Review C 1
1) A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions
Answer: D. Contractions
2) A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1 hr if unable to fall asleep
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime
Answer: D. Eat a light snack before bedtime
3) A nurse on a telemetry unit is caring for a client who becomes unconscious and whose monitor
displays ventricular tachycardia. Which of the following actions should the nurse take first after
determining the client does not have a palpable pulse?
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
D. Administer epinephrine
Answer: B. Defibrillate
4) A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding.
The nurse does not speak the same language as the client. The client's partner and 10-year-old
child are accompanying her. Which of the following actions should the nurse take to gather the
client's admission data?
A. Have the client's child translate
B. Allow the client's partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the client to translate
Answer: C. Request a female interpreter through the facility
5) A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a
cooling blanket. Which of the following findings indicates the client is having an adverse
reaction to the cooling?
A. Flushing
B. Tachycardia
C. Restlessness
D. Shivering
Answer: D. Shivering
6) A nurse is caring for a client who has deep-vein-thrombosis of the left lower extremity. Which
of the following actions should the nurse take? (Exhibit)
A. Position the client with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
C. Administer acetaminophen
D. Massage the affected extremity every 4 hr
Answer: B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
7) A nurse is reviewing assessment data from several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4)
Answer: B. A client who has a nonhealing leg ulcer
8) A nurse is providing discharge teaching to a client who has a chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
A. Eat 1 g/kg of protein per day
B. Take magnesium hydroxide for indigestion
C. Drink at least 3 L of fluid dailyD. Consume foods high in potassium- restrict
Answer: A. Eat 1 g/kg of protein per day
9) A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial?
Answer: B. A history of gastroesophageal reflux disease
10) A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse
should tell the client that she will undergo which of the following screening tests at 16 weeks of
gestation?
A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
C. Nonstress test -28 weeks
D. Maternal serum alpha-fetoprotein- 16 to 18 weeks
Answer: D. Maternal serum alpha-fetoprotein- 16 to 18 weeks
11) A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the
following findings is a complication of immobility?
A. Decreased serum calcium levels- increased serum calcium
B. Increased blood pressure- hypotension
C. Swollen area on calf
D. Urinary frequency
Answer: C. Swollen area on calf
12) A nurse in acute care mental health facility is participating in a medication-education group.
The leader of the group uses a laissez-faire leadership style. Which of the following actions
should the nurse expect from the leader during the session?
A .The leader encourages group members to remain silent until questions are called for
B. The leader lecture about medication adverse effects to the group members
C. The leader allows the group to discuss whatever they would like to regarding their
medications
D. The leader has group members vote on what they would like to learn about during the session
Answer: D. The leader has group members vote on what they would like to learn about during
the session
13) A nurse is providing teaching about digoxin administration to the parents of a toddler who
has heart failure. Which of the following statements should the nurse include in the teaching?
A. “You can add the medication to a half-cup of your child's favorite juice.”
B. “Repeat the dose if your child vomits within 1 hour after taking medication.” X
C. “Limit your child's potassium intake while she is taking this medication.”
D. “Have your child drink a small glass of water after swallowing the medication.”
Answer: D. “Have your child drink a small glass of water after swallowing the medication.”
14) A nurse is providing teaching to a client who has a depressive disorder and a new
prescription for phenelzine. Which of the following foods should the nurse instruct the client to
avoid?
A. Grapefruit
B. Spinach
C. Cottage cheese- cream cheese ok.
D. Smoked salmon
Answer: D. Smoked salmon
15) A nurse is planning care for a client who has COPD and weighs 99 lb. The provider has
prescribed a diet of a 1.5 g protein/kg/day. How many grams of protein per day should the nurse
include in the client's dietary plan? (Round to the nearest whole number
A. 68
B. 57
C. 47
D. 17
Answer: A. 68
16) A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room
B. Withdraw the client's TV privileges if he does not attend group therapy X
C. Encourage the client to take frequent rest periods
D. Place the client in seclusion when he exhibits signs of anxiety X
Answer: C. Encourage the client to take frequent rest periods
17) A parish nurse is leading a support group for clients whose family members have committed
suicide. Which of the following strategies should the nurse plan to use during the group session?
A. Encourage clients to establish a timeline for their own grieving process
B. Initiate a discussion with clients about ways to cope with changes in family dynamics
C. Discourage clients from sharing negative aspects of their relationship with the deceased
persons
D. Assist clients in identifying ways suicide could have been prevented
Answer: B. Initiate a discussion with clients about ways to cope with changes in family
dynamics
18) A nurse manager observes two staff nurses reviewing the computer records of a client who is
not under their care. Which of the following actions should the nurse manager take first?
A. Instruct the nurses to close the client's computer record
B. Request the nurses present an in-service on client confidentiality
C. Advise the nurses to read the facility's confidentiality policy
D. Place documentation of the nurses' actions in the personnel file
Answer: A. Instruct the nurses to close the client's computer record
19) A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine?
A. Heart rate 58/min
B. Fasting blood glucose 100 mg/dL
C. Hgb 14 g/dL
D. WBC count 2,900/mm3 - also agranulocytosis same thing or soar throat.
Answer: D. WBC count 2,900/mm3 - also agranulocytosis same thing or soar throat.
20) A nurse is caring for several clients on a medical-surgical unit. For which of the following
nurses activities is it required that the nurse use sterile gloves?
A. Inserting an NG tube
B. Administering total parenteral nutrition through a central venous access device
C. Initiating IV access
D. Performing tracheostomy care
Answer: D. Performing tracheostomy care
21) A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse give?
A. Influenza
B. Measles, mumps and rubella
C. Human papilloma virus
D. Varicella
Answer: A. Influenza
22) A nurse is inserting an indwelling catheter for a male client. Which of the following actions
should the nurse take?
A. Perform the cleansing procedure with a fresh swab two times
B. Lift the penis so that it is perpendicular to the client's body
C. Cleanse the tip of the penis in a side-to-side motion
D. Pick up the catheter 13 cm (5 cm) from its tip
Answer: B. Lift the penis so that it is perpendicular to the client's body
23) A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the teaching?
A. Bleeding gums- low platelet
B. Faintness upon rising
C. Swelling of the face
D. Urinary frequency
Answer: C. Swelling of the face
24) A nurse has received change-of-shift report for a group of clients. Which of the following
actions should the nurse take to manage time effectively?
A. Document client care at the end of the shift
B. Make the client to-do list for the day
C. Skip breaks until the client tasks are completed
D. Focus on several client tasks at a time
Answer: B. Make the client to-do list for the day
25) A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A. Minimize noise in the newborn's environment
B. Administer naloxone to the newborn
C. Swaddle the newborn with his legs extended
D. Maintain eye contact with the newborn during feedings
Answer: A. Minimize noise in the newborn's environment
26) A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings
should the nurse recognize as an expected finding?
A. The anterior fontanel is open
B. The posterior fontanel is open
C. Both fontanels are the same size
D. Both fontanels show molding
Answer: A. The anterior fontanel is open
27) A nurse is caring for client who has acute diverticulitis. Which of the following diets should
the nurse recommend to the client? Diverticulosis - High fiber
A. High residue
B. Lactose-free
C. Gluten-free
D. Low-fiber
Answer: D. Low-fiber
28) A nurse is caring for a client who is 48 hr postoperative following a total hip arthroplasty.
Which of the following actions should the nurse include in the plan of care?
A. Administer low-dose heparin
B. Place the client on a full liquid diet
C. Use an incentive spirometer every 3 hr
D. Maintain the client on bed rest
Answer: A. Administer low-dose heparin
29) A nurse is providing teaching to the parent of an infant who has a cleft lip palate. Which of
the following feeding techniques should the nurse include in the teaching?
A. Burp the infant frequently during feedings
B. Position the nipple at the front of the infant's mouth
C. Hold the infant in a supine position
D. Use feeding devices without nipples
Answer: A. Burp the infant frequently during feedings
30) A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which
of the following clients should the nurse see first?
A. A client who depressive disorder and requires assistance with ADLs
B. A client who has obsessive-compulsive disorder and is upset about a change in a daily routine
C. A client who is taking clozapine to treat schizophrenia and reports sore throat
D. A client who has narcissistic personally disorder and is mocking other during group therapy
Answer: C. A client who is taking clozapine to treat schizophrenia and reports sore throat
31) A nurse is planning care for a group of clients and is working with one licensed practical
nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse
take first to manage her time effectively?
A. Develop an hourly time frame for tasks
B . Schedule daily activities
C. Determine goals of the day
D. Delegate tasks to the AP
Answer: C. Determine goals of the day
32) A nurse is performing an admission assessment for a client who is in the manic phase of
bipolar disorder. Which of the following behaviors should the nurse expect?
A. Performance of ritualistic behaviors- ocd
B. Suspiciousness and distrust- schizo
C. Distractibility and poor judgment
D. Reports of physical discomfort -anxiety
Answer: C. Distractibility and poor judgment
33) A nurse is caring for an infant who has coarctation of the aorta. Which of the following
should the nurse identify as an expected finding?
A. Weak femoral pulses?- they get upper extremity hyper, lower extremity hypo
B. Frequent nosebleeds- yes
C. Upper extremity hypotension
D. Increased intracranial pressure
Answer: A. Weak femoral pulses?- they get upper extremity hyper, lower extremity hypo
34) A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
A. “The client might act seductively”- histrionic
B. “The client is overly concerned about minor details”- ocd
C. “The client exhibits impulsive behavior”
D. “The client is exceptionally clingy to others”- dependent
Answer: C. “The client exhibits impulsive behavior”
35) A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon
assessment, the nurse notes tidaling in the water seal. Which of the following is an explanation
for the tidaling? TIDLING IN WATER SEAL AND CONTINUOUS IN SUCTION CHAMBER
OKAY! WATER SEAL BUBBLING IS AIR LEAK.
A. There is a loop of tubing below the drainage system
B. The system is working properly
C. The lung has re-expanded
D. The tubing is partially obstructed by clots
Answer: B. The system is working properly
36) A nurse in an emergency department is caring for a client who is experiencing stimulant
withdrawal. Which of the following findings should the nurse expect?
A. Runny nose
B. Decreased appetite -Increased appetite
C. Muscle spasms
D. Fatigue, agitated anxiety, increased appetite
Answer: D. Fatigue, agitated anxiety, increased appetite
37) A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best
predictor of future violence?
A. A history of being in prison
B. Experiencing delusions
C. Male gender
D. Previous violent behavior
Answer: D. Previous violent behavior
38) A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the
following actions should the nurse plan to take?
A. Instruct the client to lift her chin when swallowing X
B. Talk to the client during feeding X
C. Discourage the client from coughing during feedings
D. Sit at or below the client's eye level during feedings
Answer: D. Sit at or below the client's eye level during feedings
39) A nurse is providing teaching to a client who has a depressive disorder and a new
prescription for amitriptyline. Which of the following statements by the client indicates an
understanding of the teaching?
A. “I expect this medication to raise my blood pressure”
B. “I should take this medication on an empty stomach”
C. “I can continue to take St. John's wort while taking this medication”
D. “I know it will be a couple of weeks before the medication helps me feel better”
Answer: D. “I know it will be a couple of weeks before the medication helps me feel better”
40) A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea.
To promote intake, which of the following actions should the nurse include in the plan of care?
A. Ambulate the client before each meal
B. Offer the client three large meals each day X
C. Administer a bronchodilator after meals
D. Limit fluid intake with meals YES drinking before and after can bloat you
Answer: D. Limit fluid intake with meals YES drinking before and after can bloat you
41) A nurse in the emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take first? (Exhibit)
A. Encourage the client to verbalize feelings *
B. Assess for hopelessness
C. Implement seizure precautions for the client
D. Administer ondansetron to the client for nausea
Obtain the client's weight
Answer: A. Encourage the client to verbalize feelings *
42) A home health nurse is completing screenings for elder abuse during client visits. Which of
the following findings should the nurse identify as an indication of potential elder abuse?
A. A client who lives with family members and begins to take more responsibility of self-care
B. A client who reports being given sedative medications by family members
C. A client who is taking warfarin and has several small bruises on her shins and hands
D. A client who schedules multiple visits with his provider every month
Answer: B. A client who reports being given sedative medications by family members
43) A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in
the coronary artery. Which of the following actions should the nurse include in the plan of care?
ALTEPLASE TREATS STROKES, HEART ATTACKS AND CLOTS.
A. Administer medications intramuscularly X- it is IV
B. Provide a diet low in protein X- why
C. Observe for bruising of the skin- check for bleeding
D. Monitor vital signs every hour for the first 4 hr- X every 15 min for the first hour
Answer: C. Observe for bruising of the skin- check for bleeding
44) A nurse is caring for a client who is postoperative following an appendectomy and is
receiving gentamicin. Which of the following assessment findings should the nurse identify as an
adverse effect of this medication?
A. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity
B. Respiratory rate 22/min
C. 2+ pitting edema of the ankles
D. Hgb 8.7 g/dL
Answer: A. Creatinine 2.3 mg/dL (0.6-1.2) nephrotoxicity
45) A nurse in an acute care facility is caring for a client who is homeless and has a decubitus
ulcer. Which of the following actions should the nurse take as a client advocate?
A. Gather dressing supplies for the client's discharge
B. Provide client teaching about nutrition
C. Consult with the facility's quality improvement team
D. Contact the facility's case management department?
Answer: D. Contact the facility's case management department?
46) A nurse is caring for client who has diarrhea and is receiving intermittent enteral feedings.
Which of the following actions should the nurse take?
A. Discard the open can of formula after 36 hrB. Administer feedings at a slower rate---can give d10W.
C. Flush the tube with 10 mL of water after feedings
D. Provide chilled formula- room temperature
Answer: B. Administer feedings at a slower rate---can give d10W.
47) A nurse is caring for a client who is postoperative and has a new prescription for
hydromorphone. Which of the following actions should the nurse take?
A. Withhold the medication if the client does not appear to be in pain
B. Withhold the medication if the client has a fever
C. Document administration of the medication upon removal from the medication dispensing
system
D. Count the current number of unit doses available in the medication dispensing system
Answer: D. Count the current number of unit doses available in the medication dispensing
system
48) A nurse in a provider's office is caring for a client who asks about using acupuncture to
manage his osteoarthritis pain. The nurse should identify which of the following conditions as a
contraindication for receiving this treatment?
A. Herpes zoster
B. Hypertension
C. Obesity
D. Hypothyroidism
Answer: A. Herpes zoster
49) A nurse is assessing a client following abdominal surgery. Which of the following findings
should the nurse report to the provider?
A. Temperature 37.6 C (99.7 F)
B. Urinary output 20 mL/hr
C. Blood pressure 100/70 mm Hg
D. Serious drainage on abdominal dressing
Answer: B. Urinary output 20 mL/hr
50) A nurse in a long-term care facility is admitting a client who has dementia. Which of the
following actions should the nurse take to reduce the risk for client injury?
A. Place the bedside table at the foot of the bed
B. Keep the television on during the night
C. Assist the client to the toilet frequently
D. Raise the side rails up when the client is in bed
Answer: C. Assist the client to the toilet frequently
51) A certified IV nurse is providing education about peripherally inserted central catheters
(PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching?
A. “Use a vein in the middle of the lower arm to insert a PICC”- above elbow, below shoulder
B. “Flush a PICC using a 3-mililiter syringe”- 10 mL
C. “Informed consent is required prior to a PICC placement”
D. “Position the client's arm in adduction for PICC placement”
Answer: C. “Informed consent is required prior to a PICC placement”
52) A nurse is teaching self-administration of insulin glargine to a client who has type 1 diabetes
mellitus. Which of the following statements by the client indicates an understanding of the
teaching?
A. “I will take this insulin before meals”
B. “I will not mix this insulin with other types of insulin”
C. “I will rotate the injection sites between my arm and my thigh” (abdomen)
D. “I will shake the vial to mix the insulin” (you must roll)
Answer: B. “I will not mix this insulin with other types of insulin”
53) A nurse is caring for a client who is immunocompromised. Which of the following antiseptic
solutions should the nurse use to perform hand hygiene?
A. Isopropyl alcohol
B. Bleach
C. Chlorhexidine
D. Povidone-iodine
Answer: C. Chlorhexidine
54) A nurse is assessing a client in the emergency department. Which of the following actions
should the nurse take first? (exhibit)
A. Place the client on a cooling blanket
B. Obtain arterial blood gas levels
C. Elevate the head of the client's bed to 30
D. Administer an analgesic
Answer: B. Obtain arterial blood gas levels
55) A nurse is providing teaching to the parents of a newborn about newborn genetic screening.
Which of the following statements should the nurse include in the teaching?
A. “This test should be performed after your baby is 24 hours old”
B. “A nurse will draw blood from your baby's inner elbow”
C. “Your baby will be given 2 ounces of water to drink prior to the test”
D. “This test will be repeated when your baby is 2 months old”
Answer: A. “This test should be performed after your baby is 24 hours old”
56) A nurse is teaching a prenatal class about infection prevention at a community center. Which
of the following statements by a client indicates an understanding of the teaching?
A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted”
B. “I can clean my cat's litter box during my pregnancy”
C. “I should take antibiotics when I have a virus”
D. “I should wash my hands for 10 seconds with hot water after working in the garden”
Answer: A. “I can visit my nephew who has chickenpox 5 days after the sores have crusted”
57) A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks
the nurse about becoming a living kidney donor for her father. Which of the following conditions
in the child's medical history should the nurse identify as a contraindication to the procedure?
A. Primary glaucoma
B. Amputation
C. Hypertension
D. Osteoarthritis
Answer: C. Hypertension
58) A home health nurse is planning care for a client who has Alzheimer's disease. Which of the
following actions should the nurse include in the plan of care?
A. Replace the carpet with hardwood floors
B. Place locks at the tops of exterior doors
C. Wear clothing with zippers instead of buttons?
D. Encourage physical activity prior to bedtime
Answer: B. Place locks at the tops of exterior doors
59) A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive
personal (AP) telling the client, “If you don't eat, I'll put restraints on your wrists and feed you.”
The nurse should intervene and explain to the AP that this statement constitutes which of the
following torts?
A. Malpractice
B. Negligence
C. Assault
D. Battery
Answer: C. Assault
60) A nurse is reviewing a client's laboratory results prior to surgery. Which of the following
findings should the nurse report to the provider?
A. Bicarbonate 26 mEq/L -- 22-28 norm calcium 8-10
B. Chloride 100 mEq/L -- norm is 96-106
C. Potassium 3.8 mEq/L norm 3.5-5
D. Sodium 160 mEq/L - norm is 135-145
Answer: D. Sodium 160 mEq/L - norm is 135-145
61) A charge nurse is evaluating a newly licensed nurse's understanding of advance directives.
Which of the following statements by the newly licensed nurse indicates an understanding of
advance directives?
A. “I'll refer clients who do not have advance directives for legal assistance”
B. “I have to witness a client's signature on his advance directives”
C. “I have to document whether or not a client has prepared his advance directives”
D. “I'll encourage clients to follow their provider's wishes for end-of-life care”
Answer: C. “I have to document whether or not a client has prepared his advance directives”
62) A clinic nurse is assessing an 8-year-old child during an annual physical examination. Which
of the following findings indicates the need for intervention by the nurse?
A. The client eats at least one snack daily
B. The client's height has increased by 6.35 cm (2.5 in) 2 inches/year
C. The client's weight has increased by 0.9 kg (2 lb)- should gain at least 4-6 lbs (OR)
D. The client drinks 3 cups of 1% milk per day
Answer: C. The client's weight has increased by 0.9 kg (2 lb)- should gain at least 4-6 lbs
(OR)
D. The client drinks 3 cups of 1% milk per day
63) A nurse is assessing a client who presents to the labor and delivery unit reporting the onset of
contractions. Which of the following findings should the nurse identify as a manifestation of
false labor?
A. Presence of a bloody show
B. Intermittent, painless contractions
C. Slow change in dilation and effacement
D. Contraction intensity increased by ambulation
Answer: B. Intermittent, painless contractions
64) A nurse is caring for a client who has a urinary tract infection and has been taking cefaclor.
Which of the following serum laboratory results indicates the medication is effective?
A. Creatinine 2.3 mg/dL
B. BUN 32 mg/dL
C. Eosinophils 3.9%
D. WBC 9,200 mm3
Answer: D. WBC 9,200 mm3
65) A charge nurse is mentoring a newly licensed nurse. Which of the following actions by the
newly licensed nurse indicates the need for intervention by the charge nurse?
A. Uses an IV infusion pump to administer total parenteral nutrition to a client
B. Inserts an NG tube for a client using clean technique
C. Crushes an SL tablet to administer into a client's feeding tube
D. Stabilizes a client's indwelling urinary catheter with the nondominated hand prior to inflation
of the balloon
Answer: C. Crushes an SL tablet to administer into a client's feeding tube
66) A nurse is reviewing laboratory results for a client who has a heart failure and notes a serum
potassium level of 5.2 mEq/L. Which of the following medications should the nurse withhold?
A. Furosemide
B. Spironolactone
C. Atorvastatin
D. Metoprolol
Answer: B. Spironolactone
67) A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce
the need for pharmacological interventions. Which of the following information should the nurse
include in the teaching?
A. “Biofeedback stimulates certain pressure points to relax muscles”
B. “Biofeedback improves energy flow through soft tissue manipulation to increase circulation”
C. “Biofeedback requires concentration to control physiological responses”
D. “Biofeedback uses herbs to reduce inflammation”
Answer: C. “Biofeedback requires concentration to control physiological responses”
68) A nurse is teaching the parents of a child who has a new onset of seizures and is to undergo
an electroencephalogram (EEG) about the procedure. Which of the following instructions should
the nurse include in teaching?
A. “Give the child acetaminophen for pain following the procedure”
B. “Ensure the child's hair is clean and without conditioner before the procedure”
C. “Keep the child out of the sun for 4 hr following the procedure”
D. “Make the child NPO before the procedure”
Answer: B. “Ensure the child's hair is clean and without conditioner before the procedure”
69) A school nurse is teaching a parent about absence seizures. Which of the following
information should the nurse include?
A. “This type of seizure can be mistaken for daydreaming”
B. “This type of seizure lasts 30 to 60 seconds”
C. “The child usually has an aura prior to onset”
D. “This type of seizure has a gradual onset”
Answer: A. “This type of seizure can be mistaken for daydreaming”
70) A nurse in an outpatient mental health facility is providing teaching to a group of
adolescents. Which of the following statements by a client indicates an understanding of the
teaching?
A. “I will limit my alcohol use to one drink daily while taking disulfiram” X not within 12 hours
B. “I will take my lithium on an empty stomach” X with food
C. “I will take the sustained-release methylphenidate every morning”
D. “I will avoid foods containing tyramine while taking fluoxetine” SSRI
Answer: C. “I will take the sustained-release methylphenidate every morning”
71) A nurse is caring for a client who is 4 days postpartum. Which of the following assessment
findings should the nurse expect? (Select all that apply)
A. Foul perineal odor
B. Lochia serosa
C. Postpartum... if blues, then correct (MAYBE)
D. Fundus displaced to the right
E. Fundus 4 cm (1.6 cm) below the umbilicus decends 1cm per day
Answer: B. Lochia serosa
C. Postpartum... if blues, then correct (MAYBE)
E. Fundus 4 cm (1.6 cm) below the umbilicus decends 1cm per day
72) A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse
should instruct the client about which of the following medications
A. Vitamin K
B. Ranitidine
C. Metoclopramide
D. Vitamin B12- lifelong
Answer: D. Vitamin B12- lifelong
73) A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
A. Hold hand flat to perform percussions on the child- cup shape
B. Perform the procedure twice a day (maybe)
C. Administer a bronchodilator after the procedure
D. Perform the procedure prior to meals * best time
Answer: B. Perform the procedure twice a day (maybe)
D. Perform the procedure prior to meals * best time
74) A nurse at a community health clinic is planning care for an adolescent who recently learned
that she is pregnant and is concerned about her ability to afford and care for her baby. Which of
the following actions should the nurse take?
A. Contact the adolescent's parent for assistance
B. Advise the adolescent to place the newborn for adoption
C. Assist the adolescent in applying for Medicaid
D. Refer the adolescent to a local mental health clinic
Answer: C. Assist the adolescent in applying for Medicaid
75) A nurse is admitting an older adult client who is transferring from another facility. The nurse
notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the
following actions should the nurse take to address suspicions of elder abuse?
A. Contact the family regarding the client's condition
B. Notify risk management
C. Privately interview the client about her condition
D. Inform the transferring agency of the client's condition
Answer: C. Privately interview the client about her condition
76) A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis
following a cerebrovascular accident. Which of the following actions by the nurse best promotes
communications among staff caring for the client?
A. Noting changes in the treatment plan in the client's medical record
B. Recording the client's progress in the nurses' notes
C. Posting swallowing precautions at the head of the client's bed
D. Having interdisciplinary team meetings for the client on a regular basis
Answer: D. Having interdisciplinary team meetings for the client on a regular basis
77) A nurse is caring for a client who has an indwelling urinary catheter. Which of the following
actions should the nurse take to provide catheter care?
A. Empty the collected urine once every 24 hr
B. Hang the drainage bag on a bed rail
C. Provide perineal hygiene after defecation
D. Change the indwelling catheter every 8 hr
Answer: C. Provide perineal hygiene after defecation
78) A nurse is assisting a client who has acute glomerulonephritis to choose menu items for
breakfast. Which of the following food choices should the nurse recommend?
A. Eggs- protein
B. Banana- proteinX
C. Smoked salmon- protein X
D. Bagel
Answer: D. Bagel
79) A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her
position at the clinic. Which of the following tasks should the nurse identify as tertiary
prevention?
A. Helping clients understand health screenings covered by their insurance plans
B. Using an electronic messaging system to remind clients when to take medications
C. Educating clients about contraindications to specific immunizations
D. Providing clients with information about the benefits of exercise
Answer: B. Using an electronic messaging system to remind clients when to take medications
80) A nurse in a long-term care facility is managing the care of an older adult client who has
difficulty swallowing and occasional choking during meals. The nurse should initiating a referral
to which of the following members of the interprofessional care team?
A. Occupational therapist
B. Respiratory therapist
C. Social worker
D. Speech-language pathologist
Answer: D. Speech-language pathologist
81) A nurse is performing a preoperative assessment for a client who reports having an allergy to
several goods. Which of the following food allergies indicates a risk factor for a latex allergy?
A. Peanuts
B. Eggs
C. Bananas
D. Shrimp
Answer: C. Bananas
82) A nurse is planning care for a client who is scheduled to receive a peripherally inserted
central catheter in the arm. Which of the following interventions is appropriate for the nurse to
include in the plan care?
A. Measure the arm circumference above the insertion site daily
B. Schedule an MRI post procedure to verify placement (Xray) X
C. Administer sedation for the procedure X - local anesthetic
D. Use gauze to secure an arm board to involved extremity- used for midline
Answer: A. Measure the arm circumference above the insertion site daily
83) A nurse is caring for a group of clients. Which of the following wounds should the nurse
expect to heal by primary intention? PRIMARY FASTEST TYPE ON ITS OWN, SECONDARY
REQUIRES GRANULATION TISSUES AND CREATES SCAR TISSUES, AND TETRIARY
IS DELAYED WOUND CLOSURE.
A. Approximated surgical incision
B. Infected laceration- TERTIARY
C. Stage II pressure ulcer -SECONDARY
D. Partial-thickness burn- SECONDARY
Answer: A. Approximated surgical incision
84) A nurse is performing a change-of-shift assessment. Which of the following clients has the
priority finding?
A. A client who has a first-degree heart block and a heart rate of 62/min
B. A client who is 2 hr post cast placement and has a 2+ pitting edema and pallor
C. A client who has pneumonia with a productive cough and a fever of 38.8 C (101.8 F)
D. A client who has type 2 diabetes mellitus and a blood glucose of 250 mg/Dl
Answer: B. A client who is 2 hr post cast placement and has a 2+ pitting edema and pallor
85) A nurse on a medical-surgical unit delegating tasks to an assistive personnel (AP). Which of
the following client care tasks is within the scope of practice for the AP?
A. Interpreting blood glucose values
B. Performing postmortem care
C. Explaining the steps for a 24-hr urine collection
D. Assisting with low-carbohydrate diet selections
Answer: B. Performing postmortem care
86) A nurse in a mental health clinic receives a request from a client who is undergoing
psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should
the nurse make?
A. “We can provide a copy of your records, but the therapist's notes aren't included”
B. “I don't think you will benefit from reviewing your therapist's notes right now”
C. “Why are you interested in seeing your therapist's notes?”
D. “Are you not happy with your treatment?”
Answer: A. “We can provide a copy of your records, but the therapist's notes aren't included”
87) A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy.
Which of the following statements indicates an understanding of the teaching?
A. “I will wipe my nose instead of blowing it”
B. “I will remove my shoes when I'm inside my house”
C. “I will floss between my teeth every time I brush”
D. “I will use an enema to manage my constipation”
Answer: A. “I will wipe my nose instead of blowing it”
88) A home care nurse is making follow-up visit with a client has COPD and is using a
compressed oxygen system in his home. Which of the following actions should the nurse take?
A. Store the oxygen tank wrench in a locked cabinet
B. Have the client store smaller tanks under his bed
C. Ensure that the client checks the gauge weekly
D. Place the oxygen tank away from curtains or drapes
Answer: D. Place the oxygen tank away from curtains or drapes
89) A nurse is conducting health promotion education regarding contraindications to combination
oral contraceptive use to a group of women. Which of the following conditions should the nurse
include in the teaching?
A. Renal calculi
B. Fibrocystic breast disease?
C. Fibromyalgia
D. Hypertension
Answer: D. Hypertension
90) A nurse is caring for a client following a thyroidectomy. For which of the following
complications should the nurse assess the client?
A. Hypokalemia
B. Muscular depression
C. Laryngeal stridor
D. Hyperglycemia
Answer: C. Laryngeal stridor
91) A nurse is teaching a client who is to start a new prescription for carbidopa-levodopa. Which
of the following instructions should the nurse include?
A. “Take with the protein snack” - limit protein
B. “Report dark-colored urine”- this normal
C. “Monitor for hyperglycemia”
D. “Change positions slowly”
Answer: D. “Change positions slowly”
92) A nurse is caring for a school-age child who is postoperative and received morphine via IV
bolus for pain 10 min ago. Which of the following findings is the nurse's priority?
A. Constipation
B. Sedation
C. Euphoria
D. Bradypnea
Answer: D. Bradypnea
93) A nurse is teaching the parents of a 6-year-old child who has sickle cell anemia about
managing the disease. The nurse should emphasize the importance of which of the following
factors to prevent a sickle cell crisis?
A. Adequate hydration
B. Calorie restriction
C. Increased iron intake
D. A low-protein diet
Answer: A. Adequate hydration
94) A community health nurse is working with a group of clients. The nurse practices the ethical
principle of distributive justice by performing which of the following tasks?
A. Accepting the decision of an older adult client to live alone in her home
B. Ensuring that a client who is homeless receives preventive medical care-be fair
C. Keeping a promise to visit with a client who is housebound after the delivery of care
D. Being honest with the parents of a child about the need to report suspected abuse
Answer: B. Ensuring that a client who is homeless receives preventive medical care-be fair
95) A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and
has had recent weight loss. Which of the following is the priority admission data for the nurse to
obtain?
A. Changes in appetite
B. Prescribed medications
C. Swallowing ability
D. Daily fluid intake
Answer: C. Swallowing ability
96) A nurse is caring for a client who has a new prescription for piperacillin/tazobactum 3.75 g
intermittent IV bolus Q6H to infuse over 30 min. Available is piperacillin/tazobactum 3.75 g in
50 mL 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many
mL/hr?
A. 100 mL/hr.
B. 200 mL/hr.
C. 400 mL/hr.
D. 600 mL/hr.
Answer: A. 100 mL/hr.
97) A nurse is assessing a client who has acute angle-closure glaucoma. Which of the following
findings should the nurse expect?
A. Increased light perception
B. Reddened cornea
C. Severe periocular pain
D. Gray cast sclera
Answer: C. Severe periocular pain
98) A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last
5 days. The client's laboratory values this morning are the following: WBC 10,000/mm 3, RBC
5.2 million/mm3, platelets 250,000mm3, BUN 32 mg/dL, and serum creatinine 2.1 mg/dL. The
nurse should report these findings to which of the following members of the interdisciplinary
team? And
A. Dietitian
B. Infection control nurse
C. Nephrologist
D. Cardiologist
Answer: C. Nephrologist
99) A nurse is caring for a toddler who has retinoblastoma. Which of the following 100 findings
should the nurse expect?
A. Hyphema
B. Opacity of the lens
C. Nystagmus
D. White eye reflex
Answer: D. White eye reflex
100) A client who does not speak the same language as the nurse. The nurse is communicating
with the client using an interpreter. Which of the following actions should the nurse take?
A. Use gestures to convey meaning
B. Speak directly to the client
C. Pause in the middle of sentences
D. Speak slowly when talking to the interpreter
Answer: B. Speak directly to the client
101) A nurse is providing teaching about exercise to a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I can continue to do exercises that require the supine position” X
B. “I should check my pulse rate once every hour while exercising”
C. “I should increase my exercise level to prepare for labor” X
D. “I should drink 16 to 24 ounces of water after I exercise”
Answer: D. “I should drink 16 to 24 ounces of water after I exercise”
102) A nurse is providing discharge teaching to the parents of toddler who has cystic fibrosis.
What should nurse include?
A. “Use a nebulizer to administer a bronchodilator following airway clearance therapy”
B. “Restrict intake of foods that contain gluten”
C. “Perform chest percussion and postural drainage at least twice daily”
D. “Administer pancreatic enzymes on an empty stomach”- X with meal
Answer: C. “Perform chest percussion and postural drainage at least twice daily”
103) A nurse is developing Plan of care for client who has preeclapsia and is to receive
magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse
include in the plan?
A. Monitor the FHR via Doppler every 30 min
B. Restrict the client's total fluid intake to 250 mL/hr
C. Give the client protamine if signs of magnesium sulfate toxicity occur
D. Measure the client's urine output every hour
Answer: D. Measure the client's urine output every hour
104) A nurse is planning discharge teaching for a client who is to start a new .prescription for
metoprolol. For which of the following should the nurse instruct the client to monitor and report
to the provider?
A. Tinnitus
B. Polyuria
C. Hyperglycemia
D. Bradycardia
Answer: D. Bradycardia
105) A nurse is providing teaching to the parents of a newborn who has been circumcised. Which
of the following instructions should the nurse include in the teaching?
A. “Remove yellow exudate around the penis”
B. “Wrap sterile gauze around the penis if bleeding occurs”
C. “Use soap to cleanse the site”
D. “Apply petroleum jelly to the glans with diaper changes”
Answer: D. “Apply petroleum jelly to the glans with diaper changes”
106) Care plan for bucks traction and is scheduled for surgery for a fractured femur of the right
leg. Which of the following interventions should the nurse delegate to an assistive personnel?
A. Remind the client to use the incentive spirometer
B. Ask the client to describe her pain
C. Observe the position of the suspended weight
D. Check the client's pedal pulse on the right leg
Answer: A. Remind the client to use the incentive spirometer
107) A nurse is assessing the growth and development of a 3-year-old child. Which of the
following questions should the nurse ask the parent to determine if the child exhibiting typical
developmental expectations?
A. “Can your child catch and throw a small ball?”
B. “Can your child ride a tricycle?”
C. “Can your child name give colors?”
D. “Can your child draw a stick figure?”
Answer: B. “Can your child ride a tricycle?”
108) A nurse is caring for a newborn whose mother was taking methadone during her pregnancy.
Which of the following findings indicates the newborn is experiencing withdrawal?
A. Bradycardia
B. Acrocyanosis
C. Hypertonicity
D. Bulging fontanels
Answer: C. Hypertonicity
109) A charge nurse is admitting four clients to an acute care unit. Which of the following clients
should the nurse place near the nurses' station?
A. A client who is on fluid restriction
B. A client who is in Buck's traction
C. A client who has orthostatic hypotension
D. A client who has an open wound
Answer: C. A client who has orthostatic hypotension
110) A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant
is sitting on my chest.” The client is weak and unable to walk. After the nurse initiates chest pain
protocol, which of the following is the priority diagnostic test?
A. Serum potassium
B. 12-lead ECG
C. PT and INR
D. Chest x-ray
Answer: B. 12-lead ECG
111) A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an external disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A. A client who has COPD and a respiratory rate of 44/min
B. A client who has cancer with a sealed implant for radiation therapy
C. A client who is receiving heparin for deep-vein thrombosis
D. A client who is 1 day postoperative following a vertebroplasty
Answer: D. A client who is 1 day postoperative following a vertebroplasty
112) A home health nurse is caring for a child who has Lyme disease. Which of the following is
an appropriate action for the nurse to take?
A. Assess for skin necrosis
B. Educate the family to avoid sharing personal belongings
C. Ensure the state health department has been notified
D. Administer antitoxin
Answer: C. Ensure the state health department has been notified
113) A nurse is reviewing annual educational requirements for fire safety. Identify the sequence
the nurse should use when operating a fire estinguisher.
A. Point the hose at the base of the fire
B. Sweep the extinguisher from side to side
C. Squeeze the handles together
D. Unlock the handle by pulling on the pin
Answer: D, A, C, B
114) A nurse is caring for a client who has a nasogastric tube. Which of the following actions
should the nurse take to verify placement prior to each feeding.
A. Auscultate air insertion into the tube
B. Test the bilirubin level of gastric contents
C. Palpate the abdomen for tube placement
D. Test the pH of gastric contents
Answer: D. Test the pH of gastric contents
115) A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks gestation.
Which of the following actions should the nurse take?
A. performan leopold maneuvers prior to auscultating the fetal heart rate
B. position the ultrasound stethoscope above the symphysis pubis to assess fetal heart rate
C. measure the fundal height to determine the placement of the ultrasound stethescope
D. place the client in a side lying position prior to assessing the fetal heart rate
Answer: B. position the ultrasound stethoscope above the symphysis pubis to assess fetal heart
rate
116) While performing a routine assessment, a nurse notices fraying on the electrical cord of a
client CPM device. Which of the following actions should the nurse take first.
A. ensure the device inspection sticker is current
B. report the defect to the equipment maintenance staff
C. remove the device from the room
D. initiate a requisition for a replacement CPM device
Answer: C. remove the device from the room
117) A nurse is caring for a newly admitted client who has bacterial meningitis. Which following
actions should the nurse take?
A. Implement seizure precautions
B. Monitor the client for hypoglycemia
C. Perform range-of-motion exercises once per shift
D. Place the client in high-Fowler's position
Answer: A. Implement seizure precautions
118) A nurse is providing teaching to a client about the adverse effects sertraline. Which of the
following adverse effects should the nurse include?
A. Excessive sweating
B. Increased urinary frequency
C. Dry cough
D. Metallic taste in mouth
Answer: A. Excessive sweating
119) A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
A. Contractions lasting 80 seconds-too long?
B. Depending on frequency*
C. FHR baseline 170/min normal 110-160 maybe this! * Early decelerations in the FHR
D. Temperature 37.4 C (99.3 F)
Answer: C. FHR baseline 170/min normal 110-160 maybe this! * Early decelerations in the
FHR
120)
A nurse is preparing a client to undergo cardiac cauterization. Which of the following tasks
should the nurse perform prior to the procedure?
A. Draw blood specimens for culture and sensitivity
B. Administer nitroglycerin 0.4 mg SL 30 min before the procedure
C. Transport the client to radiology for a CT scan
D. Obtain a CBC with differential?
Answer: D. Obtain a CBC with differential?
121) A nurse is developing a plan of care for a client who has schizophrenia and is experiencing
auditory hallucinations. Which of the followings actions should the nurse include in the plan?
A. Ask the client directly what he is hearing
B. Encourage the client to lie down in a quiet room
C. Avoid eye contact with the client
D. Refer to the hallucinations as if they are real
Answer: A. Ask the client directly what he is hearing
122) A nurse is reviewing the preadmission laboratory test results of a client who is to undergo
hip arthroplasty in 2 days. Which of the following results should the nurse report to the provider?
A. Sodium 142
B. Potassium 3.3
C. Blood Glucose 80 mg/dl
D. pt 11.5 seconds
Answer: B. Potassium 3.3
123) A nurse is in the emergency department is caring for client who has a new diagnosis of
acute myocardial infarction and is being treated with a thrombolytic, aspirin, and IV heparin.
Which of the following findings should indicate to the nurse that the client is experiencing a
satisfactory response to these interventions?
A. The client's stool is guaiac positive
B. S3 heart sounds are present
C. The client's aPPT is two times the control
D. Q wave is noted on the cardiac monitor tracing
Answer: C. The client's aPPT is two times the control
124) A nurse observes a client on the psychiatric unit muttering and standing near a window. The
client states, “The voices are telling me to jump.” Which of the following is an appropriate
response by the nurse?
A. “I understand the voices are frightening you, but I do not hear any voices”
B. “Do you recognize the voices as belonging to anyone you know?”
C. “You shouldn't be afraid when you think the voices are telling you to hurt yourself”
D. “That can't be true. The only voices in this room are yours and mine”
Answer: A. “I understand the voices are frightening you, but I do not hear any voices”
125) A home health nurse is visiting a client whose partner states that she is overwhelmed by
caring for him. When suggesting respite care, which of the following explanation should the
nurse provide?
A. “Respite care includes volunteers who will perform household tasks”
B. “Respite care provides clinicians to work with you in caring for your husband”
C. “Respite care offers financial resources to help care for your husband”
D. “Respite care allows for time away from caring for your husband”
Answer: D. “Respite care allows for time away from caring for your husband”
126) A nurse working in the postpartum unit is reviewing a client's new prescription for
methylergonovine. The nurse should recognize that which of the world following is a
contraindication for this medication?
A. hypertension
B. confusion
C. chlamydia
D. polyuria
Answer: A. hypertension
127) A nurse is caring for a client who is in labor and has received an epidural. Which following
actions should the nurse take?
A. Decrease the maintenance infusion rate of IV fluid X more hypotension
B. Have protamine sulfate available at the bedside- X Heparin
C. Reposition the client side-to-side each hour
D. Monitor the client hypertension X hypotension
Answer: C. Reposition the client side-to-side each hour
128) A charge nurse observes a coworker who has impaired coordination and is drowsy while
performing routine tasks. Which of the following actions should the nurse take first?
A. document the observations about the nurse's behavior
B. report the nurses' behavior to the nurse manager
C. reassign the nurse's client-care duties to another nurse
D. obtain support from another nurse before filing report
Answer: B. report the nurses' behavior to the nurse manager
129) A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A. A client who has sinus arrhythmia and is receiving cardiac monitoring
B. A client who has epidural analgesia and weakness in the lower extremities
C. A client who has a hip fracture and a new onset of tachypnea
D. A client who has diabetes mellitus and hemoglobin A1C of 6.8%
Answer: C. A client who has a hip fracture and a new onset of tachypnea
130) A nursed is caring for a client who has implanted venous access port. Which of the
following should the nurse use to access the port?
A. A noncoring needle-Huber point needle
B. A butterfly needle
C. An angiocatheter
D. A 25-gauge needle
Answer: A. A noncoring needle-Huber point needle
131) A nurse is receiving change-of- shift report for four clients. Which of the following clients
should the nurse assess first?
A. A client who has leukemia and a platelet level of 95,000/mm3 (150-400)
B. A client who has hepatitis B and total bilirubin of 1.2 mg/dL (0.1-1.0)
C. A client who has diabetes mellitus and a HbA1c of 5.2%
D. A client who received IV furosemide and has a serum potassium of 3.6 mEq/L
Answer: A. A client who has leukemia and a platelet level of 95,000/mm3 (150-400)
132) A nurse is admitting a client who has a history of atrial fibrillation. The nurse should
recognize the atrial fibrillation places the client at risk for which conditions?
A. cardiac tamponade
B. pulmonary emboli
C. hemothorax
D. widened pulse pressure
Answer: B. pulmonary emboli
133) A nurse is teaching about home care to the parents of an infant who has a tracheostomy.
Which of the following instruction should the nurse include in the teaching?
A. set the suction machine to 60 mm Hg
B. advance the suction catheter just past the point of resistance
C. instill 2 ml of saline in the tracheostomy prior suctioning
D. apply suction for 30 seconds after advancing the catheter
Answer: A. set the suction machine to 60 mm Hg
134) A nurse is caring for a client who has given informed consent for electroconvulsive therapy.
Just before the procedure, the client tells the nurse she is considering not going forward with the
treatment. Which of the following statements by the nurse is appropriate?
A. “You don't have to go through with the treatment”
B. “It's okay to be nervous before this treatment”
C. “Most people who have this procedure feel better following the treatment”
D. “Your doctor wouldn't have ordered this treatment unless it was necessary”
Answer: A. “You don't have to go through with the treatment”
135) A home health nurse is providing teaching about home safety to an older adult client. Which
of the following statements by the client indications that the teaching has been effective?
A. I put on socks when getting out of bed at night
B. I have marked the steps with black tape
C. I have grab bars next to my tub
D. I have played throw rugs in the hallways
Answer: C. I have grab bars next to my tub
136) A nurse is providing teaching to a client who is undergoing radiation therapy and has
stomatitis. Which of the following responses by the client indicate understanding of the
teaching?
A. I should gargle with an alcohol-based mouthwash
B. I should use a soft-bristle toothbrush to clean my teeth after meals
C. I should limit my intake of dairy products to prevent nausea
D. I should moisten my lips with lemon-glycerin swabs
Answer: B. I should use a soft-bristle toothbrush to clean my teeth after meals
137) A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a
client. Which of the following actions should the nurse take first?
A. Check the compatibility of cefazolin with the client's existing IV fluids
B. Obtain the reconstituted antibiotic from pharmacy
C. Review the client's allergy history
D. Assess the IV for patency
Answer: C. Review the client's allergy history
138) A nurse is caring for a child who reports migraine headaches for the past 4 months. Which
of the following actions should the nurse take first?
A. review the child's electronic pain diary
B. set up an appointment with the school
C. Refer the family to a chronic pain support group
D. Request a change in medication from the provider
Answer: A. review the child's electronic pain diary
139) A nurse is providing teaching to a client who is receiving misoprostal for induction of labor.
Which of the following information should the nurse include in the teaching?
A. You will have intermittent fetal monitoring while you receive the medication” (intermittent)
B. “You will lie on your side for 30 minutes after the medication is inserted” (yes lie down for 30
minutes but only when aborting)
C. “You will have a urinary catheter inserted prior to the placement of the medication” (d. you
should empty your bladder prior to insertion)-placement is for abortion, you get a cath when you
are under epidural
D. You will have oxytocin initiated within 3 hours of administration of the medication
Answer: B. “You will lie on your side for 30 minutes after the medication is inserted” (yes lie
down for 30 minutes but only when aborting)
D. You will have oxytocin initiated within 3 hours of administration of the medication
140) A nurse is assessing the peripheral catheter insertion site of a client who is receiving an
infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse
should document the finding as which of the following complications?
A. Phlebitis
B. Extravasation
C. Circulatory overloadd
D. Infiltration
Answer: A. Phlebitis
141) A nurse is caring for a client who is in active labor and notes the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause for fetal bradycardia.
A. maternal fever
B. fetal anemia
C. maternal hypotension
D. chorioamnioitis
Answer: C. maternal hypotension
142) A nurse is preparing to administer an IV medication to a client and accidentally punctures
the IV bag causing the medication to leak on the counter. Which of the following medications
requires the nurse to follow facility procedures in the safe handling of a biohazards material
spill?
A. Doxorubicin hydrochloride-chemo drug it is hazardous
B. Ampicillin sodium
C. Metronidazole
D. Phenytoin
Answer: A. Doxorubicin hydrochloride-chemo drug it is hazardous
143) A nurse is reviewing the medication administration record of a client who has rheumatoid
arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following
medication places the client at risk for delayed wound healing?
A. Omeprazole 0
B. Morphine
C. Prednisone (steroid)
D. Digoxin
Answer: C. Prednisone (steroid)
144) A nurse is an emergency department is reviewing the medical record for a client who is
having an acute myocardial infarction. Which of the following findings places the client at risk if
he receives alteplase?
A. hip arthroplasty 1 week ago
B. family history of malignant hypertension
C. Chronic obstructive pulmonary disease
D. Acute renal failure 6 months
Answer: A. hip arthroplasty 1 week ago
145) A nurse is caring for a client who has permanent dropping on the left side off the face
following a cerebrovascular accident (CVA). The client refuses to see any family members.
Which of the following interventions will be assist the client to adapt to his body image change?
A. Establish short-term goals that will enable the client to look in the mirror (OR)
B. Offer contact information for CVA recovery support groups
C. Initiate a family conference to address the issue
D. Educate the client about short- and long-term effects of a CVA
Answer: A. Establish short-term goals that will enable the client to look in the mirror (OR)
D. Educate the client about short- and long-term effects of a CVA
146) A nurse is teaching the parent of an infant who who's positional plagiocephaly. Which of the
following statements by the parent indicates an understanding of the teaching?
A. “I should avoid tummy time when my baby is wearing the helmet”
B. “I should place my baby in the left side-lying position at night when using the helmet”
C. “I should keep the helmet on my baby for 23 hours a day” (18-22 hours a day)
D. “I should expect to have my baby wear this helmet for 10 months”
Answer: C. “I should keep the helmet on my baby for 23 hours a day” (18-22 hours a day)
147) A nursed manager is updating protools for the use of belt restraints. Which of the following
guidelines should the nurse include?
A. Remove the client's restraints every 4 hr- its every 2 hours
B. Document the client's condition every 15 min
C. Attach the restraint to the bed's side rails
D. Request a PRN restraint prescription for clients who are aggressive X
Answer: B. Document the client's condition every 15 min
148) A nurse is assessing a client who has fine hair, exophthalmos, ad reports intolerance to heat.
Which of the following endocrine disorders is associated with these findings?
A. Hyperparathyroidism
B. Hyperthyroidism
C. Hypoparathyroidism
D. Hypothyroidism
Answer: B. Hyperthyroidism
149) A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nursed include in the teaching?
A. Leaving a nasogastric tube clamped after administering oral medication
B. Documenting communication with a provider in the progress notes of the client's medical
record
C. Administering potassium via IV bolus
D. Placing a yellow bracelet on a client who is at risk for falls
Answer: C. Administering potassium via IV bolus
150) A nurse is an acute care facility is caring for four clients. Which of the following clients
should the nurse refer for speech therapy?
A. A client who has dysphagia following a stroke
B. A client who has sensorineural hearing loss
C. An older adult client who has stage III Alzheimer's disease
D. A client who is postoperative following a tonsillectomy and adenoidectomy
Answer: A. A client who has dysphagia following a stroke
