1A client at risk for ______ as evidenced by ________
- Spontaneous abortion
- Cervical dilation
2The client likely experienced _______ a evidenced by ______
- Opioid intoxication
- pupil characteristics
3The child is at risk for developing ______ as evidenced by ________ and ______
- pneumonia
- shallow breathing
- lack of spirometer use
4The nurse recommends the adolescent notify the provider immediately if _____ or _____ occurs during therapy.
- a change in mood
- decreased night vision
5A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take?
Weigh the patient before and after the procedure
6A charge nurse is concerned about a recent increase in facility-aquired catheter infections. Which of the following actions should the nurse take first?
Identify possible precipitating factors related to the infections
7A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?
Critical paathways should reduce health care costs
8A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?
Footboard
9A nurse is teaching a group of parents about expected development of gross motor skills during infancy. The nurse should teach that the following developmental tasks are expected to occur in what order?
Rolls from back to side; rolls from back to abd; sits steadily unsupported; changes from prone to sitting
10A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?
The client exhibits impulsive behavior.
11A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching?
Avoid hot tubs while wearing the patch
12A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
Ask the client directly what they are hearing
13A nurse in an emergency department is assessing four clients. Which of the following clients should the nurse see first?
A client who has new onset urticaria and angioedema
14Which of the following lab tests should the nurse plan to report to obtain the prescription for the warfarin?
INR
15A nurse is teaching a client about skin cancer prevention. Which of the following statements from the client indicates an understanding of the teaching?
“I will apply sunscreen before and after swimming.”
16A nurse is caring for a client who has a potassium level of 3.2 mEq/L. Which of the following foods should the nurse recommend as being the best source of potassium.
1 cup cantaloupe
17A nurse is preparing a client for transfer to a long-term rehab facility following a below-the-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client’s confidentality?
Provide a verbal report of the patient’s condition to the paramedic
18A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete?
Metoprolol 5 mg IV now
19A nurse is caring for a client who has preeclampsia and is experiencing a postpoartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications?
Oxytocin
20A nurse is assessing a client prior to administering the influenza vaccine. The nurse should assess if the client has an allergy to which of the following foods?
Egg
21A nurse caring for a client who is postop following a total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
Keep an abduction pillow between the client’s legs
22A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?
Review the child’s electronic pain diary
23Which of the following instructions should the nurse provide to the parent of a school-age child who has a nosebleed that won’t stop bleeding?
“Use your thumb and forefinger to apply pressure to the sides of your child’s nose.”
24A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching.
“Use an electric razor when shaving while taking this medication”
25Which of the followinf should the charge nurse include when teaching about a durable power of attroney?
“The proxy can make treatment decisions if the client is under anesthesia.”
26Identify the sequence of steps the nurse should follow after applying sterile gloves when caring for a patient with a tracheostomy.
Lubricate the catheter with sterile saline; insert the catheter until resistance is felt; withdraw 1-2cm; Rotate the catheter while suctioning
27Which of the following medications should the nurse prepare to administer after antibiotics when caring for a patient with urticaria?
Diphenhydramine
28The client asks the nurse if the medication can be given 2 hours earlier. Which of the following statements should the nurse make?
“I have up to 2 hours after the usual scheduled time to give you this medication”
29A nurse is caring for a client who has a Clostridium difficile infection. Which of the following actions shouldd the nurse take?
- Change gloves after contact with infectious material
- Wear a gown when providing care
30A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s blood glucose. The nurse should identify this finding as an adverse effect of which of the following medications?
Methylprednisolone
31A nurse is caring for a client who has hearing loss. While communicating with the client, which of the following actions should the nurse take?
Decrease background noise when talking with the client
32A nurse is assessing a client who has a colostomy 24 hours ago. Which of the following findings is the nurse’s priority?
The stoma appears dark purple in color
33Which of the following actions should the nurse take when setting up the sterile field for a sterile dressing change?
Place the cap from the solution sterile side up on a clean surface
34A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?
Ensure the patient’s id band matches the number on the blood unit
35Continous bladder irrigation- which of the following actions should the nurse take after noting pink-tinged urine in the drainage bag?
Maintain the irrigation solution rate
36Health screening for a group of farmers- which of the following client statements indicates a possible health risk?
“I eat vegetables directly from the field where I work”
37A nurse is measuring the fundal height of a client who is 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?
Position the patient on her side
38Terminal diagnosis-family is having a hard time letting the patient go. The nurse should recognize that the family member is experiencing what type of grief?
Anticipatory
39P-r intervel of 0.35 seconds. Which of the following is the client displaying?
First degree atrioventricular block
40A nurse is assessing a client who has endometritis. Which of the following findings should the nurse expect?
Malodorous lochia
41A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?
- Wear a dosimeter film badge to measure exposure
- Place a caution sign on the client’s door
- Don a lead apron when providing care
42Which of the following findings should the nurse identify as a contraindication for heat therapy?
Peripheral Neuropathy
43A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
Choose a vein that is palpable and straight
44Which of the following clients should the instruct instruct the staff to evacuate first?
A client who is ambulatory and receiving oxygen
45Which of the following should the nurse expect when completing an assessment on a client with narcississtic personality disorder?
Preoccupied with aging
46A nurse is caring for a client who is experiencing status epilepticus. Which of the following medications should the nurse expect to administer?
Lorazepam
47Which of the following should the nurse identify as a manifestation of false labor?
Intermittent, painless contractions
48Client has an actively bleeding stab wound- which action should the nurse take first?
Apply direct pressure to the wound with thick dressing material
49Initation of epidural alangesia-which action should the nurse take?
Review the client’s platelet count level prior to the procedure
50Which of the following actions should the nurse take when communicating with a client that speaks another language?
Ask the client if they would prefer a translator who is the same gender
51Client who is comatase and AD says they don’t want life-sustaining measures; family wants life-sustaining measures. Which of the following actions should the nurse take?
Arrange for the ethics committee meeting to address the family’s concerns
52A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?
Severe abdominal pain
53Patient is postop following a cardiac cath- which of the following actions should the nurse take?
Assess the client’s peripheral pulses every 15 minutes
545 findings that require follow-up for a client at 30 weeks gestation
BP; DTR; Lower extremity assessment; weight assessment; nausea
55The client is at risk for developing _____ due to _______
- placental abruption
- hypertension
56Patient is at highest risk for _____ as evidenced by ____ and _____
- preeclampsia
- urinalysis
- pain assessment
57Based on the findings the nurse should first _____ and then prepare to administer _____
- apply oxygen via nasal cannula
- calcium gluconate
58Which of the following supplements should the nurse identify as increasing the client’s risk for hypotension during surgery?
Black Cohosh
59A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?
Sore throat
60A nurse is caring for a newborn who is experiencing neonatal abstince syndrome. Which of the following actions should the nurse take?
Decrease the lighting levels in the nursery
61Which of the following instructions should the nurse include in the teachings about family planning using the basal body temperature method?
Take your temperature immediately after waking and before getting out of bed
62When can a newly licensed nure delegate weighing patients to an AP?
When the AP has been trained to use the scale
63Community programs- Which of the following ethical principles should the nurse use to guide their planning?
Utilitarianism
64Which of the following actions should the nurse take when caring for a client experiencing a panic level of anxiety?
Use short sentences when communicating with the client
65Which of the following actions should the nurse take when trying to obtain a BP but has difficulty auscultating sounds?
Use the palpatory method to determine BP
66Which of the following statements by the parent indicates an understanding of breastfeeding teachings?
“The more my baby is at the breast sucking, the more milk I will produce”
67Which of the following medications should the nurse expect to administer for a patient who has a fractured leg and rates their pain as 7 on a scale of 0-10?
Hydrocodone
68A nurse is working with a local group that is in the process of reducing the use of pesticides in community gardens. The nurse should identify that the group is in which of the following stages of change?
Action
69Select the four findings that require immediate follow-up for a 52-year old client that appears to be listeing to unseen others.
- Sleep pattern
- Skin turgor
- Hallucinations
- Heart rate
70A client is most likely experiencing _______ as evidenced by ____-
71Select the 3 statements the nurse should include when teaching about lithium
- This medication can cause nausea and drowsiness
- It will take at least a week before this medication reaches a therapeutic level
- This medication can cause weight gain
72Which of the following findings indicates an improvement of the condition of the 52- years old patient who appears to be talking to unseen others?
- The client slept 5 hours the previous night
- The client consumes 8 oz of high-calorie fluids each hour
- The client engages in quiet activities in their room
73Which of the following statements should the nurse make when providing teaching to a patient with a heart condition and a new prescription for furosemide?
Rise slowly when getting out of bed
74Which of the following resources should the nurse recommend for a young adult client below the poverty level?
75Which of the following interventions should the nurse include for a terminal cancer patient that is nearing the end of their life?
Offer the client a blanket to keep warm
76Which of the following statements should the nurse make to an obese client that states everyone is staring at them?
“It sounds like you’re saying that you feel uncomfortable around others”
77Which of the following food choices shoulf the nurse include on the tray of a client who follows kosher dietary traditions?
Scrambled eggs and toast with milk
78A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
Palpate the pulse distal to the cast
79Which of the following manifestations should the nurse expect in a client with Obsessive-compulsive personality disorder?
Shows perfectionism
80Which of the following info should the nurse include in the teaching for a client who has a newly implanted?
Wear loose fitting clothing
81Identify the sequence of steps the nurse should take if there’s a small fire in the patient’s room
Transport client to another area of the nursing unit; activate the fire alarm; close all nearby windows and doors; use the fire extinguisher
82Which of the following should a nurse report to the provider for a client who has a new presciption for TPN with fat emulsion?
Egg allergy
83Which of the following types of continuous infusions should the nurse initiate for a client who has diabetic ketoacidosis?
0.45% saline
84A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropiate action by the nurse?
Provide humidification of the room air
85A nurse is assessing a client who is receiving maagnesium sulfate for preeclampsia. Which of the following findings is the nurse’s priority?
Respiratory rate 10/min
86A nurse is monitoring a client who is 36 hours postop following gaastric banding. Which of the following findings should the nurse expect?
A client is tolerating clear liquids
87The client is most likely experiencing _______ as evidenced by the client’s _______
- endometritis
- uterus and lochia assessment
88The nurse should anticipate a provider’s prescription for _______ and an increase in _______
- IV antibiotics
- daily fluid intake
89Which of the following actions should the nurse take when caring for a client who is 39 weeks gestation and has a prolonged rupture of membranes?
Instruct the client to wash her hands before & after changing her perineal pad; encourage the client to maintain a semi-fowler’s position to enhance uterine drainage; monitor the height and tone of the client’s fundus; obtain a culture specimen of the lochia from the client’s perineal pad using a sterile swab
90Select the five findings that indicate the client who is 39 weeks gestation and has prolonged rupture of membranes’s condition has improved
- Heart rate
- Temperature
- WBC count
- Fundal height
- Lochia
91The nurse should identify that which of the following findings is an early indication of cardiac tamponade?
Muffled heart sounds
92Which of the following techniques should the nurse implement when caring for a patient needing wound care?
Irrigate the wound with a low-pressure flow of solution
93Which of the following should the nurse include in the plan of care for a patient 22 weeks gestation prior to an amniocentesis?
Monitor the fetal heart rate prior to the procedure
94Which of the following instructions should the nurse include when providing preop teaching to a client about promoting circulation?
Participate in range of motion exercises
95Which of the following findings should the nurse anticipate for a client who is experiencing an acute exacerbation of systemic lupus erythematosus?
Fever
96Which of the following statements should the nurse make for a client who is pregnant and asks how she should help her 4-year-old son prepare for the new baby?
“Purchase a gift for your son from the baby”
97Which of the following STIs is a nationally notifiable infectious disease that should be reported to the state health department?
Chlamydia
98Which of the following statements by the newly licensed nurse indicates an understanding of caring for a patient who is receiving TPN?
“I will hang a new bag of TPN and IV tubing every 24 hours”
99Which of the following actions should the nurse take when making a follow-up visit for a client who has COPD and is using a compressed oxygen system in his home?
Place the oxygen tank away from the curtains or drapes
100Which of the following statements should the nurse include in the hand-off report when transferring a patient from PACU to med/surg?
“The estimated blood loss was 250 milliliters”
101For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?
Distended Neck Veins
102Which of the following statements by the newly licensed nurse indicates an understanding of the teaching about mechanical restraints?
I should visually monitor the client continously when in mechanical restraints
103Which of the following medications should the nurse administer for a client who reports a headache and has a history of peptic ulcers?
Acetaminophen
104Which of the following should the nurse include when teaching a client about administering NPH insulin and regular insulin together in one injection?
Draw up regular insulin prior to NPH insulin
105Which of the following actions should the nurse take when caring for a client who is on fall precautions?
Establish an elimination schedule for the client
106A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include?
Provide a diet that is high in protein and calories
107The nurse should recognize that which of the following information should be provided to the client by the provider before signing the consent form?
- Possible alternative treatments
- expected outcome of the procedure
- Explanation of the procedure
- Potential complications
108Which of the following conflict-resolution strategies should the charge nurse use?
Encouraging collaboration between the two nurses when making the assignments
109The nurse anticipates the need for _______ due to the patient’s ______ and ______
- Antibiotic prescription
- WBC count
- Temperature
110A nurse is caring for a client who has an impanted venous access port. Which of the following should th enurse use to access the port?
A noncoring (Huber) needle
111The client asks the nurse to warm up seaaweed soup that their partner brought in for her. Which of the following responses should the nursse make?
“Of course, I will heat this up for you”
112Which of the following interventions should the nurse include in the teaching for a child newly diagnosed with juvenile idiopathic arthritis?
Have the child take a tub bath each morning
113Which of the following entries should the nurse make in the medical record when receiving a telephone prescription from a provider?
“Morphine 3 mg subcutaneous every 4 hours PRN for pain”
114Which of the following clients should the nurse instruct the AP to report to the nurse?
A client who has a prescription for compression stockings and did not receive them
115Which of the following actions should the nurse plan to take when preparing to administer a NG tube feeding to a school-age child?
Measure the tubing from the nose to the distal port
116Which of the following responses by the nurse is therapeutic?
“Can you talk about what is happening with your partner at home?”
117Which of the following locations on the client’s body should the nurse observe to assess for cyanosis on a client who has dark skin?
Palms of the hands
118Which of the following medications should the nurse expect to be prescribed to aide with smoking cessation?
Bupropion
11950mcg levothyroxine ordered. Available is Levothyroxine 0.025mg/tablet. How many tablets should the nurse administer?
2
120Which of the following information should the nurse include when educated a patient about their new packmaker?
“Limit strenuous physical activity for 8 weeks”
121a nurse is using an IV pump for a newly admitted clent. Which of the following actions should the nurse take?
Check the cords of the IV pump for fraying
122Which of the following manifestations should the nurse include in the teachings about hypercalcemia?
Personality change
123The client is at risk for developing ______ due to the interaction between ____
- Serotonin syndrome
- citalopram & St. John’s wort
124Which of the following ethical priniciple is the nurse demonstrating when they sit with someone after their partner recently died?
Beneficence
125Which of the following findings is expected during a cardiac catheterization?
Sensation of skin warmth
126A nurse realizes that the wrong mediciation has been administered to a client. Which of the following actions should the nurse take first?
Measure the patient’s vital signs
127Which of the following actions should the nurse plan to take to demonstrate effective time management?
Complete activities for one client before moving to the next
128Which of the following actions should the nurse take when caring for a client who is receiving continous enteral feedings?
- Maintain the head of the client’s bed at a 30 degrees angle or higher
- Check gastric residuals every 4 hours
- Change the feeding container and tubing every 24 hours
129A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?
Plan to urinate every 3 hours when you are awake
130Which of the following conditions in the client’s history is a contraindication to the use of combination oral contraceptives?
Thrombophlebitis
131The nurse should notify the provider about which of the following findings for a client with COPD?
pH
132Which of the following interventions should the nurse include in the plan of care for a client weraing antiembolic stockings?
Determine if the stockings are binding
133Which of the following interventions should the nurse include in the care plan for a client who has paranoid personality disorder and refuses to take their medication?
Speak in a neutral tone when addressing the client
134Which of the following foods should the nurse suggest to a client with HTN?
Fish
135(Pancreatitis) The nurse should first address _____ followed by ______
136(Pancreatitis) Select the three statements the nurse should include while providing teaching to the client about self-care.
- You should eat foods high in protein
- Notify your provider if you experience vomiting or diarrhea
- You should eat foods that are low in fat
137(Pancreatitis) Which of the following statements by the client indicates an understanding of the discharge teaching?
- I will eat fish for dinner at least twice per week
- I will eat small, frequent meals
- I will notify my provider if my urine is dark
138Which of the following actions should the nurse include in the plan of care for a patient with Alzheimer’s?
Place locks at the tops of exterior doors
139A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?
BP 80/40 mmHg
140The client is refusing to eat meals. Which of the following actions should the nurse take?
Discuss the client’s food preferences with the hospital’s dietitian
141Which of the followinf resources should the nurse consult when a newly licensed nurse is unsure is an assigned task is within their scope of practice?
State Nurse Practice Act
142Which of the following interventations should the nurse include in the plan of care for a client who is receiving continous enteral tube feedings through an open system?
Flush the tubing with 30 mL of water every 4 hours
143(Acute MI) The client is at risk for developing ____ and _____
- Decreased cardiac output
- Respiratory failure
144(Acute MI) The nurse should first ______ followed by ______
- apply oxygen via nasal cannula
- initiating a consult for cardiac rehab
145(Acute MI) Which of the following topics should the nurse recommend the team plan to address with the client?
- Relaxation Therapy
- BP management
- Meal planning ideas
- Nitroglycerin self-administration
- Physical activity recommendations
- Smoking cessation program
146(Acute MI) Select the 4 statements the nurse should include in the teaching
- You should avoid salting your food prior to eating
- You should aim to consume fish as least twice a week
- You should wear a medical identification bracelet or necklace
- You should keep your nitroglycerin with you at all times
147Which of the following actions should the nurse take when preparing to measure the temperature of an infant?
Place the tip of the thermometer under the center of the infant’s axilla
148Which of the following actions should the nurse take when caring for a client who is in labor and has received an epidural?
Reposition the client side-to-side each hour
149Which of the following information should the nurse include about preventing the spread of HIV?
Clean blood-contaminated surfaces with bleach
150Which of the following instructions should the nurse include when providing teaching to an older adult client about methods to promote nighttime sleep?
Eat a light snack before bedtime
151(Patient in MVC) The client is at risk for developing ______ and ______
- compartment syndrome
- osteomyelitis
152Which of the following provider prescriptions should the nurse first implement for a client who has abdominal trauma from a MVC?
Place a large-bore IV catheter in an upper extremity
153The nurse should recommend that the client consume which of the following foods to enhance the absorption of nonheme iron?
Orange slices
154Which of the following actions should the nurse take for a client who is at 38 weeks of gestation, is in active labor and has ruptured membranes?
Apply a fetal heart rate monitor
155Ceftriaxone 1 g intermittent IV blous over 30 mins. Available is Ceftriaxone 1 g in 100 mL of dextrose 5% in water. How many mL per hour?
200 mL/hr
156A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?
Prime the tubing with 0.9% sodium chloride
157Which of the following should the nurse expect when caring for an infant who presents with vomiting, diarrhea, and decreased oral intake?
Oliguria
158Which of the following images indicates the appropiate use of ergonomic principles?
(Standing upright) Key principles: keeping the back straight; bending at the knees & hips; shoulder width stance; holding objects close to the body