1 The nurse asks a patient with heart failure to identify a food to eliminate from the desired diet. Which
selection if made by the client would confirm the learning objective has been accomplished?
A. Fresh Green Apples
B. Honey Baked Ham
C. Yellow Squash
D. Multi-grain bread
2 The nurse is reviewing the client's lab values. It would be a priority for the nurse to follow up with
which client immediately?
A. A 52 year old client with a nasogastric tube to low wall suction and a potassium level of 3.2 mEq/L.
B. A 96 year old with pneumonia and a white blood cell count of 12000 cells/mcL.
C. A 72 year old client with a heparin infusion and a activated Partial Thromboplastin Time (aPTT) of 72
seconds.
3 The nurse is assessing the vital signs of a 3-year old brought to the well-child clinic by her parents. The
client has a heart rate of 140. The nurse recognizes that this rate in a child indicates:
A. Sinus Tachycardia
B. Sinus Rhythm
C. Atrial Tachycardia
D. Ventricular Tachycardia
4 The nurse is caring for a client with a urinary tract infection. It would be a priority for the nurse to
follow up with the primary healthcarer provider for which laboratory result?
A. Lactate 6.2 mmol/L
B. Potassium 4.2 mEq/L
C. Calcium 9 mg/dl
D. Magnesium 1.5 mEq/L
5 The charge nurse of a telemetry unit is planning assignments for the next shift. Which client should be
assigned to the registered nurse?
A. A client with asthma complaining of chest tightness.
B. A client who is two days post cardiac catheterization.
C. A client diagnosed with heart failure who has 1+ pitting edema.
A client who had a percutaneous coronary intervention and is being discharged tomorrow.
6 The nurse is assessing a 10-year old client one-day after an appendectomy. Which of the follow
manifestations requires follow up by the nurse?
A. A urine output of 40 mL in the last 2 hours
B. Hypoactive bowel sounds
C. Pulse rate of 90 beats per minute
D. Blood pressure 92/54
7 The nurse is performing a physical assessment on a healthy client. Which of the following indicate
correct assessment technique? SELECT ALL THAT APPLY
A. Use the Bell of the stethoscope to listen for low pitched heart sounds. B. Auscultate bowel sounds
prior to palpation of the abdomen. D. Assist the client to to turn to the left side to listen for a gallop.
C. Instruct the client to breathe through the nose when listening to lung sounds.
E. Assess the apical pulse at the 5th intercostal space mid-scapular line
8 The nurse is performing discharge planning for a client newly diagnosed with diabetes mellitus. It
would be most important for the plan to include: SELECT ALL THAT APPLY
A. Reporting blood sugars over 200
B. Dietary plan to achieve significant weight loss
C. Emphasizing the need to get the eyes checked frequently
D. Monitoring the skin for rashes and dryness.
E. Using a 23 Gauge 1/2 inch needle for subcutaneous insulin
9 The nurse is working on a medical surgical unit. Which client should the nurse see first?
A. The client complaining of pain (7) on a scale of 0 (None) - 10 (Intolerable pain).
B. A client with a continuous bladder irrigation that is pink tinged and contains debris.
C. A client status post thyroidectomy who has tremors, is diaphoretic and complains of being anxious.
D. A client with a percutaneous endoscopic gastrostomy (PEG) tube feeding that requires flushing to
maintain patency.
10 The nurse is assessing a client who suffered a myocardial infarction (AMI). Which sign if manifested
by the client would require immediate follow up by the nurse?
A. Persistent, non-productive cough
B. SpO2 93% on FiO2 of 21%
C. Dependent peripheral edema
D. Jugular neck vein distention when lying flat.
11 The nurse is assessing a client's ability to self administer insulin. It would require follow up by the
nurse if the client is observed:
A. Massaging the administration site after removing the needle.
B. Cleansing the administration site prior to injection.
C. Performing hand hygiene prior to performing injection.
D. Rotating the site
E. Using a 31 Gauge 1/2 inch needle for subcutaneous insulin
12 The nurse caring for a client who performs continuous ambulatory peritoneal dialysis (CAPD) at
home. Which response by the client should indicate to the nurse the need for additional teaching?
SELECT ALL THAT APPLY
A. "I will be able to take my daily bath." E. I will remain hooked up to the machine at night.
B. "I will not touch the end of the catheter"
C. "I should eat foods low in sodium and phosphorus"
D. I should keep the catheter site clean.
13 The nurse is assessing a client with suspected tuberculosis (TB). Which of the following findings
would be consistent with this diagnosis?
A. Bloody sputum and diaphoresis at night
B. Bilateral wheezing and shortness of breath
C. Weight loss and loss of appetite
D. Lower extremity edema and frothy sputum.
14 The nurse is preparing to teach a client with a venous stasis ulcer about her care. Which of the
following instructions should be optimal to include in the teaching? SELECT ALL THAT APPLY
A. Elevate the affected leg when sitting. C. Use compression hose to reduce swelling. E. Report if they
notice any side effects such as numbness, tingling, pain, and dusky toes.
B. Eat a diet high in carbohydrates and proteins
D. Use a wound care treatment that adds moisture to the wound.
15 The nurse is receiving shift report. Which client should be assessed immediately?
A. 56 year old client with a SpO2 reading of 88% on 2 Liters of Oxygen
B. 48 year old client with finger stick blood glucose of 153 mg/dL
C. 68 year old client with an IV that needs restarting due to infiltration
D. 25 year old complaining of heavy vaginal bleeding
16 The nurse is working in the women's health clinic and teaching performance of breast self exam
(BSE). Which of the following statements by the client indicates teaching has been effective?
A. "BSE should be performed 5- 7 days after menstruation has begun
B. "BSE should be performed by the age of 30 if there is family history"
C. "BSE can be perfomed at anytime during the month"
17 The nurse is reviewing the client's lab values. It would be a priority for the nurse to follow up with
the healthcare provider for which of the lab values?
A. Serum potassium of 2.8 mEq/L
B. Serum Sodium level of 150 mEq/L
C. Serum Creatinine level of 2.0 mg/dl
D. Hemoglobin level of 10 gm/dl
18 The nurse is reviewing the client's lab values. It would be a priority for the nurse to follow up with
the healthcare provider for which of the lab values?
A. Hemoglobin A1c of 7.1%
B. Serum Sodium level of 140 mEq/L
C. Serum Creatinine level of 1.0 mg/dl
D. Blood urea nitrogen of 15 mg/dl
Hematocrit level of 40%
19 The nurse is instructing a newly hired nurse on care of client with a nasogastric feeding. It would
indicate understanding if the new nurse is observed:
A. Positioning the client in fowlers position during and immediately after the feeding
B. Discarding excess residual feeding after checking the pH
C. Flushing the nasogastric tube with equal amounts of water
D. Verifying the tube's placement by injecting air and listening over the stomach
20 The nurse is assessing a client diagnosed with hypertension. Which of the following responses should
encourage the nurse to follow up with the client?
A. "I love bologna and cheese pn whole wheat bread"
B. "I drink 2-3 cups of coffee a day"
C. "I can eat broccoli, but I don't like it"
D. "I don't have to worry about green leafy vegetables interfering with the drug."
21 The nurse is assessing a patient who had an ischemic stroke. Which of the following should require
immediate follow-up?
A. Coughing after drinking water
B. Difficulty holding a fork
C. Difficulty ambulating to the bathroom
D. Moving her right leg better than the left one
22 The nurse is preparing to administer digoxin (Lanoxin). Which of the following actions should the
nurse perform immediately prior to administering the drug?
A. Assess the apical pulse
B. Assess the SpO2
C. Assess the EKG rhythm
D. Assess the blood pressure
23 The nurse is caring for a client with end stage liver disease. The client is scheduled for a liver biopsy.
Which of the following would require immediate follow up by the nurse?
A. Protime (PT) 25 seconds
B. Several spider angiomas
C. Hemoglobin 10 g/dl
D. Distended abdomen
24 The nurse is reviewing clients for transfer to a sub-acute unit. Which client is appropriate for
transfer?
A. An 85 year old with twice a day dressing changes
B. An 88 year old with urinary retention of unknown etiology
C. An 80 year old post stroke with active titration of blood pressure medication
D. A 90 year old with hip fracture awaiting surgery.
25 The nurse is teaching a new nurse about care of a client with suspected tuberculosis. If observed by
the nurse, which would indicate a correct understanding of infection control guidelines?
A. A N-95 mask is worn upon entering the room
B. A gown and gloves is worn while in the room
C. A surgical mask is required when transporting the patient.
D. Goggles are not worn during pulmonary toileting.
26 The nurse is working in the obstetrics clinic. Which procedure is contraindicated when evaluating a
pregnant client who is experiencing vaginal bleeding?
A. Vaginal exam
B. Urine dip stick test
C. External fetal monitor electrodes
D. Ultrasound
27 The nurse is caring for a client 8 hours after a cardiac catheterization. It would be most important for
the nurse to document which of the following in the client's medical record: SELECT ALL THAT APPLY
B. Appearance of site C. Condition of the affected extremity D. Presence/Absence of pulses
A. Physician performing the catheterization
E. Assess the apical pulse at the 5th intercostal space mid-scapular line
28 The nurse is assessing a client with a 3 day old colostomy. The stoma is noted to be dark and dusky in
color. What does this assessment indicate?
A. Circulation to the stoma may be compromised
B. The stoma is in the early stages of healing
C. The lumen of the stoma is blocked with stool.
D. The client's SpO2 is low.
29 The nurse is inserting an indwelling urinary catheter. While inflating the balloon of the catheter, the
client complains of pain. Which of the following actions should the nurse implement first?
A. Withdraw the fluid from the balloon.
B. Assure the client that the pain will subside
C. Advance the catheter further into the urethra
D. Place the client in a lateral position.
30 The nurse is administering intravenous fluids to a client with hypovolemia. The nurse recognizes that
the fluids are ineffective when which of the following manifestation are observed?
A. Decreased systolic blood pressure
B. Brisk capillary refill
C. 100 mL of urine in the past 2 hours
D. Strong radial pulse
31 The nurse is caring for a client whose urinary output is 100 mL for the last 4 hours. What action
should the nurse perform next?
A. Notify the provider
B. Continue to monitor
C. Weigh the client
D. Increase intake of oral fluids
32 The nurse is admitting a client to the emergency department after an anaphylactic response to
ingesting peanut butter. Which task below is the highest priority for the care of this client?
A. Preventing further compromise to the airway
B. Administer epinephrine to decrease bronchodilation
C. Attach the electrocardiogram (EKG) to monitor for arrhythmias
D. Apply oxygen
33 The emergency room nurse ausculates the lungs of a client who is having an acute asthma attack.
The nurse notes that the wheezing has stopped and breath sounds are diminished. Which of the
following should the nurse consider next?
A. Prepare for endotracheal intubation
B. Reassess lung sounds and SpO2 in 5 minutes
C. Apply non-rebreather mask with 100% FiO2
D. Administer .25 mg Epinephrine intramuscularly
34 The nurse is caring for a client with pre-eclampsia. To determine the renal status of the client, the
normal urine output should be:
A. 55 - 70 mL per hour
B. 10 - 25 mL per hour
C. 30 - 50 mL per hour
D. 75 - 100 mL per hour
35 The nurse is evaluating a client's response to escitalopram (Lexapro). Which symptoms if
experienced by the client should be of immediate concern to the nurse? SELECT ALL THAT APPLY
A. Robust appetite B. increased thirst C. Hyperthermia E. Tachycardia >120
D. High salt levels in the blood
36 The nurse is assessing a client with colorectal cancer. Which finding is consistent with this diagnosis?
A. Rectal bleeding
B. Recurrent vomiting
C. Diarrhea
D. Bloating
37 The nursing faculty is reviewing electronic health records (EHR) with students. A nursing student
demonstrates understanding of EHR by which of the following statements?
A. "The person before me forgot to log off, so I logged them off. Then I logged back in."
B. I shared my log in information with a fellow student, who forgot her own."
C. "My nurse preceptor allowed me to document using her log in."
D. "I recycle the same passwords so I can remember them."
38 The charge nurse is observing a nursing assistant caring for a client with a long leg cast. Which of the
following if observed would require additonal guidance from the nurse?
A. Nursing assistant assists with moving the leg using the tips of the fingers.
B. The nursing assistant provides pillows under the leg with the cast.
C. The nursing assistant positions the client's casted leg open to air.
D. The nursing assistant notifies the nurse if the client complains of pain.
39 The nurse is caring for a client with an SpO2 reading of 95%. Which of the following actions should
the nurse take?
A. Continue to monitor the client's respiratory rate
B. Apply a nasal cannula at 2 L/min
C. Encourage the use of the incentive spirometer every 4 hours
D. Adjust the SpO2 probe to improve the reading.
40 A client is NPO prior to scheduled surgery. D5NS is infusing at 125 mL/hour. The client reports
frequent watery diarrhea. It would be most important to assess the client for which of the following?
A. Urine output of at least 60 mL/hr
B. Breakdown of rectal mucosa
C. Patency of intravenous site
D. Presence of abdominal pain
41 The nurse is making assignments. Which client should the nurse see first?
A. A 58 year old, who just returned from surgery.
B. A 12 year old with a daily dressing change
C. A 80 year old who needs a blood glucose check performed.
D. A client with a SpO2 of 96%
42 After receiving morning shift report, the nurse should see which of the following children first?
A. A 2 year old child with RSV with diminished breath sounds at the bases
B. A child with a diagnosis of asthma
C. A 2 year old with a respiratory rate of 30 bpm.
D. A 3 year old child cystic fibrosis and a SpO2 of 97%.
43 The nurse is assessing the dietary choices of a client with generalized edema. It would require
immediate follow up by the nurse if the client chooses which food?
A. Salami and crackers
B. Broccoli with unsalted butter.
C. Grilled chicken filet
D. Oatmeal
44 The nurse is preparing to administer furosemide (Lasix) 80 mg IV to a client with acute renal failure.
Prior to giving this medication, it should be important for the nurse to assess which of the following?
A. Serum potassium
B. Serum Creatinine
C. Serum Sodium
D. Serum blood urea nitrogen (BUN)
45 Which of the following standard of care should the nurse include when caring for a client with an
absolute neutrophil count (ANC) of 500 mm3?
A. Use an antibacterial gel when handwashing is not possible
B. Wear gown, gloves and mask upon entering the room
C. Encourage colored vegetables from the salad bar
D. Institute bed fall precautions
46 The nurse is assessing the client's laboratory results. Which of the following results should the nurse
notify the primary healthcare provider?
A. Hemoglobin 9.3 g/dl
B. White blood count 9,000 mm3
C. Potassium level 4.0 mEq/L
D. Sodium level 140 mEq/L
47 The nurse is caring for a client who suddenly grabs his chest, complains of shortness of air and coughs
frothy, pink sputum. Which action below should the nurse employ first?
A. Place the client in high fowler's position
B. Obtain a 12 lead electrocardiogram (EKG)
C. Notify the physician immediately
D. Draw a serum CPK-mb and troponin level.
48 The nurse is caring for a client who just delivered a 9lb 8oz male. It would be most important for the
nurse to assess the client for which of the following?
A. Fundal consistency
B. Level of pain
C. Hypertension
D. Adequate urine output
49 The nurse is assessing the client who was recently diagnosed with gestational hypertension. Which
of the following signs or symptoms would be consistent with this diagnosis?
A. Generalized edema
B. Increased thirst
C. Decreased hemoglobin
D. Profuse sweating
50 The nurse is assessing a client for the risk of developing skin cancer. It would be a priority for the
nurse to suggest follow up for which client?
A. 24 year old using a tanning booth on a weekly basis
B. 50 year old who goes to the beach every day to swim
C. A 40 year old who complains of freckles all over her body
D. A 45 year old who uses a tanning spray in the summer
51 The nurse is caring for a client who is receiving normal saline solution (NSS) at 100 mL/hr for 8 hours.
The client's urine output during that 8 hour shift is 100 ml. What should be the nurse's priority
response?
A. Notify the provider
B. Document the intake and output in the medical record
C. Increase the fluids to 125 ml/hr
D. Continue to monitor the client
52 The nurse is completing a discharge plan for a client that admitted for worsening congestive heart
failure. Which response by the client should alert the nurse that follow up is needed?
A. "I will eat no more than two deli sandwichs for lunch per week."
B. "I can eat fresh fruit with this disease."
C. "I can eat broccoli, but I don't like it"
D. "I will watch how much salt is in the breads I eat"
53 The home care nurse is assessing several clients. Which of the following clients should the nurse
assess first?
A. A 65 year old with a change in mental status
B. A client undergoing surgery in the am with a blood glucose of 150 mg/dL
C. An older adult being admitted with a sacral ulcer.
D. A client with an acute ischemic stroke with a potassium of 3.5 mEq/L
54 The nurse is assessing a client with a traumatic brain injury (TBI). Which finding if new would indicate
deterioration in the client's condition?
A. Decorticate posturing
B. Positive occulocephalic reflex
C. Negative Babinski reflex
D. Bilateral pupillary constriction
55 The nurse is performing an hourly neurological assessment on a client who sustained a traumatic
brain injury (TBI). The nurse notes a new finding of unequal pupils. Which is the next appropriate
nursing action?
A. Notify the provider
B. Increase the rate of the hypertonic saline solution
C. Place the client in the modified trendelenburg position
D. Administer midazolam (Versed) 2 mg IV now
56 The nurse is assessing a client who has chronic renal failure (CRF). When monitoring the clients
urinary output, how many milliliters per hour are expected?
A. 55 - 70 mL per hour
B. 10 - 25 mL per hour
C. 30 - 50 mL per hour
D. 75 - 100 mL per hour
57 The nurse is assessing a client who has chronic renal failure (CRF). When monitoring the clients
urinary output, how many milliliters per hour are associated with oliguria?
A. < 400 mL in 24 hour period
B. 55 - 70 mL per hour
C. 30 - 50 mL per hour
D. < 200 mL in 24 hour period
58 The nurse is assessing a client diagnosed with a deep vein thrombosis (DVT). Which of the following
findings would confirm this diagnosis?
A. Erythema and a weak pedal pulse
B. +3 pedal edema
C. Absent hair growth to extremity
D. Complaints of numbness and tingling
59 The nurse is assessing a client who has undergone a fasciotomy. The circulatory status of the client's
foot can be accurately assessed by which of the following assessments?
A. Assessment of the warmth, color and pulses of the foot
B. Monitoring for edema in the affected leg
C. Observing for increased pain
D. Assessment of the femoral pulse
60 The nurse is preparing to administer a prescribed dose of metaprolol (Lopressor, Toprol XL) to a
client. Prior to administering the medication, it would be most important for the nurse to assess the
client for which of the following?
A. Heart rate and blood pressure
B. Respiratory rate and SpO2
C. Potassium and Sodium levels
D. Temperature and White Blood Cell (WBC) count
61 The nurse is assessing a client with 60% of his body with full thickness burns for evidence of
inhalation injury. Which of the following findings would indicate the client is becoming hypoxic?
A. Change in level of consciousness
B. Carbonaceous sputum
C. Facial Swelling
D. Singing of the nasal hair
62 The nurse has taught a client how to perform foot care. It would indicate the client is able to
correctly perform foot care if the client did which of the following?
A. Locates a mirror to examine feet during performance
B. Soaks feet twice a day in warm water
C. Wears white socks daily
D. Cuts nails in a concave manner.