FUNDAMENTALS
Which assessment is most important for the
nurse to make before advancing a client from
liquid to solid food?
•
Bowel sounds
•
Chewing Ability
•
Current Appetite
•
Food Preferences
Which assessment is most important for the
nurse to make before advancing a client from
liquid to solid food?
•
Bowel sounds
•
Chewing Ability
•
Current Appetite
•
Food Preferences
A client experiences wound dehiscence when
coughing. After assisting the client to a low
fowler’s position with legs slightly elevated,
what is the next best action?
•
•
•
Push the internal organs back into the
abdominal opening.
Cover the wound with a moist hydrocolloid
dressing.
Cover the wound with a sterile, saline,
A client experiences wound dehiscence when
coughing. After assisting the client to a low
fowler’s position with legs slightly elevated,
what is the next best action?
•
•
•
Push the internal organs back into the
abdominal opening.
Cover the wound with a moist hydrocolloid
dressing.
Cover the wound with a sterile, saline,
A client is admitted to the cardiac intensive care
unit following cardiac surgery. The nurse notes
that in the first hour after admission, the
mediastinal chest tube drainage was 75mL.
During the second hour, the drainage has
dropped to 5 mL. The nurse interprets that:
•
​This is normal.
•
The tube may be occluded.
•
The lung has fully expanded.
A client is admitted to the cardiac intensive care
unit following cardiac surgery. The nurse notes
that in the first hour after admission, the
mediastinal chest tube drainage was 75mL.
During the second hour, the drainage has
dropped to 5 mL. The nurse interprets that:
•
​This is normal.
•
The tube may be occluded.
•
The lung has fully expanded.
The patient has a closed fracture of the right
femur and tibia on xray with multiple
contusions to the RLE. The nurse should:
•
Prepare for application of skeletal traction
•
Apply ice to the contusions
•
Prepare for open reduction
•
Assess the circulatory, motor, ad sensory
status of the RLE
The patient has a closed fracture of the right
femur and tibia on xray with multiple
contusions to the RLE. The nurse should:
•
Prepare for application of skeletal traction
•
Apply ice to the contusions
•
Prepare for open reduction
•
Assess the circulatory, motor, ad sensory
status of the RLE
The nurse is planning care for a patient with an
internal radiation implant. Which intervention
would be inappropriate to include in the plan
of care?
•
•
•
Wear gloves when emptying patient’s
bedpan
Keep all linens in patient’s room until
implant is removed
Wear a lead apron when providing direct
The nurse is planning care for a patient with an
internal radiation implant. Which intervention
would be inappropriate to include in the plan
of care?
•
•
•
Wear gloves when emptying patient’s
bedpan
Keep all linens in patient’s room until
implant is removed
Wear a lead apron when providing direct
What is the number one cause of injury that
causes patients to be admitted to the
hospital?
•
Falls
•
MVA
•
Medication errors
•
Brain Injury
What is the number one cause of injury that
causes patients to be admitted to the
hospital?
•
Falls
•
MVA
•
Medication errors
•
Brain Injury
Which of the following nursing interventions
decreases a patient’s risk for falls?
•
​Keeping the side rails up
•
Keeping socks on the patient
•
Keeping the call bell in reach
•
Keeping a chair away from the bed
Which of the following nursing interventions
decreases a patient’s risk for falls?
•
​Keeping the side rails up
•
Keeping socks on the patient
•
Keeping the call bell in reach
•
Keeping a chair away from the bed
The nurse is teaching a client with a history of
falls about home safety. Which of the
following statements indicates that the client
understands the instructions?
•
•
•
“I will keep the ceiling light on in my room
at all times.”
“I will put a nonskid floor mat on the side of
the bed that I exit.”
“I will wear treaded slipper socks on my
The nurse is teaching a client with a history of
falls about home safety. Which of the
following statements indicates that the client
understands the instructions?
•
•
•
“I will keep the ceiling light on in my room
at all times.”
“I will put a nonskid floor mat on the side
of the bed that I exit.”
“I will wear treaded slipper socks on my
What observation by the nurse indicates
inappropriate restraint application by a CNA?
•
•
•
•
CNA ties a safety knot in the restraint straps​
CNA secures the restraint straps to the bed
frame​
CNA crosses vest behind patient​
CNA checks for 2 finger space between vest
and skin​
What observation by the nurse indicates
inappropriate restraint application by a CNA?
•
•
•
•
CNA ties a safety knot in the restraint straps​
CNA secures the restraint straps to the bed
frame​
CNA crosses vest behind patient​
CNA checks for 2 finger space between vest
and skin​
The nurse prepares a client who is being
discharged from the hospital to receive
oxygen therapy at home. Which should the
nurse include in client teaching about oxygen
safety?
•
•
Hold the oxygen tank on your lap when
traveling.
Light candles a few feet away from the
oxygen tank.
The nurse prepares a client who is being
discharged from the hospital to receive
oxygen therapy at home. Which should the
nurse include in client teaching about oxygen
safety?
•
•
Hold the oxygen tank on your lap when
traveling.
Light candles a few feet away from the
oxygen tank.
A hospitalized client becomes disoriented
frequently. Which should the nurse implement
to ensure client safety at all times?
•
Request the family hire a sitter.
•
Check in with the client frequently.
•
Position the call bell within easy reach.
•
Keep all side rails in the raised position at all
times.
A hospitalized client becomes disoriented
frequently. Which should the nurse implement
to ensure client safety at all times?
•
Request the family hire a sitter.
•
Check in with the client frequently.
•
Position the call bell within easy reach.
•
Keep all side rails in the raised position at all
times.
A dangerous fire has occurred in the hospital
and you must evacuate . Based on the
following reports, which patient should be
evacuated last?
•
•
•
Severe head injury, no DTR, receiving
continuous IVs, and ventilated
Right-sided paralysis, total bedrest s/p CVA,
feeding tube, nonambulatory
RLE long leg plaster cast, RUE external
A dangerous fire has occurred in the hospital
and you must evacuate . Based on the
following reports, which patient should be
evacuated last?
•
•
•
Severe head injury, no DTR, receiving
continuous IVs, and ventilated
Right-sided paralysis, total bedrest s/p CVA,
feeding tube, nonambulatory
RLE long leg plaster cast, RUE external
A client is having a Cesarean section for failure
to progress. The husband is present and is
sitting next to his wife's head. As the surgical
procedure is taking place, the surgeon asks
the circulating nurse to get a specific type of
suture that is not already on the sterile field.
The circulating nurse hands the scrub nurse
the size and type of suture the surgeon
requested. The scrub nurse prepares the
suture, and hands it off to the surgeon to use.
A client is having a Cesarean section for failure
to progress. The husband is present and is
sitting next to his wife's head. As the surgical
procedure is taking place, the surgeon asks
the circulating nurse to get a specific type of
suture that is not already on the sterile field.
The circulating nurse hands the scrub nurse
the size and type of suture the surgeon
requested. The scrub nurse prepares the
suture, and hands it off to the surgeon to use.
The nurse teaches a client’s daughter to perform
a dressing change using sterile technique.
Which of the following actions by the
daughter should indicate to the nurse that the
daughter understands prevention of infection?
•
•
The daughter washing her hands before
applying gloves.
The daughter placing herself between the
sterile field and the client.
The nurse teaches a client’s daughter to perform
a dressing change using sterile technique.
Which of the following actions by the
daughter should indicate to the nurse that the
daughter understands prevention of infection?
•
•
The daughter washing her hands before
applying gloves.
The daughter placing herself between the
sterile field and the client.
The nurse must assess the temperature and
blood pressure of a client on contact
precautions every shift. Which is the
appropriate nursing action to minimize the
spread of microorganisms?
•
•
•
Keep the equipment in the client’s room.
Store the equipment in the soiled utility
room between uses.
Cleanse the equipment after each use.
The nurse must assess the temperature and
blood pressure of a client on contact
precautions every shift. Which is the
appropriate nursing action to minimize the
spread of microorganisms?
•
•
•
Keep the equipment in the client’s room.
Store the equipment in the soiled utility
room between uses.
Cleanse the equipment after each use.
Which measure used by the nurse would be
most effective in preventing exposure when
caring for a client with Hepatitis B?
•
•
•
Wearing a gown when changing an IV bag
Applying a mask before entering the client’s
room.
Wearing gloves when taking the client’s
pulse.
Which measure used by the nurse would be
most effective in preventing exposure when
caring for a client with Hepatitis B?
•
•
•
Wearing a gown when changing an IV bag
Applying a mask before entering the client’s
room.
Wearing gloves when taking the client’s
pulse.
Which of the following is required for a patient
diagnosed with bacterial meningitis?
•
Contact isolation
•
Airborne precautions
•
Droplet precautions
•
Standard precautions
Which of the following is required for a patient
diagnosed with bacterial meningitis?
•
Contact isolation
•
Airborne precautions
•
Droplet precautions
•
Standard precautions
The nurse prepares to provide colostomy care to
a patient on contact precautions. Which of the
following protective items is needed to
perform this procedure?
•
Gloves and gown
•
Gloves, gown, goggles, and face shield
•
Gloves and goggles
•
Gloves
The nurse prepares to provide colostomy care to
a patient on contact precautions. Which of the
following protective items is needed to
perform this procedure?
•
Gloves and gown
•
Gloves, gown, goggles, and face shield
•
Gloves and goggles
•
Gloves
A nurse is inserting an indwelling catheter into
the urethra of a male client. As the nurse
inflates the balloon, the client complains of
discomfort. The appropriate nursing action is
to:
•
•
Aspirate the fluid, remove the catheter, and
insert a new catheter.
Aspirate the fluid, withdraw the catheter
slightly, and reinflate the balloon
A nurse is inserting an indwelling catheter into
the urethra of a male client. As the nurse
inflates the balloon, the client complains of
discomfort. The appropriate nursing action is
to:
•
•
Aspirate the fluid, remove the catheter, and
insert a new catheter.
Aspirate the fluid, withdraw the catheter
slightly, and reinflate the balloon
Which of the following statements by a client
would alert the nurse that further teaching on
the idea of a restful sleep is indicated?
•
•
•
“ I have a small snack and take a bath before
going to bed each day.”
“I went to bed earlier than usual and I
rested and watched television until I fell
asleep.”
“I go to bed and get up routinely at the
Which of the following statements by a client
would alert the nurse that further teaching on
the idea of a restful sleep is indicated?
•
•
•
“ I have a small snack and take a bath before
going to bed each day.”
“I went to bed earlier than usual and I
rested and watched television until I fell
asleep.”
“I go to bed and get up routinely at the
The nurse knows discharge teaching in relation
to warfarin sodium (Coumadin) therapy has
been understood when the client states, “I
will:
•
Take Tylenol for my occasional headaches.”
•
Spend most of the day working at my desk.”
•
Ask the doctor for antibiotics before going
to the dentist.”
The nurse knows discharge teaching in relation
to warfarin sodium (Coumadin) therapy has
been understood when the client states, “I
will:
•
Take Tylenol for my occasional headaches.”
•
Spend most of the day working at my desk.”
•
Ask the doctor for antibiotics before going
to the dentist.”
The nurse is reviewing medications on the MD’s
order sheet and notes a medication with a
dose that is two times greater than the
customary amount. The nurse should:
•
•
Understand that there may be special
circumstances in which additional medication
is needed and give the medication as ordered.
Ask the client if he or she has been receiving
the dose of medication as ordered.
The nurse is reviewing medications on the MD’s
order sheet and notes a medication with a
dose that is two times greater than the
customary amount. The nurse should:
•
•
Understand that there may be special
circumstances in which additional medication
is needed and give the medication as ordered.
Ask the client if he or she has been receiving
the dose of medication as ordered.
The nurse arrives for work and is asked to count
the narcotics with the nurse finishing her shift
duty. The arriving nurse should be the nurse
who does which of the following?
•
•
Visually counts the actual sign-out sheets
for the balance of narcotics administered by
nurses after the nurses leave the unit.
Visually counts the actual sign-out sheets
for the balance of narcotics administered by
The nurse arrives for work and is asked to count
the narcotics with the nurse finishing her shift
duty. The arriving nurse should be the nurse
who does which of the following?
•
•
Visually counts the actual sign-out sheets
for the balance of narcotics administered by
nurses after the nurses leave the unit.
Visually counts the actual sign-out sheets
for the balance of narcotics administered by
A nurse is preparing to administer medication
through a nasogastric tube that is connected
to suction. The nurse would:
•
•
•
​ lamp the nasogastric tube for 30 minutes
C
following administration of the medication.
Aspirate the nasogastric tube after
medication administration to maintain
patency.
Position the client supine to assist in
A nurse is preparing to administer medication
through a nasogastric tube that is connected
to suction. The nurse would:
•
•
•
Clamp the nasogastric tube for 30 minutes
following administration of the medication.
Aspirate the nasogastric tube after
medication administration to maintain
patency.
Position the client supine to assist in
Ear drops are prescribed for an infant with otitis
media. The most appropriate method to
administer the ear drops to the infant is to:
•
•
Pull down and back on the pinna and direct
the solution toward the wall of the
canal.​42.86%
Pull up and back on the earlobe and direct
the solution toward the wall of the
canal.​5.71%
Ear drops are prescribed for an infant with otitis
media. The most appropriate method to
administer the ear drops to the infant is to:
•
•
Pull down and back on the pinna and direct
the solution toward the wall of the
canal.​42.86%
Pull up and back on the earlobe and direct
the solution toward the wall of the
canal.​5.71%
Nurse #1 has prepared an IM injection for a
preoperative client. Suddenly, another of her
clients becomes entangled in IV tubing and
yells for help. The surgery orderly is waiting
for the preoperative client, so nurse #1 asks
nurse #2 to give the injection to the
preoperative client so nurse #1 can assist the
patient. Which of the following is the best
response by nurse #2?
•
Help the second client.
Nurse #1 has prepared an IM injection for a
preoperative client. Suddenly, another of her
clients becomes entangled in IV tubing and
yells for help. The surgery orderly is waiting
for the preoperative client, so nurse #1 asks
nurse #2 to give the injection to the
preoperative client so nurse #1 can assist the
patient. Which of the following is the best
response by nurse #2?
•
Help the second client.
MED SURG
A client who has acromegaly and diabetes
undergoes a hypophysectomy. The nurse
identifies that further teaching is needed
when the client states, “I know I will:
•
•
•
Be sterile for the rest of my life.”
Require larger doses of insulin than I did
preoperatively.”
Have to take thyroxine or similar
preparation for the rest of my life.”
A client who has acromegaly and diabetes
undergoes a hypophysectomy. The nurse
identifies that further teaching is needed
when the client states, “I know I will:
•
•
•
Be sterile for the rest of my life.”
Require larger doses of insulin than I did
preoperatively.”
Have to take thyroxine or similar
preparation for the rest of my life.”
A client is scheduled for a bilateral
adrenalectomy. Before surgery, steroids are
administered to the client. The nurse
understands the reason for this is to:
•
•
•
Foster accumulation of glycogen in the liver
Increase the inflammatory action to
promote scar formation
Facilitate urinary excretion of salt and water
following surgery
A client is scheduled for a bilateral
adrenalectomy. Before surgery, steroids are
administered to the client. The nurse
understands the reason for this is to:
•
•
•
Foster accumulation of glycogen in the liver
Increase the inflammatory action to
promote scar formation
Facilitate urinary excretion of salt and water
following surgery
The nurse is caring for a client with Addison’s
disease. Which information should the nurse
include in a teaching plan as a means of
encouraging this client to improve dietary
intake?
•
•
Increased amounts of potassium are
needed to replace renal losses
Increased protein is needed to heal the
adrenal tissue and thus cure the disease
The nurse is caring for a client with Addison’s
disease. Which information should the nurse
include in a teaching plan as a means of
encouraging this client to improve dietary
intake?
•
•
Increased amounts of potassium are
needed to replace renal losses
Increased protein is needed to heal the
adrenal tissue and thus cure the disease
A client is admitted for a head injury. The nurse
identifies that the client’s urinary retention
catheter is draining large amounts of clear,
colorless, urine. What does the nurse identify
as the most likely cause?
•
Poor renal perfusion
•
Increased serum glucose
•
Inadequate ADH secretion
A client is admitted for a head injury. The nurse
identifies that the client’s urinary retention
catheter is draining large amounts of clear,
colorless, urine. What does the nurse identify
as the most likely cause?
•
Poor renal perfusion
•
Increased serum glucose
•
Inadequate ADH secretion
After a surgical clipping of a cerebral aneurysm,
the client develops syndrome of inappropriate
antidiuretic hormone. The nurse should assess
the client for which manifestations of excess
levels of ADH? Select all that apply
•
Polyuria
•
Weight gain
•
Hypotension
After a surgical clipping of a cerebral aneurysm,
the client develops syndrome of inappropriate
antidiuretic hormone. The nurse should assess
the client for which manifestations of excess
levels of ADH? Select all that apply
•
Polyuria
•
Weight gain
•
Hypotension
What is important for the nurse to tell the client
before a routine glycoslated hemoglobin (Hgb
A1c) test?
•
•
•
NPO after midnight except AM po
medications
Eat a full breakfast and wait 2-4 hours
before arriving at the testing site
Expect to be at the testing site for several
hours due to multiple blood draws
What is important for the nurse to tell the client
before a routine glycoslated hemoglobin (Hgb
A1c) test?
•
•
•
NPO after midnight except AM po
medications
Eat a full breakfast and wait 2-4 hours
before arriving at the testing site
Expect to be at the testing site for several
hours due to multiple blood draws
When caring for a client with thyroid crisis, the
nurse would question an order for:
•
IV fluids
•
Propanolol (Inderal)
•
Propylthiouracil (PTU)
•
Warming blanket
When caring for a client with thyroid crisis, the
nurse would question an order for:
•
IV fluids
•
Propanolol (Inderal)
•
Propylthiouracil (PTU)
•
Warming blanket
The nurse is caring for several clients who have
diabetes. When assessing these clients, the
nurse should understand that a difference
between diabetic ketoacidosis (DKA) and
hyperglycemic hyperosmolar State (HHS)
(formally HHNS) is that a response in clients
with DKA is:
•
Fluid loss
•
Glycosuria
The nurse is caring for several clients who have
diabetes. When assessing these clients, the
nurse should understand that a difference
between diabetic ketoacidosis (DKA) and
hyperglycemic hyperosmolar State (HHS)
(formally HHNS) is that a response in clients
with DKA is:
•
Fluid loss
•
Glycosuria
Cardiac monitoring is initiated for a patient in
DKA to identify:
•
Effects of fluid overload on cardiac output
•
Hypovolemic shock r/t osmotic diuresis
•
•
CV collapse r/t effects of hypergylcemia on
the myocardium
Potassium imbalances
Cardiac monitoring is initiated for a patient in
DKA to identify:
•
Effects of fluid overload on cardiac output
•
Hypovolemic shock r/t osmotic diuresis
•
•
CV collapse r/t effects of hypergylcemia on
the myocardium
Potassium imbalances
The patient is receiving TPN (total parenteral
nutrition) and complains of nausea, excessive
thirst, and urinary frequency. Which of the
following actions should the nurse complete
initially?
•
Check the serum BUN and creatinine level
•
Take the patient’s temperature
•
Obtain a finger stick glucose
The patient is receiving TPN (total parenteral
nutrition) and complains of nausea, excessive
thirst, and urinary frequency. Which of the
following actions should the nurse complete
initially?
•
Check the serum BUN and creatinine level
•
Take the patient’s temperature
•
Obtain a finger stick glucose
A client is receiving TPN through a central
venous catheter. The client suddenly
complains of chest pain and shortness of
breath and becomes pale and anxious. Which
of the following is the most appropriate action
by the nurse?
•
•
Check the blood sugar
Slow the rate of the TPN and notify the
physician
A client is receiving TPN through a central
venous catheter. The client suddenly
complains of chest pain and shortness of
breath and becomes pale and anxious. Which
of the following is the most appropriate action
by the nurse?
•
•
Check the blood sugar
Slow the rate of the TPN and notify the
physician
The preoperative patient tells the nurse that he
researched the surgical procedure on the
Internet and has no questions at this time.
Which of the following should the nurse do?
•
•
Document that the patient studied the
procedure on the Internet
Assess the patient’s understanding of the
procedure to supplement any areas not
reviewed through the Internet
The preoperative patient tells the nurse that he
researched the surgical procedure on the
Internet and has no questions at this time.
Which of the following should the nurse do?
•
•
Document that the patient studied the
procedure on the Internet
Assess the patient’s understanding of the
procedure to supplement any areas not
reviewed through the Internet
A postoperative patient is demonstrating a
distended abdomen with no bowel sounds.
Which of the following should the nurse do to
help the patient?
•
Advance to full diet
•
Restrict all fluids
•
Ambulate three times a day
•
Administer antiemetic medication
A postoperative patient is demonstrating a
distended abdomen with no bowel sounds.
Which of the following should the nurse do to
help the patient?
•
Advance to full diet
•
Restrict all fluids
•
Ambulate three times a day
•
Administer antiemetic medication
A patient receiving a unit of PRBC’s complains of
chest and back pain within 5 minutes of the
start of the transfusion. What should the
nurse do?
•
Slow the transfusion
•
Stop the transfusion, call a rapid response
•
Administer Epinephrine
•
Provide antipyretics
A patient receiving a unit of PRBC’s complains of
chest and back pain within 5 minutes of the
start of the transfusion. What should the
nurse do?
•
Slow the transfusion
•
Stop the transfusion, call a rapid response
•
Administer Epinephrine
•
Provide antipyretics
A patient is admitted with rib fractures after
falling from a ladder while on the job. Which
of the following is a priority for the care of this
patient?
•
Safety precautions
•
Pain management
•
Employment counseling
•
Rehabilitation therapy
A patient is admitted with rib fractures after
falling from a ladder while on the job. Which
of the following is a priority for the care of this
patient?
•
Safety precautions
•
Pain management
•
Employment counseling
•
Rehabilitation therapy
Morning assessment for a patient with fluid
volume excess includes bounding peripheral
pulses, weight gain of two pounds, +3 pitting
ankle edema and crackles bilaterally bottom
1/3rd of lung fields. Which of the following
physician orders is the priority?
•
Weigh patient daily
•
Maintain strict I&O
•
Restrict fluid intake to 1500mL per day
Morning assessment for a patient with fluid
volume excess includes bounding peripheral
pulses, weight gain of two pounds, +3 pitting
ankle edema and crackles bilaterally bottom
1/3rd of lung fields. Which of the following
physician orders is the priority?
•
Weigh patient daily
•
Maintain strict I&O
•
Restrict fluid intake to 1500mL per day
The nurse is caring for a patient with pneumonia
who has an ABG of pH=7.20, CO2=75, HCO3=28, and PaO2 =44. Which of the following
would be a priority for this patient?
•
Assist the patient to breathe into a paper
bag
•
Prepare to administer sodium bicarbonate
•
Place the patient in high Fowler’s position
The nurse is caring for a patient with pneumonia
who has an ABG of pH=7.20, CO2=75, HCO3=28, and PaO2 =44. Which of the following
would be a priority for this patient?
•
Assist the patient to breathe into a paper
bag
•
Prepare to administer sodium bicarbonate
•
Place the patient in high Fowler’s position
A client with active TB continues to have
positive sputum cultures after 6 months of
treatment because she says she cannot
remember to take the medication all the time.
The best action by the nurse is to:
•
•
Schedule the client to come to the clinic
every day
Have a client who has recovered from TB
tell the client about his successful treatment
A client with active TB continues to have
positive sputum cultures after 6 months of
treatment because she says she cannot
remember to take the medication all the time.
The best action by the nurse is to:
•
•
Schedule the client to come to the clinic
every day
Have a client who has recovered from TB
tell the client about his successful treatment
A client with pneumonia has a nursing diagnosis
of ineffective airway clearance r/t thick
secretions. An appropriate nursing
intervention for the client is to:
•
•
•
Encourage a fluid intake of 3L/day
Administer oxygen as prescribed to
maintain SpO2 95%
Place the client in a semi-Fowler’s position
A client with pneumonia has a nursing diagnosis
of ineffective airway clearance r/t thick
secretions. An appropriate nursing
intervention for the client is to:
•
•
•
Encourage a fluid intake of 3L/day
Administer oxygen as prescribed to
maintain SpO2 95%
Place the client in a semi-Fowler’s position
Two days after pelvic surgery a client develops
marked dyspnea and anxiety. What action
should the nurse take first?
•
Raise the head of the bed
•
Notify the healthcare provider
•
Take the client’s pulse and BP
•
Determine the client’s SpO2
Two days after pelvic surgery a client develops
marked dyspnea and anxiety. What action
should the nurse take first?
•
Raise the head of the bed
•
Notify the healthcare provider
•
Take the client’s pulse and BP
•
Determine the client’s SpO2
To decrease the client’s sense of panic during an
asthma attack, the best action of the nurse is
to:
•
•
•
Leave the client alone in a quiet, calm
environment
Stay with the client and encourage slow,
purse-lip breathing
Reassure the client that the attack can be
controlled
To decrease the client’s sense of panic during an
asthma attack, the best action of the nurse is
to:
•
•
•
Leave the client alone in a quiet, calm
environment
Stay with the client and encourage slow,
purse-lip breathing
Reassure the client that the attack can be
controlled
The husband of a client with COPD tells the
nurse that they have not had sexual activity
since the client was diagnosed with COPD
because she becomes too short of breath. The
best response by the nurse is:
•
•
“You need to discuss your feelings with your
wife so she knows what you expect of her.”
“There are other ways to maintain intimacy
besides sexual intercourse that will not make
The husband of a client with COPD tells the
nurse that they have not had sexual activity
since the client was diagnosed with COPD
because she becomes too short of breath. The
best response by the nurse is:
•
•
“You need to discuss your feelings with your
wife so she knows what you expect of her.”
“There are other ways to maintain intimacy
besides sexual intercourse that will not make
A client with mitral valve prolapse tells the nurse
during a clinic visit that she is scheduled to get
her teeth cleaned. Which response by the
nurse is most appropriate?
•
•
•
The physician will need to evaluate your
heart prior to your dental visit
Be sure to remind your dentist that you
have a heart condition
It is important that you care for your teeth
A client with mitral valve prolapse tells the nurse
during a clinic visit that she is scheduled to get
her teeth cleaned. Which response by the
nurse is most appropriate?
•
•
•
The physician will need to evaluate your
heart prior to your dental visit
Be sure to remind your dentist that you
have a heart condition
It is important that you care for your teeth
A client who has had her jaws wired is vomiting
and appears cyanotic. What should be the
nurse’s first action?
•
Insert an NG tube and connect to suction
•
Use the wire cutters to cut the wire
•
Suction the client’s airway
•
Administer an antiemetic intravenously
A client who has had her jaws wired is vomiting
and appears cyanotic. What should be the
nurse’s first action?
•
Insert an NG tube and connect to suction
•
Use the wire cutters to cut the wire
•
Suction the client’s airway
•
Administer an antiemetic intravenously
During assessment of a client’s mouth, the nurse
notes the absence of saliva. The client also
complains of pain around the ear. The client
has been NPO for several days because of the
insertion of a NG tube. The nurse suspects
which of the following conditions?
•
Stomatitis
•
Oral candidiasis
•
Parotitis
During assessment of a client’s mouth, the nurse
notes the absence of saliva. The client also
complains of pain around the ear. The client
has been NPO for several days because of the
insertion of a NG tube. The nurse suspects
which of the following conditions?
•
Stomatitis
•
Oral candidiasis
•
Parotitis
A client admitted to the hospital after vomiting
bright red blood and is diagnosed with a
bleeding duodenal ulcer. The client develops
sudden, sharp, midepigastric pain and a rigid
abdomen. These clinical manifestations
indicate which of the following?
•
An intestinal obstruction
•
Additional ulcers have developed
•
The esophagus has become inflamed
A client admitted to the hospital after vomiting
bright red blood and is diagnosed with a
bleeding duodenal ulcer. The client develops
sudden, sharp, midepigastric pain and a rigid
abdomen. These clinical manifestations
indicate which of the following?
•
An intestinal obstruction
•
Additional ulcers have developed
•
The esophagus has become inflamed
The nurse finds a client diagnosed with PUD
surrounded by papers from his briefcase and
arguing on the phone with one of his
coworkers. The nurse’s response to observing
these actions should be based on the
knowledge that:
•
•
Involving the client’s job will prevent
boredom
A relaxing environment will promote ulcer
The nurse finds a client diagnosed with PUD
surrounded by papers from his briefcase and
arguing on the phone with one of his
coworkers. The nurse’s response to observing
these actions should be based on the
knowledge that:
•
•
Involving the client’s job will prevent
boredom
A relaxing environment will promote ulcer
Fluid intake for clients suffering from dumping
syndrome should be:
•
Between meals
•
Only with meals
•
Any time they want
•
Restricted to 1200ml/day
Fluid intake for clients suffering from dumping
syndrome should be:
•
Between meals
•
Only with meals
•
Any time they want
•
Restricted to 1200ml/day
Which would the nurse expect to see with
dumping syndrome?
•
Feeling of hunger
•
Constipation
•
Increased strength
•
Diaphoresis
Which would the nurse expect to see with
dumping syndrome?
•
Feeling of hunger
•
Constipation
•
Increased strength
•
Diaphoresis
A client with suspected gastric cancer undergoes
an endoscopy of the stomach. Which of the
following assessments made after the
procedure would indicate the development of
a potential complication? The client:
•
Complains of a sore throat
•
Displays signs of sedation
•
Experiences a sudden increase in
temperature
A client with suspected gastric cancer undergoes
an endoscopy of the stomach. Which of the
following assessments made after the
procedure would indicate the development of
a potential complication? The client:
•
Complains of a sore throat
•
Displays signs of sedation
•
Experiences a sudden increase in
temperature
A client diagnosed with GERD complains of a
chronic cough. The nurse understands that
this symptoms may be indicative of which of
the following conditions?
•
Development of laryngeal cancer
•
Aspiration of gastric contents
•
Esophageal scar tissue formation
•
Irritation of the esophagus
A client diagnosed with GERD complains of a
chronic cough. The nurse understands that
this symptoms may be indicative of which of
the following conditions?
•
Development of laryngeal cancer
•
Aspiration of gastric contents
•
Esophageal scar tissue formation
•
Irritation of the esophagus
The nurse instructs the client on health
maintenance activities to help control
symptoms of a hiatal hernia. Which of the
statements if made by the client indicates the
client has understood the instructions?
•
“I’ll avoid laying down after meals”
•
“I wish I didn’t have to give up swimming”
•
“If I wear a girdle, I’ll have more support for
my stomach”
The nurse instructs the client on health
maintenance activities to help control
symptoms of a hiatal hernia. Which of the
statements if made by the client indicates the
client has understood the instructions?
•
“I’ll avoid laying down after meals”
•
“I wish I didn’t have to give up swimming”
•
“If I wear a girdle, I’ll have more support for
my stomach”
While changing the client’s colostomy bag and
dressing, the nurse assesses that the client is
ready to participate in her care by noting the
following?
•
•
•
The client asks about the doctor’s next visit
The client asks about the supplies used
during the dressing change
The client talks about an article she read in
the newspaper
While changing the client’s colostomy bag and
dressing, the nurse assesses that the client is
ready to participate in her care by noting the
following?
•
•
•
The client asks about the doctor’s next visit
The client asks about the supplies used
during the dressing change
The client talks about an article she read in
the newspaper
A client who has a history of Crohn’s disease is
admitted to the hospital for fever, diarrhea,
cramping, abdominal pain, and weight loss.
Which of the following laboratory conditions
would be anticipated for the client?
•
Hyperalbuminemia
•
Thrombocytopenia
•
Hypokalemia
A client who has a history of Crohn’s disease is
admitted to the hospital for fever, diarrhea,
cramping, abdominal pain, and weight loss.
Which of the following laboratory conditions
would be anticipated for the client?
•
Hyperalbuminemia
•
Thrombocytopenia
•
Hypokalemia
During a postoperative period following an open
cholecystectomy, the client has a t-tube
connected to gravity drainage. The nurse
knows that the purpose of the t-tube is to:
•
•
•
Maintain patency of the common bile duct
Reduce the occurrence of postoperative
hemorrhage
Prevent infection
During a postoperative period following an open
cholecystectomy, the client has a t-tube
connected to gravity drainage. The nurse
knows that the purpose of the t-tube is to:
•
•
•
Maintain patency of the common bile duct
Reduce the occurrence of postoperative
hemorrhage
Prevent infection
A client hospitalized for pancreatitis does not
drink alcohol because of religious reasons. The
client becomes upset when the nurse asks her
questions about alcohol intake. The nurse
should explain the reason for these questions
is that
•
•
There is a strong link between alcohol use
and pancreatitis
Alcohol intake can interfere with the tests
A client hospitalized for pancreatitis does not
drink alcohol because of religious reasons. The
client becomes upset when the nurse asks her
questions about alcohol intake. The nurse
should explain the reason for these questions
is that
•
•
There is a strong link between alcohol use
and pancreatitis
Alcohol intake can interfere with the tests
The nurse notes that a client with acute
pancreatitis is occasionally experiencing
muscle twitching and jerking. How should the
nurse interpret the significance of these
symptoms? The client
•
•
•
May be developing hypocalcemia
Is experiencing a reaction to prescribed
opioids
Has a nutritional imbalance
The nurse notes that a client with acute
pancreatitis is occasionally experiencing
muscle twitching and jerking. How should the
nurse interpret the significance of these
symptoms? The client
•
•
•
May be developing hypocalcemia
Is experiencing a reaction to prescribed
opioids
Has a nutritional imbalance
What would be the nurse’s best response to the
client’s feelings of isolation as a result of
having viral hepatitis?
•
•
Don’t worry. It’s normal to feel that way
Your friends are probably afraid of
contracting the disease
•
I’m sure you’re imagining that
•
Tell me more about your feelings of
What would be the nurse’s best response to the
client’s feelings of isolation as a result of
having viral hepatitis?
•
•
Don’t worry. It’s normal to feel that way
Your friends are probably afraid of
contracting the disease
•
I’m sure you’re imagining that
•
Tell me more about your feelings of
The client with cirrhosis has developed ascites.
The nurse should recognize that the
pathological basis for the development of
ascites in clients with cirrhosis is portal
hypertension and
•
An excess of serum sodium level
•
An increased metabolism of aldosterone
•
A decreased flow of hepatic lymph
The client with cirrhosis has developed ascites.
The nurse should recognize that the
pathological basis for the development of
ascites in clients with cirrhosis is portal
hypertension and
•
An excess of serum sodium level
•
An increased metabolism of aldosterone
•
A decreased flow of hepatic lymph
A male patient is admitted for a suspected
myocardial infarction and is attached to a
cardiac monitor and has an IV in place. His
cardiac rhythm has been normal sinus.
Suddenly the nurse notes that the cardiac
monitor is very irregular chaotic-looking
pattern. The client appears to be sleeping. The
most appropriate action by the nurse is to...
•
Administer a precordial thump
A male patient is admitted for a suspected
myocardial infarction and is attached to a
cardiac monitor and has an IV in place. His
cardiac rhythm has been normal sinus.
Suddenly the nurse notes that the cardiac
monitor is very irregular chaotic-looking
pattern. The client appears to be sleeping. The
most appropriate action by the nurse is to...
•
Administer a precordial thump
A client with acute renal failure develops severe
hyperkalemia. The nurse anticipates which of
the following medications will be used to treat
this imbalance?
•
Furosemide (Lasix)
•
Amphojel (aluminum hydroxide)
•
50% glucose and regular insulin
•
Epoetin (Procrit)
A client with acute renal failure develops severe
hyperkalemia. The nurse anticipates which of
the following medications will be used to treat
this imbalance?
•
Furosemide (Lasix)
•
Amphojel (aluminum hydroxide)
•
50% glucose and regular insulin
•
Epoetin (Procrit)
The nurse is admitting a client to the hospital
who has a diagnosis of Guillain-Barre
syndrome. During history-taking, the nurse
asks the family member if the client has
recently experienced which of the following?
•
Meningitis
•
Seizures or head trauma
•
A back injury or spinal cord trauma
The nurse is admitting a client to the hospital
who has a diagnosis of Guillain-Barre
syndrome. During history-taking, the nurse
asks the family member if the client has
recently experienced which of the following?
•
Meningitis
•
Seizures or head trauma
•
A back injury or spinal cord trauma
A patient comes to the clinic with a history of
headaches. Which of the following
manifestations leads the nurse to believe that
the patient may be experiencing migraines?
Select all that apply.
•
Photophobia
•
Nausea and vomiting
•
Headache throbbing
A patient comes to the clinic with a history of
headaches. Which of the following
manifestations leads the nurse to believe that
the patient may be experiencing migraines?
Select all that apply.
•
Photophobia
•
Nausea and vomiting
•
Headache throbbing
A client is scheduled for a labyrinthectomy to
treat Meniere’s syndrome. The nurse
concludes that the client understood
preoperative instructions when the client
identifies that the surgery results in:
•
Anosmia
•
Absence of pain
•
Decreased cerumen
A client is scheduled for a labyrinthectomy to
treat Meniere’s syndrome. The nurse
concludes that the client understood
preoperative instructions when the client
identifies that the surgery results in:
•
Anosmia
•
Absence of pain
•
Decreased cerumen
LEADERSHIP
A client was admitted to the nursing unit with a
closed head injury six hours ago. During the
initial assessment the nurse finds that the
client has vomited, is confused, and complains
of dizziness and headache. Which of the
following is the most important nursing
action?
•
Notify the physician.
•
Administer an antiemetic.
A client was admitted to the nursing unit with a
closed head injury six hours ago. During the
initial assessment the nurse finds that the
client has vomited, is confused, and complains
of dizziness and headache. Which of the
following is the most important nursing
action?
•
Notify the physician.
•
Administer an antiemetic.
A primigravida is admitted to the labor unit.
During the assessment of her client, her
membranes rupture spontaneously. The
priority nursing action is which of the
following?
•
Monitor the contraction pattern.
•
Assess the fetal heart rate.
•
Note the color, amount, and odor of the
amniotic fluid.
A primigravida is admitted to the labor unit.
During the assessment of her client, her
membranes rupture spontaneously. The
priority nursing action is which of the
following?
•
Monitor the contraction pattern.
•
Assess the fetal heart rate.
•
Note the color, amount, and odor of the
amniotic fluid.
The RN listens to the report from the previous
shift. Which patient should the nurse see first?
•
•
•
Room 7204, a six month old with
dehydration, IV decreased to 42mL/hr last
shift
Room 7201, a six year old with diabetes,
blood sugar ordered this morning
Room 7202, a 2 month old with pertussis,
O2 3L mask
The RN listens to the report from the previous
shift. Which patient should the nurse see first?
•
•
•
Room 7204, a six month old with
dehydration, IV decreased to 42mL/hr last
shift
Room 7201, a six year old with diabetes,
blood sugar ordered this morning
Room 7202, a 2 month old with pertussis,
O2 3L mask
A teenager arrives by private car. He is alert and
ambulatory, but his shirt and pants are
covered with blood. He and hysterical friends
are yelling and trying to explain that they were
goofing around and he got poked in the
abdomen with a stick. Which of the following
comments should be given first consideration?
•
“There was a lot of blood and we used
three bandages.”
A teenager arrives by private car. He is alert and
ambulatory, but his shirt and pants are
covered with blood. He and hysterical friends
are yelling and trying to explain that they were
goofing around and he got poked in the
abdomen with a stick. Which of the following
comments should be given first consideration?
•
“There was a lot of blood and we used
three bandages.”
A nurse is assigned to care for a pregnant client
with a diagnosis of sickle cell anemia. The
nurse reviews the plan of care and notes
documentation of four nursing diagnoses.
Which diagnosis would the nurse select as the
priority?
•
Activity intolerance
•
Ineffective coping
•
Imbalanced nutrition: less than body
A nurse is assigned to care for a pregnant client
with a diagnosis of sickle cell anemia. The
nurse reviews the plan of care and notes
documentation of four nursing diagnoses.
Which diagnosis would the nurse select as the
priority?
•
Activity intolerance
•
Ineffective coping
•
Imbalanced nutrition: less than body
The nurse receives a hand-off communication
report for the change of shift. Which client
should the nurse see first?
•
•
•
A 50 year old woman who is scheduled for a
breast biopsy this morning and is crying.
An 85 year old man admitted during the
night because of increasing confusion who
remains disoriented this morning.
A 65 year old woman who had a
The nurse receives a hand-off communication
report for the change of shift. Which client
should the nurse see first?
•
•
•
A 50 year old woman who is scheduled for a
breast biopsy this morning and is crying.
An 85 year old man admitted during the
night because of increasing confusion who
remains disoriented this morning.
A 65 year old woman who had a
When caring for a client with mental illness,
which initial nursing intervention is the most
essential?
•
•
•
Administering prescribed anti-anxiety drugs.
Decreasing the noise level and the harsh
lighting.
Removing phone cords and oxygen tubing
from the room.
When caring for a client with mental illness,
which initial nursing intervention is the most
essential?
•
•
•
Administering prescribed anti-anxiety drugs.
Decreasing the noise level and the harsh
lighting.
Removing phone cords and oxygen tubing
from the room.
A client with arthritic pain is considering taking
an herbal supplement to relieve arthritic pain.
What teaching is most important for the nurse
to carry out with this client?
•
•
•
Inform any health care providers about the
use of this supplement.
Practice imagery along with the herbal
supplement.
Take only herbal supplements that are
A client with arthritic pain is considering taking
an herbal supplement to relieve arthritic pain.
What teaching is most important for the nurse
to carry out with this client?
•
•
•
Inform any health care providers about the
use of this supplement.
Practice imagery along with the herbal
supplement.
Take only herbal supplements that are
A nurse is called to a client’s room by another
nurse. When the nurse arrives at the room,
she discovers that a fire has occurred in the
client’s wastebasket. The first nurse has
removed the client from the room. What is
the second nurse’s next action?
•
Confine the fire.
•
Evacuate the unit.
•
Extinguish the fire.
A nurse is called to a client’s room by another
nurse. When the nurse arrives at the room,
she discovers that a fire has occurred in the
client’s wastebasket. The first nurse has
removed the client from the room. What is
the second nurse’s next action?
•
Confine the fire.
•
Evacuate the unit.
•
Extinguish the fire.
A nurse in the newborn nursery receives a
telephone call and is informed that a newborn
infant with APGAR scores of 1 and 4 will be
brought to the nursery. The nurse quickly
prepares for the arrival of the newborn and
determines that the priority intervention is to:
•
•
Connect the resuscitation bag to the
oxygen.
Turn on the apnea and cardio-respiratory
A nurse in the newborn nursery receives a
telephone call and is informed that a newborn
infant with APGAR scores of 1 and 4 will be
brought to the nursery. The nurse quickly
prepares for the arrival of the newborn and
determines that the priority intervention is to:
•
•
Connect the resuscitation bag to the
oxygen.
Turn on the apnea and cardio-respiratory
You are caring for a patient who has just
undergone hypophysectomy for
hyperpituitarism. Which post-operative
finding requires immediate intervention?
•
Presence of glucose in the nasal drainage.
•
Presence of nasal packing in the nares.
•
Urine output of 40 to 50 mL/hr.
•
Patient complaints of thirst.
You are caring for a patient who has just
undergone hypophysectomy for
hyperpituitarism. Which post-operative
finding requires immediate intervention?
•
Presence of glucose in the nasal drainage.
•
Presence of nasal packing in the nares.
•
Urine output of 40 to 50 mL/hr.
•
Patient complaints of thirst.
The nurse on the postpartum unit is preparing 4
clients for discharge. It would be most
important for the nurse to refer which of the
following clients for home care?
•
•
•
A 15 year old primipara who delivered a 7
lb. male 2 days ago.
An 18 year old multipara who delivered a 9
lb. female by cesarean section 2 days ago.
A 20 year old multipara who delivered 1 day
The nurse on the postpartum unit is preparing 4
clients for discharge. It would be most
important for the nurse to refer which of the
following clients for home care?
•
•
•
A 15 year old primipara who delivered a 7
lb. male 2 days ago.
An 18 year old multipara who delivered a 9
lb. female by cesarean section 2 days ago.
A 20 year old multipara who delivered 1 day
A registered nurse is delegating activities to the
nursing staff. Which activity is least
appropriate for the nursing assistant?
•
•
•
Collecting a urine specimen from a client.
Obtaining frequent oral temperatures on a
client.
Accompanying a man being discharged to
transportation to home.
A registered nurse is delegating activities to the
nursing staff. Which activity is least
appropriate for the nursing assistant?
•
•
•
Collecting a urine specimen from a client.
Obtaining frequent oral temperatures on a
client.
Accompanying a man being discharged to
transportation to home.
Which of the following tasks is appropriate for
the nurse to delegate to an experienced
nursing assistant?
•
•
•
Obtain a 24 hour diet recall from a client
recently admitted with anorexia nervosa.
Obtain a clean catch urine specimen from a
client suspected of having a urinary tract
infection.
Observe the amount and characteristics of
Which of the following tasks is appropriate for
the nurse to delegate to an experienced
nursing assistant?
•
•
•
Obtain a 24 hour diet recall from a client
recently admitted with anorexia nervosa.
Obtain a clean catch urine specimen from a
client suspected of having a urinary tract
infection.
Observe the amount and characteristics of
Which of the following clients should the nurse
on a pediatric unit assign to a LPN?
•
•
•
A 3 year old girl admitted yesterday with
laryngotracheobronchitis who has a
tracheosotomy.
A 5 year old girl admitted after gastric
lavage for Tylenol ingestion.
A 6 year old boy admitted for a fracture of
the femur, in balanced suspension traction.
Which of the following clients should the nurse
on a pediatric unit assign to a LPN?
•
•
•
A 3 year old girl admitted yesterday with
laryngotracheobronchitis who has a
tracheosotomy.
A 5 year old girl admitted after gastric
lavage for Tylenol ingestion.
A 6 year old boy admitted for a fracture of
the femur, in balanced suspension traction.
The nurse is caring for clients on the surgical
floor and has just received report from the
previous shift. Which of the following clients
should the nurse see first?
•
•
A 35 year old admitted 3 hours ago with a
gunshot wound; 1.5cm area of dark drainage
noted on the dressing.
A 43 year old who had a mastectomy 2 days
ago; 23mL of serosanguinous fluid noted in
The nurse is caring for clients on the surgical
floor and has just received report from the
previous shift. Which of the following clients
should the nurse see first?
•
•
A 35 year old admitted 3 hours ago with a
gunshot wound; 1.5cm area of dark drainage
noted on the dressing.
A 43 year old who had a mastectomy 2 days
ago; 23mL of serosanguinous fluid noted in
The nurse is on duty on a busy cardiac telemetry
unit. Which of the following situations
requires the nurse’s immediate attention?
•
•
The wife of a cardiac client states that his IV
pump is alarming and he is not receiving the
pain medication dose due to the pump
malfunctioning.
The daughter of an elderly client states that
her mother is uncomfortable and that her
The nurse is on duty on a busy cardiac telemetry
unit. Which of the following situations
requires the nurse’s immediate attention?
•
•
The wife of a cardiac client states that his IV
pump is alarming and he is not receiving the
pain medication dose due to the pump
malfunctioning.
The daughter of an elderly client states that
her mother is uncomfortable and that her
A registered nurse (RN) is planning the
assignments for the day and is leading a team
composed of a licensed practical nurse (LPN)
and an nursing assistant (NA). The RN assigns
which client to the LPN?
•
A client with dementia.
•
A two day postoperative mastectomy client.
•
A client who requires some assistance with
bathing.
A registered nurse (RN) is planning the
assignments for the day and is leading a team
composed of a licensed practical nurse (LPN)
and an nursing assistant (NA). The RN assigns
which client to the LPN?
•
•
•
A client with dementia.
A two day postoperative mastectomy
client.
A client who requires some assistance with
A 69 year old female client admitted with
pneumonia is receiving gentamicin
(Garamycin). For this client, which of the
following laboratory values would be most
important for the nurse to monitor?
•
BUN and creatinine
•
Hemoglobin and hematocrit
•
Sodium and potassium
A 69 year old female client admitted with
pneumonia is receiving gentamicin
(Garamycin). For this client, which of the
following laboratory values would be most
important for the nurse to monitor?
•
BUN and creatinine
•
Hemoglobin and hematocrit
•
Sodium and potassium
The RN is preparing the assignment for the day
shift. Which patient is appropriate for the RN
to assign to the LPN?
•
•
•
Mrs. Johnson, age 66, pleural effusion,
bilateral chest tubes to Pleurovac.
Mrs. Smith, age 44, chronic renal failure,
admitted for peritoneal dialysis this afternoon
Miss Andrews, age 48, total right hip
replacement, two days post-operative
The RN is preparing the assignment for the day
shift. Which patient is appropriate for the RN
to assign to the LPN?
•
•
•
Mrs. Johnson, age 66, pleural effusion,
bilateral chest tubes to Pleurovac.
Mrs. Smith, age 44, chronic renal failure,
admitted for peritoneal dialysis this afternoon
Miss Andrews, age 48, total right hip
replacement, two days post-operative
You are the charge nurse on a medical surgical
unit and are working with a newly graduated
RN who has been on orientation to the unit
for 3 weeks. Which client is best to assign to
the new graduate?
•
•
A 34 year old who was just admitted to the
unit with periorbital cellulitis.
A 40 year old who needs discharge
instructions after having skin grafts to the
You are the charge nurse on a medical surgical
unit and are working with a newly graduated
RN who has been on orientation to the unit
for 3 weeks. Which client is best to assign to
the new graduate?
•
•
A 34 year old who was just admitted to the
unit with periorbital cellulitis.
A 40 year old who needs discharge
instructions after having skin grafts to the
A nursing team consists of an RN, LPN, and a
CAN. The nurse should assign which of the
following clients to the LPN?
•
•
•
A 72 year old client with diabetes who
requires a dressing change for a stasis ulcer.
A 42 year old client with cancer of the bone
complaining of pain.
A 55 year old client with terminal cancer
being transferred to hospice home care.
A nursing team consists of an RN, LPN, and a
CAN. The nurse should assign which of the
following clients to the LPN?
•
•
•
A 72 year old client with diabetes who
requires a dressing change for a stasis ulcer.
A 42 year old client with cancer of the bone
complaining of pain.
A 55 year old client with terminal cancer
being transferred to hospice home care.
You are the charge nurse in the intensive care
unit (ICU) tonight. The Central Staffing office
has informed you that a medical-surgical
nurse will be floated to your unit to replace a
nurse who called out due to illness. Which of
the following patients would be the best
assignment for the medical-surgical nurse?
•
A 23 year old woman admitted with a
diagnosis of intravenous drug abuse who is
complaining of abdominal cramps and severe
You are the charge nurse in the intensive care
unit (ICU) tonight. The Central Staffing office
has informed you that a medical-surgical
nurse will be floated to your unit to replace a
nurse who called out due to illness. Which of
the following patients would be the best
assignment for the medical-surgical nurse?
•
A 23 year old woman admitted with a
diagnosis of intravenous drug abuse who is
complaining of abdominal cramps and severe
As the charge nurse, you are making
assignments for the next shift. Which client
should be assigned to the fairly new nurse (2
months) pulled from the surgical unit to the
medical unit?
•
•
A 58 year old client on airborne precautions
for tuberculosis (TB).
A 65 year old client who just returned from
bronchoscopy procedure.
As the charge nurse, you are making
assignments for the next shift. Which client
should be assigned to the fairly new nurse (2
months) pulled from the surgical unit to the
medical unit?
•
•
A 58 year old client on airborne precautions
for tuberculosis (TB).
A 65 year old client who just returned from
bronchoscopy procedure.
Which client in the neurologic intensive care
unit will be best to assign to an RN who has
been pulled from the medical unit?
•
•
A 26 year old with a basilar skull fracture
who has clear drainage coming out of the
nose.
A 42 year old admitted several hours ago
with a headache and a diagnosis of a ruptured
berry aneurysm.
Which client in the neurologic intensive care
unit will be best to assign to an RN who has
been pulled from the medical unit?
•
•
A 26 year old with a basilar skull fracture
who has clear drainage coming out of the
nose.
A 42 year old admitted several hours ago
with a headache and a diagnosis of a ruptured
berry aneurysm.
A hospitalized client with a diagnosis of anorexia
nervosa and in a state of starvation is placed
in a two bed hospital room. A newly admitted
client will be admitted to this room. Which
client would be inappropriate to assign to this
two bed hospital room?
•
A client with pneumonia
•
A client who can perform self care
•
A client with a fractured leg that is casted
A hospitalized client with a diagnosis of anorexia
nervosa and in a state of starvation is placed
in a two bed hospital room. A newly admitted
client will be admitted to this room. Which
client would be inappropriate to assign to this
two bed hospital room?
•
A client with pneumonia
•
A client who can perform self care
•
A client with a fractured leg that is casted
The nurse is responsible for ensuring the safety
of the client. The nurse is providing care to a
client in a full length leg cast. The nurse is
legally obligated to check blood circulation in
the toes:
•
On the basis of nursing judgment
•
Only with a physicians order
•
If checking blood circulation is mentioned in
the nursing care plan
The nurse is responsible for ensuring the safety
of the client. The nurse is providing care to a
client in a full length leg cast. The nurse is
legally obligated to check blood circulation in
the toes:
•
On the basis of nursing judgment
•
Only with a physicians order
•
If checking blood circulation is mentioned in
the nursing care plan
The physician has ordered a bronchoscopy for a
client with a chronic cough. The nurse brings
the informed consent document into the
client’s room for a signature. The client asks
the nurse to explain why the process of
informed consent is necessary. The nurse
responds that informed consent means:
•
The client agrees to a procedure ordered by
the physician, even if he/she does not
understand what the outcome will be.
The physician has ordered a bronchoscopy for a
client with a chronic cough. The nurse brings
the informed consent document into the
client’s room for a signature. The client asks
the nurse to explain why the process of
informed consent is necessary. The nurse
responds that informed consent means:
•
The client agrees to a procedure ordered by
the physician, even if he/she does not
understand what the outcome will be.
A woman identifying herself as a family friend
telephones the home health nurse to inquire
if there is anything she can do, as a friend, to
assist her neighbors, the parents with an
infant who has a tracheoesophageal fistula.
The parents expressed nervousness about
giving enteral feedings. The best nursing
action is to:
•
Inform the friend to directly contact the
family and offer her assistance to them.
A woman identifying herself as a family friend
telephones the home health nurse to inquire
if there is anything she can do, as a friend, to
assist her neighbors, the parents with an
infant who has a tracheoesophageal fistula.
The parents expressed nervousness about
giving enteral feedings. The best nursing
action is to:
•
Inform the friend to directly contact the
family and offer her assistance to them.
A nurse is morally opposed to abortion during
any time of a pregnancy. Which statement
best describes the nurse’s responsibility
related to this belief?
•
•
The nurse must make this position known
before being employed at an agency that
provides abortions.
The nurse may decline in participating in
abortions, but must care for women after the
A nurse is morally opposed to abortion during
any time of a pregnancy. Which statement
best describes the nurse’s responsibility
related to this belief?
•
•
The nurse must make this position known
before being employed at an agency that
provides abortions.
The nurse may decline in participating in
abortions, but must care for women after the
WOMEN’S
The nurse correctly calculates the EDC of a client
with a last menstrual period of April 11 as:
•
January 4
•
January 25
•
January 18
•
February 14
The nurse correctly calculates the EDC of a client
with a last menstrual period of April 11 as:
•
January 4
•
January 25
•
January 18
•
February 14
Using the gravida and para system, how would
the nurse record the obstetric history of a
client who is currently pregnant, has 7-yearold twins, a 2-year-old son, and had a
spontaneous abortion at 12 weeks gestation
last year?
•
Gravida 3, Para 3
•
Gravida 3, Para 2
•
Gravida 4, Para 3
Using the gravida and para system, how would
the nurse record the obstetric history of a
client who is currently pregnant, has 7-yearold twins, a 2-year-old son, and had a
spontaneous abortion at 12 weeks gestation
last year?
•
Gravida 3, Para 3
•
Gravida 3, Para 2
•
Gravida 4, Para 3
A pregnant woman with 4 children reports the
following obstetric history: a still birth at 32
weeks of gestation, triplets (2 sons and a
daughter) born via cesarean section at 30
weeks gestation, a spontaneous abortion at 8
weeks ,and a daughter born vaginally at 39
weeks of gestation. Which of the following
accurately expresses this woman’s current
obstetric history using the 5 digit system?
•
5-1-4-1-4
A pregnant woman with 4 children reports the
following obstetric history: a still birth at 32
weeks of gestation, triplets (2 sons and a
daughter) born via cesarean section at 30
weeks gestation, a spontaneous abortion at 8
weeks ,and a daughter born vaginally at 39
weeks of gestation. Which of the following
accurately expresses this woman’s current
obstetric history using the 5 digit system?
•
5-1-4-1-4
Which woman should receive RhoGAM immune
globulin after birth?
•
•
•
Rh negative mother; Rh positive infant;
positive direct Coombs’ test
Rh positive mother; Rh negative infant;
negative direct Coombs’ test
Rh negative mother; Rh positive infant;
negative direct Coombs’ test
Which woman should receive RhoGAM immune
globulin after birth?
•
•
•
Rh negative mother; Rh positive infant;
positive direct Coombs’ test
Rh positive mother; Rh negative infant;
negative direct Coombs’ test
Rh negative mother; Rh positive infant;
negative direct Coombs’ test
The nurse reviews the results of the following
stress test performed on a pregnant client and
interprets the finding as which of the
following?
•
Reactive non-stress test
•
Nonreactive non-stress test
•
Negative contraction stress test
•
Positive contraction stress test
The nurse reviews the results of the following
stress test performed on a pregnant client and
interprets the finding as which of the
following?
•
Reactive non-stress test
•
Nonreactive non-stress test
•
Negative contraction stress test
•
Positive contraction stress test
A client who is undergoing a non-stress test asks
the nurse to explain why she is using an
acoustic vibration device. The nurse states
that the device is used to:
•
Stimulate uterine contractions
•
Relax uterine contractions
•
Soothe the baby to sleep
•
Awaken the sleeping fetus
A client who is undergoing a non-stress test asks
the nurse to explain why she is using an
acoustic vibration device. The nurse states
that the device is used to:
•
Stimulate uterine contractions
•
Relax uterine contractions
•
Soothe the baby to sleep
•
Awaken the sleeping fetus
A client who is 29 weeks pregnant comes to the
labor and delivery unit. She states that she’s
having contractions every eight minutes. The
client is also 3cm dilated. Which medications
can the nurse expect to administer? Select all
that apply.
•
Folic Acid (Folvite)
•
Terbutaline (Brethine)
•
Betamethasone
A client who is 29 weeks pregnant comes to the
labor and delivery unit. She states that she’s
having contractions every eight minutes. The
client is also 3cm dilated. Which medications
can the nurse expect to administer? Select all
that apply.
•
Folic Acid (Folvite)
•
Terbutaline (Brethine)
•
Betamethasone
The health care provider prescribes Terbutaline
(Brethine) for a client in preterm labor. Before
initiating this order, it is most important for
the nurse to assess the client for which
condition?
•
Gestational diabetes
•
Elevated blood pressure
•
Urinary tract infection
The health care provider prescribes Terbutaline
(Brethine) for a client in preterm labor. Before
initiating this order, it is most important for
the nurse to assess the client for which
condition?
•
Gestational diabetes
•
Elevated blood pressure
•
Urinary tract infection
During active labor, a client’s membranes
rupture and her cervix is 5 cm dilated and 50%
effaced. The fluid is clear and the fetal heart
rate is stable. The nurse should anticipate
that:
•
Birth of the fetus will occur within 24 hours.
•
The second stage of labor will be prolonged.
•
An oxytocin infusion will be required to
stimulate labor.
During active labor, a client’s membranes
rupture and her cervix is 5 cm dilated and 50%
effaced. The fluid is clear and the fetal heart
rate is stable. The nurse should anticipate
that:
•
Birth of the fetus will occur within 24
hours.
•
The second stage of labor will be prolonged.
•
An oxytocin infusion will be required to
A nurse applies an external fetal monitor and
tocotransducer to monitor the fetal heart rate
(FHR) and contractions of a client in labor. The
FHR is in the 140s. Contractions are every 5
min and 45-50 seconds in duration. The nurse
performs a vaginal exam and finds the cervix is
2cm dilated, 50% effaced, and the fetus is -2
station. One hour later the dilation is still 2
cm, but now the effacement is 80%. Which of
the following stages and phases of labor is this
A nurse applies an external fetal monitor and
tocotransducer to monitor the fetal heart rate
(FHR) and contractions of a client in labor. The
FHR is in the 140s. Contractions are every 5
min and 45-50 seconds in duration. The nurse
performs a vaginal exam and finds the cervix is
2cm dilated, 50% effaced, and the fetus is -2
station. One hour later the dilation is still 2
cm, but now the effacement is 80%. Which of
the following stages and phases of labor is this
A 21 year old gravida 1 para 0 is in labor. The
nurse observes that the patient is having
intense contractions 2-3 minutes apart lasting
80-90 seconds. She says she has an urge to
push sometimes and is irritable. The nurse
would expect to find her:
•
dilated 3-4 cm and 100% effaced.
•
dilated 5-6 cm and 75% effaced.
•
dilated 7-8 cm and 50% effaced.
A 21 year old gravida 1 para 0 is in labor. The
nurse observes that the patient is having
intense contractions 2-3 minutes apart lasting
80-90 seconds. She says she has an urge to
push sometimes and is irritable. The nurse
would expect to find her:
•
dilated 3-4 cm and 100% effaced.
•
dilated 5-6 cm and 75% effaced.
•
dilated 7-8 cm and 50% effaced.
A client has been in active labor for 10 hours.
Contractions are every 3 minutes and last for
60 seconds. Further findings include: cervix
100% effaced and 6 cm dilated; membranes
ruptured; vertex at +1 station. The nurse
determines that an appropriate nursing
diagnosis at this time would be:
•
ineffective coping related to loss of control.
•
high risk for fetal injury related to prolapsed
A client has been in active labor for 10 hours.
Contractions are every 3 minutes and last for
60 seconds. Further findings include: cervix
100% effaced and 6 cm dilated; membranes
ruptured; vertex at +1 station. The nurse
determines that an appropriate nursing
diagnosis at this time would be:
•
ineffective coping related to loss of control.
•
high risk for fetal injury related to prolapsed
Emergency Medical Service brings a woman into
the emergency room on a stretcher. She is in
active labor and on physical examination,
crowning is noted. The nurse is aware that the
priority action is to:
•
get the patient to the labor unit as quickly
as possible.
•
provide gentle pressure on the fetal head.
•
maintain a sterile environment for the
Emergency Medical Service brings a woman into
the emergency room on a stretcher. She is in
active labor and on physical examination,
crowning is noted. The nurse is aware that the
priority action is to:
•
get the patient to the labor unit as quickly
as possible.
•
provide gentle pressure on the fetal head.
•
maintain a sterile environment for the
A client with a large fetus is to have a pudendal
block during the second stage of labor. The
nurse plans to instruct the client that once the
block is working she:
•
May lose bladder sensation
•
Will not feel an episiotomy
•
May lose the ability to push
•
Will no longer feel contractions
A client with a large fetus is to have a pudendal
block during the second stage of labor. The
nurse plans to instruct the client that once the
block is working she:
•
May lose bladder sensation
•
Will not feel an episiotomy
•
May lose the ability to push
•
Will no longer feel contractions
As you evaluate a 29-year-old gravida 2 para 1,
which of the following would determine that
she is in true labor?
•
•
•
Her cervix has dilated an additional 2 cm in
the last 3 hours.
Fetal heart tones have remained in the
range of 130-140 beats per minute.
Her contractions have remained every 10
minutes lasting 25 seconds for the past 4
As you evaluate a 29-year-old gravida 2 para 1,
which of the following would determine that
she is in true labor?
•
•
•
Her cervix has dilated an additional 2 cm in
the last 3 hours.
Fetal heart tones have remained in the
range of 130-140 beats per minute.
Her contractions have remained every 10
minutes lasting 25 seconds for the past 4
•
The nurse interprets a deceleration pattern
when monitoring a laboring client. This
pattern inversely mirrors the contraction and
rises to baseline as the contraction ends. The
nurse interprets this pattern as a(n):
•
sinusoidal pattern.
•
variable deceleration.
•
early deceleration.
The nurse interprets a deceleration pattern
when monitoring a laboring client. This
pattern inversely mirrors the contraction and
rises to baseline as the contraction ends. The
nurse interprets this pattern as a(n):
•
sinusoidal pattern.
•
variable deceleration.
•
early deceleration.
The nurse's rapid response to late decelerations
is based on the knowledge that these fetal
heart rate patterns are due to:
•
umbilical cord compression.
•
head compression.
•
uteroplacental insufficiency.
•
intact nervous system.
The nurse's rapid response to late decelerations
is based on the knowledge that these fetal
heart rate patterns are due to:
•
umbilical cord compression.
•
head compression.
•
uteroplacental insufficiency.
•
intact nervous system.
A patient has been admitted to the labor and
delivery unit; an electronic fetal monitor is in
use. The patient's coach wants to know how
to elicit information from the monitor strip.
The nurse correctly teaches the patient's
coach that measuring the beginning of one
contraction to the beginning of the next
contraction will tell the:
•
Frequency
A patient has been admitted to the labor and
delivery unit; an electronic fetal monitor is in
use. The patient's coach wants to know how
to elicit information from the monitor strip.
The nurse correctly teaches the patient's
coach that measuring the beginning of one
contraction to the beginning of the next
contraction will tell the:
•
Frequency
A nurse's first response to late decelerations
would be:
•
call the birth attendant immediately.
•
turn the client to her left side.
•
increase the IV flow rate.
•
place the client in Trendelenburg.
A nurse's first response to late decelerations
would be:
•
call the birth attendant immediately.
•
turn the client to her left side.
•
increase the IV flow rate.
•
place the client in Trendelenburg.
A 25 year old primigravida at 40 weeks gestation
is in the active stage of labor. She is being
monitored with an internal transducer and a
fetal scalp clip. Upon reviewing the monitoring
strip, the nurse notices decelerations of the
fetal heart rate. Which pattern will most likely
indicate fetal hypoxia and acidosis?
•
Decelerations that are mirror images of the
uterine contractions.
A 25 year old primigravida at 40 weeks gestation
is in the active stage of labor. She is being
monitored with an internal transducer and a
fetal scalp clip. Upon reviewing the monitoring
strip, the nurse notices decelerations of the
fetal heart rate. Which pattern will most likely
indicate fetal hypoxia and acidosis?
•
Decelerations that are mirror images of the
uterine contractions.
If the physician plans to do a speculum exam on
a client with a marginal placenta previa, the
nurse should have available
•
One unit of freeze dried plasma
•
Vitamin K for intramuscular injection
•
Two units of type and screened blood
•
Heparin sodium for intravenous injection
If the physician plans to do a speculum exam on
a client with a marginal placenta previa, the
nurse should have available
•
One unit of freeze dried plasma
•
Vitamin K for intramuscular injection
•
Two units of type and screened blood
•
Heparin sodium for intravenous injection
A pregnant woman at 32 weeks of gestation
comes to the emergency room because she
has begun to experience bright red vaginal
bleeding. She reports that she is experiencing
no pain. The admission nurse suspects
•
Abruptio placentae
•
Disseminated intravascular coagulation
•
Placenta previa
•
A pregnant woman at 32 weeks of gestation
comes to the emergency room because she
has begun to experience bright red vaginal
bleeding. She reports that she is experiencing
no pain. The admission nurse suspects
•
Abruptio placentae
•
Disseminated intravascular coagulation
•
Placenta previa
During an admission assessment, a woman in
active labor informs you that she is positive
for HIV. What will be included in your plan of
care that will decrease the chance of HIV
transmission to the fetus?
•
•
All healthcare personnel will be required to
wear gloves.
The patient will receive intravenous antiviral
medications prior to delivery.
During an admission assessment, a woman in
active labor informs you that she is positive
for HIV. What will be included in your plan of
care that will decrease the chance of HIV
transmission to the fetus?
•
•
All healthcare personnel will be required to
wear gloves.
The patient will receive intravenous
antiviral medications prior to delivery.
A client is progressing in normal labor when her
membranes rupture; the nurse notes that the
fluid is greenish-brown in color. The nurse
caring for this client would give highest
PRIORITY to:
•
helping the client in to the knee-chest
position.
•
preparing the client for a cesarean section.
•
observing for signs of a precipitate birth.
A client is progressing in normal labor when her
membranes rupture; the nurse notes that the
fluid is greenish-brown in color. The nurse
caring for this client would give highest
PRIORITY to:
•
helping the client in to the knee-chest
position.
•
preparing the client for a cesarean section.
•
observing for signs of a precipitate birth.
Five minutes after a spontaneous vaginal
delivery, a full-term newborn presents with
the following: apical heart rate: 120;
respirations: 24 and shallow; position: partial
flexion; cry when suctioned; bluish
extremities. The nurse would determine that
the APGAR score is:
•
5
•
7
Five minutes after a spontaneous vaginal
delivery, a full-term newborn presents with
the following: apical heart rate: 120;
respirations: 24 and shallow; position: partial
flexion; cry when suctioned; bluish
extremities. The nurse would determine that
the APGAR score is:
•
5
•
7
A preterm newborn of 34 weeks gestation is
born limp and pale. Her respirations are slow,
weak and irregular; heart rate is 90. She has a
facial grimace when suctioned. At one minute
after birth, the nurse would assess this
newborn's APGAR score as:
•
0
•
3
•
5
A preterm newborn of 34 weeks gestation is
born limp and pale. Her respirations are slow,
weak and irregular; heart rate is 90. She has a
facial grimace when suctioned. At one minute
after birth, the nurse would assess this
newborn's APGAR score as:
•
0
•
3
•
5
A client at 36 weeks gestation attends the
prenatal clinic for a routine exam. The nurse
identifies that the client’s blood pressure has
increased from 102/60 to 134/88 and is
concerned she may be developing mild
preeclampsia. The nurse should also assess
the client for:
•
Proteinuria
•
Mild ankle edema
A client at 36 weeks gestation attends the
prenatal clinic for a routine exam. The nurse
identifies that the client’s blood pressure has
increased from 102/60 to 134/88 and is
concerned she may be developing mild
preeclampsia. The nurse should also assess
the client for:
•
Proteinuria
•
Mild ankle edema
Magnesium Sulfate is being administered
intravenously to a client who has severe
preeclampsia for seizure prophylaxis. Which of
the following indicates Magnesium Sulfate
toxicity.
•
Respirations less than 12/min
•
Urinary output less than 50mL/hour
•
Hyper-reflexic deep tendon reflexes
Magnesium Sulfate is being administered
intravenously to a client who has severe
preeclampsia for seizure prophylaxis. Which of
the following indicates Magnesium Sulfate
toxicity.
•
Respirations less than 12/min
•
Urinary output less than 50mL/hour
•
Hyper-reflexic deep tendon reflexes
PEDS
Which of the following is a developmental red
flag for a 3 month old infant?
•
•
The child does not pick up objects with his
fingers.
The child does not attempt to raise his head
when placed on his stomach.
•
The child has intense stranger anxiety.
•
The child does not attempt to sit without
Which of the following is a developmental red
flag for a 3 month old infant?
•
•
The child does not pick up objects with his
fingers.
The child does not attempt to raise his
head when placed on his stomach.
•
The child has intense stranger anxiety.
•
The child does not attempt to sit without
The mother of a 3 month old asks the nurse
about starting solid foods. What is the most
appropriate response by the nurse?
•
•
•
“It’s okay to start pureed solids at this age if
fed via the bottle.”
“Infants don’t require solid food until 12
months of age.”
“Solid food should be delayed until age 6
months, when the infant can handle a spoon
The mother of a 3 month old asks the nurse
about starting solid foods. What is the most
appropriate response by the nurse?
•
•
•
“It’s okay to start pureed solids at this age if
fed via the bottle.”
“Infants don’t require solid food until 12
months of age.”
“Solid food should be delayed until age 6
months, when the infant can handle a spoon
The father of a 2 month old girl is expressing
concern that his infant may be getting spoiled.
The nurse’s best response is:
•
•
•
“She just needs love and attention. Don’t
worry; she’s too young to spoil.”
“Consistently meeting the infant’s needs
helps promote a sense of trust.”
“Infants need to be fed and cleaned; if
you’re sure those needs are met, just let her
The father of a 2 month old girl is expressing
concern that his infant may be getting spoiled.
The nurse’s best response is:
•
•
•
“She just needs love and attention. Don’t
worry; she’s too young to spoil.”
“Consistently meeting the infant’s needs
helps promote a sense of trust.”
“Infants need to be fed and cleaned; if
you’re sure those needs are met, just let her
The nurse is assessing development of a 4
month old boy during a regular visit. Which of
the following observations may be a warning
sign?
•
•
•
The infant focuses on near or high contrast
objects.
The infant responds to his mother only
when he sees her.
The infant makes babbling sounds, but no
The nurse is assessing development of a 4
month old boy during a regular visit. Which of
the following observations may be a warning
sign?
•
•
•
The infant focuses on near or high contrast
objects.
The infant responds to his mother only
when he sees her.
The infant makes babbling sounds, but no
The nurse finds that a 6-month-old infant has an
apical pulse of 166 beats/min during sleep.
The nurse should do which of the following?
•
Administer oxygen
•
Record data on nurses’ notes
•
Report data to the practitioner
•
Place child in high Fowler position
The nurse finds that a 6-month-old infant has an
apical pulse of 166 beats/min during sleep.
The nurse should do which of the following?
•
Administer oxygen
•
Record data on nurses’ notes
•
Report data to the practitioner
•
Place child in high Fowler position
A cardiac defect that allows blood to shunt from
the (high pressure) left side of the heart to the
(lower pressure) right side can result in:
•
cyanosis.
•
congestive heart failure.
•
decreased pulmonary blood flow.
•
bounding pulses in upper extremities
A cardiac defect that allows blood to shunt from
the (high pressure) left side of the heart to the
(lower pressure) right side can result in:
•
cyanosis.
•
congestive heart failure.
•
decreased pulmonary blood flow.
•
bounding pulses in upper extremities
The nurse is examining an 8 month old girl for
appropriate development during a regular
checkup. Which of the following observations
is most likely a warning sign?
•
Cannot sit from standing.
•
Crawling on hands and knees.
•
Cannot pull herself to standing.
•
Using only the left hand to grasp.
The nurse is examining an 8 month old girl for
appropriate development during a regular
checkup. Which of the following observations
is most likely a warning sign?
•
Cannot sit from standing.
•
Crawling on hands and knees.
•
Cannot pull herself to standing.
•
Using only the left hand to grasp.
An 11 month old infant has Ibuprofen (Advil)
ordered every 6 hours. It has been 6 hours
since the last dose and his parent has
requested that he receive his pain medication.
When the nurse enters the room, the child is
asleep. The parent requests that the pain
medication be given because the child is still
restless in sleep. What is the best nursing
action?
•
Refuse to awaken the child.
An 11 month old infant has Ibuprofen (Advil)
ordered every 6 hours. It has been 6 hours
since the last dose and his parent has
requested that he receive his pain medication.
When the nurse enters the room, the child is
asleep. The parent requests that the pain
medication be given because the child is still
restless in sleep. What is the best nursing
action?
•
Refuse to awaken the child.
When evaluating the growth and development
of a healthy 6 month old infant, which
activities should the nurse expect the infant to
perform?
•
•
•
Sit alone, display a pincer grasp, and wave
bye-bye.
Crawl, transfer a toy from one hand to the
other, and be fearful of strangers.
Pull up to a standing position, release a toy
When evaluating the growth and development
of a healthy 6 month old infant, which
activities should the nurse expect the infant to
perform?
•
•
•
Sit alone, display a pincer grasp, and wave
bye-bye.
Crawl, transfer a toy from one hand to the
other, and be fearful of strangers.
Pull up to a standing position, release a toy
The nurse must assess 10-month-old Chad. He is
sitting on his father’s lap and appears to be
afraid of the nurse and of what might happen
next. Which of the following initial actions by
the nurse would be most appropriate?
•
•
•
Initiate a game of peek-a-boo.
Ask father to place Chad on the examination
table.
Talk softly to Chad while taking him from his
The nurse must assess 10-month-old Chad. He is
sitting on his father’s lap and appears to be
afraid of the nurse and of what might happen
next. Which of the following initial actions by
the nurse would be most appropriate?
•
•
•
Initiate a game of peek-a-boo.
Ask father to place Chad on the examination
table.
Talk softly to Chad while taking him from his
In assessing the physical development of a 12
month old, the nurse observes that there is
still a slight opening in the baby’s anterior
fontanel. Which of the following actions
would be most appropriate for the nurse to
take?
•
•
Notify the physician immediately because
this could be a sign of a serious problem
Initiate a series of neurological assessments
In assessing the physical development of a 12
month old, the nurse observes that there is
still a slight opening in the baby’s anterior
fontanel. Which of the following actions
would be most appropriate for the nurse to
take?
•
•
Notify the physician immediately because
this could be a sign of a serious problem
Initiate a series of neurological assessments
The nurse is examining a 2 year old for speech
and language development. Which finding
would suggest a delay in speech
development?
•
•
•
The child repeats what the mother says out
of context.
The child sometimes repeats or elongates
words.
The child doesn’t use the names of familiar
The nurse is examining a 2 year old for speech
and language development. Which finding
would suggest a delay in speech
development?
•
•
•
The child repeats what the mother says out
of context.
The child sometimes repeats or elongates
words.
The child doesn’t use the names of familiar
A home care nurse provides instructions to the
mother of a toddler with croup. The mother
expresses concern regarding the occurrence of
an acute spasmodic episode, and the nurse
instructs the mother regarding management if
an acute episode occurs. Which statement by
the mother indicates a need for further
instructions?
•
“I will place a steam vaporizer in my child’s
room.”
A home care nurse provides instructions to the
mother of a toddler with croup. The mother
expresses concern regarding the occurrence of
an acute spasmodic episode, and the nurse
instructs the mother regarding management if
an acute episode occurs. Which statement by
the mother indicates a need for further
instructions?
•
“I will place a steam vaporizer in my child’s
room.”
The nurse is teaching the mother of a 2 year old
boy about age appropriate toys. Which
suggestion would most likely be successful?
•
•
•
Giving the child a child-size toy vacuum
cleaner.
Giving the child old bowls, pans, and large
spoons.
Offering the child a variety of large stuffed
toys.
The nurse is teaching the mother of a 2 year old
boy about age appropriate toys. Which
suggestion would most likely be successful?
•
•
•
Giving the child a child-size toy vacuum
cleaner.
Giving the child old bowls, pans, and large
spoons.
Offering the child a variety of large stuffed
toys.
A nurse is admitting a 13 month old child with a
tentative diagnosis of intussusception. What
question to the mother would be most helpful
in obtaining additional information to confirm
the diagnosis?
•
•
•
“Does your child vomit after each feeding?”
“What does the child do when experiencing
pain?”
“Is your child passing ribbon-like stools?
A nurse is admitting a 13 month old child with a
tentative diagnosis of intussusception. What
question to the mother would be most helpful
in obtaining additional information to confirm
the diagnosis?
•
•
•
“Does your child vomit after each feeding?”
“What does the child do when
experiencing pain?”
“Is your child passing ribbon-like stools?
The father of a 4 year old boy has contacted the
nurse because he is concerned that his son is
always touching his genitals. The nurse
explains that this is very normal. Which of the
following statements by the father would
indicate a need for further teaching?
•
•
“I should teach him certain rules about this
activity.”
“I will eventually need to punish him if this
The father of a 4 year old boy has contacted the
nurse because he is concerned that his son is
always touching his genitals. The nurse
explains that this is very normal. Which of the
following statements by the father would
indicate a need for further teaching?
•
•
“I should teach him certain rules about this
activity.”
“I will eventually need to punish him if this
The nurse is conducting a well-child examination
of a 4 year old boy. Which of the following
statements would alert the nurse that the
child is at risk for iron deficiency?
•
“He enjoys fortified cereals and eggs.”
•
“He would drink milk all day if I let him.”
•
“He eats a well-balanced diet.”
•
“He does not like spinach, but he does like
The nurse is conducting a well-child examination
of a 4 year old boy. Which of the following
statements would alert the nurse that the
child is at risk for iron deficiency?
•
“He enjoys fortified cereals and eggs.”
•
“He would drink milk all day if I let him.”
•
“He eats a well-balanced diet.”
•
“He does not like spinach, but he does like
A preschool child is admitted for treatment of
pneumonia. The mother is embarrassed
because the child has wet the bed, which he
hasn’t done since he was toilet trained. Which
of the following statements might the nurse
make to the mother?
•
“This happens quite often with children
when they are admitted to the hospital. When
he feels better, his toileting skills will return to
normal.”
A preschool child is admitted for treatment of
pneumonia. The mother is embarrassed
because the child has wet the bed, which he
hasn’t done since he was toilet trained. Which
of the following statements might the nurse
make to the mother?
•
“This happens quite often with children
when they are admitted to the hospital.
When he feels better, his toileting skills will
return to normal.”
The parent of a preschooler hospitalized with
acute glomerulonephritis asks the nurse why
blood pressure readings are being taken so
often. The nurse’s reply should be based on
knowledge of which of the following?
•
•
The antibiotic therapy contributes to labile
blood pressure values.
Hypotension leading to sudden shock can
develop at any time.
The parent of a preschooler hospitalized with
acute glomerulonephritis asks the nurse why
blood pressure readings are being taken so
often. The nurse’s reply should be based on
knowledge of which of the following?
•
•
The antibiotic therapy contributes to labile
blood pressure values.
Hypotension leading to sudden shock can
develop at any time.
PHARM
A client recently began med therapy with
propanolol (Inderal). The nurse would be
most concerned if which of the following was
noted?
•
complaints of insomnia
•
audible expiratory wheezes
•
bp 136/84 from 162/90
•
HR 86 down to 78
A client recently began med therapy with
propanolol (Inderal). The nurse would be
most concerned if which of the following was
noted?
•
complaints of insomnia
•
audible expiratory wheezes
•
bp 136/84 from 162/90
•
HR 86 down to 78
Patient receiving Clonidine (Catapres)
0.1mg/24hr transdermal patch. Desired effect
is?
•
denies recent angina
•
change in edema from +3 to +1
•
denies n/v
•
BP from 180/120 to 140/70
Patient receiving Clonidine (Catapres)
0.1mg/24hr transdermal patch. Desired effect
is?
•
denies recent angina
•
change in edema from +3 to +1
•
denies n/v
•
BP from 180/120 to 140/70
New prescription for ACE inhibitor. What
contraindicates its use?
•
asthma
•
HF
•
renal artery stenosis
•
CAD
New prescription for ACE inhibitor. What
contraindicates its use?
•
asthma
•
HF
•
renal artery stenosis
•
CAD
CHF client discharged with ACE inhibitor
Captopril (Capoten). Discharge instructions
include reporting which problem?
•
weight loss
•
dizziness
•
muscle cramps
•
dry mucus mucus membranes
CHF client discharged with ACE inhibitor
Captopril (Capoten). Discharge instructions
include reporting which problem?
•
weight loss
•
dizziness
•
muscle cramps
•
dry mucus mucus membranes
Nurse is giving a new medication of enalapril
(Vasotec). Which is an unpleasant SE?
•
rapid pulse
•
persistent cough
•
hypokalemia
•
alopecia
Nurse is giving a new medication of enalapril
(Vasotec). Which is an unpleasant SE?
•
rapid pulse
•
persistent cough
•
hypokalemia
•
alopecia
Nursing dx with client receiving the ARB
irbesartan (Avapro)?
•
fluid volume deficit
•
risk for infection
•
risk for injury
•
impaired sleep patterns
Nursing dx with client receiving the ARB
irbesartan (Avapro)?
•
fluid volume deficit
•
risk for infection
•
risk for injury
•
impaired sleep patterns
Lasix is prescribed for L HF. Which instructions
apply?
•
restrict fluid intake
•
expect muscle weakness
•
take meds at bedtime
•
expect increased UO
•
eat foods high in K
•
Lasix is prescribed for L HF. Which instructions
apply?
•
restrict fluid intake
•
expect muscle weakness
•
take meds at bedtime
•
expect increased UO
•
eat foods high in K
Client with HF prescribed spironalactone
(Aldactone). Which is most important for
diet?
•
do no add salt
•
refrain from high K foods
•
restrict to 1000mL per day fluid
•
increase intake of milk and milk products
Client with HF prescribed spironalactone
(Aldactone). Which is most important for
diet?
•
do no add salt
•
refrain from high K foods
•
restrict to 1000mL per day fluid
•
increase intake of milk and milk products
Before administering digoxin (Lanoxin) the apical
pulse is 54. What actions should the nurse
take?
•
assess the client for signs of dig toxicity
•
notify the physician of the apical pulse rate
•
check results of most recent dig level
•
check results of most recent K level
•
give dig and recheck the apical pulse 1 hour
Before administering digoxin (Lanoxin) the apical
pulse is 54. What actions should the nurse
take?
•
assess the client for signs of dig toxicity
•
notify the physician of the apical pulse rate
•
check results of most recent dig level
•
check results of most recent K level
•
give dig and recheck the apical pulse 1 hour
When assessing prior to giving digoxin, which is
most important to consider?
•
presence of grade 2 murmur
•
nail bed cap refill of 5 seconds
•
irregular apical pulse of 87
•
bilateral LE dependent rubor
When assessing prior to giving digoxin, which is
most important to consider?
•
presence of grade 2 murmur
•
nail bed cap refill of 5 seconds
•
irregular apical pulse of 87
•
bilateral LE dependent rubor
Client receiving digoxin. Which correlates with
dig level of 2.4ng/mL
•
nausea
•
drowsiness
•
photophobia
•
increased appetite
•
increased energy level
Client receiving digoxin. Which correlates with
dig level of 2.4ng/mL
•
nausea
•
drowsiness
•
photophobia
•
increased appetite
•
increased energy level
Following sublingual nitro, which assessment
indicates effectiveness?
•
chest pain is relieved
•
pulse decrease from 120 to 90
•
systolic bp decreases from 180 to 90
•
SaO2 increases from 92% to 96%
Following sublingual nitro, which assessment
indicates effectiveness?
•
chest pain is relieved
•
pulse decrease from 120 to 90
•
systolic bp decreases from 180 to 90
•
SaO2 increases from 92% to 96%
New nitro tablet prescription. What is proper
teaching?
•
•
•
•
take at least one hour before a meal
monitor pulse for 60 seconds before
administration
place under tongue as needed every 5
minutes up to 3 times
resume normal activities after chest pain is
New nitro tablet prescription. What is proper
teaching?
•
•
•
•
take at least one hour before a meal
monitor pulse for 60 seconds before
administration
place under tongue as needed every 5
minutes up to 3 times
resume normal activities after chest pain is
Which instructions for nitro patch (Nitro-dur)?
•
•
•
•
apply to a nonhairy, nonfatty area of upper
torso or arms
apply to the same site each day
if you get a headache remove patch for four
hours and reapply
if you get chest pain, apply a second patch
next to the first one
Which instructions for nitro patch (Nitro-dur)?
•
•
•
•
apply to a nonhairy, nonfatty area of upper
torso or arms
apply to the same site each day
if you get a headache remove patch for four
hours and reapply
if you get chest pain, apply a second patch
next to the first one
Sublingual nitro prescribed for acute angina.
Which instructions to provide?
•
take tab at first sign of pain
•
take while sitting or lying down
•
check expiration date
•
•
swallow for most effective ness and
rapidness
keep bottle away from light and moisture
Sublingual nitro prescribed for acute angina.
Which instructions to provide?
•
take tab at first sign of pain
•
take while sitting or lying down
•
check expiration date
•
•
swallow for most effective ness and
rapidness
keep bottle away from light and moisture
After abdominal surgery patient is prescribed
Lovenox, why is he receiving it?
•
•
med is a blood thinner to prevent blood clot
formation
med enhances antibiotics to prevent
infection
•
med dissolves clots that develop in the legs
•
abdominal injection assists with healing of
After abdominal surgery patient is prescribed
Lovenox, why is he receiving it?
•
•
med is a blood thinner to prevent blood
clot formation
med enhances antibiotics to prevent
infection
•
med dissolves clots that develop in the legs
•
abdominal injection assists with healing of
Plan of care for heparin. Which interventions
included?
•
provide soft toothbrush
•
monitor for bruising and bleeding
•
have antidote available
•
•
apply pressure to venipuncture and other
injection sites
allow client to take acetylsalicylic acid
Plan of care for heparin. Which interventions
included?
•
provide soft toothbrush
•
monitor for bruising and bleeding
•
have antidote available
•
•
apply pressure to venipuncture and other
injection sites
allow client to take acetylsalicylic acid
Warfarin sodium (Coumadin) has been
instructed to limit vitamin K. Avoid what?
•
tea
•
romaine lettuce
•
oranges
•
cabbage
•
broccoli
Warfarin sodium (Coumadin) has been
instructed to limit vitamin K. Avoid what?
•
tea
•
romaine lettuce
•
oranges
•
cabbage
•
broccoli
CAD client on digoxin. Gets new prescription for
avorstatin (Lipitor). 2 weeks later the nurse
assesses, which requires immediate
intervention
•
heartburn
•
HA
•
constipation
•
vomiting
•
CAD client on digoxin. Gets new prescription
for avorstatin (Lipitor). 2 weeks later the
nurse assesses, which requires immediate
intervention
•
heartburn
•
HA
•
constipation
•
vomiting
DM patient receives NPH at 7am. Nurse most
carefully monitors for hypoglycemia between:
•
9am-11am
•
1pm-7pm
•
7pm-11pm
•
midnight-6am
DM patient receives NPH at 7am. Nurse most
carefully monitors for hypoglycemia between:
•
9am-11am
•
1pm-7pm
•
7pm-11pm
•
midnight-6am
Nurse teaches family of a new DM client. Nurse
evaluates understanding of glucagon for
emergency by indicating the purpose for:
•
DKA
•
hypoglycemia from insulin OD
•
hyperglycemia from insufficient insulin
•
hyperglycemia occurring on "sick days"
Nurse teaches family of a new DM client. Nurse
evaluates understanding of glucagon for
emergency by indicating the purpose for:
•
DKA
•
hypoglycemia from insulin OD
•
hyperglycemia from insufficient insulin
•
hyperglycemia occurring on "sick days"
Nurse provides which instructions for
levothyroxine (Synthroid)?
•
monitor pulse rate
•
take med in the morning
•
notify physician if chest pain occurs
•
take med at the same time each day
•
expect the pulse to be greater than 100
Nurse provides which instructions for
levothyroxine (Synthroid)?
•
monitor pulse rate
•
take med in the morning
•
notify physician if chest pain occurs
•
take med at the same time each day
•
expect the pulse to be greater than 100
DC prednisone for COPD. What instructions to
give?
•
•
lifelong treatment tis common for chronic
disease
drug should be stopped immediately if no
longer needed
•
dose must be tapered over 7-10 days
•
another corticosteroid should be used to
DC prednisone for COPD. What instructions to
give?
•
•
lifelong treatment tis common for chronic
disease
drug should be stopped immediately if no
longer needed
•
dose must be tapered over 7-10 days
•
another corticosteroid should be used to
Serious SE for high dose prednisone
•
alopecia
•
anorexia
•
n/v
•
susceptibility to infection
Serious SE for high dose prednisone
•
alopecia
•
anorexia
•
n/v
•
susceptibility to infection
Nurse is preparing to administer Albuterol
(Proventil). Assess what before?
•
n/v
•
lung sounds and presence of dyspnea
•
HA and LOC
•
UO and BUN
Nurse is preparing to administer Albuterol
(Proventil). Assess what before?
•
n/v
•
lung sounds and presence of dyspnea
•
HA and LOC
•
UO and BUN
Order to give Metaproterenol sulfate (Alupent)
and Beclomethasone (QVAR)
•
beclomethasone first
•
metaproterenol first
•
alternating beginning with beclomethasone
•
alternating beginning with metaproterenol
Order to give Metaproterenol sulfate (Alupent)
and Beclomethasone (QVAR)
•
beclomethasone first
•
metaproterenol first
•
alternating beginning with beclomethasone
•
alternating beginning with metaproterenol
Upon admission to ED, an adult client with acute
status asthmaticus is prescribed a series of
meds, which order?
•
prednisone (deltasone) orally
•
gentamicin (Garamycin) IM
•
albuterol (Proventil) nebulizer
•
aminophylline (Truphyline) IV
Upon admission to ED, an adult client with acute
status asthmaticus is prescribed a series of
meds, which order?
•
prednisone (deltasone) orally
(1)
•
gentamicin (Garamycin) IM
•
albuterol (Proventil) nebulizer
(3)
•
aminophylline (Truphyline) IV
(4)
(2)
Nurse teaches patient taking tetracycline to do
what?
•
regular PT and INR
•
long sleeves, sunglasses
•
•
take with milk or food to minimize GI
disturbances
change positions slowly to avoid orthostatic
hypotension
Nurse teaches patient taking tetracycline to do
what?
•
regular PT and INR
•
long sleeves, sunglasses
•
•
take with milk or food to minimize GI
disturbances
change positions slowly to avoid orthostatic
hypotension
Allergy to penicillin. What related allergy?
•
aminoglycosides
•
cephalospoins
•
sulfonamides
•
tetracyclines
Allergy to penicillin. What related allergy?
•
aminoglycosides
•
cephalospoins
•
sulfonamides
•
tetracyclines
Trichomonis vaginalis prescription for
metronidazole (Flagyl)
•
do not ingest with dairy
•
notify clinic with urine color change
•
TP/TPP q3months
•
avoid OTC antitussives
Trichomonis vaginalis prescription for
metronidazole (Flagyl)
•
do not ingest with dairy
•
notify clinic with urine color change
•
TP/TPP q3months
•
avoid OTC antitussives
Phenytoin (Dilantin) capsules prescribed for
tonic-clonic seizures. What instructions?
•
perform good oral hygiene and gum
massage
•
CBC monthly
•
report rashes
•
contact physician if a red-brown
discoloration of the urine occurs
Phenytoin (Dilantin) capsules prescribed for
tonic-clonic seizures. What instructions?
•
perform good oral hygiene and gum
massage
•
CBC monthly
•
report rashes
•
contact physician if a red-brown
discoloration of the urine occurs
Levodopa PO TID for Parkinson's. New script for
sustained levodopa/carbidopa PO BID. Took
levodopa at 8am, what now?
•
•
•
take first dose of sinemet today, as soon as
prescription is filled
since you took levodopa, wait until
tomorrow for sinemet
take both for the first week, then switch to
only sinemet
Levodopa PO TID for Parkinson's. New script for
sustained levodopa/carbidopa PO BID. Took
levodopa at 8am, what now?
•
•
•
take first dose of sinemet today, as soon as
prescription is filled
since you took levodopa, wait until
tomorrow for sinemet
take both for the first week, then switch to
only sinemet
What client is highest risk for opioid
complications
•
older client with type 2 DM
•
chronic RA
•
open compound fracture
•
young adult with inflammatory bowel
disease
What client is highest risk for opioid
complications
•
older client with type 2 DM
•
chronic RA
•
open compound fracture
•
young adult with inflammatory bowel
disease
When assessing acetaminophen OD. Most
important assessment for pain?
•
flank
•
abdomen
•
chest
•
head
When assessing acetaminophen OD. Most
important assessment for pain?
•
flank
•
abdomen
•
chest
•
head
Teaching about antiinflammatories. Education
with aspirin, acetominophen, or NSAIDS?
•
•
•
radial pulse and temp prior to admin
consult provider before OTC meds because
of combinations that may have more of the
med than is safe
cholesterol levels measures before
treatment
Teaching about antiinflammatories. Education
with aspirin, acetominophen, or NSAIDS?
•
•
•
radial pulse and temp prior to admin
consult provider before OTC meds because
of combinations that may have more of the
med than is safe
cholesterol levels measures before
treatment
Child from ED with acetominophen OD. Which
for OD?
•
protamine
•
epoeitin alfa (Epogen)
•
acetylcysteine (Mucomyst)
•
ethylenediaminetetraacetic acid (EDTA)
Child from ED with acetominophen OD. Which
for OD?
•
protamine
•
epoeitin alfa (Epogen)
•
acetylcysteine (Mucomyst)
•
ethylenediaminetetraacetic acid (EDTA)
Dx with glaucoma has miotic medication
prescription. Teaching effects:
•
reshape the lens to eliminate blurred vision
•
dilate pupil to reduce intraocular pressure
•
•
interrupt the drainage of aqueous humor
from the eye
lower intraocular pressure and enhance
blood flow to the retina
Dx with glaucoma has miotic medication
prescription. Teaching effects:
•
reshape the lens to eliminate blurred vision
•
dilate pupil to reduce intraocular pressure
•
•
interrupt the drainage of aqueous humor
from the eye
lower intraocular pressure and enhance
blood flow to the retina
Allopurinol (Zyloprim) administered knowing
that what is accurate
•
used for lysis of thrombi obstructing
coronary arteries
•
decreases sympathetic outflow from CNS
•
prevents calcium absorption
•
decreases uric acid
Allopurinol (Zyloprim) administered knowing
that what is accurate
•
used for lysis of thrombi obstructing
coronary arteries
•
decreases sympathetic outflow from CNS
•
prevents calcium absorption
•
decreases uric acid
Tamoxifen (Nolvadex) is prescribed for
metastatic breast carcinoma.
•
increase DNA and RNA synthesis
•
promote biosynthesis of nucleic acids
•
•
increase estrogen concentration an
estrogen response
compete with estradiol for binding to
estrogen in tissues containing high
Tamoxifen (Nolvadex) is prescribed for
metastatic breast carcinoma.
•
increase DNA and RNA synthesis
•
promote biosynthesis of nucleic acids
•
•
increase estrogen concentration an
estrogen response
compete with estradiol for binding to
estrogen in tissues containing high