<Source>NCLEX-RN Prep Plus 2018 2 Practice Tests + Proven Strategies + Online + Video Chap quizzes (Kaplan Nursing)<\Source>

<Tests> 
<Section>SAFE AND EFFECTIVE CARE ENVIRONMENT: MANAGEMENT OF CARE - Ch 4
<Questions>
<Number>1,4,0<\Number>
<Answers>A<\Answers>
<Body>
A 58-year-old man with head and neck cancer is admitted to the hospital and tells the nurse he
does not want parenteral nutritional therapy as his cancer progresses. The nurse explains he can
specify his wishes by creating an advance directive. The nurse knows that the requirement to
provide clients with this type of information can be found in which of the following?

(A) The Patient Self-Determination Act
(B) Nursing Scope and Standards of Practice
(C) The Patient Protection and Affordable Care Act
(D) The Patients’ Bill of Rights
<\Body>
<Number>2,4,0<\Number>
<Answers>D<\Answers>
<Body>
A 14-year-old girl newly diagnosed with diabetes is preparing for discharge. Which of the
following activities BEST describes the nurse’s role as a client advocate?

(A) Arranging for a visit with a home health nurse
(B) Providing written medication instructions to the client’s parents
(C) Instructing the client to follow up with her provider in 4 weeks
(D) Teaching the client how to administer insulin injections
<\Body>
<Number>3,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is seen for an outpatient appointment and asks the nurse if he can obtain a copy of his
medical record. The nurse knows the client has the right to read and copy his medical records, and
that this is guaranteed by virtue of which of the following?

(A) The Code of Ethics for Nurses
(B) The Health Insurance Portability and Accountability Act (HIPAA)
(C) The Patient Self-Determination Act
(D) The Americans with Disabilities Act
<\Body>
<Number>4,4,0<\Number>
<Answers>A<\Answers>
<Body>
After receiving report at the start of the evening shift, which of the following clients should the
nurse attend to FIRST?

(A) A 34-year-old man undergoing treatment for non-Hodgkin lymphoma with a
potassium level of 7.5 mEq/L
(B) A 21-year-old woman with sickle-cell anemia with pain of 6 on a scale of 1–10
(C) A 55-year-old woman with ovarian cancer waiting to be discharged
(D) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse
oximetry of 96% on room air
<\Body>
<Number>5,4,0<\Number>
<Answers>D<\Answers>
<Body>
A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with
carbamazepine is being transferred in stable condition from the intensive care unit to the medical
unit. There are 4 beds available. The nurse knows the BEST choice of roommates for this client is
which of the following?

(A) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA)
(B) A 28-year-old woman diagnosed with diarrhea
(C) A 72-year-old man with fever of unknown origin
(D) A 68-year-old woman with atrial fibrillation
<\Body>
<Number>6,4,0<\Number>
<Answers>A,C<\Answers>
<Body>
A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilitation
center. The nurse case manager is assisting in the process. The nurse knows that the goals of case
management include which of the following? Select all that apply.

(A) Improving the coordination of care
(B) Increasing referrals to local organizations
(C) Reducing the fragmentation of care
(D) Discharging clients quickly
<\Body>
<Number>7,4,0<\Number>
<Answers>B<\Answers>
<Body>
An 18-year-old client with acute lymphocytic leukemia is admitted to the bone marrow
transplantation unit. His family is having trouble dealing with the emotional and financial
pressures of his disease. The nurse, case manager, physician, and social worker meet to discuss the
plan of care. The nurse knows this type of interdisciplinary interaction is BEST referred to as
which of the following?

(A) Case management
(B) Collaboration
(C) Cooperation
(D) Collegiality
<\Body>
<Number>8,4,0<\Number>
<Answers>C,D<\Answers>
<Body>
A pregnant woman at 15 weeks’ gestation is scheduled for an amniocentesis. As the client is being
prepped for the procedure, it becomes clear to the nurse that the client doesn’t fully understand the
risks and benefits associated with the procedure. Which of the following describe the nurse’s role in
obtaining informed consent? Select all that apply.

(A) Explain the risks and benefits associated with the procedure.
(B) Describe alternatives to the procedure.
(C) Witness the client’s signature on the consent form.
(D) Advocate for the client by ensuring she is making an informed decision.
<\Body>
<Number>9,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse noticed an increase in the prevalence of pressure ulcers among clients in an intensive
care unit. She documented her findings and worked with her manager to develop and implement a
new policy using a pressure ulcer risk assessment scale. Which of the following BEST describes the
nurse’s actions?

(A) Quality improvement
(B) Collaboration
(C) Advocacy
(D) Case management
<\Body>
<Number>10,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is working on a surgical unit. Which of the following tasks would be appropriate for the
nurse to delegate to nursing assistive personnel (NAP)?

(A) Assist a new postoperative client to the bathroom.
(B) Set up the clients’ lunch trays.
(C) Change a central line dressing.
(D) Teach a client how to administer discharge medications.
<\Body>
<Number>11,4,0<\Number>
<Answers>A,B<\Answers>
<Body>
The nurse has been asked to administer a drug by IV push. She is uncertain whether or not this
task falls within her scope of practice. The nurse knows that which of the following are the BEST
sources to refer to for information related to her scope of practice in this situation? Select all that
apply.

(A) Hospital and unit policies and procedures
(B) Nurse Practice Act
(C) Ordering physician
(D) Hospital pharmacist
<\Body>
<Number>12,4,0<\Number>
<Answers>A<\Answers>
<Body>
A 20-year-old client with leukemia has consented to a blood transfusion against the wishes of his
family, who are all Jehovah’s Witnesses. The nurse knows that which of the following ethical
principles BEST supports this decision?

(A) Autonomy
(B) Beneficence
(C) Nonmaleficence
(D) Justice
<\Body>
<Number>13,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse wants to delegate the task of showering an elderly client in a wheelchair to the nursing
assistive personnel (NAP). Before delegating a task to the NAP, the nurse should FIRST ensure
which of the following is accomplished?

(A) The UAP is supervised at all times.
(B) The UAP demonstrated competency for the task during orientation.
(C) The UAP has performed the task before.
(D) The UAP has received the assignment during report.
<\Body>
<Number>14,4,0<\Number>
<Answers>B<\Answers>
<Body>
A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff
member who is not involved in the client’s care reading his medical record. The nurse knows she
should FIRST do which of the following?

(A) Nothing. The staff member has a hospital ID badge and is authorized to read the
medical record.
(B) Inform the staff member that without a legitimate need for the information, staff should
not be reading the medical record.
(C) Tell the client his medical records have been read by an unauthorized individual.
(D) Page the physician and ask if it’s acceptable for the staff member to access the medical
records.
<\Body>
<Number>15,4,0<\Number>
<Answers>A,B<\Answers>
<Body>
The nurse is learning how to use the hospital’s new electronic medication administration record.
The nurse knows this tool has the potential to do which of the following? Select all that apply.

(A) Reduce medication administration errors.
(B) Improve access to information at the point of care.
(C) Eliminate the need for the nurse to document medication administration.
(D) Eliminate the need for the nurse to verify dose calculations.
<\Body>
<Number>16,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse uses the Internet to receive electrocardiogram results from a client living in a nursing
home. The nurse knows this type of information technology is BEST described as which of the
following?

(A) Encryption
(B) Telecommunications
(C) Telehealth
(D) Nursing informatics
<\Body>
<Number>17,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is preparing to transfer a client to the operating room. She knows that adhering to the
hospital policy for client handoffs BEST ensures which of the following?

(A) Case management
(B) Continuity of care
(C) Confidentiality protection
(D) Collaboration
<\Body>
<Number>18,4,0<\Number>
<Answers>B,D<\Answers>
<Body>
The nurse is preparing to perform an admission assessment on a 28-year-old man being admitted
for Crohn’s disease. The nurse knows that according to the Patients’ Bill of Rights, this client is
responsible for which of the following? Select all that apply.

(A) Consenting to treatment
(B) Providing information about medications
(C) Providing proof of insurance
(D) Providing information about past illnesses
<\Body>
<Number>19,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is caring for a 41-year-old man with a new colostomy. As part of the care planning for
this client, the nurse knows a referral to which of the following will be the priority?

(A) A certified wound, ostomy, and continence nurse (CWOCN)
(B) Social services
(C) Physical therapy
(D) Occupational therapy
<\Body>
<Number>20,4,0<\Number>
<Answers>A<\Answers>
<Body>
An RN is in charge of a team on a medical/surgical unit that includes an LPN. The RN
understands that which of the following is an activity that falls within the scope of practice of an
LPN?

(A) Administer oral medications to a client.
(B) Collaborate with social services to develop a discharge plan.
(C) Formulate a nursing diagnosis.
(D) Develop a policy.
<\Body>
<Number>21,4,0<\Number>
<Answers>B,C<\Answers>
<Body>
21. The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices
concern about her ability to manage when she gets home. Which of the following statements
BEST illustrates quality care delivery by the nurse? Select all that apply.

(A) “Just focus on how lucky you are to have two healthy babies.”
(B) “We can arrange for follow-up visits with a home health nurse.”
(C) “Here is some information on support groups for parents of multiples.”
(D) “You will find it easier to formula-feed your babies at home.”
<\Body>
<Number>22,4,0<\Number>
<Answers>B<\Answers>
<Body>
After responding to a code, several staff nurses express concerns over their confidence levels and
performance to the nurse in charge of the hospital’s performance improvement program. The nurse
in charge knows the BEST way to evaluate and improve performance is to implement which of the
following?

(A) A program that collects and analyzes performance data
(B) Mock codes
(C) Inservice training
(D) Written competency exams
<\Body>
<Number>23,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is being treated for uncontrolled hypertension. The nurse knows that the involvement of
nursing, pharmacy, cardiology, and nutritional services is an example of which of the following
approaches?

(A) Managed care
(B) Multidisciplinary
(C) Case management
(D) Performance improvement
<\Body>
<Number>24,4,2<\Number>
<Answers>B,D,A,C<\Answers>
<Body
The nurse is caring for a client newly diagnosed with diabetes, and performs the following tasks.
Place the tasks the nurse would perform in the appropriate order. All options must be used. (Use comma alone to seperate)

(A) The nurse establishes a goal with the client to be able to self-administer insulin
injections.
(B) The nurse assesses the client’s level of knowledge about how to administer insulin
injections.
(C) The nurse evaluates the client while self-administering insulin injections.
(D) The nurse establishes the diagnosis of knowledge deficit.
<\Body>
<Number>25,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse administers the first dose of chemotherapy to a client on an oncology unit. The nurse
knows that which of the following activities is appropriate to delegate to the LPN?

(A) Obtain the client’s blood pressure.
(B) Provide teaching about the side effects of chemotherapy.
(C) Administer the second dose of chemotherapy.
(D) Flush the client’s central line with heparin.
<\Body>
<\Questions>
<\Section>

<Section>SAFE AND EFFECTIVE CARE ENVIRONMENT: SAFETY AND INFECTION CONTROL - CH5
<Questions>
<Number>1,4,0<\Number>
<Answers>B<\Answers>
<Body>
The physician orders an MRI of the brain for an adult male client. Which of the following
findings in the client’s history should the nurse report to the physician?

(A) Allergy to contrast dye
(B) Implanted cardiac pacemaker
(C) Chronic obstructive pulmonary disease (COPD)
(D) Hernia repair
<\Body>
<Number>2,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is developing a care plan for a client with hepatitis C. The nurse knows that the primary
route of transmission of this hepatitis virus is which of the following?

(A) Contaminated food
(B) Feces
(C) Blood
(D) Sputum
<\Body>
<Number>3,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is preparing to discharge a client with rheumatic heart disease who is recovering from
endocarditis. Which of the following statements from the client indicates that the client
understands the teaching?

(A) “I’m so glad I don’t need any more antibiotics now that I’m feeling better.”
(B) “I can restart my exercise program in a day or two.”
(C) “I will watch for signs of relapse the first few days after discharge.”
(D) “I will inform my dentist should I ever need any dental work.”
<\Body>
<Number>4,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is preparing to test a client who has allergies from an unknown cause. Which of the
following tests should the nurse perform?

(A) Tzanck test
(B) Patch test
(C) Rinne test
(D) Stress test
<\Body>
<Number>5,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to
home. Which of the following instructions should the nurse include?

(A) “Avoid sharing articles such as razors and toothbrushes.”
(B) “Do not share eating utensils with family members.”
(C) “Limit the time you spend in public places.”
(D) “Avoid eating food from serving dishes shared with others.”
<\Body>
<Number>6,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is preparing to administer a tuberculin (Mantoux) skin test to a client suspected of
having tuberculosis (TB). The nurse knows that the test will reveal which of the following?

(A) How long the client has been infected with TB
(B) Active TB infection
(C) Latent TB infection
(D) Whether the client has been infected with TB bacteria
<\Body>
<Number>7,4,0<\Number>
<Answers>B<\Answers>
<Body>
An older adult has been admitted with diagnosis of stroke and a history of dementia. Which of the
following nursing diagnoses has the highest priority for this client?

(A) Bathing/hygiene self-care deficit
(B) Risk for injury
(C) Impaired physical mobility
(D) Disturbed thought processes
<\Body>
<Number>8,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse has just administered insulin to a diabetic client. In which of the following ways should
the nurse dispose of the needle?

(A) Re-cap the needle and discard it in the nearest puncture-resistant container.
(B) Re-cap the needle and discard it in the nearest biohazard container.
(C) Discard the needle in a puncture-resistant container.
(D) Break the needle and discard it in the nearest puncture-resistant container.
<\Body>
<Number>9,7,2<\Number>
<Answers>F,C,A,B,G,D,E<\Answers>
<Body>
The nurse is preparing to administer packed red blood cells (PRBCs) to a client. Arrange the
following steps in the order the nurse should perform them. All options must be used. (Use comma alone to seperate)

(A) Explain the procedure to the client.
(B) Obtain the client’s vital signs.
(C) Assess that the client has a blood bank identification armband.
(D) Obtain the PRBCs from the blood bank according to hospital policy and perform a
visual check of the blood.
(E) Perform a bedside identification and blood product verification by two licensed
individuals.
(F) Verify the physician order.
(G) Prime the transfusion tubing with a 0.9% sodium chloride solution.
<\Body>
<Number>10,4,0<\Number>
<Answers>D<\Answers>
<Body>
Two nurses are preparing to lift a client up in bed. Which of the following should the nurses do to
help avoid injuring their backs?

(A) Bend from the waist.
(B) Lift with the back, not with the legs.
(C) Lower the head of the bed to about 30 degrees, if the client can tolerate it.
(D) Make certain the bed is in a reasonably high position.
<\Body>
<Number>11,4,0<\Number>
<Answers>C<\Answers>
<Body>
In the emergency room, the nurse assesses a 4-year-old child suspected of having measles. Which
of the following kinds of precautions should the nurse initiate?

(A) Contact precautions
(B) Droplet precautions
(C) Airborne precautions
(D) Reverse isolation
<\Body>
<Number>12,4,0<\Number>
<Answers>C<\Answers>
<Body>
A female client comes to the Emergency Department reporting vaginal discharge, irritation of the
vagina, and the need to urinate often. The nurse suspects a sexually transmitted disease (STD), and
the physician orders diagnostic testing of the vaginal discharge. Which of the following STDs does
the nurse know must be reported to the Department of Public Health?
(A) Genital herpes
(B) Human papillomavirus infection
(C) Gonorrhea
(D) Trichomoniasis
<\Body>
<Number>13,6,0<\Number>
<Answers>A,B,E,F<\Answers>
<Body>
An elderly client, who is not oriented to time, place, or person, had a total hip replacement. The
client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. The client
has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the
nurse are appropriate? Select all that apply.

(A) Ask the client if he needs to use the bathroom, and provide range-of-motion exercises
every 2 hours.
(B) Document the type of restraint used and assess the need for continued use.
(C) Tie the restraints to the side rails of the bed.
(D) Obtain a new physician order for the restraint every 12 hours.
(E) Observe for correct placement of restraints.
(F) Tie the restraints in a quick-release knot.
<\Body>
<Number>14,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is preparing to administer a unit of PRBCs to an anemic client. After obtaining the
blood from the blood bank, the nurse must begin administering it within which of the following
time periods?

(A) 15 minutes
(B) 30 minutes
(C) 45 minutes
(D) 60 minutes
<\Body>
<Number>15,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is assessing an elderly client for risk of falls. Which of the following should the nurse
collect?

(A) The facility’s restraint policy
(B) Gait, balance, and visual impairment information
(C) Psychosocial history
(D) The facility’s environmental safety plan
<\Body>
<Number>16,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is administering nightly medications, which include an anticoagulant and a stool
softener. Which of the following should the nurse do FIRST before administering the
medications?

(A) Scan the medication label and the client’s wristband.
(B)Ask the client his or her name to properly identify this client as the one for whom the
medications were ordered.
(C) Match the client’s date of birth and name on the client’s wristband with the same
information on the medication order.
(D) Match the client’s name and room number with the medication order.
<\Body>
<Number>17,4,0<\Number>
<Answers>A<\Answers>
<Body>
The physician verbally orders a medication for a client during an emergency code. Which of the
following should the nurse do?

(A) Repeat the order back to the physician for confirmation and administer it.
(B) Retrieve the medication and administer it.
(C) Write the order down, retrieve the medication, and administer it.
(D) Read the order to another nurse, have that nurse retrieve the medication, and stay with
the client.
<\Body>
<Number>18,4,0<\Number>
<Answers>A,B,D<\Answers>
<Body>
The client has a new order for placement of a Foley catheter due to urinary retention. Which of the
following should the nurse do before starting the procedure? Select all that apply.

(A) The nurse should confirm the client’s identity, because a procedure requires proper
identification.
(B) The nurse should confirm the client’s medical record number via the wristband and
order.
(C) Ask the client his or her name only, because this is a procedure and not a medication
administration.
(D) The nurse should confirm the client’s name via the wristband (D) and order.
<\Body>
<Number>19,4,0<\Number>
<Answers>D<\Answers>
<Body>
Which of the following actions by the nurse is the MOST effective means of preventing infection?

(A) Washing hands after client contact
(B) Washing hands after removing gloves
(C) Hand hygiene between clients
(D) Hand hygiene before entry to a client’s room and upon exit of a client’s room
<\Body>
<Number>20,4,0<\Number>
<Answers>B<\Answers>
<Body>
The client is an obese male with decubitus ulcers. Treatment of the ulcers requires frequent turning
and repositioning. The nursing unit has a special lift that allows for turning of clients and
placement onto a bedpan without any lifting on the part of the staff. The client urgently requests
the bedpan. Because the lift apparatus takes a few minutes to set up, which of the following should
the nurse do?

(A) Quickly assist the client onto the bedpan without the lift because he needs to use it
urgently.
(B) Encourage the client to try to be patient, and set up the apparatus.
(C) Get the assistance of an aide to help lift the client.
(D) Encourage the client to wear an incontinence brief.
<\Body>
<Number>21,4,0<\Number>
<Answers>C<\Answers>
<Body>
The client has experienced multiple episodes of hyperglycemia not manageable by subcutaneous
insulin injections. The client has an active order for infusion of an insulin drip for glycemic
management to be discontinued at bedtime, after which the client is NPO. The client’s most
recent blood sugar level, taken at 3 P.M., was 60. Which of the following actions by the nurse is the
MOST appropriate?

(A) The nurse should follow the order and allow the insulin to infuse until bedtime.
(B) The nurse should recheck the client’s blood sugar.
(C) The nurse should bring this blood sugar level to the physician’s attention and discuss
stopping the infusion.
(D) The nurse should seek advice from other nurses.
<\Body>
<Number>22,4,0<\Number>
<Answers>D<\Answers>
<Body>
The adult children of a hospice home care client inquire about whether it is safe to hug their
mother, because she has had a methicillin-resistant Staphylococcus aureus (MRSA) infection in the
past. Which of the following statements by the children would indicate a need for further teaching
by the nurse?

(A) “We should wash our hands frequently.”
(B) “We should use hand sanitizer.”
(C) “Those of us with poor immune systems should be extra careful.”
(D) “We should wear gowns and gloves at all times when having contact with our mother.”
<\Body>
<Number>23,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse witnesses another nurse, wearing a gown and gloves, enter a client room labeled
“Airborne Precautions.” Which of the following actions by the witnessing nurse is MOST
appropriate?

(A) Notify the nurse manager to discuss policies with the other nurse.
(B) Ask a physician to give a presentation on which precautions require which types of
personal protective equipment (PPE).
(C) Remind the other nurse that she needs a mask in addition to a gown and gloves for
airborne-type precautions.
(D) Ask the other nurse to look up the policy about precautions.
<\Body>
<Number>24,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse discovers a client on the floor in the client’s hospital room. After examining the client
and assisting him safely back to bed, which of the following should the nurse do FIRST?

(A) File an incident report.
(B) Put the bed alarm back on.
(C) Institute a client observer to sit with the client and prevent further falls.
(D) Notify the nurse manager.
<\Body>
<Number>25,4,0<\Number>
<Answers>A<\Answers>
<Body>
The hospitalized client is receiving an infusion and the pump has malfunctioned. Which of the
following actions by the nurse is MOST appropriate once the infusion has been stopped and
restarted with a functioning pump?

(A) Place a “Broken” sticker on the malfunctioning pump according to hospital policy, and
place the pump in the designated malfunctioning equipment area.
(B) Place the malfunctioning pump in the utility room.
(C) Remove the malfunctioning pump from the client’s room and place with other pumps.
(D) Place the malfunctioning pump to the side in the client’s room.
<\Body>
<Number>26,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse completes a peripherally inserted central catheter (PICC) line dressing change for a
home care client. When removing the PPE, the nurse should do which of the following?

(A) Remove the mask and then the gloves.
(B) Remove the gloves and then the mask.
(C) Remove only the gloves; there is no need to wear a mask.
(D) Remove only the mask; there is no need to wear gloves.
<\Body>
<Number>27,4,0<\Number>
<Answers>C<\Answers>
<Body>
The client is found on the floor by the nursing assistive personnel (NAP). Once the client is safe,
which of the following should the nurse do next?

(A) Document the event in the client’s medical record and file an incident report.
(B) File an incident report only.
(C) Document the event in the client’s medical record and have the NAP file an incident
report.
(D) Document the event in the client’s medical record only.
<\Body>
<Number>28,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is making a home visit to an elderly client during the winter. The nurse notices upon
arrival that the client has the oven turned on with the oven door open, and is using it as a form of
heat. Which of the following actions by the nurse is MOST appropriate?

(A) Take care of the client’s medical needs and do not get involved in the client’s private
matters.
(B) Shut the oven off and continue with the home visit.
(C) Report the event to the local Fire Department.
(D) Have a meeting with the client and family and warn them of the fire and safety risks of
using the oven for heat.
<\Body>
<Number>29,4,0<\Number>
<Answers>A<\Answers>
<Body>
The medical center encounters a bomb threat. The emergency response team informs the staff that
the threat is legitimate and that clients should start being evacuated. Which of the following clients
should the nurse begin evacuating FIRST to the safe designated area?

(A) Ambulatory clients
(B) Bedridden clients
(C) ICU clients
(D) Infant clients
<\Body>
<Number>30,4,0<\Number>
<Answers>B<\Answers>
<Body>
3The nurse discovers that the last dose of intravenous antibiotic administered to a client was the
wrong dose. Which of the following should the nurse do?

(A) Document the event in the client’s medical record only.
(B) File an incident report, and document the event in the client’s medical record.
(C) Document in the client’s medical record that an incident report was filed.
(D) File an incident report, but don’t document the event in the client’s medical record,
because information about the incident is protected.
<\Body>
<\Questions>
<\Section>

<Section>HEALTH PROMOTION AND MAINTENANCE - Ch 6
<Questions>
<Number>1,4,0<\Number>
<Answers>C<\Answers>
<Body>
A 20-year-old client has just given birth. The baby looks healthy, with the exception of giving a
grimace instead of a cry. Which of the following would the nurse expect the obstetrician to say?

(A) “The APGAR score is 3.”
(B) “The APGAR score is 6.”
(C) “The APGAR score is 9.”
(D) “The APGAR score is 12.”
<\Body>
<Number>2,4,0<\Number>
<Answers>D<\Answers>
<Body>
The outpatient client is postmenopausal. In discussing breast self-examination, which of the
following should the nurse let the client know that she can do?

(A) Switch to an annual schedule, because she does not have periods.
(B) Discontinue self-examination, because hormone changes decrease her risks.
(C) Wait until her mammogram shows some findings.
(D) Continue to palpate monthly, picking her own meaningful date.
<\Body>
<Number>3,4,0<\Number>
<Answers>A<\Answers>
<Body>
A client with acne has been using isotretinoin. She tells the nurse that she recently learned she is
pregnant. She asks “Will my pregnancy interfere with the medication’s effectiveness?” Which of
the following is the appropriate response by the nurse?

(A) “The medication is contraindicated for pregnant women.”
(B) “You will have to change the route of administration, because you are pregnant.”
(C) “There is no reason you can’t continue taking it.”
(D) “If the medication helps you look better, that will help feel better about yourself.”
<\Body>
<Number>4,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is preparing for a women’s health fair. The nurse knows that which of the following is
correct when teaching about the risks and benefits of hormone replacement therapy (HRT)?

(A) HRT is related to a decreased risk of deep vein thrombosis (DVT).
(B) HRT is related to an increased risk for coronary artery disease (CAD).
(C) HRT is related to an increased risk for osteoporosis-related bone fractures.
(D) HRT is related to a decreased risk of breast cancer.
<\Body>
<Number>5,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse has been working with a 45-year-old African American who bicycles to work. Lab tests
show low serum lipids. The nurse knows that the client’s risk factors for primary (essential)
hypertension include which of the following?

(A) Being under the age of 65
(B) Race
(C) Low serum lipids
(D) Active lifestyle
<\Body>
<Number>6,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is designing a diet plan for a 70-year-old with poorly fitting dentures who has been
recently diagnosed with type 2 diabetes. The nurse knows that which of the following is the
LEAST likely risk to the client?

(A) Malnutrition
(B) Dehydration
(C) Hyperglycemia
(D) Low blood sugar
<\Body>
<Number>7,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is providing education at a senior center. Which of the following measures will the nurse
say is MOST effective in attaining normal blood sugar levels in a client with type 2 diabetes?

(A) Decreasing sodium intake
(B) Increasing potassium and calcium intake
(C) Reaching recommended weight
(D) Decreasing daily exercise
<\Body>
<Number>8,4,0<\Number>
<Answers>C<\Answers>
<Body>
A local high school is having a health fair. Which of the following main courses should the nurse
recommend as most healthful for a teenager whose cholesterol level is 300 mg/dL?

(A) Medium-rare hamburger with only one slice of cheese
(B) Vegetarian New York–style pizza
(C) Grilled chicken breast
(D) Salad with extra dressing
<\Body>
<Number>9,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is talking to a client who is still grieving the loss of a parent to stomach cancer. The
nurse knows that which of the following would increase the client’s risk of cancer?

(A) Keeping a strict high-protein diet
(B) Following a low-fat, low-carbohydrate diet
(C) Using considerable spices when cooking
(D) Smoking cigarettes
<\Body>
<Number>10,4,0<\Number>
<Answers>B<\Answers>
<Body>
10. A 3-month-old child accompanies her parents to a seasonal flu clinic. Assuming that the child does
not have a fever, can the nurse give the child a flu shot?

(A) Yes, if regular immunizations are up to date.
(B) No, because the child is not old enough.
(C) Yes, because then the child won’t get sick later.
(D) No, because it would interfere with regular immunizations.
<\Body>
<Number>11,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 28th week of
pregnancy. Which of the following client situations requires the nurse to take this action?

(A) Rh-positive mother and Rh-negative father
(B) Rh-positive mother and Rh-positive father
(C) Rh-negative mother and Rh-negative father
(D) Rh-negative mother and Rh-positive father
<\Body>
<Number>12,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is teaching a young male client to recognize the most common early sign of testicular
cancer. The nurse emphasizes the fact that he should be aware of which of the following?

(A) Lumbar pain
(B) Urinary frequency
(C) Urinary urgency
(D) Painless testicular enlargement
<\Body>
<Number>13,4,0<\Number>
<Answers>B<\Answers>
<Body>
New parents are concerned about an unexpected characteristic of their newborn baby. Which of
the following would cause the nurse to initiate contact with the physician?

(A) Swollen genitals and breast
(B) High-pitched crying
(C) Misshapen head
(D) Milia
<\Body>
<Number>14,4,0<\Number>
<Answers>D<\Answers>
<Body>
A public health nurse visits a client at home three days after the client gave birth. In which of the
following situations should the nurse instruct the client to report to a clinician?

(A) Vaginal drainage with streaks of bright red blood
(B) Some discomfort at the site of her episiotomy
(C) Feelings of fatigue late in the afternoon and evening
(D) An elevated temperature without other symptoms
<\Body>
<Number>15,5,0<\Number>
<Answers>A,B,D,E<\Answers>
<Body>
The pediatric nurse is providing discharge instructions to the parents of a newborn. In which of the
following situations would the nurse advise the parents to call a physician? Select all that apply.

(A) The infant has a temperature higher than 100.4° F (38° C).
(B) The infant vomits more than once in 24 hours.
(C) The infant’s respirations are even and unlabored.
(D) The infant is unable to keep down food or water.
(E) The infant has sunken or swollen soft spots on the head.
<\Body>
<Number>16,4,0<\Number>
<Answers>A<\Answers>
<Body>
The client’s first day of her last period was February 1. Which of the following should the nurse
tell the client is her expected date of delivery?

(A) November 8
(B) October 8
(C) December 1
(D) November 20
<\Body>
<Number>17,4,0<\Number>
<Answers>B<\Answers>
<Body>
The client is 7 months pregnant with her first child. She is anxious because she feels some mild
contractions at times. The nurse tells her which of the following?

(A) She should increase her bed rest to prevent those contractions.
(B) The contractions are normal unless they increase in severity.
(C) The contractions are a way of her body asking for more exercise.
(D) She should avoid getting constipated and having gas as a result.
<\Body>
<Number>18,4,0<\Number>
<Answers>C<\Answers>
<Body>
The client is 40 years old and pregnant with her first child. Her obstetrician has asked the nurse to
schedule her for an amniocentesis. The client inquires why she needs that test. The nurse says
which of the following as an explanation?

(A) “We routinely do an amniocentesis on all our clients to check the child’s gender.”
(B) “An amniocentesis is not invasive, so there is less risk than doing an ultrasound.”
(C) “The standard for doing an amniocentesis is motherhood over age 35.”
(D) “If we know the baby’s size, you can better count on having a vaginal birth.”
<\Body>
<Number>19,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is educating a mother-to-be about possible danger signs during the last three months of
pregnancy. Which of the following would NOT cause the nurse concern about danger signs?

(A) Rectal bleeding
(B) Continuous headaches
(C) Marked swelling of hands
(D) Blurred vision
<\Body>
<Number>20,5,0<\Number>
<Answers>B,C,D,E<\Answers>
<Body>
A first-time parent is discussing developmental milestones with the nurse. The nurse tells the
client that she can reasonably expect her child to achieve which of the following by the time the
child is 1 year old? Select all that apply.

(A) Walking
(B) Rolling from tummy to side
(C) Transferring toys from hand to hand
(D) Beginning to respond selectively to words
(E) Vocalizing sounds (coos)
<\Body>
<Number>21,4,0<\Number>
<Answers>C<\Answers>
<Body>
A parent is discussing the behavior of her 3-year-old child with the nurse. At 3 years, the nurse
would expect the client’s child to be doing all of the following EXCEPT which activity?

(A) Saying “no” often
(B) Using a limited vocabulary of 500–3,000 words
(C) Speaking in 10-word sentences
(D) Believing that adults know everything
<\Body>
<Number>22,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is teaching a group of mothers of toddlers how to prevent accidental poisoning from
medications. The nurse teaches the mothers to store medications in which of the following
locations?

(A) In a secure, locked place
(B) In vials with childproof caps
(C) On the highest shelf in the room
(D) Disguised in different containers
<\Body>
<Number>23,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is assessing an elderly couple, both 80 years old, to determine if they can safely continue
to live independently. They insist they are getting along fine but need help with grocery shopping
and housekeeping. The nurse determines that they have difficulty in doing which of the following?

(A) Activities of daily living (ADLs)
(B) Instrumental activities of daily living (IADLs)
(C) Daily living milestones (DLMs)
(D) Preventive health activities (PHAs)
<\Body>
<Number>24,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is giving a lecture at the senior center about preventative health activities for people over
age 60. The nurse tells the clients that the Centers for Disease Control and Prevention (CDC)
now recommends which of the following vaccines for this age group?

(A) Shingles (herpes zoster)
(B) Diphtheria
(C) Pertussis (whooping cough)
(D) Meningitis
<\Body>
<Number>25,5,0<\Number>
<Answers>A,B,D,E<\Answers>
<Body>
The nurse is teaching about the challenges of smoking cessation. Which of the following factors
will the nurse identify as known challenges that clients face when attempting to quit smoking?
Select all that apply.

(A) Stress and depression
(B) Low level of income
(C) High level of education
(D) Psychosocial problems
(E) Continued exposure to smoking-associated stimuli
<\Body>
<Number>26,4,0<\Number>
<Answers>B,C,D<\Answers>
<Body>
Stress reduction techniques include biofeedback and meditation. The nurse conducting classes on
these methods knows that studies have shown a cause-and-effect relationship between stress and
which of the following? Select all that apply.

(A) Adverse medication effects
(B) Infectious diseases
(C) Traumatic injuries, such as motor vehicle accidents
(D) Some chronic illnesses
<\Body>
<Number>27,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is performing the initial assessment of an adult from a culture the nurse is not familiar
with, and asks about the client’s use of alternative therapies. The client says, irritably, “Do you have
to ask all these questions?” Which of the following is the BEST explanation for what the nurse
should do in response?

(A) Ask the question, because the nurse might learn about therapies used by a different
culture.
(B) Ask the question, because knowledge about actual use of other therapies is imperative.
(C) Don’t ask the question, because it is important to not upset the irritable client any
further.
(D) Don’t ask the question, because the client needs to choose to initiate discussion of other
therapies.
<\Body>
<Number>28,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is preparing a community educational presentation. The topic is the leading cause of
death for people from ages 1–44. The nurse knows that which of the following is the leading
cause?

(A) Cancer
(B) Heart disease
(C) Unintentional injuries
(D) Diabetes
<\Body>
<Number>29,5,2<\Number>
<Answers>1(E),2(A),3(B),4(C),5(D)<\Answers>
<Body>
The nurse is reviewing the client’s lipid profile to determine if education is needed to reduce the
risk of heart disease. The nurse knows how to match healthy target values with lab descriptions.
Match the appropriate part of the profile below on the left to the values on the right. All options
must be used.
Respond in the format: 1(B),2(C),3(D),4(A),5(E)

(1) Total cholesterol
(2) HDL cholesterol for men
(3) HDL cholesterol for women
(4) LDL cholesterol
(5) Triglycerides
(A) More than 40 mg/dL
(B) More than 50 mg/dL
(C) Less than 100 mg/dL
(D) Less than 150 mg/dL
(E) Less than 200 mg/dL
<\Body>
<Number>30,3,2<\Number>
<Answers>1(B),2(C),3(A)<\Answers>
<Body>
The nurse is assessing the best approach to prepare three clients for surgery. Each has a different
learning preference. Match the learning preference to the appropriate approach. All options must
be used.
Respond in the format: 1(A),2(B),3(C)

(1) Brochures about preparation activities
(2) Models of the relevant anatomy
(3) Discussions about the surgery
(A) Auditory
(B) Visual
(C) Tactile
<\Body>
<\Questions>
<\Section>

<Section>PSYCHOSOCIAL INTEGRITY - Ch 7
<Questions>
<Number>1,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse cares for an elderly client who appears fully alert and oriented. As it gets later in the day,
the nurse notices the client becoming increasingly confused and agitated. It would be MOST
appropriate for the nurse to take which of the following actions?

(A) Reorient the client, and then turn on the lights and television to distract the client from
his confusion.
(B) Encourage the client’s alert roommate to talk with the client.
(C) Tell the client he is at home in his own bed to get him to settle down and go to sleep.
(D) Reorient the client, pull the shades down, shut the lights and television off, and
promote a quiet environment.
<\Body>
<Number>2,4,0<\Number>
<Answers>C<\Answers>
<Body>
On the evening shift, the nurse is caring for a client who will be undergoing a mastectomy in the
morning. A call from the front desk alerts the nurse that the client’s family has arrived. It would be
MOST appropriate for the nurse to take which of the following actions?

(A) Tell the family that they cannot come in because visiting hours are over.
(B) Tell the client you want to make sure she has some alone time to relax.
(C) Invite the family in to offer support after confirming with the client.
(D) Tell the nursing assistive personnel (NAP) to sit with the client who needs company.
<\Body>
<Number>3,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is caring for a young man who has expressed his desire to commit suicide. He has
informed the nurse of plans to pursue this. The nurse requests a sitter to stay with the client around
the clock, but the client says he does not want this. Which of the following is the MOST
appropriate response by the nurse?

(A) The nurse allows the young man to refuse, because clients do have a right to refuse care.
(B) The nurse implements the intervention, because protecting the client’s safety trumps the
client’s right to refuse care.
(C) The nurse checks on the client every hour to be sure he is safe.
(D) The nurse asks the NAP to check on the client every 30 minutes to be sure he is safe.
<\Body>
<Number>4,4,0<\Number>
<Answers>D<\Answers>
<Body>
A client is scheduled to have surgery the following day. The client tells the nurse, “I’m very scared.
I have never had surgery before and am afraid that I might not make it through.” Which of the
following responses by the nurse is the MOST appropriate?

(A) “Why do you feel this way?”
(B) “Don’t worry, you will be fine.”
(C) “Why don’t we take some time to explore why (C) you feel this way?”
(D) “It’s completely normal to be scared. You will be taken care of. Tell me how you are
feeling.”
<\Body>
<Number>5,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is working on a pediatric unit. The client is a 13-month-old child diagnosed with failure
to thrive. The parents report that the child cries frequently, does not like to be held, and will not
eat. The nurse learns that the child’s uncle lives in the house with the family. When the uncle visits
in the hospital, the nurse notices the child acting differently and turning away from the uncle.
Sometimes the child’s heart rate increases when the uncle is present. The nurse should take which
of the following actions FIRST?

(A) Immediately report the possible situation of abuse to the authorities.
(B) Call the physician, who will probably have more long-term knowledge.
(C) Discuss it with other nurses to see which approaches they have taken.
(D) Encourage the team that’s caring for the client to have a family meeting including the
parents, but not the uncle, to gather more information.
<\Body>
<Number>6,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse learns that the client’s sibling has passed away during his hospitalization, and the client
is distraught by this news. Which of the following should the nurse do FIRST?

(A) Allow the client an opportunity to verbalize feelings, and inquire if the client would like
to be visited by social services, chaplaincy, or psychiatry for support.
(B) Provide alone time by not going into the client’s room unless absolutely necessary.
(C) Call psychiatry services to arrange for them to see the client as soon as possible.
(D) Find out which religion the client practices by viewing the chart and then request a
chaplain from that religion to see the client.
<\Body>
<Number>7,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is working on a busy locked psychiatric unit. The alarm gets tripped when somebody
tries to go through the locked doors without permission from the front desk. Which of the
following actions should the nurse take after the alarm is tripped?

(A) Reset the alarm from the front desk after verifying that everybody is safe and nobody
has escaped from the unit.
(B) Reset the alarm from the location where the alarm was tripped after verifying that
everybody is safe and nobody has escaped from the unit.
(C) Reset the alarm from a client’s room after doing a quick scan of the hallway.
(D) Reset the alarm from the front desk once the receptionist says everybody is accounted
for.
<\Body>
<Number>8,4,0<\Number>
<Answers>A<\Answers>
<Body>
The client is an intoxicated male on the medical/surgical unit who attempts to get out of bed every
few minutes. He is unsteady on his feet, and the nurse is concerned that he will fall if he does get
out of bed. The doctor writes an order for the nurse to place wrist restraints to maintain the client’s
safety and prevent him from falling. The man refuses the restraints. The nurse should take which
of the following actions?

(A) Place the restraints in compliance with hospital policy.
(B) Refrain from placing restraints to honor the client’s wishes, because he has the right to
refuse care.
(C) Call the physician for advice on how to proceed.
(D) Check on the client every hour to ensure his safety.
<\Body>
<Number>9,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is working in an outpatient clinic. The nurse has a client who appears intoxicated and
who drove to the appointment. The nurse is concerned about the client’s ability to drive home.
Which of the following should the nurse do FIRST?

(A) Call the police immediately.
(B) Ask the client’s permission to call a family member or friend for a ride.
(C) Give the client a ride home to protect his privacy.
(D) Call clinic security to detain the client to protect his safety.
<\Body>
<Number>10,4,0<\Number>
<Answers>A<\Answers>
<Body>
The mother of a teenage client who has permission to be involved in the plan of care is asking the
nurse questions, after it has been explained to her that her child has bipolar disorder. Which of the
following statements by the mother indicates that further teaching is needed?

(A) “My child will be cured after being on medications for a few months.”
(B) “My child will require support and encouragement.”
(C) “My child will be on psychiatric medications probably for the rest of her life.”
(D) “The goal of the medication is to reduce symptoms associated with bipolar disorder and
to hopefully help with the mood swings.”
<\Body>
<Number>11,4,0<\Number>
<Answers>D<\Answers>
<Body>
The home care nurse makes a visit to the home of an elderly client who has episodic confusion but
who has remained safe at home while occasionally alone. The nurse finds the client disheveled,
confused, and agitated, and the home is messy. This degree of confusion is unusual for this client.
The nurse takes the client’s vital signs, which are BP 115/70, HR 70, RR 16, and temperature
98.7º F (37º C). Which of the following actions should the nurse take FIRST?

(A) Nothing, because the client’s vital signs are stable.
(B) Plan to come back the following day to reevaluate the client.
(C) Encourage the client to verbalize his or her feelings.
(D) Call the client’s family to take the client to be evaluated by a physician because the
client is not safe to be alone right now.
<\Body>
<Number>12,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is on an Alzheimer’s unit. A client is agitated and pulling at things. Which of the
following should the nurse do?

(A) Provide the client with therapeutic sensory devices.
(B) Cohort the client with another client who is agitated, because they will calm each other.
(C) Place the client in a room with several other clients.
(D) Leave the client alone for a period of time to reduce stimulation.
<\Body>
<Number>13,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is caring for a terminally ill client who has agreed to enter hospice care. Which of the
following statements by the spouse indicates a need for further teaching by the nurse?

(A) “You will help to make my spouse as comfortable as possible while in hospice care.”
(B) “You will help my spouse get better so we can get back to our old life.”
(C) “The goal is to make the end of my spouse’s life as comfortable as possible.”
(D) “You will provide me with support during this difficult time.”
<\Body>
<Number>14,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is caring for a male client. The client has exhibited some signs of anxiety and hostility.
The nurse is aware that the client is a recently returned combat veteran. The nurse should assess
the client for which of the following conditions?

(A) Post-traumatic stress disorder (PTSD)
(B) Bipolar disorder
(C) Schizophrenia
(D) Borderline personality disorder (BPD)
<\Body>
<Number>15,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is caring for a client with a known past medical history for intravenous substance abuse.
The client requests to go outside for a few minutes to smoke a cigarette and promises to come right
back. The client has a peripheral intravenous line in. The nurse should take which of the following
actions?

(A) Allow the client to go outside but set a time limit in which to return.
(B) Call security to escort the client to an approved smoking area.
(C) Make a behavioral contract with the client that includes an agreement to have the NAP
accompany the client outside.
(D) Watch the client from the window to make sure the IV line stays open.
<\Body>
<Number>16,4,0<\Number>
<Answers>A<\Answers>
<Body>
The client is a non-English-speaking elderly woman who is being admitted to the hospital for
worrisome symptoms. She is accompanied by family members who speak English. The nurse
admitting the client needs to ask some general admission questions. It would be MOST
appropriate for the nurse to take which of the following actions?

(A) Call the hospital’s interpreter services to assist with asking the client questions in her
native language.
(B) Ask family members the questions and document their responses.
(C) Ask family members to translate and ask the questions for the nurse.
(D) Document “Unable to obtain answers, patient does not speak English.”
<\Body>
<Number>17,4,0<\Number>
<Answers>D<\Answers>
<Body>
The client has a medical history of alcohol abuse and had a drink yesterday. The nurse notes
tremors, diaphoresis, and an elevated heart rate. The nurse should perform which of the following
actions FIRST?

(A) Call the physician to report the symptoms and administer hydromorphone per the
alcohol withdrawal pathway.
(B) Assess the client every hour to monitor symptoms.
(C) Call the family and administer meperidine per the alcohol withdrawal pathway.
(D) Administer lorazepam per the alcohol withdrawal pathway.
<\Body>
<Number>18,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client with post-traumatic stress disorder (PTSD) appears to be having a flashback. It would be
MOST appropriate for the nurse to perform which of the following interventions?

(A) Encourage the client to tell the nurse how the client is feeling in that moment.
(B) Calmly reorient the client to the current situation.
(C) Assist the client in acting out the event.
(D) Tell the client loudly that what the client is experiencing is not real.
<\Body>
<Number>19,4,0<\Number>
<Answers>A<\Answers>
<Body>
An elderly client asks the nurse to kill the bugs that are crawling on the floor of her room. The
nurse does not see any bugs and suspects the client is hallucinating. Which of the following
statements by the nurse would be MOST appropriate?

(A) “It may seem to you that there are bugs crawling on the floor, but I do not see any
bugs.”
(B) “I see them too. How should I kill them?”
(C) “Can you tell me more about these bugs?”
(D) “What do the bugs look like?”
<\Body>
<Number>20,4,0<\Number>
<Answers>C<\Answers>
<Body>
The client has had a depressed mood, decreased sleep, poor concentration, and poor appetite for
the past 4 months. Which of the following does the nurse expect the physician to prescribe?

(A) Quetiapine
(B) Haloperidol
(C) Mirtazapine
(D) Clonazepam
<\Body>
<Number>21,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is experiencing a manic episode. It would be MOST appropriate for the nurse to perform
which of the following interventions?

(A) Give the client materials to make a collage.
(B) Encourage the client to use an exercise bike.
(C) Encourage the client to attend a group about managing feelings.
(D) Ask the client to play a board game with other clients.
<\Body>
<Number>22,4,0<\Number>
<Answers>D<\Answers>
<Body>
A client with bipolar disorder makes a sexually inappropriate comment to the nurse. The nurse
should take which of the following actions?

(A) Ignore the comment because the client has a mental health disorder and cannot help it.
(B) Report the comment to the nurse manager.
(C) Ignore the comment, but tell the incoming nurse to be aware of the client’s propensity
to make inappropriate comments.
(D) Tell the client that it is inappropriate for clients to speak to any nurse that way.
<\Body>
<Number>23,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse makes a home visit to a child with a G-tube. Upon arrival, the nurse notices that the
client’s sibling is wearing dirty clothes that are too small. The nurse also notices that there is no
food in the refrigerator or in the kitchen cabinets. Which of the following MOST appropriately
describes how the nurse should respond to these observations?

(A) The nurse should not be concerned because the sibling is not her client and the client is
being fed through a G-tube appropriately.
(B) The nurse should not be concerned because there are no signs of physical abuse.
(C) The nurse should be concerned and take action because there is no food or appropriate
clothing available to the sibling.
(D) The nurse should not be concerned because her client is well cared for.
<\Body>
<Number>24,4,0<\Number>
<Answers>A,B<\Answers>
<Body>
The nurse is caring for a hospice client who lives at home with an attentive spouse. The client’s
spouse quit work to care for the client. During the nurse’s visit, the spouse expresses frustration and
hostility toward the nurse. Which of the following are appropriate interventions by the nurse?
Select all that apply.

(A) The nurse should encourage the spouse to verbalize feelings.
(B) The nurse should encourage the spouse to attend a caregiver support group.
(C) The nurse should encourage the spouse to go back to work part-time.
(D) The nurse should encourage the spouse not to verbalize negative feelings that may upset
the client.
<\Body>
<Number>25,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is taking a history from a client in an outpatient clinic. The client has been taking
lorazepam for 6 months. Which of the following is the MOST likely side effect that the nurse
would expect to see as a result of the client using Ativan for this time period?

(A) Excessive appetite
(B) Physical dependence
(C) Suicidal ideation
(D) Seizure activity
<\Body>
<Number>26,4,0<\Number>
<Answers>A<\Answers>
<Body>
A client requires a lifesaving blood transfusion per hospital guidelines. The client refuses based on
religious beliefs. It would be MOST appropriate for the nurse to take which of the following
actions?

(A) Confirm with the client that the client understands the potential risks of not having the
blood transfusion.
(B) Tell the client that, regardless of personal beliefs, the client has to have the lifesaving
transfusion.
(C) Call the Legal Department of the hospital immediately.
(D) Try to gently encourage the client to change his or her mind.
<\Body>
<Number>27,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse monitors clients’ medications in a day program for clients with disabilities. The nurse
notices a teenage client who is frequently alone and often quiet. It would be MOST appropriate for
the nurse to take which of the following actions?

(A) Allow the client alone time since the client seems to prefer this. The client has the right
to make that choice.
(B) Make an effort to interact with the client periodically.
(C) Encourage the client to join a youth group.
(D) Encourage other clients in the program to interact more frequently with the client.
<\Body>
<Number>28,4,2<\Number>
<Answers>D,C,A,B<\Answers>
<Body>
The nurse on the inpatient psychiatric ward is caring for a client with known suicidal ideation. The
24-hour observer calls the nurse to report that the client took off down the hall. The nurse is
unable to immediately locate the client. Arrange the following actions by the nurse in the order
that is MOST appropriate. All options must be used. (Use comma alone to seperate)

(A) Notify security that the client has eloped, and provide a description of the client.
(B) Notify the nurse manager.
(C) Notify other staff on the unit.
(D) Ask the observer in what direction the client headed.
<\Body>
<Number>29,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse discovers a hospice client has expired. The family members are regrouping in the
facility’s waiting room. Which of the following actions by the nurse would be the MOST
appropriate?

(A) Tell the family it would not be in their best interests to see their loved one.
(B) Encourage the family to view the body to help accept the situation.
(C) Provide condolences to the family and offer them viewing time.
(D) Tell the family “I will give you some time to spend with your loved one. Let me know if
you need anything.”
<\Body>
<Number>30,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is caring for a newly admitted client in a hospital setting. The client was recently
diagnosed with cancer but is alert and oriented. The client is a Greek immigrant, but does speak
English. During the admission process, the nurse inquires about advance directives with the client.
The client tells the nurse: “I do not want to make any medical decisions. I want my daughter to
make these decisions for me.” The nurse should take which of the following actions?

(A) Make sure that the written advance directives document the (A) client’s wishes.
(B) Tell the client that, being alert and oriented, the client should make his or her own
medical decisions.
(C) Tell the client that due to confidentiality, the daughter will not be informed of details of
the client’s care.
(D) Encourage both the daughter and the client to work together on making medical
decisions.
<\Body>
<\Questions>
<\Section>

<Section>PHYSIOLOGICAL INTEGRITY: BASIC CARE AND COMFORT - Ch 8
<Questions>
<Number>1,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is assessing an irritable 6-month-old infant during a well-baby checkup. The infant’s
weight is 19 lb., 6.4 oz. (8.8 kg). The infant does not have an elevated temperature, the heart rate is
102, and the respiratory rate is 32. The mother states that the infant wakes every hour or two
throughout the night. The infant wants a bottle, and falls asleep while eating, but doesn’t stay
asleep. Which of the following instructions should the nurse give the parents?

(A) Instruct the parents to offer acetaminophen 325 mg orally for comfort, and
diphenhydramine 25 mg orally for sleep.
(B) Instruct the parents to offer high-calorie solid foods during daytime hours so the infant
does not wake up hungry during the night.
(C) Instruct the parents to offer the last feeding as late as possible, and put the infant to bed
awake without a bottle.
(D) Suggest using pacifiers, taking the infant to the parent’s bed, or rocking the infant to
sleep.
<\Body>
<Number>2,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse caring for a child burned over 20% of her body assists the physician in performing
dressing changes on day 5 after the initial injury. The child appears disoriented, has a fever of 101º
F (38.3º C), and is crying in pain. Which of the following nursing interventions would be the
MOST appropriate in caring for this client?

(A) Gather equipment for the dressing change and explain the procedure to the child.
(B) Do a complete physical assessment and notify the physician of the findings.
(C) Administer appropriate analgesics and gather equipment for the dressing change.
(D) Offer the child an enticing distraction from pain, such as a video, music, or toy.
<\Body>
<Number>3,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is taking care of a young child a few hours after a tonsillectomy. Which of the following
nursing interventions would be appropriate to promote adequate nutrition and oral hydration for
this child?

(A) Offer the child warm soup, watch for signs of bleeding, and suction vigorously to
remove old blood.
(B) Offer ice chips after the child awakens; advance to cool, clear liquids; and suction gently
to remove oral secretions without causing the child to cough or gag.
(C) Maintain the intravenous fluids appropriate for the child’s weight for the next 24 hours
and keep the child NPO.
(D) Offer soft, warm foods so the child will not be hungry; orange juice to provide vitamin
C; and milk shakes for calories.
<\Body>
<Number>4,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is caring for a child who had an adenoidectomy and tonsillectomy 10 hours ago. The
parents are in the room and preparing the child for bedtime. Which of the following nursing
interventions would be helpful to promote rest and sleep for this client?

(A) Provide a cool water rinse, adjust the head of the bed to a 30–45-degree angle, and offer
an ice collar for comfort.
(B) Encourage the parents to leave so the child can sleep.
(C) Suction vigorously before the child falls asleep to ensure the child has a patent airway.
(D) Provide a water rinse, offer an ice collar for discomfort, and assist the child in finding a
position of comfort while promoting a patent airway for sleep.
<\Body>
<Number>5,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse has been assigned to an adult male client who is less than 24 hours post-op. In report,
the nurse learns that he rings his call light frequently, is anxious, and has had pain medication as
ordered. Which of the following nondrug nursing interventions should the nurse include when
caring for this client?

(A) Assure the client his anxiety is understandable, because the pain medication needs time
to take effect.
(B) Assess other clients first, giving this client time to relax before evaluating his level of
pain.
(C) Call the client’s physician to increase the amount or frequency of pain medications
ordered.
(D) Provide a quiet environment, offer repositioning, straighten the bed linens, offer fluids,
and assess his pain level.
<\Body>
<Number>6,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is taking care of an adult male with bilateral leg fractures. He has a long leg cast on his
right leg as well as traction applied to the left femur. Which of the following is the MAIN purpose
served by the cast for this client?

(A) Immobilizes the tibia and fibula and corrects deformities
(B) Keeps the client, who is in traction, more comfortable
(C) Immobilizes the pelvic bones for better healing
(D) Encircles the trunk and stabilizes the spine
<\Body>
<Number>7,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is taking care of an elderly male client who has shortness of breath, cough, and fluid in
his pleural space. The physician asks the nurse to assist in the performance of a therapeutic and
diagnostic thoracentesis. Which of the following nursing interventions should the nurse perform to
assist this client?

(A) Make certain the consents are signed, witnessed, and filed in the chart.
(B) Offer oral fluids, because the client will not be able to take a drink during the procedure.
(C) Help the client to lie flat with a pillow under his feet for comfort during the procedure.
(D) Help the client to sit up and place his arms over a bedside table, encouraging him to
remain still during the procedure.
<\Body>
<Number>8,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse has been assigned to a 2-day-old male infant on the mother/baby unit of an acute care
facility. The infant will undergo a circumcision procedure in the afternoon, before being discharged
the following morning. Which of the following non-pharmacologic interventions should the nurse
teach the parents to keep this infant comfortable while the circumcision heals?

(A) Fasten his diaper tightly to avoid having it move (A) around the wound.
(B) Apply petroleum jelly to gauze and place over the end of the penis when changing the
diaper, leaving the diaper slightly loose when fastening.
(C) Offer feedings more often to soothe the child who is in pain.
(D) Wash the end of the penis vigorously to prevent infection.
<\Body>
<Number>9,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is taking care of a quadriplegic young man who suffers from a C2-C3 fracture after an
auto accident 3 months prior. He has a tracheotomy, is ventilator-dependent, and has been
discharged to home with skilled home nursing care. The nurse knows that this client is at risk for
autonomic dysreflexia. Which of the following measures should this nurse take to keep the client
comfortable, manage his elimination needs, and prevent common causes of autonomic dysreflexia?

(A) Turn the client at least every two hours and look for skin breakdown.
(B) Allow the client to sleep 8–10 hours without interruption each night to promote rest.
(C) Offer appetizing fluids at least every two hours during the day to promote hydration.
(D) Straight catheterize the client to prevent bladder distention and maintain a regular
bowel program to prevent impaction.
<\Body>
<Number>10,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is taking care of a child after an open reduction of the radius and ulna of her right arm.
The child is now immobilized in a plaster cast splint reinforced with an Ace wrap. Which of the
following non-pharmacological nursing interventions will promote comfort for this child?

(A) Apply a heat pack to the approximate area of the surgical incision.
(B) Position the child so the cast is flat on the mattress for firm support.
(C) Elevate the cast on a pillow, apply an ice pack to the approximate area of the surgical
incision, and reposition the child every two hours.
(D) Do not move any part of the child’s arm until the physician orders a specific position.
<\Body>
<Number>11,4,0<\Number>
<Answers>A,B<\Answers>
<Body>
The nurse is taking care of an elderly client with left-sided heart failure. Which of the following
are the MOST appropriate nursing interventions to reduce the workload of the heart and to
promote comfort and rest? Select all that apply.

(A) Assist the client on short walks at least two times per shift to increase circulation.
(B) Provide a comfortable armchair or raise the head of the bed to increase the reserve of the
heart and to decrease the work of breathing.
(C) Allow the client to (C) lie flat to sleep.
(D) Help the client walk to the bathroom rather than using a bedside commode.
<\Body>
<Number>12,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is instructing a male client on the proper use of crutches for an ankle injury. He will be
required to be non-weight bearing for 4–6 weeks. Which of the following crutch gaits should the
nurse teach this client for safe ambulation?

(A) The two-point gait
(B) The three-point gait
(C) The four-point gait
(D) None, there is no special gait for crutch training
<\Body>
<Number>13,4,0<\Number>
<Answers>D,C,B,A<\Answers>
<Body>
The nurse is working in an extended care facility when a nursing assistive personnel (NAP) reports
that an elderly client is crying in pain. The nurse finds the client in the bathroom reporting severe
constipation. What would be the appropriate order of nursing interventions to assist this client
with his immediate elimination needs? All options must be used.

(A) Offer oral fluids to ease the constipation.
(B) Notify the physician.
(C) Offer PRN medications orally, if ordered.
(D) Use a gloved hand with lubricant to manually assess for fecal impaction and to stimulate
the rectal wall to loosen the fecal matter.
<\Body>
<Number>14,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is caring for a young child who has recently had a vesicostomy. Which of the following
nursing interventions should the nurse undertake to assist this child with basic comfort and
elimination?

(A) Offer fluids, apply an absorbent diaper or incontinence pads, and dilate the opening
once or twice a day as ordered by the physician.
(B) Double-diapering the area is the only intervention needed.
(C) Apply a urine bag and change it daily.
(D) Double-diaper the area after applying a urine bag.
<\Body>
<Number>15,4,0<\Number>
<Answers>A<\Answers>
<Body>
A client who has chronic pain asks the nurse about alternative therapy in conjunction with
traditional treatment. Which of the following forms of alternative therapy could the nurse provide
for this client?

(A) Music therapy or guided imagery
(B) Acupuncture
(C) Kegel exercises
(D) None, nurses do not participate in providing alternative treatments
<\Body>
<Number>16,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is taking care of an adult client with a fractured femur who must be maintained in
traction for several days before surgical interventions can take place. The client has several
abrasions, his hair is dirty, and he has healing wounds in his mouth. Which of the following
nursing interventions should the nurse use in caring for the personal hygiene of this client?

(A) Place everything within the reach of the client so he can bathe himself.
(B) Assist with a bed bath, with teeth brushing, and by washing his hair with soap and
water or a non-shampoo product for bed-bound clients.
(C) Allow a family member to bathe the client.
(D) Offer an oral rinse for hygiene, but postpone the bath until a later time due to the
traction.
<\Body>
<Number>17,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is taking care of an adult client with a long-bone fracture. The nurse encourages the
client to move fingers and toes hourly, to change positions slightly every hour, and to eat high-iron
foods as part of a balanced diet. Which of the following foods or beverages should the nurse advise
the client to avoid while on bed rest?

(A) Fruit juices
(B) Large amounts of milk or milk products
(C) Cranberry juice cocktail
(D) No need to avoid any foods while on bed rest
<\Body>
<Number>18,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse working in an outpatient clinic has the opportunity to teach an insulin-dependent client.
Which of the following topics would be MOST appropriate for the nurse to include when teaching
personal hygiene?

(A) Oral care is not a top priority.
(B) Hair care is the most important part of personal hygiene for the diabetic client.
(C) It is most important to keep skin clean and dry, especially the feet.
(D) Personal hygiene is not included in diabetic teaching because it is an individual choice.
<\Body>
<Number>19,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is taking care of a child in the ambulatory care clinic. The parents relate a 24-hour
period of gastrointestinal distress, including vomiting several times and 3 watery stools. Which of
the following should the nurse do to assist in maintaining nutrition for this child?

(A) Educate the parents on the signs of dehydration and the slow introduction of fluids to
rehydrate the child.
(B) Offer no advice to the parents other than to suggest parents offer whatever foods the
child feels like taking.
(C) Encourage the parents to offer the child milk products for the vitamins and rehydration.
(D) Encourage the parents to offer solid foods to improve the nutritional status quickly.
<\Body>
<Number>20,4,2<\Number>
<Answers>3.1<\Answers>
<Body>
An 11-lb. (5-kg) infant is NPO after a minor surgical procedure. What would be the appropriate
rate of infusion of intravenous fluids if the physician ordered fluids to run at 15 mL/kg/day?
Record your answer using one decimal place.
		
		mL/hr




<\Body>
<Number>21,4,0<\Number>
<Answers>D<\Answers>
<Body>
An adult diagnosed with pancreatic cancer is having a consultation with the nurse about nutrition
and hydration. Which of the following suggestions might the nurse include when providing
education to this client?

(A) Drink clear water, progress diet rapidly as tolerated, and weigh daily.
(B) Puree foods, choose low-protein foods for easier digestion, and weigh weekly.
(C) Take herbal therapies, avoid vitamins, and don’t monitor weight.
(D) Use spices to stimulate taste buds, eat cool foods to decrease odor, and eat small but
frequent high-protein and high-carbohydrate meals.
<\Body>
<Number>22,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is caring for an elderly client who has been on long-term nutritional support. The nurse
is reviewing the infusion procedure with the client’s daughter. The nurse states which of the
following as the rationale for removing the formula from the refrigerator and infusing it through
the gastrostomy tube at room temperature?

(A) “The formula tastes better at room temperature.”
(B) “This method will be the least likely to give your father gastric discomfort.”
(C) “There is no need to bring the formula to room temperature.”
(D) “Room-temperature prepared formula reduces aspiration.”
<\Body>
<Number>23,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is working with a middle-aged female after a knee injury. Ambulation is still difficult for
the client, and the physical therapist has suggested the client use a cane. The nurse states which of
the following with respect to using a cane rather than a walker for this injury?

(A) “The cane is just a reminder to use good posture.”
(B) “The cane can be more dangerous than helpful, and another type of assistive device
should be considered for this client.”
(C) “The cane will help with fatigue while assisting the client with balance and support.”
(D) “A cane does not offer any relief on weight-bearing joints.”
<\Body>
<Number>24,4,2<\Number>
<Answers>1(E),2(D),3(B),4(C),5(A)<\Answers>
<Body>
The nurse is preparing for a pediatric trauma admission in which traction will be applied to
immobilize a femur fracture for a child. The nurse reviews the forms of traction and the purposes
for each before gathering equipment prior to the child’s arrival. Match the type of traction on the
left with the type of injury or indication on the right. All options must be used.
Respond in the format: 1(B),2(C),3(D),4(A),5(E)

(1) Bryant’s traction
(2) Russell’s traction
(3) 90-degree traction
(4) Buck’s traction
(5) Cervical traction
Stabilizes a spinal fracture (A) or muscle spasm
(B) Used on the femur if skin traction isn't suitable
(C) Temporarily immobilizes a fractured leg
(D) May reduce fractures of the hip or femur
(E) Used in children younger than age 2 to reduce femur fractures or stabilize hips
<\Body>
<Number>25,4,1<\Number>
<Answers>C<\Answers>
<Body>
It is important to evaluate pain in the neonate. Look at the chart below. What would the pain
score be for an infant with a high-pitched cry, O2 saturation of 96%, a grimace, and frequent
periods of wakefulness?

(A) Score of 0
(B) Score of 2
(C) Score of 3
(D) Not enough information
<\Body>
<\Questions>
<\Section>

<Section>PHYSIOLOGICAL INTEGRITY: PHARMACOLOGICAL AND PARENTERAL THERAPIES - Ch 9
<Questions>
<Number>1,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is conducting a home visit with a client who has a history of angina. Which of the
following BEST demonstrates that further teaching about nitroglycerin therapy is required?

(A) “I take a tablet about 10 minutes before I walk up the stairs.”
(B) “I take no more than 3 doses in a 15-minute period of time.”
(C) “I keep the tablets in a glass dish on the windowsill so they are readily available.”
(D) “I will call my doctor immediately if I experience blurred vision.”
<\Body>
<Number>2,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse assesses the peripheral IV site of a client receiving a doxorubicin infusion and suspects
extravasation. After stopping the infusion and disconnecting the IV tubing, which of the following
should the nurse do next?

(A) Apply a hot compress to the IV site.
(B) Apply a cold compress to the IV site.
(C) Elevate the affected extremity.
(D) Attempt to aspirate the residual drug.
<\Body>
<Number>3,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is preparing to discharge a 72-year-old man on warfarin therapy for a pulmonary
embolism. The nurse’s discharge teaching should include which of the following instructions?

(A) Follow a healthy diet by increasing ingestion of green, leafy vegetables.
(B) Take herbal remedies to manage cold symptoms.
(C) Avoid alcohol due to enhanced anticoagulant effect.
(D) Take Coumadin only on an empty stomach.
<\Body>
<Number>4,4,0<\Number>
<Answers>D<\Answers>
<Body>
A 75-year-old woman has been prescribed amitriptyline hydrochloride to manage neuropathic pain
associated with diabetic neuropathy. She reports to the nurse that her pain level has decreased from
a 7 to a 3 on a scale of 1–10. However, she is experiencing severe xerostomia. Which of the
following strategies should the nurse choose to help relieve this symptom?

(A) Increase caffeine intake.
(B) Decrease fluid intake.
(C) Increase dietary sodium.
(D) Chew sugar-free gum.
<\Body>
<Number>5,4,0<\Number>
<Answers>B<\Answers>
<Body>
Prior to administering digoxin 0.125 mg PO to a client with chronic heart failure, the nurse
determines that the apical pulse is 56. Which of the following should the nurse do FIRST?

(A) Administer the drug and recheck the pulse in one hour.
(B) Withhold the drug and notify the physician.
(C) Obtain an EKG.
(D) Send a blood sample to the laboratory for a digoxin level.
<\Body>
<Number>6,4,0<\Number>
<Answers>C<\Answers>
<Body>
A 65-year-old man with metastatic colon cancer has been prescribed hydromorphone PO/PRN to
help manage his pain. The nurse knows that the rectal route of administration is contraindicated
when which of the following is present?

(A) Nausea and vomiting
(B) Difficulty swallowing
(C) Neutropenia
(D) Fever
<\Body>
<Number>7,4,0<\Number>
<Answers>A,B,D<\Answers>
<Body>
A client is admitted for gastrointestinal bleeding. He has a platelet count of 15,000/mm and
platelets have been ordered from the blood bank. Which of the following does the nurse know are
required for platelet transfusions? Select all that apply.

(A) ABO compatibility
(B) Rh compatibility
(C) Crossmatching
(D) A specialized platelet filter
<\Body>
<Number>8,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client’s red blood cell transfusion was discontinued due to an acute hemolytic transfusion
reaction. Which of the following strategies should the nurse use to BEST minimize the risk of such
a reaction?

(A) The nurse ensures the client’s temperature does not increase more than 1.8º F during
the transfusion.
(B) The nurse verifies all client-identifying information according to hospital protocol prior
to hanging the unit of blood.
(C) The nurse administers meperidine for severe rigors.
(D) The nurse administers acetaminophen prior to the transfusion.
<\Body>
<Number>9,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is receiving a blood transfusion. The nurse observes that the client is experiencing
diarrhea, abdominal pain, and chills. Which of the following actions should the nurse take FIRST?

(A) Assist the client to the bathroom.
(B) Stop the transfusion.
(C) Administer meperidine.
(D) Get a warming blanket.
<\Body>
<Number>10,4,0<\Number>
<Answers>A,B,D<\Answers>
<Body>
The nurse aspirates a central venous catheter prior to drug administration but is not able to verify
blood return. The nurse does not feel resistance when flushing or see any fluid leakage, swelling, or
redness around the catheter site. Which of the following does the nurse know are appropriate
steps? Select all that apply.

(A) Flush the catheter with saline, using a 10-mL syringe and a push-pull technique.
(B) Request that the client cough and reattempt aspiration.
(C) Administer IV medication and observe for signs and symptoms of catheter malfunction.
(D) Follow institutional protocol to initiate a declotting protocol.
<\Body>
<Number>11,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is admitted for pulmonary embolism and is receiving heparin 1,500 units/hour IV. In case
of a serious bleeding reaction, the nurse has which of the following drugs readily available?

(A) Vitamin K
(B) Protamine sulfate
(C) Promethazine hydrochloride
(D) Protamine
<\Body>
<Number>12,4,0<\Number>
<Answers>C<\Answers>
<Body>
A client with known heparin-induced thrombocytopenia (HIT) is undergoing chemotherapy and
is having a central venous access device placed. Which of the following types of central venous
access device does the nurse know BEST minimizes the risk of HIT-related complication?

(A) Hickman
(B) Broviac
(C) Groshong
(D) Port
<\Body>
<Number>13,4,0<\Number>
<Answers>C<\Answers>
<Body>
A client has been instructed by his physician to increase his warfarin sodium dose from 5 mg to 7.5
mg. He only has 5-mg tablets available. How many tablets should the nurse instruct him to take?

(A) 0.5
(B) 1
(C) 1.5
(D) 2
<\Body>
<Number>14,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is preparing to set up an intravenous infusion of normal saline 1,000 mL over a 6-hour
period. The tubing drop factor is 10 gtt/mL. Which of the following rates of infusion should the
nurse choose?

(A) 12 gtt/min
(B) 28 gtt/min
(C) 33 gtt/min
(D) 36 gtt/min
<\Body>
<Number>15,4,0<\Number>
<Answers>A<\Answers>
<Body>
A man weighs 165 lb. and is being treated for shock. The nurse is preparing a dopamine
hydrochloride infusion to start at 5 mcg/kg/min. The nurse has prepared the following to infuse:
dopamine 400 mg in 250 mL D5W. Which of the following rates of infusion should the nurse
choose?

(A) 14 mL/hr
(B) 16 mL/hr
(C) 22.5 mL/hr
(D) 37.5 mL/hr
<\Body>
<Number>16,4,2<\Number>
<Answers>105<\Answers>
<Body>
A 45-year-old woman with breast cancer is receiving doxorubicin 60 mg/m2 as part of her cancer
therapy. She is 5 ft. 6 in. tall and weighs 145 lb. Her body surface area is 1.75 m2. What is the
correct dose that the nurse should administer? Record your answer using one decimal place.

		mg




<\Body>
<Number>17,4,0<\Number>
<Answers>C<\Answers>
<Body>
A client is admitted with sickle-cell anemia and voices concerns about becoming addicted to pain
medicine. The nurse explains the difference between physical dependence, tolerance, and
addiction. Which of the following symptoms or behaviors does the nurse know is BEST associated
with addiction?

(A) Withdrawal symptoms when the drug is abruptly stopped
(B) Withdrawal symptoms when the drug dose is reduced
(C) Habitual and compulsive use of a drug
(D) A state of adaptation
<\Body>
<Number>18,4,0<\Number>
<Answers>C<\Answers>
<Body>
A client is admitted with severe back pain and is requesting pain medication. During her
assessment, the nurse notes the client has been taking acetaminophen 650 mg every 4 hours at
home with minimal relief. Based on this information, which of the following PRN-ordered drug(s)
should the nurse consider administering?

(A) Hydrocodone with acetaminophen
(B) Acetaminophen
(C) Ibuprofen
(D) Acetaminophen with oxycodone
<\Body>
<Number>19,4,0<\Number>
<Answers>B<\Answers>
<Body>
A 14-year-old boy has been prescribed amphetamine and dextroamphetamine for attentiondeficit/
hyperactivity disorder (ADHD). The nurse explains that the client should be alert for which
of the following adverse drug effects?

(A) Weight gain
(B) Depression
(C) Somnolence
(D) Bradycardia
<\Body>
<Number>20,4,2<\Number>
<Answers>D,B,A,C<\Answers>
<Body>
The nurse is administering a drug by Z-track and must follow the proper technique. Place the
following steps in the appropriate order. All options must be used. (Use comma alone to seperate)

(A) Withdraw the needle.
(B) Administer the drug intramuscularly (IM) in the dorsogluteal site.
(C) Release the skin.
(D) Displace the skin lateral to the injection site.
<\Body>
<Number>21,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client admitted with chronic heart failure is taking furosemide. Which of the following
statements, if made by the client, BEST demonstrates to the nurse that the client understands the
side effects associated with this drug?

(A) “My blood pressure might be abnormally high.”
(B) “I should include more foods such as bananas, apricots, and legumes in my diet.”
(C) “I should take the drug before bedtime.”
(D) “I should not take the pill with food.”
<\Body>
<Number>22,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is administering vancomycin 1 g every 12 hours for a soft tissue infection. The nurse
reminds the client to report symptoms associated with one of the serious side effects of the drug,
ototoxicity. Which of the following statements by the client indicates to the nurse that the client
may be experiencing this adverse reaction?

(A) “I hear ringing in my ear.”
(B) “The IV is burning.”
(C) “My skin is very itchy.”
(D) “I have a bad taste in my mouth.”
<\Body>
<Number>23,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is leaving the clinic with a new prescription for lisinopril. Which of the following
suggestions can the nurse make to minimize one of the major effects of lisinopril?

(A) Eat fruits and vegetables high in iron.
(B) Rise slowly from a lying to a sitting position.
(C) Increase fluid intake.
(D) Avoid aspirin-containing drugs.
<\Body>
<Number>24,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is administering a doxorubicin IV push to a client with breast cancer. Which of the
following should the nurse explain is to be expected during therapy with this drug?

(A) Burning at the IV site during administration
(B) Red-colored urine
(C) Permanent alopecia
(D) Teeth discoloration
<\Body>
<Number>25,4,0<\Number>
<Answers>A,B,D<\Answers>
<Body>
A 60-year-old woman with anorexia nervosa is having an indwelling central venous access device
placed in preparation for total parenteral nutrition (TPN) administration. Which of the following
factors does the nurse know accounts for the client’s increased risk of thrombophlebitis with a
peripheral intravenous line? Select all that apply.

(A) Age
(B) Hypertonicity of the TPN
(C) Hypotonicity of the TPN
(D) Poor peripheral venous access
<\Body>
<\Questions>
<\Section>

<Section>PHYSIOLOGICAL INTEGRITY: REDUCTION OF RISK POTENTIAL - Ch 10
<Questions>
<Number>1,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is reviewing the chart of an older adult male client after surgery for removal of the
parathyroid glands. The client reports difficulty swallowing and a feeling of “pins and needles.”
The nurse expects which of the following laboratory values to be abnormal?

(A) Calcium
(B) Lipase
(C) Potassium
(D) Sodium
<\Body>
<Number>2,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is assessing a young-adult pregnant client with no allergies who has tested positive for
gonorrhea. Which of the following medications should the nurse expect to be part of the treatment
plan?

(A) Tetracycline
(B) Ciprofloxacin
(C) Azithromycin
(D) Ceftriaxone
<\Body>
<Number>3,4,0<\Number>
<Answers>C<\Answers>
<Body>
A client is one day post-op for abdominal surgery. The nurse is teaching the client techniques to
reduce pain when he moves, coughs, or breathes deeply. Which of the following statements from
the client indicates that the client understands the teaching?

(A) “I can start exercising my limbs as soon as you medicate me.”
(B) “I will just lie here for a few days until the pain goes away.”
(C) “I will use the side rail for support when I move or turn.”
(D) “I will ask for pain medication only when absolutely necessary.”
<\Body>
<Number>4,4,0<\Number>
<Answers>D<\Answers>
<Body>
A 36-year-old primigravid client with a history of diabetes is admitted with preeclampsia. Which
of the following actions should the nurse take FIRST?

(A) Administer low-dose aspirin as ordered.
(B) Ask the physician for an order for calcium supplements.
(C) Monitor the client’s blood pressure.
(D) Prepare the client for delivery.
<\Body>
<Number>5,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse has just answered a call light for a client who is two days post-op for abdominal surgery.
The client states, “I coughed and heard this pop.” The nurse assesses the surgical site and observes
dehiscence of the wound. Which of the following should the nurse do FIRST?

(A) Stay with the client and have a colleague notify the physician.
(B) Help the client to lie with his head slightly elevated and with knees bent.
(C) Apply warm, sterile normal saline soaks.
(D) Help the client to sit up, which will reduce the harmful effects of further coughing.
<\Body>
<Number>6,4,0<\Number>
<Answers>D<\Answers>
<Body>
An elderly man is admitted to the hospital from the Emergency Department during the night
shift. The nurse is assessing the client’s cerebellar function. Which of the following questions
should the nurse ask the client?

(A) “Who is the current president of the United States?”
(B) “Do you have trouble swallowing fluids or foods?”
(C) “Do you have any muscle pain?”
(D) “Do you have problems with balance?”
<\Body>
<Number>7,4,0<\Number>
<Answers>A,B,E<\Answers>
<Body>
An older adult male client with a history of myasthenia gravis is admitted to the medical/surgical
unit. Which of the following tests should the nurse expect to see ordered? Select all that apply.

(A) Tensilon test
(B) Nerve conduction studies
(C) Lumbar puncture
(D) EEG
(E) Electromyography
<\Body>
<Number>8,4,0<\Number>
<Answers>B<\Answers>
<Body>
A middle-aged female client with a history of atherosclerosis is admitted with complaints of
abdominal tenderness during deep palpation. The nurse notices a pulsating mass in the
periumbilical area. Which of the following does the nurse suspect?

(A) Appendicitis
(B) Abdominal aortic aneurysm
(C) Acute cholecystitis
(D) Paralytic ileus
<\Body>
<Number>9,4,0<\Number>
<Answers>A<\Answers>
<Body>
An older adult client with a history of blood clots is in the emergency room with suspected deep
vein thrombosis (DVT) of the left leg. The nurse starts IV heparin as ordered. Which of the
following is LEAST likely to be included in the care plan?

(A) Ambulation as tolerated
(B) Warm, moist soaks applied to the affected area
(C) Analgesics as ordered
(D) Anti-embolism stockings
<\Body>
<Number>10,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is caring for a client with a history of chronic liver disease and cirrhosis of the liver. Lab
values reveal rising ammonia levels. Which of the following treatments should the nurse question?

(A) Calorie intake 1,800–2,400 cal/day in the form of glucose or carbohydrates
(B) Protein 100 g/day
(C) An order to administer neomycin
(D) Potassium supplements
<\Body>
<Number>11,4,0<\Number>
<Answers>C,D<\Answers>
<Body>
The laboratory values of an adult male client reveal the presence of hepatitis B surface antigens and
hepatitis B antibodies. Which of the following laboratory results should the nurse also expect to
see? Select all that apply.

(A) Elevated serum albumin
(B) Low serum globulin
(C) Elevated serum transaminate (ALT and AST)
(D) Prolonged prothrombin time (PT)
(E) Low urine bilirubin
<\Body>
<Number>12,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is assessing a client with Addison’s disease. The nurse expects to note which of the
following?

(A) Anorexia
(B) Weight gain
(C) Yellow skin coloration
(D) A craving for sweets
<\Body>
<Number>13,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is having a tonic-clonic seizure. Which of the following should the nurse do FIRST?

(A) Check the client’s breathing.
(B) Remove objects from the client’s surroundings.
(C) Place a tongue blade in the client’s mouth.
(D) Restrain the client.
<\Body>
<Number>14,4,0<\Number>
<Answers>B<\Answers>
<Body>
A client is recovering from a bout with chronic glomerulonephritis. The nurse prepares the client
for discharge and home management. Which of the following statements indicates the client
understands his condition and how to control it?

(A) “I should stop taking my blood pressure medication if I feel better or have side effects.”
(B) “I will take my furosemide medications as ordered every morning.”
(C) “I will keep my negative feelings to myself, so I don’t get stressed.”
(D) “I don’t need a follow-up examination unless I’m feeling poorly.”
<\Body>
<Number>15,4,0<\Number>
<Answers>D<\Answers>
<Body>
A nursing home client is admitted to the hospital with a pressure ulcer involving full-thickness loss
extending to the bone. The nurse documents the pressure ulcer as being at which of the following
stages?

(A) Stage I
(B) Stage II
(C) Stage III
(D) Stage IV
<\Body>
<Number>16,4,0<\Number>
<Answers>C<\Answers>
<Body>
A client with Raynaud’s disease is experiencing an acute attack. The nurse should anticipate which
of the following assessment findings?

(A) Involuntary muscle contractions and twitching
(B) Unilateral facial weakness and drooping mouth
(C) Numbness and tingling of fingers and blanching of the skin at the fingertips
(D) Photophobia
<\Body>
<Number>17,4,0<\Number>
<Answers>B<\Answers>
<Body>
The physician orders a CT scan of the client’s chest with IV contrast. Which of the following
findings in the client’s history should the nurse report to the physician?

(A) Hypertension
(B) Allergy to shellfish
(C) Urinary tract infection (UTI)
(D) Allergy to penicillin
<\Body>
<Number>18,4,0<\Number>
<Answers>B<\Answers>
<Body>
The oncologist examines a client in the clinic and subsequently admits the client to the hospital
with severe bone marrow depression. The client’s therapy included radiation and chemotherapy.
Which of the following nursing diagnoses takes priority in the client’s care plan?

(A) Imbalanced nutrition: less than body requirements
(B) Risk for infection
(C) Pain
(D) Risk for injury
<\Body>
<Number>19,4,0<\Number>
<Answers>B,D,E<\Answers>
<Body>
The nurse is preparing to discharge a client who is stable after a sickle-cell anemia crisis. Which of
the following instructions should the nurse provide to the client to avoid future crises? Select all
that apply.

(A) Limit your fluid intake.
(B) Avoid strenuous exercise.
(C) Apply cold compresses to painful areas.
(D) Take pain medications as ordered.
(E) Avoid tight clothing.
<\Body>
<Number>20,4,0<\Number>
<Answers>A<\Answers>
<Body>
The clinic nurse is updating the medications being taken by an anxious middle-aged client, and
sees that the physician prescribed an antidiuretic hormone. The nurse knows the medication has
which of the following effects on the kidneys?

(A) Increases water reabsorption and urine concentration
(B) Decreases water reabsorption and dilutes the urine
(C) Regulates sodium retention
(D) Controls potassium secretion
<\Body>
<Number>21,4,0<\Number>
<Answers>A,C,D<\Answers>
<Body>
The nurse is performing an assessment on a client who has developed cirrhosis. Which of the
following signs and symptoms should the nurse expect to see? Select all that apply.

(A) Dull abdominal ache
(B) Cyanosis
(C) Poor tissue turgor
(D) Bruises
(E) Fruity breath
<\Body>
<Number>22,4,2<\Number>
<Answers>2<\Answers>
<Body>
22. The physician orders 0.5 mg of digoxin for a client with atrial fibrillation. The pharmacy has 250-
mcg tablets available. How many tablets will the nurse give?

_______________________

<\Body>
<Number>23,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is preparing to administer a red blood cell transfusion to a client with a low hemoglobin
level and low hematocrit. The nurse knows which of the following statements about blood
transfusion practice is true?

(A) The client should be monitored for at least one hour after the start of the transfusion.
(B) The transfusion should be completed within 2 hours.
(C) The transfusion should be started within 30 minutes of removing the blood or blood
components from the blood bank.
(D) The only solution that should be added to blood or blood components is 0.45% sodium
chloride (half normal saline solution).
<\Body>
<Number>24,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is providing discharge teaching to a client stabilized after an acute attack of primary
gout. Which of the following foods should the nurse instruct the client to avoid to prevent future
attacks?

(A) Cauliflower, asparagus, and mushrooms
(B) Anchovies, liver, and lentils
(C) Cherries, strawberries, and blueberries
(D) Cereal, pasta, and rice
<\Body>
<Number>25,4,0<\Number>
<Answers>D<\Answers>
<Body>
In the emergency room, the nurse is caring for a client who reports substernal pain radiating to the
arm and jaw, shortness of breath, and a feeling of impending doom. The client had a stroke one
month ago. The client’s vital signs are blood pressure 146/72, pulse 128, and respirations 36. The
12-lead ECG reveals evolving acute myocardial infarction (MI). Which of the following physician
orders should the nurse question?

(A) Beta-adrenergic blocker
(B) Morphine for pain
(C) IV nitroglycerin
(D) Thrombolytic therapy
<\Body>
<Number>26,4,0<\Number>
<Answers>B<\Answers>
<Body>
An older adult female, newly diagnosed with type 2 diabetes, is ready for discharge. When
providing discharge instructions, the nurse teaches the client that the key to preventing diabetic
foot complications is which of the following?

(A) Taking the medication as ordered
(B) Following the recommended diet
(C) Surgical intervention
(D) Regular evaluation of the look and feel of her feet
<\Body>
<Number>27,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse knows that the physician is most likely to order which of the following laboratory tests
to evaluate a client for hypoxia?

(A) Hematocrit
(B) Sputum analysis
(C) Arterial blood gas (ABG) analysis
(D) Total hemoglobin
<\Body>
<Number>28,4,1<\Number>
<Answers>A<\Answers>
<Body>
The nurse is performing a 12-lead ECG on a client who has come to the emergency room
reporting chest pain. Where should the nurse place lead V1?

(A) A
(B) B
(C) C
(D) D
<\Body>
<Number>29,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse is assessing a client admitted with a cerebrovascular accident (CVA). The physician has
ordered a swallow study. The nurse knows which of the following lobes of the cerebral hemisphere
is involved in the control of voluntary muscle movement, including those necessary for the
production of speech and swallowing?

(A) Frontal
(B) Parietal
(C) Temporal
(D) Occipital
<\Body>
<Number>30,6,2<\Number>
<Answers>E,B,A,D,C,F<\Answers>
<Body>
The nurse is preparing to do the Heimlich maneuver on a choking middle-aged adult male client.
Arrange the following steps in the order the nurse should perform them. All options must be used. (Use comma alone to seperate)

(A) Make a fist with one hand.
(B) Stand behind the client.
(C) Wrap your other arm around the client and place that hand on top of your fist.
(D) Place your thumb toward the client, below the rib cage and above the waist, and wrap
one arm around the client.
(E) Ask the client if he is choking.
(F) Thrust upward 6–10 times.
<\Body>
<\Questions>
<\Section>

<Section>PHYSIOLOGICAL INTEGRITY: PHYSIOLOGICAL ADAPTATION - Ch 11
<Questions>
<Number>1,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse has just completed setting up an external warming device (Bear Hugger) for a 48-yearold
client and is ready to initiate therapy. The core temperature taken with a rectal probe is
currently 91.4° F (33° C). Which of the following actions should the nurse perform?

(A) Active rewarming to increase the core temperature no more than 0.9° F (0.5° C) per
hour
(B) Active rewarming to increase the core temperature as quickly as possible
(C) Active rewarming to increase the core temperature to 96.8° F (36° C)
(D) Active rewarming to increase the core temperature to 100.4° F (38° C)
<\Body>
<Number>2,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse is cleansing a simple surgical wound. The client is two days postoperative, and the
incision has well-approximated edges with no sign of infection. A Jackson-Pratt drain is adjacent
to the incision site. Which of the following should the nurse do?

(A) Cleanse the incision and drain sites while wearing standard clean gloves.
(B) Cleanse in a back-and-forth motion across the incision line and in a circular motion
around the drain site.
(C) Cleanse the incision site and drain site together.
(D) Cleanse the incision and drain sites using a sterile saline solution.
<\Body>
<Number>3,4,2<\Number>
<Answers>D,B,C,A,E<\Answers>
<Body>
The nurse is emptying an evacuator of a Jackson-Pratt drain. The nurse has drained the fluid into a
calibrated container and has placed the container on a level flat surface. The nurse measures 20 mL
of bloody fluid. Arrange the following actions the nurse should take in sequential order. All
options must be used. (Use comma alone to seperate)

(A) Dispose of the bloody drainage.
(B) Compress the evacuator completely.
(C) Replace the plug in the evacuator.
(D) Cleanse the plug with an alcohol wipe.
(E) Document the amount, odor, and consistency of the drainage.
<\Body>
<Number>4,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse in an outpatient clinic has received an order from the physician to remove the client’s
sutures. The nurse should do which of the following?

(A) Use gloves when removing sutures.
(B) Apply hydrogen peroxide gauze pads to cleanse the area first, then remove the sutures.
(C) Use sterile technique when removing sutures.
(D) Nothing, suture removal is outside of the nurse’s scope of practice.
<\Body>
<Number>5,4,0<\Number>
<Answers>D<\Answers>
<Body>
The medical floor nurse receives report from the Emergency Department on a 42-year-old client
who is admitted to the hospital for hyperphosphatemia related to end-stage renal disease. The
client receives continuous ambulatory peritoneal dialysis (CAPD), and the physician has ordered
continuation of treatment during hospitalization. The nurse should do which of the following?

(A) Maintain a permanent peritoneal catheter with flushes of 0.9% normal saline (0.9% NS)
every 4–6 hours.
(B) Obtain a pump in preparation for dialysate infusion.
(C) Ensure the dialysate is refrigerated until ready to infuse, and obtain a warming pad or a
warming machine to warm the dialysate to body temperature prior to exchange.
(D) Weigh the client at the same time every day, and use sterile technique while working
with a permanent peritoneal catheter.
<\Body>
<Number>6,4,0<\Number>
<Answers>D<\Answers>
<Body>
An 8-year-old girl is discharged from the hospital with a new tracheostomy. The parents have
received initial teaching in the hospital, and the home health nurse will reinforce this teaching. Per
report, the parents are willing to learn and are grasping the concepts well. The home health nurse
would expect the parents to verbalize and demonstrate which of the following?

(A) “The cleansing and dressing of the stoma will be done at least every 24 hours.”
(B) “It is not always necessary to suction before tracheostomy care.”
(C) “The inner cannula should be changed by the physician or home health nurse.”
(D) “Hydrogen peroxide is used to cleanse the stoma area.”
<\Body>
<Number>7,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is preparing to suction a client with an endotracheal tube. After ventilating, which is the
correct sequence of actions for the nurse to follow during suctioning?

(A) Apply suction, insert a sterile catheter, and withdraw while rotating the catheter.
(B) Insert a sterile catheter, begin to withdraw, apply suction, and continue to withdraw
while rotating the catheter.
(C) Apply suction, insert a sterile catheter, and withdraw without rotating the catheter.
(D) Insert a sterile catheter, begin to withdraw, apply suction, and continue to withdraw
without rotating the catheter.
<\Body>
<Number>8,4,0<\Number>
<Answers>D<\Answers>
<Body>
The nurse assesses a client with a diagnosis of parathyroid disease. The client is having abdominal
cramping, positive Chovstek’s and Trousseau’s signs, and tingling in the extremities. The nurse
knows that these findings could be signs and symptoms of which of the following?

(A) Hypermagnesemia
(B) Hypomagnesemia
(C) Hypercalcemia
(D) Hypocalcemia
<\Body>
<Number>9,4,2<\Number>
<Answers>1030<\Answers>
<Body>
The physician has ordered a 2-L daily fluid restriction for a client diagnosed with congestive heart
failure. The nurse is totaling the client’s fluid intake for the 8-hour shift. The client drank 5 oz. of
juice at breakfast, 2 oz. of water with medications, 8 oz. of soup at lunch, and 6 oz. of milk with
lunch. Intravenous fluids, flushes, and intravenous antibiotics for the shift were 400 mL. Urinary
output was 300 mL, 100 mL, and 250 mL. What should the nurse document, in milliliters, as the
total fluid intake for the shift?

		mL




<\Body>
<Number>10,4,0<\Number>
<Answers>C<\Answers>
<Body>
A 70-year-old male presented to the Emergency Department with shortness of breath, crackles in
the bases and middle of the lung fields bilaterally, +2 pitting edema bilaterally of the lower
extremities, and a weight increase of 6 lb. in one week. His heart rate is 82 and his blood pressure
is 162/90. Per physician’s order, the nurse administers 40 mg of furosemide intravenously. The
nurse knows that which of the following indicates effectiveness of the medication?

(A) A heart rate of 58
(B) A blood pressure of 100/52
(C) Urine output increase of 200 mL over the next hour
(D) Diminished lung sounds bilaterally with crackles in the bases
<\Body>
<Number>11,4,1<\Number>
<Answers>B<\Answers>
<Body>
The nurse takes report on a client returning from left-sided cardiac catheterization. The client also
underwent a percutaneous transluminal coronary angioplasty (PTCA), with drug-eluding stents
placed in the right coronary artery and left coronary artery, and the site was closed with a collagen
plug. The nurse would expect to assess the entry site on the client at which of the following
locations?

(A) A
(B) B
(C) C
(D) D
<\Body>
<Number>12,4,1<\Number>
<Answers>B<\Answers>
<Body>
The progressive care unit nurse is assessing the following cardiac rhythm. Using the following
exhibit, the nurse should identify this rhythm as which of the following?

(A) Atrial fibrillation
(B) Atrial flutter
(C) Ventricular fibrillation
(D) Third-degree atrioventricular block
<\Body>
<Number>13,4,0<\Number>
<Answers>B<\Answers>
<Body>
The critical care nurse is caring for a client with an arterial line (A-line). The nurse can utilize this
line for which of the following?

(A) Monitoring blood pressure and heart rate, and infusing medications
(B) Monitoring blood pressure and heart rate, and obtaining blood gases and other
laboratory samples
(C) Monitoring heart rate, obtaining blood gases and other laboratory samples, and infusing
medications
(D) Obtaining blood gases and other laboratory samples, and infusing medications
<\Body>
<Number>14,4,0<\Number>
<Answers>D<\Answers>
<Body>
An 82-year-old woman is admitted with a diagnosis of rapid atrial fibrillation. The nurse has
initiated telemetry monitoring per the physician’s order. Two hours after initiation of monitoring,
an alarm sounds at the central monitoring station: the client is in what appears to be ventricular
tachycardia. Which of the following actions should the nurse take FIRST?

(A) Call a code blue.
(B) Silence the alarm and change the alarm parameters.
(C) Notify the physician of a change in rhythm.
(D) Assess the client and check lead placement.
<\Body>
<Number>15,4,0<\Number>
<Answers>A<\Answers>
<Body>
A 39-year-old client has been diagnosed with end-stage renal disease and is on the transplant
waiting list. The client has been receiving dialysis through a subclavian central vein catheter while
an arteriovenous fistula is maturing. Besides dialysis access, the surgical floor nurse can utilize this
subclavian central vein catheter for which of the following?

(A) Nothing
(B) Blood draws only
(C) Infusion of normal saline (0.9% NS) and obtaining blood draws
(D) Infusion of medications, all intravenous fluids, and obtaining blood draws
<\Body>
<Number>16,4,0<\Number>
<Answers>B<\Answers>
<Body>
A 76-year-old man is brought into the Emergency Department by his spouse. The client’s spouse
tells the nurse he is confused, disoriented, and weak, and has not been eating well. The nurse
obtains blood work as ordered by the physician, including a complete blood count (CBC) and a
comprehensive metabolic panel (CMP). For which result should the nurse immediately notify the
physician?

(A) Potassium (K+) 3.8 mEq/L
(B) Sodium (Na+) 122 mEq/L
(C) Magnesium (Mag+) 1.9 mg/dL
(D) Hemoglobin (Hgb) 12 g/dL
<\Body>
<Number>17,4,0<\Number>
<Answers>C<\Answers>
<Body>
The nurse is providing discharge instructions to a client going home on enoxaparin. Which of the
following responses by the client indicates to the nurse that the teaching was effective?

(A) “Prior to injection, I will rub the site with an alcohol wipe.”
(B) “I will use the same site for each injection.”
(C) “I will not pull back the plunger after inserting the needle into the site.”
(D) “After injection, I will massage the site to increase absorption.”
<\Body>
<Number>18,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nursing home nurse finds a 92-year-old client on the floor during rounds. The client is not
responsive. Vital signs have been taken by the certified nursing assistant: blood pressure 98/52,
heart rate 120, respirations 28, and oxygen saturation 94%. The client has a history of falls,
hypertension, and an extensive cardiac history. The client’s chart indicates a signed physician order
that states “Do not resuscitate” and “Do not intubate” (DNR/DNI). Which of the following
should the nurse do?

(A) Stay with the client and have another staff member call 911.
(B) Begin CPR and have another staff member call 911.
(C) Move the client into the bed and call the physician.
(D) Call the family and ask what they would like to have done for the client.
<\Body>
<Number>19,4,0<\Number>
<Answers>C<\Answers>
<Body>
The surgical floor nurse is working with a client on coughing and deep breathing. The mildly obese
client is six days postoperative, and has a large midline abdominal incision that is not well
approximated. The client stops the exercise and states she felt a popping sensation in her
abdominal area. Upon assessment, the nurse finds a small portion of the viscera to be protruding
through the incision. Which of the following actions should the nurse take FIRST?

(A) Do nothing; this is a normal finding for a large midline abdominal incision.
(B) Call the surgeon who operated on the client and inform the physician of the finding.
(C) Place sterile dressings moistened with sterile normal saline (0.9% NS) over the viscera
and hold in place with a sterile gloved hand.
(D) Place an abdominal binder on the area, elevate the head of the bed no more than 20
degrees, and have the client recline with her knees bent.
<\Body>
<Number>20,4,0<\Number>
<Answers>A,C,D<\Answers>
<Body>
The intensive care nurse is caring for a client requiring mechanical ventilation. Which of the
following are interventions the nurse should take to help prevent ventilator-associated pneumonia
(VAP)? Select all that apply.

(A) Reposition the client at least every 2 hours and maintain the head of the bed upright at
30–45 degrees.
(B) Promote nutrition with the use of a nasogastric tube and high-calorie feedings.
(C) Suction oral and pharynx secretions, and provide thorough oral care at least every 2
hours.
(D) Assess the client for sedation reduction and weaning/extubation readiness.
Perform hand hygiene before and after care of the client, and implement prophylactic
intravenous antibiotic therapy.
(E)
<\Body>
<Number>21,4,0<\Number>
<Answers>C<\Answers>
<Body>
The night nurse on a medical floor has just received report. On which of the following clients
should the nurse make rounds FIRST?

(A) The 52-year-old female with pancreatitis who is experiencing abdominal pain rated 4
on a 1–10 scale
(B) The 70-year-old male who underwent a transurethral resection of the prostate (TURP)
yesterday and is having a burning sensation during urination
(C) The 78-year-old male with diagnosis of left-sided heart failure who has developed a
new nonproductive cough and is restless
(D) The 37-year-old female diagnosed with cellulitis of the left leg yesterday who is
experiencing redness and warmth of the left leg
<\Body>
<Number>22,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse knows which of the following body systems is responsible for the production of
erythropoietin?

(A) Urinary system
(B) Cardiovascular system
(C) Lymphatic system
(D) Endocrine system
<\Body>
<Number>23,4,0<\Number>
<Answers>B<\Answers>
<Body>
The nurse is initiating cefazolin therapy following a physician’s order. The nurse notes that the
client has an allergy to penicillin. The client states he becomes a little short of breath and itches
after receiving penicillin. The nurse should do which of the following?

(A) Call the pharmacy to therapeutically change the medication and notify the physician of
this change.
(B) Hold the medication and call the physician to double-check the order.
(C) Give the medication as ordered—cefazolin is not a penicillin.
(D) After asking another nurse, give the medication as ordered.
<\Body>
<Number>24,4,0<\Number>
<Answers>C<\Answers>
<Body>
A 52-year-old woman is admitted with a new diagnosis of gastrointestinal (GI) bleed. The
physician has ordered the client to receive 2 units of packed red blood cells (PRBCs) for a
hemoglobin (Hgb) of 6.8 g/dL. The nurse begins the infusion of the first unit at 100 mL/hr.
Fifteen minutes after the start of the infusion, the client reports that she is feeling chilled, is short
of breath, and is experiencing lumbar pain rated 8 on a 1–10 scale. Which of the following should
be the nurse’s FIRST action?

(A) Obtain vital signs and notify the physician of potential reaction.
(B) Slow the infusion to 75 mL/hr and reassess in 15 minutes.
(C) Stop the infusion and run normal saline (NS) to keep the vein open (KVO).
(D) Administer PRN pain medication as ordered, apply oxygen at 2 L/min, and provide an
additional blanket.
<\Body>
<Number>25,4,0<\Number>
<Answers>A<\Answers>
<Body>
The nurse receives report on a client with a right total knee arthroplasty who developed
methicillin-resistant Staphylococcus aureus (MRSA) in the surgical incision. The incision was
cultured and showed sensitivity to vancomycin. The client’s blood urea nitrogen (BUN) is 14
mg/dL and serum creatinine (Cr) is 0.9 mg/dL. Intake and output are balanced. A peak and
trough have been ordered. The third dose of vancomycin is to be given on the nurse’s shift. The
nurse should do which of the following?

(A) Draw a trough 30 minutes prior to dose and draw a peak 60 minutes after infusion.
(B) Draw a peak 30 minutes prior to dose and draw a trough 60 minutes after infusion.
(C) Hold the dose of vancomycin and notify the physician of the BUN and Cr levels.
(D) Give the dose of vancomycin as ordered and draw the peak and trough with other
evening labs.
<\Body>
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