1.

A client with chronic renal failure plans to receive a kidney

transplant. Recently, the physician told the client that he is a
poor candidate for transplant because of chronic uncontrolled
hypertension and diabetes mellitus. Now, the client tells the
nurse, “I want to go off dialysis. I’d rather not live than be on
this treatment for the rest of my life.” Which responses are
appropriate? Select all that apply.
1. Take a seat next to the client and sit quietly.
2. Say to the client, “We all have days when we don’t feel Ike
going on.”
3. Leave the room to allow the client to collect his thoughts.
4. Say to the client, “You’re feeling upset about the news you
got about the transplant.”
5. Say to the client, “The treatments are only 3 days a week.
You can live with that.”

2. Which signs and symptoms might a nurse observe in a client

having an adverse reaction to a loop diuretic? Select all that
apply.
1. Weakness 5. A client is ordered heparin 6,000 units subcutaneously every
2. Irregular pulse 12 hours for deep vein thrombosis prophylaxis. The pharmacy
3. Hyperactive bowel sounds dispenses a vial containing 10,000 units/ml. How many
4. Decreased muscle tone milliliters of heparin should the nurse administer? Record your
5. Potassium level of 3.1 mEq/L answer using one decimal place.
6. Ventricular arrhythmias Answer: 0.6ml

3. A nurse is caring for a client with advanced cancer. Based on 6. A nurse is caring for a client with a hiatal hernia. The client
the nursing progress notes below, what should be the nurse’s complains of abdominal pain and sternal pain after eating. The
next intervention? pain makes it difficult for him to sleep. Which instructions
should the nurse recommend when teaching this client? Select
all that apply.
1. Avoid constrictive clothing.
2. Lie down for 30 minutes after eating.
3. Decrease intake of caffeine and spicy foods.
4. Eat three meals per day.
5. Sleep in semi-Fowler’s position.
6. Maintain a normal body weight.

7. A nurse is performing cardiac assessment. Identify where

the nurse places the stethoscope to best auscultate the
pulmonic valve.

1. Reread the Patient’s Bill of Rights to the client.

2. Call the client’s spouse to discuss the client’s statements.
3. Tell the client that he can receive adequate pain relief only
in the hospital.
4. Explain that an advance directive can express the client’s
wishes.
RATIONALE: The nurse should explain how an advance
directive can be used to express the client’s wishes. An
advance directive is a legal document that’s used as a
guideline for life-sustaining medical care of the client with an
advanced disease or disability who can no longer indicate his
own wishes. This document can include a living will, which 8. A nurse is caring for a client who underwent surgical repair
instructs the physician not to administer life-sustaining of a detached retina of the right eye. Which interventions
treatment, and a health care power of attorney, which names should the nurse perform? Select all that apply.
another person to act on the client’s behalf for medical 1. Place the client in a prone position.
decisions in the event that the client can’t act for himself. The 2. Approach the client from the left side.
Patient’s Bill of Rights doesn’t specifically address the client’s 3. Encourage deep breathing and coughing.
wishes regarding future care. Calling the spouse is a breach of 4. Discourage bending down.
the client’s right to confidentiality. Stating that only a hospital 5. Orient the client to his environment.
can provide adequate pain relief in a terminal situation 6. Administer a stool softener.
demonstrates inadequate knowledge on the nurse’s part of
the resources available through collaboration with hospice 9. A client is admitted with a possible diagnosis of
osteomyelitis. Based on the documentation below, which
4. While assessing a client’s spine for abnormal curvatures, the laboratory result is the priority for the nurse to report to the
nurse notes lordosis. Identify the area of the spine that is physician?
affected by lordosis.
 13. A nurse should expect to find which defining
characteristics in a client with a nursing diagnosis of ineffective
tissue perfusion (peripheral)? Select all that apply.
1. Edema
2. Skin pink in color
3. Strong, bounding pulses
4. Normal sensation
5. Skin discoloration
6. Skin temperature changes

14. While examining the hands of a client with osteoarthritis, a

nurse notes heberden’s node on the second (pointer) finger.
1. Rheumatoid factor Identify the area on the finger where the nurse observed the
2. Blood culture node.
3. Alkaline Phosphatase
4. ESR

10. A nurse is caring for dlent5 with diabetes insipidus and

must be aware of the disorder’s pathophysiology. Place the
following events in chronological sequence to show the
pathophysiologic process. Use all of the options.

15. 1. A client with sepsis and hypotension is being

treated with dopamine hydrochloride. A nurse asks a
colleague to double-check the dosage that the client is
receiving. The 250-ml bag contains 400 mg of dopa-
mine, the infusion pump ¡s running at 23 mI/hour,
and the clent weighs 80 kg. How many micrograms
per kilogram per minute is the client receiving? Record
your answer using one decimal point.
Answer: 7.7 mg/kg/min
11. The nurse is admitting a client with newly diagnosed
diabetes mellitus and left-sided heart failure. Assessment
reveals low blood pressure, increased respiratory rate and
depth, drowsiness, and confusion. The client complains of
headache and nausea. Based on the serum laboratory results
below, how would the nurse interpret the client’s acid—base
balance?

16. The nurse is evaluating an electrocardiogram (ECG) tracing.

Which graphic shows the QT interval?

1. Metabolic Alkalosis
2. Metabolic Acidosis
3. Respiratory Alkalosis
4. Respiratory Acidosis

12. An elderly client has a history of aortic stenosis. Identify

the area where the nurse should place the stethoscope to best
hear the murmur.
17. A client with a bicuspid aortic valve has severe stenosis and 21. A nurse observes the following pattern when monitoring
is scheduled for valve replacement. While teaching the client the electrocardiogram (ECG) of a stable client. What should
about the condition and upcoming surgery, the nurse shows a the nurse do?
heart illustration. Which valve should the nurse indicate as
needing replacement?

1. Continue to observe for deterioration of the heart rhythm.

2. Administer 0.5 mg of atropine sulfate by I.V. push as
ordered.
3. Prepare for transvenous pacemaker insertion as ordered.
4. Administer amiodarone (Cordarone) 150 mg I.V. as ordered.

22. A nurse is caring for a client with pulmonary edema. The

physician writes the following orders. Which order should the
nurse clarify?

18. A nurse places electrodes on a collapsed individual who

was visiting a hospitalized family member, the monitor
exhibits the following. Which interventions should the nurse
do first?

1. Place the client on oxygen

2. Confirm the rhythm with a 12-lead ECG
3. Administer amiodarone I.V. as prescribed
4. Assess the client’s airway, breathing, and circulation.

19. Following coronary artery bypass graft surgery, a client is 1. Morphine LV. 2 mg every 2 hours P.R.N. for shortness of
admitted to the surgical intensive care unit and connected to a breath
cardiac monitor. The nurse can’t detect a pulse or blood 2. Furosemide I.V. 40 mg every 6 hours
pressure and observes the following pattern on the 3. 0.9% normal saline solution I.V. at 150 ml/hour
electrocardiogram (ECG) monitor. What does this pattern 4. Dobutamine 5 mcg/kg/minute I.V
show?
23. A client who is receiving procainamide has the following
electrocardiogram (ECG) tracing. The nurse anticipates that
the physician will order which drug?

1. Artifact
2. Ventricular tachycardia
3. Ventricular fibrillation
4. Pulseless electrical activity 1. Quinidine sulfate
2. Lidocaine (Xylocaine)
20. A nurse determines that a hockey player hospitalized with 3. A higher dose of procainamide (Pronestyl)
bilateral leg fractures is hemodynamically stable, She observes 4. Magnesium sulfate
the following pattern on the electrocardiogram (ECG) monitor. RATIONALE: This ECG shows torsades de pointes. In this
Which nursing intervention is most appropriate at this time? variant form of ventricular tachycardia, QRS complexes rotate
about the baseline, their amplitude decreasing and increasing
gradually as the rhythm progresses. To shorten the QT interval
and prevent this arrhythmia from recurring, the physician is
likely to order magnesium sulfate. Because torsades de
pointes is precipitated by a long QT interval, drugs that
prolong the QT interval, such as quinidine and procainamide,
1. None; this arrhythmia is benign are contraindicated. The most effective treatment is overdrive
2. Administering atropine sulfate, 0.5 mg, as ordered to pacing with an electronic pacemaker until the offending drug
increase heart rate. is excreted. Typically, such drugs as lidocaine — normally
3. Continuing to monitor if lengthening PR intervals
4. Evaluating the client’s serum electrolyte studies
effective in suppressing ventricular activity — fail to convert 1. Administer the medications.
torsades de pointes to a normal sinus rhythm. 2. Call the physician.
3. Withhold the captopril.
24. A client is admitted with acute coronary syndrome. The 4. Question the metoprolol dose.
nurse measures the client’s blood pressure at 97/66 mm Hg,
obtains a palpable femoral pulse, notes that the client is 28. The nurse observes the cardiac rhythm (see below) for a
awake and coherent, and observes the following pattern on client who is being admitted with a myocardial infarction.
the electrocardiogram (ECG) monitor. Based on these findings, What should the nurse do first?
the nurse should take which action?

1. Prepare for immediate cardioversion.

1. Defibrillate at 200 jouIes as ordered. 2. Begin cardiopulmonary resuscitation (CPR).
2. Administer a precordial thump as ordered. 3. Check for a pulse.
3. Administer amiodarone (Cordarone) 150 mg I.V. 4. Prepare for immediate defibrillation.
4. Continue to defibrillate at increasing joules, as ordered,
until a stable heart rhythm is restored. 29. The nurse is monitoring a client admitted with a
myocardial infarction (MI) who is at risk for cardiogenic shock.
25. The nurse is assessing a client who has had a myocardial The nurse should report which of the following changes on the
infarction. The nurse notes the cardiac rhythm shown on the client's chart to the physician?
electrocardiogram strip below. The nurse identifies this
rhythm as:

1. Atrial fibrillation.
2. Ventricular tachycardia.
3. Premature ventricular contractions.
4. Sinus tachycardia.
1. Urine output.
26. The nurse is assessing a client who has had a myocardial 2. Heart rate.
infarction (MI). The nurse notes the cardiac rhythm on the 3. Blood pressure.
monitor (see the electrocardiogram strip below). The nurse 4. Respiratory rate.
should:
30. An 85-year-old client is admitted to the emergency
department (ED) at 8 PM with syncope, shortness of breath,
and reported palpitations (See nurse's notes below). At 8:15
PM, the nurse places the client on the ECG monitor and
identifies the following rhythm (see below). The nurse should
do which of the following? Select all that apply.

1. Notify the physician.

2. Call the rapid response team.
3. Assess the client for changes in the rhythm.
4. Administer lidocaine as prescribed.

27. Captopril, furosemide, and metoprolol are prescribed for a

client with systolic heart failure. The client's blood pressure is
136/82 and the heart rate is 65. Prior to medication
administration at 9 AM, the nurse reviews the following lab
tests (see chart). Which of the following should the nurse do
first?
1. Apply oxygen.
2. Prepare to defibrillate the client.
3. Monitor vital signs.
4. Have the client sign consent for cardioversion as
prescribed. 1. Stage 1, latent phase
5. Teach the client about warfarin (Coumadin) treatment and 2. Stage 2
the need for frequent blood testing. 3. Stage 1, active phase
6. Draw blood for a CBC count and thyroid function study. 4. Stage 1, transition phase
RATIONALE: During the active phase of stage 1 labor,
31. Twenty-four hours after a client undergoes aortic valve membranes may rupture spontaneously. Contractions last
replacement surgery, the following pattern appears on the about 40 to 60 seconds and recur every 3 to 5 minutes, and
electrocardiogram (ECG) monitor. How should the nurse the cervix dilates from about 3 cm to 7 cm. During the latent
interpret this pattern? phase of stage 1, contractions last 20 to 40 seconds and occur
every 5 to 30 minutes and the cervix dilates from O to 3 cm.
During stage 2 labor, the cervix is fully dilated and effaced and
the neonate is born. During the transition phase of stage 1,
contractions last 60 to 90 seconds and occur every 2 to 3
minutes and the cervix dilates from 7 cm to 10 cm.

1. Atrial fibrillation 34. A nurse is evaluating an external fetal monitoring strip.

2. Normal Sinus tachycardia Identify the are on this strip that causes her to be concerned
3. Atrial Flutter about uteroplacental insufficiency.
4. Multifocal atrial tachycardia

32. A client is admitted to the surgical intensive care unit

following small-bowel resection. The ECG monitor shows the
pattern below. What does this pattern indicate?

1. Ventricular tachycardia
2. Atrial Flutter
3. Atrial fibrillation
4. Normal sinus rhythm

33. On the waveform below, identify the area that indicates

possible umbilical cord compression.

35. The nurse is preparing to administer digoxin 0.25 mg IVP to

a client in severe congestive heart failure who is receiving
D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance.
1. Administer the medication over 5 minutes.
2. Dilute the medication with normal saline.
3. Draw up the medication in a tuberculin syringe.
4. Check the client’s identification band.
5. Clamp the primary tubing distal to the port.
11. Correct Answer: 3, 2, 4, 5, 1
3. Because this is less than 1 mL, the nurse
should draw this medication up in a 1-mL
tuberculin syringe to ensure accuracy of
dosage.
2. The nurse should dilute the medication
with normal saline to a 5- to 10-mL bolus
to help decrease pain during administration
and maintain the IV site longer.
3. Administering 0.25 mg of digoxin in
0.5 mL is very difficult, if not impossible,
33. While waiting to receive report at shift change, a nurse to push over 5 full minutes, which is the
reads the entry below in a client’s chart. After reading this manufacturer’s recommended administration
note, the nurse knows her client is in which stage of labor? rate. If the medication is diluted
to a 5- to 10-mL bolus, it is easier for the
nurse to administer the medication over
5 minutes. 2. The UAP is requested to obtain a bedside glucometer
4. The nurse must check two identifiers reading.
according to the Joint Commission safety 3. The UAP is asked to assist with a portable chest x-ray.
guidelines. 4. The UAP is told to feed a client who is dysphagic.
5. The nurse should clamp the tubing 14. 1. All clients in the ICU are on telemetry, and
between the port and the primary IV line the UAP could bathe the client. This would
so that the medication will enter the vein, not warrant intervention by the charge
not ascend up the IV tubing. nurse.
1. Cardiovascular and narcotic medications 2. The UAP can perform glucometer checks at
are administered over 5 minutes. the bedside, and there is nothing that indicates
the client is unstable. This would not
36. The client is in the cardiac intensive care unit on warrant intervention by the charge nurse.
dopamine, a vasoconstrictor, and B/P increases to 210/130. 3. The UAP can assist with helping the client
Which intervention should the intensive care nurse implement sit up for a portable chest x-ray as long as the
first? UAP is not pregnant and wears a shield.
1. Discontinue the client’s vasoconstrictor, dopamine. 4. This client is at risk for choking and is
2. Notify the client’s healthcare provider. not stable; therefore, the charge nurse
3. Administer the vasopressor hydralazine. should intervene and not allow the UAP
4. Assess the client’s neurological status. to feed this client.
12. 1. The nurse should first discontinue the
medication that is causing the increase in 39. The nurse is administering medications to clients in the
the client’s blood pressure prior to doing cardiac critical care area. Which client should the nurse
anything else. question administering the medication?
2. The nurse should notify the HCP but not 1. The client receiving a calcium channel blocker (CCB) who is
prior to taking care of the client’s elevated drinking a glass of grapefruit juice.
blood pressure. 2. The client receiving a beta-adrenergic blocker who has an
3. The client may need a medication to decrease apical heart rate of 62 beats/min.
the blood pressure but the nurse 3. The client receiving nonsteroidal anti-inflammatory drugs
should first discontinue the medication (NSAIDs) who has just finished eating breakfast.
causing the elevated blood pressure. 4. The client receiving an oral anticoagulant who has an
4. The nurse must first decrease the client’s International Normalized Ratio (INR) of 2.8.
blood pressure prior to assessing the client. 15. 1. The client receiving a CCB should avoid
MAKING NURSING DECISIONS: The test taker grapefruit juice because it can cause the CCB to rise to toxic
should remember that when the client is in levels. Grapefruit juice inhibits cytochrome P450-3A4
distress, do not assess. The nurse must intervene and take found in the liver and the intestinal wall. This inhibition
care of the client. If any of the options is assessment data the affects the metabolism of some drugs and can, as is the case
HCP will need or an intervention that will help the client, with CCBs, lead to toxic levels of the drug. For this reason,
then the test taker should not select the option to notify the the nurse should investigate any medications the client is
HCP. taking if the client drinks grapefruit juice.
2. The apical heart rate should be greater than 60
37. The charge nurse is making client assignments in the beats/minute before administering the medication; therefore,
cardiac critical care unit. Which client should be assigned to the nurse would not question administering this medication.
the most experienced nurse? 3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be
1. The client with acute rheumatic fever carditis who does not taken with foods to prevent gastric upset; therefore, the nurse
want to stay on bed rest. would not question administering this medication.
2. The client who has the following ABG values: pH, 7.35; 4. The INR therapeutic level for warfarin (Coumadin), an
PaO2, 88; PaCO2, 44; CO3, 22. anticoagulant, is 2 to 3; therefore, the nurse would not
3. The client who is showing multifocal premature ventricular question administering this medication.
contractions (PVCs).
4. The client diagnosed with angina who is scheduled for a 40. Which individual is at greatest risk for developing
cardiac catheterization. hypertension?
13. 1. The client with rheumatic heart fever is A) 45 year-old African American attorney
expected to have carditis and should be on B) 60 year-old Asian American shop owner
bed rest. The nurse needs to talk to the client C) 40 year-old Caucasian nurse
about the importance of being on bed rest D)55 year-old Hispanic teacher
but this client is not in a life-threatening The correct answer is A: 45 year-old African American attorney
situation and does not need the most experienced The incidence of hypertension is greater among African
nurse. Americans than other groups in the US. The incidence among
2. These ABG values are within normal limits; the Hispanic population is rising.
therefore, a less experienced nurse could care
for this client. 41. A child who ingested 15 maximum strength
3. Multifocal PVCs are an emergency acetaminophen tablets 45 minutes ago is seen in the
and are possibly life threatening. An emergency department. Which of these orders should the
experienced nurse should care for this nurse do first?
client. A) Gastric lavage PRN
4. A cardiac catheterization is a routine procedure B) Acetylcysteine (mucomyst) for age per pharmacy
and would not require the most experienced C) Start an IV Dextrose 5% with 0.33% normal saline to keep
nurse. vein open
D) Activated charcoal per pharmacy
38. The primary cardiac nurse is delegating tasks to the The correct answer is A: Gastric lavage PRN Removing as much
unlicensed assistive personnel (UAP). Which delegation task of the drug as possible is the first step in treatment for this
warrants intervention by the charge nurse of the cardiac unit? drug overdose. This is best done by gastric lavage. The next
1. The UAP is instructed to bathe the client who is on drug to give would be activated charcoal, then mucomyst and
telemetry. lastly the IV fluids.
42. Which complication of cardiac catheterization should the As part of the teaching plan, the nurse emphasizes that this
nurse monitor for in the initial 24 hours after the procedure? medication:
A) angina at rest A) Should be taken in the morning
B) thrombus formation B) May decrease the client's energy level
C) dizziness C) Must be stored in a dark container
D) falling blood pressure D) Will decrease the client's heart rate
The correct answer is B: thrombus formation Thrombus The correct answer is A: Should be taken in the morning
formation in the coronary arteries is a potential problem in the Thyroid supplement should be taken in the morning to
initial 24 hours after a cardiac catheterization. A falling BP minimize the side effects of insomnia
occurs along with hemorrhage of the insertion site which is
associated with the first 12 hours after the procedure. 48. A 3 year-old child comes to the pediatric clinic after the
sudden onset of findings that include irritability, thick muffled
43. A client is admitted to the emergency room with renal voice, croaking on inspiration, hot to touch, sit leaning
calculi and is complaining of moderate to severe flank pain and forward, tongue protruding, drooling and suprasternal
nausea. The client’s temperature is 100.8 degrees Fahrenheit. retractions. What should the nurse do first?
The priority nursing goal for this client is A) Prepare the child for x-ray of upper airways
A) Maintain fluid and electrolyte balance B) Examine the child's throat
B) Control nausea C) Collect a sputum specimen
C) Manage pain D) Notify the healthcare provider of the child's status
D) Prevent urinary tract infection The correct answer is D: Notify the health care provider of the
The correct answer is C: Manage pain The immediate goal of child''s status These findings suggest a medical emergency and
therapy is to alleviate the client’s pain. may be due to epiglottises. Any child with an acute onset of an
inflammatory response in the mouth and throat should receive
44. What would the nurse expect to see while assessing the immediate attention in a facility equipped to perform
growth of children during their school age years? intubation or a tracheostomy in the event of further or
A) Decreasing amounts of body fat and muscle mass complete obstruction.
B) Little change in body appearance from year to year
C) Progressive height increase of 4 inches each year 49. In children suspected to have a diagnosis of diabetes,
D) Yearly weight gain of about 5.5 pounds per year which one of the following complaints would be most likely to
The correct answer is D: Yearly weight gain of about 5.5 prompt parents to take their school age child for evaluation?
pounds per year School age children gain about 5.5 pounds A) Polyphagia
each year and increase about 2 inches in height. B) Dehydration
C) Bed wetting
45. At a community health fair the blood pressure of a 62 year- D) Weight loss
old client is 160/96. The client states “My blood pressure is The correct answer is C: Bed wetting In children, fatigue and
usually much lower.” The nurse should tell the client to bed wetting are the chief complaints that prompt parents to
A) go get a blood pressure check within the next 48 to 72 take their child for evaluation. Bed wetting in a school age
hours child is readily detected by the parents
B) check blood pressure again in 2 months
C) see the health care provider immediately 50. A client comes to the clinic for treatment of recurrent
D) visit the health care provider within 1 week for a BP check pelvic inflammatory disease. The nurse recognizes that this
The correct answer is A: go get a blood pressure check within condition most frequently follows which type of infection?
the next 48 to 72 hours The blood pressure reading is A) Trichomoniasis
moderately high with the need to have it rechecked in a few B) Chlamydia
days. The client states it is ‘usually much lower.’ Thus a C) Staphylococcus
concern exists for complications such as stroke. However D) Streptococcus
immediate check by the provider of care is not warranted. The correct answer is B: Chlamydia Chlamydial infections are
Waiting 2 months or a week for follow-up is too long. one of the most frequent causes of salpingitis or pelvic
inflammatory disease.
46. The hospital has sounded the call for a disaster drill on the
evening shift. Which of these clients would the nurse put first 51. An RN who usually works in a spinal rehabilitation unit is
on the list to be discharged in order to make a room available floated to the emergency department. Which of these clients
for a new admission? should the charge nurse assign to this RN?
A) A middle aged client with a history of being ventilator A) A middle-aged client who says "I took too many diet pills"
dependent for over 7 years and admitted with bacterial and "my heart feels like it is racing out of my chest."
pneumonia five days ago B) A young adult who says "I hear songs from heaven. I need
B) A young adult with diabetes mellitus Type 2 for over 10 money for beer. I quit drinking 2 days ago for my family. Why
years and admitted with antibiotic induced diarrhea 24 hours are my arms and legs jerking?"
ago C) An adolescent who has been on pain medications for
C) An elderly client with a history of hypertension, terminal cancer with an initial assessment finding of pinpoint
hypercholesterolemia and lupus, and was admitted with pupils and a relaxed respiratory rate of 10
StevensJohnson syndrome that morning D) An elderly client who reports having taken a "large crack
D) An adolescent with a positive HIV test and admitted for hit" 10 minutes prior to walking into the emergency room The
acute cellulitus of the lower leg 48 hours ago correct answer is c: An adolescent who has been on pain
The correct answer is A: A middle aged client with a history of medications for terminal cancer with an initial assessment
being ventilator dependent for over 7 years and admitted with finding of pinpoint pupils and a relaxed respiratory rate of 10
bacterial pneumonia five days ago The best candidate for Nurses who are floated to other units should be assigned to a
discharge is one who has had a chronic condition and is most client who has minimal anticipated immediate complications
familiar with their care. This client in option A is most likely of their problem. The client in option C exhibits opoid toxicity
stable and could continue medication therapy at home. with the pinpoint pupils and has the least risk of complications
to occur in the near future.
47. A client has been newly diagnosed with hypothyroidism
and will take levothyroxine (Synthroid) 50 mcg/day by mouth. 52. When teaching a client with coronary artery disease about
nutrition, the nurse should emphasize
A) Eating 3 balanced meals a day A) Place a call to the client's health care provider for
B) Adding complex carbohydrates instructions
C) Avoiding very heavy meals B) Send him to the emergency room for evaluation
D) Limiting sodium to 7 gms per day C) Reassure the client's wife that the symptoms are transient
The correct answer is C: Avoiding very heavy meals Eating D) Instruct the client's wife to call the doctor if his symptoms
large, heavy meals can pull blood away from the heart for become worse
digestion and is dangerous for the client with coronary artery The correct answer is B: Send him to the emergency room for
disease. evaluation This client requires immediate evaluation. A delay
in treatment could result in further deterioration and harm.
53. Which of these findings indicate that a pump to deliver a Home care nurses must prioritize interventions based on
basal rate of 10 ml per hour plus PRN for pain break through assessment findings that are in the client''s best interest.
for morphine drip is not working?
A) The client complains of discomfort at the IV insertion site 58. Which of the following should the nurse implement to
B) The client states "I just can't get relief from my pain." prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph
C) The level of drug is 100 ml at 8 AM and is 80 ml at noon test?
D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon A) Client must be NPO before the examination
The correct answer is C: The level of drug is 100 ml at 8 AM B) Enema to be administered prior to the examination
and is 80 ml at noon The minimal dose of 10 ml per hour C) Medicate client with Lasix 20 mg IV 30 minutes prior to the
which would be 40 ml given in a 4 hour period. Only 60 ml examination
should be left at noon. The pump is not functioning when D) No special orders are necessary for this examination
more than expected medicine is left in the container. The correct answer is D: No special orders are necessary for
this examination No special preparation is necessary for this
54. The nurse is speaking at a community meeting about examination.
personal responsibility for health promotion. A participant
asks about chiropractic treatment for illnesses. What should 59. The nurse is giving discharge teaching to a client 7 days
be the focus of the nurse’s response? post myocardial infarction. He asks the nurse why he must
A) Electrical energy fields wait 6 weeks before having sexual intercourse. What is the
B) Spinal column manipulation best response by the nurse to this question?
C) Mind-body balance A) "You need to regain your strength before attempting such
D) Exercise of joints exertion."
The correct answer is B: Spinal column manipulation The B) "When you can climb 2 flights of stairs without problems, it
theory underlying chiropractic is that interference with is generally safe."
transmission of mental impulses between the brain and body C) "Have a glass of wine to relax you, then you can try to have
organs produces diseases. Such interference is caused by sex."
misalignment of the vertebrae. Manipulation reduces the D) "If you can maintain an active walking program, you will
subluxation. have less risk."
The correct answer is B: "When you can climb 2 flights of stairs
55. The nurse is performing a neurological assessment on a without problems, it is generally safe." There is a risk of
client post right CVA. Which finding, if observed by the nurse, cardiac rupture at the point of the myocardial infarction for
would warrant immediate attention? about 6 weeks. Scar tissue should form about that time.
A) Decrease in level of consciousness Waiting until the client can tolerate climbing stairs is the usual
B) Loss of bladder control advice given by health care providers.
C) Altered sensation to stimuli
D) Emotional lability 60. A triage nurse has these 4 clients arrive in the emergency
The correct answer is A: Decrease in level of consciousness A department within 15 minutes. Which client should the triage
further decrease in the level of consciousness would be nurse send back to be seen first?
indicative of a further progression of the CVA. A) A 2 month old infant with a history of rolling off the bed and
has buldging fontanels with crying
56. A child who has recently been diagnosed with cystic B) A teenager who got a singed beard while camping
fibrosis is in a pediatric clinic where a nurse is performing an C) An elderly client with complaints of frequent liquid brown
assessment. Which later finding of this disease would the colored stools
nurse not expect to see at this time? D) A middle aged client with intermittent pain behind the right
A) Positive sweat test scapula
B) Bulky greasy stools The correct answer is B: A teenager who got singed a singed
C) Moist, productive cough beard while camping This client is in the greatest danger with
D) Meconium ileus a potential of respiratory distress, Any client with singed facial
The correct answer is C: Moist, productive cough Option c is a hair has been exposed to heat or fire in close range that could
later sign. Noisy respirations and a dry non-productive cough have caused damage to the interior of the lung. Note that the
are commonly the first of the respiratory signs to appear in a interior lining of the lung has no nerve fibers so the client will
newly diagnosed client with cystic fibrosis (CF). The other not be aware of swelling.
options are the earliest findings. CF is an inherited (genetic)
condition affecting the cells that produce mucus, sweat, saliva 61. While planning care for a toddler, the nurse teaches the
and digestive juices. Normally, these secretions are thin and parents about the expected developmental changes for this
slippery, but in CF, a defective gene causes the secretions to age. Which statement by the mother shows that she
become thick and sticky. Instead of acting as a lubricant, the understands the child's developmental needs?
secretions plug up tubes, ducts and passageways, especially in A) "I want to protect my child from any falls."
the pancreas and lungs. Respiratory failure is the most B) "I will set limits on exploring the house."
dangerous consequence of CF. C) "I understand the need to use those new skills."
D) "I intend to keep control over our child."
57. The home health nurse visits a male client to provide The correct answer is C: "I understand the need to use those
wound care and finds the client lethargic and confused. His new skills." Erikson describes the stage of the toddler as being
wife states he fell down the stairs 2 hours ago. The nurse the time when there is normally an increase in autonomy. The
should child needs to use motor skills to explore the environment.
62. The nurse is preparing to administer an enteral feeding to assessed through the evaluation of the central venous
a client via a nasogastric feeding tube. The most important pressures (CVP).
action of the nurse is
A) Verify correct placement of the tube 68. A nurse enters a client's room to discover that the client
B) Check that the feeding solution matches the dietary order has no pulse or respirations. After calling for help, the first
C) Aspirate abdominal contents to determine the amount of action the nurse should take is
last feeding remaining in stomach A) Start a peripheral IV
D) Ensure that feeding solution is at room temperature B) Initiate closed-chest massage
The correct answer is A: Verify correct placement of the tube C) Establish an airway
Proper placement of the tube prevents aspiration. D) Obtain the crash cart
The correct answer is C: Establish an airway Establishing an
63. The nurse is caring for a client with a serum potassium airway is always the primary objective in a cardiopulmonary
level of 3.5 mEq/L. The client is placed on a cardiac monitor arrest.
and receives 40 mEq KCL in 1000 ml of 5% dextrose in water
IV. Which of the following EKG patterns indicates to the nurse 69. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The
that the infusions should be discontinued? health care provider has written a new order to give
A) Narrowed QRS complex metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client
B) Shortened "PR" interval prior to administering the medications, which of the following
C) Tall peaked T waves should the nurse report immediately to the health care
D) Prominent "U" waves provider?
The correct answer is C: Tall peaked T waves A tall peaked T A) Blood pressure 94/60
wave is a sign of hyperkalemia. The health care provider B) Heart rate 76
should be notified regarding discontinuing the medication. C) Urine output 50 ml/hour
D) Respiratory rate 16
64. A nurse prepares to care for a 4 year-old newly admitted The correct answer is A: Blood pressure 94/60 Both
for rhabdomyosarcoma. The nurse should alert the staff to pay medications decrease the heart rate. Metoprolol affects blood
more attention to the function of which area of the body? pressure. Therefore, the heart rate and blood pressure must
A) All striated muscles be within normal range (HR 60-100; systolic B/P over 100) in
B) The cerebellum order to safely administer both medications.
C) The kidneys
D) The leg bones 70. While assessing a 1 month-old infant, which finding should
The correct answer is A: All striated muscles the nurse report immediately?
Rhabdomyosarcoma is the most common children''s soft A) Abdominal respirations
tissue sarcoma. It originates in striated (skeletal) muscles and B) Irregular breathing rate
can be found anywhere in the body. The clue is in the middle C) Inspiratory grunt
of the word and is “myo” which typically means muscle. D) Increased heart rate with crying
The correct answer is C: Inspiratory grunt Inspiratory grunting
65. The nurse anticipates that for a family who practices is abnormal and may be a sign of respiratory distress in this
Chinese medicine the priority goal would be to infant.
A) Achieve harmony
B) Maintain a balance of energy 71. The nurse practicing in a maternity setting recognizes that
C) Respect life the post mature fetus is at risk due to
D) Restore yin and yang A) Excessive fetal weight
The correct answer is D: Restore yin and yang For followers of B) Low blood sugar levels
Chinese medicine, health is maintained through balance C) Depletion of subcutaneous fat
between the forces of yin and yang. D) Progressive placental insufficiency
The correct answer is D: Progressive placental insufficiency
66. During an assessment of a client with cardiomyopathy, the The placenta functions less efficiently as pregnancy continues
nurse finds that the systolic blood pressure has decreased beyond 42 weeks. Immediate and long term effects may be
from 145 to 110 mm Hg and the heart rate has risen from 72 related to hypoxia.
to 96 beats per minute and the client complains of periodic
dizzy spells. The nurse instructs the client to 72. The nurse is caring for a client who had a total hip
A) Increase fluids that are high in protein replacement 4 days ago. Which assessment requires the
B) Restrict fluids nurse’s immediate attention?
C) Force fluids and reassess blood pressure A) I have bad muscle spasms in my lower leg of the affected
D) Limit fluids to non-caffeine beverages extremity.
The correct answer is C: Force fluids and reassess blood B) "I just can't 'catch my breath' over the past few minutes and
pressure Postural hypotension, a decrease in systolic blood I think I am in grave danger."
pressure of more than 15 mm Hg and an increase in heart rate C) "I have to use the bedpan to pass my water at least every 1
of more than 15 percent usually accompanied by dizziness to 2 hours."
indicates volume depletion, inadequate vasoconstrictor D) "It seems that the pain medication is not working as well
mechanisms, and autonomic insufficiency. today."
The correct answer is B: "I just can''t ''catch my breath'' over
67. A client has a Swan-Ganz catheter in place. The nurse the past few minutes and I think I am in grave danger." The
understands that this is intended to measure nurse would be concerned about all of these comments.
A) Right heart function However the most life threatening is option B. Clients who
B) Left heart function have had hip or knee surgery are at greatest risk for
C) Renal tubule function development of post operative pulmonary embolism. Sudden
D) Carotid artery function dyspnea and tachycardia are classic findings of pulmonary
The correct answer is B: Left heart function The Swan-Ganz embolism. Muscle spasms do not require immediate attention.
catheter is placed in the pulmonary artery to obtain Option C may indicate a urinary tract infection. And option D
information about the left side of the heart. The pressure requires further investigation and is not life threatening.
readings are inferred from pressure measurements obtained
on the right side of the circulation. Rightsided heart function is
73. A client has been taking furosemide (Lasix) for the past D) May be competitive
week. The nurse recognizes which finding may indicate the The correct answer is B: Lead to dehydration The client must
client is experiencing a negative side effect from the take in adequate fluids before and during exercise periods.
medication?
A) Weight gain of 5 pounds 79. During the evaluation of the quality of home care for a
B) Edema of the ankles client with Alzheimer's disease, the priority for the nurse is to
C) Gastric irritability reinforce which statement by a family member?
D) Decreased appetite A) At least 2 full meals a day is eaten.
The correct answer is D: Decreased appetite Lasix causes a loss B) We go to a group discussion every week at our community
of potassium if a supplement is not taken. Signs and symptoms center.
of hypokalemia include anorexia, fatigue, nausea, decreased C) We have safety bars installed in the bathroom and have 24
GI motility, muscle weakness, dysrhythmias. hour alarms on the doors.
D) The medication is not a problem to have it taken 3 times a
74. A client who is pregnant comes to the clinic for a first visit. day.
The nurse gathers data about her obstetric history, which The correct answer is C: We have safety bars installed in the
includes 3 yearold twins at home and a miscarriage 10 years bathroom and have 24 hour alarms on the doors. Ensuring
ago at 12 weeks gestation. How would the nurse accurately safety of the client with increasing memory loss is a priority of
document this information? home care. Note all options are correct statements. However,
A) Gravida 4 para 2 safety is most important to reinforce.
B) Gravida 2 para 1
C) Gravida 3 para 1 80. Scenario #1 Mr. O is 63 years old. He was dizzy and light-
D) Gravida 3 para 2 headed at home and almost fell. His wife brought him by car
The correct answer is C: Gravida 3 para 1 Gravida is the to the ER. Mr. O was admitted to KP DMC with syncope. This is
number of pregnancies and Parity is the number of not his first time being admitted to the hospital. He has been
pregnancies that reach viability (not the number of fetuses). treated in the past for congestive heart failure and acute
Thus, for this woman, she is now pregnant, had 2 prior myocardial infarction. He feels like he is pretty healthy as he
pregnancies, and 1 viable birth (twins). only takes NSAIDs at home for chronic back pain. Mr. O got to
KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him
75. The nurse is caring for a client with a venous stasis ulcer. and found his blood pressure 138/84, pulse 76 and regular,
Which nursing intervention would be most effective in and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs
promoting healing? were normal, but his IV infiltrated during transport. Betsy, RN
A) Apply dressing using sterile technique started a new IV and put a warm compress on the old site.
B) Improve the client's nutrition status Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA
C) Initiate limb compression therapy found Ben, RN and told him that he had just helped get Mr. O
D) Begin proteolytic debridement off the bedpan. Mr. O had a large, black tarry stool and was
The correct answer is B: Improve the client''s nutrition status complaining of not feeling well. Ben, RN asked him how he
The goal of clinical management in a client with venous stasis was feeling. Mr. O said he just didn’t feel well and could not
ulcers is to promote healing. This only can be accomplished get comfortable. He asked if he could have something for his
with proper nutrition. The other answers are correct, but belly, he states “it’s really hurting!”. Ben, RN assessed his
without proper nutrition, the other interventions would be of abdomen and found that it was distended and Mr. O had
little help. diffuse abdominal pain. He rated his pain a 6 on a scale of 1-
10. For Scenario #1, which of the following statements is the
76. A nurse is to administer meperidine hydrochloride best example of "situation"?
(Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and A. This is Nurse Joe from 6 East. This is in regards to Mr. O in
promethizine hydrochloride (Phenergan) 50 mg IM to a pre- Room 6322. I am concerned about his distended abdomen and
operative client. Which action should the nurse take first? associated pain.
A) Raise the side rails on the bed B. Hi doctor, my patient here on 6 East says his stomach hurts
B) Place the call bell within reach really bad.
C) Instruct the client to remain in bed C. Hello, Mr. O said his belly is "really hurting" . He got here
D) Have the client empty bladder sometime yesterday I think and I believe he's here for
The correct answer is D: Have the client empty bladder The syncope.
first step in the process is to have the client void prior to D. Hello, my patient's stomach is really distended and he says
administering the preoperative medication. The other actions it hurts a lot.
follow this initial step in this sequence: 4 3 1 2
81. Scenario #1 Mr. O is 63 years old. He was dizzy and light-
77. Which of these statements best describes the headed at home and almost fell. His wife brought him by car
characteristic of an effective reward-feedback system? to the ER. Mr. O was admitted to KP DMC with syncope. This is
A) Specific feedback is given as close to the event as possible not his first time being admitted to the hospital. He has been
B) Staff are given feedback in equal amounts over time treated in the past for congestive heart failure and acute
C) Positive statements are to precede a negative statement myocardial infarction. He feels like he is pretty healthy as he
D) Performance goals should be higher than what is attainable only takes NSAIDs at home for chronic back pain. Mr. O got to
The correct answer is A: Specific feedback is given as close to KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him
the event as possible Feedback is most useful when given and found his blood pressure 138/84, pulse 76 and regular,
immediately. Positive behavior is strengthened through and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs
immediate feedback, and it is easier to modify problem were normal, but his IV infiltrated during transport. Betsy, RN
behaviors if the standards are clearly understood. started a new IV and put a warm compress on the old site.
Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA
78. A client with multiple sclerosis plans to begin an exercise found Ben, RN and told him that he had just helped get Mr. O
program. In addition to discussing the benefits of regular off the bedpan. Mr. O had a large, black tarry stool and was
exercise, the nurse should caution the client to avoid activities complaining of not feeling well. Ben, RN asked him how he
which was feeling. Mr. O said he just didn’t feel well and could not
A) Increase the heart rate get comfortable. He asked if he could have something for his
B) Lead to dehydration belly, he states “it’s really hurting!”. Ben, RN assessed his
C) Are considered aerobic abdomen and found that it was distended and Mr. O had
diffuse abdominal pain. He rated his pain a 6 on a scale of 1-
10. For Scenario #1, which of the following statements is the
best example of what's included in "background"?
A. The patient has a history of CHF and MI. The patient also fell
at home and was having black stool here at the hospital.
B. The patient is in the hospital because of syncope. His
abdomen is distended and he had large black tarry stool.
C. He had a large black stool, his IV was infiltrated in the ED,
and he fell at home.
D. Mr. O has CHF and MI in the past, he also fell at home and
his BP is 94/66

82. Scenario #1 Mr. O is 63 years old. He was dizzy and light-

headed at home and almost fell. His wife brought him by car
to the ER. Mr. O was admitted to KP DMC with syncope. This is
not his first time being admitted to the hospital. He has been
treated in the past for congestive heart failure and acute
myocardial infarction. He feels like he is pretty healthy as he
only takes NSAIDs at home for chronic back pain. Mr. O got to
KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him
and found his blood pressure 138/84, pulse 76 and regular,
and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs
were normal, but his IV infiltrated during transport. Betsy, RN
started a new IV and put a warm compress on the old site.
Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA
found Ben, RN and told him that he had just helped get Mr. O
off the bedpan. Mr. O had a large, black tarry stool and was
complaining of not feeling well. Ben, RN asked him how he
was feeling. Mr. O said he just didn’t feel well and could not
get comfortable. He asked if he could have something for his
belly, he states “it’s really hurting!”. Ben, RN assessed his
abdomen and found that it was distended and Mr. O had
diffuse abdominal pain. He rated his pain a 6 on a scale of 1-
10. For Scenario #1, which of the following statements is the
best example of what's included in "assessment"?
A. My assessment of the situation is that the patient may have
a GI bleed as a result of his use of NSAIDs for chronic back
pain.
B. The patient isn't feeling good so what should we do.
C. This isn't the first time the patient has been in the hospital.
He takes NSAIDS at home.
D. I guess if you want to come see the patient to assess him
you can.

83. Scenario #1 Mr. O is 63 years old. He was dizzy and light-

headed at home and almost fell. His wife brought him by car
to the ER. Mr. O was admitted to KP DMC with syncope. This is
not his first time being admitted to the hospital. He has been
treated in the past for congestive heart failure and acute
myocardial infarction. He feels like he is pretty healthy as he
only takes NSAIDs at home for chronic back pain. Mr. O got to
KP DMC at 1600. His nurse Betsy, RN. Betsy, RN assessed him
and found his blood pressure 138/84, pulse 76 and regular,
and his respiratory rate 16. He is afebrile at 98.6. Mr. O’s labs
were normal, but his IV infiltrated during transport. Betsy, RN
started a new IV and put a warm compress on the old site.
Betsy, RN reported off to Ben, RN at 1900. At 2130, the CNA
found Ben, RN and told him that he had just helped get Mr. O
off the bedpan. Mr. O had a large, black tarry stool and was
complaining of not feeling well. Ben, RN asked him how he
was feeling. Mr. O said he just didn’t feel well and could not
get comfortable. He asked if he could have something for his
belly, he states “it’s really hurting!”. Ben, RN assessed his
abdomen and found that it was distended and Mr. O had
diffuse abdominal pain. He rated his pain a 6 on a scale of 1-
10. For Scenario #1, which of the following statements is the
best example of what's included in "recommendation"?
A. I think we need to draw an H/H for the patient and keep the
patient NPO.
B. What should we do?
C. What do you think is going on with the patient?
D. I guess the patient is really sick, so what did you want me to
do?