cold before
administration
151. A nurse is assessing a client who has bipolar disorder and is experiencing depressive
episode. which of the following findings should the nurse expect?
Clent expresses ilusions of grandeur Inability to carry out a simple task Client reports auditory
hallucinations Moves quickly from one idea to the next
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152. A nurse is caring for a client who is postoperative immediately following a cardiac
catheterizacion with a right femoral appro..Which of the following actions should the nurse
take?
Elevate the head of the client's bed to 45
Assess the client's peripheral pulses every 15 min. Change the client's dressing 4 hr following
the procedure. Instruct the client to flex the right knee every 30 min.
153. A nurse is teaching a client who has chronic low back pain about the use of alternative
therapy to manage pain. Which of the following by the client indicates an understanding of the
use of distraction?
I will have electrodes inserted in my skin to treat the pain
I should apply my heating blanket to my back to reduce tension I should jog every morning to
improve my circulation
I will watch my favorite old movies when I want to reduce stress
154. A nurse is providing dietary teaching to a client who has hyperlipidemia .The nurse
should include in the teaching that which obtains she lowest amount of saturated fats ?
Coconut oil Olive oil Canola oil Palm oil
155. A nurse is reviewing assessment data from several clients. For which of the following
clients should the nurse referral to a dietitian?
An older adult client who has a BMI of 24 A client who has a nonhealing leg ulcer An older adult
client who has presbyopia
A client who has an albumin level of 3.7g/Dl
156. A nurse is teaching a childbirth education class and is discussing sexual intercourse
during pregnancy. Which of the following statements should the nurse make?
“The female superior position can be used during the third trimester of pregnancy.” “Frequent
intercourse increases the risk for miscarriage in early pregnancy.”
“You should limit the frequency of intercourse after weeks of pregnancy.” Your sexual desire
might increase during the first trimester of pregnancy.”
157. A nurse is caring for an older adult client in a long-term care facility, recently lab values
shows increased hemoglobin, hematocrit, and urine irregularity which findings suggest anemia
Anemia. Dehydration Hepatic failure Acute renal failure
158. A nurse is creating a plan of care for a female client who has recurrent urinary tract
infections. Which of the following interventions should the nurse include in the plan?
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Take a bubble bath after intercourse Void every 5 to 6 hr during the day
Drink four 240 mL (8 oz) glasses of water each day. Wear loose-fitting underwear.
159. A charge nurse is planning a staff education and competence session about operating
newly acquired cardiac monitoring equipment. Which of the following actions should the nurse
plan to take? (Select all that apply.)
Caution staff that the equipment is complicated to use.
Wait to offer feedback on staff use of the equipment until the end of the session. Identify the
current level of staff knowledge about the equipment.
160. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
G. “Dehydration is treated with calcium supplements” “Dehydration can increase the risk of
preterm labor”
I. “Dehydration associated gastroesophageal reflux
J. “Dehydration is caused by a decreased hemoglobin and hematocrit”
161. A nurse is preparing a change of shift report for an adult female client who is
postoperative. Which of the following client information should the nurse include in the report?
CONFIRMED
Hgb 12.8 g/dl - 12- 16
Potassium 4.2 meq/l 3.5 - 5.0 meq
RBC 4.4 million/mm3
Platelets 100,000/mm3
162. A nurse is caring for a client who tells the nurse that he feels he is being discharged from
the facility too soon
.which of the following the nurse demonstrate client advocacy?
I will contact your insurance company to see if they will pay for you to be have longer? Your
provider understands your illness and is acting according to your best interests
I will that the provider about your concerns
I know you will be able to recover faster at home
163. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which
of the following statements by a client indicated an understanding of the teaching?
“I will consume 48 ounces of carbonated beverages daily prior to the surgery.” “I will need to
lose 25 percent of my excess body weight prior to surgery.”
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“I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after
surgery.” “I should wait 30 minutes after eating solid foods to drink beverages following
surgery.”
164. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse use sterile gloves?
Inserting an NG tube
Administering total parenteral nutritional through a central venous access device Initiating IV
access
Performing tracheostomy care
165. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a
modified radical mastectomy. Which of the following statements by the client indicates an
understanding of the teaching?
“I can begin to drive 24 hours after surgery.”
“I can shower within 48 hours of my surgery.”
“I will have my drains removed 1 hour prior to going home.” ‘I will complete my arm exercises
four times a day.”
166. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the
following statements by the client indicates an understanding of the teaching?
“I should apply power to my skin after showering.” “I will not able to go for my daily walk.”
“I will cleanse my skin using a mild soap.”
“I should check my skin once weekly for rashes.”
167. A nurse is providing discharge teaching to a female client who has tuberculosis and a
new prescription for rifampin. Which of the following information should the nurse include?
“Your urine will be orange while this medication.”
Weight gain is an expected adverse effect of this medication
You should avoid getting pregnant for 6 months after stooping this medication You should avoid
sun exposure while taking this medication
168. A nurse is providing discharge Instructions to a client who has a new prescription for
spironolactone .Which of the following the nurse include in the teaching?
Monitor weight once a week
Take the medication in the morning Use a salt substitute with meals
Administer a potassium supplement daily
169. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of
the following prescriptions should the nurse expect the provider to prescribe?
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Atorvastatin Amoxicillin Enoxaparin Interferon beta-1a
170. A nurse is caring for a client who has a history of depression and is experiencing a
situational crisis. Which of the following actions should the nurse take first?
A.
Confirm the client’s perception of the event
B.
Notify the client’s support system
C.
Help the client identify personal strengths
D.
Teach the client relaxation techniques
171. A nurse is counseling a group of clients from a town that was affected by a hurricane 6
months ago. For which of the following clients should the nurse initiate a referral to assess for
the presence of posttraumatic stress disorder? (Select all that apply.)
A client who describes having persistent feelings of anger about the hurricane. A client who has
frequent nightmares about the hurricane.
A client who expresses a realization that life will not return to the way it was before the
hurricane.
A client who moved to an apartment located on higher ground than her previous home.
A client who describes feeling disconnected from those around him following the hurricane.
172. A nurse is caring for a client who has cancer of the throat and is receiving radiation
therapy. The nurse should monitor for which of the following finding as an adverse effect of the
radiation?
Excessive salivation Insomnia
Altered sensation Elevate platelet count
173. A nurse is providing teaching to a client who is breastfeeding and experiencing
engorgement. Which of the following recommendations should the nurse include?
Wear a tight-fitting underwire bra.
Apply warm compresses on the breasts before feedings. Allow the infant to nurse on one breast
per feeding.
Take aspirin to reduce pain and swelling.
174. A nurse is a community clinic is caring for client who request assistant with smoking
censation The nurse should expect a prescription for which of the following medications?
Bupropion Chiordiazepoxide Naltrexone Clonidine
175. A nurse is preparing to administer an IV medication to a client and accidently punctures
the IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of biohazardous material
spill?
Doxorubicin hydrochloride Ampicillin sodium Metronidazole
Phenytoin
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107. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions
should the nurse plan to take?
Obtain the newborn’s body temperature using a tympanic thermometer. Assess the newborn
pain level using FACES pain scale.
Auscultate the newborn’s apical pulse for 60 seconds.
Measure the newborn’s head circumference over the eyebrows and below the occipital
prominence.
108. A nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make in
the medical record?
“Morphine 3 mg SQ every 4 hr. PRN for pain.” “Morphine 3 mg Subcutaneous every 4 hr PRN for
pain “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” “Morphine 3 mg SC q 4 hr. PRN for pain.”
109. A nurse is caring for a client who has gestational hypertension and is experiencing toxic
effects due to magnesium sulfate therapy. The nurse should anticipate administering which of
the medications?
Calcium gluconate Sodium bicarbonate. Potassium chloride. Magnesium citrate
110. A nurse is reviewing the formulary about NPH insulin before administering the
medication to a client. Which of the following information the nurse expect ?
Administrer NPH Insulin 30min before breakfast. Give NPH Insulin by IV bolus
Use NPH insulin to treat ketoacidosis
Discard the NPH insulin vial if the medication is cloudy
111. A nurse is planning care for a school age child who is 4 hr postoperative following
appendicitis .Which of the following action should the nurse include in the plan of care ?
Administer analgesics on a scheduled basis for the first 24 hr Apply a warm compress to the
operative site once daily Offer small amounts of dear liquids 6 hr following surgery Give
cromolyn nebulized solution every8 hr
112. A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of the
fetal well being due to potencial preterm labor following places of equipment should the nurse
use to evaluate the fetal heart rate?
Intrauterine pressure catheter Spiral electrode
Toco transducer ultrasound transducer
113. A nurse is reviewing the medical record of a client who has delayed healing of a leg ulcer.
Which of the following findings should the nurse identify as a contributing factor?
The client takes prednisone for arthritis.
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The client is receiving IV dextrose 5% in water at 100 mL/hr. The client has a total cholesterol
level of 190 mg/dL.
The client has an albumin level of 3.8 g/dL
114. A nurse is caring for a client who has hypertension and a new prescription for
chlorthalidone. The nurse should monitor for which of the following adverse effects?
Hypoglycemia Hypokalemia Euphoria
Increased intraocular pressure
115. A nurse is providing discharge instructions about newborn safety to a client who is 2
days postpartum. Which of the following instructions should the nurse include?
Change smoke detector batteries every other year.
Lay the baby on his stomach to nap during the daytime. Use a car seat when traveling by
airplane
Place a plastic waterproof sheet over the crib bedding.
116. A nurse is caring for a client who is 12 hr postoperative following aortofemoral bypass
surgery .which of the following finding should the nurse impact in the affected extremity?
Cool extremities Pedal pulse of 2+ Throbbing pain
Capillary refill of 4 seconds
117. A home health nurse is teaching a new parent about caring for his 1-week-old-infant.
Which of the following statements by the client indicates an understanding of the teaching?
“I can use a form pillow to prop up the bottle when feeding my baby.” “I will avoid picking up my
baby too often to keep from spoiling him.” “I will hang a pastel-colored mobile 24 inches above
my baby’s crib.”
“I will place a ticking clock nearly to soothe my baby throughout the day.”
118. A nurse is caring for a client who has diaper dermatitis. Which of the following actions
should the nurse take?
Apply zinc oxide ointment to the irritated area.
Wipe stool from the skin using store bought baby wipes. Wipe urine from the skin using a cool
cloth
Apply talcum powder to the irritable area
119. A nurse is assessing a client who is receiving daily aspirin therapy .The nurse should
identify that which of the following allergic reaction to this medication ?
Difficulty swallowing Blurred vision Weight gain
High blood pressure
120. A nurse is preparing to measure a temperature of an infant. Which of the following
action should the nurse take?
Place the tip of the thermometer under the center of the infant’s axilla. Pull the pinna of the
infant’s ear forward before inserting the probe.
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Insert the probe 3.8 cm (1.5in) into the infant’s rectum. Insert the thermometer in front of the
infant’s tongue.
121. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
Q. Coffee with creamer.
R. Lettuce with sliced avocados.
Broiled skinless chicken breast with brown rice.
T.
Warm toast with margarine.
122. A nurse in a provider’s office is reviewing a female client’s medical record during a
routine visit. The nurse should recommend increasing dietary intake of which of the following
vitamins? (Exhibit) --only tab shown is Tab 3:
a.
b.
c.
d.
Vitamin D
Vitamin K
Vitamin A
Vitamin B12
123. A nurse is assessing a client who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings should the nurse to report?
Chest pain Muscle spasms. Cool, moist skin. Incisional pain.
124. A nurse is providing teaching to a client who is to begin external radiation therapy for
cancer .Which of the following information include ?
Wash your skin thoroughly with a washcloth after each treatment Wear a binder over the
radiation site
You might experience altered taste sensations Use rubbing alcohol to remove the ink maricings
125. A nurse is caring for an infant who has respiratory svncytial virus . Which of the following
intervention should the nurse take ?
Suction nares prior to feeding Request a prescription for guaifenesin
Administer palivizumab intravenously Initiate neutropenic precautions
126. A nurse is interviewing the partner of a client who was admitted in the manic phase of
bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so
quickly.” Which of the following by the nurse is therapeutic?
“Can you talk about what happens with your partner at home?”
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“Why do you think your partner’s symptoms are progressing so quickly?” “You should make
sure your partner takes the prescribed medication.” “You did the right thing by bringing your
partner in for treatment.”
127. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The
nurse should identify that which of the following sexually transmitted infections is a nationally
notifiable infectious disease that should be reported to the state health department?
A.
B.
C.
D.
Chlamydia
Human papillomavirus
Candidiasis
Herps simplex virus
128. A nurse is caring for a client who is recovering from an amputation of her right arm
below the elbow. Which of the following information should the nurse report to the
occupational therapist?
The client’s parent is in a skilled nursing facility The client is allergic to penicillin
The client has two small children at home The client lives in a two-story home
129. A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hrintake is 1.750 mL and output is 425 mL. Which of the following actions should the nurse take
first?
Compare the client’s wight to the previous day. Reduce the client’s sodium intake.
Encourage the client to change positions frequently. Administer furosemide to the client.
130. A nurse in a mental health facility receives change-of-shift report for four clients. Which
of the following clients should the nurse plan to assess first?
A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 months A client
who will be receiving her first ECT treatment today
A client placed in restraints due to aggressive behavior
A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
131. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome.
which of the following actions should the nurse take
Decrense the lighting levels in the nursery Wrap the newborn loosely in a bianket
Encourase frequent eye contact with the newborn during feeding Provide frequent stimulation
for the newborn
176. A nurse is calculating a client's expected date of delivery. The clients fast menstral period
began April 12
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Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery
date?
A nurse is discussing group treatment and therapy with a client. The nurse should include which
of the following as being a characteristic of a therapeutic group?
A.
The group is organized in an autocratic structure.
B.
The group encourages members to focus on a particular issue. (
C.
The group must be led by a licensed psychiatrist.
D.
The group encourages clients to form dependent relationships.
177. A nurse manger is reviewing documentation with a newly licensed nurse. Which of the
following notations by the newly licensed nurse indicates an understanding of the teaching?
UNSURE IF ON THE REPORT
A. “OOB with assistance for breakfast”
E.
“Given 2 mg MSO4 IM for report of pain”
F.
“Dressing changed qd”
G.
“Administered 8 u regular insulin sq.”
178. A nurse is preparing to administer eye drops to a school-age child. Identify the actions
the nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.)
6.
Apply pressure to the lacrimal punctum.5
7.
Ask the child to look upward. 2
8.
Pull the lower eyelid downward. 3
9.
Instill the drops of medication. 4
10.
Place the child in a sitting position. 1
179. A nurse is caring for a client who speaks a language different from the nurse. Which of
the following should the nurse take?
E.
Request an interpreter of a different sex from the client.
F.
Request a family member or friend to interpret information for the client.
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G.
Direct attention toward the interpreter when speaking to the client.
H.
Review the facility policy about the use of an interpreter.
180. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the
following findings indicates that the nurse should increase the rate of infusion?
ON THE REPORT needs double checking
A. Urine output 20 ml/hr.
D.
Montevideo units constantly 300 mm Hg.
E.
FHR pattern with absent variability.
F.
Contractions every 5 min that last 30 seconds.
181. A nurse is planning care for a group of clients and is working with one licensed practical
nurse LPN and one assistive personal AP. Which of the following actions should the nurse take
first to manage her time effectively?
Develop an hourly time frame for tasks Schedule daily activities
Determine goals of the day
Delegate tasks to the AP
182. A public health nurse is managing several projects for the community. Which of the
following interventions should the nurse identify as a primary prevention strategy?
A. Teaching parenting skills to expectant mothers and their partners.
C. Conducting mental health screenings at the local community center.
C.
Referring client who have obesity to community exercise programs.
D.
Providing crisis intervention through a mobile counseling unit.
183. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of
the following statements by the client indicates an understanding of the teaching?
a.
“I will take sucralfate with meals three times per day”
b.
“I will avoid food and beverages that contain caffeine”
c.
“I will decrease my daily protein intake to 15 grams per day”
d.
“I will use ibuprofen as needed to control abdominal pain”
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184. A nurse is assessing a client who is receiving packed RBCs. Which of the following
findings indicate fluid overload?
A.
Low back pain.
Dyspnea. Hypotension. Thready pulse.
185. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which
of the following statements should the nurse include in the teaching?
U.
“The PCA will deliver a double dose of medication when you push the button twice.”
V.
“You can adjust the amount of pain medication you receive by pushing on the keypad.”
W.
“Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” X.
“You should push the button before physical activity to allow maximum pain control.”
186. A nurse is preparing to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
M.
N.
O.
P.
Match the client’s blood type with the type and cross match specimens.
Confirm the provider’s prescription matches the number on the blood component.
Ask the client to state the blood type and the date of their last blood donation.
Ensure that the client’s identification band matches the number on the blood unit.
187. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of
the following statements by the client indicates the need for a referral to physical therapy?
E.
“I noticed that I am having a harder time holding on to my toothbrush”
F.
“Lately, I feel like my feet are freezing up, as they are stuck to the ground”
G.
“Sometimes, I feel I am making a chewing motion when I’m not eating”
188. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which
of the following findings should the nurse expect?
A.
Increased creatine.
B.
Increased hemoglobin.
C. Increased bicarbonate.
D. Increased calcium.
189. A nurse is teaching at a community health fair about electrical fire prevention. Which of
the following information should the nurse include in the teaching?
I.
Use three pronged grounded plugs.
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J.
K.
L.
Cover extension cords with a rug.
Check the tingling sensations around the cord to ensure the electricity is working.
Remove the plug from the socket by pulling the cord.
190. A charge nurse is recommending postpartum client discharge following a local disaster.
Which of the following should the nurse recommend for discharge?
F.
A 15-year-old client who delivered via emergency cesarean birth 1 day ago.
G.
A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.
H.
A client who delivered precipitously 36 hr. ago and has a second-degree perineal
laceration.
I.
A 42 yoars old client who has preeclampsia and BP of 166/110 mmHG
191. A nurse is administering a scheduled medication to a client. The client reports that the
medication appears different than what they take at home. Which of the following responses
should the nurse take?
140
“I recommend that you take this medication as prescribed”
141
“Do you know why this medication is being prescribed to you?”
142
“I will call the pharmacist now to check on this medication”
Did the doctor discuss with you that there was a change in this medication
192. A community health nurse is developing a plan to improve the communitys
environmental health. which of the following action nurse take first?
Establish a timeframe for environmental improvements.
Encourage community Involvement in environmental improvement Request funding from
community organizations
Collect information about the community's environmental status
193. A nurse is reviewing the laboratory report of a client who has been having lithium
carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the
following orders from the provider should the nurse expect?
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M.
Withhold the next dose.
N.
O.
P.
Increase the dosage.
Discontinue the medication.
Administer the medication.
194. A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the
nurse report to the provider?
Pulse 140/min
Closed anterior fontanel Respiratory rate 26/min Abdominal breathing
195. A nurse is reviewing legal issues in health care with a group of newly licensed nurses.
Which of the following recommendations should the nurse make?
Place copies of incident reports in client’s medical records Overestimate clients acuilty to
prevent short staffing
Ensure that each client has a living will on file prior to treatment Obtain personal professional
liability insurance coverage
196. A nurse is planning care for a child who has neutropenia due to leukemia. Which of the
following Interventions should the nurse Include in the plan of care?
Screen the child's visitors for active Infections. Initiate Prepare the child for a platelet
transfusion. Prepare the child for a platelet transfusion.
Monitor the child for indications of active bleeding
197. A nurse is caring for a client who is near the end of life and is on complete bed rest. The
client states that he needs to have a bowel movement and the nurse offers a bed pan. The client
states. “I’ve always used the bathroom. “Which of the following responses should the nurse
make?
“Tell me what concerns you have about using a bed pan.”
“I will have the physical therapist ambulate you to the bathroom.” “You have to use the bed pan
for you own safety.”
“Make sure to use nearby furniture to support yourself when walking to the bathroom.
198. A newly licensed nurse is unsure if an assigned task is within their scope of practice.
which of the following resources should the nurse consult?
Written prescription from the provider Institutional policies and procedures Verbal direction
from the nurse manager State Nurse Practice Act
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199. A Nurse is teaching participants at a community center about advance directives. Which
of the following information should the nurse include in the teaching?
Assigning a health care surrogate requires legal consultation
A client must create a do not resuscitate order when completing advances directives. Advance
directives cannot be changed once implemented.
A health care surrogate makes health care decisions when the client is no longer able.
200. A nurse is reviewing the facility’s safety protocols considering newborn abduction with
the parent of a newborn. Which of the following statements indicates an understanding of the
teaching?
Q.
“Staff will apply identification band after first bath”
“I will not publish public announcement about my baby’s birth”
S. “I can remove my baby’s identification band as long as she is in my room”
T. “I can leave my baby in my room while I walk in the hallway”
201. A nurse is planning care for four clients who are at risk for fluid imbalances. The nurse
should identity that which of the following client for fluid volume excess?
A client who has ulcerative colitis
A client who has an exacerbation of peptic ulcer disease A client who has diabetes insipidus
A client who has advanced stage liver cirrhosis
202. A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube
The high pressure alarmis beeping and the.. experiencing respiratory distress. the nurse is
unable to determine the cause pf the alarm. Which of the following actions should the nurse …
Deliver breaths manually with a resuscitation bag
Decrease the ventilation flow rate Reevaluate the client for an ET cuff leak Assess for
disconnected tubing
203. A nurse on a mental health unit is admitting a client who has posttraumatic stress,
disorder.Which of the following should the nurse expect ?
Experiences frequent grandiose thoughts Talks continuously about the event
has difficulty concentrating on a task Preoccupled with having a serious illness
204. A nurse is verifying a record of informed consent for a client who is sheduled for
surgery .Which of the following actions should the nurse ….?
Inform the client about the condition that requires teatment Confirm the client's signature Is
authentic
Explain the procedure to the client before verifying informed
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Provide Information on the informed consent form about the benefits of the surgery
205. A nurse in a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist’s notes. Which of the following responses
should the nurse make?
We can provide a copy of your records, but the therapists notes are not included I don’t think
you will benefit from reviewing your therapists notes right now Why are you interested in
seeing your therapist’s notes?
Are you not happy with your treatment?
206. A nurse is screening food brought in by a family member for a client who takes
phenelzine. The nurse should instruct the family members…of the following foods can cause an
interaction with this medication ?
Cottage cheese loeberg lettuce salad bologna sandwich Orange gelatin
207. A nurse is assessing a client who is in skeletal traction for a fractured left tibia.The nurse
should identify that which of the following … altered tissue perfusion of the affected extremity ?
Faint pedal pulse of left leg
Warm sidn temperature distal to pin site Pain with movement of the left great toe Purulent
drainage at the pin site
208. A nurse is caring for a client who has bipolar disorder. Which of the following behaviors
should the nurse identify as indicating the client experiencing mania ?
The client speaks using echopraxia The client speaks using word salad.
The client is easily distracted by external stimuli The client is socially withdrawn
209. A nurse is obtaining a urine specimen from a client who has had an indwelling urinary
catheter for three days. Which of the following action should the nurse take after collecting the
specimens?
Remove gloves after labeling the specimen
Place the specimen in a biohazard bag for transport Obtain the specimen from the drainage
collection bag Wipe the outside of the specimen container with alcohol
210. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the
following should the toddler participate?
Y.
Looking at alphabet flashcards. Playing with a large plastic truck.
AA.Use scissors cut out paper shapes. BB. Watching a cartoon in the dayroom.
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211. A nurse is reviewing the cardiac rhythm of a client who is ….. on indication ventricular
tachycardia?
P wave present with every QRS complex Sowtooth shaped P waves
PR interval of 0.24 seconds
QRS complexes wider than 0.15 seconds
212. A nurse is admitting an older adult client who is transferring from another facility. The
nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the
following actions should the nurse take to address the suspicions of elder abuse?
Inform the transferring agency of the client’s condition.
Privately interview the client about her condition.
Notify risk management
Contact the family regarding the client’s condition.
213. community health nurse is reviewing laboratory reports for a group of client. The nurse
should identify that which of the following disorder on the CDC's Nationally Notifiable
Conditions list! Bacterial vaginosis
Lyme disease
Respiratory syncytial virus Pediculosis capitis
214. A nurse is teaching a client who is trying to conceive. Which of the following should the
nurse instruct in her diet to prevent a neural tube defect?
Folate
Zinc Iron Calcium
215. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the
following manifestations should the nurse expect?
Loose stools Jitteriness Hypertonia Abdominal distention
216. A Nurse is preparing to administer PRN pain medication to a client who has cholelithiasis
and experiencing moderate abdominal pain. Which of the following medications should the
nurse plan to administer?
Omeprazole Ketorolac Acetaminophen Metoclopramide
217. A nurse is giving an intramuscular injection to a newborn who has delivered at 38 weeks
of gestation .Which of the following pain scale should the nurse use to assess the newborn
pain ? FACE pain rating scale
Premature Infant Pain Profile (PIPP) Visual analog scale (VAS)
Neonatal Infant Pain Scale (NIPS)
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218. A nurse is admitting a client who does not speak the same language as the nurse and
scheduled for outpatient surgery. Which of following actions should the nurse take?
Request a family member to interpret the information. Explain the procedure to the client
through an interpreter.
Provide consent form that is written in the client’s own language.
Help the client look up the information about the procedure on the internet
219. A nurse is preparing to initiate IV therapy for an older adult client. Which of the
following actions should the nurse plan to take ?
Clean the site using vigorous friction
Apply a tourniquet firmly above the insertion Use 22-gauge catheter for insertion
Select a vein on the back of the hand
220. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which
of the following medications should the nurse administer?
Pregabalin Lorazepam Colchicine
Codeine
221. A nurse is providing discharge teaching for a group of clients. The nurse should
recommend a referral to a dietitian
E. A client who has a prescription for warfarin and states “I will need to limit how much spinach
I eat”.
A client who has gout and states, “I can continue to eat anchovies on my pizza.”
G. A client who has a prescription for spironolactone and states “I will reduce my intake of foods
that contain potassium”.
H. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full
glass of water”.
222. A nurse is reviewing the medical record of a client who has a prescription for
intermittent heat therapy for a foot injury. Which if the following findings should the nurse
identify as a contraindication for heat therapy?
Phlebitis
Abdominal aortic aneurysm Osteoarthritis
Peripheral neuropathy
223. A nurse is planning teaching for a client who has a new diagnosis of HIV. Which of the
following information should the nurse include about preventing the spread infection?
Clean blood contaminated surfaces with bleach. Use condoms with a petroleum-based
lubricant. Wash soiled clothes in cold water.
Buy disposable dishes for daily use.
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224. A nurse is caring for a client who is receiving continuous enteral feedings. which of the
following actions should the nurse take? Select
Check placement of the feeding tube by x-ray once daily Maintain the head of the client's bed at
a30% angle or higher Check gastric residuals every 4 hr.
Change the feeding container and tubing every 24 hr. Ensure the formula is cold before
administration
225. A nurse is assessing a client who has bipolar disorder and is experiencing depressive
episode. which of the following findings should the nurse expect?
Clent expresses ilusions of grandeur Inability to carry out a simple task Client reports auditory
hallucinations Moves quickly from one idea to the next
226. A nurse is caring for a client who is postoperative immediately following a cardiac
catheterizacion with a right femoral appro..Which of the following actions should the nurse
take?
Elevate the head of the client's bed to 45
Assess the client's peripheral pulses every 15 min.
Change the client's dressing 4 hr following the procedure. Instruct the client to flex the right
knee every 30 min.
227. A nurse is teaching a client who has chronic low back pain about the use of alternative
therapy to manage pain. Which of the following by the client indicates an understanding of the
use of distraction?
I will have electrodes inserted in my skin to treat the pain
I should apply my heating blanket to my back to reduce tension I should jog every morning to
improve my circulation
I will watch my favorite old movies when I want to reduce stress
228. A nurse is providing dietary teaching to a client who has hyperlipidemia .The nurse
should include in the teaching that which obtains she lowest amount of saturated fats ?
Coconut oil Olive oil Canola oil Palm oil
229. A nurse is reviewing assessment data from several clients. For which of the following
clients should the nurse referral to a dietitian?
An older adult client who has a BMI of 24 A client who has a nonhealing leg ulcer An older adult
client who has presbyopia
A client who has an albumin level of 3.7g/Dl
230. A nurse is teaching a childbirth education class and is discussing sexual intercourse
during pregnancy. Which of the following statements should the nurse make?
“The female superior position can be used during the third trimester of pregnancy.” “Frequent
intercourse increases the risk for miscarriage in early pregnancy.”
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“You should limit the frequency of intercourse after weeks of pregnancy.” Your sexual desire
might increase during the first trimester of pregnancy.”
231. A nurse is caring for an older adult client in a long-term care facility, recently lab values
shows increased hemoglobin, hematocrit, and urine irregularity which findings suggest anemia
Anemia. Dehydration Hepatic failure Acute renal failure
232. A nurse is creating a plan of care for a female client who has recurrent urinary tract
infections. Which of the following interventions should the nurse include in the plan?
Take a bubble bath after intercourse Void every 5 to 6 hr during the day
Drink four 240 mL (8 oz) glasses of water each day.
Wear loose-fitting underwear.
233. A charge nurse is planning a staff education and competence session about operating
newly acquired cardiac monitoring equipment. Which of the following actions should the nurse
plan to take? (Select all that apply.)
Caution staff that the equipment is complicated to use.
Wait to offer feedback on staff use of the equipment until the end of the session. Identify the
current level of staff knowledge about the equipment.
234. A nurse is providing teaching to a client who is experiencing preterm contractions and
dehydration. Which of the following statements should the nurse make?
K. “Dehydration is treated with calcium supplements” “Dehydration can increase the risk of
preterm labor”
M.“Dehydration associated gastroesophageal reflux
N. “Dehydration is caused by a decreased hemoglobin and hematocrit”
235. A nurse is preparing a change of shift report for an adult female client who is
postoperative. Which of the following client information should the nurse include in the report?
CONFIRMED
Hgb 12.8 g/dl - 12- 16
Potassium 4.2 meq/l 3.5 - 5.0 meq
RBC 4.4 million/mm3
Platelets 100,000/mm3
236. A nurse is caring for a client who tells the nurse that he feels he is being discharged from
the facility too soon .which of the following the nurse demonstrate client advocacy?
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I will contact your insurance company to see if they will pay for you to be have longer? Your
provider understands your illness and is acting according to your best interests
I will that the provider about your concerns
I know you will be able to recover faster at home
237. A nurse is teaching a group of clients who are planning to have bariatric surgery. Which
of the following statements by a client indicated an understanding of the teaching?
“I will consume 48 ounces of carbonated beverages daily prior to the surgery.” “I will need to
lose 25 percent of my excess body weight prior to surgery.”
“I should reduce my daily caloric intake by 250 calories to lose 2 pounds each week after
surgery.” “I should wait 30 minutes after eating solid foods to drink beverages following
surgery.”
238. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse use sterile gloves?
Inserting an NG tube
Administering total parenteral nutritional through a central venous access device Initiating IV
access
Performing tracheostomy care
239. A nurse in a surgical clinic is providing teaching to a client who is scheduled for a
modified radical mastectomy. Which of the following statements by the client indicates an
understanding of the teaching?
“I can begin to drive 24 hours after surgery.” “I can shower within 48 hours of my surgery.”
“I will have my drains removed 1 hour prior to going home.” ‘I will complete my arm exercises
four times a day.”
240. A nurse is teaching a client who has systemic lupus erythematosus (SLE). Which of the
following statements by the client indicates an understanding of the teaching?
“I should apply power to my skin after showering.” “I will not able to go for my daily walk.”
“I will cleanse my skin using a mild soap.”
“I should check my skin once weekly for rashes.”
241. A nurse is providing discharge teaching to a female client who has tuberculosis and a
new prescription for rifampin. Which of the following information should the nurse include?
“Your urine will be orange while this medication.”
Weight gain is an expected adverse effect of this medication
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You should avoid getting pregnant for 6 months after stooping this medication You should avoid
sun exposure while taking this medication
242. A nurse is providing discharge Instructions to a client who has a new prescription for
spironolactone .Which of the following the nurse include in the teaching?
Monitor weight once a week
Take the medication in the morning Use a salt substitute with meals
Administer a potassium supplement daily
243. A nurse is caring for a client who has acute exacerbation of multiple sclerosis. Which of
the following prescriptions should the nurse expect the provider to prescribe?
Atorvastatin Amoxicillin Enoxaparin Interferon beta-1a
244.
A nurse is caring for a client who has a history of depression and is experiencing a
situational crisis. Which of the following actions should the nurse take first?
A.
Confirm the client’s perception of the event
B.
Notify the client’s support system
C.
Help the client identify personal strengths
D.
Teach the client relaxation techniques
245. A nurse is counseling a group of clients from a town that was affected by a hurricane 6
months ago. For which of the following clients should the nurse initiate a referral to assess for
the presence of posttraumatic stress disorder? (Select all that apply.)
A client who describes having persistent feelings of anger about the hurricane. A client who has
frequent nightmares about the hurricane.
A client who expresses a realization that life will not return to the way it was before the
hurricane. A client who moved to an apartment located on higher ground than her previous
home.
A client who describes feeling disconnected from those around him following the hurricane.
246. A nurse is caring for a client who has cancer of the throat and is receiving radiation
therapy. The nurse should monitor for which of the following finding as an adverse effect of the
radiation?
Excessive salivation Insomnia
Altered sensation Elevate platelet count
247. A nurse is providing teaching to a client who is breastfeeding and experiencing
engorgement. Which of the following recommendations should the nurse include?
Wear a tight-fitting underwire bra.
Apply warm compresses on the breasts before feedings. Allow the infant to nurse on one breast
per feeding.
Take aspirin to reduce pain and swelling.
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248. A nurse is a community clinic is caring for client who request assistant with smoking
censation The nurse should expect a prescription for which of the following medications?
Bupropion Chiordiazepoxide Naltrexone Clonidine
249. A nurse is preparing to administer an IV medication to a client and accidently punctures
the IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of biohazardous material
spill?
Doxorubicin hydrochloride Ampicillin sodium Metronidazole
Phenytoin
132. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions
should the nurse plan to take?
Obtain the newborn’s body temperature using a tympanic thermometer. Assess the newborn
pain level using FACES pain scale.
Auscultate the newborn’s apical pulse for 60 seconds.
Measure the newborn’s head circumference over the eyebrows and below the occipital
prominence.
133. A nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make in
the medical record?
“Morphine 3 mg SQ every 4 hr. PRN for pain.” “Morphine 3 mg Subcutaneous every 4 hr PRN for
pain “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” “Morphine 3 mg SC q 4 hr. PRN for pain.”
134. A nurse is caring for a client who has gestational hypertension and is experiencing toxic
effects due to magnesium sulfate therapy. The nurse should anticipate administering which of
the medications?
Calcium gluconate Sodium bicarbonate. Potassium chloride. Magnesium citrate
135. A nurse is reviewing the formulary about NPH insulin before administering the
medication to a client. Which of the following information the nurse expect ?
Administrer NPH Insulin 30min before breakfast. Give NPH Insulin by IV bolus
Use NPH insulin to treat ketoacidosis
Discard the NPH insulin vial if the medication is cloudy
136. A nurse is planning care for a school age child who is 4 hr postoperative following
appendicitis .Which of the following action should the nurse include in the plan of care ?
Administer analgesics on a scheduled basis for the first 24 hr Apply a warm compress to the
operative site once daily Offer small amounts of dear liquids 6 hr following surgery Give
cromolyn nebulized solution every8 hr
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137. A nurse is preparing to admit a client who is 35 weeks of gestation for evaluation of the
fetal well being due to potencial preterm labor following places of equipment should the nurse
use to evaluate the fetal heart rate?
Intrauterine pressure catheter Spiral electrode
Toco transducer ultrasound transducer
138. A nurse is reviewing the medical record of a client who has delayed healing of a leg ulcer.
Which of the following findings should the nurse identify as a contributing factor?
The client takes prednisone for arthritis.
The client is receiving IV dextrose 5% in water at 100 mL/hr. The client has a total cholesterol
level of 190 mg/dL.
The client has an albumin level of 3.8 g/dL
139. A nurse is caring for a client who has hypertension and a new prescription for
chlorthalidone. The nurse should monitor for which of the following adverse effects?
Hypoglycemia Hypokalemia Euphoria
Increased intraocular pressure
140. A nurse is providing discharge instructions about newborn safety to a client who is 2
days postpartum. Which of the following instructions should the nurse include?
Change smoke detector batteries every other year.
Lay the baby on his stomach to nap during the daytime. Use a car seat when traveling by
airplane
Place a plastic waterproof sheet over the crib bedding.
141. A nurse is caring for a client who is 12 hr postoperative following aortofemoral bypass
surgery .which of the following finding should the nurse impact in the affected extremity?
Cool extremities Pedal pulse of 2+ Throbbing pain
Capillary refill of 4 seconds
142. A home health nurse is teaching a new parent about caring for his 1-week-old-infant.
Which of the following statements by the client indicates an understanding of the teaching?
“I can use a form pillow to prop up the bottle when feeding my baby.” “I will avoid picking up my
baby too often to keep from spoiling him.” “I will hang a pastel-colored mobile 24 inches above
my baby’s crib.”
“I will place a ticking clock nearly to soothe my baby throughout the day.”
143. A nurse is caring for a client who has diaper dermatitis. Which of the following actions
should the nurse take?
Apply zinc oxide ointment to the irritated area.
Wipe stool from the skin using store bought baby wipes. Wipe urine from the skin using a cool
cloth
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Apply talcum powder to the irritable area
144. A nurse is assessing a client who is receiving daily aspirin therapy .The nurse should
identify that which of the following allergic reaction to this medication ?
Difficulty swallowing Blurred vision
Weight gain
High blood pressure
145. A nurse is preparing to measure a temperature of an infant. Which of the following
action should the nurse take?
Place the tip of the thermometer under the center of the infant’s axilla. Pull the pinna of the
infant’s ear forward before inserting the probe.
Insert the probe 3.8 cm (1.5in) into the infant’s rectum. Insert the thermometer in front of the
infant’s tongue.
146. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary
recommendations should the nurse make?
CC. Coffee with creamer. DD.Lettuce with sliced avocados.
EE. Broiled skinless chicken breast with brown rice. FF. Warm toast with margarine.
147. A nurse in a provider’s office is reviewing a female client’s medical record during a
routine visit. The nurse should recommend increasing dietary intake of which of the following
vitamins? (Exhibit) --only tab shown is Tab 3:
a.
b.
c.
d.
Vitamin D
Vitamin K
Vitamin A
Vitamin B12
148. A nurse is assessing a client who is 30 min postoperative following an arterial
thrombectomy. Which of the following findings should the nurse to report?
Chest pain Muscle spasms. Cool, moist skin. Incisional pain.
149. A nurse is providing teaching to a client who is to begin external radiation therapy for
cancer .Which of the following information include ?
Wash your skin thoroughly with a washcloth after each treatment Wear a binder over the
radiation site
You might experience altered taste sensations Use rubbing alcohol to remove the ink maricings
150. A nurse is caring for an infant who has respiratory svncytial virus . Which of the following
intervention should the nurse take ?
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Suction nares prior to feeding Request a prescription for guaifenesin
Administer palivizumab intravenously Initiate neutropenic precautions
151. A nurse is interviewing the partner of a client who was admitted in the manic phase of
bipolar disorder. The partner states “I don’t know what to do. Everything has been happening so
quickly.” Which of the following by the nurse is therapeutic?
“Can you talk about what happens with your partner at home?”
“Why do you think your partner’s symptoms are progressing so quickly?” “You should make
sure your partner takes the prescribed medication.” “You did the right thing by bringing your
partner in for treatment.”
152. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The
nurse should identify that which of the following sexually transmitted infections is a nationally
notifiable infectious disease that should be reported to the state health department?
E.
F.
G.
H.
Chlamydia
Human papillomavirus
Candidiasis
Herps simplex virus
153. A nurse is caring for a client who is recovering from an amputation of her right arm
below the elbow. Which of the following information should the nurse report to the
occupational therapist?
The client’s parent is in a skilled nursing facility The client is allergic to penicillin
The client has two small children at home The client lives in a two-story home
154. A nurse is caring for a client who has heart failure. The nurse notes the client’s 24-hrintake is 1.750 mL and output is 425 mL. Which of the following actions should the nurse take
first?
Compare the client’s wight to the previous day. Reduce the client’s sodium intake.
Encourage the client to change positions frequently. Administer furosemide to the client.
155. A nurse in a mental health facility receives change-of-shift report for four clients. Which
of the following clients should the nurse plan to assess first?
A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 months
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A client who will be receiving her first ECT treatment today A client placed in restraints due to
aggressive behavior
A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety
156. A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome.
which of the following actions should the nurse take
Decrense the lighting levels in the nursery Wrap the newborn loosely in a bianket
Encourase frequent eye contact with the newborn during feeding Provide frequent stimulation
for the newborn
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