CMA Flashcards
1
Q
A nurse is monitoring an older adult client who has an exacerba-
tion of chronic lymphocytic leukemia. The nurse notes petechiae
on the client’s skin. Which of the following actions should the nurse
take?
A. Determine the client’s blood type.
B. Implement airborne precautions. C. Avoid administering IV pain
medication.
D. Institute bleeding precautions
A
D. Initiate bleeding precautions
2
Q
A nurse is teaching a client who has diabetes mellitus about
home management of mild hypoglycemia. Which of the following
statements should the nurse include in the teaching?
A. “Eat a large snack of carbohydrates and protein after treating
hypoglycemia.
B. “Treat the symptoms of hypoglycemia by consuming 45 grams
of carbohydrates.”
C. “Drink 12 ounces of milk to treat the symptoms of hypo-
glycemia,”
D. “Retest your blood glucose 15 minutes after treatment of a
hypoglycemic episode.”
A
D. Retest your blood glucose 15 minuets after treatment of a
hypoglycemic episode
3
Q
A nurse on a medical-surgical unit is preparing to administer
amoxicillin PO when the client refuses the medication. Which of
the following actions should the nurse take?
A. Record the client’s refusal in the electronic health record.
B. Leave the medication at the client’s bedside for them to take
later.
C. Schedule the client’s medication for a later time.
D. Prepare the client’s medication intravenously instead of PO
A
A. Record the client’s refusal in the electronic health record
4
Q
A nurse is teaching a client who has HIV about infection pre-
vention. The nurse should instruct the client to avoid contact with
which of the following items?
A. Soiled cat litter
B. Scrambled eggs
C. Pasteurized milk
D. Electric razor
A
A. Soiled cat litter
5
Q
A nurse is caring for a postoperative client who has an indwelling
urinary catheter. Which of the following actions should the nurse
take when removing the catheter?
A. Rapidly deflate the balloon before removing the tubing.
B. Place the client in the dorsal recumbent position,
C. Reinsert the catheter if the client does not void within 1 hr.
D. Obtain a sterile urine specimen after catheter removal.
A
B. Place the client in the dorsal recumbent position
Place the client laying on their back for easier access to the
catheter and ensures client comfort during the removal process
6
Q
A nurse manager is providing an in-service to a group of newly
licensed nurses about the use of personal protective equipment.
Which of the following statements by a newly licensed nurse
indicates an understanding of the teaching?
A. “Sterile gloves are required when administering an IM injec-
tion.”
B. “I should wear a gown to remove linens from a client’s bed.”
C. “I should wear goggles when irrigating a wound.”
D. “I should use both hands to recap a needle.”
A
C. I should wear goggles when irrigating a wound
7
Q
A nurse is caring for a client immediately following a cardiac
catheterization through the right femoral artery. Which of the fol-
lowing actions should the nurse take?
A. Monitor the client’s vital signs once every hour.
B. Restrict the client’s fluid intake. C. Elevate the head of the
client’s bed to a 45° angle.
D. Instruct the client not to bend the affected leg.
A
D. Instruct the client not to bed the affected leg
8
Q
A nurse is providing dietary instructions to a client who has
cardiovascular disease. The nurse should identify that which of
following statements by the client indicates an understanding of
the teaching?
A. “I will increase my intake of canned vegetables.”
B. “I will limit my portions of meat to 8 ounces.”
C. “I will drink whole milk with my cereal.”
D. “I will use canola oil when making salad dressing.”
A
D. I will use canola oil when making salad dressing
9
Q
A nurse suspects that a client who has diabetes mellitus is experi-
encing hypoglycemia. Which of the following assessment findings
supports this suspicion?
A. Kussmaul respirations
B. Cool, clammy skin
C. Acetone breath
D. Increased urine output
A
B.Cool, clammy skin
10
Q
A nurse is assessing a client who has skeletal traction for a femoral
fracture. The nurse notes that the weights are resting on the floor.
Which of the following actions should the nurse take?
A. Increase the elevation of the affected extremity.
B. Remove one of the weights.
C. Tie knots in the ropes near the pulleys to shorten them.
D. Pull the client up in bed.
A
A. Increase the elevation of the affected extremity
11
Q
A nurse is caring for a client who is experiencing an acute asthma
attack. Which of the following should the nurse identify as a con-
tributing factor to the client’s manifestations?
A. Inability to exhale retained carbon dioxide
B. Acute loss of alveolar elasticity C. Suppressed bronchiolar
inflammatory response
D. Decreased responsiveness of airways to allergens
A
A. Inability to exhale retained carbon dioxide
12
Q
A nurse is caring for a client who has a sealed radiation implant.
Which of the following actions should the nurse take?
A. Give the dosimeter badge to the oncoming nurse at the end of
the shift.
B. Apply a second pair of gloves before touching the client’s
implant if it dislodges
C. Limit family member visits to 30 min per day.
D. Remove soiled linens from the room after each change.
A
C. Limit family members visits to 30 min per day
13
Q
A nurse is providing discharge teaching to a client who has os-
teomyelitis in their left leg. Which of the following findings should
the nurse identify as requiring a referral?
A. The client has a WBC count of 20,000/mm3 (5,000 to
10,000/mm3).
B. The client has type 2 diabetes mellitus and an HbA1c of 6%
(4% to 5.9% nondiabetic) (less than 7% good diabetic control).
C. The client has a prescription for furosemide.
D. The client has a prescription for long-term IV antibiotic therapy.
A
A. The client has a WBC count of 20,000/ mm3
14
Q
A nurse is providing teaching to a client and his partner about per-
forming peritoneal dialysis at home. When discussing peritonitis,
which of the following manifestations should the nurse identify as
the earliest indication of this complication?
A. Increased heart rate
B. Fever
C. Generalized abdominal pain
D. Cloudy effluent
A
D. Cloudy effluent
15
Q
A nurse is caring for a client who has rheumatoid arthritis and
reports stiffness in their hands. After reviewing the client’s medical
record, which of the following actions should the nurse take?
A. Plan to open packages for the client when they show difficulty.
B. Inform the client to limit the use of nutritional supplements.
C. Provide paraffin treatment for the client.
D. Encourage the client to limit hand and finger exercises.
A
C. Provide paraffin treatment for the client
16
Q
A nurse is planning care for a client who is receiving heparin IV to
treat a pulmonary embolism. Which of the following medications
should the nurse plan to have available?
A. Protamine sulfate
B. Vitamin K
C. Flumazenil
D. Acetylcysteine
A
A. Protamine sulfate
17
Q
A nurse is caring for a client who has a spinal cord injury and has
developed autonomic dysreflexia. Identify the sequence of steps
the nurse should take.
(Move the steps into the box on the right, placing them in the order
of performance. Use all the steps.)
A. Indicate the risk for autonomic dysreflexia in the client’s medical
record.
B. Place the client in an upright sitting position.
C. Administer an antihypertensive medication intravenously.
D. Confirm that the client’s bladder is empty.
A
B. Place the client in an upright sitting position
D. Confirm that the bladder is empty
C. Administer an antihypertensive medication intravenously
A. Indicate the risk for autonomic dysreflexia in the client’s medical
record
18
Q
A home hospice nurse is caring for a client who has end-stage os-
teosarcoma and informs the nurse that they have been receiving
acupuncture treatment to help with the pain. Which of the following
responses should the nurse make?
A. “This can be part of your plan as long as your provider ap-
proves.”
B. “This can be a good decision to help you meet your behavioral
health needs.
C. “It’s important to avoid acupuncture since complementary ther-
apy is not proven to help with end-stage care.
D. “It’s important that you choose the type of care that is most
effective for you.
A
A. This can be part of your plan as long as your provider approves
19
Q
A nurse is preparing to administer a unit of packed RBCs to a
female client who has a hemoglobin of 7.2 g/dL (12 to 16 g/dL).
Which of the following actions should the nurse take?
A. Obtain the blood from the blood bank prior to inserting the peripheral catheter.
B. Prime the tubing with lactated Ringer’s.
C. Review the medical record for type and crossmatch information.
D. Identify the client using their full name and room number.
A
C. Review the medical record for type and crossmatch information
20
Q
A nurse is obtaining a blood sample from a client’s central venous
access device. Which of the following actions should the nurse
take?
A. Flush the catheter with sterile water after specimen collection.
B. Use a vacuum tube to obtain a specimen from the catheter hub.
C. Cleanse the connections with povidone-iodine.
D. Flush the catheter with a 5 mL syringe
A
C. Cleanse the connections with poviodone-iodine
21
Q
A nurse is providing discharge teaching to a client who is post-
operative following a total hip arthroplasty. Which of the following
statements should the nurse make?
A. “Twist at the waist when standing from a seated position.”
B. “Move your stronger leg first when using a walker.”
C. “Use a raised toilet seat to maintain your hips above your
knees.”
D. “Apply a heating pad to the operative hip to decrease pain.”
A
A nurse is providing discharge teaching to a client who is post-
operative following a total hip arthroplasty. Which of the following
statements should the nurse make?
A. “Twist at the waist when standing from a seated position.”
B. “Move your stronger leg first when using a walker.”
C. “Use a raised toilet seat to maintain your hips above your
knees.”
D. “Apply a heating pad to the operative hip to decrease pain.”
22
Q
A nurse is planning care for a client who has GERD and reports
regurgitation after eating. Which of the following tests should the
nurse anticipate the provider to prescribe for the client?
A. Flexible sigmoidoscopy
B. Barium swallow
C. Paracentesis
D. Chest x-ray
A
B. Barium swallow
23
Q
A nurse is assessing a client who is 4 hr postoperative following
arterial revascularization of the left femoral artery. Which of the
following findings should the nurse report to the provider immedi-
ately?
A. Urine output 150 mL over 4 hr
B. Pallor in the affected extremity C. Bruising around the incisional
site
D. Temperature of 37.9° C (100.2° F)
A
B. Pallor in the affected extremity
24
Q
A nurse in the emergency department is managing the care of a
client who has an electrical shock injury. Which of the following
actions should the nurse take first?
A. Titrate IV fluids to maintain urine output at 75 mL/hr.
B. Administer an opioid pain medication
C. Change dressings over the entrance and exit wounds.
D. Obtain an ECG
A
D. Obtain an ECG
25
A nurse is assessing a client who is postoperative following a
transurethral resection of the prostate and is receiving continuous
bladder irrigation. The client reports bladder spasms, and the
nurse notes a scant amount of fluid in the urinary drainage bag.
Which of the following actions should the nurse take?
A. Apply a cold compress to the suprapubic area.
B. Secure the urinary catheter to the upper left quadrant of the
client's abdomen.
C. Use 0.9% sodium chloride to perform an intermittent bladder
irrigation.
D. Encourage the client to urinate every 2 hr.
A. Apply a cold compress to the suprapubic area.
26
A nurse is asking a preoperative client about food allergies. Which
of the following food allergies indicates a potential reaction to propofol?
A. Strawberries
B. Shellfish
C. Avocados
D. Eggs
D. Eggs
27
NGN:
BP 106/64, HR 95, RR 20/min, Temp 37.8, O2 95% @ 3L/min via
nasal cannual.
The nurse is assessing the client 12 hr later. How should the nurse
interpret the findings?
For each finding, click to specify whether the finding is unrelated
to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
NGN:
BP 106/64, HR 95, RR 20/min, Temp 37.8, O2 95% @ 3L/min via
nasal cannual.
The nurse is assessing the client 12 hr later. How should the nurse
interpret the findings?
For each finding, click to specify whether the finding is unrelated
to the diagnosis, a sign of potential improvement, or a sign of
UNRELATED:
C. Hct 45%
D. Butterfly rash
POTENTIAL IMPROVEMENT:
B. Oxygen saturation 96% at 2 L/min via nasal cannula
POTENTIAL WORSENING:
A. Disoriented to person, place, and time
E. Blood pressure 100/50 mm Hg
28
A nurse is teaching the family of a client who has Alzheimer's
disease about caring for the client at home. Which of the following
instructions should the nurse include?
A. Keep the client's bedroom dark at night.
B. Place a large-face clock in the client's bedroom.
C. Cover electrical outlets in the client's home with tape.
D. Hang a monthly calendar in the client's bedroom.
B. Place a large face clock in the client's bedroom
29
NGN:
Physical Exam: Jaundice, orange-brown urine, + hemoccult blood,
abd distention, lethargy, 1+edema, oriented x4, tachy, dyspnea w/
ext.
A nurse is admitting a middle adult client who has cirrhosis.
Findings upon admission:
The nurse is assessing the client 24 hr later. How should the nurse
interpret the findings?
For each finding, click to specify whether the finding is unrelated
to the diagnosis, a sign of potential improvement, or a sign of
potential worsening condition.
A. Spontaneous bruising
B. Ascites
C. Increased albumin level
D. Hematemesis
E. Elevated iron levels
UNRELATED:
POTENTIAL IMPROVEMENT:
C. Increased albumin level
WORSENING CONDITION:
A. Spontaneous bleeding
B. Ascites
D. Hematemesis
E. Elevated iron levels
30
A nurse is caring for a client who is 2 days postoperative following
a below-the-knee amputation and asks about the purpose of
maintaining an elastic bandage around the residual limb of the
extremity. Which of the following is an appropriate response by the
nurse?
A. "The elastic bandage will prevent a postoperative wound infec-
tion."
B. "The elastic bandage will keep you from seeing the surgical
site."
C. "The elastic bandage will keep the sutures from loosening."
D. "The elastic bandage will prevent excessive edema."
D. "The elastic bandage will prevent excessive edema."
31
A nurse is providing instructions to a client who has primary
syphilis. Which of the following instructions should the nurse include in the discharge plan?
A. "You will need to take an antiviral medication for 6 months."
B. "You will need cryotherapy for 1 to 2 weeks."
C. "You will need to be monitored for 15 minutes after receiving
each medication dose."
D. "You will need three follow-up blood tests within a 24-month
period."
D. "You will need three follow-up blood tests within a 24-month
period."
32
A nurse is caring for a client who has moderate Alzheimer's
disease. During weekly home visits, the nurse notices that the
client's caregiver is tired, irritable, and impatient with the client.
Which of the following actions should the nurse recommend to the
caregiver?
A. Pursue local protective services.
B. Take a nonprescription sleeping medication.
C. Contact hospice services for end-of-life care.
D. Consider respite care services.
D. Consider respite care services.
33
A nurse is assessing a client following extubation from a Ventilator.
For which of the following findings should the nurse intervene
immediately?
A. Sore throat
B. SaO, 92%
C. Stridor
D. Rhonchi
C. Stridor
34
A nurse is assessing a client who received a purified protein
derivative (PPD) skin test 48 hr ago and notes erythema with
induration of 12 mm at the injection site. Which of the following
instructions should the nurse provide to the client?
A. "You will need to have the skin test annually."
B. "You will need to follow up with your provider."
C. "You will need to return in 48 hours for re-evaluation."
D. "Your test will need to be repeated at this time."
B. "You will need to follow up with your provider."
35
A nurse is reviewing the laboratory findings of a client who has
a new diagnosis of Graves' disease. The nurse should anticipate
which of the following laboratory values to be elevated?
A. Phosphorus
B. Triiodothyronine 3
C. Thyroid-stimulating hormone
D. Calcium
B. Triiodothyronine 3
36
A nurse is planning care for a client who has a cervical spine injury
and has a halo traction device in place. Which of the following
actions should the nurse plan to take?
A. Move the client up and down in bed by holding onto the halo
traction device.
B. Ensure that there is space for one finger to fit between the vest
and the client's skin.
C. Apply medicated powder under the vest to reduce itching.
D. Loosen or tighten the screws on the device as needed for the
client's comfort.
B. Ensure that there is space for one finger to fit between the vest and the client's skin.
37
A nurse is caring for a client who has just returned from surgery
with an external fixator to the left tibia. Which of the following as-
sessment findings requires immediate intervention by the nurse?
A. The client has 100 mL blood in the closed-suction drain.
B. The client has an oral temperature of 38.3° C (100.9° F).
C. The client reports a pain level of 7 on a scale from 0 to 10 at
the operative site.
D. The client's capillary refill in the left toe is 6 seconds.
D. The client's capillary refill in the left toe is 6 seconds.
38
A nurse is providing discharge teaching to a client who has a
new prescription for sublingual nitroglycerin. Which of the following
statements made by the client indicates an understanding of the
teaching?
A. "I can take another dose after 2 minutes."
B. "I should take this medication as soon as the pain begins."
C. "I should chew the tablet before I swallow it."
D. "I can put the tablet against my cheek and gum."
B. "I should take this medication as soon as the pain begins."
39
A nurse is providing discharge teaching to a client who is recov-
ering from a sickle cell crisis. Which of the following instructions
should the include?
A. Avoid getting a flu vaccination.
B. Limit fluids to 1.5 L per day.
C. Limit alcohol intake to one drink per day.
D. Avoid extremely hot or cold temperatures.
D. Avoid extremely hot or cold temperatures.
40
A nurse is providing discharge teaching to a client who had a
bilateral orchiectomy. The nurse should instruct the client to expect
which of the following symptoms?
A. Hypoglycemia
B. Increased muscle mass
C. Increased libido
D. Hot flashes
D. Hot flashes (Orchiectomy is the removal of one or both testicles)
41
A nurse is planning care for a client who has Clostridium difficile
gastroenteritis. Which of the following is an appropriate nursing
action?
A. Wash hands with alcohol-based hand rub.
B. Clean surfaces with chlorhexidine.
C. Obtain a stool specimen with gloves.
D. Place the client in a protective environment.
C. Obtain a stool specimen with gloves.
42
A nurse working in an outpatient clinic is planning a community
education program about reproductive cancers. The nurse should
identify which of the following manifestations as a possible indication of cervical cancer?
A. Urinary hesitancy
B. Painless vaginal bleeding
C. Unexplained weight gain
D. Frequent diarrhea
B. Painless vaginal bleeding
43
A client who is deaf and communicates using sign language is
being admitted by a nurse who does not know sign language.
Which of the following actions should the nurse take?
A. Familiarize themselves with commonly used signed language.
B. Obtain a board that uses colored pictures as communication.
C. Request an interpreter during the initial assessment.
D. Ask a family member to be present during the admission.
C. Request an interpreter during the initial assessment
44
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the
nurse take?
A. Discard the radioactive device in the client's trash can.
B. Keep soiled bed linens in the client's room.
C. Instruct visitors to remain 3 feet from the client.
D. Limit time for visitors to 2 hr per day.
D. Limit time for visitors to 2 hr per day.
45
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the
nurse expect?
A. Decreased coagulation
B. Proteinuria
C. Hyperalbuminemia
D. Decreased serum lipid levels
B. Proteinuria
46
A nurse is planning to withdraw medication from an ampule to
prepare for an injection. Which of the following actions should the
nurse plan to take?
A. Dispose of the top of the ampule in a sharps container.
B. Expel air into the ampule to aspirate air bubbles.
C. Place a paper towel around the ampule's neck to break off the
top with both hands.
D. Withdraw the medication from the ampule using a needleless
system.
A. Dispose of the top of the ampule in a sharps container.
47
A nurse is preparing to receive a client from surgery following a
transverse colon resection with colostomy placement. The nurse
should expect to assess the stoma at which of the following
locations? (You will find hot spots to select in the artwork below.
Select only the hot spot that corresponds to your answer.)
B: The transverse colon is located across the
48
A nurse is caring for a client who has an arteriovenous graft.
Which of the following findings indicates adequate circulation of
the graft?
A. Absence of a bruit
B. Normotensive blood pressure
C. Dilated appearance of the graft
D. Palpable thrill
D. Palpable thrill
49
NGN:
Lab results, 0915: Blood Glucose 468, pH 7.30, Potassium 5.5,
Sodium 138, Chloride 101, BUN 21, Creatinine 1.7, Urine dipstick
positive for ketones.
Which of the following 3 provider prescriptions does the nurse
anticipate?
A. Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr
B. Potassium chloride 20 mEq/L intravenous PRN potassium less
than 5.0 mEq/L
C. Regular insulin continuous intravenous infusion, titrate per dia-
betic ketoacidosis (DKA) protocol once potassium is greater than
3.3 mEq/L
D. Regular insulin 20 units subcutaneously
E. Blood glucose checks every 4 hr
F. Initiate cardiac monitoring
G. Insert indwelling urinary catheter
B. Potassium chloride 20 mEq/L intravenous PRN potassium less
than 5.0 mEq/L
C. Regular insulin continuous intravenous infusion, titrate per dia-
betic ketoacidosis (DKA) protocol once potassium is greater than
3.3 mEq/L
F. Initiate cardiac monitoring
50
NGN: The nurse is caring for the client in the ED. The nurse understands
that the client is at risk of developing which of the following
complications? Select all that apply.
A. Respiratory alkalosis
B. Septic shock
C. Hypotension
D. Cardiac arrhythmias
E. Renal failure
F. Cerebral edema
A. Respiratory alkalosis
C. Hypotension
D. Cardiac arrhythmias
E. Renal failure
51
A nurse is assessing a client who is postoperative following an
open reduction and internal fixation (ORIF) of the femur. Which of
the following assessment should be the nurse's priority?
A. Neurovascular assessment
B. Pain assessment
C. Braden scale
D. Morse Fall Risk scale
A. Neurovascular assessment
52
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the
nurse take to prevent venous thromboembolism?
A. Massage the client's legs every 4 hr while they are awake.
B. Encourage the client to perform circumduction of the feet.
C. Limit the client's fluid intake to 2,000 mL daily.
D. Keep the client's knees in a flexed position while they are in bed.
B. Encourage the client to perform circumduction of the feet.
53
A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations
should the nurse include?
A. Increase potassium intake.
B. Decrease protein intake.
C. Increase phosphorus intake.
D. Decrease carbohydrate intake.
B. Decrease protein intake.
54
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an
indication that the client is experiencing dehydration?
A. Distended jugular veins
B. Increased blood pressure
C. Decreased blood pressure
D. Pitting, dependent edema
C. Decreased blood pressure
55
A nurse on the medical-surgical unit is caring for a client who has
a seizure disorder. Which of the following interventions should the nurse include in the plan of care?
A. Maintain peripheral IV access.
B. Pad the upper two side rails of the client's bed.
C. Teach assistive personnel how to apply restraints.
D. Keep a padded tongue blade at the client's bedside.
B. Pad the upper two side rails of the client's bed.
56
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse,
"I am afraid to have this procedure." Which of the following responses should the nurse make?
A. "Are you afraid of needles that will be used during the procedure?"
B. "Let's discuss your concerns about this procedure."
C. "Tell me why you are scared to have this procedure."
D. "After this procedure, you will feel much better."
B. "Let's discuss your concerns about this procedure."
57
A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred
pain?
A. A client who has pancreatitis reports pain in the left shoulder.
B. A client who has peritonitis reports generalized abdominal pain.
C. A client who is postoperative reports incisional pain.
D. A client who has angina reports substernal chest pain.
A. A client who has pancreatitis reports pain in the left shoulder.
58
A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?
A. Use moisturizing lotion while massaging the client's bony prominences.
B. Instruct the client to sit on a rubber ring when seated in a chair.
C. Place pillows between the client's knees when in a side-lying position.
D. Raise the head of the client's bed to a 90° angle.
C. Place pillows between the client's knees when in a side-lying position.
59
A nurse is preparing to administer fresh frozen plasma to a client.
Which of the following is correct?
A. Administer the transfusion through a 25-gauge saline lock.
B. Transfuse the plasma over 4 hr.
C. Hold the transfusion if the client is actively bleeding.
D. Administer the plasma immediately after thawing.
D. Administer the plasma immediately after thawing.
60
A nurse is caring for a client who weighs 190 lb and is receiving total parenteral nutrition. If the RDA of protein is 0.8 g/kg of body
weight, how many grams of protein should the client receive daily?
(Round the answer to the nearest whole number. Use a leading
zero if it applies. Do not use a trailing zero.)
69mg
61
NGN:
Vital Signs 1000:
Temperature 37.1° C (98.8° F)
Heart rate 110/min and irregular Respiratory rate 24/min Blood
pressure 164/80 mm Hg, Oxygen saturation 93% on room air.
The nurse is reviewing the client's medical record. Select the four
findings that require immediate follow-up.
A. Blood glucose level
B. Bowel sounds
C. Blood pressure
D. Pain level
E. Electrocardiogram findings
F. Lung sounds
G. Troponin T level
C. Blood pressure
D. Pain level
E. Electrocardiogram findings
G. Troponin T level
62
NGN:
History and Physical 1000: Client reports after eating breakfast this morning at 0630 that they began feeling tightness in chest that radiates to left arm.
History: Hyperlipidemia, hypertension, type 2 diabetes mellitus.
Non-smoker. Denies use of alcohol or recreational drug use.
Click to highlight the findings below that would indicate that the client has a potential problem.
A. Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast.
B. Client states, i had scrambled eggs and bacon like I do every
morning."
C. Client is diaphoretic and short of breath. Heart rate is irregular and tachycardic.
D. Alert and oriented to person, place, and time.
E. Lungs clear to auscultation in all lobes. Bowel sounds are
present in all 4 quadrants. +1 pedal pulses.
F. Skin is cool to touch. Capillary refill less than 2 seconds.
A. Client reports tightness in chest that radiates to left arm. States
pain as 7 on a scale of 0 to 10. Started to feel nauseous after
breakfast.
B. Client states, i had scrambled eggs and bacon like I do every
morning."
C. Client is diaphoretic and short of breath. Heart rate is irregular
and tachycardic.
F. Skin is cool to touch. Capillary refill less than 2 seconds.
63
A nurse is providing discharge teaching to a client who reports
that they cannot afford their prescribed medication. Which of the
following statements should the nurse make?
A. "Contact your pharmacy to inquire about a different medica-
tion."
tion."
B. "You should ask your provider to prescribe a cheaper medica-
C. "I can arrange for a social worker to talk with you before you leave
D. "I can contact the occupational therapist to schedule a home
visit."
C. "I can arrange for a social worker to talk with you before you
leave."
64
NGN:
Myoglobin 10, Creatine kinase 180 units/L ,Troponin T 0.40
ng/mL, Troponin I 0.35 ng/mL, Cholesterol 244 mg/dL, Triglyc-
erides 180 mg/dL, LDL cholesterol 148 mg/dL, HDL cholesterol
42 mg/dL, C-reactive protein 2 mg/m, Blood glucose 103 mg/dL.
12-lead electrocardiogram: tachycardia with ST segment eleva-
tion and T wave changes Chest x-ray: lungs are clear in all lobes
The nurse is reviewing the client's medical record.
For each potential provider's prescription, click to specify if the po-
tential prescription is anticipated, nonessential, or contraindicated
for the client.
A. Metoprolol 15 mg IV bolus
B. Oxygen at 2 L/min via nasal cannula
C. Draw electrolytes along with Hgb and Hct
D. Morphine 6 mg IV bolus every 3 hr as needed for pain
E. Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3
doses
F. Obtain daily weight
G. Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate
drops below 60
ANTICIPATED:
A. Metoprolol 15 mg IV bolus
B. Oxygen at 2 L/min via nasal cannula
C. C. Draw electrolytes along with Hgb and Hct
D. D. Morphine 6 mg IV bolus every 3 hr as needed for pain
E. E. Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3
doses
NONESSENTIAL:
F. Obtain daily weight
CONTRAINDICATED:
G. Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate
drops below 60
65
NGN:
Client reports after eating breakfast this morning at 0630 that they
began feeling tightness in chest that radiates to left arm. History:
Hyperlipidemia, hypertension, type 2 diabetes mellitus.
Non-smoker. Denies use of alcohol or recreational drug use.
The nurse is reviewing the client's medical record.
Which of the following findings indicates the client's condition has
improved? Select all that apply.
A. Blood pressure
B. Echocardiogram results
C. Respiratory rate
D. Pain level
E. Oxygenation saturation
F. Urinary output
G. Heart rate
A. Blood pressure
C. Respiratory rate
D. Pain level
E. Oxygenation saturation
G. Heart rate
66
A nurse is caring for a client who requires protective isolation fol-
lowing a hematopoietic stem cell transplant. Which of the following
interventions should the nurse implement to protect the client from
infection?
A. Monitor the client's temperature once every 6 hr.
B. Make sure the client's room has positive-pressure airflow.
C. Wear an N95 respirator when providing direct client care.
D. Make sure dietary plates and utensils are disposable.
B. Make sure the client's room has positive-pressure airflow.
67
NGN:
Client reports after eating breakfast this morning at 0630 that they
began feeling tightness in chest that radiates to left arm.
A nurse is reviewing the client's diagnostic results and vital signs.
Which of the following actions should the nurse take? Select all
that apply.
A. Anticipate client to be prepped for cardiac catheterization.
B. Assist with a continuous heparin infusion.
C. Encourage the client to ambulate.
D. Anticipate an increased dosage of metoprolol.
E. Obtain a prescription for client to be NPO.
F. Request a prescription for an antibiotic.
A. Anticipate client to be prepped for cardiac catheterization.
B. Assist with a continuous heparin infusion.
D. Anticipate an increased dosage of metoprolol.
E. Obtain a prescription for client to be NPO.
68
A nurse is teaching a client who has a new prescription for warfarin
about foods that affect the INR. The nurse should include in
the teaching that which of the following foods interacts with this
medication?
A. Orange juice
B. Beef stew
C. Kale
D. Yogurt
C. Kale
69
A nurse is caring for a client who is receiving total parenteral nutri-
tion (TPN). Which of the following nursing actions are appropriate?
(Select all that apply.)
A. Increase the rate of infusion if administration is delayed.
B. Monitor serum blood glucose during infusion.
C. Verify the solution with another RN prior to infusion.
D. Infuse 0.9% sodium chloride if the solution is not available.
E. Obtain the client's weight daily.
B. Monitor serum blood glucose during infusion.
C. Verify the solution with another RN prior to infusion.
E. Obtain the client's weight daily.
70
A nurse is assessing a client who is taking telmisartan. The nurse
should identify that which of the following findings indicates that
the medication has been effective?
A. Respiratory rate of 16/min
B. Decrease in blood pressure
C. Increase in urinary output
D. Blood glucose of 110 mg/dL
B. Decrease in blood pressure
70
A nurse is caring for a client who is receiving mechanical ventila-
tion when the low-pressure alarm sounds on the ventilator. Which
of the following actions should the nurse take?
A. Suction the client's airway.
B. Empty water from the client's ventilator tubing.
C. Increase the client's ventilator flow rate.
D. Evaluate the client for a cuff leak.
D. Evaluate the client for a cuff leak.
71
A nurse is planning care for a client who has bacterial meningitis.
Which of the following interventions should the nurse implement?
A. Ensure the client's bed is positioned to greater than 45°.
B. Initiate airborne precautions.
C. Ensure lights are dimmed in the client's room.
D. Encourage frequent ambulation.
C. Ensure lights are dimmed in the client's room ((Photophobia is
a adverse effect of meningitis))
72
A nurse is teaching about safe positioning with the caregiver of
a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an under-
standing of the teaching?
A. "I will ensure their neck is flexed backwards when they're lying
on their stomach."
B. "I will support their feet with a rolled pillow when they are lying
on their back."
C. "I will rest their heels on the mattress when they are sitting up
in bed."
D. "I will use a thick pillow under their head to support the neck."
B. "I will support their feet with a rolled pillow when they are lying
on their back."
73
A nurse is providing teaching for a client who is taking isoniazid
(INH) for tuberculosis. Which of the following statements by the
client indicates an understanding of the teaching?
A. This medication may cause my blood pressure to increase."
B. "I should take an antacid with each dose of this medication."
C. "I plan to take this medication for 1 week."
D. "I will have my liver function tested while I am taking this
medication."
D. "I will have my liver function tested while I am taking this medication."
74
A charge nurse is observing a newly licensed nurse care for
a client who has a methicillin-resistant Staphylococcus aureus
(MRSA). Which of the following observations of the newly licensed
nurse indicates an understanding of infection control precautions?
A. Remains 3 feet away from the client
B. Wears an N95 mask when providing wound care
C. Disposes of isolation gown outside of the client's room
D. Wears clean gloves when caring for the client
D. Wears clean gloves when caring for the client
75
A nurse is assessing a client who has anorexia. Which of the
following findings should the nurse identify as a manifestation of
malnutrition?
A. Alopecia
B. Diplopia
C. Oily skin
D. Increased salivation
A. Alopecia
76
A nurse is caring for a client who has left-sided heart failure. Which
of the following findings should indicate to the nurse that the client
is experiencing a decrease in cardiac output?
A. Weight gain
B. Distended abdomen
C. Confusion
D. Dyspnea
C. Confusion
77
A nurse is reviewing providers' prescriptions for four clients. Which
of the following prescriptions should the nurse verify with the
provider?
A. Apply mitten restraints to prevent the client from disconnecting
their tube feeding.
B. Apply a vest restraint daily at bedtime to prevent nighttime
wandering.
C. Apply an abduction pillow between the client's knees while they
are in bed to prevent hip dislocation.
D. Apply soft heel protectors bilaterally while client is in bed.
B. Apply a vest restraint daily at bedtime to prevent nighttime wandering.
78
A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse
administer?
A. Naloxone
B. Protamine sulfate
C. Acetylcysteine
D. Flumazenil
A. Naloxone
79
A nurse is caring for a female client who had a stroke. Which of
the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?
A. Hgb 18 g/dL (12 to 16 g/dl)
B. WBC 12.000/mm3 (5,000 to 10,000/mm3)
C. 25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL)
D. Albumin 3.1 g/dL (3.5 to 5 g/dL)
D. Albumin 3.1 g/dL (3.5 to 5 g/dL)
80
A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take?
A. Monitor vital signs at least every 4 hr.
B. Insert an indwelling urinary catheter.
C. Change the client's linens three times a day.
D. Place the client in a room with negative airflow.
A. Monitor vital signs at least every 4 hr. ((Neutropenia is low WBC))
81
A nurse is assessing a female client who has pneumonia. The
nurse should identify which of the following findings increases the
client's risk of skin breakdown?
A. Receiving bronchodilator medication
B. Weight loss of 2.8 kg (6.2 b)
C. Hemoglobin 17 g/dl (12 to 16 g/dL)
D. Wearing an oxygen device
B. Weight loss of 2.8 kg (6.2 b)
82
A nurse is assessing a client who had a total thyroidectomy 4 hr
ago. Which of the following findings should the nurse report?
A. Neck stiffness
B. Hoarseness
C. Moderate serosanguineous drainage
D. Muscle twitching
D. Muscle twitching
83
A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?
A. Use an elevated toilet seat.
B. Log roll the client onto the operative side.
C. Keep client's affected heel on the bed.
D. Perform internal and external rotation exercises of hip.
A. Use an elevated toilet seat.
84
A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?
A. Gentle bubbling in the water seal chamber
B. Drainage and warmth at tube insertion site
C. Crackling sensation felt around tube insertion site
D. Drainage output less than 70 mL/hr
A. Gentle bubbling in the water seal chamber
85
A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall
risk?
A. The client asks for help before ambulating.
B. The client has a history of urinary incontinence.
C. The client lives with their caregiver.
D. The client has bronchitis
B. The client has a history of urinary incontinence.
86
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the
nurse make?
A. "These discomforts should decrease with time."
B. "Women your age experience thickening of the vaginal tissue."
C. "Your symptoms are likely due to decreasing estrogen levels."
D. "You should avoid intercourse to prevent injury to your vagina."
C. "Your symptoms are likely due to decreasing estrogen levels."
87
A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation
of bleeding?
A. Hypertension
B. 2+ edema
C. Crackles in lungs
D. Tachycardia
D. Tachycardia
88
A nurse is providing discharge teaching for a client who has
heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of
the teaching?
A. "I will take this medication with fiber to prevent constipation."
B. "I will notify my provider if I experience muscle weakness."
C. "I will increase my dose if my vision becomes blurred."
D. "I will take my digoxin if my pulse is less than 50 beats per
minute."
B. "I will notify my provider if I experience muscle weakness."
89
A nurse working in the emergency department is caring for a client
who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
A. Increase the room temperature.
B. Cleanse the client's wounds.
C. Administer analgesic medication.
D. Start an IV with a large-bore needle.
D. Start an IV with a large-bore needle.
90
A nurse is taking an admission history from a client who reports
Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations
of Raynaud's?
A. A history of herpes zoster
B. Taking amlodipine for hypertension
C. Using a nicotine transdermal patch
D. Eating a strict vegetarian diet
C. Using a nicotine transdermal patch ((nicotine and extreme cold
temperatures exacerbates Raynaud's)
91
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings
should the nurse identify as an indication that the medication was
effective?
A. Emesis of 250 mL
B. Increased respiratory rate to 26/min
C. Decreased anxiety
D. Decreased urinary output
C. Decreased anxiety
92
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that
poses a risk to the client's safety?
A. Loss of hearing
B. Muscle wasting
C. Paresthesia
D. Changes in vision
C. Paresthesia ((the feeling of pins and needles)) (Pernicious
anemia is a lack of B12 in the body)
93
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion
begins. Which of the following actions should the nurse take first?
A. Administer oxygen to the client.
B. Collect a urine sample.
C. Stop the infusion.
D. Check the client's vital signs.
C. Stop the infusion.
94
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
A. Place the client in a supine position.
B. Administer antihypertensive medications.
C. Monitor the client for hypercalcemia.
D. Maintain the client on NPO status
D. Maintain the client on NPO status.
95
A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?
A. Provide humidified oxygen.
B. Administer antibiotic medication.
C. Implement fluid restriction
D. Administer acetaminophen orally.
D. Administer acetaminophen orally ((Flail chest: a segment of the
ribcage completely breaks & becomes detached from the rest of the chest wall, a life-threatening medical emergency ))
96
A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following
acid- base imbalances?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis
C. Metabolic alkalosis
97
A nurse is reviewing the medical record of a client who has acute
gout. The nurse should expect an increase in which of the following
laboratory results?
A. Chloride level
B. Creatinine kinase
C. Uric acid
D. Intrinsic factor
C. Uric acid
98
A nurse is reviewing the health history of a client who is scheduled for exploratory surgery. Which of the following food allergies
indicates a risk for an allergic reaction to latex?
A. Strawberries
B. Eggs
C. Peanuts
D. Shellfish
A. Strawberries
99
A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the
following tests should the nurse monitor?
A. Stool for occult blood
B. Fasting blood glucose
C. Serum calcium
D. Urine for white blood cells
A. Stool for occult blood
100
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by
the nurse is the highest priority?
A. Initiate IV fluid replacement.
B. Measure the client's urinary output.
C. Administer insulin.
D. Teach the client about manifestations of HHS
A. Initiate IV fluid replacement.
101
A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?
A. Joint inflammation
B. Tophi
C. Esophagitis
D. "Bull's eye" lesion
A. Joint inflammation
102
A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the
nurse take first?
A. Turn the client on their side.
B. Perform a neurologic check.
C. Obtain the client's vital signs.
D. Notify the rapid response team.
A. Turn the client on their side.
103
A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?
A. Pedal edema
B. Neck vein distention
C. Daytime oliguria
D. Enlarged liver
C. Daytime oliguria
104
A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury.
Which of the following IV medications should the nurse plan to
administer?
A. Chlorpromazine
B. Dobutamine
C. Mannitol
D. Propranolol
C. Mannitol
105
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medica-
tions should the nurse administer prior to chemotherapy?
A. Diphenhydramine
B. Ondansetron
C. Sertraline
D. Methylprednisolone
B. Ondansetron
106
A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the
nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)?
A. Inability to smell
B. Loss of peripheral vision
C. Disequilibrium with movement
D. Deviation of the tongue from midline
C. Disequilibrium with movement
107
A nurse is planning to meet with the interprofessional team about the care of a client who has a new diagnosis of ulcerative colitis. Which of the following recommendations should the nurse plan to
make during the meeting?
A. "The client should be referred to pain management."
B. "The client should be referred to hospice services."
C. "The client should be referred to a wound, ostomy, and conti-
nence nurse."
D. "The client should be referred to a dietitian."
D. "The client should be referred to a dietitian."
108
The nurse is preparing to administer 1 liter (1000 mL) of 0.9%
NS over 2 hours intravenously to a patient experiencing shock. At
what rate will the nurse set the infusion pump? Enter the number
only.
8.3ml
109
A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the
following choices should the nurse recommend as containing the
least potassium?
A. 1 cup white rice
B. 1/2 cup nonfat yogurt
C. 1 medium baked potato with skin
D. 2 tbsp peanut butter
A. 1 cup white rice
110
A client who has a terminal illness asks the nurse, "If I have a DNR
prescription, does that mean I will no longer receive any treatment for my condition?"Which of the following statements should the nurse provide to explain a DNR prescription?
A. A DNR prescription means you will only receive pain medication
for your treatments.
B. A DNR prescription will limit your current treatment regimen.
C. A DNR prescription will allow you to continue with your current
treatment regimen.
D. A DNR prescription will limit your ability to receive invasive
procedures.
C. A DNR prescription will allow you to continue with your current treatment regimen.
111
A nurse is evaluating an older adult client who expresses concern
about the aging process. Which of the following statements made
by the client indicates a need for follow-up?
A. "I do my best to protect my skin from bumps and cuts. It's more
fragile now."
B. "I guess feeling down is just part of aging."
C. "My hair is thinning. I'm going to go to the wig shop soon."
D. "I missed my eye appointment, but I rescheduled it.
B. "I guess feeling down is just part of aging."
112
A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a
private room?
A. A client who has diabetes mellitus and is presenting with acute
ketoacidosis.
B. An older adult client who was admitted with aspiration pneumonia.
C. A client who has a compound fracture of the right femur.
D. A client who reports having fever, night sweats, and cough for
2 days.
D. A client who reports having fever, night sweats, and cough for
2 days.
113
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
A. Place the client's bed at the lowest height.
B. Request a prescription for a nightly sedative.
C. Assist the client with toileting at least once every 4 hours.
D. Turn off all lights in the client's room at night.
A. Place the client's bed at the lowest height.
114
A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following pieces
of information should the nurse include in the teaching?
A. "The spacer should make a whistling sound as you inhale."
B. "Hold your breath for 10 seconds once you inhale."
C. "Clean the spacer daily with cold water."
D. "Wait 30 seconds between puffs."
B. "Hold your breath for 10 seconds once you inhale."
115
The nurse is caring for several clients on a hospital unit. Which of the following clients is most at risk for hypoglycemia?
A. A client with type 1 diabetes mellitus who has taken a high dose
of insulin
B. A client who has type 2 diabetes and has not taken any medication
C. An older adult client taking an antibiotic for an infection
D. A client who has metabolic syndrome and is taking a statin drug
to lower cholesterol levels
A. A client with type 1 diabetes mellitus who has taken a high dose
of insulin
116
A nurse is caring for a group of clients who are 12 hours postoperative. The nurse should identify that the client who had which
of the following procedures is at risk for developing fat embolism syndrome?
A. Thyroidectomy
B. Internal fixation of a fractured hip
C. Repair of a torn rotator cuff
D. Tympanoplasty
B. Internal fixation of a fractured hip
117
A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions
should the nurse take as part of the focused assessment?
A. Tap the client's facial nerve and note any facial twitching.
B. Strike the client's patellar tendon with a percussion hammer and note any increase in response.
C. Gently elevate the client's head and note any nuchal rigidity.
D. Run a tongue blade on the outside of the client's sole and note
any flaring of the toes.
C. Gently elevate the client's head and note any nuchal rigidity.
118
A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect?
A. Epithelialization at the site
B. Severe pain at the site
C. Edema at the site
D. Blistering at the site
C. Edema at the site
119
A nurse is reviewing orders for a patient in anaphylactic shock. Which medication should the nurse plan to administer first?
A. Glucose Dextrose Oral (GDO)
B. Epinephrine (Adrenaline)
C. Dexamethasone (Decadron)
D. 0.9% Normal Saline
B. Epinephrine (Adrenaline)
120
A nurse is reinforcing teaching with a client who has osteoporosis and is prescribed (Fosamax) alendronate 70 mg PO weekly.
Which of the following statements by the client indicates a need
for further instruction?
A. "I take my other pills at least 30 minutes after my alendronate."
B. "I take my alendronate on the same day every week with an 8-ounce glass of milk."
C. "I sit up and read the morning paper after taking my alendronate."
D. "I will need to have a bone density test occasionally while taking
this medication."
B. "I take my alendronate on the same day every week with an 8-ounce glass of milk."
121
A nurse is preparing a teaching plan for a client who has mucositis
related to chemotherapy treatment. Which of the following instructions should the nurse include?
A. Rinse your mouth with hydrogen peroxide.
B. Brush your teeth for 60 seconds twice daily.
C. Floss your teeth gently following each meal.
D. Wear your dentures only during meals.
C. Floss your teeth gently following each meal
122
A nurse is planning care for a client who is 12 hours postoperative
following a kidney transplant. Which of the following actions should
the nurse include in the plan of care?
A. Check the client's blood pressure every 8 hours.
B. Monitor for hypokalemia as a manifestation of acute rejection.
C. Assess urine output hourly.
D. Administer opioids orally.
C. Assess urine output hourly.
123
A nurse is teaching a client who has AIDS and wishes to continue
self-care at home despite living alone. Which of the following
actions by the nurse demonstrates client advocacy?
A. Instruct the client to avoid eating raw vegetables.
B. Initiate a referral for the client to a home health agency.
C. Remind the client of the importance of medication adherence.
D. Tell the client to avoid places where there are large crowds of
people.
B. Initiate a referral for the client to a home health agency.
124
A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which
of the following actions should the nurse take?
A. Turn the CPM machine off while the client is eating.
B. Store the CPM machine on the floor when not in use.
C. Check the settings of the CPM machine every 12 hours.
D. Increase the range of motion rapidly when the CPM machine is
used intermittently.
D. Turn the CMP machine off while the client is eating
125
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the
first postoperative hour should the nurse report to the provider?
A. 150 mL of serosanguineous drainage
B. 75 mL of greenish-yellow drainage
C. 100 mL of red drainage
D. 200 mL of brown drainage
C. 100 mL of red drainage (indicates possible GI bleed)
126
A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and ST-segment elevation. The
client reports shortness of breath and feeling dizzy and faint.
Which of the following medications should the nurse administer?
A. Digoxin
B. Sotalol
C. Atropine
D. Lidocaine
C. Atropine
127
A nurse is caring for a client who has been prescribed an antibiotic.
The client tells the nurse, "I don't like taking medications because
I don't think I need them." Which of the following responses should
the nurse make?
A. "Your provider wouldn't prescribe this medication if it weren't
necessary."
B. "If you don't take this medication, you will feel worse."
C. "Most clients feel better after taking the antibiotic."
D. "I will tell your provider that you do not want to take this
medication."
A. "Your provider wouldn't prescribe this medication if it weren't necessary."
128
A nurse is reinforcing discharge teaching with a client about how
to care for a newly created ileal conduit. Which of the following
instructions should the nurse include in the teaching?
A. Change the ostomy pouch daily.
B. Empty the ostomy pouch when it is 2/3 full.
C. Trim the opening of the ostomy seal to be 1/2 inch wider than
the stoma.
D. Apply lotion to the peristomal skin when changing the ostomy
pouch.
B. Empty the ostomy pouch when it is 2/3 full.
129
A nurse on a medical-surgical unit is planning care for a client who
has dementia and a history of wandering. Which of the following
actions should the nurse plan to implement?
A. Move the client to a double room.
B. Use a bed alarm.
C. Encourage participation in activities that provide excessive
stimulation.
D. Use chemical restraints at bedtime
B. Use a Bed alarm
130
A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the
client's room?
A. Tongue blade
B. NG tube
C. Oral airway
D. Wrist restraints
C. Oral airway
131
A nurse is caring for a client who has developed hives and urticaria
following the administration of IV contrast dye after a cardiac catheterization. Which of the following medications should the
nurse plan to administer?
A. Desmopressin
B. Diphenhydramine
C. Spironolactone
D. Metoclopramide
B. Diphenhydramine
132
A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for
increasing the client's dopamine dosage?
A. Heart rate 60/min
B. Oxygen saturation 95%
C. Blood pressure 90/50 mm Hg
D. Respiratory rate 14/min
C. Blood pressure 90/50 mm Hg
133
A nurse is planning care for a client who is postoperative following
the insertion of an arteriovenous graft in their left forearm. Which
of the following actions should the nurse include in the plan of
care?
A. Check the pulse distal to the graft.
B. Keep the left forearm below the level of the heart.
C. Collect blood specimens from the graft.
D. Splint the left forearm to prevent damage to the graft.
A. Check the pulse distal to the graft.
134
A nurse is completing discharge teaching with a client who has a
new diagnosis of AIDS. Which of the following statements by the
client indicates an understanding of the teaching?
A. "I will increase the amount of fresh fruits and vegetables I
consume."
B. "I will be sure to wear gloves and wash my hands when I change
my cat's litter box."
C. "I will need to take my clothes to the dry cleaners to sterilize
them."
D. "I will wipe up areas soiled with body fluids with alcohol and
immediately dispose of the trash."
B. "I will be sure to wear gloves and wash my hands when I change
my cat's litter box."
135
A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse
take?
A. Perform a Mantoux skin test on the clien
B. Assign the client to a negative-pressure airflow room.
C. Wear a surgical mask when providing care to the client.
D. Recommend that the client's family members receive antiviral
therapy.
A. Wear a surgical mask when providing care to the client (pertussis, whooping cough, is droplet precautions)
136
A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should
the nurse identify as an adverse effect of the medication?
A. Blood pressure 138/76 mm Hg
B. Temperature 36.3°C (97.3°F)
C. Heart rate 48/min
D. Respiratory rate 10/min
C. Heart rate 48/min
137
A nurse is caring for a client who is receiving a 0.9% sodium
chloride via IV infusion. The client has become dyspneic with a
blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and
an output of 300 mL in the past 12 hours. Which of the following
actions should the nurse take?
A. Administer prescribed corticosteroids.
B. Slow infusion rate and contact the provider.
C. Lower the head of the bed to semi-Fowler's.
D. Change infusion to lactated Ringer's and maintain rate.
B. Slow infusion rate and contact the provider ((The client's dys-
pnea and elevated blood pressure may indicate fluid volume
overload. Slowing the infusion rate and notifying the provider are
appropriate actions.))
138
A nurse is caring for a client who is postoperative following a
complete thyroidectomy. Which of the following findings is the
priority for the nurse to report to the provider?
A. Muscle twitching
B. Client report of nausea
C. Serosanguineous drainage
D. Client report of incisional pain
A. Muscle twitching (Parathyroid may have also been removed and
is causing hypocalcemia)
139
A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?
A. Instruct the client to expect tingling in their extremities.
B. Measure blood glucose every 2 hours.
C. Limit the client's fluid intake.
D. Instruct the client to lie flat.
D. Instruct the client to lie flat.
140
A nurse is preparing to obtain a guaiac smear sample from a client
for fecal occult blood testing. Which of the following actions should
the nurse plan to take?
A. Wear sterile gloves when collecting the sample.
B. Discard samples that contain urine.
C. Collect three samples from a single bowel movement
B. Discard samples that contain urine.
141
A charge nurse on a neurological unit is making room assign-
ments for a group of clients. Which of the following clients should
the nurse assign to the room closest to the nurses' station?
A. A client who has a headache following a grade 1 concussion.
B. A client who has experienced brain death and is awaiting organ
procurement.
C. A client who has a score of 10 on the Glasgow Coma Scale
following a motor vehicle crash.
D. A client who has a score of 0 on the NIH Stroke Scale following
a transient ischemic attack.
C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash.
142
A nurse is caring for a client who is experiencing a seizure. Which
of the following actions should the nurse take first?
A. Clear items from the client's surrounding area.
B. Loosen the client's restrictive clothing.
C. Lower the client to the floor.
D. Obtain the client's vital signs.
C. Lower the client to the floor.
143
A nurse is teaching a client who has Graves' disease about recog-
nizing the manifestations of thyroid storm. Which of the following
findings should the nurse include in the teaching?
A. Hypotension
B. Increased temperature
C. Lethargy
D. Decreased heart rate
B. Increased temperature
144
A nurse in a clinic is assessing a client who has type 1 diabetes
mellitus. The client is diaphoretic, has a heart rate of 92/min, and
reports palpitations. The client states, "I went for my morning run
and feel exhausted." Which of the following responses should the
nurse make?
A. "Were you careful to not have carbohydrates after the run?"
B. "It is normal to feel this way after a morning run."
C. "It becomes easier when exercise is a routine."
D. "Did you decrease your insulin intake before you exercised?"
D. "Did you decrease your insulin intake before you exercised?"
145
A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess
their ability to swallow?
A. "Do you feel like you have food stuck at the base of your throat?"
B. "Do you feel any burning sensations in your throat?"
C. "Do you have any feelings of fullness in the neck?"
D. "Do you have any problems with pain while swallowing?"
A. "Do you feel like you have food stuck at the base of your throat?"
146
A nurse is providing teaching for a client who has diabetes mellitus about the self administration of insulin. The client has prescrip-
tions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will draw the regular insulin into the syringe first."
B. "I will store prefilled syringes in the refrigerator with the needle
pointed upward."
C. "I will gently roll the NPH vial between my hands before drawing
up the insulin."
D. "I will insert the needle at a 90-degree angle."
A. "I will draw the regular insulin into the syringe first."
147
A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates
an understanding of the teaching?
A. The client moves the cane 2 feet ahead.
B. The client holds the cane with their right hand.
C. The client takes a step with their left foot first.
D. The client advances the weaker (left) leg forward to the cane.
D. The client advances the weaker (left) leg forward to the cane.
148
A nurse is caring for a client who is experiencing an increase in
intracranial pressure (ICP). The nurse should expect which of the
following as an early manifestation of increased ICP?
A. Papilledema
B. Restlessness
C. Projectile vomiting
D. Decorticate posturing
B. Restlessness
149
A nurse is preparing to administer heparin subcutaneously to a
client. Which of the following is an appropriate action by the nurse?
A. Inject the medication into the abdomen above the level of the
iliac crest.
B. Use a 1-inch needle to inject the medication
C. Use a 25-gauge needle to inject the medication.
D. Massage the injection site after administration of the medication.
C. Use a 25-gauge needle to inject the medication.
150
A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the
nurse include in the teaching? (Select all that apply.)
A. Frequent exposure to low-volume noise
B. Chronic infections of the middle ear
C. Perforation of the eardrum
D. Born with a high birth weight
E. Use of a loop diuretic
B. Chronic infections of the middle ear
C. Perforation of the eardrum
E. Use of a loop diuretic
151
A nurse is providing discharge teaching to a client who has
pulmonary tuberculosis. Which of the following findings should
the nurse include as an indication that the client is no longer
infectious?
A. Mantoux skin test revealing an induration of less than 1 mm.
B. Negative sputum cultures for acid-fast bacillus.
C. The client is no longer coughing up blood-tinged sputum.
D. Positive Quantiferon-TB Gold test (negative).
B. Negative sputum cultures for acid-fast bacillus.
152
A patient is exhibiting an altered level of consciousness and is
unresponsive to verbal stimuli. To elicit a response from a painful
stimulus, the nurse would:
A. Press down on the orbital area of the eye.
B. Press down on the trapezius muscle.
C. Use a 25-gauge needle.
D. Elicit a reflex with a reflex hammer.
B. Press down on the trapezius muscle.
153
A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations?
A. Severe, throbbing headache
B. Hypotension
C. Fever
D. Cyanosis of the head and neck
A. Severe, throbbing headache (autonomic dysreflexia: comes
from spinal cord injury above C6 and results in high blood pressure, throbbing headache, and bradycardia)
154
The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain:
A. Two tablets PO (by mouth) every 15 minutes.
B. One tablet SL (sublingual) every 15 minutes, up to 5 times.
C. One tablet PO (by mouth) every one hour, up to 5 times.
D. One tablet SL (sublingual) every 5 minutes, up to 3 times.
D. One tablet SL (sublingual) every 5 minutes, up to 3 times.
155
A nurse is caring for a client who has a peripherally inserted
central catheter (PICC) for the administration of total parenteral
nutrition (TPN). The transparent dressing over the insertion site
requires replacement. Which of the following actions should the
nurse take?
A. Aspirate the catheter to check for a brisk blood return.
B. Use sterile technique for the procedure.
C. Cleanse the insertion site with hydrogen peroxide.
D. Flush the TPN port with 20 mL of 0.9% sodium chloride.
B. Use sterile technique for the procedure.
156
A nurse is reinforcing discharge teaching with a client on how
to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?
A. Change the ostomy pouch daily.
B. Empty the ostomy pouch when it is 2/3 full.
C. Trim the opening of the ostomy seal to be 1/2 inch wider than the stoma.
pouch.
D. Apply lotion to the peristomal skin when changing the ostomy
B. Empty the ostomy pouch when it is 2/3 full.
157
A nurse is caring for a client who has skeletal traction applied to
the left leg. Which of the following actions should the nurse take?
A. Remove the weights before changing the client's bed linens.
B. Instruct the client to use their elbows to reposition.
C. Check pressure points every 12 hours.
D. Provide the client with a trapeze bar.
D. Provide the client with a trapeze bar.
158
A nurse is planning the discharge of a client who had an ischemic
stroke. The nurse should ensure that the client is discharged with
which of the following types of pharmacologic therapy?
A. Anticonvulsant
B. Diuretic
C. Antithrombotic
D. Opioid analgesic
C. Antithrombotic
159
A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor
the client for which of the following as an adverse effect of this
therapy?
A. Constipation
B. Decreased tear production
C. Mouth ulcers
D. Peripheral neuropathy
C. Mouth ulcers
160
The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by
the nurse should be reported to the unit care coordinator?
A. Areas around pins are dry.
B. Crusts around pins.
C. Purulent drainage around pins.
D. Absence of pain at the site.
C. Purulent drainage around pins.
161
A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?
A. Petechiae on the chest
B. Bradycardia
C. Intermittent headache
D. Photophobia
D. Photophobia
162
A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over
the past 24 hours. The nurse should anticipate a prescription for
which of the following intravenous (IV) medications?
A. Epinephrine
B. Furosemide
C. Nitroprusside
D. Desmopressin
D. Desmopressin
163
A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following
actions should the nurse take?
A. Encourage family members to press the PCA button for the
client.
B. Monitor the client's respiratory status every 4 hours.
C. Teach the client how to self-medicate using the PCA device.
D. Administer an oral opioid for breakthrough pain.
C. Teach the client how to self-medicate using the PCA device.
164
A nurse is preparing a client for a magnetic resonance angiography (MRA). The client is allergic to iodinated contrast dye. Which
of the following actions should the nurse plan to take?
A. Administer prednisone before the test.
B. Consult with the provider to change to a CT scan.
C. Assess the alkaline phosphatase level.
D. Obtain the client's allergy history to seafood.
A. Administer prednisone before the test.
165
A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?
A. Administer oxygen at 2 L/min.
B. Encourage use of incentive spirometry for 5 minutes every 2
hours.
C. Teach the client a breathing exercise with a longer inhalation
phase.
D. Limit fluid intake to 1,000 mL per day.
A. Administer oxygen at 2 L/min.
166
A nurse is planning care for a client who has a radial fracture and a
newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?
A. The client requires assistance with getting dressed.
B. The client reports numbness of the fingers of the left hand.
C. The client reports itching of the left arm.
D. The client has a pillow under their left arm.
B. The client reports numbness of the fingers of the left hand.
167
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should
the nurse include as an indication that the client is no longer
infectious?
A. Mantoux skin test revealing an induration of less than 1 mm
B. Negative sputum cultures for acid-fast bacillus
C. The client is no longer coughing up blood-tinged sputum
D. Positive Quantiferon-TB Gold test (negative)
B. Negative sputum cultures for acid-fast bacillus
168
A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates
an anaphylactic response?
A. Laryngeal edema
B. Fever
C. Hypertension
D. Arrhythmia
A. Laryngeal edema
169
A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following as-
sessment findings indicates to the nurse that the medication is
effective?
A. Respiratory rate of 24/min
B. Adventitious breath sounds
C. Weight loss of 1.8 kg (4 lb) in the past 24 hours
D. Elevation in blood pressure
C. Weight loss of 1.8 kg (4 lb) in the past 24 hours
170
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
A. "This means your lung is fully re-expanded."
B. "Your breathing pattern causes this."
C. "Suction pressure that is too high causes this."
D. "This indicates a possible air leak."
B. "Your breathing pattern causes this."
171
A nurse is providing teaching to a client who is to start furosemide
therapy for heart failure. Which of the following statements indi-
cates that the client understands a potential adverse effect of this
medication?
A. "I'm going to include more cantaloupe in my diet."
B. "I will check my pulse before I take the medication."
C. "I will try to limit foods that contain salt."
D. "I'll check my blood pressure so it doesn't get too high."
A I'm going to include more cantaloupe in my diet
Cantaloupe is high in potassium, which is relevant for clients taking
furosemide
172
A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
A. Administer aspirin.
B. Measure blood pressure.
C. Administer nitroglycerin.
D. Initiate IV access.
C. Administer nitroglycerin.
173
A nurse is providing discharge teaching for a client who is receiv-
ing treatment for genital herpes. Which of the following statements
by the client indicates the effectiveness of the teaching?
A. "I should apply antibiotic ointment to the lesions."
B. "I should use natural skin condoms during sexual intercourse."
C. "I should expect my lesions to resolve in 6 weeks."
D. "I should expect to take my medication for 3 weeks."
D. I should expect to take my medication for 3 weeks
174
A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
A. "I've been having problems with bladder control."
B. "I have difficulty swallowing food."
C. "I have a hard time with brushing my hair."
D. "I would rather be in a wheelchair than use a walker to get
around."
C. "I have a hard time with brushing my hair."
175
A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following
is the first sign of deteriorating neurological status?
A. Cheyne-Stokes respirations
B. Pupillary dilation
C. Altered level of consciousness
D. Decorticate posturing
C. Altered level of consciousness
176
A nurse is caring for a group of clients. From which of the following
clients should the nurse obtain a blood pressure reading using
only the left extremity?
A. A client who has a peripherally inserted central catheter (PICC)
in the left arm
B. A client who has left-sided Bell's palsy
C. A client who has right-sided weakness due to Parkinson's
disease
D. A client who has a right upper extremity arteriovenous fistula
D. A client who has a right upper extremity arteriovenous fistula
177
A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?
A. A client who has diabetes mellitus and is presenting with acute ketoacidosis
B. An older adult client who was admitted with aspiration pneumonia
C. A client who has a compound fracture of the right femur
D. A client who reports having fever, night sweats, and cough for
2 days
D. A client who reports having fever, night sweats, and cough for
2 days
178
A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the
priority?
A. Gurgling bowel sounds every 10 seconds
B. Centrally located umbilical protrusion
C. Abdominal distention during breathing
D. Rebound tenderness with palpation
D. Rebound tenderness with palpation
179
A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement?
A. Droplet precautions
B. Standard precautions
C. Airborne precautions
D. Contact precautions
B. Standard precautions
180
A nurse is preparing to assist with an ocular irrigation for a client
who had a chemical splash to the left eye. Which of the following
actions should the nurse plan to take?
A. Irrigate the affected eye from the inner corner toward the outer
corner.
B. Sit the client up with their head turned toward the right side.
C. Place a strip of pH paper under the upper lid of the affected eye.
D. Irrigate the affected eye using sterile water.
A. Irrigate the affected eye from the inner corner toward the outer
corner.
181
A patient is exhibiting an altered level of consciousness and is
unresponsive to verbal stimuli. To elicit a response from a painful
stimulus, the nurse would:
A. Press down on the orbital area of the eye.
B. Pinch the trapezius muscle.
C. Use a 25-gauge needle.
D. Elicit a reflex with a reflex hammer.
B. Pinch the trapezius muscle.
182
A hospice nurse is planning care for a client who has lung cancer.
Which of the following statements should the nurse make to
incorporate the client's and family's cultural beliefs?
A. "You should limit discussing past events with the client."
B. "We will respect what is important to you."
C. "We will arrange all burial services."
D. "Grieving should not be done in front of the client."
B. "We will respect what is important to you."
183
A nurse is caring for a client who has a new diagnosis of type 2
diabetes mellitus and has a referral for a dietary consult. The client
tells the nurse, "I will have to eat whatever the dietitian tells me."
Which of the following statements by the nurse encourages the
client's involvement in their plan of care?
A. "I can assist you with making a list of foods you like for the
dietitian."
B. "I understand that the dietary choices can seem overwhelming."
C. "Managing your diabetes will require you to make accommo-
dations."
D. "The dietitian will provide you with the best food choices to
manage your diabetes
A. "I can assist you with making a list of foods you like for the
dietitian."
