Nursing Comprehensive form A,B,C Questions with Answers, Exams of Nursing

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Nursing Comprehensive form A,B,C Questions with

Answers

1.A nurse is admitting a client who has antisocial personality disorder. Which of the following client

behaviors should the nurse identify as consistent with this disorder?

A. Compulsive attention to details

B. Avoids interacting with others

C. Uses others for personal gain

D. Socially awkward in group situations: C. Uses others for personal gain

2.A nurse is interpreting the cardiac rhythm strip of a client who was admitted with syncope. Which

of the following images indicates that the client has atrial fibrillation?:

3.A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery

suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take?

A. Rupture the amniotic sac

B. Medicate the client for pain

C. Prepare the client for a cesarean section

D. Perform a vaginal exam: C. Prepare the client for a cesarean section

4.A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit.

Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treat- ments B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow D. A 14-year-old client who is scheduled for discharge today following place- ment of a Harrington rod: A. A 10-year-old client who has pneumonia and is receiving respiratory treatments

5.A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After

moving the client to safety, which of the following is the priority action?

A. Notify the facility operator.

B. Close the fire doors on the unit.

C. Turn off oxygen sources.

D. Put out the fire with the appropriate extinguisher.: A. Notify the facility opera- tor.

6.A nurse is assessing an infant who has water intoxication. Which of the following findings

should the nurse expect?

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A. Generalized edema

B. Elevated urine specific gravity

C. Thready pulse

D. Increased hematocrit: A. Generalized edema

7.A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which

of the following statements indicates the newly licensed nurse understands the purpose of the technique?

A. This technique prevents injury to the sciatic nerve

B. This technique decreases the risk of subcutaneous infiltration

C. This technique allows a larger amount of medication to be injected

D. This technique increases the absorption rate of the drug: This technique decreases the risk

of subcutaneous infiltration

8.A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following

interventions should the nurse include in the plan?

A. Encourage the client to gain 2.3 kg per week

B. Weigh the client once per week throughout hospitalization

C. Monitor the client for 1 hr after meals

D. Allow the client to choose mealtimes: C. Monitor the client for 1 hr after meals

9.A nurse is planning care for a child who has increased intracranial pressure with a decrease in

level of consciousness. Which of the following interven- tions should the nurse include in the plan of care?

A. Perform active range-of-motion exercises

B. Maintain the head at a midline position

C. Suction the airway frequently

D. Perform neurological checks every 4 hrs: B. Maintain the head at a midline position

10.10. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following

findings should the nurse expect?

A. Hallucinations

B. Agnosia

C. Bradycardia

D. Aphasia: A. Hallucinations

11.A nurse is assessing a client who is receiving enteral feedings via a gas- trostomy tube. The

nurse should identify that which of the following findings indicates fluid overload?

A. Diminished bowel sounds

B. Bradycardia

C. Hypotension

D. Bounding pulses: D. Bounding pulses

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12.A nurse is caring for a client following an open colectomy. Which of the following findings

places the client at risk for delayed wound healing?

A. INR 1.

B. Hyperemesis

C. HbA1c 5.6%

D. Uncontrolled pain: B. Hyperemesis

13.A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The

nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels?

A. 3-hr oral glucose tolerance test

B. HbA1c

C. Fasting blood glucose test

D. Urinalysis for ketones: B. HbA1c

14.A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions

should the nurse take while caring for this client?

A. Wear an N95 respirator

B. Insert an indwelling urinary catheter to monitor urinary output

C. Monitor the client's vital signs every 8 hr

D. Use a dedicated stethoscope: D. Use a dedicated stethoscope

15.A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following

actions should the nurse take?

A. Encourage the client to ambulate in the hallway 1 hr before bedtime

B. Tell the client to avoid drinking fluids 1 hr before bedtime

C. Schedule routine care tasks during hours when the client is awake

D. Advise the client to leave the television in the room on when trying to fall asleep: C. Schedule

routine care tasks during hours when the client is awake

16.A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive

phototherapy. Which of the following interventions should the nurse include?

A. Clothe the newborn in light cotton

B. Check the newborn's temperature every 8 hrs. (every 4)

C. Administer 120 mL of water between feedings

D. Place the newborn 45 cm from the light source: D. Place the newborn 45 cm from the light

source

17.A nurse is planning care for a client who has schizophrenia and is having difficulty expressing

their feelings. Which of the following referrals should the nurse make?

A. Art therapist

B. Speech-language pathologist

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C. Social worker

D. Recreational therapist: A. Art therapist

18.A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which

of the following findings indicates the client is experi- encing an adverse effect of the medication?

A. Decreased reflexes

B. Weight gain of 1.4 kg

C. Increased urinary output

D. Jugular vein distention: A. Decreased reflexes

19.At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list

of client reports. Which of the following client reports should the nurse assess first?

A. Constipation

B. Indigestion

C. Swollen ankles

D. Urinary frequency: B. Indigestion

20.. A nurse is caring for a client who has just returned to the unit following a bronchoscopy.

Which of the following actions by the assistive personnel requires the nurse to intervene?

A. Encourages the client to use the incentive spirometer

B. Elevates the head of the client's bed

C. Offers oral fluids to the client

D. Checks the client's pulse oximetry: C. Offers oral fluids to the client

21.. A nurse in a mental health facility is interviewing a newly admitted client. Which of the following

actions should the nurse take when conducting the interview?

A. Insist the client use direct eye contact during the interview

B. Seat the client at least 3.7m from the nurse

C. Position the client's chair between the nurse's chair and the door

D. Lean in slightly when speaking to the client: D. Lean in slightly when speaking to the client

22.A nurse on a medical unit has just received change-of-shift report. Which of the following clients

should the nurse assess first? A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10 B. A 48-year-old client who has AIDS, pneumocystis pneumonia, and a tem- perature of 38.3 C (101F) C. A 60-year-old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an oxygen saturation of 89% D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void: A 68-year- old client who had a myocardial infarction 2 days ago and reports chest pain 4 on a scale of 0 to 10

23.A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an

allergy to which of the following food can indicate that the client has an allergy to latex?

A. Peanuts

B. Shellfish

C. Avocados

D. Eggs: C. Avocados

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24.A nurse is preparing to witness a client's signature on an informed consent for a total knee

arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon?

A. I wonder if the metal in my knee will show up in airport screenings

B. The physical therapy has not been working, so I will need to have the surgery

C. I look forward to being able to bend my knee again when I sit in a chair

D. I am thankful there are no serious complications from this type of surgery-

: D. I am thankful there are no serious complications from this type of surgery

25.A nurse is teaching the parent of a school-age child who has scabies about the application of

permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication?

A. Burning

B. Discoloration

C. Photosensitivity

D. Alopecia: A. Burning

26.A nurse is teaching a client who has a new prescription for digoxin. Which of the following

statements should the nurse include in the teaching?

A. "Notify your provider if you experience muscle weakness."

B. "Reports a weight gain of one-half pound per day."

C. "Expect this medication to increase your blood pressure."

D. "You will need to take a diuretic while taking this medication.": A. "Notify your provider if you

experience muscle weakness."

27.A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of

urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention?

A. Decrease intake of citrus foods and beverages

B. Wear nylon underwear

C. Empty the bladder before and after intercourse

D. Increase the time between voiding: C. Empty the bladder before and after intercourse

28.A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed.

Which of the following should the nurse recommend the client increase in their diet during lactation?

A. Vitamin D

B. Iron

C. Vitamin A

D. Calcium: D. Calcium

29.A nurse is providing teaching about preventing mastitis to a client who is postpartum and

breastfeeding her newborn. Which of the following instruc- tions should the nurse include?

A. "Wear an underwire bra between feedings."

B. "Cover your breasts immediately after feedings."

C. "Apply cold compresses to your breasts before feedings."

D. "Try to have your baby empty your breasts with each feeding.": D. "Try to have your baby

empty your breasts with each feeding."

30.A nurse is caring for a client who reports chest pain. Which of the following findings indicates

myocardial damage?

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A. aPTT 80 seconds

B. Troponin I 1.8 ng/mL

C. Erythrocyte sedimentation rate 17 mm/hr

D. Human B-type natriuretic peptide 88 pg/mL: B. Troponin I 1.8 ng/mL

31.A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of

the following statements by the parent indicates an understanding of the teaching?

A. "I should place a rolled blanket along each side of my baby's head in the car seat."

B. "I should place my baby's car seat rear-facing until 6 months of age."

C. "I should put the car seat retainer clip at the level of my baby's belly button."

D. "I should position my baby's car seat at a 90-degree angle in the car.": A. "I should place a rolled

blanket along each side of my baby's head in the car seat."

32.A nurse is performing high-frequency chest compressions using a me- chanical chest

compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective?

A. The child develops a dry, hacking cough

B. The child has increased nasal secretions

C. The child has increased sputum production

D. The child develops diminished breath sounds: C. The child has increased sputum

production

33.A nurse is caring for a client following a possible exposure to anthrax. Which of the following

actions should the nurse take?

A. Administer an antitoxin

B. Quarantine the client

C. Monitor the client for a productive cough

D. Begin prophylactic treatment with ciprofloxacin: D. Begin prophylactic treat- ment with

ciprofloxacin

34.A nurse is caring for a client who has a newly implanted sealed internal ra- diation device to treat

cervical cancer. Which of the following is an appropriate action for the nurse to take?

A. Prohibit visitors for the first 24 hrs

B. Keep a 3-foot distance from the radiation implant

C. Maintain the client on bed rest for 72 hr

D. Require the client wear a dosimeter badge: C. Maintain the client on bed rest for 72 hr

35.A nurse is admitting a client to the medical-surgical unit. Which of the following actions

should the nurse take first?

A. Place the client's valuables in the facility's safe

B. Observe the client's level of mobility

C. Administer prescribed medications

D. Electronically enter the prescriptions from the provider: B. Observe the client's level of

mobility

36.A nurse at a public health clinic is caring for a group of clients. Which of the following should the

nurse identify as a reportable diagnosis to the CDC?

A. Herpes simplex virus (HSV) type 1

B. Hepatitis A

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C. Human papillomavirus (HPV)

D. Pediculosis capitis: B. Hepatitis A

37.A charge nurse is evaluating the time management skills of a newly li- censed nurse. Which of

the following actions should the charge nurse identify as an effective time management skill?

A. Delegates creation of a client's teaching plan to a licensed practical nurse

B. Completes activities for one client before moving to the next client

C. Focuses on activities rather than objectives

D. Skips break times to catch up on charting: B. Completes activities for one client before

moving to the next client

38.A nurse delegates tasks to a licensed practical nurse and an assistive personnel. When

admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

A. Insert an indwelling catheter if the client has not voided in 3 hr

B. Obtain the abdominal girth now and every 4 hr

C. Assess and document the level of consciousness every hour

D. Measure the amount of gastric drainage every 2 hr: A. Insert an indwelling catheter if the

client has not voided in 3 hr

39.A nurse is assessing a client who has a long arm cast. For which of the following findings

should the nurse monitor when assessing for acute compartment syndrome

A. Edema

B. Shortness of breath

C. Petechiae

D. Change in mental status: A. Edema

40.A nurse is caring for a client who has opioid use disorder and is experi- encing withdrawal.

Which of the following findings should the nurse expect?

A. Hyperreflexia

B. Meiosis (mydriasis)

C. Euphoria (intended sign of opioid toxicity)

D. Hypothermia (hyperthermia): A. Hyperreflexia

41.A nurse is planning to perform wound irrigation for a client who has an open secondary wound.

When creating a sterile field, which of the following actions should the nurse take?

A. Set up the sterile field 7.6 cm below waist level

B. Hold the bottle of sterile solution with the palm over the label while pouring

C. Place the sterile items within 1 cm of the edge of the sterile border

D. Place the lid of a bottle of sterile solution within the sterile field: B. Hold the bottle of sterile

solution with the palm over the label while pouring

42.A nurse is assessing a client who was brought to the emergency de- partment by his adult

child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

A. Report the incident to Adult Protective Services

B. Interview the client with his adult child present

C. Tell the client he must answer every assessment question

D. Advise the client to consult a social worker: A. Report the incident to Adult Protective

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43.44. A nurse is assessing a client who is postoperative following abdominal surgery. The client

states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? Med Surg page 670

A. Extend the client's legs above heart level

B. Place the client in a low-Fowler's position

C. Instruct the client to perform the Valsalva maneuver

D. Apply a dry gauze dressing to the incision: B. Place the client in a low-Fowler's position

44.45. A nurse is providing teaching to the parent of a 6-month-old infant who is teething and having

difficulty sleeping. Which of the following instructions should the nurse include?

A. Rub your child's gums with an aspirin tablet before bedtime

B. Place an amber teething necklace on your child before bedtime

C. Administer acetaminophen drops to your child before bedtime: C. Administer acetaminophen

drops to your child before bedtime

45.A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of

the following foods should the nurse recommend?

A. Beef liver

B. Egg whites

C. Steamed claims

D. Broiled lobster: B. Egg whites

46.A home health nurse is teaching a guardian about administering tube feedings to their 3-month-

old infant. Which of the following information should the nurse include in the teaching?

A. Allow the infant to suck on a pacifier during feedings

B. Place enough formula for 12 hr in the feeding container

C. Change the tube feeding setup every 36 hr

D. Flush the tube with 30 mL of water between feedings: A. Allow the infant to suck on a pacifier

during feedings

47.A nurse is assessing a client who has pericarditis. Which of the following findings is the

priority?

A. Dependent edema

B. Pericardial friction rub

C. Paradoxical pulse

D. Substernal chest pain: C. Paradoxical pulse

48. A charge nurse is creating assignments for the next shift for several nurses and one of the

nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant?

10 / 76 A. A 60-year-old client who is recovering from shingles B. A 20-year-old client who is HIV positive C. A 40-year-old client who is suspected of having tuberculosis D. An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo: A. A 60- year-old client who is recovering from shingles

49.A nurse is performing triage following a natural disaster. Which of the following clients should

the nurse identify as the highest priority to receive care? A. A client who has agonal respirations B. A client who has an open skull fracture and is unresponsive C. A client who has a traumatic arm amputation D. A client who has a fracture of the femur: C. A client who has a traumatic arm amputation

50.51. A nurse is reviewing the medical records of four clients. Which of the following

prescriptions correct documentation?

A. Atropine .4 mg IV stat

B. Lorazepam 1.0 mg IV PRN every 6 hr

C. Sucralfate 1 g PO 1 hr ac

D. Enoxaparin 30 mg SC every 12 hr: C. Sucralfate 1 g PO 1 hr ac

51.A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is

receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings?

A. Contractions are strong to palpation

B. Cervix is dilating at 1 cm every 4 hr

C. Consistent contractions last 80 seconds

D. Contractions occur every 90 seconds: C. Consistent contractions last 80 seconds

52.A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood

pressure. The nurse should identify that these findings are potential manifestations of which of the following?

A. Cannabis withdrawal

B. Opioid intoxication

C. Amphetamine intoxication

D. Alcohol withdrawal: B. Opioid intoxication

53.A nurse is precepting a nursing student who brings the following client observations to the

nurse's attention. Which of the following clients should the nurse assess first? A. A client who is 3 hr post foley catheter removal and has not voided B. A client who is 3 days postoperative colectomy with a large, loose melena

11 / 76 stool C. A client who is 1-day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago: B. A client who is 3 days postoperative colectomy with a large, loose melena stool

54.A nurse manager is reviewing documentation standards with a group of newly licensed nurses.

Which of the following statements should the nurse manager include in the teaching?

A. Include the complete name of the medication morphine sulfate

B. Do not use a leading zero prior to a decimal point

C. Write the letter U when noting the dosage of insulin

D. Use the abbreviation QOD when indicating every other day: A. Include the complete name of

the medication morphine sulfate

55.A nurse is planning care for a newly admitted client. Which of the following interventions should

the nurse plan to take first?

A. Initiate an IV access for the client

B. Administer pain medication to the client

C. Send the client to radiology for a CT scan

D. Insert an NG tube for the client: A. Initiate an IV access for the client

56.. A community health nurse is performing a vision screening on a

4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding?

A. The infant's eyes turn toward the light

B. The infant's head turns away from the light

C. The infant's eyes remain focused toward the floor

D. The infant closes their eyes: D. The infant closes their eyes

57.A nurse is teaching a client and their family about home hospice care. Which of the following

information should the nurse include in the teaching?

A. Hospice care improves quality of life through palliative care

B. Hospice care provides 24 hr, in home care

C. Hospice care is intended to postpone death

D. Hospice care encourages the family to coordinate health care services: A. Hospice care

improves quality of life through palliative care

58.A nurse suspects another nurse is chemically impaired during their shift. Which of the following

is an appropriate action for the nurse to take?

A. Report to the nurse manager

B. Set up a time to meet with the nurse

C. Assume care of the nurse's assigned clients

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D. Ask another staff nurse to confirm the suspicion: A. Report to the nurse manager

59.A nurse is preparing a client for surgery and has just administered the preoperative injection.

Which of the following actions should the nurse take?

A. Take the client to the bathroom to void

B. Ask the client to verify the surgical site

C. Review deep breathing and coughing exercises

D. Raise the side rails on the bed: D. Raise the side rails on the bed

60.. A charge nurse is teaching a group of unit nurses about the policy for clients who have a

history of methicillin-resistant Staphylococcus aureus. Which of the following information should the nurse include? A. A client who has a history of MRSA will need antibiotics B. A client who has a history of MRSA can develop immunity to the infection C. A client who has a history of MRSA requires a protective environment D. A client who has a history of MRSA can still transmit the infection: D. A client who has a history of MRSA can still transmit the infection

61.A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure.

Which of the following information should the nurse include in the teaching?

A. Change clothes after working in the field

B. Apply petroleum jelly to the nostrils prior to working in the field

C. Wipe fruits and vegetables from the field with a dry cloth before consuming

D. Take a hot shower 1 hr after finishing work: A. Change clothes after working in the field

62.A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions

should the nurse take?

A. Monitor for abdominal ascites

B. Implement a low-carbohydrate diet

C. Review serum amylase levels

D. Place warm compresses on area of pruritus: A. Monitor for abdominal ascites

63.A nurse is caring for a client who has a new prescription for lithium car- bonate. Prior to

administering the first dose, which of the following laboratory values should the nurse evaluate?

A. Arterial blood gases

B. Total cholesterol

C. Thyroid hormones

D. Hemoglobin: C. Thyroid hormones

64.A nurse is caring for a client who is receiving systematic desensitization therapy to treat

agoraphobia. Which of the following client statements should

13 / 76 indicate to the nurse that the treatment has been effective? A. I have been able to watch a church service on television without anxiety B. I was able to sit on a park bench for 30 minutes C. I enjoyed a visit from four of my work friends at my house D. I had a panic attack when driving by the grocery store: B. I was able to sit on a park bench for 30 minutes

65.A nurse is caring for a client who is receiving a blood transfusion at 125mL/hr and develops a

hemolytic reaction. Which of the following actions should the nurse perform?

A. Infuse 0.9% sodium chloride IV

B. Administer an antipyretic

C. Decrease the infusion rate to 75 mL/hr

D. Place the client in a left lateral position: A. Infuse 0.9% sodium chloride IV

66.A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral

feedings at 65mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

A. The gastric residual volume is 250 mL following 2 hr of infusion

B. The client is lying in a supine position

C. The infusion pump for administering continuous feeding is turned off

D. The enteral feeding bag and tubing are not dated: B. The client is lying in a supine position

67.A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases

should the nurse implement droplet precautions?

A. Varicella-zoster

B. Vancomycin-resistant enterococcus

C. Pertussis

D. Rotavirus: C. Pertussis

68.A nurse discovers that the wrong dosage of a medication was given to a client. When

determining what action to take, the nurse should recognize that which of the following ethical principles should be applied?

A. Utility

B. Paternalism

C. Fidelity

D. Veracity: D. Veracity

69.A nurse is providing postoperative teaching to a client who has a newly-in- serted pacemaker.

Which of the following statements by the client indicates that the teaching has been effective? A. I will use my cell phone on the ear opposite of my pacemaker B. I can play softball with my family in 3 weeks

14 / 76 C. I should perform arm exercises daily D. I will go to my cardiologist's office when the battery needs to be changed: A. I will use my cell phone on the ear opposite of my pacemaker

70. A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a

continuous IV infusion. After confirming compatibility, which of the following actions should the nurse take?

A. Use the injection port farthest from the IV catheter insertion site

B. Occlude the IV tubing above the injection port

C. Check for blood return after medication administration

D. Flush the IV tubing with a heparinized solution: B. Occlude the IV tubing above the injection port

71.A nurse is caring for a client who is postpartum and has a new prescrip- tion for

methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the ad- ministration of methylergonovine?

A. Diabetes mellitus

B. Hypertension

C. Migraine headaches

D. Hepatitis B: B. Hypertension

72.A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client

is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?

A. 0900

B. 1800

C. 1300

D. 2100: B. 1800

73.A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following should

the nurse plan to take?

A. Wear an N95 respiratory mask while caring for the toddler

B. Place the toddler in a room with negative air pressure

C. Use a designated stethoscope when caring for the toddler

D. Remove the disposable gown after leaving the toddler's room: C. Use a designated

stethoscope when caring for the toddler

74.A nurse is performing a skin assessment for a client who is on bedrest. Which of the following

actions should the nurse take to prevent a pressure injury?

A. Encourage client fluid intake of 2,500 mL daily.

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B. Moisturize dry skin areas on the client every other day

C. Place a dehumidifier in the client's room

D. Apply a donut ring pillow under the client's sacral area: A. Encourage client fluid intake of 2,

mL daily.

75. A nurse from the State Health Development is instructing a group of nurses regarding reportable

infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention?

A. Herpes simplex virus 2

B. Candida albicans

C. Staphylococcus aureus

D. Lyme disease: D. Lyme disease

76.A nurse is planning care for a client following gastric bypass surgery. The nurse should

include which of the following dietary instructions when preparing the client for discharge?

A. Limit your meals to three times per day

B. Consume at least 25 grams of fiber daily

C. Start each meal with a protein source

D. Check your blood glucose levels before each meal: C. Start each meal with a protein source

77.A home health nurse is admitting a client who is prescribed peritoneal dialysis. Which of the

following actions should the nurse take first?

A. Confirm schedule for delivery of supplies

B. Coordinate interdisciplinary health care services

C. Demonstrate how to perform the procedure

D. Clarify the client's actual and perceived health needs: D. Clarify the client's actual and

perceived health needs

78.A nurse is performing an admission assessment for a client who is to un- dergo a colonoscopy.

The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?: B. Clopidogrel

79.A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy

with clozapine. Which of the following is the highest priority for the client to report to the provider?

A. Blurred vision

B. Dry mouth

C. Fever

D. Constipation: C. Fever

80.A Nurses caring for client who has breast cancer and has been covering receiving

chemotherapy. Which of the following laboratory values should

16 / 76 nurse report to provider?

a) WBC 3,000/mm

b) Hemoglobin 14 g/dl

c) Platelet 250,000/mm

d) aPTT 30 seconds: a) WBC 3,000/mm

81.A nurse is reviewing the lab report of a client who has a magnesium level of 1.0mEq/L. Which

of the following should the nurse expect?: Cardiac dysrhythmia

82.A nurse is teaching a client about nutritional intake. The nurse should include which of the

following in the teaching?

a. "Carbohydrates should be at least 45% of your caloric intake."

b. "Protein should be at least 55% of your calorie intake."

c. "Carbohydrates should be at least 30% of your caloric intake."

d. "Protein should be at least 60% of your caloric intake.": a. "Carbohydrates should be at least

45% of your caloric intake."

83.A nurse in a provider's office is providing education to a client who is 16 weeks of gestation and

has a new prescription for ferrous sulfate. Which of the following instructions should the nurse provide

a. Avoid strawberries, citrus fruit, and melon to ensure that your iron medica- tion is effective."

b. "Take your iron medication with fluids other than coffee or tea."

c. "It is important to take your iron medication on a full stomach."

d. "If you miss a dose one day, take two doses the next day.": b. "Take your iron medication with

fluids other than coffee or tea."

84.Four clients present to the emergency department. The nurse should plan to see which of the

following clients first? GL

a) A 6 year old client whose left shoulder is dislocated

b) A 26 year old client for sickle cell disease and a severe joint pain

c) A 76 year old client was confused, febrile and has foul smelling urine

d) A 50- year old client who has slurred speech, is disoriented, and reports a headache: d) A 50-

year old client who has slurred speech, is disoriented, and reports a headache

85.Placenta previa. Which of the following client findings should the nurse include?: Bring red

vaginal bleeding

86.A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy. What

should the nurse include in the teaching: Estrogen therapy increase the risk for thrombus formation

87.A nurse administers a dose of metoclopramide to a client prior to chemotherapy treatment. Which

of the following medications should the nurse

17 / 76 administer?

a. Albuterol sulfate

b. Hydromorphone

c diphenidramine d Amitriptiline: c diphenidramine

88.A nurse on the medical surgical unit is caring for a group of clients. Which of the following

clients would benefit from a three-way indwelling catheter? a. A female client who is prone to development of blood clots in the urine. b. A female client who has a history of chronic urinary tract infections

c. A male client who has spontaneous bladder emptying.

d. A male client who has postoperative acute urinary retention: a. A female client who is prone

to development of blood clots in the urine.

89.A nurse is assessing the vital signs of a newborn who was born 8hrs ago. Which of the following

findings require interventions by the nurse?: Blood pressure

90.Windshield survey: The availability of religious facilities.

91.A nurse is caring for a postoperative client. Which of the following inter- ventions will reduce

the risk of DVT: apply venous plexus foot pumps

92.A nurse is providing teaching about nutrition to the parents of a preschool- er who has chronic

renal failure. Which of the following indicates understand- ing teaching: I should limit my child's intake of protein

93.A nurse is assessing a client who has COPD and experienced recent weight loss. Which of

the following findings should the nurse report to the provider?: Coughing and wheezing after eating

94.Risk for metabolic alkalosis

A client who has severe: hyperemesis

95.A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following

task should the nurse delegate to the AP: Sit with the client who has anorexia nervosa during meals

96.Obtaining a culture: 1. Assess the appearance of the wound

2.Cleanse the would with 0.9%5.

3.Obtain the specimen from granulation tissue of the wound

4.Place the swab in the culture tube.

5. Cover the wound with a sterile dressing

97.A nurse is about to administer an injection to a client who states, "I don't want that injection. The

last time I got that I was sore for a week." The nurse goes ahead and administers the injection against the clients wishes. The nurse committed which of the following?

18 / 76

a. Battery

b. Assault

c. False Imprisonment

d. Libel: a. Battery

98.Client taking phenelzine, avoid.: cheddar cheese

99.. hip arthroplasty and notes the dressing is saturated with sanguineous drainage. Which of the

following actions should the nurse take?: Reinforce the dressing with sterile gauze

100. At the beginning of the day shift, a team leader delegates the following tasks to the

assistive personnel (AP); bathe four clients, distribute fresh water, and obtain the morning vital signs. At noon, the nurse asks the AP to transport one client to physical therapy. The AP reports two clients still need bed baths. Which of the following is an appropriate strategy for the nurse to delegate more effectively in the future?

a. Plan a more reasonable job assignment

b. Co-assign a more qualified individual to assist the AP.

c. Set a clear time for the completion of each task.

d. Volunteer to give the baths for the AP.: c. Set a clear time for the completion of each task.

101. Is caring for clients was a new prescription for enoxaparin for the preven- tion of DVT.

Which of the following is an appropriate action by the nurse?

a) Expel air bubble at the top of the prefilled syringe

b) Massage the injection site to evenly distribute the medication

c) Inject the medication the lateral abdominal wall

d) Administer an NSAID for injection site discomfort: c) Inject the medication the lateral abdominal

wall

102. A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of

the following is an expected finding?

a. dry, raised facial rash

b. subcutaneous nodules

c. hyperuricemia

d. polycythemia: a. dry, raised facial rash

103. A nurse is teaching the parent of an infant a bout manifestations of food allergies. The

nurse should identify which of the following findings as a common manifestation of a food allergy?

a. vomiting

b. dry mouth

c. decreased respiratory rate

d. hypertension: a. vomiting

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104. A nurse is setting up a sterile field for a dressing change on a postoper- ative client.

Which of the following actions should the nurse plan to take to maintain the sterile field?

a. select a work surface at the nurses hip level

b. drop the items onto the sterile field from a height of 20.3 cm

c. open the first flap of the sterile package away from the nurse body

d. apply sterile gloves to the non-dominant hand first.: c. open the first flap of the sterile

package away from the nurse body

105. A nurse on a mental health unit receives report on four clients. Which of the following

clients should the nurse attend to first? a. a client who had compulsive behavior and is frequently drinking from the water fountain b. a client who has begun to demonstrate catatonic behavior c. a client who is making sexual comments to clients of the opposite sex d. a client who is having auditory hallucinations and is becoming agitated: d. a client who is having auditory hallucinations and is becoming agitated

106.. a nurse is assessing a full-term newborn who is 24 hr old. Which of the following

findings should the nurse report to the provider?

a. the newborns neck is short and surrounded by skin folds

b. the newborns glucose level is 50 mg/dl

c. the newborns sclera have a yellowish tiny

d. the newborn has experienced a weight loss of 3% since birth: c. the newborns sclera have a

yellowish tiny

107. a nurse on an orthopedic floor is completing the morning assessments on several

clients. Which of the following clients has the greatest risk for fat embolism syndrome (FES)? a. a 24 yr old male who has a casted femur fracture b. a 10 yr old female who has an ulnar fracture in an external fixator c. a 49 yr old male who has multiple rib fractures d. a 62 yr old female who has vertebral fractures due to osteoporosis: a. a 24 yr old male who has a casted femur fracture

108.. a community health nurse is caring for a client who requests a referral for family therapy.

The nurse should initiate a referral to which of the following members of the interdisciplinary team?

a. occupational therapist

b. social worker

c. recreational therapist

d. paramedical technologist: b. social worker

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109. a nurse manage is reviewing documentation standards with a group of newly licensed

nurses. Which of the following statements should the nurse manager include in the teaching?

a. include the complete name of the medication morphine sulfate

b. do not use a leading zero to a decimal point

c. write the letter U when noting the dosage of insulin

d. use the abbreviation QOD when indicating every other day: a. include the complete name of

the medication morphine sulfate

110. a nurse is caring for a client who is manic. Which of the following activates is appropriate

for the nurse to suggest?

a. participating in a basketball game with other clients

b. playing a computer game with another client

c. taking a daily walk on the hospital grounds

d. reading quietly in the room: c. taking a daily walk on the hospital grounds

111.. a nurse is assessing an adolescent who has anorexia nervosa. Which of the following

findings should the nurse expect?

a. hypertension

b. menorrhagia

c. hypokalemia

d. diarrhea: c. hypokalemia

112. a nurse is preparing to discharge a newborn who has an atrial septal defect. The nurse

should expect the provider to refer the client to which of the following inter professional team members?

a. case manager

b. physical therapist

c. occupational therapist

d. nurse manager: a. case manager

113. a nurse is caring for a client who is receiving gentamicin. Which of the following

indicates the client is developing toxicity?

a. lethargy

b. weight gain

c. tinnitus

d. blurred vision: c. tinnitus

114. a nurse is assessing a client for pitting edema. When pressing into the dorsal side of the

clients foot, the nurse's fingers leaves a depression in the skin that is 8 mm (0.3in) deep. With which of the following classifications should the nurse document this finding?

a. 1+ edema

b. 2+ edema

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c. 3+ edema

d. 4+ edema: d. 4+ edema

115. a nurse is teaching a client who is at 35 weeks of gestation about amnio- centesis. Which

of the following statements should the nurse include in the teaching?

a. you should receive terbutaline subcutaneously at the start of the test

b. you will need to have a fully bladder at the start of the test

c. you will have to stay in the hospital overnight for fetal monitoring after the test

d. you should monitor and report the onset of contractions after the test: you should monitor and

report the onset of contractions after the test

116. nurse is caring for a client who has heart failure and a potassium of 3 mEq/L. the nurse

should obtain verification of which of the following prescrip- tions from the provider?

a. digoxin 0.125 mg PO daily

b. strict intake and output

c. cardiac monitoring

d. spironolactone 25 mg PO daily: a. digoxin 0.125 mg PO daily

117. a nurse is caring a client who has a diagnosis of antisocial personality disorder. The

nurse should expect the client to demonstrate which of the following?

a. magical thinking

b. mood swings

c. ritualistic behaviors

d. poor impulse control: d. poor impulse control

118. a nurse is assessing a client who is 8 hr postoperative following a right-modified radical

mastectomy. Which of the following should the nurse recognize as the priority finding?

a. urinary output of 100 mL in 4 hr

b. coughing frothy; pink secretions

c. emesis of 110 mL of thick, yellow fluid

d. red drainage on the dressing: b. coughing frothy; pink secretions

119.. a nurse is planning care for a client who has new diagnosis of dysphagia. Which of the

following foods should the nurse recommend?

a. apple juice

b. oatmeal

c. beef broth

d. toast: b. oatmeal

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120. a nurse is caring for a client who has schizophrenia. The client states, "run cats spine the

rain throwing procedure mechanical paper lake." The nurse should document that the client is demonstrating which of the following speech alterations?

a. echolalia

b. word salad

c. neolgisms

d. clang association: b. word salad

121. a nurse is preparing to administer eye drops to a preschooler who has conjunctivitis.

Which of the following actions should the nurse take?

a. maintain the child in a sitting position for 3 min following administration

b. administer the drops directly to the center of the eyeball

c. apply pressure to the lacrimal punctum for 1 min following administration

d. wipe excess medication from the outer canthus toward the nose.: c. apply pressure to the

lacrimal punctum for 1 min following administration

122. an infection control nurse is reviewing the medical records of several clients. Which of

the following infections should the nurse report to the Cen- ters for Disease Control and Prevention?

a. candidiasis

b. pelvic inflammatory disease

c. MRSA

d. syphilis: d. syphilis

123. a nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate

via continuous IV infusion. Which of the following findings should the nurse report to the provider?

a. respiratory rate 14/min

b. blood pressure 150/98 mm Hg

c. magnesium 9 mEq/L

d. 2+ deep tendon reflexes: c. magnesium 9 mEq/L

124. a nurse is caring for a client who has meningitis. Which of the following assessments

should the nurse perform?

a. homans' sign

b. trousseau's sign

c. brudzinski's sign

d. chvostek's sign: c. brudzinski's sign

125. a nurse is planning care for a child who is unresponsive and has in- creased

intracranial pressure.

23 / 76 Which of the following actions should the nurse take?

a. schedule routine oral suctioning

b. pad the side rails of the bed

c. obtain isolation supplies

d. place the child in Trendelenburg position: b. pad the side rails of the bed

126. a nurse is caring for a client who has a new prescription for chlor- promazine by IM

injection. Which of the following is an appropriate nursing action?

a. administer chlorpromazine with a loop diuretic

b. check orthostatic blood pressure 1 hr after administration

c. administer once daily 30 min before breakfast

d. check weekly calcium levels: b. check orthostatic blood pressure 1 hr after administration

127.. a nurse is caring for a child who has infectious mononucleosis. Which of the following

findings are associated with this diagnosis?

a. koplik spots

b. splenomegaly

c. malaise

d. sore throat

e. vertigo: b. splenomegaly

c. malaise d. sore throat

128. A nurse is planning care for a newly admitted adolescent client who has bacterial

meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care?

a. assist the client to a supine position

b. recommend prophylactic acyclovir

c. initiate droplet precautions for the client

d. perform a Glasgow coma scale every 24 hr: c. initiate droplet precautions for the client

129. A nurse is caring for a client who has a chest tube and notes continuous bubbling in the

water-seal chamber. Which of the following actions should the nurse take?

a. turn down the wall suction

b. observe the system for an air leak

c. obtain a prescription to discontinue the chest tube

d. empty the drainage from the collection chamber: b. observe the system for an air leak

24 / 76

130. breech of client confidentiality: Discussing the clients reaction to the transfer with

another staff nurse

131. A nurse is delegating task to an AP. For which of the following can the nurse assign to

the AP to measure vital signs: A client who is requisition pain medication 2 days after surgery

132. A circulating nurse is implementing a "time-out" before moving a client who is having

total hip arthroplasty to the surgical site. Which of the following actions should the nurse take.: confirm the provider has marked the surgical site

133. The nurses caring for a client whose taking allopurinol. The nurse should monitor which

of the following laboratory findings to determine the effective- ness of the medication?

a) Serum chloride

b) Uric acid level

c) Serum albumin

d) Magnesium level: b) Uric acid level

134. A nurse is planning care for a client who takes haloperidol for the treat- ment of

schizophrenia. Which of the following should the nurse include in the plan of care?

a. Monitor the client for hypothermia.

b. Screen the client for tardive dyskinesia.

c. Check the client's weekly potassium level.

d. Schedule the client for a 24-hour urine collection: b. Screen the client for tardive

dyskinesia.

135.. A nurse is caring for a preschool-age child who has a short-leg plaster cast applied 1 hr

ago. Which of the following is an appropriate intervention: - support the affected leg on a pillow

136. bone marrow transplant is in protective isolation while undergoing total body radiation

and intense chemo.: Allow the silbling to wave at the client through the window of the door

137.. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune

globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborns blood type is B positive. Which of the following statements is appropriate? GL

a. You only need to receive Rh immune globulin if you have a positive blood type."

b. You should receive Rh immune globulin within 72 hours of delivery."

c. "Both you and your baby should receive Rh immune globulin at your -week appointment."

25 / 76

d. "immune globulin is not necessary since this is your second pregnancy."-

: You should receive Rh immune globulin within 72 hours of delivery.

138. receiving lasted Ringer's to treat fluid volume deficit. Indicates a thera- peutic response

to the treatment: Increased blood pressure

139. neutropenia about food safety to prevent food borne illness: Refrigerate leftover with 2

hrs

140. A nurse is caring for a female client who has bruises on her arms that she explains are

result of physical abuse by her partner.: a) Help the client to recognize the signs of escalation of abuse behavior

141. A nurse is performing a vision screening for a client. Which of the fol- lowing finding

should the nurse identify as an indication that the client has cataract: increased opacity of the lens of the eye

142. A nurse is caring for a client who is receiving radiation therapy through a sealed implant.

Which of the following actions should the nurse take?: Wear a lead apron when providing care for the client.

143. A nurse is planning an education session for a client who has type 1 diabetes

mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia? GL

a. diaphoresis

b. polyuria

c. abdominal pain

d. thirst: a. diaphoresis

144. A nurse is inserting an IV catheter for a client who requires fluid replace- ment. Which of

the following actions should the nurse take: Apply the tourniquet 15cm(6in) about the insertion site

145. Client who had a CVA. perform to prevent foot dropping: Place positing boots on the

client's feet

146. fetal lung maturation: betamethsone

147. a client who has dysphasia and a new prescription for divalproex sodium extended

release: administer with applesauce

148. A nurse is caring for a client who is taking alprozolam. Which prescription needs clarifying

with the provider: lorazepam

149. A nurse is completing a dietary assessment for client who is Jewish and observes kosher

dietary practices. Which of the following behaviors should the nurse expect to find? GL

a) Leavened bread maybe eaten during Passover.

b) Shellfish is commonly consumed in the diet.

c) Meat and dairy products are eaten separately.

d) Fasting from meat occurs during Hanukkah.: c) Meat and dairy products are eaten separately.

150. A nurse is assessing a client who has non-Hodgkin's lymphoma. Which of the following

findings should indicate to the nurse that the client might be experiencing syndrome of inappropriate antidiuretic hormone: diminished deep tendon reflexes

151. Which of the following methods should the nurse use to confirm place- ment prior to

initatiaing feeding: Test pH level from client gastric aspirate

152. A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescence