exit exam practice questions Flashcards
(159 cards)
1
Q
Before leaving the room of the confused client the nurse notes that a half bow knot was used to attach the clients wrist restraints to the movable portion of the client’s bed frame what action should the nurse take before leaving the room?
A
Ensured that the knot can quickly be released.
2
Q
The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?
A
Instruct the mother to change the child’s diaper more often.
2
Q
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?
A
Ventricular arrhythmias.
3
Q
In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Place personal religious artifacts on the body.
b. Confirm the client’s wishes for tissue donation
c Observe consent for autopsy signature by family.
d. Attach identifying name tags to the body.
e. Follow cultural beliefs in preparing the body.
A
a. Place personal religious artifacts on the body.
d. Attach identifying name tags to the body.
e. Follow cultural beliefs in preparing the body.
4
Q
During discharge teaching, the nurse discusses the
parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most
important for the client to acknowledge?
A
Report weight gain of 2 pounds (0.9kg) in 24 hours
5
Q
The nurse is providing education to a client who is experiencing recurrent levels of moderate anxiety to a situations and perceived stress in addition to information about prescribed medications and administration which instructions should the nurse include in the teaching?
A
Practice using muscle relaxation techniques
5
Q
a client presses the call bell and requests pain medication for a severe headache, to assess the quality of the client’s pain which approach should the nurse use?
A
Ask the client to describe the pain
6
Q
An older male client with
history of diabetes mellitus,
chronic gout, and osteoarthritis comes to the
clinic with a bag of medication bottles. Which intervention should the nurse implement first?
A
Identify pills in the bag
7
Q
healthcare provider prescribes a sepsis protocol for a client with multi organ failure caused by a ruptured appendix which intervention is most important for the nurse to include in the plan of care?
A
Maintain strict intake and output
7
Q
A client with a prescription for do not resuscitate (DNR) begins to manifest signs of impending death after notifying the family of the client status what priority action should the nurse implement?
A
The clients need for pain
medication should be determined
8
Q
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound a high protein diet is encouraged to promote wound healing. which lunch choice by the client indicates that the teaching was effective?
A
A tuna fish sandwich with chips and ice cream
9
Q
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effect is the nurse likely to note as result of this increase in glaucoma surgeries?
A
Decreased prevalence of glaucoma in the population
10
Q
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s immediate attention?
A. 16-year-old client diagnosed with major depression who refuses to participate in group.
B.17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.
C. 18-year-old client with antisocial behavior who is being yelled at by other clients.
D. 4-year-old client with anorexia nervosa who is refusing to eat the evening snack.
A
An 18-year-old client with antisocial behavior who is being yelled at by other clients.
11
Q
The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?
A
Get an eye examination with an ophthalmologist annually.
12
Q
the he nurse initiates the procedure to remove a client’s peripherally inserted central catheter (PICC) when a code blue is called tor another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP).
Which action should the nurse take?
A Call for an assistant.
B Finish the procedure
C Respond to the code.
D Close the room door.
A
C Respond to the code.
13
Q
How do we know if the heart meds are working?
A
Loss of 2 pounds in 24 hours
14
Q
When is the most important for the nurse to assess a pregnant clients deep tendon reflexes ?
A
If the client has elevated blood pressure
15
Q
An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postburn infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8°F (39.3°C., heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?
A
Culture sputum, urine, burn wound, and all intravenous access sites.
16
Q
A mother brings her four month old son son to the clinic with a quarter taped over his umbilicus and tell the nurse the quarter is supposed to fix her child’s hernia. Which exclamation should the nurse provide?
A
This hernia is a normal variation that resolves without treatment
17
Q
When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic the client tells the nurse that he usually takes a different dosage. Which action should the nurse take ?
A
Withhold the medication until the dosage can be confirmed
18
Q
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a supra pubic catheter
A
Observe insertion site
19
Q
The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in their diet
A
Low-fat dairy products
Calcium-rich foods:
Dairy products: Milk, yogurt, cheese (especially low-fat varieties)
Leafy green vegetables: Kale, collard greens, broccoli, turnip greens
Fortified foods: Cereals, juices, plant-based milk alternatives
Fish with bones: Canned sardines, salmon
Tofu and soy products
20
Q
Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?
A
Obtain a capillary glucose level.
21
Q
A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?
A
Intravenous administration of benztropine.
22
The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?
Cervical spine stiffness.
23
Prescribed 500 mL bolus to be infused over 30 minutes how many milliliters per hour would you set the pump?
1000 mL per hour
24
A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa 3 times a week. Which laboratory value should the nurse review?
CBC
25
Hypothyroid labs
High TSH
Low T4
26
Heparin
Monitor PT
27
When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?
Explain to the mother that the finding is due to increased androgen.
28
A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?
Determine if the sensation feels uncomfortable.
29
The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?
Mediastinal shift to the right.
30
A client who is having gastrointestinal (GI) difficulties is undergoing diagnostic procedures.
The client asks the nurse about the difference between ulcerative colitis and Crohn's disease.
Which information should the nurse offer?
Rectal bleeding is a predominant symptom in ulcerative colitis.
31
The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record?
Excessive concave curvature of the lumbar spine.
32
After receiving report on an inpatient acute care unit , which client should the nurse assess first ?
A The client with an obstruction of the large intestine who is experiencing abdominal distention .
B The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
C The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid .
D The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity .
the client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity .
33
A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?
A.Right lower abdominal pain.
B.Peripheral neuropathy.
C.Confusion.
D.Depression.
Confusion
34
A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast.
The nurse determines that the client's nipples are inverted. Which action should the nurse implement?
Recommend using a breast shield.
35
The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?
Frequency of laxative use for chronic constipation.
36
A client with a history of hypertension and diabetes mellitus is admitted with uncontrolled atrial fibrillation. The health care provider performed synchronized cardioversion and prescribed a STAT dose of dronedarone 400mgPO
Which assessment finding warrants immediate intervention by the nurse?
A Premature ventricular beats.
B Paroxysmal atrial fibrillation.
C Third degree heart block.
D Elevated mean arterial pressure.
Third degree heart block.
37
A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?
Give the client a schedule of planned daily activities.
38
During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. What food choice(s) included on the client's list should the nurse encourage? Select all that apply.
A.Plain, air-popped popcorn.
B.Cheddar cheese cubes.
C.Lightly salted potato chips.
D.Natural whole almonds.
E.Canned fruit in heavy syrup.
A.Plain, air-popped popcorn.
D.Natural whole almonds.
39
A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of 2 hours. In reviewing the laboratory results, the nurse finds the client's hemoglobin is 12 g/dL (120 g/L) and the hematocrit is 35% (0.35). Which action should the nurse prepare to take?
administer 1,000 mL (1 L) normal saline
40
treatment of UC
obtain bun, Creat, LFT
bowel patterns
Mesalamine
41
In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?
Hematocrit of 28% (0.28 volume fraction).
42
A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?
Complete blood count.
43
The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?
Auscultate for irregular heart rate.
44
Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?
A.Call the pharmacy to obtain a client's next antibiotic dose.
B.Observe a client's gait to determine the need for assistance.
C.Bring a sterile chest drainage unit from central supply to the unit.
D.Evaluate a client's urinary catheter for proper drainage.
Bring a sterile chest drainage unit from central supply to the unit.
45
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?
A.Keep head of bed raised 45 degrees.
B.Monitor blood glucose level.
C.Maintain strict intake and output.
D.Assess warmth of extremities.
Maintain strict intake and output.
46
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention if most important for the nurse to include in the plan of care?
a) Administering pain medication
b) Providing emotional support to the family
c) Initiating intravenous fluids and antibiotics promptly
d) Ensuring the patient has a comfortable environment
c) Initiating intravenous fluids and antibiotics promptly
47
A client is experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?
IV administration of benztropine
48
The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?
Average client scores improved on specific risk factor knowledge tests.
49
The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dL (325 µmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?
Reposition the infant every 2 hours.
50
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
A.Instructions about how much fluid the child should drink daily
B.information about non-pharmaceutical pain reliever measures
C.Referral for social services for the child and family
D.Signs of addiction to opioid and medications
Instructions about how much fluid the child should drink daily
51
A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. What actions should the nurse take to monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS)? (Select all that apply)
a. Check urine for ketones
b. Measure blood glucose
c. Monitor vital signs
d. Assessed level of consciousness
e. Obtain culture of the wound
b. Measure blood glucose
c. Monitor vital signs
d. Assessed level of consciousness
52
When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site?
deltoid
53
A female nurse who took drugs from the unit for personal use was temporarily released from duty. After compliance of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administration approaches the charge nurse with the impaired nurses request , what action is best for the charge nurse to take?
Allow the nurse to return to work and monitor medication administration
54
The nurse identifies an electrolyte imbalance, and elevated pulse rate, and an elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take?
Auscultate for irregular heart rate
55
In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?
Observe both lower extremities for redness and swelling.
56
While caring for a toddler receiving oxygen (O2) via face mask, the nurse observes that the child’s lips and nares are dry and cracked. Which intervention should the nurse implement?
Use a water soluble lubricant on affected oral and nasal mucosa
57
a male client with heart failure becomes short of breath, anxious, and has audible wheezing with pink
frothy sputum. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives
a prescription to administer a one-time dose of morphine sulfate intravenously. What action should the
nurse take?
Administer the morphine sulfate as prescribed
58
The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?
White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)
A.Moderate amount of foul-smelling lochia.
B.Blood pressure of 122/74 mm Hg
C.Oral temperature of 100.2°F (37.9°C..
D.White blood cell count of 19,000/mm^3 (19 x 10^9/L)
Moderate amount of foul-smelling lochia.
59
The nurse observes that a
postoperative client with a
continuous bladder
irrigation has a large blood
clot in the urinary drainage
tubing. What action should
the nurse perform first?
observe the amount of urine in the clients
urinary drainage bag.
60
A client on a long-term
mental health unit
repeatedly takes own pulse
regardless of the
circumstance. What action
should the nurse
implement?
overlook the behavior
61
A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this client's plan of care?
Monitor the client's cardiac activity via telemetry.
62
When administering an
immunization in an adult
client, the nurse palpates
and administer the injection
one inch below the
acromion process into the
center of the muscle mass.
The nurse should document
that the vaccine was
administered at what site?
Deltoid
63
A mother brings her 4-
month-old son to the clinic
with a quarter taped over his
umbilicus, and tells the
nurse the quarter is
supposed to fix her child's
hernia. Which explanations
should the nurse provide?
This hernia is a normal variation that resolves
without treatment.
64
When assessing the surgical
dressing of a client who had
abdominal surgery the
previous day, the nurse
observes that a small
amount of drainage is
present on the dressing and
the wound's Hemovac
suction device is empty with
the plug open. How should
the nurse respond?
Recompress the wound suction device and
secure to plug
65
While making rounds, the
charge nurse notices that a
young adult client with
asthma who was admitted
yesterday is sitting on the
side of the bed and leaning
over the bed-side-table. The
client is currently receiving
at 2 liters/minute via nasal
cannula. The client is
wheezing and is using
pursed-lip breathing. Which
intervention should the
nurse implement?
Administer a nebulizer Treatment
66
A child newly diagnosed
with sickle cell anemia (SCA)
is being discharged from the
hospital. Which information
is most important for the
nurse to provide the parents
prior to discharge?
Instructions about how much fluid the child
should drink daily
67
When planning care for a
client with acute
pancreatitis, which nursing
intervention has the highest
priority?
Withhold food and fluid intake
68
When assessing a
multigravida the first
postpartum day, the nurse
finds a moderate amount of
lochia rubra, with the uterus
firm, and three
fingerbreadths above the
umbilicus. What action
should the nurse implement
first?
Check for a distended bladder
69
A male client is admitted for
the removal of an internal
fixation that was inserted for
the fracture ankle. During
the admission history, he
tells the nurse he recently
received vancomycin
(vancomycin) for a
methicillin-resistant
Staphylococcus aureus
(MRSA) wound infection.
Which action should the
nurse take? (Select all that
apply.)
a. collect multiple site
screening culture for MRSA
b. Call healthcare provider
for a prescription for
linezolid (Zyrovix)
c, Place the client on
contact transmission
precautions
d. Obtain sputum specimen
for culture and sensitivity
e. Continue to monitor for
client sign of infection.
a. Collect multiple site screening culture for
MRSA
C. Place the client on contact transmission
precautions
e. Continue to monitor for client sign of
infection.
70
Which intervention should
the nurse include in the plan
of care for a child with
tetanus?
Minimize the amount of stimuli in the room
71
After receiving report on an inpatient acute care unit, which client should the nurse
assess first?
The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
72
An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
Had a cold and ear infection for the past two days
73
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply.)
A. Inspect skin for redness.
B. Use a residual limb shrinker.
C. Apply alcohol to the stump after bathing.
D. Wash the stump with soap and water.
E. Avoid range of motion exercises.
A. Inspect skin for redness.
B. Use a residual limb shrinker.
D. Wash the stump with soap and water.
74
The healthcare provider prescribes a sepsis protocol for a client with mutli-organ failure caused by a ruptured appendix. Which intervention is most important for the
nurse to Include in the plan of care?
Maintain strict intake and output.
75
A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?
Ask the client to describe the pain.
76
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)?
(Select al that apply.)
A. Report any client complaint of pain or discomfort.
B. Evaluate the client for sleep disturbances
C. Assess the client for weakness and fatigue.
D. Weigh the client and report any weight gain.
E. Note and report the client's food and liquid intake during meals and snacks.
A. Report any client complaint of pain or discomfort.
D. Weigh the client and report any weight gain.
E. Note and report the client's food and liquid intake during meals and snacks.
77
An unlicensed assistive personnel (UP) is assigned to ambulate a client with influenza who has droplet precautions implemented. The UAP requests a change in assignment,
stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take?
Instruct the UP that a standard face mask is sufficient for the provision of care for the assigned client
78
After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply)
A. Location of the initial V site
B. Red blood cell count RBC)
C. Swollen Iymph nodes in the groin.
D. White blood cell count (WBC).
E. core body temperature
C. Swollen Iymph nodes in the groin.
D. White blood cell count (WBC).
E. core body temperature
79
The nurse has completed the diet teaching of a male client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
A tuna fish sandwich with chips and ice cream.
80
An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter stated that her mother's behavior changed suddenly a few days ago and is now getting worse. Which actions should the nurse take?
a. Encourage increased intake of high protein foods
b. Instruct the daughter to check her mother's temperature
c. Review the client's current food and medication allergies
d. Ask if the mother is experiencing any pain with urination
e. Determine if the mother has recently experienced a fall.
Ask if the mother is experiencing any pain with urination.
Instruct the daughter to check her mother's temperature.
Determine if the mother has recently experienced a fall.
81
The nurse is managing 4 clients in the intensive care unit who are mechanically
ventilated. After performing a quick visual assessment, the nurse should prioritize
care for the client who is exhibiting which finding?
Restrained and restless with a low volume alarm sounding
82
Three days after initiating parenteral fluids for a newborn with a ventricular septal
defect (VSD), the nurse assesses an increase in heart rate and blood pressure. Which
intervention is most important for the nurse to implement?
restrict intake of oral fluids
83
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicates the client understands how to maintain balance safely? (Select all that apply)
A.Bends from the waist to pick trash off the floor.
B.Widens stance while working near the sink.
C.Locks knees while preparing food on the counter.
D.Brings a heavy can close to body before lifting.
E.Leans forward to pull a pan from a high shelf
B.Widens stance while working near the sink.
D.Brings a heavy can close to body before lifting.
84
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care?
Provide written instructions for eye drop administration.
85
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?
Reference Range:
Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]
Assess urine and stool for occult blood.
86
When conducting diet teaching for a client who is on a postoperative full-liquid diet, which food(s) should the nurse encourage the client to eat? (Select all that apply.)
A.Clear beef broth.
B.Vegetable juice.
C.Canned fruit cocktail.
D.Vanilla frozen yogurt.
E.Creamy peanut butter.
Clear beef broth.
Vegetable juice.
Vanilla frozen yogurt.
87
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply.)
A. Inspect skin for redness.
B. Use a residual limb shrinker.
C. Apply alcohol to the stump after bathing.
D. Wash the stump with soap and water.
E. Avoid range of motion exercises.
A. Inspect skin for redness.
B. Use a residual limb shrinker.
D. Wash the stump with soap and water.
88
A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide?
Antidepressants usually begin to improve your mood after 2 to 4 weeks.
89
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
Instructions about how much fluid the child should drink
90
An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)
A) Measure neurological vital signs every 4 hours
B)Encourage family to participate in the client's care
E) Play classical music in room while client is awake
91
A male client who is
admitted to the mental
health unit for treatment of
bipolar disorder has a
slightly slurred speech
pattern and an unsteady
gait. Which assessment
finding is most important
for the nurse to report to
the healthcare provider?
Serum lithium level of 1.6 mEg/L or mmol/I (SI)
92
The charge nurse of critical
care unit informed at
beginning of shift that less
than optimal number
registered nurses be
working that shift. In
planning assignments,
which client should receive
most care hours by a
registered nurse
An 82-year-old client with Alzheimer's disease
newly-fractures femur who has a Foley
catheter and soft wrist restrains applied
93
A client is receiving
mesalamine 800 mg PO
TID. Which assessment is
most important for the
nurse to perform to assess
the effectiveness of the
medication?
Bowel patterns
94
Which location should the
nurse choose as the best
for beginning a screening
program for
hypothyroidism?
A business and professional women's group
95
A school nurse is called to
the soccer field because a
child has a nose bleed
(epistaxis). In what position
should the nurse place the
child
Sitting up and leaning forward
96
Which instruction should
the nurse provide a
pregnant client who is
complaining of heartburn?
Eat small meal throughout the day to avoid a
full stomach.
97
An older woman who
has difficulty hearing is
being discharged from
day surgery following a
cataract extraction and
lens implantation which
intervention is most
important for the nurse
to implement to help
ensure the client's
compliance with self-
care?
Provide written instructions for eye drop administration.
98
A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement
Administer PRN dose of albuterol
99
A client admitted to the
psychiatric unit
diagnosed with major
depression wants to
sleep during the day
refuses to take a bath
and refuses to eat which
nursing intervention
should the nurse
implement first?
Establish a structured routine for the client to follow
100
A client with type one diabetes
mellitus and a large draining Ulcer
of the right foot is admitted with a
suspected Staphylococcus Aureus
infection which intervention
should the nurse implement?
select all that apply
Monitor the clients white blood cell count
send wound drainage for a culture and sensitivity
institute contact precautions for staff and visitors
101
The nurse assesses a child in 90 to
90 skeletal tractions where should
the nurse assess for signs of
compartment svndrome?
Click spot right on toes on injured foot
102
A client is receiving mesalamine
800mg po TID Which assessment
is most important for the nurse to
perform to assess the
effectiveness of the medication?
bowel patterns
103
Before leaving the room of the
confused client the nurse notes
that a half bow knot was used to
attach the clients wrist restraints
to the movable portion of the
client's bed frame what action
should the nurse take before
leaving the room?
Ensured that the knot can quickly be released.
104
The nurse is managing the care of
a client With cushings syndrome
which intervention should the
nurse delegate to the unlicensed
assistance personnel? SATA
Report any client complaints of pain or discomfort
weigh the client and report any weight gain
note and report that clients food and liquid intake during meals and snacks
105
The nurse identifies an electrolyte
imbalance crackles on
auscultation and an elevated
blood pressure in a client with
progressive heart disease which
intervention should the nurse
include in the plan of care?
Measure ankle circumference
106
A male client with persistent low
back pain has received a
prescriptions for an electronic
stimulator 10s unit after the nurse
applies the electrodes and turn on
the power the client reports a
tingling sensation how should the
nurse respond?
Determine if the sensation feels uncomfortable
107
Suicide precautions are initiated
for a child admitted to the mental
health unit following an intentional
narcotic overdose after a visitor
leaves the nurse finds a packet of
cigarettes in the clients room
which intervention is most
important for the nurse to
implement?
Remove cigarettes from the clients room
108
A client who received
hemodialysis yesterday is
experiencing a blood pressure of
200/100 mmHg, heart rate 110
beats/minute, and respiratory rate
36 breaths/minute. The client is
manifesting shortness of breath,
bilateral 2+ pedal edema, and an
oxygen saturation on room air of
89%. Which action should the
nurse take first?
Begin supplemental oxygen.
109
An older client's daughter calls
the home health nurse and
reports that her mother has
become forgetful and is very
confused at night. The daughter
stated that her mother's behavior
changed suddenly a few days ago
and is now getting worse which
action should the nurse take?
SATA
Determine if mother experienced fall recently,
Instruct the daughter to take her mother's temp,
Ask if mother is experiencing pain on urination.
110
The mother of a 7-month-old
brings the infant to the clinic
because the skin in the diaper
area is excoriated and red, but
there are no blisters or bleeding.
The mother reports no evidence
of watery stools. Which nursing
intervention should the nurse
implement?
Instruct the mother to change the child's diaper more often.
111
After six days on a mechanical
ventilator, a male client is
extubated and place on 40%
oxygen via face mask. He is awake
and cooperative, but complaining
of a severe sore throat. While
sipping water to swallow a
medication, the client begins
coughing, as if strangled. What
intervention is most important for
the nurse to implement?
Hold oral intake until swallow evaluation is done.
112
During discharge teaching, the
nurse discusses the parameters
for weight monitoring with a client
who was recently diagnosed with
heart failure (HF). Which
information is most important for
the client to acknowledge?
Report weight gain of 2 pounds (0.9kg) in 24 hours
113
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?
Decrease prevalence of glaucoma in the population.
114
The nurse is caring for a client
who is entering the second stage
of labor. Which action should the
nurse implement first?
Convey to the client that birth is imminent
cervix is fully dilated and pushing can begin
115
An older male client with history
of diabetes mellitus, chronic gout,
and osteoarthritis comes to the
clinic with a bag of medication
bottles. Which intervention should
the nurse implement first?
Identify pills in the bag.
116
The healthcare provider changes
a client's medication prescription
from IV to PO administration and
double the dose. The nurse notes
in the drug guide that the
prescribed medication, when
given orally, has a high first-pass
effect and reduce bioavailability.
What action should the nurse
implement?
Administer the medication via the oral route as prescribed
The nurse should administer the medication via the oral route as prescribed by the healthcare provider, as the doubled dose is likely an adjustment for the first-pass effect and reduced bioavailability associated with oral administration.
117
When assessing a 6-month old
infant, the nurse determines that
the anterior fontanel is bulging. In
which situation would this finding
be most significant?
Sitting upright.
118
An older adult female admitted to
the intensive care unit (ICU) with a
possible stroke is intubated with
ventilator setting of tidal volume
600, PIO2 40%, and respiratory
rate of 12 breaths/minute. The
arterial blood gas (ABG) results
after intubation are PH 7.31.
PaCO2 60, Pa02 104, SPO2 98%,
HCO3 23. To normalize the
client's ABG finding, which action
is required?
Increase ventilator rate
119
The charge nurse of a critical care
unit is informed at the beginning
of the shift that less than the
optimal number of registered
nurses will be working that shift. In
planning assignments, which client
should receive the most care
hours by a registered nurse (RN)?
An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied
120
In caring for a client with
Cushing's Syndrome, which serum
laboratory value is most important
for the nurse to monitor?
glucose
121
The healthcare provider
prescribes methylergonovine
maleate for a postpartum client
with uterine atony. What finding
should indicate to the nurse to
withhold the next dose of the
medication?
Hypertension
122
A client with leukemia who is
receiving a myleosuppressive
chemotherapy has a platelet
count of 25,000/mm3. Which
intervention is most important for
the nurse to include in this client's
plan of care?
Assess urine and stool for occult blood
123
Which instruction should the nurse
provide a pregnant client who is
reporting heartburn?
Eat small meals throughout the day to avoid a full stomach.
124
The nurse is planning to teach
infant care and preventive
measures for sudden infant death
syndrome (SIDS) to a group of
new parents. Which information is
most important for the nurse to
include?
Ensure that the infant's crib mattress is firm.
125
During discharge teaching, an
overweight client with heart
failure (HF) is asked to make a
grocery list for the nurse to
review. Which food choices
included on the client's list should
the nurse encourage? SATA
A. Canned fruit in heavy syrup
B. Natural whole almonds
C. Plain, air-popped popcorn
D. Lightly salted potato chips
E. Cheddar cheese cubes
B. Natural whole almonds
C. Plain, air-popped popcorn
126
A client with a C-6 spinal cord
injury is in rehabilitation. In the
middle of the night the client
reports a severe, pounding
headache, and has observable
piloerection or
"goose bumps".
The nurse should assess for which
trigger?
full bladder
127
The nurse discovers that an
elderly client with no history of
cardiac or renal disease has an
elevated serum magnesium level.
To further investigate the cause of
this electrolyte imbalance, what
information is most important for
the nurse to obtain from the
client's medical history?
Frequency of laxative use for chronic constipation
128
The nurse is triaging several
children as they present to the
emergency room after an
accident. Which child requires the
most immediate intervention by
the nurse?
An 11-vear-old with a headache, nausea, and projectile vomiting
129
The RN is assigned to care for
four surgical clients. After
receiving report, which client
should the nurse see first?
Three days postoperative colon resection receiving transfusion of packed RBCs..
130
An older male client is admitted
to mental health with a sudden
onset of global disorientation and
is continuously with mother, who
died 50 years ago. The nurse
reviews the multiple prescriptions
the client is currently taking and
assesses his urine specimen, which
is cloudy, dark yellow, and has a
foul odor. These findings suggest
that this client is experiencing
which condition?
Delirium
131
A client develops urticaria on the trunk and neck
shortly after a secondary infusion of piperacillin is initiated. In which order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)
Document reaction to the drug.
Contact the healthcare provider.
Assess vital signs.
Stop the infusion.
Initiate an adverse event report.
1. Stop the infusion.
2. Assess vital signs.
3. Contact the healthcare provider.
4. Document reaction to the drug.
5. Initiate adverse event report
132
An older client presents to the
emergency room department with
abdominal pain due to
constipation. The nurse is
providing a list of high-fiber foods
to the client that the healthcare
provider has prescribed. Which
action should the nurse implement
when reviewing the list of foods?
Turn on overhead lights while giving instructions
133
When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?
Explain to the parents that anger is a common response to grief.
134
The nurse is caring for a client
with pneumonia who now
develops initial signs of septic
shock and multi-organ failure. The
healthcare provider prescribes a
sepsis protocol. Which
intervention is most important for
the nurse to include in the plan of
care?
Maintain strict intake and output
135
When conducting diet teaching
for a client who is on a
postoperative full liquid diet,
which foods should the nurse
encourage the client to eat?
vanilla frozen yogurt
Vegetable juice
broth
136
The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an intravenous (IV) infusion of 1000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 mL remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8 hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report?
Soft abdomen, absent bowel sounds, no bleeding on dressing.
137
While making rounds, the charge
nurse notes that a young adult
client with asthma who was
admitted yesterday is sitting on
the side of the bed and learning
over the bed - side table. The
client is currently receiving
oxygen 2L/min via nasal cannula.
The is wheezing and is using
pursed- lip breathing which
intervention should the nurse
implement?
Administer a nebulizer Treatment
138
A client who weighs 65 kg
receives a prescription for a
lorazepam 44 mcg/kg
intravenouslv to be administered
20 minutes before a scheduled
procedure. The medication is
available in 2 mg/mL vial. How
man mL should the nurse
administer ?
1.4ml
139
Client with foul- smelling drainage
from an incision on the upper left
arm is admitted with suspected
methicillin- resistant
staphylococcus aureus(MRSA).
Which nursing intervention should
the nurse include in the plan of
care?
send wound drainage for culture
Monitor the client white blood cell
Institute contact precaution
140
A male client admitted with
chronic pulmonary obstruction
disease (COPD) exacerbation is
receiving assisted vent with
continuous positive artery
pressure (CPAP). His vitals signs
are temperature 98.8 F (37.1 C),
heart rate 118 beats/minute,
respirations 46 breaths/minute,
and blood pressure 176/82. While
completing the pulmonary
assessment his oxygen saturation
decreases and he is difficult to
arouse. Which action should the
nurse implement?
Prepare for rapid sequence intubation
141
Before leaving the room of a
confused client, the nurse notes
that a half bow knot was used to
attach the client's wrist restraints
to the moveable portion of the
client's bed frame. What action
should the nurse take before
leaving the room?
ensure the know can be released quickly
142
A client with unilateral hearing
loss is admitted for a scheduled
surgery. Which technique should
the nurse use to provide
education about pain relief
options?
Write information on a whiteboard.
143
The nurse is caring for a client
who has been admitted with
recurring headaches. To assess
the quality of the client's pain
Ask the client to describe pain
144
The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. What action should the nurse implement?
Advise the UAP that the technique being used will result in hand contamination
145
The nurse is managing the care of
a client with Cushing syndrome.
Which intervention(s) should the
nurse delegate to the unlicensed
assistive personnel (UP)? (SATA)
Weigh the client and report any weight gain
Note and report the client's food and liquid intake during meals and snacks
Report any complaint of pain and comfort
146
The charge nurse is making
assignments for one practical
nurse (PN) and three registered
nurses (RN) who is caring for
neurologically compromised
clients. Which client is best to
assign to the PN?
Viral meningitis whose temperature changed from 101F to 102F
147
An older client with Alzheimer's
disease is confused and asks the
nurse to call their mother, who is
deceased. Which
non-pharmacological interventions
should the nurse use?
Use distraction and therapeutic communication skills
148
The nurse enters a clients room to
administer scheduled daily
medications and observes the
client leaning forward and using
pursed lip breathing. Which action
is most important for the nurse to
implement first?
Evaluate oxygen saturation
149
Which is the best approach for the
nurse to use when interviewing a
client about sexual abuse?
Begin with questions that are less sensitive in nature
150
A client receiving zidovudine
reports the appearance of
pinpoint red round spots on the
skin. Which results should the
nurse report to the healthcare
provider?
CBC
151
A client with a history of peptic
ulcer disease (PUD) is admitted
after vomiting bright red blood
several times over the course of 2
hours. In reviewing the laboratory
results, the nurse finds the client's
hemoglobin is 12 g/dL, and the
hematocrit is 35%. Which action
should the nurse prepare to take?
Prepare the client for emergency surgery.
152
A client with a history of type 1
diabetes Mellitus (DM) and asthma
is readmitted to the unit for the
third time in two months with a
current fasting blood sugar (FBS)
is 325 mg/dI (18mmol/L SI). The
client describes to the nurse of
not understanding why the blood
glucose level continues to be out
of control. Which interventions
should the nurse implement?
(SATA)
- Have the client describe a typcial day at work, home, and social activities
-Have the client demonstrate a technique used to monitor blood glucose levels
153
A client arrives to the medical-
surgical unit 4 hours after a
transurethral resection of the
prostate. A triple-lumen catheter
for continuous bladder irrigation
with normal saline is infusing and
the nurse observes dark, pink-
tinged outflow with blood clots in
the tubing and collection bag.
Which action should the nurse
take?
Monitor catheter drainage.
154
A client with type one diabetes
mellitus and a large draining ulcer
of the right foot is admitted with a
suspected Staphylococcus Aureus
infection which intervention
should the nurse implement?
select all that apply
Monitor the clients white blood cell count
send wound drainage for a culture and sensitivity
institute contact precautions for staff and visitors
155
The nurse is managing the care of
a client With cushings syndrome
which intervention should the
nurse delegate to the unlicensed
assistance personnel? SATA
Report any client complaints of pain or discomfort
weigh the client and report any weight gain
note and report that clients food and liquid intake during meals and snacks
156
The nurse identifies an electrolyte
imbalance crackles on
auscultation and an elevated
blood pressure in a client with
progressive heart disease which
intervention should the nurse
include in the plan of care?
Measure ankle circumference
