Q

The home care nurse visits a client in a large apartment complex.
During the visit,

the area experiences a major earthquake. Which of the following clients should
the nurse see FIRST?
1. A restless client with a rigid abdomen and absent bowel sounds.
2. An unconscious client with left-sided tracheal shift from midline.
3. A client complaining of excruciating pain with an obvious

deformity of the left leg.
4. A client clutching her chest and complaining of severe chest
pain.
Strategy: Determine the most unstable client.

(1) likely has injuries to abdominal organs, resulting in hemorrhage and severe
circulatory compromise and requires emergent evaluation; airway and breathing
take priority
(2) CORRECT—first sign of a tension pneumothorax; airway and breathing take
priority
(3) assess for neurovascular compromise; client with breathing difficulties takes
priority
(4) circulatory problem; airway/breathing problems take priority

The nurse cares for clients in the outpatient clinic. The nurse returns to the desk
to find four phone messages. Which of the following messages should the nurse
respond to FIRST?
1. The mother of a 15-year-old reports her son is threatening to jump off a
bridge and has access to a gun.
2. A 20-year-old female reports she has lost 2 lb this week and eats only
two meals a day.
3. A 45-year-old male with a history of depression who is out of Prozac.
4. A 75-year-old male complains of insomnia and irritability after the death

of his wife.

(1) CORRECT— using Maslow Hierarchy of Needs theory to prioritize,
physiological issues take priority over psychological issues; patient is at risk for
self harm and must be seen first; observe for safety
(2) does not require immediate attention
(4) may be a normal part of grieving; nurse should assess but is not the priority

The nurse receives report on the medical/surgical unit. Which of the following
clients should the nurse see FIRST?
1. A client with an IV of normal saline infusing at 125 ml per hour
complaining of slight swelling at the IV insertion site.
2. A client 3 days post right knee replacement complaining of right calf
pain with movement.
3. A client with a respiratory rate of 24 and an oxygen saturation of 94% on
room air.
4. A client 12 hours after a hysterectomy complaining of nausea.

(1) assess site for client's comfort and to prevent complications associated with
IV infusion, probable DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and reported
to the physician immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority

The triage nurse at an urgent care center notes that four clients have signed in,
each complaining of a sore throat. Which of the following clients should the
nurse see FIRST?
1. A 7-year-old whose sibling was recently treated for
"strep throat."
2. A 10-year-old with a history of chronic allergies.
3. A 21-year-old with a history of chronic sinus

infections.
4. A 55-year-old receiving 5-fluorouracil (5-FU).

A nurse working in an emergency department performs a yearly ride-along with a
local ambulance service. Responding to the scene of a motor vehicle collision
(MVC), which of the following clients should the nurse see FIRST?
1. A client with an obvious deformity of the right humerus with
neurovascular systems intact distal to the site.
2. An unconscious client with a crushing chest wound.
3. An unconscious client with a regular heart rhythm at 64 bpm with even

and unlabored respirations.
4. An alert client with multiple scalp lacerations.

(1) client likely has a fracture that will require further stabilization; there is no
evidence of neurovascular compromise at present
(2) CORRECT— clients with crushing chest wounds are at risk for a number of
injuries that may compromise airway, breathing, circulation, cervical spine, and
the nervous system; immediate evaluation is required
(3) though the client is unconscious, cardiopulmonary assessment is stable
(4) client has circulatory compromise but is alert and able to hold pressure to any
areas where bleeding is not well controlled; requires further evaluation but does
not take priority at this time
Question 6 of 30
(1) child has likely contracted strep from his sibling; treatment should begin as
soon as possible; does not take priority
(2) likely experiencing irritation as a result of sinus drainage; does not take
priority
priority
(4) CORRECT— because many chemotherapy agents may result in neutropenia,
clients receiving drugs are more susceptible to infection, less likely to be able to
fight the infection; symptomatic clients require immediate evaluation and
treatment

The nurse cares for patients in the pediatric clinic. Which of the following
patients should the nurse see FIRST?
1. A 5-year-old diagnosed with autistic
disorder demonstrating finger flapping.
2. A 6-year-old with enuresis who often
urinates in his underwear.
3. A 7-year-old who is shy and has
difficulty reading.
4. A 9-year-old who has used a weapon toward his mother and caused
physical harm to others.
Strategy: Determine the most unstable patient.

(1) commonly seen in autistic disorder; has stereotypical and repetitive motor
mannerisms; does not require immediate attention
(2) repeated voiding of urine into bed or clothes may be involuntary or
intentional; does not require immediate attention
(4) CORRECT— unstable patient; at risk for harm to self and others

After receiving report from the night shift, the nurse plans assignments for the
day. Which of the following patients should the nurse see FIRST?
1. A patient who took 10 methylphenidate (Ritalin) and has a blood
pressure of 160/100.
2. A patient who requires a metered-dose inhaler.
3. A patient with a short arm cast on the left arm.
4. A patient diagnosed with hypothyroidism requiring TSH level.

(1) CORRECT— most unstable patient; assess for restlessness, dilated pupils,
tremors, and seizures
(2) potential problem; not priority
(3) no indications of complications; will check for complications such as
circulatory impairment and peripheral nerve damage
(4) symptoms include decreased activity level, sensitivity to cold, obesity, and
weight gain
The nurse cares for clients in a gynecological clinic. Which of the following
1. A 60-year-old complaining of dry vaginal walls and painful intercourse.
2. A 35-year-old who had a hysterosalpingogram is experiencing

tachycardia, and has a generalized rash.
3. A 30-year-old who requires preparation for a cervical biopsy.
4. A 25-year-old scheduled for a Pap smear.

(1) does not require immediate attention; instruct about estrogen replacement
therapy and water-soluble lubricants
(2) CORRECT— x-ray of the cervix, uterus, and fallopian tubes performed after
the injection of a contrast medium; assess for allergy to shellfish or iodine;
requires immediate attention because patient having an allergic reaction
(3) does not require immediate attention; physician usually performs a biopsy as
a follow-up to suspicious Pap test findings
(4) exam to detect precancerous and cancerous cells from the cervix; does not
require immediate attention

Children from a school-bus accident are transferred to the hospital. The nurse
performs triage in the emergency department (ED). Which of the following
1. An 8-year-old with a superficial burn to the
arm.
2. A 7-year-old with burns on the face.
3. A 6-year-old with small lacerations to the

arms and legs.
4. A 5-year-old complaining of elbow pain.

(2) CORRECT— burns can be life-threatening to children; airway, breathing, and
circulation are major concerns; cardiopulmonary complications may result from
exposure to electrical current, inhalation of toxic fumes, hypovolemia, and shock
day on the endocrinology unit. Which of the following patients should the nurse
see FIRST?
1. A patient who requires a fasting blood glucose test in the morning
before breakfast.
2. A patient who requires a urine test for ketone bodies.
3. A patient who will be discharged this afternoon.
4. A patient with a fasting blood glucose of 517 mg/dL.

(1) does not require immediate attention; normal fasting is 60 to 110 mg/dL
(2) does not require immediate attention; presence of ketones may indicate
ketoacidosis; check during illness, stress, or pregnancy
(4) CORRECT— normal is 60 to 110 mg/dL; requires immediate attention;
administer regular insulin
The nurse cares for patients in the psychiatric ER. Which of the following
1. A patient receiving haloperidol (Haldol) experiencing an
oculogyric crisis.
2. A patient receiving thioridazine (Mellaril) experiencing
akathisia.
3. A patient receiving risperidone (Risperdal) experiencing
blurred vision.
4. A patient receiving fluphenazine (Prolixin) experiencing
sedation.

(1) CORRECT— eyes are locked upward; acute dystonic reaction; notify
physician and physician will order an anticholinergic agent to correct this
reaction
(2) inability to sit or stand still; foot tap, pace; does not require immediate
attention; physician will change antipsychotic medication or give
antiparkinsonian agent
(3) does not require immediate attention; physician will change antipsychotic
medication
(4) common during first few weeks of therapy; does not require immediate
attention
day on the pediatric unit. Which of the following patients should the nurse see
FIRST?
1. A patient diagnosed with leukemia complaining of fatigue.
2. A patient diagnosed with Wilms tumor complaining of thirst.
3. A patient diagnosed with hemophilia complaining of joint pain.
4. A patient diagnosed with gastroesophageal reflux complaining of

abdominal pain.

(1) expected because of diagnosis and treatment; balance rest and activity
(2) does not require immediate attention; Wilms tumor is a malignant neoplasm of
the kidney; most common intra-abdominal tumor in children
(3) CORRECT— joint pain indicates bleeding; treatment includes factor VIII, RICE
( r est, i ce, c ompression, and e levation)
(4) backflow of gastric contents into the esophagus resulting from relaxation of
the lower esophageal sphincter
Question 14 of 30

The community health nurse plans visits for the day. Which of the following
1. A client diagnosed with type 2 diabetes who is complaining of GI upset
after taking chlorpropamide (Diabinese).
2. A client who is complaining of vomiting after chemotherapy.
3. A client with a tonometer reading of 21 mm Hg.
4. A client with a laryngectomy who is complaining of a greenish-yellow

discharge.
(1) Diabinese is a oral hypoglycemic; side effects include diarrhea, GI upset, and
hypoglycemia; administer in divided doses to relieve GI upset; does not require
immediate attention
(2) common side effect of chemotherapy; does not require immediate attention
(3) used to diagnose glaucoma; tonometer measures intraocular pressure;
normal IOP reading is 10 to 21 mm Hg
(4) CORRECT— most unstable client; assess breath sounds and amount, color,
and character of drainage
The nurse is seeing patients in the medical/surgical unit. Which of the following
1. A patient diagnosed with heart failure who has received 800 ml of IV
fluids in 2 hours.
2. A patient diagnosed with lung cancer with a blood calcium level of 10.5
mg/dL.
3. A patient diagnosed with hypertension requiring the 9 A.M. dose of
captopril (Capoten).
4. A patient postoperative after a laminectomy who requires supervision
when ambulating.

(1) CORRECT— assess for circulatory overload
(2) normal range is 8.5 to 10.5 mg/dL
(3) can give 30 min before or after prescribed time; ACE inhibitor
(4) nothing to indicate patient is unstable
The nurse cares for clients in the emergency department. Four clients present
complaining of side effects from prescribed medication. Which of the following
1. A client receiving clozapine (Clozaril) and experiencing flu-like
symptoms, fever, sore throat, and lethargy.
2. A client receiving valproic acid (Depakene) and experiencing tremors.
3. A client receiving lorazepam (Ativan) and experiencing abdominal

discomfort.
4. A client receiving methylphenidate hydrochloride (Ritalin) who lost 5 lb
in 4 weeks.
(1) CORRECT— unstable client; may have agranulocytosis; Clozaril is an
antipsychotic; pregnancy risk B
(2) physician will order valproic acid level to assess for toxicity; anticonvulsant;
pregnancy risk D; does not require immediate attention
(3) does not require immediate attention; antianxiety, sedative-hypnotic
(4) may cause decreased appetite; monitor weight; does not require immediate
attention
The nurse sees patients in the gastrointestinal clinic. Which of the following
1. A middle-aged adult diagnosed with irritable bowel syndrome and
complaining of cramping and loose stools.
2. A young adult complaining of not having a bowel movement in 2 days.
3. A child diagnosed with gastroenteritis with five diarrheal stools in the

last 3 days.
4. A newborn experiencing projectile vomiting and irritability.

(1) symptoms of irritable bowel syndrome; encourage patient to eat meals at
regular intervals, chew food slowly, and do not drink fluids with meals
(2) determine normal bowel pattern; encourage fluids, foods high in roughage
(3) does not require immediate attention but has potential for dehydration; real
problems take priority over potential problems
(4) CORRECT— indicates pyloric stenosis; at risk for fluid and electrolyte
imbalance

local ambulance service. Upon responding to the scene of a motor vehicle
collision (MVC), which of the following clients should the nurse see FIRST?
1. An infant who is strapped in a car seat and crying uncontrollably.
2. A child who is crying that her leg is broken.
3. A restless client with pale, cool, clammy skin and a rigid abdomen with
absent bowel sounds.
4. An alert but mildly disoriented client with a scalp laceration with well-
controlled bleeding.
(1) nothing to indicate infant is unstable
(2) priority is the client who has indications of shock
(3) CORRECT— client likely has injuries to abdominal organs, resulting in
hemorrhage and severe circulatory compromise; requires immediate evaluation
(4) though the client has circulatory compromise, the bleeding is well controlled;
requires further evaluation but does not take priority at this time
A triage nurse in a busy urgent care center is prioritizing patients for evaluation.
Which of the following patients should the nurse see FIRST?
1. A 2-month-old infant. The mother states that the child is very sleepy
and has refused to nurse for 8 hours.
2. A crying 2-year-old. The father states that the toddler fell against the
fireplace and continuously touches the right elbow.
3. A 5-year-old who is flushed. The grandmother states that the child has
a temperature of 101.9°F (39°C).
4. A 6-year-old who complains of a sore throat. The caretaker reports the
child has had two episodes of vomiting.

(1) CORRECT— significant risk for dehydration and acidosis; an infant's rate of
fluid exchange is significantly higher than an adult's, and the infant's metabolism
rate is nearly twice that of an adult's; acid forms more rapidly in infants and may
lead to acidosis; kidneys are not mature at this age, cannot adequately
concentrate urine to conserve water
(2) may have dislocation or fracture; evaluate neurovascular status of the
affected extremity and ask the patient's caregiver to report changes while
awaiting further evaluation
(3) likely flushed as a result of the fever; request an order for Tylenol or Motrin if
the child had not received either before arrival and ask the caregiver to report
changes in the patient's condition while awaiting further evaluation
(4) vomiting may pose a risk for dehydration; symptoms are likely a result of
strep throat or a virus; requires urgent evaluation, but with greater body mass
and more mature organ systems, this patient is not as acute as the infant
The nurse receives report on the following patients on the medicine unit. Which
patient should the nurse see FIRST?
1. A patient who just arrived as a transfer from the ER with an oxygen
saturation of 93% and is receiving 2 liters oxygen per nasal cannula.
2. A patient who complains of nausea while drinking contrast in
preparation for a CT scan.
3. A patient who just arrived from the physician's office as a direct
admission with a hemoglobin of 6.9 g/dL.
4. A patient who complains of abdominal pain and is requesting pain
medication.

(1) respiratory status is stable at present, though additional interventions may be
required if the patient's oxygen saturation decreases further; continue to monitor
the patient closely
(2) symptom management is important for patient comfort and to insure the
patient's ability to drink the contrast in preparation for the test; respiratory status
takes precedence
(3) CORRECT— assessment of respiratory status is required; acute onset of
anemia and/or disease may cause SOB, dyspnea, and/or chest pain; oxygen
supplementation often indicated prophylactically even if asymptomatic
(4) symptom management is important for patient comfort; respiratory status
takes precedence
The nurse sees patients in the adolescent psychiatric unit. Which of the following
1. A 13-year-old who complains of impulsivity and poor attention span.
2. A 14-year-old who frequently loses his temper and argues with his
teachers.
3. A 15-year-old who wants to be a model and only drinks water and eats
vegetables.
4. A 16-year-old who bullies, threatens, and intimidates others and
initiates physical fights.

(1) assess further for attention deficit disorder; not an immediate concern
(2) assess for oppositional-defiant disorder
(3) CORRECT— most unstable; assess nutritional status and monitor for eating
disorder
(4) assess for conduct disorder
The nurse receives report about clients on the medical/surgical unit. Which of the
following clients should the nurse see FIRST?
1. A client who is scheduled to receive verapamil (Calan).
2. A client who is scheduled to receive the prescribed metered dose

inhaler (MDI).
3. Family members of a client who threaten to sue the hospital if the
nurse doesn't talk to them immediately.
4. A client who is verbally abusive to staff and becomes increasingly
more agitated.

(1) Calan is an antihypertensive; safety takes precedence over administration of
routine, nonemergent medications
(2) safety takes precedence over administration of routine, nonemergent
medications
(3) although angry, the family members do not pose an immediate physical threat
to the patient, staff, or other visitors
(4) CORRECT— poses a potentially immediate physical threat to himself, staff
members, and/or other patients and visitors if the situation is allowed to escalate
further; nurse must attempt to intervene and initiate protocols prescribed by the
individual facility to maintain a safe environment
1. A 9-month-old infant with failure to gain weight and a lead
level of 70 g/dL.
2. A 4-year-old child scheduled for surgery who fears body
mutilation.
3. A 6-year-old who has repeated, involuntary urination at
night.
4. A 7-year-old with a persistent fear of attending school.

(1) CORRECT— high risk for injury; requires immediate attention; provide
medical treatment and chelation therapy, begin coordination of care, clinical
management, environmental investigation, and lead hazard control
(2) common fear during preschool years, does not require immediate attention
(3) describes enuresis; does not require immediate attention
1. A 5-year-old male who experiences hyperactivity and impulsivity for 2
weeks.
2. A 13-year-old female who has been truant from school for 3 days.
3. A 13-year-old female who has vomited every day for the last 3 months
because she wants to lose weight for the summer.
4. A 25-year-old male who drinks alcohol every day and is unable to
control the amount of alcohol he ingests.

(1) does not require immediate attention; using Maslow hierarchy of needs theory
to prioritize, physiological issues come before psychological issues
(3) CORRECT— at risk for fluid and electrolyte imbalances; also address
potential for decreased cardiac output and altered nutrition: less than body
requirements
(4) nurse needs to see this client second
The nurse obtains histories from four clients preparing for CT scan with oral and
IV contrast. Which of the following client statements requires an IMMEDIATE
follow-up by the nurse?
1. "I am feeling nauseated."
2. "My face gets red when I eat shrimp."
3. "I get claustrophobic when I am in a

small space."
4. "I am having joint pain."

(1) nausea may prevent the client from drinking the oral contrast; should be
addressed, but allergies to IV dye or seafood are more important
(2) CORRECT— allergies to iodine, seafood, or dye can cause an allergic reaction
(3) rarely a concern for clients undergoing CT scan; more of a concern for client
undergoing magnetic resonance imaging
(4) nurse does need to follow up, but the priority is to follow up on the client with
the potential allergic reaction
The triage nurse prioritizes patients to be evaluated in the ER. Which of the
following patients will the nurse see FIRST?
1. A young adult complaining of nausea and vomiting for the
past several hours.
2. A young adult at 8 weeks' gestation complaining of vaginal
spotting.
3. A toddler with a temperature of 101°F (39°C).
4. An infant with vomiting and diarrhea.

(1) average healthy young adult's body can adequately compensate for
dehydration over the short term
(2) vaginal spotting with pregnancy can be related to a number of factors,
including intercourse, drop in progesterone level during this particular
gestational age, and potential for spontaneous abortion; ask patient to rest and
offer reassurance until evaluated by the physician
(3) obtain an order for an antipyretic and monitor toddler until toddler can be
evaluated by the physician
(4) CORRECT— at significant risk for dehydration which may result in electrolyte
imbalances, as well as shock, depending on the amount of fluid lost
The nurse cares for clients on the medical/surgical unit. After receiving report,
which of the following clients should the nurse see FIRST?
1. An elderly client 2 days postop after a total hip replacement who
slipped out of bed when trying to stand.
2. An elderly client with a history of cardiomyopathy who aspirated
cooked cereal at breakfast.
3. An elderly client diagnosed with a right-sided CVA who requires
assistance going to the bathroom.
4. An elderly client diagnosed with heart failure (HF) who has been
vomiting for 3 days.

(1) assess whether dislocation of prosthesis has occurred; airway takes priority.
(2) CORRECT— ensure that client has patent airway; at risk to develop
pneumonia
(3) ensure client's safety; client with impaired airway takes priority
(4) assess this client second; may have digitalis toxicity; circulatory problem
The nurse cares for clients in the outpatient clinic. Each of the following clients
has asked to see the nurse due to complaints of pain. Which of the following
1. A client with a history of a herniated lumbar disc who complains of
severe pain radiating down the left leg.
2. A client with a history of migraine headaches who complains of a
headache and light sensitivity.
3. A client with a history of kidney stones who tearfully complains of
severe right flank pain.
4. A client with a history of coronary artery disease (CAD) who complains
of midepigastric pain radiating to the neck.

(1) important to address this client's pain; the condition is chronic and does not
take priority
(2) important to address this client's pain; the client is likely experiencing a
migraine headache and does not take priority
(3) assess for symptoms of obstruction of the ureter; client with symptoms that
may indicate myocardial infarction takes priority
(4) CORRECT— client with a history of coronary artery disease is at increased
risk of myocardial infarction; pain that originates in the chest or abdomen and
radiates to the neck, shoulder, or arm requires immediate evaluation
A psychiatric nurse is presented with a group of patients in the emergency

department (ED). Which of the following patients requires IMMEDIATE attention?
1. A young adult who failed medical school and verbalizes, "My pain will
be over soon."
2. A young adult who complains of hyperventilation and palpitations at
the beginning of a presentation.
3. A middle-aged adult who hears voices to harm others.
4. A middle-aged adult who is fearful after witnessing a murder.

(1) CORRECT— at risk for self-harm; determine if client has means; place on one-
to-one observation and stay with patient to help control self-destructive impulses
(2) does not require immediate attention; indications of anxiety include increased
pulse, blood pressure, and respirations, perspiration, flushing, and heat
sensations
(3) should be the second patient seen
(4) does not require immediate attention; may be experiencing post-traumatic
stress syndrome

The nurse in the psychiatric emergency room assesses 4 clients. Which of the
1. A patient was raped 30 minutes ago and expresses feelings of self-
blame, anxiety, and worthlessness.
2. A patient indicates an intent to kill himself and says he has access to a
gun.
3. A patient had a miscarriage last evening and is experiencing anger and
resentment.
4. A patient witnessed a child stabbed to death 2 weeks ago and is
experiencing anxiety.
Strategy: “FIRST” indicates priority.

1) need to assess physical needs and examine patient; second patient to see
2) CORRECT— patient is at risk for self-harm; client has intent and a way to carry
out threat
3) allow client to verbalize feelings
The nurse in a small town is called to a neighbor’s house in the middle of a

blizzard. The neighbor woman states she is in the 39th week of gestation with her
second baby and has been having contractions for several hours. The woman
has been unable to obtain assistance because the roads are impassable. The
nurse determines that the woman is in the second stage of labor. It is MOST
important for the nurse to take which of the following actions?
1. Time the frequency of the
contractions.
2. Assess the type of vaginal
discharge.
3. Monitor the strength of the
contractions.
4. Observe the perineum.
Strategy: Assess before implementing.
1) priority is assessing if baby is crowning
3) labor is not the priority; nurse should determine if the birth is imminent
4) CORRECT— baby will descend into birth canal and may crown, major
responsibility in second state of labor; support infant’s head; apply slight
pressure to control delivery
The nurse receives a call from the emergency management team that 50 victims
will be transported to the hospital in 15 minutes by ambulance. Which of the
following actions should the nurse take FIRST?
1. Contact the nursing supervisor.
2. Tell the emergency management team they will have to re-

route 25 victims.
3. Activate the hospital’s disaster plan.
4. Inform the emergency department nurses they must work

overtime.

1) CORRECT— nurse must follow chain of command
2) not the nurse’s responsibility
3) must notify immediate supervisor about the call; disaster plans are hospital
policies that detail how nurses are to perform duties
4) not the responsibility or role of the nurse
As a part of discharge teaching, the nurse instructs a client receiving citalopram

(Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the
client states which of the following?”
1. “This medication helps me with my depression.”
2. “I will notify my physician if I show signs of

hyperactivity and mania.”
3. “I will see improvement in my symptoms in 1 to 4
weeks.”
4. “If I experience a fever I will take Tylenol.”
Strategy: “Further teaching is necessary” indicates incorrect information.
1) Celexa is a selective serotonin reuptake inhibitor (SSRI) used to treat
depression
2) side effects: mania, hypomania, insomnia, impotence, headache, and dry
mouth
3) true statement
4) CORRECT— should notify physician immediately to assess for serotonin
syndrome, which is a rare, life threatening event caused by interaction between
Celexa and MAOI; symptoms include abdominal pain, fever, sweating,
tachycardia, hypertension, delirium, myoclonus, irritability, and mood changes;
may result in death
The nurse has just received change-of-shift report. Which of the following
1. A patient diagnosed with COPD with an PaO 2 of 70%.
2. A patient diagnosed with type 1 diabetes who was just informed her
husband is seriously injured.
3. A patient scheduled to leave for the operating room in 30 minutes for a
heart valve replacement.
4. A patient 10 hours postop after a right mastectomy complaining of wet
sheets under her back.

1) oxygenation considered “normal to good” for patient with COPD; stable
patient
2) physical needs take priority
3) requires preop injection; all other preparation should be completed; stable
patient
4) CORRECT— may indicate hemorrhage from operative site; unstable patient
The nurse cares for children in the outpatient pediatric clinic. It is MOST
important for the nurse to perform tuberculosis screening on which of the
following children?
1. A child just returned from a 2-week trip to Europe.
2. A child recently moved to an apartment because the family

lost their home.
3. A child with a new nanny who just emigrated from Latin
America.
4. A child who weighed 4 lb, 10 oz at birth.
Strategy: All answers are assessments. Determine how they relate to risk factors
for tuberculosis.
1) tuberculosis is endemic to Asia, Middle East, Africa, Latin America, and
Caribbean; consider screening if child has traveled to an endemic region
2) the homeless and impoverished are at risk for developing tuberculosis
3) CORRECT— children traveling to endemic areas or who have prolonged, close
contact with indigenous persons should undergo immediate skin testing
4) no reasons to undergo immediate screening
The nurse plans care for a patient in hemorrhagic shock from injuries sustained
in a fall. It is MOST important for the nurse to take which of the following actions?
1. Obtain vital signs.
2. Identify the source of the

bleeding.
3. Elevate the head of the bed
30°.
4. Administer 0.9% NaCl IV.

1) assessment; more important to determine the source of bleeding
2) CORRECT— assessment first step; initial priority to identify and then apply
direct pressure and elevate affected area if possible
3) intervention; elevate the extremities
4) intervention; 1–2 liter bolus of isotonic fluids (lactated Ringer or 0.9% NaCl)
will be given
During the change-of-shift report, the charge nurse overhears two nurses
exchanging loud, rude remarks about one nurse’s excessive use of overtime.
Which of the following statements by the charge nurse is MOST appropriate?
1. “I want to see both of you in my office right away.”
2. “Would you please lower your voices and finish the

report.”
3. “I want the two of you to stop yelling and work this
problem out.”
4. “Both of you are good nurses and are under a lot of
stress right now.”
Strategy: Determine the outcome of each response. Is it appropriate?

1) confrontation is not the appropriate conflict management approach when
emotions are high
2) CORRECT— forcing is the most appropriate conflict management technique;
enables nurses to exchange information; client care takes priority over
interpersonal conflict
3). need cooling-off period before issues can be discussed; communicating
about patient care takes priority
4) “don’t worry” response; may make the nurses feel better but does not address
the immediate task of completing the report
A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV

infusion into her left arm. It is MOST important for the nurse to observe her for
which of the following?
1. Slowed pulse and reduced blood
pressure.
2. Constipation and decreased bowel
sounds.
3. Palpitations and nervousness.
4. Difficulty voiding and oliguria.
Strategy: “MOST important” indicates discrimination is required to answer the

question.
1) causes rapid pulse and dysrhythmias; decrease intake of colas, coffee, and
chocolate because they contain xanthine
2) causes diarrhea, nausea, and vomiting; administer with food or full glass of
water
3) CORRECT— effects of aminophylline include nervousness, nausea, dizziness,
tachycardia, seizures
4) medication has no effect on the kidneys; encourage intake of 2,000 cc per day
to decrease viscosity of airway secretions
The home care nurse visits a client diagnosed with type 1 diabetes being
managed with insulin in the am and pm. The nurse identifies that which of the
following BEST measures the overall therapeutic response to management of the
diabetes?
1. Glycosylated hemoglobin (HbA 1 c) 5%
of total Hb.
2. Fasting blood sugar 128 mg/dL.
3. Blood pressure 130/82.
4. Serum amylase 100 Somogyi U/dL.
Strategy: Think about each answer.

1) CORRECT— indicates overall glucose control for the previous 120 days;
normal is 4.5–7.6% of total hemoglobin
2) normal fasting is 60–110 mg/dL; HbA 1 c more accurate indicator of glucose
control
3) evaluates response to antihypertensive medication
4) elevated in acute pancreatitis; normal is 60–160 Somogyi U/dL
The nurse cares for a client in labor. The client’s examination reveals that the
cervix is 5 cm dilated and 100% effaced and the fetal head is at –1. The
membranes rupture and the nurse notes clear fluid. Which of the following
actions should the nurse take FIRST?
1. Ambulate the client for 15 minutes and evaluate the fetal heart rate
every 30 minutes.
2. Prepare for delivery and notify the care provider.
3. Apply an electronic fetal monitor and start an IV.
4. Encourage the client to void every 1–2 hours and take her
temperature every hour.

1) do not ambulate the client; head is too high, may cause cord to prolapse
2) too early to set up for delivery, has approximately 2–3 remaining hours of
labor; sterile equipment should be opened for no more than 1 hour
3) no indication that the client is in trouble
4) CORRECT— facilitates descent of the fetal head; temperature evaluation is
necessary because of ruptured membranes
The nurse cares for a client receiving a heparin drip via an infusion pump. The
physician orders warfarin (Coumadin) 5 mg PO. Which of the following actions
should the nurse take NEXT?
1. Administer medication as ordered.
2. Notify the physician.
3. Check the most recent serum partial

prothrombin levels.
4. Assess client for signs/symptoms of bleeding.
Strategy: “NEXT” indicates priority

1) CORRECT— warfarin interferes with the hepatic synthesis of vitamin K–
dependent clotting factors; oral anticoagulant therapy should be instituted 4 to 5
days before discontinuing the heparin therapy
2) no reason to notify the physician
3) partial thromboplastin time used to monitor effectiveness of heparin;
therapeutic level is 1.5 to 2.5 times the control
4) warfarin takes 3 to 5 days to reach peak levels
The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia
nervosa. The nurse identifies that which of the following activities is MOST
appropriate for this client?
1. Making jewelry with the occupational
therapist.
2. Exercising in the physical therapy
department.
3. Assisting the dietician to plan the week’s
menus.
4. Reading teen magazines with other
patients her age.
Strategy: Determine the outcome of each answer.

1) CORRECT— one of the goals for a client with anorexia is to achieve a sense of
self-worth and self-acceptance that is not based on appearance; this activity will
promote socialization and increase self-esteem
2) goal is for client to achieve 85–95% of ideal body weight; may be able to
exercise after short term goals are met
3) meal planning is a part of self-care activities, but more important for client to
achieve a sense of self-worth
4) can read magazines in the presence of others without interacting
A mother reports to the clinic nurse that her daughter developed a large welt, red
rash, and shortness of breath after being stung by a bee. The mother asks the
nurse, “What should I do if she gets stung again?” Which of the following
responses by the nurse is BEST?
1. “Make a paste of baking soda and water and apply it
to the sting.”
2. “Remove the stinger and immediately apply ice to
the site.”
3. “Give 12.5 mg of Benadryl by mouth.”
4. “Administer 0.3 mg of epinephrine subcutaneously.”
Strategy: Determine the outcome of each answer. Is it desired?

1) treatment for sting in persons not allergic to bee stings; treats local reaction
2) not appropriate for this child because she has demonstrated hypersensitivity
to bee sting; if no previous hypersensitivity; initial action is to remove stinger as
quickly as possible to decrease the amount of venom injected into wound, wash
with soap and water, apply cool compress
3) will not work fast enough to prevent anaphylactic reaction
4) CORRECT— child who has demonstrated previous hypersensitivity should
have an EpiPen available; instruct child to wear medical identification bracelet
The nurse counsels the mother of a child diagnosed with impetigo. The nurse
notes that the infection has not improved and learns the mother has not been
caring for the child’s skin because it “takes too much time.” It is MOST important
for the nurse to assess for which of the following?
1. White patches on buccal
mucosa.
2. Hearing loss.
3. Respiratory wheezing.
4. Periorbital edema.
Strategy: What indicates a complication?
1) describes Candida , a fungal infection
2) not caused by impetigo
4) CORRECT— impetigo is caused by Staphylococcus and Streptococcus ;
untreated, can cause acute glomerulonephritis; periorbital edema indicates
poststreptococcal glomerulonephritis
The nurse on a college campus is informed by the microbiology department that

they accidentally received a shipment of highly toxic, contagious bacteria. Which
of the following actions should the nurse take FIRST?
1. Determine if there are adequate supplies of antibiotics
and antipyretics.
2. Order necessary equipment and supplies.
3. Contact the Red Cross.
4. Identify who was exposed to the shipment.

1) may be required, but not the first action; affected people will most likely be
treated in a treatment facility
2) more important to determine who was exposed to the bacteria
3) if exposure is widespread, they may send health care providers; determine
scope of problem first
4) CORRECT— assess before implementing; after determining who has been
exposed, appropriate treatment can be instituted
The nurse administers promethazine (Phenergan) 25 mg IM to a client

complaining of nausea and vomiting. After receiving the medication, the client
complains of dizziness when standing up. Which of the following actions should
the nurse take FIRST?
1. Notify physician.
2. Monitor severity of symptoms.
3. Instruct client to ask for assistance before

ambulating.
4. Assess client’s hydration status.
Strategy: Complete assessment before implementing

1) complete assessment before contacting physician
2) is complaining of orthostatic hypotension; determine if fluid volume deficit
contributing to dizziness
3) appropriate action, but nurse should first complete assessment
4) CORRECT— side effects include anorexia, dry mouth and eyes, constipation,
orthostatic hypotension; client is at risk for fluid volume deficit due to vomiting,
which exacerbates the orthostatic hypotension
The nurse in the outpatient clinic has four unscheduled clients waiting to see the
physician. Which of the following clients should the nurse see FIRST?
1. A client complaining of a sore throat and nasal drainage.
2. A client with a history of kidney stones complaining of

severe flank pain.
3. A client complaining of redness and pain in his left great
toe.
4. A client receiving digoxin (Lanoxin) complaining of
nausea and vomiting.
Strategy: “FIRST” indicates priority

1) symptoms consistent with viral rhinitis; encourage to gargle with salt water
and increase fluid intake
2) second client that should be seen; administer opioid analgesics to prevent
shock and syncope
3) indications of acute gout; attack subsides spontaneously in 3 to 4 days;
administer colchicine (Colsalide) and NSAIDS
4) CORRECT— early effects of digitalis toxicity; hold medication and monitor
client’s symptoms
The nurse cares for a client diagnosed with a recurrence of colon cancer. The
client tells the nurse that she is dreading taking chemotherapy again. Which of
the following responses by the nurse is MOST appropriate?
1. “There are web sites that provide information about
chemotherapy.”
2. “Have you discussed this with your physician?”
3. “I can give you a handout about how to treat the side effects of
chemotherapy.”
4. “What are your concerns about taking chemotherapy?”
Strategy: Assessment before implementation

1) assumes that client needs more information about chemotherapy; nurse
should respond to client’s concerns
2) don’t pass the buck; responding to client’s concerns is a nursing
responsibility
3) assess before implementing
4) CORRECT— think about the nursing process when selecting answers; allows
nurse to gather data about what is concerning the client
The nurse in the outpatient clinic receives a call from a client who has been
receiving continuous ambulatory peritoneal dialysis (CAPD) for 1 year. The client
states that he infused 2 L of dialysate and 1200 cc returned. Which of the
following statements by the nurse is BEST?
1. “Record the difference as
intake.”
2. “When was your last bowel
movement?”
3. “Are you having shoulder pain?”
4. “Increase your fluid intake.”
Strategy: Determine if it is appropriate to assess or implement.

1) the difference between inflow and outflow is counted as intake; ensure that all
fluid has drained from the peritoneal cavity; change positions or ask client to
walk around
2) CORRECT— full colon can create outflow problems; ensure that bowel
evacuation has occurred
3) referred shoulder pain may be caused by rapid infusion of dialysate; instruct to
decrease infusion rate; this client is having an outflow problem
4) will not affect outflow
The nurse evaluates assignments on the unit. The nurse determines that
assignments are appropriate if the LPN/LVN is assigned to which of the following
patients?
1. A patient with type 1 diabetes scheduled for
discharge.
2. A patient newly admitted to the unit with
chest pain.
3. A patient receiving chemotherapy.
4. A patient diagnosed with myasthenia gravis.
Strategy: Assign stable patients with expected outcomes.

1) requires teaching; LPN/LVN can reinforce teaching but cannot perform initial
teaching
2) is not a stable patient with an expected outcome; requires assessment
4) CORRECT— no indication that patient is not stable; myasthenia gravis is
deficiency of acetylcholine at myoneural junction; symptoms include muscular
weakness produced by repeated movements that soon disappear following rest
An elderly client is brought to the emergency department complaining of acute

back pain. The client denies any chronic illness, allergies, or previous
hospitalizations. Which of the following is the BEST initial response for the nurse
to make to this client?
1. “We’ll get this pain under control in no time.”
2. “Are you sure you’ve never been in the hospital?”
3. “Did you fall, lift something heavy, or turn the wrong way?”
4. “On a scale of 1 to 10, with 10 being the worst, rate the pain you
are experiencing.”
Strategy: “BEST” indicates priority.

1) false reassurance; nurse should complete assessment
2) confrontational response; pain assessment is priority
3) should first assess intensity of pain as well as location
4) CORRECT— assessment, is objective and clear, and responds directly to
client’s complaint; gives information for further intervention
A nurse observes a student nurse administer carvedilol (Coreg) to an elderly

patient. The patient refuses medication, saying, “Go away. It makes me dizzy.”
The nurse should intervene if the student nurse states which of the following?
1. “If you don’t take this medication, you will be restrained.”
2. “This medication will help control your blood pressure.”
3. “Side effects of this medication make some patients feel

uncomfortable.”
4. “When do you notice the dizziness?”
Strategy: “nurse should intervene” indicates something is wrong.

1) CORRECT— inappropriate action; client has the right to refuse medication;
restraining client is an example of battery
2) Coreg is a nonselective beta-blocker used to treat hypertension and heart
failure
3) side effects include dizziness, fatigue, weakness, orthostatic hypotension;
instruct client to change positions slowly
4) allows nurse to teach about medication
The nurse cares for clients in the emergency department (ED). An 82-year-old
client comes to the ED complaining of muscle weakness and drowsiness. The
nurse notes decreased deep tendon reflexes and hypotension. Which of the
1. Escort the client to an emergency
room unit.
2. Ask the client if he has been taking
antacids.
3. Assess for Chvostek’s sign.
4. Measure client’s intake and output

1) delegate to other personnel
2) CORRECT— increased intake of magnesium-containing antacids and laxatives
can cause hypermagnesemia (> 2.5 mEq/L); depresses CNS and cardiac impulse
transmission; discontinue oral Mg, support ventilation, administer loop diuretics
or IV calcium, teach about OTC drugs that contain Mg
3) seen with hypocalcemia; tap face just below and anterior to the ear to trigger
facial twitching on that side of face
4) renal insufficiency can cause decreased excretion of magnesium; not
appropriate for this setting
A tornado has just leveled a large housing division near the hospital, and a
disaster alarm has been declared at the hospital. The nurse caring for clients on
the maternal-child unit considers which of the following clients appropriate for
discharge within the next hour?
Select all that apply.
1. A multipara client who delivered over an intact perineum 12
hours ago.
2. A postpartum client with an infection who has been on
antibiotics for the past 24 hours.
3. A 3-year-old with newly diagnosed type 1 diabetes, diarrhea,
and vomiting.
4. A 3-day-old breast-feeding infant with a total serum bilirubin of
14 mg/dL.
5. A client at 34 weeks’ gestation diagnosed with generalized
edema and complaints of epigastric pain.
6. A 2-day-old infant delivered of a mother receiving intrapartum
antibiotic therapy for vaginal group B-streptococcus (GBS).
Strategy: Determine the most stable clients.

1) CORRECT— stable patient
2) do not know if antibiotics are effective or the current WBC count
3) requires frequent assessment of hydration status and blood glucose levels
4) CORRECT— phototherapy considered for the infant with total serum bilirubin
of >15 mg/dL at 72 hours of age
5) epigastric pain indicates pending eclampsia
6) CORRECT— group B streptococcal (GBS) disease causes sepsis; because
mother received intrapartum prophylaxis, infant has 1-in-4,000 chance of
developing sepsis due to GBS
The nurse cares for a client following a scleral buckling. Which of the following
nursing actions is MOST important?
1. Remove all reading material.
2. Assess for nausea.
3. Assess drainage from

affected eye.
4. Irrigate affected eye every 3
hours.
Strategy: “MOST important” indicates priority.

1) scleral buckling compresses the sclera to repair a detached retina; should take
precautions to prevent moving eyes rapidly
2) CORRECT— nausea and vomiting increase intraocular pressure and could
cause damage to the area repaired
3) wear eye shield; avoid sneezing, coughing, straining at stool
4) do not irrigate
The nurse supervises care for a patient admitted to the psychiatric unit with a
diagnosis of bipolar disorder: manic phase. A student nurse plans activities for
the patient. The nurse should intervene if the student nurse chooses which of the
following activities?
1. Volleyball.
2. Painting.
3. Walking.
4. Dancing.
Strategy: “Nurse should intervene” indicates an incorrect action.

1) CORRECT— avoid competitive games because they increase agitation; assign
to a single room away from activity; keep noise level low and lighting soft
2) appropriate activity; will not provoke or over-stimulate client
3) appropriate activity; activity that uses large movements until acute mania
subsides
4) appropriate activity; provides structure and safety in the milieu
The nurse on the medical/surgical unit is approached by an LPN/LVN from a

different team. The LPN/LVN expresses concern because one of her patients is
diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at
2 L/min. Which of the following statements by the nurse is MOST appropriate?
1. “I will assess the patient for oxygen toxicity.”
2. “Are you concerned about the oxygen or the new graduate’s

competency?”
3. “Please tell me more about your concerns.”
4. “Leave the oxygen in place.”
Strategy: “MOST appropriate” indicates discrimination is required to answer the

question.
1) client is assigned to another nurse; usurps assigned nurse’s authority
2) yes/no question; nontherapeutic; should allow LPN/LVN to express her
concerns
3) CORRECT— open-ended statement; therapeutic; allows the LPN/LVN to
express specific concerns and enables the nurse to further assess
4) not enough information to make a judgment; assess before implementing
The nurse cares for an infant diagnosed with congenital heart disease. The nurse
notes that the infant becomes easily fatigued during feedings and the infant’s
pulse and respirations increase. The nurse should take which of the following
actions?
1. Feed the infant soon after awakening.
2. Change the infant’s diaper before feeding.
3. Increase the caloric content of the feeding to

30 kcal/oz.
4. Mix rice cereal in the formula.

1) CORRECT— infant feeds better if well rested; offer small, frequent feeding
every 3 hours; enlarge hole in nipple
2) will not affect infant’s intake; pin diaper loosely to promote maximum chest
expansion
3) allows infant to take in more calories in a smaller quantity; to prevent diarrhea,
increase the calories by 2 kcal/oz/day; formulas provide 20 kcal/oz
4) infant would have to expend more energy to eat
The nurse instructs a client who is scheduled for a 24-hour creatinine clearance
test. Which of the following statements, if made by the client to the nurse,
indicates further teaching is required?
1. “I will eat a high-protein meal before the test begins.”
2. “I will use the specimen collection time to catch up on my

reading.”
3. “I will drink as much fluid as I want before and during the
test.”
4. “I will save all of my urine during the 24 hours and keep it in
the refrigerator.”

1) CORRECT— high-protein diet before the test may increase creatinine
clearance and affect the accuracy of the test
2) appropriate action; avoid strenuous physical activity, will increase creatinine
excretion and compromise the accuracy of the test
3) appropriate action
4) appropriate action; bottle should contain a preservative
The nurse prepares to admit a 6-month-old diagnosed with rotavirus, severe

diarrhea, and dehydration. The nurse should place the infant in which of the
following rooms?
1. In a semiprivate room with a 2-year-old in traction due to a
fracture.
2. In a semiprivate room with a 9-month-old admitted for a
shunt revision.
3. In a private room that is close to the nurse’s station.
4. In any private room that is available.
Strategy: Think about the outcome of each answer.

1) a diapered or incontinent client diagnosed with rotavirus requires contact
precautions for the duration of the illness; is a significant nosocomial pathogen
2) requires a private room; do not place a client with an infection in a room with a
client who does not have an infection
3) CORRECT— rotavirus is spread by fecal-oral route and requires contact
precautions if client is diapered or incontinent
4) due to severe nature of the symptoms requiring hospitalization, infant requires
close observation for changes in condition

following rooms?
fracture.
shunt revision.

A patient returns from surgery for a total replacement of the right hip with a large
surgical dressing and a Jackson-Pratt drain. Which of the following, if observed
by the nurse 2 hours after surgery, necessitates calling the physician?
1. There is a small amount of bloody drainage on the
surgical dressing.
2. The patient complains of increased hip pain.
3. A harsh, hollow sound is auscultated over the trachea.
4. The patient’s blood pressure is 136/86.
Strategy: “necessitates calling the physician” indicates a complication.

1) expected outcome, complications of total hip replacement include dislocation
of prosthesis, excessive wound drainage, thromboembolism, and infection
2) CORRECT— indicates dislocation of prosthesis; other indications include
shortening of affected leg, leg rotation, soft popping sound heard when affected
leg is moved; maintain abduction, use wedge pillow, avoid stopping, do not sleep
on operated side until directed to do so, flex hip only 1/4 circle, never cross legs,
avoid position of flexion during sexual activity, walking is excellent exercise,
avoid overexertion; in 3 months will be able to resume ADLs, except strenuous
sports
3) describes normal breathing sounds
4) within normal limits
An older patient is placed in balanced suspension traction for a compound

fracture of the femur. The patient complains that her hands, feet, and nose feel
cold. Which of the following actions should the nurse take FIRST?
1. Provide the patient with more blankets.
2. Assess for dependent edema.
3. Assess that patient is exhaling when

moving in bed.
4. Increase the temperature of the room.
Strategy: Determine if it is time to assess or implement.

1) because of recumbent position, cardiac workload increases; if heart is unable
to handle increased workload, peripheral areas of body will be colder; more
important to assess cardiovascular status
2) CORRECT— edema caused by heart’s inability to handle increased workload;
assess sacrum, legs, and feet; also assess peripheral pulses
3) Valsalva maneuver increases workload on heart; to prevent, teach immobilized
patients about exhaling when moving about in bed; should first assess patient
complaints
4) assess the client; cold extremities may indicate heart is not able to tolerate
increased workload
The nurse cares for an older client diagnosed with terminal lung cancer. When
told about the diagnosis, the client becomes very angry. He curses, throws
objects, and hits the nurse tech and LPN/LVN when they attempted provide care
for him. It is MOST important for the nurse to take which of the following actions?
1. Inform client that injury or risk of injury to staff is
not acceptable.
2. Send the staff out of the room.
3. Administer prescribed antianxiety with full glass of
water.
4. Report signs/symptoms to physician immediately.

1) CORRECT— set limits on client’s behavior; staff has the right to work in a safe
environment
2) gives client the power; speak calmly to client, help to verbalize feelings, use
nonthreatening body language
3) nurse should use least restrictive interventions to assist the client to regain
control
4) passing the buck; it is the nurse’s responsibility to care for the client
The nurse, caring for clients in the outpatient clinic, performs a chart review for
clients who are receiving medication. The nurse determines that which of the
following clients is at risk to develop problems with hearing?
1. A client receiving spironolactone (Aldactone) and
cefaclor (Ceclor).
2. A client receiving metformin (Glucophage) and
alendronate (Fosamax).
3. A client receiving paroxetine (Paxil) and cholestyramine
(Questran).
4. A client receiving furosemide (Lasix) and indomethacin
(Indocin).

1) Aldactone is a potassium-sparing diuretic and Ceclor is a second-generation
cephalosporin; neither drug is ototoxic
2) Glucophage is an oral hypoglycemic and Fosamax is a bone resorption
inhibitor; neither is ototoxic
3) Paxil is a selective serotonin reuptake inhibitor (SSRI) and Questran is an
antihyperlipidemic agent; neither is ototoxic
4) CORRECT— Lasix is a loop diuretic and is ototoxic, especially when given with
other ototoxic drugs; Indocin is a NSAID and is also ototoxic
The nurse in the pediatric clinic receives a phone call from the mother of a 3-
year-old child. The mother reports that her child has been complaining of a sore
throat, has a temperature of 102°F (39°C), and he has suddenly begun drooling.
Which of the following suggestions should the nurse make FIRST?
1. “Place a cold water vaporizer in your child’s
room.”
2. “Take your child to the emergency department
immediately.”
3. “Look into your child’s throat and tell me what
you see.”
4. “Frequently offer your child oral fluids.”

1) appropriate action if the child has croup
2) CORRECT— symptoms indicate acute epiglottitis which can be life
threatening; drooling occurs because of difficulty swallowing; child may become
apprehensive or anxious; transport to hospital sitting in the parent’s lap to
reduce stress
3) do not inspect the throat unless immediate intubation can be performed if
needed
4) transport to the hospital
The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two
days after admission, the client begins complaining of severe nausea. Which of
the following actions should the nurse take FIRST?
1. Determine the client’s most recent fasting serum
glucose level.
2. Perform a comprehensive client assessment.
3. Ask the client if she is pregnant.
4. Administer an antiemetic.

1) no relationship between diabetes and nausea; last glucose reading does not
give the nurse information about client’s current condition
2) CORRECT— nausea not usually associated with diabetes; assess before
implementing
3) nurse is making assumptions based on client’s age; should perform a
comprehensive assessment
A new registered nurse asks the assigned nurse mentor to check on 4 clients
who are receiving oxygen therapy. It is MOST important for the nurse mentor to
ask the nurse which of the following questions?
1. “Which client should I see first?”
2. “Have you completed your assessment?”
3. “What are your specific concerns?”
4. “Don’t you think you should be able to care for

the clients?”
Strategy: “MOST important” indicates discrimination may be required to answer

the question.
1) nurse mentor should find out about the nurse’s specific concerns
2) yes/no question; doesn’t allow nurse mentor to assess the nurse’s needs
3) CORRECT— clarifies the nurse’s concerns and will help the new nurse become
a safe practitioner
4) yes/no question; nontherapeutic; does not allow nurse mentor to assess new
nurse’s concerns
The nurse cares for a client receiving chlordiazepoxide (Librium). It is MOST

important for the nurse to observe for which of the following?
1. Skeletal muscle spasms and
insomnia.
2. Anorexia and dry mouth.
3. Diarrhea and euphoria.
4. Drowsiness and confusion.

1) dystonia is side effect of antipsychotics; insomnia caused by SSRIs
2) Ritalin causes anorexia; dry mouth is side effect of tricyclic antidepressants
3) not caused by Librium
4) CORRECT— antianxiety and sedative/hypnotic used to treat anxiety and
alcohol withdrawal; causes drowsiness and sedation; use caution when driving
or operating equipment; confusion may indicate immediate n
Following the administration of meperidine HCl (Demerol) for an adult client, the
nurse expects which of the following?
1. The client states that he feels
better.
2. The client is talking with visitors.
3. The client appears to be physically

relaxed.
4. The client is no longer crying or
moaning.
Strategy: Think about how each answer relates to pain.

1) client may express pain relief, but in reality may still be experiencing pain
2) client may still be in pain
3) CORRECT— nonverbal cues are the best indication of pain relief
4) not best indication of relief of pain
After being admitted for management of a cervical spine injury, a client in a

rehabilitation center reports a severe headache. Which of the following actions
should the nurse take FIRST?
1. Check for analgesia on physician’s
order sheet.
2. Ask the client to rank the pain from 1
to 10.
3. Ask the client if he is worried about
something.
4. Obtain the client’s blood pressure.

1) more assessment required
2) cervical spine injury and severe headache should clue nurse that client is
possibly in imminent danger
3) assess for physical causes before psychosocial causes
4) CORRECT— pounding headache and profuse sweating are indications of
autonomic hyperreflexia; place in a sitting position
1. A client newly diagnosed with type 1 diabetes who had a myocardial
infarction 2 days ago.
2. A client diagnosed with right-sided heart failure and glaucoma.
3. A client diagnosed with chronic obstructive pulmonary disease and

psoriasis.
4. A client diagnosed with rheumatoid arthritis and malnutrition.

1) CORRECT— both diseases are in the dynamic phase and require close
monitoring; most unstable client
2) client should be seen second
3) two chronic illnesses
4) client more stable than #1
The nurse cares for a 4–year–old on the pediatric unit. The child is unable to go
to sleep while in the hospital. It is MOST important for the nurse to take which of
the following actions?
1. Turn out the light and close the door.
2. Encourage the child to exercise during

the evening.
3. Identify the child’s home bedtime ritual.
4. Ask the child’s siblings to visit during the

evening.
Strategy: Assess before implementing

1) will increase the child’s fears; preschoolers fear injury, mutilation, and
punishment
2) will not promote sleep
3) CORRECT— preschoolers require bedtime rituals that should be followed in
hospital; nurse should assess before implementing
4) will be comforting to child, but to promote sleep it is more important to
determine bedtime routine
The nurse prepares an elderly client newly diagnosed with type 1 diabetes for
discharge. The client is alert and oriented and lives alone in her home. It is MOST
important for the nurse to assess for which of the following?
1. Client’s vision and manual dexterity.
2. Client’s understanding of diabetes.
3. Client’s need for visits from the home care

nurse.
4. Client’s ability to perform blood glucose
monitoring.

question.
1) CORRECT— client must have the visual acuity and manual dexterity to draw
up and administer insulin
2) it is important that the client understands diabetes, but priority is assessing
client’s ability to manage insulin administration
3) may be necessary
4) important, but first assess the client’s vision and manual dexterity
A nursing assistant informs the nurse that an elderly client admitted following a
hemorrhagic cerebrovascular accident ate half of the food on his tray. The food
left on the tray looked as if someone had drawn a straight line down the center of
the plate and eaten the food only to one side of the line. Which of the following
instructions by the nurse is MOST important?
1. “Rotate the plate so that the food is on the
other side.”
2. “Offer him a snack later in the day.”
3. “Ask the client’s family to assist him with the

next meal.”
4. “Which foods did he omit?”

question.
1) CORRECT— indicates homonymous hemianopsia (loss of half of the visual
field); client neglects one side of body; instruct client to turn head in direction of
visual loss
2) food pattern on plate indicates loss of visual field
3) passing the buck
4) situation does not require further assessment
The nurse evaluates care for a client who demonstrates manipulative behavior.
The nurse should intervene if which of the following is observed?
1. The staff discusses with the client the consequences of his
manipulative behavior.
2. The staff establishes limits on the client’s manipulative behavior.
3. The staff clarifies the consequences of the client’s manipulative

behavior.
4. The staff decreases the demands on the client.

1) appropriate that the staff help to client learn to see the consequences of his
behavior
2) appropriate; staff should communicate clearly defined expectations and carry
out limit-setting
3) appropriate behavior
4) CORRECT— fosters a sense of entitlement
The nurse in the pediatric clinic performs a well-child assessment on a 20-month-

old. The child’s mother tells the nurse that she is earning extra money by
growing houseplants in her home. Which of the following responses by the nurse
is MOST appropriate?
1. “How did you get into that
business?”
2. “What a great opportunity.”
3. “You should not have plants in

your home.”
4. “Where do you keep the plants?”

question.
1) encourages the mother to talk about her interests but does not address safety
issue of toddler
2) closed response; does not give client opportunity to respond
3) not all plants are toxic; nurse is expressing an opinion without completing the
assessment
4) CORRECT— toddlers explore by putting things in their mouth; all potentially
toxic agents should be placed out of reach of the toddler; nurse should assess
the type of plants in the home and the location of the plants
The nurse performs discharge teaching for a client diagnosed with

gastroesophageal reflux disease (GERD). The nurse determines that teaching is
successful if the client selects which of the following menus?
1. Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello,
and cola.
2. Cheddar cheese omelet, spinach salad, chocolate brownie, and milk.
3. Broiled chicken, cream of broccoli soup, rice pudding, and apple juice.
4. Baked salmon with lemon butter, baked potato, mint chocolate chip ice
cream, and lemonade.
Strategy: “Teaching is successful” indicates correct information.

1) oil dressing high in fat, tomato exacerbates GERD, as do carbonated
beverages
2) fatty foods and chocolate exacerbate GERD
3) CORRECT— menu low in fat and contains non-acidic foods
4) lemonade and mint exacerbate GERD
The nurse supervises the transfer of an elderly client with left-sided weakness
from the bed to the chair. After assisting the client to a sitting position, which of
the following actions should the nurse take NEXT?
1. Place nonskid shoes on the client’s feet.
2. Instruct the client that she will be moving toward

her left side.
3. Ask the client to pivot on her right foot.
4. Support the left leg with the nurse’s knee.

1) CORRECT— instruct client to wear shoes when transferring, nonskid soles
decrease the chance of falls
2) if client has weaker side, transfer toward the stronger side; nurse should
assess if a transfer belt is required; place chair at 45° angle to the bed
3) appropriate action; first put shoes on client; instruct client to use armrests on
chair for support
4) appropriate action to provide stability to weak leg so that client can stand
during transfer
A 16-year-old girl is brought to the emergency room by her parents for evaluation
of an eating disorder. When the nurse approaches the client to draw a blood
sample, the client cries out, “I hate having my blood drawn. Go away!” Which of
the following responses by the nurse is BEST?
1. “What’s the matter? Are you afraid of what we are
going to find?”
2. “What is it about having your blood drawn that
upsets you?”
3. “Take a deep breath. It will be over before you know
it.”
4. “I’ll be back in 15 minutes so we can discuss your
concern.”
Strategy: “BEST” indicates discrimination is required to answer the question.

1) yes/no question; nurse is making an assumption
2) CORRECT— open-ended; relates to client’s verbal and nonverbal
communication and responds to the client’s feelings
3) “don’t worry” response; nontherapeutic
4) do not leave the client alone
The nurse cares for clients in the prenatal clinic. A client comes to the clinic for a
prenatal visit on June 6. Her last menstrual period was December 10. The nurse
expects the client’s fundal height to measure
1. 24 cm.
2. 26 cm.
3. 28 cm.
4. 30 cm.
1) incorrect, determine EDC based on N ä gele’s rule–date LMP Dec. 10; EDB–
Sept. 17; client is 26 weeks pregnant; from 24–34 weeks, fundal height correlates
well with weeks of gestation; 24 cm is approximately 24 weeks’ gestation
2) CORRECT— client is 26 weeks pregnant; fundal height should correlate with
weeks of pregnancy
3) fundus is too high
Recently several staff members on the unit have complained of back strain. The
nurse determines that the staff is not consistently using correct body mechanics
when transferring patients. Which of the following suggestions should the nurse
make FIRST?
1. “Encourage your patients to assist as much
as possible.”
2. “Use your arms and legs when moving a
client.”
3. “Determine if help is required to transfer a
patient.”
4. “Position yourself close to the patient.”

1) decreases the nurse’s workload and promotes client strength and
independence
2) appropriate action; use the larger muscles of the body and not the back; don’t
twist spine
3) CORRECT— first step is to assess; determine the weight to be transferred and
if help (other staff members, mechanical devices) is required and available
4) minimizes the force felt by the nurse; always keep weight to be lifted close to
the body
A client is receiving packed red blood cells. Several minutes after the infusion is
started, the client complains of nausea and low back pain. It is MOST important
for the nurse to take which of the following actions?
1. Obtain a urine specimen.
2. Start an IV of D 5 W.
3. Discard the blood container in a biohazard
container.
4. Decrease the rate of the transfusion.

1) CORRECT— should be sent to lab for hemoglobin determination; symptoms of
hemolytic reaction include nausea, vomiting, pain in lower back, hypotension,
increase in pulse rate, decrease in urinary output, hematuria
2) should restart normal saline; stop the blood, supportive care: oxygen,
Benadryl, airway management
3) container should be returned to lab
4) should be discontinued due to hemolytic reaction; draw blood sample for
plasma, hemoglobin culture, and retyping
A 75-year-old client is brought by his wife to the outpatient clinic. The nurse
notes that the client has a 10-year history of chronic renal failure and has been
taking cimetidine (Tagamet) for two weeks. It is MOST important for the nurse to
investigate which of the following statements made by the client’s wife?
1. My husband has been complaining that his bowel movements
are hard to pass.
2. My husband takes his Tagamet just before he eats his meals.
3. My husband seems to be having more trouble with his memory

lately.
4. My husband sometimes has a headache after reading the
newspaper.
Strategy: “MOST important to investigate” indicates an adverse reaction.

1) Tagamet decreases gastric secretion by inhibiting the actions of histamine at
the H 2 -receptor site; constipation is a common side effect of this medication;
should increase fiber in diet; not most important
2) Tagamet should be taken with meals and at bedtime
3) CORRECT— elderly clients and clients with renal problems are most
susceptible to CNS side effects (confusion, dizziness) of the medication; dosage
may need to be reduced
4) headache may be side effect of medication, or may be caused by need to
change glasses; not most important
The nurse cares for an older woman with frequent bladder incontinence following
a cerebrovascular accident (CVA). Which of the following actions by the nurse is
MOST appropriate?
1. Perform intermittent catheterizations using sterile technique
2. Teach the patient how to perform Valsalva maneuver.
3. Instruct the patient how to perform the Cred é maneuver.
4. Toilet the patient when she awakens in the morning and before
and after meals.

1) only used for problems with retention
2) straining and bearing down on the abdominal muscles alters the heart rate; will
not prevent incontinence
3) used to initiate urination when there is retention; place a cupped hand over the
bladder and push inward and downward
4) CORRECT— will establish a regular toileting routine
An older man is returned to his hospital room three hours after a transurethral
resection of the prostate (TURP). The patient has a continuous bladder irrigation
(CBI). Which of the following observations, if made by the nurse, requires an
intervention?
1. The patient is in bed with his legs drawn up to
his abdomen.
2. There is 500 cc fluid in the urinary drainage bag.
3. There is 350 cc of reddish urine in the drainage

bag.
4. The head of the patient’s bed is elevated 45
degrees.
Strategy: “Requires an intervention” indicates a potential complication.

1) CORRECT— indicates pain; also, catheter is taped to thigh, and leg should be
kept straight to maintain traction on the catheter
2) expected due to the CBI; assess for shock and hemorrhage; check dressing
and drainage; urine may be bright red for 12 h; monitor vital signs
3) expected drainage soon after surgery; CBI contains isotonic fluid used to keep
the catheter patent
4) no restriction on positioning as long as leg that has catheter taped to it is
straight
The nurse on the medical/surgical floor receives four new admissions. Which of
the following clients should be placed in a private room?
1. A client with a draining abdominal abscess covered
with a dressing.
2. A client diagnosed with influenza.
3. A client diagnosed with cancer who appears septic.
4. A client with diverticulitis complaining of abdominal

pain.

1) standard precautions required as long as the abscess is covered with a
dressing and the dressing contains the drainage
2) CORRECT— requires droplet precautions; place in private room or with
patients with the same infection; maintain spatial separation of at least 3 feet;
door can remain open
3) microorganisms have entered the bloodstream due to impaired immune
function; standard precautions; assess for s/s shock
4) standard precautions
The nurse performs a prenatal assessment on a client at 20 weeks’ gestation.

Identify the location where the nurse expects to palpate the client’s fundus.
Strategy: Recall the fundal height at 20 weeks.

The correct answer: at the level of the umbilicus.
10 to 12 weeks — fundus slightly above symphysis pubis
16 weeks — fundus halfway between symphysis pubis and umbilicus
20 to 22 weeks — fundus at the level of the umbilicus
28 weeks — fundus three fingerbreadths above the umbilicus
36 weeks — fundus just below ensiform cartilage
The home care nurse visits a client diagnosed with progressive systemic
sclerosis. The client complains that she is having more trouble swallowing and
moving her right hand. Which of the following responses by the nurse is MOST
important?
1. “This must be a difficult time for you.”
2. “You should schedule an appointment with your health

care provider.”
3. “Can you tolerate pressure on your hand?”
4. “Tell me more about the problems you are having

swallowing.”

1) it is important to allow client to verbalize feelings, but physical needs take
priority
2) may be required, but nurse should complete assessment
3) appropriate assessment for Raynaud phenomenon; eating problems take
priority
4) CORRECT— progressive systemic sclerosis is a connective tissue disease
that causes dysphagia and esophageal reflux because of decreased motility;
nurse should assess before determining the appropriate imp
A terminally ill client with excruciating pain episodes complains the pain
medication given at night does not relieve the pain as well as it does during the
day. A chart review reveals that clients report pain medication being less
effective, and the clients receive more medication when a particular nurse is
working. Which of the following actions should the nurse take FIRST?
1. Set up a hidden camera in the medication room.
2. Ask physician to consider increasing the dosage of

medication at night.
3. Determine how long the client has been receiving the
medication.
4. Temporarily assign another nurse to give all of the PRN
medications.

1) priority is caring for the client in pain
2) clients complaining of pain is an indication that there may be a problem with
one of the nurses
3) assumes that client is experiencing a tolerance to the medication
4) CORRECT— primary focus is client comfort; validation of the nurse having a
substance abuse problem does not override quality client care
The nurse cares for a patient hospitalized for a head injury. The client is receiving
0.9% sodium chloride at 100 cc/h and has an indwelling Foley catheter in place.
The nurse notes the patient’s urinary output is 1,000 cc in 3 hours. Which of the
following actions by the nurse is MOST appropriate?
1. Contact the physician.
2. Decrease the amount of fluids the patient is

receiving.
3. Assess the client’s mucous membranes.
4. Measure the urine specific gravity.
Strategy: Determine if assessment or implementation is appropriate.

1) complete the assessment before contacting the physician; symptoms of
diabetes insipidus include excessive urine output, severe dehydration, excessive
thirst, anorexia, weight loss
2) ADH deficiency causes the excretion of large volumes of dilute urine; if
deprived of fluids, may cause shock
3) may see signs of dehydration, such as poor skin turgor and dry or cracked
mucous membranes
4) CORRECT— low specific gravity (1.001 and 1.005) is characteristic of diabetes
insipidus; head injury causes interference with production or release of ADH;
record I and O, urine specific gravity, and daily weight; ensure client’s intake of
fluid and administer DDAVP
The nurse cares for a patient with chest tubes. Two days after insertion, the chest
tube is accidentally pulled out of the pleural space. Which of the following
1. Don sterile gloves and replace the tube.
2. Apply pressure with a dressing that is tented

on one side.
3. Instruct the client to cough and deep–breathe.
4. Auscultate the lung.

1) inserting the tube is a medical procedure
2) CORRECT— decreases chance that atmospheric air will enter pleural space
and allows for escape of pleural air
3) increases the amount of atmospheric air that enters the pleural space
4) priority is covering the opening; listen to lungs after emergency measure
instituted
A tornado roared through a populated area, causing multiple casualties. Which of

the following patients should the nurse see FIRST?
1. A patient with a small penetrating abdominal wound caused by
flying debris.
2. A patient with blunt trauma to the abdomen that caused
bruising.
3. A patient complaining of chest pain with asymmetrical chest
movement noted.
4. A patient who is confused and restless with no visible injuries.

1) may cause bleeding; injury does not appear to be life-threatening
2) second patient that should be seen; observe for ecchymosis, which indicates
retroperitoneal bleeding into the abdominal wall
3) CORRECT— indicates flail; monitor for shock, give humidified oxygen, manage
pain, monitor ABGs
4) appears most stable
A man hospitalized for alcohol abuse comes to the nurses’ station and asks the
nurse if he can go to the cafeteria to get something to eat. When told that his
privileges do not include visiting the cafeteria, the patient becomes verbally
abusive. Which of the following actions by the nurse is MOST appropriate?
1. Tell the patient to lower his voice.
2. Ask the patient what he wants from the cafeteria.
3. Calmly but firmly escort the patient to his room.

4. Assign a nursing attendant to accompany the patient to
the cafeteria.

1) do not argue; carry out limit-setting
2) reinforces inappropriate behavior
3) CORRECT— limit-setting, ensures safety; patient with substance abuse needs
consistent, undivided staff approach, clearly defined expectations, as well as
limit-setting; avoid threats and promises
4) reinforces abusive behavior
The nurse prepares a client for a skin biopsy. Which of the following statements,
if made by the client, should the nurse report to the physician?
1. “I have been taking aspirin for my aching
joints.”
2. “I applied lotion to my skin after my shower
last night.”
3. “I laid out in the sun yesterday.”
4. “I had coffee and a sweet roll for breakfast

this morning.”
Strategy: Think about what the words mean.

1) CORRECT— aspirin can increase the risk for bleeding and should be reported
2) does not affect the biopsy
3) not a good health habit, but it does not affect the biopsy
4) a punch or shave biopsy is usually performed on the skin and does not require
NPO; clean biopsy site once a day with tap water or saline; leave site open
The nurse counsels a client diagnosed with degenerative joint disease. It is

MOST important for the nurse to include which of the following instructions?
1. “Place your joints in the position of
comfort.”
2. “Place your joints in a flexed
position.”
3. “Place your joints in full extension.”
4. “Place your joints in their functional

position.”
1) may lead to limitations in movement; place in functional position
2) would cause flexion contractures that limit mobility; only use a small pillow
under the head or neck; do not use large pillows under the knees; to reduce back
discomfort, elevate legs 8–10 inches
3) should be placed in correct functional position to maintain mobility of joint
4) CORRECT— maintains mobility of joints
The nurse is making staff assignments on the medical/surgical unit. The nurse
should assign a nursing assistant to care for which of the following clients?
1. A client diagnosed with a CVA 2 weeks ago requiring assistance
ambulating.
2. A client diagnosed with COPD who is in acute distress requiring
assistance bathing.
3. A client receiving total parenteral nutrition through a PICC line
requiring a dressing change.
4. A client diagnosed with type 1 diabetes on mechanical ventilation
requiring a bath.
Strategy: Assign the nursing assistant to stable clients with standard,

unchanging procedures
1) CORRECT— stable patient requiring a standard, unchanging procedure;
instruct nursing assistant about the how far to walk the client and any untoward
occurrences to report
2) client requires assessment; not appropriate for the nursing assistant
3) requires skill of the RN
The home care nurse visits a client receiving warfarin (Coumadin) 5 mg PO daily
for DVT. The nurse learns the client operates a horse ranch. It is MOST important
for the nurse to include which of the following instructions?
1. Ride with a companion and wear an identification
bracelet.
2. Carry a cell phone and dressings and tape.
3. Provide significant others with a written itinerary

for the day.
4. Temporarily change to activities that are safer for
client

question
1) riding with a companion is helpful but does not specifically reduce the risks;
should wear an Medic Alert bracelet
2) CORRECT— because of occupation and prescribed anticoagulant, client is at
risk for tissue damage; in case of injury, apply pressure to wound and summon
help
3) others knowing potential location is relevant but does not reduce risks
4) taking the medication is long-term; nurse should help client integrate
appropriate interventions into lifestyle
The nurse cares for clients in the outpatient clinic. A client with a pacemaker
calls to report that he just had an episode of dizziness and shortness of breath.
Which of the following responses by the nurse is MOST important?
1. “What is your pulse?”
2. “What were you doing before the

episode?”
3. “Have you experienced this before?”
4. “Is the area over the pacemaker painful

or red?”

1) CORRECT— may indicate pacemaker malfunction; nurse should assess
client’s current status
2) assess if client was close to electromagnetic field that might interfere with
function of pacemaker; more important to assess current status
3) should be asked later in conversation
4) may indicate infection; more important to assess cardiac functioning
A client is admitted to the labor and unit in a sickle-cell crisis. Which of the
following nursing actions should the nurse take FIRST?
1. Administer oxygen.
2. Turn client to right side.

3. Begin an IV with normal
saline.
4. Administer antibiotics.

1) second action; crisis caused by extensive extracellular sickling
2) no reason to turn to right side; do not keep knees and hips in a flexed position
3) CORRECT— dehydration perpetuates cell sickling; intake should be at least
200 cc/hour
4) more susceptible to blood-borne pathogens; frequent handwashing; avoid
people with URI
The nurse cares for a laboring patient. The patient requests something for pain
and says to the nurse, “I’m really scared of shots.” Which of the following
1. “A shot is your only option, because labor slows the
GI tract.”
2. “I can give you a pill now, but it will not last as long as
an injection.”
3. “What was your previous experience with shots?”
4. “What are you afraid of?”
Strategy: Remember therapeutic communication.

1) is an accurate response but does not allow the client to express her feelings
2) oral medication is not recommended in labor because of the decrease in GI
motility
3) CORRECT— an assessment to assist the nurse in gathering information
toward achieving pain relief and to this particular client’s psychological state;
assess before intervening
4) judgmental and nontherapeutic
The nurse on the medical/surgical unit admits an elderly client after the patient
has undergone a below-the-knee amputation. The nurse obtains vitals signs and
assesses that the client is able to be aroused but is sleepy. When the client
awakens and realizes that the amputation was performed, the client begins to
scream. Which of the following statements by the nurse is MOST appropriate?
1. “The physician informed you that the amputation
was required.”
2. “I’ll get you some medication so that you can rest.”
3. “Your family is waiting in the lobby to come see

you.”
4. “Since you seem upset, I’ll stay with you.”

question
1) first step of readjustment of changed body image is psychological shock;
client will not be receptive to receiving information
2) more important for the nurse to stay with the client
3) passing the buck; nurse should care for client
4) CORRECT— acknowledges client’s feelings; nurse should stay with patient,
focus on here and now, and deal with client’s immediate problems
The nurse determines that which of the following clients is MOST at risk to
develop gastroesophageal reflux disease (GERD)?
1. A 16-year-old African American male who had an NG tube for 3 days
after surgery for a ruptured appendix.
2. A 30-year-old Hispanic female with a diagnosis of cholelithiasis and a t-
tube in place.
3. A 52-year-old Caucasian female who is 5’5" tall and weighs 185
pounds.
4. A 65-year-old Caucasian male with a laryngectomy for laryngeal
cancer.

1) NG tube is a risk factor; NG tube compromises esophageal sphincter function
and permits acidic stomach contents to enter the esophagus
2) being female is a risk factor for GERD
3) CORRECT— GERD is gastrointestinal contents flowing backward into the
esophagus; risk factors include female, over the age of 45, and obesity; GERD
appears more often in Caucasians
4) risk factors include age and ethnicity; smoking is also a risk factor for GERD
The nurse cares for clients in the emergency department after an earthquake.
Which of the following clients should the nurse see FIRST?
1. A client at 7 months’ gestation complaining of cramping and blood-
streaked discharge.
2. A client with a displaced fracture of the right radius with blood seeping
from the wound.
3. A client complaining of lightheadedness; nurse notes client is clammy,
pulse 112, respirations 28.
4. A client with type 1 diabetes who took insulin immediately before the
earthquake and is complaining of lightheadedness.

1) may be in early labor, stable patient
2) illnesses that can wait up to 2 hours are considered urgent
3) CORRECT— client appears to be developing shock; most unstable client
4) lightheadedness probably due to hypoglycemia; more stable than client in
shock
The nurse on the medical unit is called to the room of an elderly client. The nurse
finds the client sitting up in bed complaining of pressure in his chest and pain in
his jaw. Vital signs are: BP 160/94, P 112, R 20, T 99.5°F (38°C). The client has a
history of hypertension and is receiving IV antibiotics for a diagnosis of
pneumonia. Which of the following actions should the nurse take FIRST?
1. Administer oxygen at 4 L/min via nasal canula.
2. Place the client on a cardiac monitor and obtain a

12-lead ECG.
3. Obtain blood for CK-MB, troponin, and myoglobin
levels.
4. Assess patency of the client’s IV line.
Strategy: Remember the ABCs.

1) CORRECT— implementation; ABCs take priority; exhibiting signs of acute
coronary syndrome (ACS) which may be unstable angina, myocardial ischemia or
infarction
2) assessment; should be completed after oxygen administration; provides data
for physician to determine required treatment
3) assessment; third action, elevations are indicative of MI; do not wait for lab
results before beginning treatment
4) assessment; ensure route for IV medication such as nitroglycerin, morphine,
fibrinolytic, and heparin
The nurse administers meperidine (Demerol) 75 mg IM to a postoperative patient.
Thirty minutes later, it is MOST important for the nurse to take which of the
following actions?
1. Reposition the patient.
2. Elevate the patient’s head and place a pillow under

the shoulders.
3. Observe the patient for restlessness and distress.
4. Ambulate the patient.

1) will promote comfort; other interventions include cool, well–ventilated, quiet
room and a back rub
2) will promote comfort
3) CORRECT— nurse should evaluate the actual outcomes; if medication
ineffective, will also see inability to concentrate and apprehension
4) more important to allow client to rest
The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It
is MOST important for the nurse to clarify which of the following orders by the
physician?
1. Furosemide (Lasix) 20 mg IV every
12 hours.
2. 2 g/day sodium diet
3. Normal saline at 125 ml/hour IV.
4. Oxygen at 2 L per nasal cannula.
Strategy: “Clarify an order” indicates an order that may harm the patient
1) appropriate order; loop diuretic that promotes the excretion of excess water;
decreases blood volume and pressure in the left ventricle
2) appropriate order; because extracellular fluid is primarily regulated by sodium,
a low-sodium diet may decrease excess water
3) CORRECT— because the patient may have excess fluid volume, may be on
fluid volume restriction; weigh daily and measure I and O
4) appropriate order; may have impaired gas exchange and develop hypoxemia
depending on the severity of heart failure
The nurse performs an assessment for a client diagnosed with bilateral cataracts.
To determine the amount of visual impairment experienced by the client, which of
the following questions by the nurse is BEST?
1. “Would you please identify what you can see
clearly?”
2. “How have your visual abilities changed?”
3. “When did you first notice that your vision had

changed?”
4. “Would you please tell me what you have
difficulty seeing?”

1) cataracts are partial or total opacity of the normally transparent crystalline lens
and cause objects to appear distorted and blurred; nurse unable to estimate loss
of vision with this question
2) question is too broad and difficult to understand
3) does not determine the client’s current vision
4) CORRECT— this question helps the nurse determine client’s current loss of
vision
The nurse performs dietary teaching with a client who has hepatitis B. Which of
the following menus, if selected by the client, is BEST?
1. Hamburger, french fries, a dill pickle, and malted
milk.
2. Lean roast beef, baked potato, green beans, and
coffee.
3. Bacon, eggs, toast with butter, and milk.
4. Biscuits with sausage, gravy, and buttered grits, and

orange juice.
Strategy: Evaluate the nutrients in each menu.

1) high-fat foods; encourage fruits, vegetables, cereals, lean meat
2) CORRECT— high-carbohydrate, low-fat
3) high-fat foods; not allowed: marbled meats, avocados, milk, bacon, egg yolks,
and butter
4) high-fat foods
The nurse assesses a client diagnosed with paranoid schizophrenia. Which of the
following assessments indicates to the nurse that the client may need assistance
with self-care activities?
1. The client speaks in a low monotone voice.
2. The client had suicidal ideation on two previous

admissions.
3. The client is fearful that poison is being placed
in his food.
4. The client is unable to maintain eye contact with
the nurse.

1) may appear guarded, intense, and reserved; may adopt a superior, hostile, and
sarcastic attitude; will have no bearing on self-care activities
2) may indicate depression
3) CORRECT— paranoia is an irrational suspicion; cannot be changed by
experience or reality; may prevent client from eating; provide food in closed
containers to prevent the suspicion of tampering
4) indicates a negative symptom of schizophrenia and contributes to poor social
functioning but does not help client needs with self-care activities
The charge nurse on the night shift receives a call from one of the nurses who is
to report the next morning. The day-shift nurse reports that she has been
diagnosed with strep throat and placed on antibiotics. Which of the following
responses by the charge nurse is MOST appropriate?
1. “How long have you had the sore
throat?”
2. “How long have you been on
antibiotics?”
3. “Do you have an elevated
temperature?”
4. “Do you have a doctor’s release to
work?”

question.
1) duration of sore throat is not relevant to being able to work
2) CORRECT— after 24 hours of antibiotic therapy, strep throat is no longer
contagious and a health care provider can resume responsibilities
3) fever is the body’s reaction to disease as a defense mechanism; being afebrile
is often a condition for being able to work but duration of antibiotic therapy is the
best indicator
4) nurse does not need a physician’s release in the case of strep throat
The nurse cares for a client receiving cholestyramine (Questran) 4 g BID. The
nurse would be MOST concerned if the client makes which of the following
statements?
1. “I have a hard bowel movement every 2 or 3 days.”
2. “I sprinkle the powder on my orange juice at

breakfast.”
3. “I have increased my intake of milk and green leafy
vegetables.”
4. “I take digoxin (Lanoxin) at lunch every day.”
Strategy: “MOST concerned” indicates incorrect information.

1) CORRECT— constipation is a side effect of medication; encourage diet high in
fiber and fluids
2) sprinkle on liquid, let stand for a few minutes, and stir thoroughly; after
drinking, add a small amount of liquid to same glass, mix, and drink to ensure
intake of entire dose
3) medication depletes fat-soluble vitamins; milk contains vitamins A and D;
green leafy vegetables contain vitamins E and K
4) take other medication one hour before or 4 to 6 hours after taking Questran
The nurse performs teaching for a client receiving alendronate (Fosamax) 10 mg

PO OD. The nurse determines that teaching is effective if the client states which
of the following?
1. “I will take the medication at lunch.”
2. “I’m glad that I don’t have to participate in a regular

exercise program.”
3. “If I forget a dose, I should take it when I remember it.”
4. “I should wear sunscreen when I go outside.”

Strategy: “Teaching is effective” indicates correct information.
1) take medication first thing in the morning at least half hour before ingesting
other medication, food, or drink
2) used for treatment and prevention of osteoporosis; client should participate in
regular weight-bearing exercise to increase bone density
3) should only be taken first thing in morning; if dose is missed, skip the dose
and resume the next morning
4) CORRECT— causes photosensitivity; wear sunscreen and protective clothing
when outdoors
The nurse admits a client to the medical unit with a diagnosis of heart failure and
pneumonia. The client’s wife states that the client has recently experienced a
significant decline in his hearing and is extremely depressed. Which of the
1. Provide the client an opportunity to express his feelings about
the hearing loss.
2. Assign the client to a nurse who has a hearing impairment.
3. Encourage the client to use the incentive spirometer every

hour while awake.
4. Contact a support group for the hearing impaired.

question.
1) according to Maslow, physical needs take priority over psychosocial needs
2) intervention aimed at the hearing loss and depression; nurse needs to deal
with physical needs first
3) CORRECT— pneumonia causes impaired gas exchange; incentive spirometry
prevents or reverses atelectasis
4) initial interventions aimed at the pneumonia
The home care nurse visits an elderly client 1 day following a colonoscopy. The
daughter states that her mother has been confused since coming home from the
procedure. Which of the following actions should the nurse take FIRST?
1. Instruct the client to increase her intake of
fluids.
2. Obtain the client’s vital signs.
3. Determine how many times the client has
voided.
4. Ask the client if she has experienced
abdominal cramping.

1) confusion may be sign of hypovolemic shock; client may be dehydrated
because of bowel prep, nurse should first assess
2) CORRECT— hypovolemia can occur from bowel prep and altered mental
status may be an early indication; assess for decreased blood pressure,
increased pulse, light-headedness and dizziness
3) if client dehydrated, will void smaller amounts of concentrated urine; priority is
to assess vital signs
4) may experience abdominal cramping caused by insufflation of air
The nurse in the outpatient clinic performs an assessment of an elderly woman.

The client states that her husband had a CVA 7 months ago, and she cared for
him for 3 months. Four months ago she had to place her husband in a long-term
care facility because she was no longer able to care for him. Since that time the
client reports she has lost 40 pounds, she is afraid to live alone, and she sorely
misses her husband. The nurse notices that the client is extremely hard of
hearing. Which of the following suggestions should the nurse make FIRST?
1. “I think you should move to the nursing home with
your husband.”
2. “Have you considered installing a security system in
your home?”
3. “I’m going to refer you to Meals on Wheels.”
4. “Perhaps you should find a hobby or join a club for

seniors.”

1) assumes client is a candidate for a nursing home; loneliness is not a reason to
move to a long-term care facility
2) addresses client’s concern about safety and security; priority is making sure
that the client eats
3) CORRECT— according to Maslow, take care of basic needs first
4) client’s nutrition and safety take priority over psychosocial needs
The nurse cares for a client diagnosed with chronic obstructive pulmonary
disease (COPD) receiving oxygen per nasal canula at 2 L/min. The nurse
observes that the client has shortness of breath and chest pain. The nurse
notifies the assigned physician, and the physician makes no changes in the
amount of oxygen the client is receiving. Which of the following responses by the
nurse is MOST appropriate?
1. Report concerns to the supervisor.
2. Contact the physician a second time.
3. Inform the family members that the physician has not changed
the client’s orders.
4. Continue to monitor the respiratory status of the client.

question.
1) client has symptoms of oxygen toxicity; hypoxemia is a greater threat than
oxygen toxicity
2) hypoxemia is greater threat than oxygen toxicity
3) inappropriate action
4) CORRECT— nurse should continue to assess client’s condition and report
changes to the physician; hypoxemia is greater threat than oxygen toxicity
The community health nurse visits the home of a client with four school-aged
children. The client is diagnosed with severely disabling migraine headaches.
Which of the following instructions by the nurse is MOST appropriate?
1. “Hire someone to help with your
children.”
2. “Report excessive menstrual
flow.”
3. “Avoid stressful situations.”
4. “Go to bed at the same time every

night.”

question.
1) may or may not be feasible for client; requires further assessment before
making this suggestion
2) fluctuating estrogen levels have been related to migraine headaches, but the
amount of flow does not appear to be related
3) triggers include eating chocolate or cheese, drinking coffee, and going for long
periods of time between meals
4) CORRECT— fatigue is a trigger
In early October, a home health nurse makes a home visit to an older client
diagnosed with cataracts who is scheduled to have cataract removal with a lens
implant in mid-November. Which of the following recommendations by the nurse
is MOST important?
1. “Notify a trusted neighbor that you will be gone overnight.”
2. “Get a flu shot as soon as possible”
3. “Read this information about surgical removal of

cataracts.”
4. “Check with your insurance company regarding co-
payment and services.”

1) usually performed on an outpatient basis, with discharge usually 2 hours after
surgery
2) CORRECT— flu can cause client to sneeze, cough, or blow nose, which would
increase intraocular pressure; flu shot helps prevent occurrence of flu
3) promoting wellness takes priority
4) is important; but client’s physical well-being takes priority
A patient is to be discharged after a right total hip replacement. Which of the

following statements, if made by the patient to the nurse, indicates that teaching
has been effective?
1. “I can’t sit in my favorite recliner with my legs up.”
2. “I should ask my wife to put on my socks and shoes.”
3. “I should clean the incision with a mixture of hydrogen peroxide and

water before applying a sterile dressing.”
4. “I don’t need to continue to do the leg exercises I learned in the
hospital.”
Strategy: Thank about what the patient’s words mean.

1) can sit in recliner as long as hip flexion is less than 45 to 60°; avoid stooping;
do not sleep on operative side until directed to do so
2) CORRECT— this self-care activity would cause hip flexion greater than 40 to
60°, might cause dislocation of hip; maintain abduction; do not cross legs
3) not needed, should use soap and water
4) should continue to do exercises
The mother of an 8-month-old boy is concerned because her son has started to
scream and refuses to eat when left with the child-care provider. Which of the
1. “Start looking for a different child-care provider.”
2. “Check your son for bruises and other injuries.”
3. “Remember that this is just a phase your son is

going through.”
4. “Hand your child his blanket as you say goodbye.”
Strategy: Determine outcome of each answer. Is it desired?

1) separation anxiety indicates normal development; fear of strangers begins at 7
months, peaks at 8 months
2) no indication of abuse; normal development
3) is normal growth and development, question asks for best response; phases–
protests, cries/screams for parents and is inconsolable by others; despair, cry
ends but is less active, not interested in food or play; denial, appears adjusted,
appears interested in environment, ignores parents when they return
4) CORRECT— exhibiting separation anxiety; reassure child by offering favorite
blanket or toy, talk to infant when leaving the room, and allow infant to hear
parent’s voice on telephone
The mother of a 4-year-old tells the nurse she is worried because her daughter
has begun to stutter. The mother asks the nurse what actions can be taken to
stop the stuttering. Which of the following responses by the nurse is BEST?
1. “What has been happening in your child’s life?”
2. “Reward your child when she speaks fluently.”
3. “Instruct your child to start over and speak more

slowly.”
4. “Slow down your own speech and talk to your
daughter calmly.”

1) implies that something is wrong; broken fluency is a normal occurrence in
preschoolers
2) because it is normal behavior, there is no reason to offer reward
3) will make child conscious of speech and increase the stuttering
4) CORRECT— does not call attention to the child’s speech pattern and does
gives the child time and space to respond; secondary stuttering is a normal
phase of language development
While sitting at the front desk completing an assessment sheet, a new graduate
nurse asks the nursing assistant to perform a finger stick blood sugar for the
assigned client. The nursing assistant responds, “Why can’t you do it?” Which of
1. “Please page me when you have completed
the task.”
2. “It is important that the blood sugar be
completed now.”
3. “Why did you ask that?”
4. “If you don’t have time, I will ask someone

else to do it.”

1) CORRECT— performing a finger stick is within the scope of practice of the
nursing assistant and the task should be carried out as delegated
2) nurse not required to explain assignment
3) nontherapeutic; leads to further discussion, which is not appropriate
4) example of reverse delegation, lower person on hierarchy delegates to person
higher on the hierarchy
The nurse cares for clients on the neurological unit. After receiving report, which
of the following clients should the nurse see FIRST?
1. A client who is non-responsive with intermittent limb
movement.
2. A client whose muscle tone of all four limbs is flaccid.
3. The client who is non-responsive but follows the staff
with his eyes.
4. The client who immediately withdrawals from painful
stimuli.

1) limb movement indicates brain injury is not severe
2) CORRECT— flaccidity most indicative of serious irreversible impairment
3) tracking with the eyes indicates client less impaired than client with flaccid
muscles
4) indicates a higher level of consciousness, according to Glasgow Coma Scale
The home care nurse visits a client receiving levothyroxine (Synthroid) 75 mcg
OD. The client tells the nurse that he has been experiencing insomnia the last
couple of weeks. Which of the following responses by the nurse is MOST
appropriate?
1. “The physician may have to decrease the dose of
medication.”
2. “Tell me about your bedtime routine.”
3. “When do you take the medication?”
4. “Take a warm bath before going to bed.”
Strategy: “MOST appropriate” indicates discrimination may be required to

answer the question.
1) should assess before implementing
2) assessment; more important to determine when client is taking the medication
3) CORRECT— should take medication before breakfast to prevent insomnia
4) assumes that medication is not the cause of the insomnia
The nurse cares for a client diagnosed with hypertension and type 1 diabetes
mellitus. The client complains to the nurse that the physician wants the client to
discontinue taking verapamil (Calan) 80 mg PO tid and begin taking captopril
(Capoten) 50 mg PO tid. The client states, “It took a long time to find a medication
that controls my blood pressure with minimal side effects, and I do not want to
go through that again.” Which of the following responses by the nurse is BEST?
1. “How many different antihypertensives did you try?”
2. “Captopril is the best drug for preventing or slowing down the
destruction of your kidneys.”
3. “Your physician is a specialist in this area and feels you need to
change.”
4. “Why not give it a try?”

1) focus on the here and now; not relevant how many different drugs the client
tried
2) CORRECT— Capoten dilates the efferent arterioles, resulting in lowering the
glomerular pressure; verapamil dilates the afferent arterioles, increasing the
pressure
3) does not give the client a reason why the physician wants to change the
medication
4) answer does not give the client any information
The nurse cares for client diagnosed in stage I chronic renal failure. During the
nursing assessment, the nurse expects the client to state which of the following?
1. “I don’t seem to urinate as much as I used
to.”
2. “I seem to have more swelling in my feet
and ankles.”
3. “I urinate more at night.”
4. “The doctor told me I need dialysis.”
Strategy: Think about what the client’s words mean.

1) oliguria occurs during stage II (renal insufficiency)
2) occurs during stage II
3) CORRECT— stage I is diminished renal reserve; renal function is reduced but
healthier kidney is able to compensate; since kidney not as able to concentrate
urine, client has polyuria and nocturia
4) required in stage III (end-stage renal disease)

old. The child’s mother tells the nurse that she is very excited because her
mother is visiting. The grandmother rarely visits, and the child’s mother is
pleased that grandmother and grandchild will spend time together. Which of the
following responses by the nurse is MOST important?
1. “Your toddler may be fearful when left alone with her
grandmother.”
2. “How long is your mother staying?”
3. “Does your mother take any medication?”
4. “I’m sure your mother will enjoy her grandchild.”

1) toddlers display less fear of strangers as long as parents are present; when
left alone, the toddler may be fearful or anxious; appropriate information for the
nurse to relate to the mother; psychosocial need
2) not the most important question
3) CORRECT— because toddlers explore by putting things in their mouths,
parents should be aware of all potentially toxic substances in the home; parents
should be aware if visitors in the home are taking medication, which should not
be left in purses or suitcases lying around
4) safety takes priority
gun.
resentment.

out threat
contractions.
discharge.
contractions.


route 25 victims.

overtime.



weeks.”

depression
mouth
3) true statement
may result in death

patient
patient
The nurse instructs a mother of a child diagnosed with a myelomeningocele who

developed an allergy to latex. The nurse determines that teaching is effective if
the mother selects which of the following menus for her child?
1. Guacamole with pita bread, lettuce, tomato
juice.
2. Poached halibut, brown rice, carrots, peach
cobbler.
3. Scrambled eggs, whole wheat toast, grapes,
skim milk.
4. Baked chicken leg, mashed potatoes, spinach,
milkshake.

1) if a person has a latex allergy, there is cross-reaction to tomatoes and
avocados
2) peach is a cross-reactive food with latex
3) grapes are cross-reactive with latex
4) CORRECT— this meal does not have any cross-reactive foods with latex;
foods to avoid include apricots, cherries, grapes, kiwis, passion fruit, bananas,
avocados, chestnuts, tomatoes, and peaches
following children?

lost their home.
America.
for tuberculosis.

bleeding.
30°.

will be given

report.”
problem out.”

emotions are high

pressure.
sounds.

question.
water
every 30 minutes.


prothrombin levels.

therapist.
department.
menus.
patients her age.

to the sting.”
the site.”

mucosa.
2. Hearing loss.


and antipyretics.



ambulating.


severe flank pain.
toe.

shock and syncope
client’s symptoms
chemotherapy.”
chemotherapy.”

responsibility
intake.”
movement?”

walk around
patients?
discharge.
chest pain.

teaching




uncomfortable.”

failure
room unit.
antacids.

hours ago.
and vomiting.
14 mg/dL.


affected eye.
hours.

4) do not irrigate
1. Volleyball.
2. Painting.
3. Walking.
4. Dancing.

subsides


competency?”

question.
concerns
actions?

30 kcal/oz.
expansion

reading.”
test.”


following rooms?
fracture.
shunt revision.

2) requires a private room; do not place a client with an infection in a room with
a client who does not have an infection
4) due to severe nature of the symptoms requiring hospitalization, infant
requires close observation for changes in condition


moving in bed.

3) Valsalva maneuver increases workload on heart; to prevent, teach
immobilized patients about exhaling when moving about in bed; should first
assess patient complaints
increased workload
The nurse cares for a client at term in labor. The client’s blood pressure is
182/88 and fetal heart rate (FHR) is 132–134 with minimal beat-to-beat variability.
Her bloody show is dark red and there is more bleeding than anticipated. Her
abdomen is firm between contractions and she complains of back pain. The
nurse understands that the client is at risk for which of the following?
1. Placenta previa.
2. Abruptio
placenta.
3. Miscarriage.
4. Imminent
delivery.

1) placenta is implanted near or over the cervical os; symptoms include
painless, sudden, profuse bleeding in third trimester
2) CORRECT— premature separation of placenta; painful vaginal bleeding,
abdomen is tender, painful, tense, possible fetal distress; prepare for immediate
delivery
3) occurs before 20–24 weeks of pregnancy; indications are persistent uterine
bleeding and cramp-like pain
4) symptoms are classic signs of abruption
not acceptable.

water.

environment
control
cefaclor (Ceclor).
(Questran).
(Indocin).

room.”
immediately.”
you see.”

reduce stress
needed
The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two
days after admission, the client begins complaining of severe nausea. Which of
1. Determine the client’s most recent fasting serum
glucose level.
2. Perform a comprehensive client assessment.
3. Ask the client if she is pregnant.
4. Administer an antiemetic.

1) no relationship between diabetes and nausea; last glucose reading does not
give the nurse information about client’s current condition
2) CORRECT— nausea not usually associated with diabetes; assess before
implementing
3) nurse is making assumptions based on client’s age; should perform a
comprehensive assessment
A new registered nurse asks the assigned nurse mentor to check on 4 clients
who are receiving oxygen therapy. It is MOST important for the nurse mentor to
ask the nurse which of the following questions?
1. “Which client should I see first?”
2. “Have you completed your assessment?”
3. “What are your specific concerns?”
4. “Don’t you think you should be able to care for

the clients?”

the question.
1) nurse mentor should find out about the nurse’s specific concerns
2) yes/no question; doesn’t allow nurse mentor to assess the nurse’s needs
3) CORRECT— clarifies the nurse’s concerns and will help the new nurse become
a safe practitioner
4) yes/no question; nontherapeutic; does not allow nurse mentor to assess new
nurse’s concerns
The nurse cares for a client receiving chlordiazepoxide (Librium). It is MOST

important for the nurse to observe for which of the following?
1. Skeletal muscle spasms and
insomnia.
2. Anorexia and dry mouth.
3. Diarrhea and euphoria.
4. Drowsiness and confusion.

1) dystonia is side effect of antipsychotics; insomnia caused by SSRIs
2) Ritalin causes anorexia; dry mouth is side effect of tricyclic antidepressants
3) not caused by Librium
4) CORRECT— antianxiety and sedative/hypnotic used to treat anxiety and
alcohol withdrawal; causes drowsiness and sedation; use caution when driving
or operating equipment; confusion may indicate immediate n
Following the administration of meperidine HCl (Demerol) for an adult client, the
nurse expects which of the following?
1. The client states that he feels
better.
2. The client is talking with visitors.
3. The client appears to be physically

relaxed.
4. The client is no longer crying or
moaning.
Strategy: Think about how each answer relates to pain.

1) client may express pain relief, but in reality may still be experiencing pain
2) client may still be in pain
3) CORRECT— nonverbal cues are the best indication of pain relief
4) not best indication of relief of pain
After being admitted for management of a cervical spine injury, a client in a

rehabilitation center reports a severe headache. Which of the following actions
1. Check for analgesia on physician’s
order sheet.
2. Ask the client to rank the pain from 1
to 10.
3. Ask the client if he is worried about
something.

1) more assessment required
2) cervical spine injury and severe headache should clue nurse that client is
possibly in imminent danger
3) assess for physical causes before psychosocial causes
4) CORRECT— pounding headache and profuse sweating are indications of
autonomic hyperreflexia; place in a sitting position
1. A client newly diagnosed with type 1 diabetes who had a myocardial
infarction 2 days ago.
2. A client diagnosed with right-sided heart failure and glaucoma.
3. A client diagnosed with chronic obstructive pulmonary disease and

psoriasis.
4. A client diagnosed with rheumatoid arthritis and malnutrition.

1) CORRECT— both diseases are in the dynamic phase and require close
monitoring; most unstable client
2) client should be seen second
3) two chronic illnesses
4) client more stable than #1
The nurse cares for a 4–year–old on the pediatric unit. The child is unable to go
to sleep while in the hospital. It is MOST important for the nurse to take which of
the following actions?
1. Turn out the light and close the door.
2. Encourage the child to exercise during

the evening.
3. Identify the child’s home bedtime ritual.
4. Ask the child’s siblings to visit during the

evening.

1) will increase the child’s fears; preschoolers fear injury, mutilation, and
punishment
2) will not promote sleep
3) CORRECT— preschoolers require bedtime rituals that should be followed in
hospital; nurse should assess before implementing
4) will be comforting to child, but to promote sleep it is more important to
determine bedtime routine
The nurse prepares an elderly client newly diagnosed with type 1 diabetes for
discharge. The client is alert and oriented and lives alone in her home. It is MOST
important for the nurse to assess for which of the following?
1. Client’s vision and manual dexterity.
2. Client’s understanding of diabetes.
3. Client’s need for visits from the home care

nurse.
4. Client’s ability to perform blood glucose
monitoring.

question.
1) CORRECT— client must have the visual acuity and manual dexterity to draw
up and administer insulin
2) it is important that the client understands diabetes, but priority is assessing
client’s ability to manage insulin administration
3) may be necessary
4) important, but first assess the client’s vision and manual dexterity
The nurse evaluates care for a client who demonstrates manipulative behavior.
The nurse should intervene if which of the following is observed?
1. The staff discusses with the client the consequences of his
manipulative behavior.
2. The staff establishes limits on the client’s manipulative behavior.
3. The staff clarifies the consequences of the client’s manipulative

behavior.
4. The staff decreases the demands on the client.

1) appropriate that the staff help to client learn to see the consequences of his
behavior
2) appropriate; staff should communicate clearly defined expectations and carry
out limit-setting
3) appropriate behavior
4) CORRECT— fosters a sense of entitlement

old. The child’s mother tells the nurse that she is earning extra money by
growing houseplants in her home. Which of the following responses by the nurse
is MOST appropriate?
1. “How did you get into that
business?”
2. “What a great opportunity.”
3. “You should not have plants in

your home.”
4. “Where do you keep the plants?”

question.
1) encourages the mother to talk about her interests but does not address safety
issue of toddler
2) closed response; does not give client opportunity to respond
3) not all plants are toxic; nurse is expressing an opinion without completing the
assessment
4) CORRECT— toddlers explore by putting things in their mouth; all potentially
toxic agents should be placed out of reach of the toddler; nurse should assess
the type of plants in the home and the location of the plants
The nurse performs discharge teaching for a client diagnosed with

gastroesophageal reflux disease (GERD). The nurse determines that teaching is
successful if the client selects which of the following menus?
1. Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello,
and cola.
2. Cheddar cheese omelet, spinach salad, chocolate brownie, and milk.
3. Broiled chicken, cream of broccoli soup, rice pudding, and apple juice.
4. Baked salmon with lemon butter, baked potato, mint chocolate chip ice
cream, and lemonade.

1) oil dressing high in fat, tomato exacerbates GERD, as do carbonated
beverages
2) fatty foods and chocolate exacerbate GERD
3) CORRECT— menu low in fat and contains non-acidic foods
4) lemonade and mint exacerbate GERD

her left side.

chair for support
during transfer

her left side.

chair for support
during transfer

her left side.

chair for support
during transfer

her left side.

chair for support
during transfer

her left side.

chair for support
during transfer
A 16-year-old girl is brought to the emergency room by her parents for evaluation
of an eating disorder. When the nurse approaches the client to draw a blood
sample, the client cries out, “I hate having my blood drawn. Go away!” Which of
1. “What’s the matter? Are you afraid of what we are
going to find?”
2. “What is it about having your blood drawn that
upsets you?”
3. “Take a deep breath. It will be over before you know
it.”
4. “I’ll be back in 15 minutes so we can discuss your
concern.”

1) yes/no question; nurse is making an assumption
2) CORRECT— open-ended; relates to client’s verbal and nonverbal
communication and responds to the client’s feelings
3) “don’t worry” response; nontherapeutic
4) do not leave the client alone
The nurse cares for clients in the prenatal clinic. A client comes to the clinic for a
prenatal visit on June 6. Her last menstrual period was December 10. The nurse
expects the client’s fundal height to measure
1. 24 cm.
2. 26 cm.
3. 28 cm.
4. 30 cm.

1) incorrect, determine EDC based on N ä gele’s rule–date LMP Dec. 10; EDB–
Sept. 17; client is 26 weeks pregnant; from 24–34 weeks, fundal height correlates
well with weeks of gestation; 24 cm is approximately 24 weeks’ gestation
2) CORRECT— client is 26 weeks pregnant; fundal height should correlate with
weeks of pregnancy
Recently several staff members on the unit have complained of back strain. The
nurse determines that the staff is not consistently using correct body mechanics
when transferring patients. Which of the following suggestions should the nurse
make FIRST?
1. “Encourage your patients to assist as much
as possible.”
2. “Use your arms and legs when moving a
client.”
3. “Determine if help is required to transfer a
patient.”
4. “Position yourself close to the patient.”

1) decreases the nurse’s workload and promotes client strength and
independence
2) appropriate action; use the larger muscles of the body and not the back; don’t
twist spine
3) CORRECT— first step is to assess; determine the weight to be transferred and
if help (other staff members, mechanical devices) is required and available
4) minimizes the force felt by the nurse; always keep weight to be lifted close to
the body
A client is receiving packed red blood cells. Several minutes after the infusion is
started, the client complains of nausea and low back pain. It is MOST important
1. Obtain a urine specimen.
2. Start an IV of D 5 W.
3. Discard the blood container in a biohazard

container.
4. Decrease the rate of the transfusion.

1) CORRECT— should be sent to lab for hemoglobin determination; symptoms of
hemolytic reaction include nausea, vomiting, pain in lower back, hypotension,
increase in pulse rate, decrease in urinary output, hematuria
2) should restart normal saline; stop the blood, supportive care: oxygen,
Benadryl, airway management
3) container should be returned to lab
4) should be discontinued due to hemolytic reaction; draw blood sample for
plasma, hemoglobin culture, and retyping
A 75-year-old client is brought by his wife to the outpatient clinic. The nurse
notes that the client has a 10-year history of chronic renal failure and has been
taking cimetidine (Tagamet) for two weeks. It is MOST important for the nurse to
investigate which of the following statements made by the client’s wife?
1. My husband has been complaining that his bowel movements
are hard to pass.
2. My husband takes his Tagamet just before he eats his meals.
3. My husband seems to be having more trouble with his memory

lately.
4. My husband sometimes has a headache after reading the
newspaper.
Strategy: “MOST important to investigate” indicates an adverse reaction.

1) Tagamet decreases gastric secretion by inhibiting the actions of histamine at
the H 2 -receptor site; constipation is a common side effect of this medication;
should increase fiber in diet; not most important
2) Tagamet should be taken with meals and at bedtime
3) CORRECT— elderly clients and clients with renal problems are most
susceptible to CNS side effects (confusion, dizziness) of the medication; dosage
may need to be reduced
4) headache may be side effect of medication, or may be caused by need to
change glasses; not most important
The nurse cares for an older woman with frequent bladder incontinence following
a cerebrovascular accident (CVA). Which of the following actions by the nurse is
MOST appropriate?
1. Perform intermittent catheterizations using sterile technique
2. Teach the patient how to perform Valsalva maneuver.
3. Instruct the patient how to perform the Cred é maneuver.
4. Toilet the patient when she awakens in the morning and before
and after meals.

1) only used for problems with retention
2) straining and bearing down on the abdominal muscles alters the heart rate; will
not prevent incontinence
3) used to initiate urination when there is retention; place a cupped hand over the
bladder and push inward and downward
4) CORRECT— will establish a regular toileting routine
An older man is returned to his hospital room three hours after a transurethral
resection of the prostate (TURP). The patient has a continuous bladder irrigation
(CBI). Which of the following observations, if made by the nurse, requires an
intervention?
1. The patient is in bed with his legs drawn up to
his abdomen.
2. There is 500 cc fluid in the urinary drainage bag.
3. There is 350 cc of reddish urine in the drainage

bag.
4. The head of the patient’s bed is elevated 45
degrees.
Strategy: “Requires an intervention” indicates a potential complication.
1) CORRECT— indicates pain; also, catheter is taped to thigh, and leg should be
kept straight to maintain traction on the catheter
2) expected due to the CBI; assess for shock and hemorrhage; check dressing
and drainage; urine may be bright red for 12 h; monitor vital signs
3) expected drainage soon after surgery; CBI contains isotonic fluid used to keep
the catheter patent
4) no restriction on positioning as long as leg that has catheter taped to it is
straight
The nurse on the medical/surgical floor receives four new admissions. Which of
the following clients should be placed in a private room?
1. A client with a draining abdominal abscess covered
with a dressing.
2. A client diagnosed with influenza.
3. A client diagnosed with cancer who appears septic.
4. A client with diverticulitis complaining of abdominal

pain.

1) standard precautions required as long as the abscess is covered with a
dressing and the dressing contains the drainage
2) CORRECT— requires droplet precautions; place in private room or with
patients with the same infection; maintain spatial separation of at least 3 feet;
door can remain open
3) microorganisms have entered the bloodstream due to impaired immune
function; standard precautions; assess for s/s shock
The nurse performs a prenatal assessment on a client at 20 weeks’ gestation.

Identify the location where the nurse expects to palpate the client’s fundus.
Strategy: Recall the fundal height at 20 weeks.

The correct answer: at the level of the umbilicus.
10 to 12 weeks — fundus slightly above symphysis pubis
16 weeks — fundus halfway between symphysis pubis and umbilicus
20 to 22 weeks — fundus at the level of the umbilicus
28 weeks — fundus three fingerbreadths above the umbilicus
36 weeks — fundus just below ensiform cartilage
The home care nurse visits a client diagnosed with progressive systemic
sclerosis. The client complains that she is having more trouble swallowing and
moving her right hand. Which of the following responses by the nurse is MOST
important?
1. “This must be a difficult time for you.”
2. “You should schedule an appointment with your health

care provider.”
3. “Can you tolerate pressure on your hand?”
4. “Tell me more about the problems you are having

swallowing.”

1) it is important to allow client to verbalize feelings, but physical needs take
priority
2) may be required, but nurse should complete assessment
3) appropriate assessment for Raynaud phenomenon; eating problems take
priority
4) CORRECT— progressive systemic sclerosis is a connective tissue disease
that causes dysphagia and esophageal reflux because of decreased motility;
nurse should assess before determining the appropriate imp
A terminally ill client with excruciating pain episodes complains the pain
medication given at night does not relieve the pain as well as it does during the
day. A chart review reveals that clients report pain medication being less
effective, and the clients receive more medication when a particular nurse is
working. Which of the following actions should the nurse take FIRST?
1. Set up a hidden camera in the medication room.
2. Ask physician to consider increasing the dosage of

medication at night.
3. Determine how long the client has been receiving the
medication.
4. Temporarily assign another nurse to give all of the PRN
medications.
1) priority is caring for the client in pain
2) clients complaining of pain is an indication that there may be a problem with
one of the nurses
3) assumes that client is experiencing a tolerance to the medication
4) CORRECT— primary focus is client comfort; validation of the nurse having a
substance abuse problem does not override quality client care
The nurse cares for a patient hospitalized for a head injury. The client is receiving
0.9% sodium chloride at 100 cc/h and has an indwelling Foley catheter in place.
The nurse notes the patient’s urinary output is 1,000 cc in 3 hours. Which of the
2. Decrease the amount of fluids the patient is

receiving.
3. Assess the client’s mucous membranes.
4. Measure the urine specific gravity.
Strategy: Determine if assessment or implementation is appropriate.

1) complete the assessment before contacting the physician; symptoms of
diabetes insipidus include excessive urine output, severe dehydration, excessive
thirst, anorexia, weight loss
2) ADH deficiency causes the excretion of large volumes of dilute urine; if
deprived of fluids, may cause shock
3) may see signs of dehydration, such as poor skin turgor and dry or cracked
mucous membranes
4) CORRECT— low specific gravity (1.001 and 1.005) is characteristic of diabetes
insipidus; head injury causes interference with production or release of ADH;
record I and O, urine specific gravity, and daily weight; ensure client’s intake of
fluid and administer DDAVP
The nurse cares for a patient with chest tubes. Two days after insertion, the chest
tube is accidentally pulled out of the pleural space. Which of the following
1. Don sterile gloves and replace the tube.
2. Apply pressure with a dressing that is tented

on one side.
3. Instruct the client to cough and deep–breathe.
4. Auscultate the lung.

1) inserting the tube is a medical procedure
2) CORRECT— decreases chance that atmospheric air will enter pleural space
and allows for escape of pleural air
3) increases the amount of atmospheric air that enters the pleural space
4) priority is covering the opening; listen to lungs after emergency measure
instituted
A tornado roared through a populated area, causing multiple casualties. Which of

the following patients should the nurse see FIRST?
1. A patient with a small penetrating abdominal wound caused by
flying debris.
2. A patient with blunt trauma to the abdomen that caused
bruising.
3. A patient complaining of chest pain with asymmetrical chest
movement noted.
4. A patient who is confused and restless with no visible injuries.

1) may cause bleeding; injury does not appear to be life-threatening
2) second patient that should be seen; observe for ecchymosis, which indicates
retroperitoneal bleeding into the abdominal wall
3) CORRECT— indicates flail; monitor for shock, give humidified oxygen, manage
pain, monitor ABGs
4) appears most stable
A man hospitalized for alcohol abuse comes to the nurses’ station and asks the
nurse if he can go to the cafeteria to get something to eat. When told that his
privileges do not include visiting the cafeteria, the patient becomes verbally
abusive. Which of the following actions by the nurse is MOST appropriate?
1. Tell the patient to lower his voice.
2. Ask the patient what he wants from the cafeteria.
3. Calmly but firmly escort the patient to his room.
4. Assign a nursing attendant to accompany the patient to

the cafeteria.

1) do not argue; carry out limit-setting
2) reinforces inappropriate behavior
3) CORRECT— limit-setting, ensures safety; patient with substance abuse needs
consistent, undivided staff approach, clearly defined expectations, as well as
limit-setting; avoid threats and promises
4) reinforces abusive behavior
The nurse prepares a client for a skin biopsy. Which of the following statements,
if made by the client, should the nurse report to the physician?
1. “I have been taking aspirin for my aching
joints.”
2. “I applied lotion to my skin after my shower
last night.”
3. “I laid out in the sun yesterday.”
4. “I had coffee and a sweet roll for breakfast

this morning.”

1) CORRECT— aspirin can increase the risk for bleeding and should be reported
2) does not affect the biopsy
3) not a good health habit, but it does not affect the biopsy
4) a punch or shave biopsy is usually performed on the skin and does not require
NPO; clean biopsy site once a day with tap water or saline; leave site open
The nurse counsels a client diagnosed with degenerative joint disease. It is

1. “Place your joints in the position of
comfort.”
2. “Place your joints in a flexed
position.”
3. “Place your joints in full extension.”
4. “Place your joints in their functional

position.”

1) may lead to limitations in movement; place in functional position
2) would cause flexion contractures that limit mobility; only use a small pillow
under the head or neck; do not use large pillows under the knees; to reduce back
discomfort, elevate legs 8–10 inches
3) should be placed in correct functional position to maintain mobility of joint
4) CORRECT— maintains mobility of joints
The nurse is making staff assignments on the medical/surgical unit. The nurse
should assign a nursing assistant to care for which of the following clients?
1. A client diagnosed with a CVA 2 weeks ago requiring assistance
ambulating.
2. A client diagnosed with COPD who is in acute distress requiring
assistance bathing.
3. A client receiving total parenteral nutrition through a PICC line
requiring a dressing change.
4. A client diagnosed with type 1 diabetes on mechanical ventilation
requiring a bath.
Strategy: Assign the nursing assistant to stable clients with standard,

unchanging procedures
1) CORRECT— stable patient requiring a standard, unchanging procedure;
instruct nursing assistant about the how far to walk the client and any untoward
occurrences to report
2) client requires assessment; not appropriate for the nursing assistant
The home care nurse visits a client receiving warfarin (Coumadin) 5 mg PO daily
for DVT. The nurse learns the client operates a horse ranch. It is MOST important
1. Ride with a companion and wear an identification
bracelet.
2. Carry a cell phone and dressings and tape.
3. Provide significant others with a written itinerary
for the day.
4. Temporarily change to activities that are safer for
client

question
1) riding with a companion is helpful but does not specifically reduce the risks;
should wear an Medic Alert bracelet
2) CORRECT— because of occupation and prescribed anticoagulant, client is at
risk for tissue damage; in case of injury, apply pressure to wound and summon
help
3) others knowing potential location is relevant but does not reduce risks
4) taking the medication is long-term; nurse should help client integrate
appropriate interventions into lifestyle
The nurse cares for clients in the outpatient clinic. A client with a pacemaker
calls to report that he just had an episode of dizziness and shortness of breath.
Which of the following responses by the nurse is MOST important?
1. “What is your pulse?”
2. “What were you doing before the

episode?”
3. “Have you experienced this before?”
4. “Is the area over the pacemaker painful

or red?”

1) CORRECT— may indicate pacemaker malfunction; nurse should assess
client’s current status
2) assess if client was close to electromagnetic field that might interfere with
function of pacemaker; more important to assess current status
3) should be asked later in conversation
4) may indicate infection; more important to assess cardiac functioning
A client is admitted to the labor and unit in a sickle-cell crisis. Which of the
following nursing actions should the nurse take FIRST?
2. Turn client to right side.
3. Begin an IV with normal

saline.
4. Administer antibiotics.

1) second action; crisis caused by extensive extracellular sickling
2) no reason to turn to right side; do not keep knees and hips in a flexed position
3) CORRECT— dehydration perpetuates cell sickling; intake should be at least
200 cc/hour
4) more susceptible to blood-borne pathogens; frequent handwashing; avoid
people with URI
The nurse cares for a laboring patient. The patient requests something for pain
and says to the nurse, “I’m really scared of shots.” Which of the following
1. “A shot is your only option, because labor slows the
GI tract.”
2. “I can give you a pill now, but it will not last as long as
an injection.”
3. “What was your previous experience with shots?”
4. “What are you afraid of?”

1) is an accurate response but does not allow the client to express her feelings
2) oral medication is not recommended in labor because of the decrease in GI
motility
3) CORRECT— an assessment to assist the nurse in gathering information
toward achieving pain relief and to this particular client’s psychological state;
assess before intervening
4) judgmental and nontherapeutic
The nurse on the medical/surgical unit admits an elderly client after the patient
has undergone a below-the-knee amputation. The nurse obtains vitals signs and
assesses that the client is able to be aroused but is sleepy. When the client
awakens and realizes that the amputation was performed, the client begins to
scream. Which of the following statements by the nurse is MOST appropriate?
1. “The physician informed you that the amputation
was required.”
2. “I’ll get you some medication so that you can rest.”
3. “Your family is waiting in the lobby to come see

you.”
4. “Since you seem upset, I’ll stay with you.”

question
1) first step of readjustment of changed body image is psychological shock;
client will not be receptive to receiving information
2) more important for the nurse to stay with the client
3) passing the buck; nurse should care for client
4) CORRECT— acknowledges client’s feelings; nurse should stay with patient,
focus on here and now, and deal with client’s immediate problems
The nurse determines that which of the following clients is MOST at risk to
develop gastroesophageal reflux disease (GERD)?
1. A 16-year-old African American male who had an NG tube for 3 days
after surgery for a ruptured appendix.
2. A 30-year-old Hispanic female with a diagnosis of cholelithiasis and a t-
tube in place.
3. A 52-year-old Caucasian female who is 5’5" tall and weighs 185
pounds.
4. A 65-year-old Caucasian male with a laryngectomy for laryngeal
cancer.

1) NG tube is a risk factor; NG tube compromises esophageal sphincter function
and permits acidic stomach contents to enter the esophagus
2) being female is a risk factor for GERD
3) CORRECT— GERD is gastrointestinal contents flowing backward into the
esophagus; risk factors include female, over the age of 45, and obesity; GERD
appears more often in Caucasians
4) risk factors include age and ethnicity; smoking is also a risk factor for GERD
The nurse cares for clients in the emergency department after an earthquake.
Which of the following clients should the nurse see FIRST?
1. A client at 7 months’ gestation complaining of cramping and blood-
streaked discharge.
2. A client with a displaced fracture of the right radius with blood seeping
from the wound.
3. A client complaining of lightheadedness; nurse notes client is clammy,
pulse 112, respirations 28.
4. A client with type 1 diabetes who took insulin immediately before the
earthquake and is complaining of lightheadedness.

1) may be in early labor, stable patient
2) illnesses that can wait up to 2 hours are considered urgent
3) CORRECT— client appears to be developing shock; most unstable client
4) lightheadedness probably due to hypoglycemia; more stable than client in
shock
The nurse on the medical unit is called to the room of an elderly client. The nurse
finds the client sitting up in bed complaining of pressure in his chest and pain in
his jaw. Vital signs are: BP 160/94, P 112, R 20, T 99.5°F (38°C). The client has a
history of hypertension and is receiving IV antibiotics for a diagnosis of
pneumonia. Which of the following actions should the nurse take FIRST?
1. Administer oxygen at 4 L/min via nasal canula.
2. Place the client on a cardiac monitor and obtain a

12-lead ECG.
3. Obtain blood for CK-MB, troponin, and myoglobin
levels.
4. Assess patency of the client’s IV line.
Strategy: Remember the ABCs.

1) CORRECT— implementation; ABCs take priority; exhibiting signs of acute
coronary syndrome (ACS) which may be unstable angina, myocardial ischemia or
infarction
2) assessment; should be completed after oxygen administration; provides data
for physician to determine required treatment
3) assessment; third action, elevations are indicative of MI; do not wait for lab
results before beginning treatment
4) assessment; ensure route for IV medication such as nitroglycerin, morphine,
fibrinolytic, and heparin
The nurse administers meperidine (Demerol) 75 mg IM to a postoperative patient.

Thirty minutes later, it is MOST important for the nurse to take which of the
following actions?
1. Reposition the patient.
2. Elevate the patient’s head and place a pillow under

the shoulders.
3. Observe the patient for restlessness and distress.

1) will promote comfort; other interventions include cool, well–ventilated, quiet
room and a back rub
2) will promote comfort
3) CORRECT— nurse should evaluate the actual outcomes; if medication
ineffective, will also see inability to concentrate and apprehension
4) more important to allow client to rest
The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It
is MOST important for the nurse to clarify which of the following orders by the
physician?
1. Furosemide (Lasix) 20 mg IV every
12 hours.
2. 2 g/day sodium diet
3. Normal saline at 125 ml/hour IV.
4. Oxygen at 2 L per nasal cannula.
Strategy: “Clarify an order” indicates an order that may harm the patient
1) appropriate order; loop diuretic that promotes the excretion of excess water;
decreases blood volume and pressure in the left ventricle
2) appropriate order; because extracellular fluid is primarily regulated by sodium,
a low-sodium diet may decrease excess water
3) CORRECT— because the patient may have excess fluid volume, may be on
fluid volume restriction; weigh daily and measure I and O
4) appropriate order; may have impaired gas exchange and develop hypoxemia
depending on the severity of heart failure
The nurse performs an assessment for a client diagnosed with bilateral cataracts.
To determine the amount of visual impairment experienced by the client, which of
the following questions by the nurse is BEST?
1. “Would you please identify what you can see
clearly?”
2. “How have your visual abilities changed?”
3. “When did you first notice that your vision had

changed?”
4. “Would you please tell me what you have
difficulty seeing?”

1) cataracts are partial or total opacity of the normally transparent crystalline lens
and cause objects to appear distorted and blurred; nurse unable to estimate loss
of vision with this question
2) question is too broad and difficult to understand
3) does not determine the client’s current vision
4) CORRECT— this question helps the nurse determine client’s current loss of
vision
The nurse performs dietary teaching with a client who has hepatitis B. Which of
the following menus, if selected by the client, is BEST?
1. Hamburger, french fries, a dill pickle, and malted
milk.
2. Lean roast beef, baked potato, green beans, and
coffee.
3. Bacon, eggs, toast with butter, and milk.
4. Biscuits with sausage, gravy, and buttered grits, and

orange juice.

1) high-fat foods; encourage fruits, vegetables, cereals, lean meat
2) CORRECT— high-carbohydrate, low-fat
3) high-fat foods; not allowed: marbled meats, avocados, milk, bacon, egg yolks,
and butter
4) high-fat foods
The nurse assesses a client diagnosed with paranoid schizophrenia. Which of the
following assessments indicates to the nurse that the client may need assistance
with self-care activities?
1. The client speaks in a low monotone voice.
2. The client had suicidal ideation on two previous

admissions.
3. The client is fearful that poison is being placed
in his food.
4. The client is unable to maintain eye contact with
the nurse.

1) may appear guarded, intense, and reserved; may adopt a superior, hostile, and
sarcastic attitude; will have no bearing on self-care activities
2) may indicate depression
3) CORRECT— paranoia is an irrational suspicion; cannot be changed by
experience or reality; may prevent client from eating; provide food in closed
containers to prevent the suspicion of tampering
4) indicates a negative symptom of schizophrenia and contributes to poor social
functioning but does not help client needs with self-care activities
The charge nurse on the night shift receives a call from one of the nurses who is
to report the next morning. The day-shift nurse reports that she has been
diagnosed with strep throat and placed on antibiotics. Which of the following
responses by the charge nurse is MOST appropriate?
1. “How long have you had the sore
throat?”
2. “How long have you been on
antibiotics?”
3. “Do you have an elevated
temperature?”
4. “Do you have a doctor’s release to
work?”
question.
1) duration of sore throat is not relevant to being able to work
2) CORRECT— after 24 hours of antibiotic therapy, strep throat is no longer
contagious and a health care provider can resume responsibilities
3) fever is the body’s reaction to disease as a defense mechanism; being afebrile
is often a condition for being able to work but duration of antibiotic therapy is the
best indicator
4) nurse does not need a physician’s release in the case of strep throat
The nurse cares for a client receiving cholestyramine (Questran) 4 g BID. The
nurse would be MOST concerned if the client makes which of the following
statements?
1. “I have a hard bowel movement every 2 or 3 days.”
2. “I sprinkle the powder on my orange juice at

breakfast.”
3. “I have increased my intake of milk and green leafy
vegetables.”
4. “I take digoxin (Lanoxin) at lunch every day.”
Strategy: “MOST concerned” indicates incorrect information.

1) CORRECT— constipation is a side effect of medication; encourage diet high in
fiber and fluids
2) sprinkle on liquid, let stand for a few minutes, and stir thoroughly; after
drinking, add a small amount of liquid to same glass, mix, and drink to ensure
intake of entire dose
3) medication depletes fat-soluble vitamins; milk contains vitamins A and D;
green leafy vegetables contain vitamins E and K
4) take other medication one hour before or 4 to 6 hours after taking Questran
The nurse performs teaching for a client receiving alendronate (Fosamax) 10 mg

PO OD. The nurse determines that teaching is effective if the client states which
of the following?
1. “I will take the medication at lunch.”
2. “I’m glad that I don’t have to participate in a regular

exercise program.”
3. “If I forget a dose, I should take it when I remember it.”
4. “I should wear sunscreen when I go outside.”

1) take medication first thing in the morning at least half hour before ingesting
other medication, food, or drink
2) used for treatment and prevention of osteoporosis; client should participate in
regular weight-bearing exercise to increase bone density
3) should only be taken first thing in morning; if dose is missed, skip the dose
and resume the next morning
4) CORRECT— causes photosensitivity; wear sunscreen and protective clothing
when outdoors
The nurse admits a client to the medical unit with a diagnosis of heart failure and
pneumonia. The client’s wife states that the client has recently experienced a
significant decline in his hearing and is extremely depressed. Which of the
1. Provide the client an opportunity to express his feelings about
the hearing loss.
2. Assign the client to a nurse who has a hearing impairment.

hour while awake.
4. Contact a support group for the hearing impaired.

question.
1) according to Maslow, physical needs take priority over psychosocial needs
2) intervention aimed at the hearing loss and depression; nurse needs to deal
with physical needs first
3) CORRECT— pneumonia causes impaired gas exchange; incentive spirometry
prevents or reverses atelectasis
4) initial interventions aimed at the pneumonia
The home care nurse visits an elderly client 1 day following a colonoscopy. The
daughter states that her mother has been confused since coming home from the
procedure. Which of the following actions should the nurse take FIRST?
1. Instruct the client to increase her intake of
fluids.
3. Determine how many times the client has

voided.
4. Ask the client if she has experienced
abdominal cramping.

1) confusion may be sign of hypovolemic shock; client may be dehydrated
because of bowel prep, nurse should first assess
2) CORRECT— hypovolemia can occur from bowel prep and altered mental
status may be an early indication; assess for decreased blood pressure,
increased pulse, light-headedness and dizziness
3) if client dehydrated, will void smaller amounts of concentrated urine; priority is
to assess vital signs
4) may experience abdominal cramping caused by insufflation of air
The nurse in the outpatient clinic performs an assessment of an elderly woman.

The client states that her husband had a CVA 7 months ago, and she cared for
him for 3 months. Four months ago she had to place her husband in a long-term
care facility because she was no longer able to care for him. Since that time the
client reports she has lost 40 pounds, she is afraid to live alone, and she sorely
misses her husband. The nurse notices that the client is extremely hard of
hearing. Which of the following suggestions should the nurse make FIRST?
1. “I think you should move to the nursing home with
your husband.”
2. “Have you considered installing a security system in
your home?”
3. “I’m going to refer you to Meals on Wheels.”
4. “Perhaps you should find a hobby or join a club for

seniors.”

1) assumes client is a candidate for a nursing home; loneliness is not a reason to
move to a long-term care facility
2) addresses client’s concern about safety and security; priority is making sure
that the client eats
3) CORRECT— according to Maslow, take care of basic needs first
4) client’s nutrition and safety take priority over psychosocial needs
The nurse cares for a client diagnosed with chronic obstructive pulmonary
disease (COPD) receiving oxygen per nasal canula at 2 L/min. The nurse
observes that the client has shortness of breath and chest pain. The nurse
notifies the assigned physician, and the physician makes no changes in the
amount of oxygen the client is receiving. Which of the following responses by the
1. Report concerns to the supervisor.
2. Contact the physician a second time.
3. Inform the family members that the physician has not changed
the client’s orders.
4. Continue to monitor the respiratory status of the client.

question.
1) client has symptoms of oxygen toxicity; hypoxemia is a greater threat than
oxygen toxicity
2) hypoxemia is greater threat than oxygen toxicity
4) CORRECT— nurse should continue to assess client’s condition and report
changes to the physician; hypoxemia is greater threat than oxygen toxicity
The community health nurse visits the home of a client with four school-aged
children. The client is diagnosed with severely disabling migraine headaches.
Which of the following instructions by the nurse is MOST appropriate?
1. “Hire someone to help with your
children.”
2. “Report excessive menstrual
flow.”
3. “Avoid stressful situations.”
4. “Go to bed at the same time every

night.”

question.
1) may or may not be feasible for client; requires further assessment before
making this suggestion
2) fluctuating estrogen levels have been related to migraine headaches, but the
amount of flow does not appear to be related
3) triggers include eating chocolate or cheese, drinking coffee, and going for long
periods of time between meals
4) CORRECT— fatigue is a trigger
In early October, a home health nurse makes a home visit to an older client
diagnosed with cataracts who is scheduled to have cataract removal with a lens
implant in mid-November. Which of the following recommendations by the nurse
is MOST important?
1. “Notify a trusted neighbor that you will be gone overnight.”
2. “Get a flu shot as soon as possible”
3. “Read this information about surgical removal of

cataracts.”
4. “Check with your insurance company regarding co-
payment and services.”

1) usually performed on an outpatient basis, with discharge usually 2 hours after
surgery
2) CORRECT— flu can cause client to sneeze, cough, or blow nose, which would
increase intraocular pressure; flu shot helps prevent occurrence of flu
3) promoting wellness takes priority
4) is important; but client’s physical well-being takes priority
A patient is to be discharged after a right total hip replacement. Which of the

has been effective?
1. “I can’t sit in my favorite recliner with my legs up.”
2. “I should ask my wife to put on my socks and shoes.”
3. “I should clean the incision with a mixture of hydrogen peroxide and

water before applying a sterile dressing.”
4. “I don’t need to continue to do the leg exercises I learned in the
hospital.”
Strategy: Thank about what the patient’s words mean.

1) can sit in recliner as long as hip flexion is less than 45 to 60°; avoid stooping;
do not sleep on operative side until directed to do so
2) CORRECT— this self-care activity would cause hip flexion greater than 40 to
60°, might cause dislocation of hip; maintain abduction; do not cross legs
3) not needed, should use soap and water
4) should continue to do exercises
The mother of an 8-month-old boy is concerned because her son has started to
scream and refuses to eat when left with the child-care provider. Which of the
1. “Start looking for a different child-care provider.”
2. “Check your son for bruises and other injuries.”
3. “Remember that this is just a phase your son is

going through.”
4. “Hand your child his blanket as you say goodbye.”
Strategy: Determine outcome of each answer. Is it desired?

1) separation anxiety indicates normal development; fear of strangers begins at 7
months, peaks at 8 months
2) no indication of abuse; normal development
3) is normal growth and development, question asks for best response; phases–
protests, cries/screams for parents and is inconsolable by others; despair, cry
ends but is less active, not interested in food or play; denial, appears adjusted,
appears interested in environment, ignores parents when they return
4) CORRECT— exhibiting separation anxiety; reassure child by offering favorite
blanket or toy, talk to infant when leaving the room, and allow infant to hear
parent’s voice on telephone
The mother of a 4-year-old tells the nurse she is worried because her daughter
has begun to stutter. The mother asks the nurse what actions can be taken to
stop the stuttering. Which of the following responses by the nurse is BEST?
1. “What has been happening in your child’s life?”
2. “Reward your child when she speaks fluently.”

3. “Instruct your child to start over and speak more
slowly.”
4. “Slow down your own speech and talk to your
daughter calmly.”

1) implies that something is wrong; broken fluency is a normal occurrence in
preschoolers
2) because it is normal behavior, there is no reason to offer reward
3) will make child conscious of speech and increase the stuttering
4) CORRECT— does not call attention to the child’s speech pattern and does
gives the child time and space to respond; secondary stuttering is a normal
phase of language development
While sitting at the front desk completing an assessment sheet, a new graduate
nurse asks the nursing assistant to perform a finger stick blood sugar for the
assigned client. The nursing assistant responds, “Why can’t you do it?” Which of
1. “Please page me when you have completed
the task.”
2. “It is important that the blood sugar be
completed now.”
3. “Why did you ask that?”
4. “If you don’t have time, I will ask someone

else to do it.”

1) CORRECT— performing a finger stick is within the scope of practice of the
nursing assistant and the task should be carried out as delegated
2) nurse not required to explain assignment
3) nontherapeutic; leads to further discussion, which is not appropriate
4) example of reverse delegation, lower person on hierarchy delegates to person
higher on the hierarchy
The nurse cares for clients on the neurological unit. After receiving report, which
of the following clients should the nurse see FIRST?
1. A client who is non-responsive with intermittent limb
movement.
2. A client whose muscle tone of all four limbs is flaccid.
3. The client who is non-responsive but follows the staff

with his eyes.
4. The client who immediately withdrawals from painful
stimuli.

1) limb movement indicates brain injury is not severe
2) CORRECT— flaccidity most indicative of serious irreversible impairment
3) tracking with the eyes indicates client less impaired than client with flaccid
muscles
4) indicates a higher level of consciousness, according to Glasgow Coma Scale
The home care nurse visits a client receiving levothyroxine (Synthroid) 75 mcg
OD. The client tells the nurse that he has been experiencing insomnia the last
couple of weeks. Which of the following responses by the nurse is MOST
appropriate?
1. “The physician may have to decrease the dose of
medication.”
2. “Tell me about your bedtime routine.”
3. “When do you take the medication?”
4. “Take a warm bath before going to bed.”

1) should assess before implementing
2) assessment; more important to determine when client is taking the medication
3) CORRECT— should take medication before breakfast to prevent insomnia
4) assumes that medication is not the cause of the insomnia

The nurse cares for a client diagnosed with hypertension and type 1 diabetes
mellitus. The client complains to the nurse that the physician wants the client to
discontinue taking verapamil (Calan) 80 mg PO tid and begin taking captopril
(Capoten) 50 mg PO tid. The client states, “It took a long time to find a medication
that controls my blood pressure with minimal side effects, and I do not want to
go through that again.” Which of the following responses by the nurse is BEST?
1. “How many different antihypertensives did you try?”
2. “Captopril is the best drug for preventing or slowing down the

destruction of your kidneys.”
3. “Your physician is a specialist in this area and feels you need to
change.”
4. “Why not give it a try?”

1) focus on the here and now; not relevant how many different drugs the client
tried
2) CORRECT— Capoten dilates the efferent arterioles, resulting in lowering the
glomerular pressure; verapamil dilates the afferent arterioles, increasing the
pressure
3) does not give the client a reason why the physician wants to change the
medication
4) answer does not give the client any information
The nurse cares for client diagnosed in stage I chronic renal failure. During the
nursing assessment, the nurse expects the client to state which of the following?
1. “I don’t seem to urinate as much as I used
to.”
2. “I seem to have more swelling in my feet
and ankles.”
3. “I urinate more at night.”
4. “The doctor told me I need dialysis.”
Strategy: Think about what the client’s words mean.

1) oliguria occurs during stage II (renal insufficiency)
2) occurs during stage II
3) CORRECT— stage I is diminished renal reserve; renal function is reduced but
healthier kidney is able to compensate; since kidney not as able to concentrate
urine, client has polyuria and nocturia
4) required in stage III (end-stage renal disease)
old. The child’s mother tells the nurse that she is very excited because her
mother is visiting. The grandmother rarely visits, and the child’s mother is
pleased that grandmother and grandchild will spend time together. Which of the
following responses by the nurse is MOST important?
1. “Your toddler may be fearful when left alone with her
grandmother.”
2. “How long is your mother staying?”
3. “Does your mother take any medication?”
4. “I’m sure your mother will enjoy her grandchild.”

1) toddlers display less fear of strangers as long as parents are present; when
left alone, the toddler may be fearful or anxious; appropriate information for the
nurse to relate to the mother; psychosocial need
2) not the most important question
3) CORRECT— because toddlers explore by putting things in their mouths,
parents should be aware of all potentially toxic substances in the home; parents
should be aware if visitors in the home are taking medication, which should not
be left in purses or suitcases lying around
The home care nurse visits a client in a large apartment complex. During the visit,
the area experiences a major earthquake. Which of the following clients should
the nurse see FIRST?

pain.

take priority
priority
priority
The nurse cares for clients in the outpatient clinic. The nurse returns to the desk
to find four phone messages. Which of the following messages should the nurse
respond to FIRST?
1. The mother of a 15-year-old reports her son is threatening to jump off a
bridge and has access to a gun.
2. A 20-year-old female reports she has lost 2 lb this week and eats only
two meals a day.
3. A 45-year-old male with a history of depression who is out of Prozac.
4. A 75-year-old male complains of insomnia and irritability after the death

of his wife.

(1) CORRECT— using Maslow Hierarchy of Needs theory to prioritize,
physiological issues take priority over psychological issues; patient is at risk for
self harm and must be seen first; observe for safety
(4) may be a normal part of grieving; nurse should assess but is not the priority
1. A client with an IV of normal saline infusing at 125 ml per hour
complaining of slight swelling at the IV insertion site.
2. A client 3 days post right knee replacement complaining of right calf
pain with movement.
3. A client with a respiratory rate of 24 and an oxygen saturation of 94%
on room air.
4. A client 12 hours after a hysterectomy complaining of nausea.

(1) assess site for client's comfort and to prevent complications associated with
IV infusion, probable DVT takes priority
(2) CORRECT—assessment for possible DVT should be performed and reported
to the physician immediately
(3) respiratory status is stable at present
(4) administer antiemetics; client with calf pain takes priority
The triage nurse at an urgent care center notes that four clients have signed in,
each complaining of a sore throat. Which of the following clients should the
nurse see FIRST?
1. A 7-year-old whose sibling was recently treated for
"strep throat."
2. A 10-year-old with a history of chronic allergies.
3. A 21-year-old with a history of chronic sinus

infections.
4. A 55-year-old receiving 5-fluorouracil (5-FU).

(1) child has likely contracted strep from his sibling; treatment should begin as
soon as possible; does not take priority
priority
priority
(4) CORRECT— because many chemotherapy agents may result in neutropenia,
clients receiving drugs are more susceptible to infection, less likely to be able to
fight the infection; symptomatic clients require immediate evaluation and
treatment
The nurse cares for clients on the pain management unit. Which of the following
1. A client receiving intraspinal anesthesia for pain control with a heart
rate of 76 bpm and a respiratory rate of 8.
2. A client receiving patient-controlled analgesia (PCA) with a heart rate of
112 bpm and a respiratory rate of 24.
3. A client requesting PRN IV medication for severe chronic back pain.
4. A client requesting PRN IV medication for acute abdominal pain.

(1) CORRECT— clients receiving intraspinal anesthesia must be closely
monitored for signs of CNS depression
(2) should be assessed for adequate pain control; does not take priority
(3) pain should be addressed; chronic condition that does not take priority
(4) though the client's pain should be addressed, it does not take priority

local ambulance service. Responding to the scene of a motor vehicle collision
(MVC), which of the following clients should the nurse see FIRST?
1. A client with an obvious deformity of the right humerus with
neurovascular systems intact distal to the site.
2. An unconscious client with a crushing chest wound.
3. An unconscious client with a regular heart rhythm at 64 bpm with even

and unlabored respirations.
4. An alert client with multiple scalp lacerations.

(1) client likely has a fracture that will require further stabilization; there is no
evidence of neurovascular compromise at present
(2) CORRECT— clients with crushing chest wounds are at risk for a number of
injuries that may compromise airway, breathing, circulation, cervical spine, and
the nervous system; immediate evaluation is required
(3) though the client is unconscious, cardiopulmonary assessment is stable
(4) client has circulatory compromise but is alert and able to hold pressure to any
areas where bleeding is not well controlled; requires further evaluation but does
not take priority at this time
1. A 5-year-old diagnosed with autistic disorder demonstrating finger
flapping.
2. A 6-year-old with enuresis who often urinates in his underwear.
3. A 7-year-old who is shy and has difficulty reading.
4. A 9-year-old who has used a weapon toward his mother and caused
physical harm to others.

(1) commonly seen in autistic disorder; has stereotypical and repetitive motor
mannerisms; does not require immediate attention
(2) repeated voiding of urine into bed or clothes may be involuntary or
intentional; does not require immediate attention
(4) CORRECT— unstable patient; at risk for harm to self and others
The nurse learns that patients from a motor vehicle accident are being
transferred to the emergency department (ED). The nurse performs triage in the
ED. Which of the following patients should the nurse see FIRST?
1. A patient with ecchymosis and lacerations to the facial
area.
2. A patient complaining of shortness of breath and
pressure in the chest.
3. A patient with blood pressure of 90/60 and apical pulse
of 120 bpm.
4. A patient complaining of dizziness and nervousness.

(2) potential problems; not the most unstable
(3) CORRECT— vital signs indicate shock; most unstable patient
(4) most stable patient of the four; use Maslow hierarchy of needs theory to
prioritize; physiological needs take priority; use ABCs
day. Which of the following patients should the nurse see FIRST?
1. A patient who took 10 methylphenidate (Ritalin) and has a blood
pressure of 160/100.
2. A patient who requires a metered-dose inhaler.
3. A patient with a short arm cast on the left arm.
4. A patient diagnosed with hypothyroidism requiring TSH level.

(1) CORRECT— most unstable patient; assess for restlessness, dilated pupils,
tremors, and seizures
(2) potential problem; not priority
(3) no indications of complications; will check for complications such as
circulatory impairment and peripheral nerve damage
(4) symptoms include decreased activity level, sensitivity to cold, obesity, and
weight gain
The nurse cares for clients in a gynecological clinic. Which of the following
1. A 60-year-old complaining of dry vaginal walls and painful intercourse.
2. A 35-year-old who had a hysterosalpingogram is experiencing

tachycardia, and has a generalized rash.
3. A 30-year-old who requires preparation for a cervical biopsy.
4. A 25-year-old scheduled for a Pap smear.

(1) does not require immediate attention; instruct about estrogen replacement
therapy and water-soluble lubricants
(2) CORRECT— x-ray of the cervix, uterus, and fallopian tubes performed after
the injection of a contrast medium; assess for allergy to shellfish or iodine;
requires immediate attention because patient having an allergic reaction
(3) does not require immediate attention; physician usually performs a biopsy as
a follow-up to suspicious Pap test findings
(4) exam to detect precancerous and cancerous cells from the cervix; does not
require immediate attention
Children from a school-bus accident are transferred to the hospital. The nurse
performs triage in the emergency department (ED). Which of the following
1. An 8-year-old with a superficial burn to the
arm.
2. A 7-year-old with burns on the face.
3. A 6-year-old with small lacerations to the

arms and legs.
4. A 5-year-old complaining of elbow pain.

(2) CORRECT— burns can be life-threatening to children; airway, breathing, and
circulation are major concerns; cardiopulmonary complications may result from
exposure to electrical current, inhalation of toxic fumes, hypovolemia, and shock
day on the endocrinology unit. Which of the following patients should the nurse
see FIRST?
1. A patient who requires a fasting blood glucose test in the morning
before breakfast.
2. A patient who requires a urine test for ketone bodies.
3. A patient who will be discharged this afternoon.
4. A patient with a fasting blood glucose of 517 mg/dL.

(1) does not require immediate attention; normal fasting is 60 to 110 mg/dL
(2) does not require immediate attention; presence of ketones may indicate
ketoacidosis; check during illness, stress, or pregnancy
(4) CORRECT— normal is 60 to 110 mg/dL; requires immediate attention;
administer regular insulin
The nurse cares for patients in the psychiatric ER. Which of the following
1. A patient receiving haloperidol (Haldol) experiencing an
oculogyric crisis.
2. A patient receiving thioridazine (Mellaril) experiencing
akathisia.
3. A patient receiving risperidone (Risperdal) experiencing
blurred vision.
4. A patient receiving fluphenazine (Prolixin) experiencing
sedation.

(1) CORRECT— eyes are locked upward; acute dystonic reaction; notify
physician and physician will order an anticholinergic agent to correct this
reaction
(2) inability to sit or stand still; foot tap, pace; does not require immediate
attention; physician will change antipsychotic medication or give
antiparkinsonian agent
(3) does not require immediate attention; physician will change antipsychotic
medication
(4) common during first few weeks of therapy; does not require immediate
attention
day on the pediatric unit. Which of the following patients should the nurse see
FIRST?
1. A patient diagnosed with leukemia complaining of fatigue.
2. A patient diagnosed with Wilms tumor complaining of thirst.
3. A patient diagnosed with hemophilia complaining of joint pain.
4. A patient diagnosed with gastroesophageal reflux complaining of

abdominal pain.

(1) expected because of diagnosis and treatment; balance rest and activity
(2) does not require immediate attention; Wilms tumor is a malignant neoplasm of
the kidney; most common intra-abdominal tumor in children
(3) CORRECT— joint pain indicates bleeding; treatment includes factor VIII, RICE
( r est, i ce, c ompression, and e levation)
(4) backflow of gastric contents into the esophagus resulting from relaxation of
the lower esophageal sphincter
1. A client diagnosed with type 2 diabetes who is complaining of GI upset
after taking chlorpropamide (Diabinese).
2. A client who is complaining of vomiting after chemotherapy.
3. A client with a tonometer reading of 21 mm Hg.
4. A client with a laryngectomy who is complaining of a greenish-yellow

discharge.

(1) Diabinese is a oral hypoglycemic; side effects include diarrhea, GI upset, and
hypoglycemia; administer in divided doses to relieve GI upset; does not require
immediate attention
(2) common side effect of chemotherapy; does not require immediate attention
(3) used to diagnose glaucoma; tonometer measures intraocular pressure;
normal IOP reading is 10 to 21 mm Hg
(4) CORRECT— most unstable client; assess breath sounds and amount, color,
and character of drainage
The nurse is seeing patients in the medical/surgical unit. Which of the following
1. A patient diagnosed with heart failure who has received 800 ml of IV
fluids in 2 hours.
2. A patient diagnosed with lung cancer with a blood calcium level of 10.5
mg/dL.
3. A patient diagnosed with hypertension requiring the 9 A.M. dose of
captopril (Capoten).
4. A patient postoperative after a laminectomy who requires supervision
when ambulating.

(1) CORRECT— assess for circulatory overload
(2) normal range is 8.5 to 10.5 mg/dL
(3) can give 30 min before or after prescribed time; ACE inhibitor
(4) nothing to indicate patient is unstable
The nurse cares for clients in the emergency department. Four clients present
complaining of side effects from prescribed medication. Which of the following
1. A client receiving clozapine (Clozaril) and experiencing flu-like
symptoms, fever, sore throat, and lethargy.
2. A client receiving valproic acid (Depakene) and experiencing tremors.
3. A client receiving lorazepam (Ativan) and experiencing abdominal

discomfort.
4. A client receiving methylphenidate hydrochloride (Ritalin) who lost 5 lb
in 4 weeks.

(1) CORRECT— unstable client; may have agranulocytosis; Clozaril is an
antipsychotic; pregnancy risk B
(2) physician will order valproic acid level to assess for toxicity; anticonvulsant;
pregnancy risk D; does not require immediate attention
(3) does not require immediate attention; antianxiety, sedative-hypnotic
(4) may cause decreased appetite; monitor weight; does not require immediate
attention
The nurse sees patients in the gastrointestinal clinic. Which of the following
1. A middle-aged adult diagnosed with irritable bowel syndrome and
complaining of cramping and loose stools.
2. A young adult complaining of not having a bowel movement in 2 days.
3. A child diagnosed with gastroenteritis with five diarrheal stools in the

last 3 days.
4. A newborn experiencing projectile vomiting and irritability.

(1) symptoms of irritable bowel syndrome; encourage patient to eat meals at
regular intervals, chew food slowly, and do not drink fluids with meals
(2) determine normal bowel pattern; encourage fluids, foods high in roughage
(3) does not require immediate attention but has potential for dehydration; real
problems take priority over potential problems
(4) CORRECT— indicates pyloric stenosis; at risk for fluid and electrolyte
imbalance




A triage nurse in a busy urgent care center is prioritizing patients for evaluation.
Which of the following patients should the nurse see FIRST?
1. A 2-month-old infant. The mother states that the child is very sleepy
and has refused to nurse for 8 hours.
2. A crying 2-year-old. The father states that the toddler fell against the
fireplace and continuously touches the right elbow.
3. A 5-year-old who is flushed. The grandmother states that the child has
a temperature of 101.9°F (39°C).
4. A 6-year-old who complains of a sore throat. The caretaker reports the
child has had two episodes of vomiting.

(1) CORRECT— significant risk for dehydration and acidosis; an infant's rate of
fluid exchange is significantly higher than an adult's, and the infant's metabolism
rate is nearly twice that of an adult's; acid forms more rapidly in infants and may
lead to acidosis; kidneys are not mature at this age, cannot adequately
concentrate urine to conserve water
(2) may have dislocation or fracture; evaluate neurovascular status of the
affected extremity and ask the patient's caregiver to report changes while
awaiting further evaluation
(3) likely flushed as a result of the fever; request an order for Tylenol or Motrin if
the child had not received either before arrival and ask the caregiver to report
changes in the patient's condition while awaiting further evaluation
(4) vomiting may pose a risk for dehydration; symptoms are likely a result of
strep throat or a virus; requires urgent evaluation, but with greater body mass
and more mature organ systems, this patient is not as acute as the infant
Question 20 of 30

The nurse receives report on the following patients on the medicine unit. Which
1. A patient who just arrived as a transfer from the ER with an oxygen
saturation of 93% and is receiving 2 liters oxygen per nasal cannula.
2. A patient who complains of nausea while drinking contrast in
preparation for a CT scan.
3. A patient who just arrived from the physician's office as a direct
admission with a hemoglobin of 6.9 g/dL.
4. A patient who complains of abdominal pain and is requesting pain
medication.

(1) respiratory status is stable at present, though additional interventions may be
required if the patient's oxygen saturation decreases further; continue to monitor
the patient closely
(2) symptom management is important for patient comfort and to insure the
patient's ability to drink the contrast in preparation for the test; respiratory status
takes precedence
(3) CORRECT— assessment of respiratory status is required; acute onset of
anemia and/or disease may cause SOB, dyspnea, and/or chest pain; oxygen
supplementation often indicated prophylactically even if asymptomatic
(4) symptom management is important for patient comfort; respiratory status
takes precedence
The nurse sees patients in the adolescent psychiatric unit. Which of the following
1. A 13-year-old who complains of impulsivity and poor attention span.
2. A 14-year-old who frequently loses his temper and argues with his
teachers.
3. A 15-year-old who wants to be a model and only drinks water and eats
vegetables.
4. A 16-year-old who bullies, threatens, and intimidates others and
initiates physical fights.

(1) assess further for attention deficit disorder; not an immediate concern
(2) assess for oppositional-defiant disorder
(3) CORRECT— most unstable; assess nutritional status and monitor for eating
disorder
(4) assess for conduct disorder
The nurse receives report about clients on the medical/surgical unit. Which of the
1. A client who is scheduled to receive verapamil (Calan).
2. A client who is scheduled to receive the prescribed metered dose

inhaler (MDI).
3. Family members of a client who threaten to sue the hospital if the
nurse doesn't talk to them immediately.
4. A client who is verbally abusive to staff and becomes increasingly
more agitated.

(1) Calan is an antihypertensive; safety takes precedence over administration of
routine, nonemergent medications
(2) safety takes precedence over administration of routine, nonemergent
medications
(3) although angry, the family members do not pose an immediate physical threat
to the patient, staff, or other visitors
(4) CORRECT— poses a potentially immediate physical threat to himself, staff
members, and/or other patients and visitors if the situation is allowed to escalate
further; nurse must attempt to intervene and initiate protocols prescribed by the
individual facility to maintain a safe environment
1. A 9-month-old infant with failure to gain weight and a lead
level of 70 g/dL.
2. A 4-year-old child scheduled for surgery who fears body
mutilation.
3. A 6-year-old who has repeated, involuntary urination at
night.
4. A 7-year-old with a persistent fear of attending school.

(1) CORRECT— high risk for injury; requires immediate attention; provide
medical treatment and chelation therapy, begin coordination of care, clinical
management, environmental investigation, and lead hazard control
(2) common fear during preschool years, does not require immediate attention
(3) describes enuresis; does not require immediate attention
1. A 5-year-old male who experiences hyperactivity and impulsivity for 2
weeks.
2. A 13-year-old female who has been truant from school for 3 days.
3. A 13-year-old female who has vomited every day for the last 3 months
because she wants to lose weight for the summer.
4. A 25-year-old male who drinks alcohol every day and is unable to
control the amount of alcohol he ingests.

(1) does not require immediate attention; using Maslow hierarchy of needs theory
to prioritize, physiological issues come before psychological issues
(3) CORRECT— at risk for fluid and electrolyte imbalances; also address
potential for decreased cardiac output and altered nutrition: less than body
requirements
(4) nurse needs to see this client second
The nurse obtains histories from four clients preparing for CT scan with oral and
IV contrast. Which of the following client statements requires an IMMEDIATE
follow-up by the nurse?
1. "I am feeling nauseated."
2. "My face gets red when I eat shrimp."
3. "I get claustrophobic when I am in a

small space."
4. "I am having joint pain."

(1) nausea may prevent the client from drinking the oral contrast; should be
addressed, but allergies to IV dye or seafood are more important
(2) CORRECT— allergies to iodine, seafood, or dye can cause an allergic reaction
(3) rarely a concern for clients undergoing CT scan; more of a concern for client
undergoing magnetic resonance imaging
(4) nurse does need to follow up, but the priority is to follow up on the client with
the potential allergic reaction
The triage nurse prioritizes patients to be evaluated in the ER. Which of the
following patients will the nurse see FIRST?
1. A young adult complaining of nausea and vomiting for the
past several hours.
2. A young adult at 8 weeks' gestation complaining of vaginal
spotting.
3. A toddler with a temperature of 101°F (39°C).
4. An infant with vomiting and diarrhea.

(1) average healthy young adult's body can adequately compensate for
(2) vaginal spotting with pregnancy can be related to a number of factors,
including intercourse, drop in progesterone level during this particular
gestational age, and potential for spontaneous abortion; ask patient to rest and
offer reassurance until evaluated by the physician
(3) obtain an order for an antipyretic and monitor toddler until toddler can be
evaluated by the physician
(4) CORRECT— at significant risk for dehydration which may result in electrolyte
imbalances, as well as shock, depending on the amount of fluid lost
The nurse cares for clients on the medical/surgical unit. After receiving report,
which of the following clients should the nurse see FIRST?
1. An elderly client 2 days postop after a total hip replacement who
slipped out of bed when trying to stand.
2. An elderly client with a history of cardiomyopathy who aspirated
cooked cereal at breakfast.
3. An elderly client diagnosed with a right-sided CVA who requires
assistance going to the bathroom.
4. An elderly client diagnosed with heart failure (HF) who has been
vomiting for 3 days.

(1) assess whether dislocation of prosthesis has occurred; airway takes priority.
(2) CORRECT— ensure that client has patent airway; at risk to develop
pneumonia
(3) ensure client's safety; client with impaired airway takes priority
(4) assess this client second; may have digitalis toxicity; circulatory problem
The nurse cares for clients in the outpatient clinic. Each of the following clients
has asked to see the nurse due to complaints of pain. Which of the following
1. A client with a history of a herniated lumbar disc who complains of
severe pain radiating down the left leg.
2. A client with a history of migraine headaches who complains of a
headache and light sensitivity.
3. A client with a history of kidney stones who tearfully complains of
severe right flank pain.
4. A client with a history of coronary artery disease (CAD) who complains
of midepigastric pain radiating to the neck.

(1) important to address this client's pain; the condition is chronic and does not
take priority
(2) important to address this client's pain; the client is likely experiencing a
migraine headache and does not take priority
(3) assess for symptoms of obstruction of the ureter; client with symptoms that
may indicate myocardial infarction takes priority
(4) CORRECT— client with a history of coronary artery disease is at increased
risk of myocardial infarction; pain that originates in the chest or abdomen and
radiates to the neck, shoulder, or arm requires immediate evaluation
A psychiatric nurse is presented with a group of patients in the emergency

department (ED). Which of the following patients requires IMMEDIATE attention?
1. A young adult who failed medical school and verbalizes, "My pain will
be over soon."
2. A young adult who complains of hyperventilation and palpitations at
the beginning of a presentation.
3. A middle-aged adult who hears voices to harm others.
4. A middle-aged adult who is fearful after witnessing a murder.

(1) CORRECT— at risk for self-harm; determine if client has means; place on one-
to-one observation and stay with patient to help control self-destructive impulses
(2) does not require immediate attention; indications of anxiety include increased
pulse, blood pressure, and respirations, perspiration, flushing, and heat
sensations
(3) should be the second patient seen
(4) does not require immediate attention; may be experiencing post-traumatic
stress syndrome
gun.
resentment.

out threat

contractions.
discharge.
contractions.


route 25 victims.

overtime.



weeks.”

depression
mouth
3) true statement
may result in death

patient
patient
The nurse instructs a mother of a child diagnosed with a myelomeningocele who

developed an allergy to latex. The nurse determines that teaching is effective if
the mother selects which of the following menus for her child?
1. Guacamole with pita bread, lettuce, tomato
juice.
2. Poached halibut, brown rice, carrots, peach
cobbler.
3. Scrambled eggs, whole wheat toast, grapes,
skim milk.
4. Baked chicken leg, mashed potatoes, spinach,
milkshake.

1) if a person has a latex allergy, there is cross-reaction to tomatoes and
avocados
2) peach is a cross-reactive food with latex
3) grapes are cross-reactive with latex
4) CORRECT— this meal does not have any cross-reactive foods with latex;
foods to avoid include apricots, cherries, grapes, kiwis, passion fruit, bananas,
avocados, chestnuts, tomatoes, and peaches
following children?

lost their home.
America.
for tuberculosis.

bleeding.
30°.

will be given

report.”
problem out.”

emotions are high

pressure.
sounds.

question.
water
The home care nurse visits a client diagnosed with type 1 diabetes being
managed with insulin in the am and pm. The nurse identifies that which of the
following BEST measures the overall therapeutic response to management of the
diabetes?
1. Glycosylated hemoglobin (HbA 1 c) 5%
of total Hb.
2. Fasting blood sugar 128 mg/dL.
3. Blood pressure 130/82.
4. Serum amylase 100 Somogyi U/dL.

1) CORRECT— indicates overall glucose control for the previous 120 days;
normal is 4.5–7.6% of total hemoglobin
2) normal fasting is 60–110 mg/dL; HbA 1 c more accurate indicator of glucose
control
3) evaluates response to antihypertensive medication
4) elevated in acute pancreatitis; normal is 60–160 Somogyi U/dL
every 30 minutes.


prothrombin levels.

therapist.
department.
menus.
patients her age.

to the sting.”
the site.”

mucosa.
2. Hearing loss.


and antipyretics.



ambulating.


severe flank pain.
toe.

shock and syncope
client’s symptoms
chemotherapy.”
chemotherapy.”

responsibility
intake.”
movement?”

walk around
patients?
discharge.
chest pain.

teaching




uncomfortable.”

failure
room unit.
antacids.

hours ago.
and vomiting.
14 mg/dL.


affected eye.
hours.

4) do not irrigate
1. Volleyball.
2. Painting.
3. Walking.
4. Dancing.

subsides


competency?”

question.
concerns
actions?

30 kcal/oz.
expansion

reading.”
test.”


following rooms?
fracture.
shunt revision.

A patient returns from surgery for a total replacement of the right hip with a large
surgical dressing and a Jackson-Pratt drain. Which of the following, if observed
by the nurse 2 hours after surgery, necessitates calling the physician?
1. There is a small amount of bloody drainage on the
surgical dressing.
2. The patient complains of increased hip pain.
3. A harsh, hollow sound is auscultated over the trachea.
4. The patient’s blood pressure is 136/86.
Strategy: “necessitates calling the physician” indicates a complication.

1) expected outcome, complications of total hip replacement include dislocation
of prosthesis, excessive wound drainage, thromboembolism, and infection
2) CORRECT— indicates dislocation of prosthesis; other indications include
shortening of affected leg, leg rotation, soft popping sound heard when affected
leg is moved; maintain abduction, use wedge pillow, avoid stopping, do not sleep
on operated side until directed to do so, flex hip only 1/4 circle, never cross legs,
avoid position of flexion during sexual activity, walking is excellent exercise,
avoid overexertion; in 3 months will be able to resume ADLs, except strenuous
sports
3) describes normal breathing sounds
4) within normal limits


moving in bed.

3) Valsalva maneuver increases workload on heart; to prevent, teach immobilized
patients about exhaling when moving about in bed; should first assess patient
complaints
increased workload
The nurse cares for a client at term in labor. The client’s blood pressure is 182/88
and fetal heart rate (FHR) is 132–134 with minimal beat-to-beat variability. Her
bloody show is dark red and there is more bleeding than anticipated. Her
abdomen is firm between contractions and she complains of back pain. The
nurse understands that the client is at risk for which of the following?
1. Placenta previa.
2. Abruptio
placenta.
3. Miscarriage.
4. Imminent
delivery.

1) placenta is implanted near or over the cervical os; symptoms include painless,
sudden, profuse bleeding in third trimester
2) CORRECT— premature separation of placenta; painful vaginal bleeding,
abdomen is tender, painful, tense, possible fetal distress; prepare for immediate
delivery
3) occurs before 20–24 weeks of pregnancy; indications are persistent uterine
bleeding and cramp-like pain
4) symptoms are classic signs of abruption
not acceptable.

water.

environment
control
cefaclor (Ceclor).
(Questran).
(Indocin).
room.”
immediately.”
you see.”

reduce stress
needed

A client receives an A-V fistula in his right arm in preparation for hemodialysis.
The nurse would be MOST concerned if the client’s wife made which of the
following statements?

1. “My husband sleeps on his right side with his arm tucked under
his pillow.”
2. “My husband carries a full bag of groceries with his left arm.”
3. “My husband goes fly fishing every weekend.”
4. “My husband likes an occasional glass of wine.”

1) CORRECT— would interfere with patency of A-V fistula; do not carry heavy
objects on affected side
2) would not interfere with A-V fistula in right arm
3) would not interfere with A-V fistula in right arm; encourage to exercise by
squeezing rubber ball to increase size of vessel
4) not contraindicated for this patient; do not use arm with vascular access for
blood pressure reading; do not perform venipuncture; elevate extremity postop
The home care nurse visits a client with a history of type 1 diabetes. The client
has recently suffered permanent loss of vision and is having difficulty adjusting.
Which of the following actions, if taken by the nurse, is MOST appropriate?

1. Ask the physician for a psychiatric referral.
2. Recommend that the client join a support group.
3. Warn client that failure to adapt can increase risk for safety.
4. Reassure client that change in visual abilities does not change

personal identity.


question.
1) loss of sight can be a devastating experience; response doesn’t necessarily
indicate client has psychiatric problems
2) CORRECT— clients often respond more positively to peers with same health
alterations than to health professionals
3) threats often do not effect change; if so, change is not lasting; threat is
disrespectful and unethical
4) false reassurance; does not address the issue
The nurse cares for a client preparing for surgery. Thirty minutes after
administering the preoperative medication, the nurse observes a nursing
assistant ambulate the client to the bathroom. Which of the following actions

1. Assist the client back to bed.
2. Ask the nursing assistant if the client had difficulty walking.
3. Determine why the nursing assistant ambulated the client.
4. Ensure that the nursing assistant receives the appropriate

training.


1) CORRECT— because of the danger of falling, client should not ambulate after
receiving preoperative medication; client should remain in bed with side rails up
2) priority is getting client back to bed
3) discussion does need to occur; client safety takes priority
4) appropriate action; client safety takes priority
The nurse cares for patients in the emergency department (ED). Which of the
following patients should the nurse see FIRST?

1. A patient complaining of a dry cough for several weeks with
frequent night sweats.
2. A patient who complains of vaginal spotting and reports that her
last menstrual period was 2 weeks ago.
3. A patient complaining of right upper quadrant abdominal pain
with nausea and vomiting.
4. A patient complaining of burning epigastric pain that radiates to
the mid-chest when the patient is lying flat.

Strategy: Determine the MOST unstable patient.

(1.) CORRECT—classic symptoms of tuberculosis; place in room with negative
air pressure or fit with an appropriate mask to prevent spread of the disease
until evaluation confirms that patient is free of disease
(2.) likely experiencing breakthrough bleeding at ovulation, though other
possibilities range from an infectious process to cervical cancer; no emergent
intervention is required at this time
(3.) important to alleviate patient’s symptoms; preventing spread of infection to
other patients, visitors, and staff takes precedence
(4.) likely experiencing symptoms of acid reflux; instruct patient to keep the head
of the bed elevated; possibly offer medication intervention
The nurse cares for a client who suffered a severe eye injury related to an acid
splash. The nurse administers proparacaine hydrochloride (Ophthaine) before
each eye examination. It is MOST important for the nurse to take which of the
following actions?

1. Instruct the client about the action of the drug.
2. Measure the client’s intraocular pressure.
3. Instruct the client not to rub the eye.
4. Inform the client that effects of the medication last

approximately 15 minutes.


1) appropriate action but not the priority; Ophthaine is a topical anesthesia
2) used to test for glaucoma
3) CORRECT— rubbing or touching eye when the eye is anesthetized may cause
corneal damage
4) appropriate statement, but preventing further damage to the eye takes priority
The nurse cares for a client diagnosed with Clostridium difficile . The nurse
should follow which of the following transmission-based precautions?

1. Standard precautions.
2. Airborne precautions.
3. Droplet precautions.
4. Contact precautions.

1) barrier precautions used for all clients to prevent nosocomial infections
2) used with pathogens transmitted by airborne route
3) used with pathogens transmitted by infectious droplets
4) CORRECT— causes pseudomembranous colitis; contact precautions required
for all client care activities that require physical skin-to-skin contact or those
that require contact with contaminated inanimate objects
A 22-year-old woman tells the nurse in the family planning clinic that she is
fearful of contracting a sexually transmitted disease. Which of the following
statements, if made by the nurse, is BEST?

1. “Douche with a vinegar solution after each act of intercourse.”
2. “Insert a diaphragm with spermicide before every act of

intercourse.”
3. “Use a condom and spermicide with every act of intercourse.”
4. “Limit your sexual encounters to people that you know.”
Strategy: Read answer choices to determine the topic. All answers are
implementation. Determine the outcome of each answer. Is it desired?
1) not effective, does not kill bacteria or viruses, can force them higher in
reproductive tract
2) semen is still deposited in the vagina, spermicide destroys some organisms
3) CORRECT— condom avoids the deposit of semen, spermicide destroys some
organisms
4) limiting number of partners is helpful, but not best
The nurse returns to a senior center to evaluate the effectiveness of a

presentation about how to prevent falls among seniors. The nurse determines
that teaching was effective if the seniors state which of the following?
Select all that apply:

1. “I started taking Tai Chi classes.”
2. “I have a new pair of athletic shoes with deep

treads.”
3. “I went to the eye doctor to have my vision
checked.”
4. “My physician reviewed all of my medications.”
5. “I stopped exercising so I won’t fall.”
6. “I bought some new lamps for my home.”

1) CORRECT— exercise is one of the most important ways to decrease the
chance of falling; Tai Chi improves balance and coordination
2) shoes with thin, nonslip soles are the safest; avoid slippers and athletic shoes
with deep treads
3) CORRECT— ensures that glasses are correct and will rule out glaucoma and
cataracts, which limit vision
4) CORRECT— medications can cause client to be drowsy or light-headed,
which can contribute to falls
5) not exercising causes weakness and increases a senior’s chance of falling
6) CORRECT— older clients needs brighter lights to see well
The nurse visits a client diagnosed with herpes zoster. Which of the following
statements, if made by the client to the nurse, indicates the client understands
the cause of the illness?

1. “I will avoid exposure to children with German
measles.”
2. “I had chickenpox in grammar school.”
3. “Using a condom during intercourse will be

necessary.”
4. “I will bathe more often than in the past.”

1) herpes zoster is contagious to anyone who has not had chickenpox
2) CORRECT—herpes zoster (shingles) is a reactivation of latent varicella
(chickenpox), which has an increased frequency rate among adults with a
weakened immune system; pain, tenderness, and pruritus over the affected
region; is contagious to anyone who has not had chickenpox or who is
immunosuppressed
3) is not a sexually transmitted disease
4) problem is not related to hygiene
The nurse instructs a student nurse about the correct way to set up a sterile
field. The nurse determines that teaching is effective if which of the following is
observed?

1. The student nurse places the supplies at the edge of the
sterile field.
2. The student nurse wears a gown and gloves at all times.
3. The student nurse sets up the sterile field above waist level.
4. The student nurse opens supplies with sterile gloves.

1) carefully place sterile items on the field; any object placed on the outer 1 inch
of the field must be discarded
2) set up field before donning sterile gloves
3) CORRECT— below waist level is considered contaminated; face sterile field;
prepare field immediately before the scheduled procedure
4) contaminates the gloves; supplies can be opened with bare hands
The nurse observes staff caring for clients on the medical/surgical unit. The
nurse determines care is appropriate if which of the following is observed?

1. The practical nurse cares for a client with a stage 1 pressure
ulcer by wearing gloves.
2. The nurse assistant wears gloves while ambulating a client with
an indwelling urinary catheter.
3. A registered nurse wears clean, non-sterile gloves when
removing a Foley catheter.
4. A nursing assistant caring for a client on droplet precautions
removes the mask prior to removing the gloves.

Strategy: "Care is appropriate" indicates appropriate nursing actions; topic of

question unstated.
(1.) skin is reddened but intact; gloves not required
(2.) not necessary; glove required if contact expected with blood, body fluids,
secretions, excretions, contaminated items, mucous membranes, or nonintact
skin
(3.) CORRECT—appropriate action; sterile gloves required for catheter insertion
(4.) incorrect action; when exiting room, untie gown, remove gloves, remove
mask, take gown off working from inside
After completing charting on a patient’s record, the nurse realizes that the
charting has been placed in the wrong patient’s chart. Which of the following
actions by the nurse is MOST appropriate?

1. Complete an incident report and place a copy in the client’s file.
2. Draw a single line through each line of the incorrect entry and
write a new note explaining what occurred.
3. Use correction fluid to delete the wrong entry and write in the
space that the note was obliterated due to patient confidentiality.
4. Copy the note into the correct patient’s chart and indicate that it
was erroneously put in the wrong patient’s chart.


1) incident report is not included in the patient’s record
2) CORRECT— does not obliterate or alter what was written; new note should be
entered into patient’s record and should include time and signature
3) mistaken entries should never be obliterated
4) error needs to be corrected
The nurse admits a 6-year-old child with an open wound that is methicillin-
resistant Staphylococcus aureus (MRSA)-positive. It is MOST appropriate that
the nurse assign this child to which of the following rooms?

1. A semiprivate room with a 2-year-old diagnosed with respiratory
syncytial virus.
2. A semiprivate room with a 5-year-old diagnosed with acute
respiratory virus.
3. A private room that is close to the nurse’s station.
4. Any private room that is available.

1) both illnesses require contact precautions; do not mix clients with different
infections
2) both illnesses require contact precautions; do not mix clients with different
infections
3) requires a private room, but there are no indications for close monitoring
4) CORRECT— requires a private room; semiprivate room is acceptable only
when there are no other rooms to admit this client, and an MRSA client can room
only with another client who is MRSA-positive
The nurse cares for clients on the medical/surgical unit. The nurse determines
that which of the following clients is MOST at risk to develop a nosocomial
infection?

1. A client with full-thickness burns with an NG tube and a Foley
catheter.
2. A client who has a history of gastric ulcer and is recovering from
an appendectomy.
3. A client diagnosed with type 1 diabetes admitted for evaluation
of peripheral neuropathy and cardiac palpitation.
4. A client diagnosed with alcohol abuse with a history of migraine
headaches admitted for alcohol detoxification.

Strategy: “MOST at risk” indicates discrimination is required to answer the

question.
1) CORRECT— nosocomial infections result from health care being delivered in
the health care setting; burns, NG tube, and Foley are all risk factors; follow
standard precautions to prevent nosocomial infecti
2) abdominal surgery is a risk factor
3) diabetes is a risk factor
4) alcoholism is a risk factor
The nurse in the outpatient clinic cares for a client diagnosed with tuberculosis.
The nurse expects to find which of the following in the client record?

1. “Client complains of low-grade fever and night sweats.”
2. “Client complains of an increased heart rate and

palpitations.”
3. “Client complains of pleuritic chest pain and feelings of
doom.”
4. “Client complains of edema and anorexia.”

1) CORRECT— other signs/symptoms include progressive fatigue, lethargy,
nausea, anorexia, and weight loss
2) symptoms of pheochromocytoma caused by hypersecretion of the adrenal
medulla
3) symptoms of pulmonary embolism
4) indication of heart failure
The nurse admits a client diagnosed with chronic adrenal insufficiency. The
nurse should intervene if the client is placed in a room with which of the
following patients?

1. An elderly client diagnosed with a cerebrovascular accident
(CVA).
2. A middle-aged client diagnosed with pneumonia.
3. A young adult diagnosed with type 1 diabetes.
4. A teen diagnosed with a fractured femur.
Strategy: “Should intervene” indicates something is wrong.

1) no risk to either client
2) CORRECT— exposure to infection, cold, or excessive fatigue can cause
circulatory collapse for a client with chronic adrenal insufficiency
4) appropriate placement
The home health nurse visits an elderly client who is diagnosed with diabetes
and osteoporosis. The client lives with her daughter in a two-story home. Which
of the following statements by the daughter MOST concerns the nurse?

1. "Mother loves a hot bath with her favorite bath oil."
2. "Mother seems to taking more of an interest in the things going

on around her."
3. "I sometimes feel guilty leaving her alone, even if it is just for
half an hour."
4. "I am not sure what we are going to do when winter comes."
Strategy: "MOST concerns" indicates a complication.

(1.) CORRECT—safety risk; oils in the bath water can result in slippery shower
or bathtub surfaces; mother is at risk for falling due to osteoporosis
(2.) positive occurrence; reflects an interest in life
(3.) may indicate that daughter may be excessively locked into the caregiver
role; caregiving feelings and options should be explored
(4.) should further assess daughter’s concern about winter; not of greatest
concern
The nurse admits a client with nuchal rigidity and photophobia. Which of the

1. Place client on droplet precautions.
2. Monitor for increased intracranial

pressure.
3. Prepare the client for a lumbar puncture.
4. Set up seizure precautions.

1) CORRECT— has symptoms of meningitis; Haemophilus influenzae and
Neisseria meningitidis (either known or suspected) require droplet precautions;
place client on droplet precautions until diagnosis is confirmed or eliminated to
protect other clients and staff
2) caused by accumulation of purulent exudate; important to assess for changes
in LOC; preventing spread of infection takes priority
3) bacterial culture and Gram staining of CSF is done
4) important to protect client from injury; priority is preventing spread of
infection
The nurse on the medical/surgical unit administers digoxin 0.125 mg by direct IV.
During the administration of the digoxin, the unit secretary informs the nurse
that a client with extensive head and facial injuries has arrived on the unit.
Which of the following actions should the nurse take FIRST?

1. Note the time and place the syringe with the remaining
medication on the medication cart.
2. Instruct the unit secretary to find another nurse to admit the
client.
3. Ask the unit secretary to obtain the sheet containing the staff’s
pager numbers.
4. Request that the LPN continue the administration of the
medication.

1) nurse is responsible for administering medication; cannot administer
medication that is not under the constant supervision of the nurse
2) inappropriate delegation; nurse’s responsibility to determine the appropriate
person to admit the client
3) CORRECT— enables nurse to safely administer the medication, and nurse
determines the appropriate person to care for the clients; when administering
digoxin by direct IV, infuse over a minimum of 5 minutes; use diluted solution
immediately; observe IV site; extravasation can lead to tissue irritation and
sloughing
4) nurse is responsible for administering the medication
The nurse evaluates care given by a nursing assistant. The nursing assistant
ambulates a client to the bathroom, and the nurse overhears the nursing
assistant ask a family member to stand with a client while the nursing assistant
cares for another client. Which of the following responses by the nurse is BEST?

1. “Why did you ask the family member to stay with the client?”
2. “Please stay with the client and call me if the client becomes
dizzy.”
3. “Do not ask a family member to do your job.”
4. “Did the client ask you to leave?”

1) do not ask “why” questions; priority is client safety
2) CORRECT— priority at this time is client safety; after client is safely back in
bed, nurse should review proper procedure with the nursing assistant
3) priority is to ensure the client is safe
4) yes/no question; address client safety first before determining why the
incident occurred

The nurse instructs the mothers of toddlers about safety precautions for their
children’s eyes, ears, and noses. Which of the following is the MOST important
statement for the nurse to include?

1. "Teach your child to blow the nose first with one nostril closed
and then the other."
2. "Cotton-tipped applicators should be used only on the outer
ear."
3. "Getting a foreign object out of the ear is best done by
irrigation."
4. "If you need to give eardrops, make sure the solution is cold
rather than hot."

Strategy: All answers are implementations. Determine the outcome of each

answer. Is it desired?
(1.) incorrect action; blowing with one nostril closed can push foreign material
into the Eustachian tube or otherwise damage the inner canal
(2.) CORRECT—applicators are not safe for the inner ear because they can force
earwax further in and block the canal
(3.) incorrect; it depends on what the object is; irrigation is contraindicated if the
object is a bean, pasta, peanut, or other vegetative matter that will swell when
fluid contacts it
(4.) ear solutions, whether to treat ear infections or to soften and remove
cerumen, should be at room temperature; hot or cold solutions could be painful
and cause nausea and vertigo

The nurse manager observes the new graduate nurse apply a transdermal patch
on a patient. The nurse manager determines that care is appropriate if which of
the following is observed?

1. The nurse wears sterile gloves when applying the patch.
2. The nurse cleanses the skin with alcohol before applying the
patch.
3. The nurse places a heat lamp over the patch for 20 minutes.
4. The nurse folds the old patch in half with sticky sides
together.


1) clean gloves are used; prevents the nurse from absorbing medications
through the fingertips
2) use clear water; do not use soaps, lotions, oils, or alcohol; may cause
irritations or prevent adhesion
3) heat increases absorption of medication and can lead to toxicity
4) CORRECT— patches retain enough medication to be hazardous to pets and
children; folding in this manner ensures medication is sealed inside before
disposal
The nurse cares for a client with an internal radium implant. It is MOST important

1. Restrict visitors with upper respiratory infections.
2. Assign the client to male caregivers.
3. Plan nursing activities to decrease time spent in the client’s

room.
4. Wear a lead-lined apron when caring for the client.

1) all visitors should limit time spent in the room because of the radiation
therapy
2) radiation is as harmful to males as females
3) CORRECT— nurse should decrease the time spent in close contact with the
client; do not stand in direct line of the radiation therapy
4) not required for routine care
A parent tells the nurse that her husband just learned that he has a positive PPD
and asks about risks to her 2-year-old child. Which of the following responses
by the nurse is BEST?

1. “If your child is in good health, there is little risk because of low
communicability of TB.”
2. “Your child should have an immediate chest x-ray.”
3. “Bring your child in for a PPD test as soon as possible.”

4. “Children should not receive skin testing before 4 years of age.”

1) TB has increased significantly in childhood populations. Communicability is
higher among household members
2) parent with the suspected TB diagnosis needs a chest x-ray; the child
requires skin testing at this point
3) CORRECT— contacts of persons with confirmed or suspected infectious
tuberculosis require immediate skin testing; includes children identified as
contacts of family members or associates in jail or prison in the last 5 years
4) infants may receive skin testing


room.

therapy
The nurse assesses patients on the medical/surgical unit. The nurse identifies
which of the following patients is at GREATEST risk for accident and injury?

1. A patient diagnosed with rheumatoid arthritis.
2. A patient diagnosed with a cardiovascular accident (CVA) of the
right hemisphere.
3. A patient recovering from a bilateral oophorectomy.
4. A patient recovering from a right hip replacement.
Strategy: "GREATEST risk" indicates discrimination is required to answer the

question.
(1.) not greatest safety risk
(2.) CORRECT—often disoriented to time, place, person; has visual spatial
defects; has proprioceptive difficulties, impulsive behavior, poor judgment,
decreased attention span, lack of awareness or denial of neurologic deficits
increase risk of injury
(3.) removal of both ovaries; not safety risk
(4.) ensure that legs abducted to prevent displacement of hip; CVA greatest risk
of injury
The nurse obtains a history from a client scheduled for a permanent pacemaker
insertion. It is MOST important for the nurse to convey which information to the
physician?

1. The client is diagnosed with obsessive-compulsive
disorder.
2. The client wears a hearing aid in the left ear.
3. The client works as a computer programmer.
4. The client lives in a two-story house.

question.
1) not most important; may impact teaching about pacemaker management,
specific directions likely to be followed, especially if written, but anxieties about
pacemaker function and safety may be intense
2) CORRECT— hearing aid battery may affect placement of pacemaker; should
not be placed under the left clavicle in this client
3) equipment that is grounded and well maintained is not a problem
4) clients with pacemakers do not require stair-climbing restrictions unless heart
rhythm shows marked variation in response to this activity
The physician prescribes ampicillin 125 mg IM q6h for a 76-year-old woman. The
injection site selected by the nurse should depend on which of the following?

1. The size of the muscle mass.
2. The total number of injections

ordered.
3. The position of the patient in bed.
4. The gauge of the needle.
Strategy: Determine how each answer relates to an IM injection.

1) CORRECT— must be injected deeply into large muscle mass; injection too
close to nerve or blood vessel causes neurovascular damage; best site for adult
upper outer quadrant of buttocks, best site for children midlateral thigh
2) would not determine site; with multiple injections, sites should be rotated
3) safety is most important consideration, not comfort
4) varies with type of medication, not site of injection or size of person
The nurse obtains a history from a client scheduled for a permanent pacemaker
insertion. It is MOST important for the nurse to convey which information to the
physician?

1. The client is diagnosed with obsessive-compulsive
disorder.
2. The client wears a hearing aid in the left ear.
3. The client works as a computer programmer.
4. The client lives in a two-story house.

question.
1) not most important; may impact teaching about pacemaker management,
specific directions likely to be followed, especially if written, but anxieties about
pacemaker function and safety may be intense
2) CORRECT— hearing aid battery may affect placement of pacemaker; should
not be placed under the left clavicle in this client
3) equipment that is grounded and well maintained is not a problem
4) clients with pacemakers do not require stair-climbing restrictions unless heart
rhythm shows marked variation in response to this activity
The physician prescribes ampicillin 125 mg IM q6h for a 76-year-old woman. The
injection site selected by the nurse should depend on which of the following?

1. The size of the muscle mass.
2. The total number of injections

ordered.
3. The position of the patient in bed.
4. The gauge of the needle.
Strategy: Determine how each answer relates to an IM injection.

1) CORRECT— must be injected deeply into large muscle mass; injection too
close to nerve or blood vessel causes neurovascular damage; best site for adult
upper outer quadrant of buttocks, best site for children midlateral thigh
2) would not determine site; with multiple injections, sites should be rotated
3) safety is most important consideration, not comfort
4) varies with type of medication, not site of injection or size of person
The nurse cares for a client diagnosed with active tuberculosis. It is MOST

1. Restrict visitors to immediate family only.
2. Wear a gown and gloves at all times.
3. Wear a mask and gloves when in direct contact with the

client.
4. Dispose of waste articles more frequently.

1) immediate family has probably already been exposed to the client’s
tuberculosis
2) requires airborne precautions; wear respiratory protection; place client in
private room with monitored negative air pressure
3) CORRECT— airborne precautions required
4) appropriate action to prevent spread of TB; priority is for the staff to maintain
airborne precautions
A nurse returns to work in an inpatient environment after not practicing for 5

years. The returning nurse reports to the employee health nurse that she
established hepatitis B immunity with a previous employer. Which of the
following responses by the employee health nurse is MOST appropriate?

1. “You must repeat the hepatitis immunity screen.”
2. “Would you like to verify your immunity to hepatitis B with a

blood test?”
3. “Do you have a copy of the results of your hepatitis screening?”
4. “Did you receive the hepatitis vaccine in the deltoid?”

question.
1) once hepatitis immunity has been established, there is no need to reconfirm it
2) no reason to verify immunity
3) CORRECT— confirms immunity
4) dorsal gluteal site is avoided because it is associated with low antibody rates;
more important to ask nurse for copy of the record
The assigned nurse is preparing a nursing home unit for a male client who had a
cerebrovascular accident resulting in right-sided paralysis. Which of the

1. Post a sign stating, “Keep floor dry and free of debris.”
2. Post a sign stating, “Do not use client’s right arm for
lifting.”
3. Post a sign stating, “Client is hard of hearing.”
4. Post a sign stating, “Client is paralyzed on the right

side.”


question.
1. is appropriate for any client; is not specific for this client
2) CORRECT— is common injury in clients with paralysis; because paralyzed
muscles cannot offer resistance, shoulder can be dislocated
3. is appropriate, but is not as significant as the risk for a dislocated shoulder
4. may help personnel address client’s specific needs; does not directly provide
specific directions for client management
The nurse cares for infants and children in a day care facility where there has
been an outbreak of hepatitis A. The nurse recognizes that which of the
following interventions is MOST likely to prevent a future outbreak of hepatitis
A?

1. Restrict children with symptoms of hepatitis A.
2. Instruct staff and children about proper

handwashing.
3. Administer immune globulin (IG).
4. Screen all potential staff for presence of hepatitis

A.


1) disease communicable 2 to 3 weeks before onset of jaundice and about 1
week after onset of jaundice; child may not have identifiable symptoms
2) CORRECT— most effective measure to prevent or control outbreak of
hepatitis A
3) effective if given within 2 weeks of exposure; handwashing more effective to
prevent outbreak
4) no screening procedures are available
The nurse in the outpatient clinic receives a call from the parent of a teenager
diagnosed with infectious mononucleosis. The mother complains that her child
seems angry and depressed since developing mononucleosis. Which of the
following responses by the nurse is MOST appropriate?

1. “Why do you think your child is angry?”
2. “Teens become frustrated because of feeling weak and

fatigued.”
3. “Would you like the physician to talk with your child?”
4. “My child had mono and was crabby all the time.”

1) nontherapeutic; do not ask “why” questions
2) CORRECT— because of teen’s active life style, may react with anger and
depression to the weakness and fatigue; allow teen to vent and reassure teen
that activities can be resumed after the acute phase
3) passing the buck; nurse should respond to the situation
4) nontherapeutic; focus is on nurse and not the client

The nurse cares for a client immediately following a pancreatectomy. The client
returns to the surgical unit with a drainage tube attached to low suction. The
nurse notes that there has been no drainage since the client’s return. Which of

2. Check for a kink in the drainage

tube.
3. Increase the suction.

1. complete assessment before notifying physician
2) CORRECT— should assess tubes and drainage devices to ensure patency to
prevent stress on the surgical site
3. assess before implementing
4. should monitor vital signs frequently, but will not ensure patency of the
drainage tubes
The nurse cares for a client diagnosed with croup. The nurse should follow
which of the following transmission-based precautions?

1. Standard precautions.
2. Airborne precautions.

4) CORRECT— acute viral disease of childhood that causes a resonant barking;
contact precautions required for all client care activities that require physical
skin-to-skin contact or those that require contact wit
The nurse in the outpatient clinic receives a phone call from a 16-year-old boy
who states, “There is no reason to live. I am going to shoot myself.” Which of

1. “Do you have access to a gun?”
2. “Why do you want to shoot yourself?”
3. “Think about how this will affect your

family.”
4. “Share with me what happened to you
today.”


1) CORRECT— nurse should ensure the client’s safety; determine if client has a
plan and the means to carry out the plan
2) “why” is not relevant at this time; more important to determine if teen has the
means to carry out the suicide
3) priority is teen’s safety
4) nurse should offer teen the security that the nurse is concerned about the
teen’s safety
The nurse cares for clients in the long-term care facility. A client is diagnosed
with Legionnaires’ disease. Which of the following actions by the nurse is MOST
appropriate?

1. Place the client on droplet precautions.
2. Ask for maintenance on the institution’s hot water

tank.
3. Sterilize the utensils used by the client.
4. Place filters on the air ducts of the client’s room.

1) no evidence of transmission between humans
2) CORRECT— caused by Legionella pneumophila , which is found in warm,
stagnant water such as hot water tanks, is spread by aerosolized route from the
environmental source to the client
3) client not immunocompromised
4) spread by aerosolized route such as showers, whirlpools, and air conditioning
cooling towers


room.

therapy
The public health nurse assesses a patient who is complaining of a persistent

cough with blood-tinged sputum and of night sweats. Which of the following

1. Assess the patient’s vital signs, including oxygen
saturation.
2. Place the patient on 2 L oxygen per nasal cannula.
3. Assist the patient in putting on a mask.
4. Assess the patient’s lung sounds.

Strategy: "FIRST" indicates priority.

(1.) appropriate action; however, prevention of potential spread of disease takes
precedence
(2.) may require supplemental oxygen; assessment is generally performed first
and prevention of potential spread of disease takes precedence over both
(3.) CORRECT—classic symptoms of tuberculosis; preventing the potential
spread of disease is the first priority
(4.) appropriate action, however prevention of potential spread of disease takes
precedence
The psychiatric home health nurse visits the home of a patient diagnosed with
middle-stage Alzheimer’s disease. The patient lives with his daughter and son-
in-law, who both insist he stay with them for as long as possible. Which of the
following observations MOST concerns the nurse?

1. There are extension cords on the floors behind
furniture.
2. There is a bowl of artificial fruit on a glass coffee
table.
3. There is a blow-dryer on a hook on the bathroom
wall.
4. The door locks are at the tops of the doors.
Strategy: The topic of the question is unstated.

(1.) appropriate action; prevents tripping hazard in any home, especially one
with elderly residents who may have visual and musculoskeletal conditions
predisposing them to fall; telephone and other cords should be put behind
furniture, not across open spaces
(2.) concerning but not priority; patient may think the artificial fruit is real and try
to eat it; also, glass coffee table could present an injury hazard due to its height
(can be bumped into) and substance (glass); if kept, the table could be put out of
the way of any traffic, have its edges padded, and be covered with lightweight
objects
(3.) CORRECT—the dryer itself could be hazardous to this patient in terms of
misperceptions of what it is—e.g., a gun—or in terms of improper use causing
burns or other injuries; also, having it in bathroom can increase potential for
electric shock by patient having contact with water while holding the device
when it is turned on
(4.) appropriate action; wandering is a frequent behavior of Alzheimer’s patients;
by the time patients are in the middle to late stages of the disorder, are unable to
look up and reach upward; door locks that are complex are best for Alzheimer’s
patients at any time
The nurse in the long-term care facility cares for clients during an outbreak of
Legionnaires’ disease. The nurse recognizes that which of the following clients
is MOST at risk to develop the disease?

1. A 95-year-old client diagnosed with a fractured right hip.
2. An 85-year-old client diagnosed with a right-sided

cerebrovascular accident.
3. A 75-year-old client diagnosed with Alzheimer’s.
4. A 65-year-old client diagnosed with end-stage renal disease.

1) clients with Legionnaires’ disease develop pneumonia caused by Legionella
pneumophila ; risk factors include advancing age and severe
immunosuppression
2) age is a risk factor
3) advancing age is a risk factor
4) CORRECT— risk factors include advanced age, severe immunosuppression,
end-stage renal disease, diabetes, smoking, and pulmonary disease
The nurse in the adolescent clinic talks with a teen who has come in for a yearly
physical. During the physical, the nurse learns that the teen’s best friend has
just gotten a driver’s license and a new car. Which of the following comments by
the nurse is MOST appropriate?

1. “I bet your parents are glad they don’t have to drive you
anymore.”
2. “I was so anxious when my teenager started driving.”
3. “How often do you ride in the car with your friend?”

4. “What kind of driver is your friend?”

question.
1) while parents may be glad, nurse’s priority should be screening and
counseling about accident prevention
2) nontherapeutic; focus is on nurse
3) CORRECT— nurse should assess before counseling teen about importance of
wearing seat belts and acting appropriately when riding with another teen
4) nurse first needs to determine if teen is riding with friend and then
concentrate on appropriate behavior for the passenger
The home care nurse visits a client diagnosed with cerebral palsy. The client’s
mother states that she has been having diarrhea and the physician diagnoses
viral gastroenteritis. It is MOST important for the nurse follow up on which of the
following?

1. The client’s mother prepares a sandwich for her
child.
2. The client’s mother washes her hands frequently.
3. The client’s mother is drinking Gatorade.
4. The client’s mother uses a separate tube of

toothpaste.

Strategy: “Nurse follow up” indicates something is wrong.

1) CORRECT— due to diarrhea, should not prepare foods eaten by others
2) appropriate action to prevent transmission of virus
3) appropriate action; Gatorade is a clear liquid that contains electrolytes
4) appropriate action; should use separate dishes, glasses, and toothpaste
After completing charting on a patient’s record, the nurse realizes that the
charting has been placed in the wrong patient’s chart. Which of the following

1. Complete an incident report and place a copy in the client’s file.
2. Draw a single line through each line of the incorrect entry and
write a new note explaining what occurred.
3. Use correction fluid to delete the wrong entry and write in the
space that the note was obliterated due to patient confidentiality.
4. Copy the note into the correct patient’s chart and indicate that it
was erroneously put in the wrong patient’s chart.


1) incident report is not included in the patient’s record
2) CORRECT— does not obliterate or alter what was written; new note should be
entered into patient’s record and should include time and signature
3) mistaken entries should never be obliterated
4) error needs to be corrected
The home care nurse visits a client diagnosed with AIDS. The nurse instructs the
client’s caregiver about how to prevent infection. What is the MOST important
instruction the nurse should give to the client’s caregiver?

1. “Cover your nose and mouth when you sneeze or
cough.”
2. “Get rid of all pets in the home.”
3. “Wash your hands frequently.”
4. “Wash the client’s dishes separately.”

1) appropriate action because client is susceptible to illness; priority is washing
hands
2) not necessary; client should not touch litter boxes, feces, bird droppings, or
water in the fish tank; encourage client to wash hands with soap and water after
handling the family pet
3) CORRECT— single best way to kill germs; caretaker should wash hands after
going to the bathroom and before and after fixing food; should also wash hands
before and after caring for the client
4) not necessary; wash all dishes together
The school nurse concludes a high-school students’ class about menstruation

with a discussion of toxic shock syndrome. Which of the following statements
by a student to the nurse indicates further teaching is necessary?

1. “I will only use tampons near the end of my menstrual period.”
2. “I will avoid all kinds of vaginal products that contain

deodorants.”
3. “If begin to vomit or have diarrhea during my period, I will
contact my physician.”
4. “I will use tampons during the day and sanitary pads at night.”

1) CORRECT— tampons should not be used near the end of a menstrual period
because there can be excessive vaginal dryness resulting from scant flow,
dryness can predispose the vaginal walls to damage when tam
2) appropriate action; may irritate the vulvar-vaginal lining
3) appropriate action; temperature greater than 102°F (38.9°C), vomiting, and
diarrhea are symptoms of toxic shock syndrome
4) tampons should be changed every 4 hours
The nurse instructs the mothers of toddlers about safety precautions for their
children’s eyes, ears, and noses. Which of the following is the MOST important
statement for the nurse to include?

1. "Teach your child to blow the nose first with one nostril closed
and then the other."
2. "Cotton-tipped applicators should be used only on the outer
ear."
3. "Getting a foreign object out of the ear is best done by
irrigation."
4. "If you need to give eardrops, make sure the solution is cold
rather than hot."

Strategy: All answers are implementations. Determine the outcome of each

(1.) incorrect action; blowing with one nostril closed can push foreign material
into the Eustachian tube or otherwise damage the inner canal
(2.) CORRECT—applicators are not safe for the inner ear because they can force
earwax further in and block the canal
(3.) incorrect; it depends on what the object is; irrigation is contraindicated if the
object is a bean, pasta, peanut, or other vegetative matter that will swell when
fluid contacts it
(4.) ear solutions, whether to treat ear infections or to soften and remove
cerumen, should be at room temperature; hot or cold solutions could be painful
and cause nausea and vertigo
The nurse evaluates care given by a nursing assistant. The nursing assistant
ambulates a client to the bathroom, and the nurse overhears the nursing
assistant ask a family member to stand with a client while the nursing assistant
cares for another client. Which of the following responses by the nurse is BEST?

1. “Why did you ask the family member to stay with the client?”
2. “Please stay with the client and call me if the client becomes
dizzy.”
3. “Do not ask a family member to do your job.”
4. “Did the client ask you to leave?”

1) do not ask “why” questions; priority is client safety
2) CORRECT— priority at this time is client safety; after client is safely back in
bed, nurse should review proper procedure with the nursing assistant
3) priority is to ensure the client is safe
4) yes/no question; address client safety first before determining why the
incident occurred
The nurse in the outpatient clinic assesses a school-age child brought to the
clinic because of a skateboarding accident. Which of the following questions
should the nurse ask FIRST?

1. “When did the accident occur?”
2. “Were you wearing a helmet?
3. “How long have you been

skateboarding?”
4. “Did you hit your head?”

1) appropriate question but not the first question the nurse should ask
2) should wear helmets and protective padding; priority is assessing current
injuries
3) not best question
4) CORRECT— injuries caused by skateboarding include wrist injuries and head
injuries; priority is to assess for head injury
A mother brings her 3-year-old to the pediatric clinic for a well-child visit. Which
of the following comments by the mother to the nurse is MOST important for the
nurse to address further?

1. "My child talks constantly, even when nobody is listening, is
forever asking questions, and sometimes stutters."
2. "My mother-in-law is coming for a visit in 2 weeks and I am
worried about the tension her visits generate. She spoils my
child and criticizes me."
3. "I am sorry we were a little late. There is so much renovation
work going on in the old house we live in that I almost lost track
of time."
4. "Lately my child has an imaginary friend named Peter and I am
supposed to set an extra plate at the table for him."

Strategy: "MOST important" indicates that discrimination is required to answer
the question.
(1.) may indicate that health teaching would be useful regarding expected
developmental behaviors; these are normal behaviors for a 3-year-old
(2.) psychosocial concern; further assessment would be useful in terms of
mother’s feelings, husband’s role, and limit-setting efforts already tried; may be
useful to offer recommendations for learning assertiveness, problem-solving
skills, and perhaps seeking family counseling
(3.) CORRECT—depending on the house’s age, renovation and remodeling can
spread lead dust that child and others could inhale and then develop lead
poisoning; houses built before 1978 are of concern; if such houses are being
remodeled, neither children nor pregnant women should be in them until the
work is fully done and cleaning has occurred
(4.) normal 3-year-old behavior

The nurse cares for clients on the urology unit. After assessing the clients, it is
MOST important for the nurse to instruct the support staff to monitor which of
the following clients?

1. A client diagnosed with diabetic retinopathy and hypertension.
2. A client with a blood urea nitrogen (BUN) of 35 mg/dL and serum

creatinine of 2.5 mg/dL.
3. A client with urinary albumin of 30 mg/24 h.
4. A client with a urinary output of 3,000 mL/24 h.

1) although diabetic retinopathy with hypertension may indicate renal failure,
these are not definitive diagnostic tools
2) CORRECT— indicates renal failure
3) normal >30 mg/24 h
4) may or may not indicate renal failure; composition of urine would determine
client status
The nurse’s elderly mother-in-law arrives at the nurse’s home for a short visit.
The mother-in-law informs the nurse that the numbers on the house need to be
replaced because pieces of the wood appear to be missing. Which of the

1. “I am going to schedule you for an appointment with the
ophthalmologist.”
2. “You always have something critical to say when you visit my
house.”
3. “We need to clean your glasses.”
4. “I’ll check to see if the house numbers are visible.”

1) further assessment required before implementing
2) assumes that the older adult can see adequately
3) assumes that client is unable to see because of dirty glasses
4) CORRECT— client may have macular degeneration; nurse needs to validate
what the client is reporting

The nurse cares for clients on the medical/surgical unit. Which of the following
situations requires an IMMEDIATE intervention by the nurse?

1. A patient who had a liver biopsy is resting quietly on his back
after the procedure.
2. A visitor is sitting without a mask just inside the doorway of a
patient on droplet precautions.
3. A patient who had a cholecystectomy 2 days ago is draining
greenish-brown fluid through the T-tube.
4. A patient scheduled for a cardiac catheterization is expressing
anxiety and reservations about undergoing the procedure.

Strategy: Think Maslow.

(1.) CORRECT—patient should be lying on his right side for several hours after
the procedure in order to promote hemostasis and thereby prevent hemorrhage
and bile leakage
(2.) doorway is likely to be 3 feet away from the patient, and that is the safe
distance for not wearing a mask
(3.) expected
(4.) psychosocial; assessment of patient’s concerns is essential, with possible
patient teaching; if patient has signed a consent and decides to rescind it,
patient can do so; physician should be notified
The nurse understands that debates over abortion rights are MOST often based
on conflict between which of the following pairs of ethical principles?

1. Beneficence and justice.
2. Veracity and fidelity.
3. Autonomy and
nonmaleficence.
4. Paternalism and restitution.

(1.) beneficence refers to doing good and justice refers to being fair to all people,
including—but not limited to—distribution of benefits and resources
(2.) veracity refers to truthfulness and fidelity refers to being faithful and loyal to
honoring commitments made to self or others
(3.) CORRECT—autonomy refers to the independence of the individual and the
right to have her/his own opinions, make her/his own choices, and take action
based on personal beliefs and values; nonmaleficence refers to preventing harm
to others, harm being interfering with the physical or mental well-being of
others; nonmaleficence includes both harm and the risk of harm, whether that
harm may be intentional or unintentional
(4.) paternalism refers to interfering with the liberty of another, under the
assumption that the interferer knows better than the other what is best for the
other; restitution is not an ethical principle, it is a legal remedy in contract
disputes which returns property or the financial value of a loss to the owner of
the property
The nurse in the outpatient clinic cares for a client diagnosed with peptic ulcer
disease (PUD) and gout. Which of the following orders, if written by the
physician, should the nurse question?

1. “Colchicine (Colsalide) 1 mg q 2 hours until cumulative dose of
8 mg achieved.”
2. “Allopurinol (Aloprim) 100 mg daily.”
3. “Probenecid (Benemid) 250 mg BID.”
4. “Indomethacin (Indocin) 50 mg QID.”
Strategy: Think about the side effects of each drug.

1) appropriate order; drug given to treat acute attack of gout
2) appropriate order; inhibits production of uric acid
3) appropriate order; prevents the reoccurrence of gouty arthritis
4) CORRECT— nonsteroidal anti-inflammatory; use cautiously in clients with
peptic ulcer disease
The medical/surgical unit is unusually busy at the start of the day shift, and one
RN and one nursing assistant have called in sick. The team leader plans
medication administration. The nurse determines that it is MOST important for
which of the following patients to receive their medications precisely on time?

1. A patient scheduled for discharge to a nursing home.
2. A patient scheduled for surgery.
3. A patient who is complaining about care received and

threatening to sue the hospital.
4. A patient who is a major donor to the hospital and is well known
in the community.


the question.
(1.) should receive medications as scheduled, prior to transfer if appropriate;
also, any medications to be transferred also need to be readied; not priority
(2.) CORRECT—preoperative medication needs to be given exactly at the time
prescribed; if administered too early, it will be past its maximum potency by the
time it is needed; if administered too late, its action will not have started before
anesthesia is begun
(3.) patient’s behaviors and threats do not determine priority of care
(4.) patient’s financial status, beneficiary status to the hospital, or fame in the
community do not determine priority of care

The nurse cares for clients in the local eye-care center. The nurse returns to the
desk to find four phone messages from clients who are 24 hours postoperative
after intracapsular cataract extraction. Which of the phone messages should the
nurse answer FIRST?

1. A client asks if it is appropriate to take acetaminophen (Tylenol)
for discomfort in the operative eye.
2. A client reports that he feels light-headed when assuming a
standing position.
3. A client reports mild itching in the operative eye.
4. A client states that her eyelid is swollen and she has difficulty
seeing with the affected eye.


1) expected outcome; encourage client to take mild analgesic, avoid aspirin
2) instruct client to change positions slowly
3) expected due to stitches in eyes; encourage use of cool compresses
4) CORRECT— may indicate bacterial infection; assess for yellow or green
drainage
Four children come to the office of the school nurse at the same time. After
performing an assessment, the nurse determines that the parents of which of the
following children should be contacted FIRST to come pick up their child?

1. A child with a red rash on the cheeks that makes the child’s face
look like it has been slapped.
2. A child with a fever who complains of headache, malaise,
anorexia, and an earache when chewing.
3. A child with an apparent upper respiratory infection (URI) and an
inflamed conjunctiva with swollen eyelids and watery drainage.
4. A child with clusters of small, erythematous, intensely pruritic
papules in the antecubital space.

Strategy: Determine the child who is most infectious.

(1.) indicates fifth disease; most contagious before rash appears, isolation not
required once rash appears; child can attend school
(2.) CORRECT—indicates probable mumps; communicability greatest
immediately before and after the swelling begins
(3.) symptoms are of viral conjunctivitis; not priority
(4.) describes eczema; not priority

The nurse on the medical/surgical unit notes a graduate nurse often seems
rushed during the shift and is staying overtime without pay to complete work.
The graduate nurse approaches the nurse and says, "I am having difficulty with
time management." Which of the following INITIAL responses by the nurse is
BEST?

1. "I have some ideas to help you better manage your time."
2. "How much practice did you get in school taking care of groups
of patients?"
3. "What ideas do you have as to the reasons for your time
management difficulties?"
4. "Tell me how you feel about time in general."

(1.) assess before implementing
(2.) relevant, but more important to first determine graduate’s perception about
why there is a time management problem
(3.) CORRECT—best to initially assess graduate’s perception of difficulty before
offering solutions; conveys respect, allows for free expression and analysis of
problem
(4.) relevant but not best initial response; obtains information about larger
framework and possible cultural issues; assessment should be focused
A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The
nurse should assign which of the following clients to the nursing assistant?

1. A client diagnosed with diabetes requiring a dressing change for
a stasis ulcer.
2. A client diagnosed with terminal cancer being transferred to
hospice home care.
3. A client diagnosed with cancer of the bone complaining of pain.
4. A client diagnosed with a fracture of the right leg asking to use

the urinal.

Strategy: Think about the skill level involved in each patient’s care.
1) stable patient with an expected outcome; assign to the LPN/LVN
2) requires nursing judgment; RN is the appropriate caregiver
3) requires assessment; RN is the appropriate caregiver
4) CORRECT— standard unchanging procedure
The nurse changes the dressing on a client with a large abdominal wound with
two Penrose drains in place. What is the priority information for the nurse to
include when recording this procedure?

1. Condition of surrounding tissue, time necessary to change the
dressing, type of dressing used.
2. Client’s tolerance of the procedure, time the dressing was
changed, amount of wound drainage.
3. Client’s response to the dressing change, status of Penrose
drains, type of drainage from Penrose drains.
4. Time dressing was changed, description of the wound, color and
amount of drainage from Penrose drains.

Strategy: All parts of the answer have to be correct.

1) good documentation is legible, accurate, timely, thorough, well organized, and
concise; time required to change dressing is not relevant
2) how client tolerated procedure and amount and character of drainage is
important; time required to change dressing is not relevant
3) not as complete as #4
4) CORRECT— contains essential information regarding the dressing change

It is MOST important for the nurse to consider which of the following concepts
when planning nursing care for a client from a culture other than the United
States?

1. The distance from the United States and the duration of time the
client has been in the United States.
2. The climate and topography of the client’s native country.
3. The concept of time and the organization of society in the

client’s native country.
4. The client’s financial status and physical characteristics.
Strategy: Think about the answers.

1) may impact how comfortable client is with the living in the United States, not
most important
2) familiar client and landscape may contribute to comfort level but not most
important
3) CORRECT— time orientation varies among cultural groups. Some cultures are
more oriented toward the present than the future; social environment in which a
person is raised is an essential part of the person’s cultural development and
identification
4) not most important to provide good care to a client from another country and
culture
The middle of the evening shift on the inpatient psychiatric unit is unusually
hectic, with a large census, high acuity level, three admissions in two hours, and
a fourth admission on the way. The unit secretary goes down to the emergency
department to get some needed paperwork for one patient. When she gets back
to the unit, she angrily and repeatedly exclaims about the ongoing rudeness of
the emergency department staff, including their not providing the necessary
documents. She states, "I am going home!" and starts to go toward the
coatroom. What is the BEST response by the charge nurse?

1. "Take a deep breath. Give it some thought and let me know what
you decide."
2. "You must stay here and do your job. If you leave, that will be
insubordination."
3. "Calm down. Overreacting does not do you or anyone else any
good."
4. "We are not the ones who were rude to you. Do not leave us,
because we need you."

Strategy: "BEST" indicates that discrimination is required to answer the

question.
(1.) does not solve the immediate need for the unit’s functioning calmly and
safely; also does not set a clear limit which could then later be used if
disciplinary actions were to be taken
(2.) not best; clear limit-setting and factual; it would be insubordination or
defiance because the secretary would not be recognizing or accepting the
authority of a superior; however, it does not acknowledge secretary’s feelings or
possible validity of her concerns, and as such may seem impersonal and
nonsupportive
(3.) not best; use of the word "overreacting" is certain to trigger an angry
response because it implies that something is wrong with the unit secretary and
that the emergency department incident was not serious; "calm down" can also
convey these feelings
(4.) CORRECT—priority is getting through the immediate situation on the unit;
points out reality; conveys genuineness, empathy, and positive regard, factors
that help people to grow; accepts secretary’s judgment and does not set up
conflict by disagreeing or challenging by choice of words
The nurse on the medical/surgical unit has just received report. Which of the

1. A 29-year-old woman undergoing peritoneal dialysis. The
outflow appears bloody.
2. A 35-year-old man diagnosed with acute postinfectious
glomerulonephritis. The client’s B/P is 150/90.
3. A 45-year-old woman diagnosed with P. carinii pneumonia. The
client complains of a persistent dry cough.
4. A 56-year-old man diagnosed with angina. The client is
scheduled for discharge today.

1) not unusual that because of tonicity of dialysate, endometrial lining may be
pulled through the fallopian tubes
2) hypertension caused by volume overload; give antihypertensives and
diuretics, restrict salt
3) CORRECT— opportunistic infection associated with AIDS; causes
progressive hypoxemia and cyanosis
4) stable client; requires teaching regarding importance of weight reduction,
regular exercise, and medication
The nurse cares for clients on the medical/surgical unit. While irrigating a
client’s NG tube, an LPN/LVN approaches the nurse to report that another client
is hemorrhaging from the rectum. Which of the following actions by the nurse is
MOST appropriate?

1. Instruct the LPN/LVN to take over the irrigation of the NG tube
while the nurse assesses the other client.
2. Direct the LPN/LVN to contact the physician to report the client
is bleeding.
3. Ask the LPN/LVN to obtain the client’s vital signs and
immediately report them.
4. Tell the LPN/LVN to find another nurse and report about the
client’s difficulties.


question.
1) CORRECT— irrigating an NG tube is within the scope of LPN/LVN practice and
client is stable
2) nurse should complete assessment prior to contacting the physician
3) nurse has identified that client is hemorrhaging
4) passing the buck; there is no reason to involve another nurse; priority is the
client in need of immediate care
The triage nurse in a busy emergency department prioritizes clients for

evaluation. The nurse determines that which of the following client should be
seen FIRST?

1. A client who was a restrained passenger in a motor vehicle
collision who complains of neck pain.
2. A toddler who is making harsh, high-pitched noises on
inspiration.
3. An infant with a temperature of 102.8°F (39.0°C) who received
routine immunizations yesterday.
4. A client receiving warfarin (Coumadin) who has a deep
laceration to the right hand.


1) at risk for spinal injury; airway takes precedence over potential neurological
deficit; immobilize the patient’s neck and spine until can be evaluated
2) CORRECT— stridor indicates an upper airway obstruction; airway takes
precedence in all situations
3) elevated temperature is a side effect of immunizations
4) though client requires urgent attention, airway takes precedence over
circulation
A nurse is promoted to charge nurse, and the staff is very excited about the
promotion. Three months later, the staff is very unhappy and feels as if their
colleague has abandoned them. The charge nurse reports that the supervisor is
very pleased with the charge nurse’s performance. When interacting with the
staff, the charge nurse should take which of the following actions?

1. Try to accommodate the staff as much as possible.
2. Allow the staff time and space to adapt to their colleague’s role
change.
3. Resign the position and return to the original staff nurse
position.
4. Explain to the staff that the charge nurse had to change to meet
the requirements of the position.


1) unit is in transition; staff is adapting to the behavioral changes that
accompany the charge nurse’s new role
2) CORRECT— avoidance conflict management technique is best when
individuals need a temporary cooling off or adjustment period
3) staff needs to adapt to this change; things will not return to the previous
status
4) offering explanations is not likely to reduce the discomfort
The nurse prepares to change the dressing on the wound of a 4-year-old child.
After explaining the procedure to the child, the child begins to cry and refuses to
have the dressing changed. Which of the following responses by the nurse is
BEST?

1. “When would you like to have the dressing
changed?”
2. “I’ll come back later to change the dressing.”
3. “Your mom is going to be here with you.”
4. “It’s not going to hurt at all.”

1) appropriate to offer the child choices, but this question allows the child to
refuse or delay the treatment
2) allows child time to fantasize and worry about procedure
3) CORRECT— parents offer child comfort and security and reduce the child’s
anxiety
4) more important to explain to child what they will experience and what they can
do during the procedure; do not tell the child what they will not feel

The nurse cares for a patient diagnosed with COPD who is brought to the
hospital by EMS for increasing shortness of breath. The patient is placed on a
cardiac monitor and an IV access is established. The patient’s vital signs are:
B/P 130/70, HR 84, RR 26, and oxygen saturation is 100% on 6 L oxygen per
nasal cannula. Which of the following interventions should the nurse perform
FIRST?

1. Attempt to wean the patient’s supplemental
oxygen.
2. Elevate the head of the bed to 45°.
3. Administer aminophylline (Truphylline).

4. Obtain arterial blood gases as ordered.

1) appropriate action because high oxygen flow rate may decrease the COPD
patient’s stimulus for breathing; proper positioning improves respiratory
functioning; if positioned incorrectly, other interventions would be less effective
2) CORRECT— proper positioning maximizes respiration and decreases
respiratory effort
3) appropriate action but is less effective without proper positioning
4) appropriate action; however, proper positioning maximizes respiration and
decreases respiratory effort while additional interventions are performed
The nurse in the postanesthesia care unit (PACU) assesses the motor/sensory
function of a client recovering from spinal anesthesia. The nurse notes that the
client can feel the lower extremities and is able to wiggle the toes and move the
legs. Which of the following actions should the nurse take NEXT?

2. Auscultate for bowel sounds.
3. Assess the client’s skin temperature and

color.
4. Auscultate breath sounds.
Strategy: "NEXT" indicates priority.

(1.) CORRECT—ability to feel and move toes and legs indicates motor blockade
from anesthetic is wearing off; blockage of autonomic nervous system may still
be present and cause hypotension; monitor for hypotension, gradually elevate
head of client’s bed
(2.) important to assess but priority is blood pressure due to spinal anesthesia
(3.) not related to neurological functioning
(4.) important action but priority is to determine if client is hypotensive due to
spinal anesthesia
The nursing team on the medical/surgical unit consists of an RN, an LPN, and a
nursing assistant. Which of the following clients should be assigned to the RN?

1. A client diagnosed with toxic shock
syndrome.
2. A client recovering from an ectopic
pregnancy.
3. A client recovering from a hydatidiform mole.
4. A client recovering from a vaginal

hysterectomy.

Strategy: The RN cares for clients requiring assessment, teaching, and nursing
judgment.
1) CORRECT— Staph infection that causes vomiting, diarrhea, and shock; early
diagnosis critical to avoid involvement with other organ systems; assign to the
RN
2) stable client with an expected outcome
3) degenerative anomaly of chorionic villi; curettage done to completely remove
all molar tissue; assign to nursing assistant
4) monitor pain, hemorrhage, and ability to void; assign to LPN/LVN
The triage nurse at a busy urgent care center prioritizes clients for evaluation.
The nurse determines that which of the following clients should be seen FIRST?

1. A woman at 6 weeks’ gestation who complains of left lower
quadrant abdominal pain and vaginal spotting.
2. A toddler whose parents report nausea and vomiting for 2 hours
and a fever of 102.8°F (39.0°C).
3. A patient diagnosed with renal disease who missed his dialysis
appointment the day before and who complains of swelling in
his feet and ankles.
4. A toddler who has a forehead laceration from a fall and who is
smiling and playful.

1) CORRECT— symptoms of ectopic pregnancy, which may result in death if
allowed to progress
2) though at risk for dehydration, short duration of the child’s symptoms indicate
a potential and not actual risk at this time; nurse likely to obtain an order for an
antipyretic while the patient waits for evaluation
3) likely requires dialysis; ectopic pregnancy is an actual risk
4) level of consciousness is appropriate

The nurse cares for a client diagnosed with an acute episode of pancreatitis. The
nurse should intervene if which of the following is observed?

1. A nursing assistant obtains and records the daily
weight.
2. A nurse administers morphine sulfate IV.
3. The LPN/LVN maintains nasogastric suctioning.
4. The family won’t let the client get out of bed.

1) appropriate action due to fluid and electrolyte imbalance; assess intake and
output, skin turgor, and mucus membranes
2) CORRECT— causes spasms of the sphincter of Oddi; meperidine is drug of
choice
3) appropriate action; client NPO to decrease the secretion of secretin;
nasogastric suctioning removes gastric secretions and decreases abdominal
distention
4) appropriate action; bedrest decreases the metabolic rate and the secretion of
pancreatic enzymes
The nurse cares for clients in the long-term care facility. The nursing team
consists of the RN, one LPN/LVN, and two nursing assistants. The nurse should
assign the LPN/LVN to which of the following clients?

1. A client diagnosed with Alzheimer’s disease and diabetes
requiring help with feeding.
2. A client diagnosed with a stage 2 pressure ulcer requiring a
sterile dressing change.
3. A client diagnosed with Parkinson’s disease and osteoporosis
requiring ambulation.
4. A client just transferred from the hospital after admission for
evaluation of a fall.

Strategy: Assign LPN/LVN to stable clients with expected outcomes.

(1.) assign to the nursing assistant
(2.) CORRECT—sterile dressing change appropriate assignment for the LPN/LVN
(3.) standard, unchanging procedures assigned to nursing assistant
(4.) requires assessment skills of RN
The nurse educator prepares a class on crisis management. It is MOST

important for the nurse to emphasize which of the following principles?

1. The most charismatic person should assume leadership during
a crisis.
2. During a crisis, leadership should be equally shared by the team
members.
3. A well-prepared team does not require leadership during a
crisis.
4. One person should be in charge during a crisis.
Strategy: "MOST important" indicates discrimination is required to answer the

question.
(1.) charisma is a type of personal magnetism with an exceptional ability to win
the devotion of large numbers of people; not the deciding factor about
leadership during a crisis
(2.) not effective during a crisis
(3.) good preparation helps in a crisis, but no leadership is not appropriate
during a crisis
(4.) CORRECT—autocratic or directive leadership where leader maintains strong
control and issues commands rather than makes suggestions or seeks input is
appropriate in a crisis or emergency situation
The community health nurse receives telephone messages from clients
scheduled to be seen today. After speaking to each of the clients, which of the
clients should the nurse visit FIRST?

1. A 21-year-old recovering from multiple injuries sustained in a
motor vehicle accident experiencing neck and shoulder
stiffness.
2. A 49-year-old complaining of epigastric discomfort and nausea 3
days after a cholecystectomy.
3. A 54-year-old with a history of hypertension complaining of
headache and blurred vision.
4. A 72-year-old with Parkinson’s disease who is suddenly unable
to get up out of bed.


(1.) aches and stiffness in joints and muscles expected following traumatic
injury; requires further assessment
(2.) discomfort and nausea expected following a cholecystectomy; requires
further assessment
(3.) CORRECT—symptoms of a hypertensive crisis; requires immediate
intervention
(4.) inability to ambulate can occur in advanced Parkinson’s; patient experiences
muscular rigidity and akinesia

The medical unit charge nurse plans assignments of the staff, which consists of
three RNs, one LPN/LVN, and one nursing assistant. The charge nurse
determines assignments are correct if the nursing assistant is assigned to which
of the following clients?

1. A patient with a 5-day-old ostomy requiring stoma care and
application of an ostomy appliance.
2. A patient diagnosed in a coma after suffering a head injury
requiring cranial nerve assessment and Glasgow coma scale
evaluation.
3. A patient diagnosed with a spinal cord injury requiring range of
motion (ROM) exercises and instruction about autonomic
dysreflexia.
4. A patient diagnosed with COPD and type 1 diabetes requiring a
sputum collection for culture and sensitivity and blood glucose
glucometer reading.

Strategy: Nursing assistance is assigned to stable clients with expected

outcomes.
(1.) care of newly created ostomy assigned to RN; assessment required
(2.) assessment and judgment required
(3.) instruction about autonomic dysreflexia should be done by RN
(4.) CORRECT—standard, unchanging procedures; RN should instruct nursing
assistant about type of specimen to collect, timing, proper collection container,
and appropriate labeling of specimen
Four mothers have delivered their infants vaginally within a 10-minute period.
Which of the following mothers should the nurse evaluate FIRST?

1. A multipara who delivered a 5-lb, 8-oz baby girl after 2.5 hours
of labor and has a history of rapid labor.
2. A primipara who delivered a 7-lb, 2-oz baby boy after 16 hours
of labor and is crying.
3. A multipara who delivered a 6-lb, 3-oz baby boy after 12 hours
of labor and has a history of alcohol and marijuana use.
4. A primipara who delivered a 7-lb, 10-oz baby girl after 19 hours
of labor and has a history of having been abused as a child.

Strategy: Determine the MOST unstable client.

(1.) CORRECT—precipitous labor is a risk factor for early postpartum
hemorrhage and also for amniotic fluid embolism; it is defined as a labor pattern
which progresses quickly and ends less than 3 hours from when it began;
multipara status, small fetus in a favorable position, and history of previous
rapid labors are contributing factors to this rapid labor
(2.) birth weight and delivery time are within normal limits; need to investigate
crying
(3.) will need to assess mother for alcohol withdrawal symptoms
(4.) first; birth weight and delivery time are within normal limits; careful and
thorough patient teaching and follow-up will be particularly important; since
there is a tendency for parents who have been abused as children themselves to
then abuse their own children

Which of the following is an appropriate and cost-effective measure for the
charge nurse to implement during a low-census shift?

1. Keep all staff in case the census increases.
2. Contact the hospital supervisor.
3. Dismiss excessive staff with instructions to stay by the

phone.
4. Dismiss excessive staff and give them the day off
without pay.


1) is not cost effective
2) CORRECT— excessive staff may be floated to another unit that requires
additional personnel; only supervisor will have this information
3) violates labor laws to ask nurse to stay by the phone without paying them
4) using staff on floors with increased census is a cost-effective solution
A Buddhist patient dies on the medical unit in a private room after a protracted
battle with cancer. Family and friends have gathered around the bedside. Which
of the following actions by the nurse is BEST?

1. Provide a basin of warm water and a washcloth.
2. Hand the closest family members a clean white sheet.
3. Close the door to provide privacy for chanting around the

bedside.
4. Call the hospital chaplain to tie a thread around the neck or
waist.


question.
(1.) useful if patient were Hindu; priest pours water into the mouth of the corpse
and the family washes the body before cremation
(2.) no particular need for this; the color white means death in this religion
(3.) CORRECT—in Buddhism, those at the bedside after the death often perform
last rites of chanting; a Buddhist priest should be contacted by the nurse or
family
(4.) not appropriate; in Hinduism, a Hindu priest may be called when death has
occurred and, as a blessing, might tie a string around the waist or neck of the
deceased
The nurse asks the nursing assistant to perform soapsuds enemas for a patient
scheduled for a diagnostic test. The nurse should

1. observe the returns from the enemas in the patient’s bedside
commode.
2. ask the nursing assistant to describe the returns from the
enemas.
3. ask the patient to describe the returns from the enemas.
4. palpate the patient’s abdomen, noting firmness and tenderness.

1) performing an enema is a standard, unchanging procedure that can be
delegated to the nursing assistant; responsibility and authority for performing
the task (function, activity, decision) is transferred to another individual; it is the
nurse’s responsibility to describe clear outcomes; observing returns is a part of
the task delegated and should be performed by the nursing assistant
2) CORRECT— describing returns from the enema is a part of the
responsibilities delegated; nurse should monitor performance and results
according to established goals
3) inappropriate; this information should be reported by the nursing assistant
4) should be performed by the RN if patient complains of tenderness or the
nursing assistant identifies a problem with the procedure
The nurse cares for clients on a medical/surgical unit in a large metropolitan

hospital. The family of a client diagnosed with end stage liver disease has been
consistently dissatisfied with the nursing care. Early one morning, the nurse
discovers the client has died. The charge nurse notifies the family, who come to
the hospital. Prior to the family arriving, the staff expresses concern about
having to interact with the client’s family. Which of the following responses by
the charge nurse is MOST appropriate?

1. “The nursing supervisor will be here when the family arrives.”
2. “I will notify the legal department about the family’s

complaints.”
3. “Please wash the client and place pads under the client’s
perineum.”
4. “The chaplain will greet the family.”

question.
1) passing the buck; staff should care for the client and family
2) priority is caring for the deceased client and family
3) CORRECT— appropriate postmortem care; staff’s priority is caring for the
deceased client and family; charge nurse can offer staff an opportunity to
express their feelings after caring for client
4) passing the buck; chaplain comes when requested by the family
A 10-week-old infant is admitted for recurrent pyloric stenosis. The parents have
gone to get something to eat and the grandparents are with the child. When the
nurse enters the room and prepares to insert a nasogastric (NG) tube prior to the
surgery, the grandparents say, "Don’t you need a consent for that?" Which of

1. "Thanks for reminding me. I will get the form and have you sign
it before I go any further."
2. "Consent is not needed for inserting this type of tube in any
patient."
3. "You sound worried. Let me explain how this tube works and
why it is needed before this type of surgery."
4. "This is in preparation for the surgery, and the consent for the
surgery has been signed."


question.
(1.) no consent is required for NG tube insertion; even if it were, it is not the role
of the nurse to get the consent signed, and it is not the grandparents who would
be eligible to sign it
(2.) accurate, but not best; by itself, does not get to the deeper concern being
expressed
(3.) CORRECT—answers the question directly and proceeds to make an
empathic response followed by education to address the grandparents’
underlying concern; is clear and conveys caring and respect; the consent-to-
treatment forms signed when a patient is admitted to a hospital give general
consent to routine types of procedures or treatments; routine usually implies
noninvasive and low risk for injury; invasive surgery needs specific informed
consent
(4.) accurate but does not address grandparents’ concern
A new graduate nurse is asked to make staff assignments for the first time.
Immediately after completing assignments, the nurse is called to a mandatory
new employee meeting. After returning to the unit, the graduate nurse discovers
another nurse made extensive changes to the assignments. Which of the
following responses by the new graduate is BEST?

1. “I noticed you changed the assignments. Did something happen
while I was gone?”
2. “Why did you change the assignments? The head nurse asked
me to make them.”
3. “Changing the assignments makes me appear incompetent.”
4. “I would appreciate it if you would not make changes in the

assignments.”

Strategy: Use therapeutic communication.

1) CORRECT— seeking information in a non-accusatory way; allows staff
members to discuss situation
2) don’t ask “why” questions; implies the behavior is improper without
appropriate validation
3) emotional response; should determine why assignments were changed before
responding
4) should determine the reason for the changes; because this is the graduate’s
first attempt at making assignments, it is reasonable to expect that changes may
have to be made
The nursing team at the home care agency consists of an RN, an LPN, and a
nursing assistant. The RN should assign the LPN/LVN to which of the following
clients?

1. A client just discharged from the hospital with a diagnosis of
hypertension and hypothyroidism.
2. A client recovering from a kidney transplant complaining of
fever and tenderness over the transplant site.
3. A client diagnosed with regional enteritis requiring a dressing
change for an abdominal abscess.
4. A client recovering from a hip fracture requiring assistance with
a bath and hair washing.

Strategy: Assign stable clients with expected outcomes.

1) requires the assessment and teaching skills of the RN
2) could indicate rejection or infection; requires the assessment skills of the RN
3) CORRECT— LPN/LVN recognizes normal from abnormal and can perform
dressing change
4) standard, unchanging procedure; assign to nursing assistant
The emergency department nursing educator presents an inservice on

evidentiary specimen collection in criminal or forensic cases. At the end of the
program, participants are asked to state what they remember as the most
important points that were made. Which of the following statements made by a
participant requires correction by the educator?

1. "Shotgun wadding, bullets, or head shot projections should be
wrapped in gauze and put in a cup or envelope."
2. "It is important to save any gravel, soil, grass, twigs, or glass
that are on the victim or on the sheets used for transport."
3. "Swabs of both dry and moist secretions should be air-dried
prior to placement in the appropriate container."
4. "The victim’s clothing should be carefully removed and put into
new, clean plastic bags."

Strategy: "Requires correction" indicates incorrect information.

(1.) appropriate action; the specimens may be found on the victim’s clothing or
sheets or blankets on which the person was transported
(2.) appropriate action; helps place victim at the crime scene
(3.) appropriate action; swabs and smears of vaginal, cervical, rectal, or penile
secretions should be allowed to air-dry before being placed in the appropriate
swab box or slide holder, which is then sealed in an envelope and labeled
(4.) CORRECT—correct that clothing should be removed and bagged; however,
the bags should be made of paper, not plastic, because bacteria could destroy
DNA evidence if plastic bags were used
The nurse in the outpatient clinic has four phone messages. Which of the
following messages should the nurse return FIRST?

1. An elderly client undergoing bowel prep complains of watery
diarrhea.
2. A mother of a 5-day-old infant is complaining of engorged
breasts.
3. A client who had a cataract extraction 3 days ago complains of
nausea.
4. A client with a spinal cord injury at the level of C7 complains of a
headache.


1) expected outcome
2) find out if client is breast or bottle feeding; if breast-feeding, encourage client
to nurse more frequently and empty breast completely; if bottle feeding, instruct
client to wear supportive bra and take analgesia for discomfort
3) second phone call to return; vomiting increases intraocular pressure, which
will affect the suture line
4) CORRECT— headache indicative of autonomic dysreflexia; ensure that
catheter is draining appropriately and the client’s bowels are not impacted
The nurse prepares to discharge a postpartum client in 1 hour. The client

requests more peripads, diapers, wipes, and perineal spray. Which of the
following responses by the nurse is BEST?

1. I will be glad to get these supplies for you.
2. Why don’t you stop at the store on the way

home?
3. I don’t think that you need any more supplies.
4. What items do you need during the next hour?
Strategy: Topic of question is not clearly stated.

1) nurse is responsible for maintaining costs on the unit; many insurance
companies consider ordering extra supplies the day of discharge as stockpiling
and may refuse to pay the bill
2) client does need to be responsible for obtaining needed items, but this
response is nontherapeutic
3) argumentative
4) CORRECT— provides for client’s immediate needs in a cost effective way
At a rehabilitation center for spinal chord injured (SCI) clients, the nurse
conducts an orientation session for a group of unlicensed assistive personnel
(UAP). It is MOST important for the nurse to include which of the following
statements?

1. “The clients may appear angry at times.”
2. “Obtain the client’s permission before touching

him/her.”
3. “Most clients arrive believing they will walk out of
here.”
4. “Personnel in this environment often need
counseling.”


question.
1) grief reactions and depression are common
2) CORRECT— client with spinal cord injury has reduced sensation; instruct
personnel to respect all of the client’s body and personal boundaries
3) often true in this setting; UAP will be responsible for standard, unchanging
procedures
4) burnout is high in this setting, because clients are usually young; progress is
slow and self-limiting; staff may need assistance dealing with feelings of
helplessness; client needs are priority
The nurse who is caring for patients in the outpatient clinic receives four phone
calls. Which of the following calls should the nurse return FIRST?

1. A patient reports a headache that is unrelieved by medications.
The patient reports taking two propoxyphene napsylate
acetaminophen (Darvocet-N) and two acetaminophen (Tylenol)
every 4 hours for 3 days.
2. A patient complains of left ankle pain and swelling that is
reddened and warm to the touch. The patient states the redness
and swelling occurred spontaneously and denies injury to the
ankle.
3. The mother of a toddler calls to report that her child has a rash
and a sore throat.
4. The father of a toddler calls to report that his child swallowed a
dime.


(1.) both contain acetaminophen which is 90 to 95% metabolized by the liver; at
risk for damage to the liver as a result of overdose
(2.) the possibility of an infectious process requiring evaluation and treatment
exists; an overdose takes precedence
(3.) probably Streptococcus A infection; not emergent unless patient is having
respiratory difficulty
(4.) CORRECT—nurse should immediately evaluate to determine if the toddler is
having respiratory difficulty
The nurse on the medical/surgical unit has just received report. Which of the

1. A client 1 day postop after an appendectomy.
2. A client who had a detached retina surgically repaired 4 hours

ago.
3. A client with an esophagogastric tube inserted.
4. A client 2 days postop after a laminectomy with spinal fusion.

1) stable client
2) administer analgesics and antiemetics as prescribed; report increase in pain
and instruct client not to bend from waist, cough or sneeze, or strain to have a
bowel movement
3) CORRECT— used to treat bleeding esophageal varices; assess vital signs for
decreased blood pressure and elevated pulse; ensure that balloon pressure and
volume is maintained
4) maintain body alignment; assess for sensation and circulatory status of lower
extremities
A client diagnosed with acute streptococcal glomerulonephritis (ASGN) visits

the nurse at the university health center. The client is receiving captopril
(Capoten) 25 mg PO and is concerned about side effects. Which of the following

1. “Where did you get this information?”
2. “What are your concerns?”
3. “You need to continue with the

medication.”
4. “This is the best medication for you.”

1) important to determine if client is making decisions based on valid
information; not the priority response
2) CORRECT— allows client to verbalize concerns so that nurse can give client
appropriate information to make an informed decision
3) client has the right to refuse treatment but should be given appropriate
information
4) may be a true statement but nurse should further assess client’s concerns
The nurse makes rounds on the medical unit to assess the care given by the
nursing assistants. Which of the following observations requires an intervention
by the nurse?

1. The nursing assistant places the fingers of one hand on the
wrist of a patient in order to evaluate the respirations.
2. The nursing assistant prepares to take a blood pressure in the
left arm of a patient recovering from a right mastectomy.
3. The nursing assistant weighs a patient on a standing scale while
the patient is balanced on crutches.
4. The nursing assistant prepares to take an oral temperature on a
patient recovering from a rhinoplasty.

Strategy: "Requires an intervention by the nurse" indicates that something is

wrong.
(1.) appropriate action; best if patients are not aware when respirations are being
counted, because if they are aware it is hard for them to maintain a normal
breathing pattern; fingers on the wrist makes it seem like the pulse is being
taken
(2.) appropriate action; lymphedema of the arm occurs after mastectomy; taking
blood pressure on that arm would be painful and decrease the already
compromised lymph circulation
(3.) appropriate action; if a patient uses crutches, weight should be taken with
crutches in place so patient can support weight during the process; afterward,
the crutches should be weighed and their weight then subtracted from the total
to conclude the weight of the patient
(4.) CORRECT—rhinoplasty compromises ability of patient to breathe through
the nose due to the packing in both nostrils
The clinic nurse determines that which of the following clients requires an
immediate intervention?

1. A male client whose fourth and fifth fingers are contracted onto
the palm.
2. A female client who complains of numbness, tingling, and pain
when the nurse taps lightly over the inside of her wrist.
3. A female client who reports her fingers hurt and have begun to
turn from white to blue to red in cold weather.
4. A male client in an arm cast whose fingers and wrist are
contracted.


1) characteristic appearance of Dupuytren contracture, which is a slow,
progressive contracture of the plantar fascia; not of immediate concern
2) positive response to Tinel sign, which indicates carpal tunnel syndrome;
nurse percusses lightly over median nerve on inner aspect of wrist; not of
immediate concern
3) indicates Raynaud disease; color change is normal sequence and
accompanied by tingling, numbness, and burning pain
4) CORRECT— describes Volkmann contracture, which is a type of compartment
syndrome caused by obstruction of arterial blood flow to the forearm and hand;
cannot straighten fingers, has severe pain, and there may be signs of diminished
circulation
The nurse cares for clients on a medical/surgical unit in a large metropolitan

hospital. The family of a client diagnosed with end stage liver disease has been
consistently dissatisfied with the nursing care. Early one morning, the nurse
discovers the client has died. The charge nurse notifies the family, who come to
the hospital. Prior to the family arriving, the staff expresses concern about
having to interact with the client’s family. Which of the following responses by
the charge nurse is MOST appropriate?

1. “The nursing supervisor will be here when the family arrives.”
2. “I will notify the legal department about the family’s

complaints.”
3. “Please wash the client and place pads under the client’s
perineum.”
4. “The chaplain will greet the family.”

question.
1) passing the buck; staff should care for the client and family
2) priority is caring for the deceased client and family
3) CORRECT— appropriate postmortem care; staff’s priority is caring for the
deceased client and family; charge nurse can offer staff an opportunity to
express their feelings after caring for client
4) passing the buck; chaplain comes when requested by the family
The charge nurse demonstrates an understanding of appropriate delegation

when an LPN/LVN is assigned to which of the following clients?

1. A client diagnosed with psychosis.
2. A client receiving chemotherapy.
3. A client in Buck’s traction.
4. A client receiving a blood

transfusion.


1) unstable client; requires skill of RN
2) unstable client; requires skill of RN
3) CORRECT—stable client with an expected outcome
4) unstable client; requires frequent assessment
The nurse cares for clients on the medical/surgical unit. While irrigating a
client’s NG tube, an LPN/LVN approaches the nurse to report that another client
is hemorrhaging from the rectum. Which of the following actions by the nurse is
MOST appropriate?

1. Instruct the LPN/LVN to take over the irrigation of the NG tube
while the nurse assesses the other client.
2. Direct the LPN/LVN to contact the physician to report the client
is bleeding.
3. Ask the LPN/LVN to obtain the client’s vital signs and
immediately report them.
4. Tell the LPN/LVN to find another nurse and report about the
client’s difficulties.


question.
1) CORRECT— irrigating an NG tube is within the scope of LPN/LVN practice and
client is stable
2) nurse should complete assessment prior to contacting the physician
3) nurse has identified that client is hemorrhaging
4) passing the buck; there is no reason to involve another nurse; priority is the
client in need of immediate care

A triage nurse in the outpatient clinic prioritizes patients for evaluation. Which of
the following patients does the nurse determine should be seen first?

1. A lethargic 2-month-old who has refused to nurse for 8 hours.
2. A 2-year-old complaining of elbow pain with an obvious

deformity.
3. A 5-year-old who is flushed and has a temperature of 101.9°F
(39.0°C).
4. A 6-year-old with two episodes of vomiting and a sore throat.

1) CORRECT— significant risk for dehydration and acidosis; infant’s rate of fluid
exchange is significantly higher than an adult’s and the metabolism rate is
nearly twice that of an adult’s; because the kidneys are not mature at this age,
they cannot adequately concentrate urine to conserve water
2) may be dislocated or fractured; evaluate neurovascular status of the affected
extremity and alert the patient’s caregiver to report changes while awaiting
further evaluation
3) likely flushed from fever; nurse should request an order for Tylenol or Motrin
if the child had not received either before arrival and alert the caregiver to report
changes in the patient’s condition while awaiting further evaluation
4) though vomiting may pose a risk for dehydration, symptoms likely a result of
strep throat or a virus; requires urgent evaluation but with greater body mass
and more mature organ systems, this patient is not as acute as infant
The nurse in the medical clinic performs an initial assessment for an older adult.
The client states that she does not want to be kept alive by feeding tubes or
other artificial methods. Which of the following initial responses by the nurse is
BEST?

1. "How do you feel about hospice care?"
2. "Do you have an advanced directive?"
3. "Have you told your children about how you

feel?"
4. "Tell me about your meal plan."
Strategy: "BEST" indicates discrimination may be required to answer the

question.
(1.) may want to explore how client feels about hospice, but is not the best initial
response
(2.) CORRECT—living will, durable power of attorney for health care allows client
to state wishes about life-sustaining treatment and is legally binding
(3.) important to discuss but finding out if client has advanced directive is
priority
(4.) assumes that client doesn’t want to eat; nurse should find out about
advanced directive
The nurse on the medical/surgical floor has four new admissions. Each patient
has an order for an IV to be started. It is MOST important for the nurse to start
the IV for which of the following patients?

1. A patient complaining of abdominal pain.
2. A patient diagnosed with sickle crisis.
3. A patient with poor skin turgor.
4. A patient with surgery scheduled in the

morning.

Strategy: MOST important indicates priority

1) priority is to care for client in sickle crisis
2) CORRECT— priority for fluids due to sickling of the RBCs; hydration is
important during painful sickling crisis
3) indicates dehydration; second client to receive IV therapy
4) IV started before surgery

The nurse supervises care for a patient on the hospice unit who practices
orthodox Judaism. The nurse determines care is appropriate if which of the
following is observed?

1. An unleavened wafer is placed on the tongue of the
patient.
2. The patient has a continuous intravenous morphine
infusion.
3. The patient is turned to face east as signs of death
appear.
4. The patient’s forehead is anointed with oil.
Strategy: "Care is appropriate" indicates correct nursing actions.

(1.) wafer known as the Eucharist is offered to Roman Catholic patients and may
be given by lay persons; not appropriate for an orthodox Jewish patient
(2.) CORRECT—control of pain (palliative treatment) during end of life is most
important to Jewish persons
(3.) end of life care in the Islam religion requires the dying to face east towards
Mecca
(4.) anointing with oil is performed in many Christian religions
The nurse surveys patients midway through the evening shift. It is MOST
important for the nurse to intervene in which of the following situations?

1. A patient diagnosed with emphysema and a smoker’s cough is
watching television with a visitor who is wearing a mask and
gloves.
2. A patient diagnosed with gastroesophageal reflux disease
(GERD) is sitting in a chair sipping a can of ginger ale after
eating dinner.
3. A patient diagnosed with peripheral arterial disease (PAD) is
sitting on the side of the bed with legs dangling.
4. A patient diagnosed with myasthenia gravis is being assisted
with dinner by the nursing assistant, who is cutting the food into
small pieces.

Strategy: "Nurse to intervene" indicates that something is wrong.

(1.) intervention useful but not most important; emphysema not infectious and
does not require particular infection control precautions such as mask, gloves,
or gown
(2.) not most important for intervention, although intervention would be useful;
patients with GERD should not drink carbonated beverages because they cause
increased pressure in the stomach
(3.) CORRECT—patients with peripheral vascular disease (PVD), either venous
or arterial, should sit with feet flat on the floor or comparable surface to prevent
hyperflexion of the knee and compression of pelvic, thigh, and popliteal area
vessels which would occur from the flexion and the unsupported weight of the
lower limbs
(4.) no need for intervention; patients with myasthenia gravis have easy muscle
fatigue, including muscles used for chewing and swallowing; as long as patient
can swallow, food should be cut into small bites and patient encouraged to eat
slowly
The charge nurse in the emergency department receives a call from EMS that
they are en route with four patients involved in a motor vehicle collision. Based
on the report from EMS, the nurse plans to see which of the following clients
FIRST?

1. An adult with an obvious deformity to the left knee, weak pedal
pulses bilaterally, and complaining of pain.
2. An adult without obvious injuries, a decreased level of
consciousness, and a heart rate of 126.
3. A child with an obvious deformity to the right forearm, a strong
radial pulse, and complaints of pain.
4. A child, crying uncontrollable, with an abrasion on the forehead
and a heart rate of 112.


1) likely a dislocation or fracture, pulses are equal and this is likely the client’s
baseline assessment
2) CORRECT— may be experiencing hypovolemic shock related to an unknown
hemorrhagic injury
3) likely a fracture, distal circulation is intact; risk for hemorrhage takes
precedence
4) may be at risk for neurological deficit from head injury, crying indicates
appropriate level of consciousness at this time; elevated heart rate is likely
caused by patient crying; requires evaluation; however, risk for hemorrhage
takes precedence
The nurse observes the nursing assistant perform mouth care on an elderly
client admitted to the hospital with fever of unknown origin. Which of the
following actions, if performed by the nursing assistant, requires an intervention
by the nurse?

1. The nursing assistant applies petrolatum jelly to the client’s lips.
2. The nursing assistant flushes the client’s mouth with a 50:50

dilution of hydrogen peroxide and normal saline.
3. The nursing assistant rinses the patient’s mouth with a glycerin-
based mouthwash.
4. The nursing assistant uses a soft bristled toothbrush to clean
the client’s teeth.

Strategy: “Requires an intervention” indicates an incorrect action.

1) prevents drying, cracking, and the formation of encrustations
2) used to remove debris and helps keeps the mucosa clean and moist
3) CORRECT— causes dehydration and irritation of tissues
4) used to prevent trauma to the mucosa
he home care nurse returns to the office to find four phone messages. Which of
the following messages should the nurse return FIRST?

1. The daughter of a client diagnosed with lung cancer states that
her father refuses chemotherapy today.
2. A client is asking when staples can be removed from his
abdominal incision.
3. A client with a colostomy complains that the skin is raw around
the stoma.
4. The wife of a client with a cerebrovascular accident states that
her husband is refusing a bath.

1) CORRECT— assess whether client is experiencing side effects
2) should ask client if incision is red or if there is any drainage
3) second call to be returned; ensure that skin sealant does not contain alcohol
and instruct client to use stoma powder or paste
4) stable client
The home care nurse returns to the office to find four phone messages. Which of
the following messages should the nurse return FIRST?

1. The daughter of a client diagnosed with lung cancer states that
her father refuses chemotherapy today.
2. A client is asking when staples can be removed from his
abdominal incision.
3. A client with a colostomy complains that the skin is raw around
the stoma.
4. The wife of a client with a cerebrovascular accident states that
her husband is refusing a bath.


1) CORRECT— assess whether client is experiencing side effects
2) should ask client if incision is red or if there is any drainage
3) second call to be returned; ensure that skin sealant does not contain alcohol
and instruct client to use stoma powder or paste
4) stable client
The nurse cares for clients on an acute pulmonary unit. The nurse prepares a
written report for the next shift. It is critical to communicate which of the
following to the next shift?

1. Laboratory work drawn on the client, arterial blood gas reports,
nutritional intake, and vital signs for the shift.
2. Any respiratory difficulty client has experienced, activity
tolerance, sputum production, and significant variances in vital
signs during the shift.
3. Name of client’s physician, date client was admitted, dietary
intake, and client’s general condition.
4. Urinary output, fluid intake, visits by the attending physician,
vital signs, any respiratory problems encountered.


1) all is important information, but answer choice #2 is more complete
2) CORRECT— report should include client’s status, current care plan, response
to current care, and care that requires further teaching
3) physician and date admitted can be obtained from client’s record
The nurse cares for clients on the medical/surgical floor. Which of the following
clients should the nurse assign to the LPN/LVN?

1. A client who returns after an appendectomy complicated by a
pneumothorax during surgery.
2. A client with increased intracranial pressure who responds to
painful stimuli.
3. A client diagnosed with cellulitis receiving antibiotics.
4. A client with a mandibular fracture immobilized by wiring the jaw

who is preparing for discharge.


1) requires assessment and nursing judgment; assign to RN
2) requires assessment and nursing judgment; assign to RN
3) CORRECT— stable client with expected outcome
4) requires discharge teaching regarding importance of oral hygiene and
nutrition
The nurse receives a report from the previous shift. Which of the following

1. A patient who had a lobectomy 24 hours ago and has a chest
tube.
2. A patient who had a laryngectomy 12 hours ago.
3. A patient complaining of a headache.

4. A patient in Buck’s traction for a fracture of the R femur.

1) no indication that patient is unstable
2) CORRECT— postop complications include respiratory difficulties
3) stable patient
4) assess for fat embolism; postop laryngectomy patient is priority
The nurse admits four clients to labor and delivery. Which of the following

1. A primigravida woman, cervix 5 cm dilated, baseline fetal heart
tones 125 bpm with decelerations to 100 bpm at the apex of the
contraction.
2. A multigravida woman, cervix 4 cm dilated and 60% effaced,
baseline fetal heart tones of 150 bpm increasing to 170 bpm
mirroring uterine contractions.
3. A multigravida woman, cervix 6 cm dilated, fetal presenting part
at +1, fetal heart tones 160 bpm in lower left quadrant.
4. A primigravida woman, 7 cm dilated, baseline fetal heart tones
136 bpm with periodic decelerations of 20 beats below baseline
independent of uterine contractions.


1) caused by head compression and is considered a normal finding
2) accelerations may indicate fetal well-being or may indicate an occlusion of
umbilical vein; see this client second
3) indicates healthy fetus in vertex position during first phase of labor
4) CORRECT— repetitive variable deceleration; indicates umbilical cord
occlusion that needs to be resolved
The new graduate registered nurse emerging from a patient’s room is asked by
the preceptor why the time spent with the patient was longer than expected. The
new graduate replies "I taught the patient how to use the incentive spirometer.
She did not understand that you have to inhale and hold your breath." The
preceptor responds, "It’s not inhale with an incentive spirometer, it’s exhale."
Which of the following actions should the new graduate take FIRST?

1. Return to the patient and explain that the patient should hold the
breath on exhalation, not inhalation.
2. Suggest that the preceptor join the new graduate in reviewing
the unit’s policy and procedure manual and also the
manufacturer’s guidelines for use of the machine.
3. Remind the preceptor that the new graduate just left school and
it was stressed that inhalation, not exhalation, was appropriate
for the incentive spirometer.
4. Tell the preceptor that this erroneous information is shocking
and is not appreciated, and that the matter obviously needs to
be taken to the nurse manager for resolution.


(1.) incorrect information; new graduate was correct the first time
(2.) CORRECT—referral to supporting legitimate and respected documents
defuses emotional nature of the situation and enables resolution; incentive
spirometry requires inhalation or holding of the breath 3 to 5 seconds; deep
inhalations expand alveoli and therefore prevent atelectasis and other lung
complications
(3.) does not refer to written objective documents; also somewhat implies
preceptor is not up-to-date
(4.) will antagonize the preceptor and set up a powerfully conflictive situation;
proceeding up the chain of command for resolution may be necessary, but not
initially
The new graduate registered nurse emerging from a patient’s room is asked by
the preceptor why the time spent with the patient was longer than expected. The
new graduate replies "I taught the patient how to use the incentive spirometer.
She did not understand that you have to inhale and hold your breath." The
preceptor responds, "It’s not inhale with an incentive spirometer, it’s exhale."
Which of the following actions should the new graduate take FIRST?

1. Return to the patient and explain that the patient should hold the
breath on exhalation, not inhalation.
2. Suggest that the preceptor join the new graduate in reviewing
the unit’s policy and procedure manual and also the
manufacturer’s guidelines for use of the machine.
3. Remind the preceptor that the new graduate just left school and
it was stressed that inhalation, not exhalation, was appropriate
for the incentive spirometer.
4. Tell the preceptor that this erroneous information is shocking
and is not appreciated, and that the matter obviously needs to
be taken to the nurse manager for resolution.


(2.) CORRECT—referral to supporting legitimate and respected documents
defuses emotional nature of the situation and enables resolution; incentive
spirometry requires inhalation or holding of the breath 3 to 5 seconds; deep
inhalations expand alveoli and therefore prevent atelectasis and other lung
complications
(3.) does not refer to written objective documents; also somewhat implies
preceptor is not up-to-date
proceeding up the chain of command for resolution may be necessary, but not
initially
The nurse on the medical/surgical unit prepares several clients for discharge
today. Which of the following statements, if said by one of the clients to the
nurse, indicates the need for further teaching?

1. "Because my colostomy is pink and moist, I can take a relaxing
bath."
2. "Now that I’ve had this old hip replaced, I can get back on the
tennis court."
3. "In about a week, I’ll need to have the stitches removed from my
head. Perhaps I should wear a hat while I’m outdoors."
4. "I can’t wait to go for a walk in the park. My knee feels so much
better with the new joint in place."

Strategy: "Need for further teaching" indicates incorrect information.

(1.) may resume hygiene
(2.) CORRECT—playing tennis would put the patient at risk for dislocation of the
new hip prosthesis
(3.) wearing a hat may help patient’s self-image by hiding suturesand protect
surgical site from weather conditions
(4.) client with a joint replacement is encouraged to walk to establish joint
mobility
The community health nurse receives telephone messages from clients

scheduled to be seen today. After speaking to each of the clients, which of the
clients should the nurse visit FIRST?

1. A 21-year-old recovering from multiple injuries sustained in a
motor vehicle accident experiencing neck and shoulder
stiffness.
2. A 49-year-old complaining of epigastric discomfort and nausea 3
days after a cholecystectomy.
3. A 54-year-old with a history of hypertension complaining of
headache and blurred vision.
4. A 72-year-old with Parkinson’s disease who is suddenly unable
to get up out of bed.


(1.) aches and stiffness in joints and muscles expected following traumatic
injury; requires further assessment
(2.) discomfort and nausea expected following a cholecystectomy; requires
further assessment
(3.) CORRECT—symptoms of a hypertensive crisis; requires immediate
intervention
(4.) inability to ambulate can occur in advanced Parkinson’s; patient experiences
muscular rigidity and akinesia
The nurse prepares to discharge a postpartum client in 1 hour. The client

requests more peripads, diapers, wipes, and perineal spray. Which of the

1. I will be glad to get these supplies for you.
2. Why don’t you stop at the store on the way

home?
3. I don’t think that you need any more supplies.
4. What items do you need during the next hour?

Strategy: Topic of question is not clearly stated.

1) nurse is responsible for maintaining costs on the unit; many insurance
companies consider ordering extra supplies the day of discharge as stockpiling
and may refuse to pay the bill
2) client does need to be responsible for obtaining needed items, but this
response is nontherapeutic
3) argumentative
4) CORRECT— provides for client’s immediate needs in a cost effective way
The nurse on the medical unit administered an incorrect dose of IV medication to

a client. The nurse should record which of the following statements on the
incident report?

1. “Due to illegible physician order, gentamycin (Garamycin) 9 mg
given IV at 0200 instead of 7 mg IV.”
2. “At 0200, gentamycin (Garamycin) 9 mg administered IV.
Gentamycin (Garamycin) 7 mg IV ordered.”
3. “At 0200, client received 2 mg more of gentamycin (Garamycin)
than was ordered.”
4. “Gentamycin (Garamycin) 9 mg IV was given at 0200.
Physician’s order to decrease dose was not transcribed by
previous shift.”

Strategy: Think about each answer

1) incident report is an accurate and comprehensive report on any unexpected
or unplanned occurrence that affects or could potentially affect a client, family
member, or staff; do not explain the cause or blame any staff member
2) CORRECT— describe what happened in concise, objective terms
3) draws a conclusion
4) do not assign blame or explain the cause

The nurse on the surgical unit receives a call from the operating room to
administer preoperative medication to a client scheduled for surgery. After
administering the preoperative medication, the nurse discovers that the client
has not signed the informed consent for the surgery. Which of the following
actions should the nurse take NEXT?

2. Ask the client to sign the consent form.
3. Transfer the client to the operating

room.
4. Inform the nursing supervisor.
Strategy: “NEXT” indicates priority.

1) nurse should stay within the chain of command
2) consent not valid if client has been drinking or has been premedicated
3) surgery performed without consent considered battery
4) CORRECT— nurse should follow chain of command; risks and benefits of the
procedure must be explained by the person performing the procedure
The home care nurse visits a client in a large apartment complex. During the
visit, the area experiences a major earthquake. Which of the following clients
should the nurse see FIRST?


pain.


take priority
priority
priority
The nurse cares for clients in the outpatient surgical center. Four clients
scheduled for surgery present to the surgical center at the same time. Which of
the following clients should the nurse see FIRST?

1. A 19-year-old scheduled for a tonsillectomy.
2. A 25-year-old scheduled for an inguinal hernia

repair.
3. A 32-year-old scheduled for a mastoidectomy.
4. A 39-year-old scheduled for removal of nasal

polyps.


1) not the priority client
2) stable client; not the priority
3) CORRECT— chronic ear infections often cause vertigo, priority client due to
safety
4) stable client

The nurse in the critical care unit reviews postoperative care for a patient after a
supratentorial craniotomy. It is MOST important for the nurse to instruct the aide
to do which of the following?

1. "Put an ice pack on the patient’s eyes and a cool compress on
his forehead."
2. "Determine how much pain the patient is experiencing on a
scale of 1 to 10 and report back to me."
3. "Keep the head of the bed flat, with the patient lying on his
back."
4. "If the patient starts to have a seizure, place a padded tongue
blade in his mouth right away and call for help."

Strategy: Topic of question is unstated.

(1.) CORRECT—appropriate to delegate to unlicensed assistive personnel (UAP)
application of heat or cold to a closed inflamed or painful area; patient may have
periorbital edema and burning after the surgery; ice will help with
vasoconstriction and decrease of edema; cool compress is a comfort measure
(2.) incorrect delegation; pain assessment must be done regularly and routinely
by the registered nurse
(3.) incorrect action; the head of the bed should be elevated 30 degrees to
encourage venous drainage and help prevent increased intracranial pressure;
patient may stay supine or be turned side to side; if the removed tumor was
large, patient should be turned only to the nonoperative side in order to prevent
gravity from displacing cranial contents
(4.) incorrect action; tongue blades are not used for seizure management; they
are not needed and can cause injury to teeth, affect aspiration, or even obstruct
airway
The nurse in the critical care unit reviews postoperative care for a patient after a
supratentorial craniotomy. It is MOST important for the nurse to instruct the aide
to do which of the following?

1. "Put an ice pack on the patient’s eyes and a cool compress on
his forehead."
2. "Determine how much pain the patient is experiencing on a
scale of 1 to 10 and report back to me."
3. "Keep the head of the bed flat, with the patient lying on his
back."
4. "If the patient starts to have a seizure, place a padded tongue
blade in his mouth right away and call for help."


(1.) CORRECT—appropriate to delegate to unlicensed assistive personnel (UAP)
application of heat or cold to a closed inflamed or painful area; patient may have
periorbital edema and burning after the surgery; ice will help with
vasoconstriction and decrease of edema; cool compress is a comfort measure
(2.) incorrect delegation; pain assessment must be done regularly and routinely
by the registered nurse
(3.) incorrect action; the head of the bed should be elevated 30 degrees to
encourage venous drainage and help prevent increased intracranial pressure;
patient may stay supine or be turned side to side; if the removed tumor was
large, patient should be turned only to the nonoperative side in order to prevent
gravity from displacing cranial contents
(4.) incorrect action; tongue blades are not used for seizure management; they
are not needed and can cause injury to teeth, affect aspiration, or even obstruct
airway

The nurse manager of the oncology unit is planning an inservice to address
confidentiality issues. Which of the following measures should the nurse
manager stress as being BEST to prevent confidentiality violations?

1. Keep ambulatory patients and visitors away from the nursing
station as much as possible.
2. Call patients and one another by first names only.
3. Answer the telephone by saying the type of unit, but not the
floor number.
4. Accompany the physicians doing walking rounds at the bedside.

(1.) CORRECT—much activity goes on at the nursing station in terms of in-
person and telephone conversations, paperwork, computer screens, etc., and
multiple disciplines participate there; ambulatory patients, or visitors waiting for
their needs to be addressed or just standing nearby, can easily be exposed to
information about other patients
(2.) does not prevent confidentiality violations and may be disrespectful; some
patients may prefer to be addressed by their surname
(3.) this is more likely to violate confidentiality by conveying patient’s diagnosis
to the caller (e.g., answering with "Oncology" = cancer) than if the phone were
answered simply with the floor number, which is the usual procedure
(4.) very useful in interdisciplinary collaboration and, if done correctly, in terms
of involving the patient; however, in terms of confidentiality, it can be a problem
if there is more than one patient in a room and also if discussions are held
outside patient rooms in hallways before and/or after seeing patient, as they
often are
The nurse in the diabetic specialty unit has just received report. Which of the

1. A 17-year-old boy with pale, cool skin complaining of a
headache.
2. A 28-year-old woman with fruity breath smell complaining of
thirst.
3. A 38-year-old man with a B/P of 120/50 complaining of frequent
urination and thirst.
4. A 45-year-old woman with a B/P of 90/60 and skin is hot and dry
to touch.


1) indicates hypoglycemia
2) CORRECT— indicates metabolic acidosis from ketosis
3) symptoms of diabetes
4) indicates dehydration caused by hyperglycemia; first stage of diabetic
ketoacidosis
The nurse in the postanesthesia care unit (PACU) assesses the motor/sensory
function of a client recovering from spinal anesthesia. The nurse notes that the
client can feel the lower extremities and is able to wiggle the toes and move the
legs. Which of the following actions should the nurse take NEXT?


color.

(1.) CORRECT—ability to feel and move toes and legs indicates motor blockade
from anesthetic is wearing off; blockage of autonomic nervous system may still
be present and cause hypotension; monitor for hypotension, gradually elevate
head of client’s bed
(4.) important action but priority is to determine if client is hypotensive due to
spinal anesthesia

The nurse’s elderly mother-in-law arrives at the nurse’s home for a short visit.
The mother-in-law informs the nurse that the numbers on the house need to be
replaced because pieces of the wood appear to be missing. Which of the

1. “I am going to schedule you for an appointment with the
ophthalmologist.”
2. “You always have something critical to say when you visit my
house.”
3. “We need to clean your glasses.”
4. “I’ll check to see if the house numbers are visible.”

1) further assessment required before implementing
2) assumes that the older adult can see adequately
3) assumes that client is unable to see because of dirty glasses
4) CORRECT— client may have macular degeneration; nurse needs to validate
what the client is reporting
A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The

nurse should assign which of the following clients to the nursing assistant?

1. A client diagnosed with diabetes requiring a dressing change for
a stasis ulcer.
2. A client diagnosed with terminal cancer being transferred to
hospice home care.
3. A client diagnosed with cancer of the bone complaining of pain.
4. A client diagnosed with a fracture of the right leg asking to use
the urinal.

1) stable patient with an expected outcome; assign to the LPN/LVN
2) requires nursing judgment; RN is the appropriate caregiver
3) requires assessment; RN is the appropriate caregiver
4) CORRECT— standard unchanging procedure
situations requires an IMMEDIATE intervention by the nurse?

1. A patient who had a liver biopsy is resting quietly on his back
2. A visitor is sitting without a mask just inside the doorway of a
patient on droplet precautions.
3. A patient who had a cholecystectomy 2 days ago is draining
greenish-brown fluid through the T-tube.
4. A patient scheduled for a cardiac catheterization is expressing
anxiety and reservations about undergoing the procedure.

Strategy: Think Maslow.

(1.) CORRECT—patient should be lying on his right side for several hours after
the procedure in order to promote hemostasis and thereby prevent hemorrhage
and bile leakage
(2.) doorway is likely to be 3 feet away from the patient, and that is the safe
distance for not wearing a mask
(3.) expected
(4.) psychosocial; assessment of patient’s concerns is essential, with possible
patient teaching; if patient has signed a consent and decides to rescind it,
patient can do so; physician should be notified
The nurse cares for clients on the urology unit. After assessing the clients, it is
MOST important for the nurse to instruct the support staff to monitor which of

2. A client with a blood urea nitrogen (BUN) of 35 mg/dL and serum
creatinine of 2.5 mg/dL.

1) although diabetic retinopathy with hypertension may indicate renal failure,
these are not definitive diagnostic tools
4) may or may not indicate renal failure; composition of urine would determine
client status
The nurse cares for a patient receiving lithium carbonate (Lithobid) 600 mg po
TID for the last 10 days. Which of the following nursing assessments warrants
the nurse to withhold the next scheduled dose?

1. Serum lithium level of 1.2 mEq/L.
2. Weight gain of 5 lb since initiation of

medication.
3. Fine hand tremors.
4. Loose stools
Strategy: Determine how each answer relates to lithium carbonate.

(1.) normal therapeutic range with initial treatment is 0.5 to 1.5 mEq/L
(2.) expected side effect, review low-calorie diet
(3.) frequent expected side effect known as "lithium tremor"; muscle twitching is
danger sign
(4.). CORRECT—diarrhea is sign of lithium toxicity along with oversedation,
ataxia, tinnitus, slurred speech, and muscle weakness/twitching; stop lithium
and obtain serum levels when diarrhea present
The nurse performs discharge teaching for a patient receiving ethacrynic acid
(Edecrin). The nurse determines that further teaching is needed if the client
states which of the following?

1. I will take the medication early in the
day.
2. I will contact the physician if I feel
dizzy.
3. I will take the medication with meals.
4. I will avoid orange juice and bananas.

1) appropriate action, sleep will not be disturbed by increased urination
2) loop diuretic that may cause orthostatic hypotension; instruct client to rise
slowly
3) minimizes GI upset
4) CORRECT— loop diuretics are potassium wasting; encourage client to
increase intake of potassium-rich foods
The physician orders a patient to receive D 5 W 100 cc/h and to discontinue the
IV after the fluids have infused. The nurse hangs D 5 W 1,000 cc at 0545. What
time (in military time) does the nurse anticipate discontinuing the IV fluids? Type
the correct answer in the blank.

Your Response: 1545
Correct 1545
Response:

Strategy: Miliary time uses a 24 hour time scale. To calculate times after 12
noon, add the time to 1200.
Correct answer: 1545
Ten hours from 0545 would be 0545 + 1000 = 1545.

A client is scheduled for orthopedic surgery in two weeks. The nurse notes that
the client has been taking carbamazepine (Tegretol) 100 mg BID PO for two
years. The nurse expects the physician to take which of the following actions?

1. Instruct the client to withhold the medication to the morning of
surgery.
2. Gradually discontinue the medication 24–48 hours before
surgery.
3. Increase the dosage of the medication before surgery.
4. Inform the anesthetist.

1) anticonvulsant medication is needed to prevent seizure activity; monitor
urinary and liver function, CBC, platelet and reticulocyte counts; never
discontinue suddenly
2) anticonvulsant medication is needed to prevent seizure activity
3) dose of anticonvulsant therapy determined by control of seizures; side effects
include dizziness, vertigo, fatigue, ataxia, worsening of seizures, confusion,
headache, syncope, heart failure, arrhythmias, urinary frequency and retention
4) CORRECT— anticonvulsant medication is needed to prevent seizure activity;
amount of anesthetic may need to be reduced because client is on
anticonvulsant
The nurse performs client teaching for a client receiving aluminum hydroxide
(Amphojel). The nurse determines teaching is successful if the client makes
which of the following statements?

1. “It is important to take my medicine during the evening.”
2. “By taking the medication before meals, I will decrease the side
effects.”
3. “I will take the medication after meals.”
4. “As I start to feel uncomfortable, I will take the medication.”

1) Amphojel is an antacid; neutralizes hydrochloric acid and reduces pepsin
activity; take one hour pc and hs
2) maximum acid secretion occurs 1 to 3 hours after a meal
3) CORRECT— antacids are most effective after digestion has started, but prior
to the emptying of the stomach
4) antacids are used to prevent pain by protecting the gastric mucosa
The physician orders propranolol (Inderal) for a client with type 1 diabetes
mellitus (IDDM). The client asks the nurse if there is anything special she needs
to know about this medication since she takes NPH and regular insulin each
morning. Which of the following responses by the nurse is BEST?

1. “Inderal potentiates the action of insulin and may increase the
number of episodes of hypoglycemia you experience.”
2. “Inderal interferes with the action of the insulin and may cause
you to experience hyperglycemia.”
3. “Inderal may mask symptoms of hypoglycemia, removing your
body’s early warning system.”
4. “Inderal has no effect on your body’s metabolism other than to
lower your blood pressure.”


1) no effect on blood sugar levels
3) CORRECT— beta-blockers bind beta-adrenergic receptor sites, which
prevents adrenaline from causing symptoms and glycogenolysis
4) will lower BP, but also interferes with body’s response to hypoglycemia
The nurse in the emergency department cares for a client diagnosed with a
heroin overdose. The nurse administers naloxone (Narcan) to the client. The
nurse anticipates which of the following responses?

1. Decreased pulse and pallor.
2. Decreased urinary output and

hypotension.
3. Lethargy and stupor.
4. Nausea and vomiting.

1) is a narcotic antagonist; will cause tachycardia
2) will cause hypertension due to opioid withdrawal
3) does not cause lethargy and stupor
4) CORRECT— will cause signs and symptoms of opioid withdrawal: nausea,
vomiting, restlessness, abdominal cramping
The office nurse prepares to administer iron dextran (DexFerrum) IM to a patient

with severe iron deficiency anemia. Which of the following actions indicates that
the nurse does NOT have a correct understanding of the appropriate medication
procedures?

1. The nurse adds 0.2 mL of air to the syringe after drawing up the
medication.
2. The nurse pulls the skin and subcutaneous tissue 1 inch to one
side of the intended injection site and holds it there while
injecting the medication.
3. The nurse waits 10 seconds after injecting the medication before
removing the needle.
4. The nurse proceeds to penetrate to the deltoid muscle site,
injects the medication slowly and smoothly, and massages the
site upon needle withdrawal.

Strategy: Determine the incorrect actions.

(1.) ensures an air-lock which clears excess medication from the needle; done to
prevent medication, especially irritating and/or staining medication such as iron
dextran, from leaking into the subcutaneous tissues and skin surface either on
injection or upon withdrawal of the needle
(2.) Z-track method, especially for IM administration of irritating or staining
medication
(3.) permits the medication to disperse and the muscle to start absorbing it
(4.) CORRECT—site for Z-track injection in adult must always be the dorsal
gluteal; aspiration must be done before injection to ensure the needle is in
muscle and not in a blood vessel; since iron dextran is black, it is essential to
look very closely to see if blood is being aspirated; the injection site should not
be massaged
The home care nurse observes a client administer her morning dose of insulin.
The nurse determines the client is administering the insulin correctly if which of
the following is observed?

1. The client rotates the vial between both hands for at least one
minute.
2. The client gently shakes each vial for at least one minute.
3. The client disposes of the bottle of cloudy insulin.
4. The client takes the vials out of the refrigerator for 30 minutes.
Strategy: Determine the outcome of each answer choice. Is it desired?

1) CORRECT— rotating resuspends modified insulin preparations
2) shaking causes bubbles and foam, which can alter the dose
3) Lente, protamine zinc insulin (PZI), and NPH are supposed to be cloudy
4) insulin does not have to be refrigerated; store in a cool place
The nurse cares for a patient 2 months after suffering a spinal cord injury at the
level of T-2. The nurse enters the room and notes that the client’s face is flushed,
he is sweating profusely, and his blood pressure is 260/160 mm Hg. The nurse
should prepare to administer which of the following medications?

1. Docusate sodium (Colace) 100 mg PO.
2. Prochlorperazine (Compazine) 10 mg IM.
3. Hydralazine hydrochloride (Apresoline) 10 mg

IV.
4. Diazepam (Valium) 20 mg IV.

Strategy: Think about the action of each drug.
1) stool softener; symptoms indicate autonomic dysreflexia; check for and
remove impaction
2) antiemetic used to control nausea and vomiting, anxiety; nausea is a
symptom of autonomic dysreflexia; blood pressure is priority
3) CORRECT— symptoms indicate autonomic dysreflexia; Apresoline is a fast
acting antihypertensive; relaxes smooth muscle; side effects include headache,
angina, tachycardia, palpitations, sodium retention, anorexia, lupus
erythematosus-like syndrome (sore throat, fever, muscle-joint aches, rash)
4) treatment for seizures; untreated autonomic dysreflexia can cause seizures,
CVA, MI
The nurse prepares a patient diagnosed with cervical cancer for the insertion of
an internal radiation implant. The nurse knows that it is MOST important to
respond to which of the following patient statements?

1. "Unless I have a bowel movement every day, I just do not feel
right."
2. "I am glad this whole process is only going to last 3 days."
3. "I will get up only when I have to urinate, and then I will go right
back to bed."
4. "If it were not for my children, I would not be going through all of
this."


(1.) of concern, but not priority; prior to patient receiving implant, an enema is
given so rectum is empty in order to facilitate placing the implant through the
vagina and into uterus; bowel movement during the implantation period (1–3
days) is avoided in order to prevent the implant from dislodging
(2.) internal radiation treatment for this condition is 1–3 days
(3.) CORRECT—patient will be on strict bedrest on her back with head of bed
elevated no more than 20 degrees; movement is restricted; a Foley catheter is
inserted into bladder in order to prevent the implant from being dislodged by a
full bladder or by voiding attempts; severe radiation burns can result from a
distended bladder
(4.) indicates probable depression; requires further exploration but is not priority
The nurse cares for clients in the outpatient clinic. During the nursing
assessment, the nurse learns that the client takes garlic capsules daily. After
completing the history, it is MOST important for the nurse to follow up on which
of the following client information?

1. The client was diagnosed with hypertension 2 years
ago.
2. The client takes insulin for type 1 diabetes.
3. The client is CEO of a large real-estate company.
4. The client’s father died at age 42 of a myocardial

infarction.


the question.
(1.) garlic taken for hypertension; side effects include heartburn, flatulence,
gastric irritation
(2.) CORRECT—can have direct hypoglycemic effect; may potentiate action of
diabetic drugs; information should be reported to physician
(3.) may add to stress level; hypoglycemic effect of garlic takes priority
(4.) unmodifiable risk factor for coronary artery disease; should control
hypertension, maintain appropriate body weight, monitor fats in diet, exercise
regularly
A patient suffers from a pulmonary embolism in the recovery room following abdominal
surgery. Which of the following conditions, if found by the nurse in the patient’s history,
would contraindicate the use of thrombolytic therapy?
1. The patient was diagnosed with type 2 non-insulin-dependent diabetes mellitus
(NIDDM) two years ago.
2. The patient takes medications as needed for angina pectoris.
3. The patient suffered a concussion in a car accident three weeks ago.
4. The patient uses an inhaler for treatment of asthma.
1) not contraindication; side effects of tissue plasminogen activor (t-PA) include
anaphylaxis; spontaneous bleeding cerebral, GI, GU; dysrhythmias
2) not contraindication; nursing considerations: monitor EKG, have antiarrhythmic
medication available
3) CORRECT— contraindicated with trauma in last two months, active internal bleeding,
history of hemorrhagic stroke, intracranial or intraspinal surgery, intracranial neoplasm,
atriovenous malformation, aneurysm, severe uncontrolled hypertension
4) not a contraindication; beta blocker should be used cautiously if patient has asthma

The fire alarm sounds in the general hospital that houses a locked acute inpatient
psychiatric unit on the eighth floor. The alarm code indicates that the fire is in the third-
floor medical unit. Which of the following actions should the eighth-floor nurse take
FIRST?
1. Ensure that all patients are out of their rooms and in the dayroom.
2. Assign a staff member to each of the unit’s locked doors.
3. Explore with patients their past experiences with fire and their current
concerns.
4. Prepare for evacuation of the unit using the stairs.
(1.) CORRECT—priority is direct patient care (think RACE, even though fire is not on
this unit); psychiatric patients are usually mobile versus confined to bed, and the unit
usually has a central gathering area; staff should be assigned to check all rooms and
direct patients to leave their rooms and go to the dayroom
(2.) priority is locating and centralizing patients; locked doors do need to be staffed,
particularly since fire alarms in a large institution often automatically unlock all locked
doors in the building
(3.) priority is safety of patients
(4.) not first; if evacuation is necessary, use of stairs (versus elevators) is the correct
method
The nurse cares for a client after abdominal surgery, and the client complains of gas
pains. Which of the following suggestions by the nurse is BEST?
1. Encourage the client to increase intake of fresh fruits and
vegetables.
2. Instruct the client to ambulate frequently.
3. Show the client how to splint the abdomen.
4. Position the client on the right side.
1) appropriate if client constipated
2) CORRECT— increases the return of peristalsis and facilitates the expulsion of flatus
3) decreases discomfort when client coughs and breathes deeply
4) ambulation assists client to expel flatus
The nurse assesses a client diagnosed with M é ni è re’s disease. The client reports that
even though he takes the prescribed medications regularly, he continues to have
episodes of vertigo. It is MOST important for the nurse to ask which of the following
questions?
1. “Tell me about your diet.”
2. “How are things going at work?”
3. “When was M é ni è re’s disease
diagnosed?”
4. “What were the results of your last blood
test?”
Strategy: “MOST important” indicates discrimination may be required to answer the
question.
1) CORRECT— symptoms are usually controlled by adhering to a low-sodium diet (2000
mg/day); nurse should assess if client following diet
2) a psychological evaluation may be warranted if client anxious, fearful, or depressed;
more important for nurse to determine if client adhering to medical regimen
3) priority is to determine if client is following the low-sodium diet
4) M é ni è re diagnosed through history and evaluation of cranial nerve VIII
A patient is brought to the emergency department by EMS with a blood glucose level of
32 mg/dL. The patient received 25 cc of 50% dextrose in water before arrival. While
assessing the patient, the nurse instructs the patient care tech to do which of the
following?
1. Recheck the patient’s blood
glucose.
2. Obtain orange juice for the
patient.
3. Pad the side rails of the stretcher.
4. Obtain an EKG on the patient.
1) although this is an appropriate action, the patient is at increased risk for seizures as a
result of hypoglycemia; seizure precautions should be initiated immediately on arrival
2) blood sugar will not be helped immediately with orange juice; patient is likely to have
an altered mental status at this critically low level and should remain NPO until mental
status resumes baseline or until ordered by the physician
3) CORRECT— patient is at risk for seizures, precautions should be initiated
immediately on arrival
4) should take seizure precautions
The nurse makes a prenatal visit to the home of a woman who is pregnant with her first
child. It is MOST important for the nurse to intervene if which of the following is
observed?
1. A cat is sleeping peacefully on the windowsill.
2. Cleaning supplies are in an unlocked cabinet under the
kitchen sink.
3. There are throw rugs on the living room floor.
4. The smoke detector is chirping intermittently.
(1.) CORRECT—cat presents a toxoplasmosis risk to the pregnant woman and her
unborn/newborn infant; toxoplasmosis is a parasitic disease transmitted in the feces of
cats who have eaten infected mice and animals; preventive measures include
handwashing after touching cats, have the litter box changed daily (it takes about 48
degrees for the cat’s feces to become infectious) by someone other than the pregnant
woman, prevent cats from eating raw meat or wild animals, wear gloves when
gardening, do not garden in areas frequented by cats, avoid undercooked meat and
contact with stray animals
(2.) will be an issue for future teaching prior to yet-unborn infant becoming a toddler
(3.) could be a falling hazard for the woman; priority is follow-up about the cat
(4.) indicates that battery needs changing, or that unit is defective
The nurse cares for clients on the cardiovascular unit. As the nurse is administering
medications to the clients, a nursing assistant approaches the nurse to report that a
client has a large amount of thick, dry mucus on one side of the tracheostomy tube.
Which of the following responses by the nurse to the nursing assistant is MOST
appropriate?
1. “Please take this tray of medications into the medication room for
me.”
2. “Is the client having difficulty breathing?”
3. “Take a sterile cotton swab and remove the mucus using sterile
technique.”
4. “Please find another nurse to take care of the client.”
Strategy: “MOST appropriate” indicates discrimination may be required to answer the
question.
1) passing medication is the nurse’s responsibility; nurse is responsible for managing
tray of medications
2) CORRECT— nursing assistant can observe whether or not client is in distress; many
cardiovascular drugs require administration in a timely manner; assess before
implementing
3) sterile procedures not within the scope of practice for a nursing assistant; risk
pushing the mucus into the airway
4) inappropriate delegation
A patient and spouse are visiting the outpatient neurology clinic for the first time. The
patient denies any seizure activity, but the spouse states that the patient has "fits." As
part of the workup for evaluation of seizure activity, an electroencephalogram (EEG) is
ordered for the next day. Which of the following statements is MOST important for the
nurse to include when preparing the patient for the test?
1. "Set your alarm for 2 A.M. and force yourself to stay awake for the rest of the
night."
2. "You will need to wash your hair after the test, so do not bother washing it
beforehand."
3. "Be careful not to eat or drink anything for at least 6 hours before the test."
4. "There will be harmless pricking sensations during the test as the electricity
enters your brain."
Strategy: "MOST important" indicates that discrimination is required to answer the
question.
(1.) CORRECT—patient usually needs to be sleep-deprived (from 2 or 3 A.M. onward) in
order for one part of the test to be most effectively carried out; it is during sleep that
some abnormalities are most evident
(2.) hair is washed after the test, usually with acetone and shampoo, in order to remove
the electrode gel and glue or paste from the scalp and hair; however, hair should also
be shampooed clean before the test, with no spray, oils, or hairpins used, to ensure that
EEG patches or electrodes remain firmly in place during the test
(3.) because hypoglycemia affects brain activity, food and fluids can be consumed
beforehand; caffeine-containing fluids such as tea or coffee should be avoided for 24 to
48 hours before the test
(4.) no pricking sensations, and the electricity does not enter the brain or give a shock
During a flood, two ambulances arrive at an emergency substation at the same time.
One contains a 2-year-old near drowning victim on a ventilator. The other contains an
80-year-old client with a left-sided CVA who is conscious and has a blood pressure of
220/130. Which patient should the nurse see INITIALLY?
1. The 2-year-old because she is on a ventilator.
2. The 80-year-old because he is hypertensive.
3. The 2-year-old because she is a victim of the
flooding.
4. The 80-year-old because he is older.
1) even though patient is on a ventilator, there is no indication that she is unstable
2) CORRECT— blood pressure is an obvious threat to health status and is an emergent
problem
3) no indication that patient is unstable; cause of condition is not a consideration
4) age is not a consideration to determine instability
The nurse cares for a client diagnosed with tuberculosis. The nurse should follow which
of the following transmission-based precautions?
1. Standard
precautions.
2. Airborne
precautions.
2) CORRECT— used with pathogens transmitted by airborne route
4) contact precautions required for all client care activities that require physical skin-to-
skin contact or those that require contact with contaminated inanimate objects in the
client’s environment
The nurse counsels a client diagnosed with a seizure disorder. The client has just won a
national beauty pageant and will be frequently traveling during the next year. It is MOST
important for the nurse to include which of the following instructions?
1. “Travel with a person experienced in handling health
problems.”
2. “Place your medication in a carry-on bag.”
3. “Ask for hotel rooms on the first floor.”
4. “Avoid flashing lights.”
Strategy: “MOST important” indicates discrimination is required to answer the question.
1) constant supervision not required for health management; client should carry
medical alert bracelet or card
2) CORRECT— take medication as prescribed to keep drug levels constant to prevent
seizures; should carry medication because luggage can get lost
3) should avoid exercise in excessive heat; room location not a priority
4) priority is carrying anti-seizure medication
The nurse in the pediatric clinic receives a phone call from a mother who says, “My 10-
year-old has a nosebleed that won’t stop bleeding even though I have applied
pressure.” Which of the following responses by the nurse is MOST important?
1. “Place pressure on the nose using an ice-cold
washcloth.”
2. “How much bleeding has occurred?”
3. “Instruct your child not to blow his nose.”
4. “How long have you applied pressure?”
1) appropriate action; nurse needs to first complete assessment
2) difficult for lay person to estimate
3) appropriate action; first complete assessment
4) CORRECT— assess before implementing; initially, should apply direct pressure for
5–10 minutes continuously; if this is ineffective, may require treatment with silver nitrate
applicator and Gelfoam
The nurse instructs a student nurse about the correct way to prepare a sterile field.
Place the following instructions by the nurse to the student nurse in the correct order
from the FIRST action to the LAST. All options must be used.
Strategy:
Think about each answer.
(1) Assemble the necessary equipment: prevents breaks in technique
(2) Place sterile drape on the work surface: hold drape away from body; lay bottom half
of drape on work surface and then the top half of the drape
(3) Open wrapper of sterile item: appropriate after assembling necessary equipment and
placing sterile drape on work surface
(4) Dispose of outer wrapper: prevents accidental contamination of sterile field
The nurse on the medical/surgical floor receives four new admissions. Which of the
following clients should be placed in a private room?
1. A client diagnosed with Pneumocystis carinii pneumonia.
2. A client diagnosed cellulitis of the left calf infected with group A
streptococcus .
3. A client diagnosed with Guillain-Barr é syndrome.
4. A client diagnosed with cutaneous anthrax.
1) requires standard precautions
2) CORRECT— requires contact precautions until 24 hours after initiation of effective
therapy
The nurse is caring for a patient with a pulse oximeter probe in place. Which of the
following situations requires an intervention by the nurse?
1. The probe is in place on the woman’s ring finger, which has clear polish on the
nail.
2. The emitting and receiving sensors of the probe are directly opposite each
other.
3. The hand with the probe attached is directly beneath a procedure light to
prevent chilling.
4. The SaO 2 alarm for the pulse oximeter is set at 95%.
Strategy: “Requires an intervention” indicates a complication.
1) equipment includes wave of infrared light and sensor placed on finger, nose, toe,
earlobe, or forehead; no intervention needed; measures oxygen saturation through the
skin
2) correct placement of equipment
3) CORRECT— don’t expose the probe to direct sunlight or strong light, gives
inaccurate results, cover with dry washcloths; rotate site every 4 h to prevent skin
irritation
4) normal SaO 2 is 95–100%; measures reserve oxygen attached to hemoglobin; results
below 86–91% considered emergency, below 70% life-threatening
The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse
observes the student nurse enter wearing a gown, gloves, and a facemask. The nurse
determines that the precautions are correct if the student nurse is caring for which of
1. An infant diagnosed with respiratory syncytial
virus.
2. A school-aged child diagnosed with hepatitis
A.
3. A teenager diagnosed with toxic shock
syndrome.
4. A teenager diagnosed with influenza.
Strategy: Remember transmission-based precautions.
1) requires contact precautions, no mask
4) CORRECT— droplet precautions used for organisms that can be transmitted by face-
to-face contact; door may remain open
The nurse evaluates care for an elderly client diagnosed with disseminated herpes
zoster. The nurse should intervene if which of the following is observed?
1. A nursing assistant wears an N-95 mask when entering the
room.
2. The phlebotomist leaves the door open when leaving the
room.
3. The client is placed in a room with negative air pressure.
4. The LPN/LVN removes the gown before leaving the client’s
room.
1) appropriate action; disseminated herpes zoster requires both airborne and contact
precautions
2) CORRECT— keep door closed at all times
3) appropriate action for airborne precautions
The nurse observes that a family member enters an adult client’s room, leaves the door
open, and stands 3 feet from the client. The nurse determines that these precautions are
appropriate if the client is diagnosed with which of the following?
1. Haemophilus influenzae
pneumonia.
2. Localized herpes zoster.
3. Lyme disease.
4. Influenza.
4) CORRECT— requires droplet precautions for the duration of the hospitalization
One day after a coronary artery bypass graft (CABG), the nurse discovers a client sitting
in a chair, sonorous. The client is cold and pale, and responds to verbal stimuli. Which
of the following actions by the nurse is MOST appropriate?
1. Perform cardiac assessment.
2. Review chart for prior sedative
administration.
3. Administer oxygen per nasal cannula.
4. Transfer client back to bed.
Strategy: “MOST appropriate” indicates priority
1) Transient changes in LOC can be due to hypothermia; check neurological function
every 2 to 4 hours
2) alternation in LOC due to hypothermia
3) no information to indicate oxygenation issue; more important to put client back to
bed
4) CORRECT— cold, pale client needs to be reclining in bed; hypothermia causes
vasoconstriction and hypertension; hypertension causes leakage from suture lines and
may cause bleeding
During a regional outbreak of the flu, a nursing assistant reports to work on the
oncology unit. The nurse notes that the nursing assistant is coughing and has a runny
nose, and the nurse assistant says that she has an elevated temperature. The nursing
assistant tells the nurse that she has no sick leave and is the breadwinner of her family.
Which of the following responses by the nurse is MOST appropriate?
1. “Did you take a flu shot?”
2. “You may work at the desk and help the unit secretary with the
charts.”
3. “I will call one of the other units where clients are less
vulnerable.”
4. “I’m sorry, but you will have to go home.”
question.
1) should take an annual flu shot; not relevant to this conversation
2) influenza is spread by droplets; even though nursing assistant will not be caring for
clients, will still come in contact with other staff members; clients in oncology are
immunocompromised
3) hospital is full of immunocompromised clients
4) CORRECT— during community outbreaks of the flu, should exclude staff with febrile
infections from caring for high risk clients
The nurse in the clinic formulates a teaching plan for a client with open-angle glaucoma.
The nurse should include which of the following in the teaching plan?
1. Limit eye movements.
2. Wear protective eyewear in sunlight.
3. Instill mydriatic eye drops every four hours.
4. Return to the clinic for periodic tonometer
readings.
1) implementation; moderate use of eyes allowed; glaucoma is abnormal increase in
intraocular pressure, leading to visual disability and blindness; obstruction of outflow
of aqueous humor
2) implementation; should be done by all people, not just patients with glaucoma
3) implementation; mydriatics (Atropine, Ephedrine) dilate pupil; contraindicated;
miotics used to constrict pupil (Isopto Carpine, Diamox)
4) CORRECT— implementation; 1–2 times a year; normal IOP is 10–21 mm Hg;
symptoms of glaucoma include cloudy, blurry vision, or loss of vision, artificial lights
appear to have rainbows or halos around them, decreased peripheral vision, pain,
headache, nausea, vomit
The nurse instructs a client about how to collect a 24-hour urine specimen for a
creatinine clearance test. The nurse should intervene if the client states which of the
following?
1. “I will have to have my blood drawn during the
test.”
2. “I will go to the lab after I work out in the gym.”
3. “I will drink at least one cup of water hourly.”
4. “I will void and discard the urine before the test
begins.”
Strategy: “Nurse should intervene” indicates incorrect information.
1) appropriate action; almost all creatinine in the blood is excreted by the kidneys;
creatinine clearance is most accurate indicator of renal function
2) CORRECT— creatinine is waste product of muscle breakdown; should not engage in
strenuous exercise during the test
3) appropriate action; produces urine
4) appropriate action; after discarding urine, time is noted and all urine is saved for 24
hours
The nurse obtains a health history from a 72-year-old Caucasian female. It is MOST
important for the nurse to ask which of the following questions?
1. “What kind of coffee do you drink?”
2. “When did your mother go through
menopause.”
3. “Is there a family history of osteoporosis?”
4. “Do you take calcium supplements?”
1) client at risk to develop osteoporosis; excessive caffeine intake is a risk factor;
caffeine should be ingested in moderation
2) primary osteoporosis occurs in woman after menopause; prevention is the key
3) no known familial relationship
4) CORRECT— small-framed non-obese Caucasian women are at risk; not only has a 72-
year-old woman lost bone mass, but the elderly also absorb calcium less efficiently;
should take regular calcium supplements
The nurse cares for a client diagnosed with croup. The nurse should follow which of the
following transmission-based precautions?
1. Standard
precautions.
2. Airborne
precautions.
4) CORRECT— acute viral disease of childhood that causes a resonant barking; contact
precautions required for all client care activities that require physical skin-to-skin
contact or those that require contact wit
The nurse prepares a client for surgery. Place the following preoperative activities in the
correct sequence from FIRST action to LAST. All options must be used.
Strategy:
Determine the outcome of each answer when determining the order of nursing actions.
(1) Verify that operative permit is signed: perform first before continuing preparation;
confirm that lab results are posted
(2) Obtain and record the vital signs: provides baseline for anesthesiologist
(3) Ask the client to empty the bladder: do not allow client to ambulate after receiving
preoperative medication
(4) Instruct the client to remain in bed: safety measure; raise side rails and put bed in
low position
(5) Administer preoperative medication: provide all nursing care prior to administering
preoperative medication
The home health nurse visits an elderly client who is diagnosed with diabetes and
osteoporosis. The client lives with her daughter in a two-story home. Which of the
following statements by the daughter MOST concerns the nurse?
2. "Mother seems to taking more of an interest in the things going on
around her."
3. "I sometimes feel guilty leaving her alone, even if it is just for half an
hour."
(1.) CORRECT—safety risk; oils in the bath water can result in slippery shower or
bathtub surfaces; mother is at risk for falling due to osteoporosis
(3.) may indicate that daughter may be excessively locked into the caregiver role;
caregiving feelings and options should be explored
(4.) should further assess daughter’s concern about winter; not of greatest concern
The nurse answers the call light of a patient who is complaining of a severe headache
30 minutes after undergoing a lumbar puncture. Which of the following actions should
1. Assess the puncture site.
2. Administer an analgesic as
ordered.
3. Assess the patient’s blood
pressure.
4. Encourage the patient to lie flat.
(1.) CORRECT—headaches are a common side effect of a lumbar puncture procedure,
however assessing for leakage of cerebrospinal fluid or the presence of a hematoma
that may increase the likelihood of complications is required to determine if further
intervention is indicated
(2.) appropriate action; assess before intervening
(3.) assessment of vital signs is an appropriate action, but assessment of the site takes
precedence because it may be directly linked to the patient’s symptoms
(4.) appropriate action if the patient is not following the pre- and post-procedure
instructions given by the nurse; assess before intervening
While working at a local food processing plant, a flying object penetrates an employee’s
right eye. He is admitted to an emergency department. After administering pain
medication, it is MOST important for the nurse to ask which of the following questions?
1. “Does the company provide worker’s
compensation?”
2. “Do you wear glasses?”
3. “Did you have visual problems before the
injury?”
4. “Are you afraid?”
1) priority is assessing client’s current condition
2) CORRECT— helps determine whether material other than known object had
penetrated the eye
3) relevant data but priority is to determine what material may be in the client’s eye
4) physical injury takes priority over assessment about anxiety
The nurse cares for a client with a head injury on a volume-cycled ventilator. Which of
the following actions, if performed by the nurse, BEST indicates an understanding of
proper management of a patient on a mechanical ventilator?
1. Water is added to the tubing to provide for humidification of inspired air.
2. The sigh setting on the ventilator is adjusted to occur every hour.
3. Ventilator settings are adjusted according to the patient’s serum
electrolytes.
4. A high concentration of oxygen is delivered to prevent tissue ischemia and
necrosis.
1) no water should be in tubing; check tubing for presence of water and remove;
humidifier is used
2) CORRECT— setting should be set for 1.5 times tidal volume and occur every 1–3
hours
3) setting are based on findings of arterial blood gases
4) machine is adjusted to deliver lowest concentration of oxygen to maintain normal
arterial blood gasses
The nurse in the outpatient clinic cares for a client diagnosed with Bell’s palsy. It is
MOST important for the nurse to intervene if the client makes which of the following
statements?
1. “I place the food on the unaffected side of my
mouth.”
2. “I should frequently use artificial tears.”
3. “I like to sleep with the window open.”
4. “I tape my eye shut at night.”
Strategy: “Should intervene” indicates incorrect information.
1) appropriate action; avoids trapping food in the affected side of the mouth
2) appropriate action; causes an inability to close the eye; prevents drying of the cornea
3) CORRECT— due to trigeminal hyperesthesia, protect face from cold and drafts
4) appropriate action; may use impermeable eye shield; eye ointment also helps the eye
retain moisture
During a sudden rise in a nearby river, the nurse at a day camp evacuates the children
to an area away from the river. Which of the following actions should the nurse take
NEXT?
1. Place an identification bracelet on each
child.
2. Go back for an adequate supply of water.
3. Notify the parents of the children’s
location.
4. Comfort children who are anxious.
1) CORRECT— aids in communication after rescue or recovery
2) nurse should not leave the children alone
3) identification takes priority over notification
4) priority is assuring that each child can be identified
The nurse reviews dietary guidelines with a client diagnosed with gastroesophageal
reflux disease (GERD). The nurse determines teaching is successful if the client states
1. “If my stomach feels bloated, I will drink peppermint tea.”
2. “I will switch from orange juice to tomato juice at breakfast.”
3. “I will eat three meals per day and not snack between meals.”
4. “I will sleep on my left side with my head elevated about 12
inches.”
1) peppermint exacerbates reflux; caffeine also exacerbates reflux
2) both juices are acidic and exacerbate reflux; apple juice is an appropriate alternative
3) big meals exacerbate reflux by increasing volume and pressure in the stomach as
well as delay gastric emptying
4) CORRECT— recumbent position significantly impairs esophageal clearance; head
should be elevated 6 to 12 inches to prevent nighttime reflux
The nurse in the outpatient clinic counsels a client diagnosed with genital herpes. The
client states, “I don’t know how I keep getting reinfected because I am really careful.”
Which of the following responses by the nurse is BEST?
1. “What do you mean, ‘ I am really careful’?”
2. “The virus remains in your body in a dormant
state.”
3. “Are you sure that you protect yourself
adequately?”
4. “Have you notified all of your sexual contacts?”
1) recurrences occur because virus is dormant in client’s body; recurrence is not
caused by reinfection; can shed virus even though there are no symptoms, so client
may give disease to others
2) CORRECT— should not engage in sexual activity while lesions are present; to
prevent spread, either abstain or use a condom
3) nontherapeutic; once client is infected, virus is dormant in body
4) appropriate action for STDs; priority is teaching client about the disease
The nurse on a bone marrow transplant unit receives a call from a coworker who reports
that 2 days ago her husband was possibly exposed to tuberculosis (TB) at his job.
1. “When did you have your last TB test?”
2. “What were the results of your last TB test?”
3. “Has your husband ever been exposed to TB
before?”
4. “Are you concerned that you may be infected with
TB?”
Strategy: “BEST” indicates discrimination may be required to answer the question.
1) takes 2 to 12 weeks before TB transmission can be detected; question asks about
past exposure and has no relevance to recent exposure
2) does not matter; staff member is concerned about recent exposure; while in the latent
stage, TB is not contagious
3) obtains information about husband’s past history, has no relevance to current
situation
4) CORRECT— directly addresses the coworker’s concerns; uses reflection
The nurse cares for clients on the medical/surgical unit. The nurse instructs a nursing
assistant to put elastic stockings on a client scheduled for surgery. It is MOST
important for the nurse to follow up on which of the following statements if made by the
nursing assistant?
1. “I will apply talcum powder to the client’s feet and legs before applying the
stockings.”
2. “I will elevate the client’s legs before applying the stockings.”
3. “The client has obese thighs.”
4. “I will make sure there are no wrinkles in the stockings.”
1) allows for easier application of the stockings
2) prevents stagnation of blood in the lower extremities
3) CORRECT— may decrease venous return because of constriction around thighs
4) can cause irritation to the skin
The nurse prepares a client for computerized axial tomography (CAT) scan without the
use of contrast dye. It is MOST important for the nurse to assess for which of the
following?
1. Problem client may have with being in a closed
space.
2. Allergies to medication.
3. Intact swallow and gag reflex.
4. Range of motion of all extremities.
1) CORRECT— provides three-dimensional assessment of the lungs and thorax; if client
is claustrophobic, scan may cause severe anxiety
2) not important
3) not necessary
4) client has to lie still for half an hour
The nurse instructs a client diagnosed with peptic ulcer disease (PUD) receiving
cimetidine (Tagamet). Which of the following statements, if made by the client to the
nurse, indicates that teaching is successful?
1. “I should eat foods like creamed soups, oatmeal, and
pudding.”
2. “I should eat 3 meals each day.”
3. “I can’t eat salad or strawberries.”
4. “I can drink coffee as long as it is decaffeinated.”
1) should avoid diets rich in milk and cream, stimulates acid secretions; symptoms of
PUD include dull, gnawing pain or burning in the midepigastrium
2) CORRECT— if taking a histamine blocker, small frequent feedings are not necessary;
should avoid aspirin, meat extracts, alcohol, and caffeinated beverages
3) should avoid aspirin, meat extracts, alcohol, and caffeinated beverages; other foods
are based on tolerance
4) avoid all coffee because it stimulates acid secretion; encourage to take medication
until ulcer has healed; many clients are symptom-free after a week and might
discontinue medication
The clinic nurse evaluates a client diagnosed with type 1 diabetes. Which of the
following observations indicates to the nurse that the client is not rotating insulin
injection sites?
1. A wheal develops at the site of the injection.
2. There is increased discomfort at the site of the injection.
3. Glucose levels rise temporarily.
4. There is skin breakdown and ulceration at the site of the
injection.
Strategy: Determine the significance of each answer choice and how it relates to insulin
administration.
1) represents an allergic reaction to insulin
2) repeated injections into same site become less painful rather than more
uncomfortable
3) CORRECT— failure to rotate sites results in poor absorption of insulin, which
increases blood sugar
4) is not a complication of repeated insulin injections in same site
compensation?”
injury?”
penetrated the eye
Which of the following actions, if performed by a nurse, would be considered
negligence?
1. The nurse does not aspirate before injecting heparin SQ into a patient’s
abdomen.
2. The nurse removes wrist restraints hourly and puts the patient’s arm through
passive range of motion.
3. The nurse checks the pedal pulses 2 hours after a patient returns from a
cardiac catheterization.
4. The nurse administers a preoperative injection to a patient before removing the
patient’s dentures.
Strategy: Determine the outcome of each answer choice.
1) unnecessary to aspirate before giving the medication to prevent bruising; negligence
is the unintentional failure of nurse to perform an act that a reasonable person would or
would not perform in similar circumstances; can be act of commission or omission
2) acceptable procedure to maintain range of motion while a patient is in restraints; re-
evaluate the need for restraints
3) CORRECT— checking the pedal pulses after a cardiac catheterization should be done
immediately after the procedure and repeated every 15 minutes for several hours to
detect changes in circulation; act of omission
4) acceptable procedure to prepare a patient for surgery; standards of care are the
actions that other nurses would do in the same or similar circumstances that provide
for quality client care
The nurse manager of the psychiatric unit plans the biweekly unit-wide multidisciplinary
team case conference focused on one particular patient. Which of the following patients
is MOST important for the manager to select for discussion?
1. A patient who was admitted after a second serious suicide attempt and refuses
to talk.
2. A patient toward whom the staff have sharply conflicting attitudes and actions.
3. A patient who talks to invisible beings, takes possessions from other patients,
and paces continually.
4. A patient, well known and well liked by staff, whose diagnostic testing reveals
a brain tumor.
question.
(1.) important to address, but not most important at this time; patient requires close
one-to-one observation and protection; is still a serious suicide risk, at least in part
because of the two serious suicide attempts
(2.) CORRECT—sharply conflicting attitudes and actions toward a patient must be
addressed, quickly and openly, and resolved; they are best prevented in the first place;
often stem from a patient with a personality disorder, particularly a borderline patient,
as part of their manipulative pattern of behavior
(3.) important to address but can be managed outside the multidisciplinary team case
conference at this time; behaviors reflect possible chronic schizophrenia process
(4.) important to address by the team, but not most important; staff need to be allowed
to receive accurate information, express their feelings, support one another, and plan
for care of patient, both at present and in any future follow-up
Following an exploratory laparotomy, the client requests analgesia for pain. While the
nurse is preparing the medication, the nurse asks the nursing assistant to take the
client’s vital signs. The client’s blood pressure is 97/62, pulse is 105, and respirations
are 22. The client is alert and talking, and the skin is warm, dry, and pink. The nursing
assistant asks the nurse, “How can the blood pressure be so low when the client states
she is having severe pain?” Which of the following responses by the nurse is BEST?
1. “The rapid heart beat results in decreased cardiac output, resulting in
hypotension.”
2. “You don’t need to worry about that.”
3. “I think there is another patient light on.”
4. “Did you check on the client in the next bed?”
1) CORRECT— addresses the problem directly; ANA Standards of Practice indicate the
nurse contributes to the development of support personnel, resulting in a higher quality
of heath care
2) the more information the personnel has, the better care he/she can provide
3) respect for the personnel is imperative; is entitled to an answer; nurse is the
individual with advanced knowledge; should communicate effectively with team
members
4) evasiveness does not promote trust; ANA Standards of Practice indicate the nurse
acts to establish and maintain trust among team members
The nurse in the outpatient clinic counsels an 18-year-old boy who is 6’5" tall and
weighs 190 pounds. The teen states he is trying to increase his weight. The nurse
determines that teaching is effective if the client states which of the following?
1. “I have increased my intake of fresh fruits and
vegetables.”
2. “I eat bread at each meal.”
3. “I use low-fat salad dressings.”
4. “I like to snack on pecans and raisins.”
1) foods are low in calories and high in fiber
2) adds carbohydrates but not increased calories
3) does not add calories
4) CORRECT— foods add calories and are nutritious
The nurse in the outpatient clinic counsels an 18-year-old boy who is 6’5" tall and
weighs 190 pounds. The teen states he is trying to increase his weight. The nurse
1. “I have increased my intake of fresh fruits and
vegetables.”
2. “I eat bread at each meal.”
3. “I use low-fat salad dressings.”
4. “I like to snack on pecans and raisins.”
1) foods are low in calories and high in fiber
2) adds carbohydrates but not increased calories
3) does not add calories
4) CORRECT— foods add calories and are nutritious
The nurse cares for clients on the medical/surgical floor. Because of a staffing shortage,
an RN has been reassigned from postpartum. Which of the following clients should the
nurse give to the reassigned nurse?
1. A client admitted with facial trauma after an auto accident.
2. A client diagnosed with a heat stroke.
3. A client having a systemic reaction to latex.
4. A client with progressive systemic sclerosis experiencing Raynaud’s
phenomenon.
1) requires close monitoring to assess for a patent airway; assess eye functioning,
observe for neurological changes; not a stable client
2) dehydration and hyperthermia, place in air-conditioned room, lie flat with legs
elevated, administer oxygen; not a stable client
3) potential anaphylactic reaction; not a stable client
4) CORRECT— chronic connective tissue disease that caused inflammation, fibrosis,
and sclerosis of the skin and vital organs; stable client who can be assigned to the
reassigned RN
The nurse on the long-term care unit identifies a higher than expected incidence of
impaired skin integrity among the patients. The nurse decides to call a staff meeting to
obtain the staff’s input about the problem. Which of the following suggestions, if made
by a staff member to the nurse, indicates that the staff member feels empowered to
solve the problem?
1. The nursing assistant states that the facility's sheets are too irritating and
suggests home sheets be requested or donated by employees.
2. An LPN/LVN states that incontinence during the night is the main factor and
suggests that fluids be restricted after the 6 P.M. meal.
3. An LPN/LVN states that shearing force is a contributing factor and suggests
that the nursing assistants be more gentle when repositioning the patients.
4. The RN states that patients are left sitting for too long and announces that from
now on patients will be repositioned every hour.
(1.) CORRECT—empowerment involves innovation in problem solving, resulting in a
sense of accomplishment and feeling of worth
(2.) fluids should never be restricted to control incontinence; non-innovative response
(3.) this staff member is blaming others; no evidence of empowerment
(4.) this staff member is too authoritarian, and the suggestion is unrealistic and non-
innovative
The nurse supervises care of a client in Buck’s traction. The nurse determines that care
is appropriate if which of the following is observed?
1. The nurse removes the foam boot three times per day to inspect
the skin.
2. The staff turns the client to the unaffected side.
3. The staff provides back care for the client once per shift.
4. The nurse asks the client to dorsiflex the foot on the affected leg.
5. The staff offers magazines to the client when she complains of
pain.
6. The staff elevates the foot of the client’s bed.
1) CORRECT— important to observe for skin breakdown; a second nurse should
support the extremity during the inspection
2) CORRECT— appropriate if client has a fracture; if no fracture, may turn to either side
3) back care should be provided every 2 hours to prevent pressure sores
4) CORRECT— assess function of the peroneal nerve; weakness of dorsiflexion may
indicate pressure on the nerve
5) any complaints of should be promptly investigated to rule out nerve pressure
6) CORRECT— provides countertraction
Prior to the patient’s discharge, the nurse in the cardiac unit reviews dietary
management with a patient diagnosed with hypertension. Which of the following
statements, if made by the patient to the nurse, indicates further teaching is necessary?
1. "I will use a rack whenever I cook meats."
2. "I will ask for some nice pans with nonstick coating for my
birthday."
3. "I will make stews and soups in advance and refrigerate
them."
4. "I will use vegetable oils instead of butter to fry my foods."
Strategy: "Further teaching is necessary" indicates incorrect information.
(1.) allows the fat to drip off; lean cuts of meat are best and all visible fat should be
trimmed first
(2.) decreases the need for shortening or oil
(3.) allows the fat to harden and then be skimmed off
(4.) CORRECT—low-fat, low-cholesterol diet is recommended for patients with
hypertension, fried foods should be avoided; baking, roasting, boiling, or broiling are
appropriate cooking methods
A famous rock star is admitted to a psychiatric unit with a diagnosis of major
depression with psychotic features. A nurse who works on the medical surgical unit
asks the psychiatric nurse why the patient was admitted. Which of the following
1. “I cannot share that information with you.”
2. “You can look at his chart the next time you are on the unit.”
3. “I’ll tell you why he’s here, but you have to promise not to tell anyone.”
4. “I’ll introduce you to the patient, and you can ask him about his
hospitalization.”
1) CORRECT— maintains confidentiality
2) violates patient’s confidentiality
3) violates patient’s confidentiality
4) violates patient’s privacy
A client with a history of lupus erythematous is hospitalized following a seizure. A few

minutes after admission, the client asks for something for severe pain in the right hip
joint. Because the client was applying makeup and talking on the phone when the
LPN/LVN enters the room, the LPN/LVN exited the room to confer with the charge nurse.
1. “Hold the pain medication for now. I will report the information to the
physician.”
2. “The pain medication is ordered so please give it.”
3. “Give the medication. People with chronic pain often do not exhibit
signs/symptoms of tissue injury.”
4. “Tell me exactly what you want from me.”
1) statement indicates nurse lacks competency in pain management of clients with
chronic pain; joint pain is very common in clients with lupus erythematous
2) assessment of pain before administration of analgesia is appropriate; response
should be directed at level of pain
3) CORRECT— clients with chronic pain exhibit little or no autonomic hyperactivity
4) inappropriate response; it appears the medication nurse is questioning whether or
not the client is experiencing pain and needs help figuring out what to do about the
conclusion.
The nurse instructs a client diagnosed with gout about how to prevent recurrent
attacks. It is MOST important for the nurse to include which of the following
statements?
1. “Increase your intake of dried peas, beans, and
lentils.”
2. “Drink at least 2,000–3,000 mL of fluid every day.”
3. “Decrease your intake of milk, cheese, and
yogurt.”
4. “Follow a low-carbohydrate diet.”
1) gout is characterized by overproduction or underexcretion of uric acid; high purine
foods increase incidence of gout; foods include organ meats, meat soups, gravy,
anchovies, sardines, fish, seafood, asparagus, spinach, peas, dried legumes, wild game
2) CORRECT—increases urinary uric acid excretion; eliminate or restrict alcohol intake;
drug therapy includes colchicine (Colsalide), allopurinol (Zyloprim), and NSAIDs
3) foods high in calcium can provide moderate protein; appropriate for diet
4) cause formation of ketones that inhibit uric acid excretion; high-carbohydrate diet
increases uric acid excretion
1. A client receiving tissue plasminogen activator (t-Pa).
2. A client diagnosed with Raynaud disease who had a sympathectomy.
3. A client admitted in sickling crisis.
4. A client diagnosed with dysrhythmia who had a permanent pacemaker
implanted.
1) thrombolytic given to treat embolism; side effects include anaphylaxis, spontaneous
bleeding, and dysrhythmias; client is not stable
2) CORRECT— Raynaud disease is a form of intermittent arteriolar vasoconstriction;
sympathectomy interrupts the sympathetic nerves; stable client with an expected
outcome
3) unstable client
4) assess client’s cardiac output and hemodynamic stability to evaluate the success of
the pacemaker
The nursing team includes two RNs, one LPN/LVN, a nurse reassigned from the
postpartum, and one nursing assistant. The nurse should consider the assignments
appropriate if the reassigned RN is assigned to care for which of the following clients?
1. A client diagnosed with spinal cord injury requiring assistance with meals.
2. A client diagnosed with a myocardial infarction complaining of burning on
urination.
3. A client diagnosed with terminal cancer exhibiting Cheyne-Stokes
respirations.
4. A client diagnosed with a head injury with a Glasgow coma score of 7.
Strategy: Assign stable client with expected outcome.
1) assign to the nursing assistant
2) CORRECT— reassigned RN given same clients as LPN/LVN; assign stable client with
expected outcome; burning on urination indicative of UTI
3) periodic breathing characterized by rhythmic waxing and waning of the depth of
respirations; client may be dying, RN should monitor client
4) score of 8 or less indicates severe brain damage; assign to RN
T
The nurse supervises care of a client after a laminectomy. Three staff members who
have completed training prepare to turn the client. Which of the following observations
by the nurse requires an immediate intervention?
1. One staff member stands alone holding the draw sheet.
2. Two staff members stand side by side supporting the client’s head, neck,
shoulders, hips, and knees.
3. The arms of the client are crossed on the chest.
4. The legs of the client are straight and in contact with each other.
Strategy: “Requires an intervention” indicates something is wrong.
1) appropriate action; rolling draw sheet closely toward client and holding it firmly
supports client’s torso and maintains body alignment
2) appropriate action; client movement is coordinated to move all body parts at same
time to prevent injury to neck and spinal column
3) appropriate action; keeps body straight and prevents arms from becoming trapped
under the body
4) CORRECT— pillow should be placed longitudinally between legs to prevent hip and
lower leg adduction and spinal torque
he nurse observes that two staff members have been in frequent conflict for the last
several weeks. The nurse decides to schedule a meeting with both staff members after
observing them argue while putting a client back to bed. When meeting with the staff
members, which of the following strategies by the nurse is MOST appropriate?
1. “One ground rule guiding this discussion is no negative comments are
allowed.”
2. “One of you will speak first, and the other person will refrain from commenting
until the first person is done.”
3. “I am here to listen. My expectation is for the two of you to work this out.”
4. “Each of you will summarize what you hear the other person saying. The other
person will then validate the summary.”
question.
1) one principle of conflict management is to discuss all of the issues and concerns
2) frequent exchange or feedback is more appropriate; when emotions are high,
listening decreases and content retention is low
3) because the conflict is ongoing, some type of third party intervention is needed
4) CORRECT— enhances communication; each party is actively listening and hears the
other person’s perspective
The home care nurse visits a client diagnosed with lupus erythematous. When
instructing the client, it is MOST important for the nurse to include which of the
following?
1. “Ask your physician to order a lipid profile and a urinalysis with the yearly
examination.”
2. “Ask your physician to include a blood urea nitrogen (BUN) with the
examination.”
3. “Seek psychological support with a support group if you get depressed.”
4. “Vigorous exercise will help with the aching and stiffness in your joints.”
1) CORRECT— proteinuria and hyperlipidemia are common with systemic lupus
erythematous; instructing the client empowers him/her to assume responsibility for
health
2) usually normal
3) probably should explore personal preferences with client
4) should balance rest and activity
following?
examination.”
examination.”
health
2) usually normal
The nurse cares for clients on an oncology floor. After receiving the report, which of the
following clients should the nurse assess FIRST?
1. A client diagnosed with breast cancer with extensive bone metastasis who is
irritable and confused.
2. A client who complains of nausea and vomiting 6 hours after receiving
chemotherapy.
3. A client diagnosed with lung cancer who complains of fatigue and mild
shortness of breath with ambulation.
4. A client with a white blood count of 1,600/mm 3 who complains of burning with
urination.
1) CORRECT— hypercalcemia (>10.5 mg/dL) may occur as a result of bone destruction
by the tumors; elevated levels affect mental status and can negatively affect multiple
organ systems
2) symptoms management important; electrolyte imbalance takes precedence
3) because the symptoms occur with activity, the patient requires teaching related to the
disease process and symptom management; however, electrolyte imbalance takes
precedence
4) requires evaluation of possible urinary tract infection because of low white count; an
electrolyte imbalance takes precedence
The nurse obtains a health history from a teen admitted with acute glomerulonephritis.
The nurse expects to find which of the following in the patient’s health history?
1. The teen had impetigo 2 weeks ago.
2. The teen’s mother had glomerulonephritis.
3. The teen had renal calculi 2 years earlier.
4. The teen had an untreated bladder infection 2 months
ago.
1) CORRECT— occurs 5–21 days after infection of pharynx or skin by group A β
-hemolytic streptococci; symptoms include fever, chills, hematuria, weakness, pallor,
generalized and/or facial and periorbital edema, moderate to severe hypertension
2) inflammation of glomeruli caused by immunological response and is not hereditary
3) symptoms of renal calculi include abdominal or flank pain, nausea and vomiting,
hematuria, and renal colic; no connection between renal calculi and glomerulonephritis
4) symptoms of UTI include urgency, frequency, and burning on urination
The nurse cares for a patient diagnosed with COPD who is brought to the hospital by
EMS for increasing shortness of breath. The patient is placed on a cardiac monitor and
an IV access is established. The patient’s vital signs are: B/P 130/70, HR 84, RR 26, and
oxygen saturation is 100% on 6 L oxygen per nasal cannula. Which of the following
interventions should the nurse perform FIRST?
1. Attempt to wean the patient’s supplemental
oxygen.
2. Elevate the head of the bed to 45°.
3. Administer aminophylline (Truphylline).
4. Obtain arterial blood gases as ordered.
1) appropriate action because high oxygen flow rate may decrease the COPD patient’s
stimulus for breathing; proper positioning improves respiratory functioning; if
positioned incorrectly, other interventions would be less effective
2) CORRECT— proper positioning maximizes respiration and decreases respiratory
effort
3) appropriate action but is less effective without proper positioning
4) appropriate action; however, proper positioning maximizes respiration and decreases
respiratory effort while additional interventions are performed
The nurse cares for a client who has an immediate prosthetic fitting after an above-the-
knee amputation. Which of the following actions by the nurse takes priority?
1. Observe drainage from surgically placed
drains.
2. Provide cast care to the affected extremity.
3. Observe the dressing for excessive
bleeding.
4. Elevate the residual limb for 72 hours.
1) drains are used to control formation of hematoma if soft dressing is used
2) CORRECT— closed, rigid cast prevents bleeding and controls pain; because rigid
plaster cast is used, cast care is required
3) closed rigid cast prevents bleeding
4) will cause contractures
The nurse cares for a client diagnosed with myasthenia gravis. Which of the following
clinical manifestations would the nurse expect to see?
1. Rigidity.
2. Muscle weakness that improves with
rest.
3. Paresthesia of the lower extremities.
4. Propulsive gait.
5. Ptosis.
6. Diplopia.
Strategy: Determine how each answer relates to myasthenia.
1) resistance to passive movement of the extremities; seen with Parkinson’s disease
2) CORRECT— caused by acetylcholine deficiency, transmission of nerve impulses is
limited, resulting in difficulty stimulating or initiating muscular movement; muscle
weakness increases with exertion; administer medication on time and plan activities to
follow medication
3) seen with injury to spinal canal
4) seen with Parkinson’s disease; short, hesitant steps
5) CORRECT— drooping eyelids, may also have impaired speech, dysphagia
6) CORRECT— double vision
The nurse cares for a client who is in Buck’s traction due to a fractured right hip. It is
MOST important for the nurse to take which of the following actions?
1. Assess for pain at regular intervals.
2. Encourage the client to move from side to
side.
3. Allow the weights to hang freely at all
times.
4. Remove weights if client complains of pain.
1) pain is considered the fifth vital sign and it is important to assess; client may be
given analgesics, anti-inflammatories, and/or muscle relaxants
2) should not twist from side to side; encourage client to move unaffected areas
3) CORRECT— weights need to hang freely in order to maintain traction; reposition
client frequently to maintain the proper reduction of the fracture
4) do not remove the weights unless ordered by the physician
The nurse in the postanesthesia care unit (PACU) assesses the motor/sensory function
of a client recovering from spinal anesthesia. The nurse notes that the client can feel the
lower extremities and is able to wiggle the toes and move the legs. Which of the
following actions should the nurse take NEXT?
color.
(1.) CORRECT—ability to feel and move toes and legs indicates motor blockade from
anesthetic is wearing off; blockage of autonomic nervous system may still be present
and cause hypotension; monitor for hypotension, gradually elevate head of client’s bed
(4.) important action but priority is to determine if client is hypotensive due to spinal
anesthesia
color.
anesthesia
The nurse supervises care of for a client who just had a short leg cast applied. The
nurse determines that care is appropriate if which of the following is observed?
1. The cast is covered with a light sheet.
2. The staff handles the cast using the palms of their hands.
3. The affected limb is elevated to the level of the heart.
4. The nurse compares the toes of the casted leg with the
opposite leg.
5. The staff places a fan in the client’s room.
6. The staff turns the client every 4 hours.
1) leave cast uncovered and exposed to the air
2) CORRECT— prevents development of pressure area
3) CORRECT— decreased edema
4) CORRECT— assess for neurovascular functioning; also assess circulation, motion,
and sensation in the casted extremity
5) CORRECT— increases circulation of air in room to facilitate drying the cast
6) turn the client every 2 hours to facilitate drying the cast, support major joints when
turning
The wellness nurse finishes a class series on memory improvement at the community
center. A 68-year-old female participant who appears alert, oriented, well-groomed, and
intellectually curious approaches the nurse. In the process of discussing memory
issues, the 68-year-old says that while her memory concerns seem to be common and
the same as those of other seniors at the center, there is something "strange" that has
been happening lately. "I am seeing thing that are not there. It is always people. I am
awake and sitting down and I know they are not there, but I see them." When asked if
the people she sees say anything or appear to be like anyone she knows, she says no.
Which of the following responses should the nurse make FIRST?
1. "Has anyone in your family ever been diagnosed with
schizophrenia?"
2. "What medications have you been taking recently?"
3. "Don’t worry. You may actually have been asleep and
dreaming."
4. "The Alzheimer’s organization offers some tests you may want
to take."
(1.) assessment; not appropriate; is a closed-ended question requiring only a yes or no
answer; also implies the hallucination is a symptom of schizophrenia
(2.) CORRECT—some medications can cause confusion and hallucinations
(3.) implementation; dismisses the woman’s concerns with "don’t worry" and blocks
further communication
(4.) implementation; inappropriate response, both factually and in terms of tone and
implications
The nurse cares for a client on bedrest with an order to immobilize the right leg because
of tenderness, increased warmth, and diffuse swelling. Which of the following nursing
actions is MOST appropriate?
1. Install a trapeze to the client’s bed.
2. Assess bony prominences every 12
hours.
3. Apply granular spray to bony
prominences.
4. Turn the client every 2 hours.
1) encourages the client to move independently, but does not relieve pressure on bony
prominences
2) should assess frequently
3) does not protect the bony prominences from pressure
4) CORRECT— turning client at frequent intervals prevents skin breakdown caused by
pressure, friction, or shearing forces; client is immobilized because of symptoms of
DVT
The industrial nurse receives a visit from a worker diagnosed in the early stages of
chronic renal failure. The client relates to the nurse that he does not understand why the
physician thinks he is “having trouble” with his kidneys when they are working better
than they have in the past. He states that he urinates large volumes of urine all day and
gets up to go to the bathroom all through the night. Which of the following response by
the nurse is BEST?
1. “Did you tell the physician you are putting out lots of urine?”
2. “If you manage your diabetes well, there should be no further
damage.”
3. “You seem to be very upset about this.”
4. “A high volume of urine indicates your kidneys are releasing too
much fluid.”
1) yes/no question; nontherapeutic
2) does not address the client’s misunderstand about the symptoms
3) can be appropriate lead statement when exploring subject; has enough information to
have structured discussion
4) CORRECT— hypertrophy of renal tissue results in increased surface available for
urinary excretion
The nurse instructs a client about care of a colostomy. The client is especially
concerned about controlling odor and gas. The nurse should include which of the
following instructions to the client?
1. “Place a breath mint inside the colostomy pouch.”
2. “Eat onions, beans, and cucumbers.”
3. “Drink cranberry juice and buttermilk.”
4. “Eat crackers, toast, and yogurt.”
5. “Use a commercially prepared deodorizer inside the
pouch.”
6. “Do not skip meals or chew gum.”
1) CORRECT— eliminates odors in the pouch
2) avoid these foods because they contribute to gas production
3) CORRECT— helps prevent odor; eating parsley and yogurt is also helpful
4) CORRECT— helps prevent gas
5) CORRECT— helps eliminate odors
6) CORRECT— chewing gum, skipping meals, drinking beer, and smoking contribute to
the production of flatus
The middle of the evening shift on the inpatient psychiatric unit is unusually hectic, with
a large census, high acuity level, three admissions in two hours, and a fourth admission
on the way. The unit secretary goes down to the emergency department to get some
needed paperwork for one patient. When she gets back to the unit, she angrily and
repeatedly exclaims about the ongoing rudeness of the emergency department staff,
including their not providing the necessary documents. She states, "I am going home!"
and starts to go toward the coatroom. What is the BEST response by the charge nurse?
1. "Take a deep breath. Give it some thought and let me know what you
decide."
2. "You must stay here and do your job. If you leave, that will be
insubordination."
3. "Calm down. Overreacting does not do you or anyone else any good."
4. "We are not the ones who were rude to you. Do not leave us, because we
need you."
Strategy: "BEST" indicates that discrimination is required to answer the question.
(1.) does not solve the immediate need for the unit’s functioning calmly and safely; also
does not set a clear limit which could then later be used if disciplinary actions were to
be taken
(2.) not best; clear limit-setting and factual; it would be insubordination or defiance
because the secretary would not be recognizing or accepting the authority of a
superior; however, it does not acknowledge secretary’s feelings or possible validity of
her concerns, and as such may seem impersonal and nonsupportive
(3.) not best; use of the word "overreacting" is certain to trigger an angry response
because it implies that something is wrong with the unit secretary and that the
emergency department incident was not serious; "calm down" can also convey these
feelings
(4.) CORRECT—priority is getting through the immediate situation on the unit; points
out reality; conveys genuineness, empathy, and positive regard, factors that help
people to grow; accepts secretary’s judgment and does not set up conflict by
disagreeing or challenging by choice of words
The nurse on the cardiac unit notes that a patient recovering from a myocardial
infarction appears worried and irritable. When asked about his thoughts, the patient
replies, "I’m worried about my business. You know, I own a restaurant and I’m not there.
I’m used to working 6 days a week, at least 12 hours a day. I’m worried about how
things are going there now, and I’m worried about whether I will be able to handle the
stress once I’m back there." Which of the following responses by the nurse is BEST?
1. Give him a list of complementary therapies related to relaxation and say,
"Pretend this is a menu. Which of these would you like to order for yourself?"
2. "You might find it interesting to attend the cardiac cooking class the dietitian
gives before you are discharged."
3. "Who is supposed to be taking care of the restaurant while you are here in the
hospital?"
4. Hand the patient the TV control and say, "Sometimes when I have a lot on my
mind, I watch a movie. It makes me feel better."
(1.) CORRECT—patient needs to learn to relax, both to prevent and to cope with
stressors of the job and avoid further physiologic damage; relaxation strategies also
part of cardiac rehabilitation program; providing a list of possible complementary
therapies gives the patient choices
(2.) valid idea; relates to patient’s professional life, but does not address expressed
concerns
(3.) assessment to elicit factual information related to one of the patient’s current
concerns, but by itself does not offer coping options; also, does not respond to
emotional tone and is rather closed-ended
(4.) distraction can be a valid stress management technique at times; however, this
response does not respond directly enough to the content and tone of patient’s
concerns
The nurse instructs a client with right-sided weakness how to use a cane. Which of the
following behaviors, if demonstrated by the client, indicates to the nurse that teaching
is successful?
1. The client holds the cane in his right hand, moves it forward followed by his
right leg, and then his left leg.
2. The client holds the cane in his right hand, moves the cane forward followed by
his left leg, and then his right leg.
3. The client holds the cane in his left hand, moves the cane forward followed by
his right leg, and then his left leg.
4. The client holds the cane in his left hand, moves the cane forward followed by
his left leg, and then his right leg.
Strategy: Each part of the answer has to be correct for the entire answer to be correct.
1) hold the cane on the side opposite the affected extremity (left side)
2) the purpose of the cane it to support the weak side; it is advanced at the same time
the weak extremity is advanced
3) CORRECT— the cane acts as support and aids in weight-bearing for the weaker right
leg; elbow should be flexed 30° and tip of cane should be 15 cm lateral to the base of
the fifth toe
4) cane is advanced at the same time the weak extremity advances and client leans on
cane
A woman is admitted to the hospital with a diagnosis of multiple myeloma. Her husband
states she has been complaining of persistent lower back pain. The nurse should
position the patient in which of the following positions?
1. In bed with her head elevated 45 degrees and her hips and knees moderately
flexed.
2. In bed with her head elevated 60 degrees and her arms resting on the
overhead table.
3. In bed with the head of the bed elevated 15 degrees and her legs extended.
4. In a straight-backed chair with her feet resting on the floor.
Strategy: Determine outcome of each answer.
1) CORRECT— flexing knees relieves pressure on sciatic nerve and disk
2) position for orthopnea; would put pressure on lumbosacral region
3) knees should be flexed for comfort
4) knees should be higher than hips for comfort; encourage client to alternate lying,
sitting, and walking
The charge nurse meets with the head nurse to discuss the staff’s concerns about
implementing a new delivery of care model. The charge nurse gives the head nurse a
document providing extensive rationales about why the staff has voted not to
implement the new model. Which of the following actions by the head nurse is MOST
appropriate?
1. Inform the charge nurse that the process was inappropriately initiated.
2. Reprimand the charge nurse in writing for insubordination.
3. Instruct nurse to inform the staff that the delivery model will be implemented.
4. Meet with the staff to obtain feedback regarding their concerns about the
delivery model.
1) CORRECT— the role of the charge nurse is to support agency decisions; charge
nurse should have informed staff that voting would not negate the process
2) insubordination is disobedience to authority; charge nurse made a mistake in
allowing staff to vote
3) does not deal with the charge nurse’s decision
4) does not deal with the charge nurse’s decision
Which of the following is an appropriate and cost-effective measure for the charge
nurse to implement during a low-census shift?
1. Keep all staff in case the census increases.
2. Contact the hospital supervisor.
3. Dismiss excessive staff with instructions to stay by the
phone.
4. Dismiss excessive staff and give them the day off
without pay.
1) is not cost effective
2) CORRECT— excessive staff may be floated to another unit that requires additional
personnel; only supervisor will have this information
3) violates labor laws to ask nurse to stay by the phone without paying them
4) using staff on floors with increased census is a cost-effective solution
The hospital nursing educator plans an inservice for staff on the topic of working with
interpreters. Which of the following statements is MOST important for the nurse to
include?
1. "Look directly at the interpreter while you are asking the questions."
2. "Keep your questions short and simple in structure and wording."
3. "Interrupt the patient and interpreter if they seem to be talking longer than the
question requires."
4. "Focus primarily on the patient’s body language and tone of voice."
(1.) look directly at the patient; reinforces nurse’s interest in patient and allows for
observation of nonverbal behaviors
(2.) CORRECT—easiest for interpreter to understand and translate and for patient to
understand and answer; do not use medical jargon, slang, clichés, contractions, and
pronouns; phrase questions so that they are focused on getting only one answer at a
time
(3.) may take longer to directly say or explain something in non-English; occurs when
word and/or concept has no equivalent in the other culture, when topic is seen by the
other culture as embarrassing or taboo, when there are dialect differences
(4.) focus on words as they are translated to the nurse so the nurse can formulate a new
question; do note patient’s body language and tone of voice
The home care nurse visits a client diagnosed with progressive systemic sclerosis. The
client complains that she is having more trouble swallowing and moving her right hand.
1. “Eat small, frequent meals.”
2. “Participate in a support group.”
3. “Wear a glove on the right hand.”
4. “Lie down for one hour after
eating.”
1) CORRECT— progressive systemic sclerosis causes dysphagia and esophageal
reflux; instruct client to avoid spicy foods, caffeine, and alcohol because they stimulate
gastric secretions
2) appropriate suggestion, but physical needs take priority
3) appropriate action for Raynaud phenomenon if client can tolerate the pressure of the
glove on her hand; eating takes priority
4) should sit up during meal and for at least one hour after each meal; instruct client to
chew each bite of food thoroughly
The school nurse is observing a high-school basketball game. Two cheerleaders are
tumbling and hit each other in mid-air. One of the cheerleaders begins to cry and says,
“I think my arm is broken.” Which of the following actions should the school nurse take
FIRST?
1. Call 911.
2. Immobilize the arm.
3. Observe the arm for deformity.
4. Cut away the teen’s sweater on the affected
arm.
3) first, expose the extremity by cutting away any clothing; if any bleeding noted, apply
direct pressure to the area
4) CORRECT— inspection is the first step of physical assessment; remove the clothing
to inspect for bleeding, swelling, or deformity
The nurse cares for a 2-year-old who received ipecac syrup after accidental ingestion of
a poisonous plant. It is MOST important for the nurse to report which of the following to
the next shift?
1. No vomiting occurred after administration of the ipecac
syrup.
2. An antiemetic was ordered and administered.
3. A slight increase in the client’s temperature is noted.
4. The client is to remain NPO until the following day.
1) CORRECT— if no vomiting occurs, may repeat dose in 20 minutes; notify next shift
so further action can be taken
2) priority is reporting the lack of vomiting
3) not a priority
4) not a high priority
The charge nurse of a psychogeriatric unit makes rounds on the unit. Which of the
following situations requires an IMMEDIATE interventionby the nurse?
1. The dietary aide removes a full breakfast tray untouched by a patient with
major depression who is still in bed wearing night clothing.
2. The psychiatric aide makes the bed while a patient with schizophrenia is sitting
in the bedside chair shaving with a disposable razor and mirror.
3. The LPN/LVN assigned to medication administration argues loudly with a
bipolar patient who is refusing to take prescribed medication.
4. The patient care technician places personal care items in reach of a patient
with stage 2 dementia of the Alzheimer type and then leaves to fill the wash
basin with water.
(1.) these are expected signs of depression that need to be addressed but are not the
priority
(2.) self-care with sharp items is allowed under staff supervision; this patient is
supervised
(3.) LPN’s behavior needs addressing; patient may have the right to refuse medication
(4.) CORRECT—patient at risk for choking on inedible items such as soap, lotions, caps
of sample bottles,
1. A client receiving tissue plasminogen activator (t-Pa).
2. A client diagnosed with Raynaud disease who had a sympathectomy.
3. A client admitted in sickling crisis.
4. A client diagnosed with dysrhythmia who had a permanent pacemaker
implanted.
1) thrombolytic given to treat embolism; side effects include anaphylaxis, spontaneous
bleeding, and dysrhythmias; client is not stable
2) CORRECT— Raynaud disease is a form of intermittent arteriolar vasoconstriction;
sympathectomy interrupts the sympathetic nerves; stable client with an expected
outcome
3) unstable client
4) assess client’s cardiac output and hemodynamic stability to evaluate the success of
the pacemaker
The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse
observes the student nurse enter wearing a gown, gloves, and a facemask. The nurse
determines that the precautions are correct if the student nurse is caring for which of
1. An infant diagnosed with respiratory syncytial
virus.
2. A school-aged child diagnosed with hepatitis
A.
3. A teenager diagnosed with toxic shock
syndrome.
4. A teenager diagnosed with influenza.
Strategy: Remember transmission-based precautions.
1) requires contact precautions, no mask
4) CORRECT— droplet precautions used for organisms that can be transmitted by face-
to-face contact; door may remain open
schizophrenia?"
dreaming."
to take."
implications
The nurse in the pediatric clinic notes that several preschool children have received a
single dose of hepatitis B vaccine during infancy. Which of the following actions by the
1. Inform the children’s parents that the children must start the hepatitis B series
over again.
2. Note the immunization in the child’s history.
4. Make an appointment for the children to continue the series of hepatitis B
vaccine.
Strategy: Determine the outcome of each answer. Is it appropriate?
1) do not start series over again
2) hepatitis B immunization is a series of three injections
3) no reason to contact the physician
4) CORRECT— continue immunization series; total of three doses given; should
schedule the third dose 3 to 4 months after the second dose; second dose usually given
1 to 2 months after first dose
An elementary school teacher noticed a student’s eyes have been severely inflamed for
10 days. The student stated her parents refused to take her to a physician. The teacher
notifies the school nurse. Which of the following actions should the nurse take FIRST?
1. Discuss the condition of the child’s eyes with the parents.
2. Notify the principal of the parents’ refusal to seek health care.
3. Notify the child protective division of the department of human
resources.
4. Cleanse the drainage from child’s eyes.
1) CORRECT— data collection needs to be objective, not based on the child’s report
2) nurse should first talk with parents before drawing conclusion; validate before
implementing
3) complete assessment before implementing
4) no action should be taken before diagnosis of problem; inflammation could be related
to surgical procedure
state.”
adequately?”
The nurse prepares for the admission of a patient diagnosed with diabetes and a latex
allergy. The only private room on the unit is occupied by a patient diagnosed with
tuberculosis. The nurse should take which of the following actions when assigning the
new patient to a room on the unit?
1. Transfer a patient diagnosed with tuberculosis to a room with a patient
diagnosed with bronchitis, and then clean the private room for the patient with
latex allergy.
2. Admit the patient diagnosed with latex allergy to a room with a patient
diagnosed with Parkinson’s disease, and treat both patients as being latex-
sensitive.
diagnosed with diverticulitis, and keep the beds and all equipment at least 3
feet apart.
diagnosed with diabetes who has a Foley catheter and is receiving oxygen.
(1.) private room is best for a patient with latex allergy; however, a patient with active
tuberculosis must be placed on airborne precautions in a private, negative air-pressure
room with the door closed; the air is vented directly to the outside of the building or
filtered before it is recirculated
(2.) CORRECT—private room is best for a patient with latex allergy; if a private room is
not available, then all patients in the room with the patient with latex allergy must be
treated as though they too were latex-sensitive; latex-free environment is essential for
treatment of patients having latex allergy
(3.) 3 feet separation between patient and others is appropriate for droplet precautions,
not latex allergy
(4.) not safe; although both patients have diabetes and might have something in
common, the Foley catheter and the oxygen equipment are usually latex; also, staff
caring for the catheter are likely to use latex gloves and other supplies for that patient
and for others they care for; patient with latex allergy requires a latex-free environment
The nurse manager of the psychiatric unit plans the biweekly unit-wide multidisciplinary
team case conference focused on one particular patient. Which of the following patients
is MOST important for the manager to select for discussion?
1. A patient who was admitted after a second serious suicide attempt and refuses
to talk.
2. A patient toward whom the staff have sharply conflicting attitudes and actions.
3. A patient who talks to invisible beings, takes possessions from other patients,
and paces continually.
4. A patient, well known and well liked by staff, whose diagnostic testing reveals
a brain tumor.
question.
(1.) important to address, but not most important at this time; patient requires close
one-to-one observation and protection; is still a serious suicide risk, at least in part
because of the two serious suicide attempts
(2.) CORRECT—sharply conflicting attitudes and actions toward a patient must be
addressed, quickly and openly, and resolved; they are best prevented in the first place;
often stem from a patient with a personality disorder, particularly a borderline patient,
as part of their manipulative pattern of behavior
(3.) important to address but can be managed outside the multidisciplinary team case
conference at this time; behaviors reflect possible chronic schizophrenia process
(4.) important to address by the team, but not most important; staff need to be allowed
to receive accurate information, express their feelings, support one another, and plan
for care of patient, both at present and in any future follow-up
The nurse prepares to perform the initial assessment on a 6-year-old client with an open
wound with methicillin-resistant Staphylococcus aureus (MRSA). The nurse plans to
take which of the following precautions?
1. Wear gloves only.
2. Wear gown and gloves.
3. Wear gown, gloves, and
mask.
4. No precautions are
necessary.
1) requires contact precautions.
2) CORRECT— wear clean, nonsterile gloves and gown when entering client’s room if
nurse is going to have any contact with the client or with surfaces that the client
touches
3) masks, eye protection, and face shield required if client care activity likely to generate
splashes or sprays
4) MRSA requires contact precautions
The nurse counsels a client diagnosed with tuberculosis. The client asks the nurse what
he should do to prevent the spread of the disease. Which of the following
recommendations should the nurse make FIRST?
1. “Take all of your medication exactly as prescribed by your health care
provider.”
2. “Cover your mouth and nose when you sneeze.”
3. “Dispose of all of your tissues in a paper bag.”
4. “Keep all of your clinic appointments.”
1) CORRECT—combination drug therapy most effective to treat tuberculosis; to ensure
compliance, assess for side effects
2) appropriate action; do not go to work or school until 3 negative sputum specimens
3) appropriate action; air out room frequently
4) appropriate action; health care provider will evaluate effectiveness of medication
The nurse observes a nursing assistant providing care on the medical/surgical unit. The
nurse should intervene if which of the following is observed?
1. The nursing assistant performs perineal care for a client diagnosed with a
cerebrovascular accident.
2. The nursing assistant removes dead leaves from a plant in the client’s room.
3. The nursing assistant removes the contact lenses from a client with right-sided
weakness.
4. The nursing assistant collects a clean catch urine specimen from a client
diagnosed with pneumonia.
Strategy: “Nurse should intervene” indicates something is wrong.
1) appropriate action; instruct to report any drainage, excoriation, or rash
2) CORRECT— caregivers should not be caring for plants and clients; plants should be
cared for by a different person
3) appropriate action; instruct nursing assistant about correct way to remove contacts
so that client is not harmed and the contacts are not damaged
compensation?”
injury?”
penetrated the eye
A nursing team discusses the new nurse manager’s leadership style. A nurse states,
“The new nurse manager does not give us any direction or supervision.” The nurse is
describing which of the following leadership styles?
1. Autocratic.
2. Democratic.
3. Situational.
4. Laissez faire.
Strategy: Think about the answers.
1) nurse manager makes all decisions and does not ask for input from the group; stifles
creativity and motivation
2) nurse manager asks the group to participate in making decisions; leader shares
planning, decision-making, and responsibility for the outcomes
3) nurse manager assumes a combination of leadership styles depending on the needs
of the group
4) CORRECT— nurse manager gives little direction to group; lack of leadership;
decisions are made by the group (if at all); many people feel confused and frustrated
under this style of leadership
When administering preoperative medication to a client, the nurse notices a large
number of small insects crawling out of the closet where the client placed his suitcase.
The client refuses to allow the nurse to inspect his luggage. Which of the following
1. Notify security.
2. Kill the insects.
3. Inspect the client’s bag.
4. Double-bag the suitcase and
insects.
1) priority is containing the contamination
2) kills the insects but does not control contamination from the suitcase
3) client has refused the nurse permission; priority is containing the contamination
4) CORRECT— take action to limit the area of contamination
During a sudden rise in a nearby river, the nurse at a day camp evacuates the children
to an area away from the river. Which of the following actions should the nurse take
NEXT?
1. Place an identification bracelet on each
child.
2. Go back for an adequate supply of water.
3. Notify the parents of the children’s
location.
4. Comfort children who are anxious.
1) CORRECT— aids in communication after rescue or recovery
2) nurse should not leave the children alone
3) identification takes priority over notification
4) priority is assuring that each child can be identified
The nurse receives a report from the previous shift. Which of the following patients
1. A patient diagnosed with myocardial infarction; monitoring indicates 4–6
premature beats per hour.
2. A patient diagnosed with heart failure; patient confused and constantly
dribbling urine.
3. A patient diagnosed with pneumonia; patient increasingly confused and has a
temperature of 104°F (40°C).
4. A patient diagnosed with diabetes; patient restless during the night and fasting
blood sugar is 170 g/dL.
1) 4–6 premature beats per hour is benign
2) not a priority
3) CORRECT— elevated temperature indicates pneumonia is worse and confusion can
indicate hypoxia
4) is the second patient the nurse should see to follow up on blood sugar
1. A client admitted with facial trauma after an auto accident.
2. A client diagnosed with a heat stroke.
3. A client having a systemic reaction to latex.
4. A client with progressive systemic sclerosis experiencing Raynaud’s
phenomenon.
1) requires close monitoring to assess for a patent airway; assess eye functioning,
observe for neurological changes; not a stable client
2) dehydration and hyperthermia, place in air-conditioned room, lie flat with legs
elevated, administer oxygen; not a stable client
3) potential anaphylactic reaction; not a stable client
4) CORRECT— chronic connective tissue disease that caused inflammation, fibrosis,
and sclerosis of the skin and vital organs; stable client who can be assigned to the
reassigned RN
A physician notifies the head nurse of an inpatient medical unit that the chairperson of
the board of the medical facility is going to be admitted for 24 hours. The physician
relates to the head nurse that he considers one of the nurses on the unit “disheveled
and unkempt” and asks that the nurse be reassigned for the duration of the
chairperson’s hospitalization. Which of the following responses by the nurse is MOST
appropriate?
1. “I’ll talk to the nurse about his appearance.”
2. “I am unable to comply with your request.”
3. “Where do you suggest this nurse work?”
4. “I have not had any complaints from any other
clients.”
question.
1) if appearance is an issue, nurse manager should have already addressed it
2) CORRECT— client care assignments are made based on knowledge and abilities of
staff members; the head nurse is in the best position to assess the needs of the clients
and make the appropriate assignments;
3) head nurse is the appropriate person to make this decision
4) physician inappropriate person to discuss this issue
The nurse observes a patient care technician (PCT) prepare to obtain the vital signs of a
6-month-old diagnosed with respiratory syncytial virus (RSV). The nurse should
intervene if which of the following is observed?
1. The PCT wears a gown and gloves when entering the room.
2. The PCT is using the stethoscope found in the infant’s room.
3. The PCT provided care to a postop client after a shunt repair before tending to
the client with RSV.
4. The PCT removes the gown and gloves and places them in a hamper in the
hall.
1) appropriate action; RSV requires contact precautions; staff should change gloves
after contact with wound drainage or fecal material
2) with contact precautions, equipment should be left in the client’s room or cleaned
thoroughly before use on another client
3) appropriate action; wash hands after caring for client
4) CORRECT— remove gown and gloves before leaving room and wash hands
thoroughly
The home health nurse visits an elderly client who is diagnosed with diabetes and
osteoporosis. The client lives with her daughter in a two-story home. Which of the
following statements by the daughter MOST concerns the nurse?
2. "Mother seems to taking more of an interest in the things going on
around her."
3. "I sometimes feel guilty leaving her alone, even if it is just for half an
hour."
(1.) CORRECT—safety risk; oils in the bath water can result in slippery shower or
bathtub surfaces; mother is at risk for falling due to osteoporosis
(3.) may indicate that daughter may be excessively locked into the caregiver role;
caregiving feelings and options should be explored
(4.) should further assess daughter’s concern about winter; not of greatest concern
The nurse cares for patients in the emergency department (ED). Which of the following
1. A patient complaining of a dry cough for several weeks with frequent night
sweats.
2. A patient who complains of vaginal spotting and reports that her last menstrual
period was 2 weeks ago.
3. A patient complaining of right upper quadrant abdominal pain with nausea and
vomiting.
4. A patient complaining of burning epigastric pain that radiates to the mid-chest
when the patient is lying flat.
(1.) CORRECT—classic symptoms of tuberculosis; place in room with negative air
pressure or fit with an appropriate mask to prevent spread of the disease until
evaluation confirms that patient is free of disease
(2.) likely experiencing breakthrough bleeding at ovulation, though other possibilities
range from an infectious process to cervical cancer; no emergent intervention is
required at this time
(3.) important to alleviate patient’s symptoms; preventing spread of infection to other
patients, visitors, and staff takes precedence
(4.) likely experiencing symptoms of acid reflux; instruct patient to keep the head of the
bed elevated; possibly offer medication intervention
include?
question requires."
time
The nurse cares for a client diagnosed with a cerebrovascular accident (CVA). When
creating a teaching plan, which of the following actions by the nurse is MOST
important?
1. Ask the client to discuss his perception of his health status.
2. Identify the client’s strengths and weaknesses.
3. Encourage the client to discuss his concerns with a client who has
rehabilitated after a CVA.
4. Offer the client a written plan of therapy.
1) CORRECT— for teaching to be successful, the nurse should assess client’s
perception about his health problem
2) appropriate, but more important to determine client’s perceptions
urination.
respirations.
A nurse driving home from work observes a car go off the road into a shallow
embankment. When an ambulance arrives, the nurse advises the paramedics to
transport which of the following patients to the hospital FIRST?
1. A crying infant restrained in a rear-facing child safety seat.
2. The restrained front seat passenger who has a laceration to the right side of
his head.
3. The restrained rear seat adult passenger who has a deformity of the right
forearm and who complains of pain at the site.
4. The restrained driver who has faint discoloration around the umbilicus and
complains of abdominal pain.
1) infant properly restrained; crying indicates adequate respiratory function; requires
evaluation, however, actual risk takes precedence over potential risk
2) requires evaluation; however, any bleeding that may occur can be controlled with
pressure and risk for hemorrhage takes precedence over risk for neurological deficit
related to a head injury
3) likely to have a fracture; risk of hemorrhage takes precedence
4) CORRECT— ecchymosis around the umbilicus or in either flank indicates
retroperitoneal blee
The fire alarm is ringing at a 50-bed nursing facility. Arrange the following actions by
the nurse in the appropriate order from MOST important to LEAST. All options must be
used.
Strategy:
Determine the outcome of each answer.
(1) Move clients away from the fire: remember the acronym RACE (rescue/remove,
alarm, confine/close, evacuate)
(2) Pull the fire alarm after removing clients
(3) Close all of the fireproof doors: prevents fire from spreading
(4) Locate all of the residents: appropriate if evacuation required
During a regional outbreak of the flu, a nursing assistant reports to work on the
oncology unit. The nurse notes that the nursing assistant is coughing and has a runny
nose, and the nurse assistant says that she has an elevated temperature. The nursing
assistant tells the nurse that she has no sick leave and is the breadwinner of her family.
Which of the following responses by the nurse is MOST appropriate?
1. “Did you take a flu shot?”
2. “You may work at the desk and help the unit secretary with the
charts.”
3. “I will call one of the other units where clients are less
vulnerable.”
4. “I’m sorry, but you will have to go home.”
question.
1) should take an annual flu shot; not relevant to this conversation
2) influenza is spread by droplets; even though nursing assistant will not be caring for
clients, will still come in contact with other staff members; clients in oncology are
immunocompromised
3) hospital is full of immunocompromised clients
4) CORRECT— during community outbreaks of the flu, should exclude staff with febrile
infections from caring for high risk clients
The nurse cares for clients on the urology unit. After assessing the clients, it is MOST
important for the nurse to instruct the support staff to monitor which of the following
clients?
2. A client with a blood urea nitrogen (BUN) of 35 mg/dL and serum creatinine of
2.5 mg/dL.
1) although diabetic retinopathy with hypertension may indicate renal failure, these are
not definitive diagnostic tools
4) may or may not indicate renal failure; composition of urine would determine client
status
The nurse admits to the unit a client with a history of heart failure. The physician writes
orders for the client. It is MOST important for the nurse to question which of the
following orders?
1. “Digoxin (Lanoxin) 0.25 mg PO in
am.”
2. “Oxygen at 4 L/min per nasal
cannula.”
3. “Propranolol (Inderal) 20 mg PO
TID.”
4. “Furosemide (Lasix) 40 mg IV now.”
1) appropriate order; cardiac glycoside used to treat heart failure
2) appropriate order
3) CORRECT— Inderal is contraindicated in clients with uncompensated heart failure
and pulmonary edema
4) appropriate order; loop diuretic; monitor BP, pulse rate, I and O
The parish nurse knows that it is MOST important to encourage which of the following
men to obtain screening for prostate cancer?
1. A 24-year-old Caucasian computer programmer diagnosed with
cryptorchidism.
2. A 42-year-old Asian American restaurant owner diagnosed with ulcerative
colitis.
3. A 55-year-old African American factory worker in automobile tire
manufacturing.
4. A 62-year-old Caucasian retired house painter who has been smoking for
40 years.
question.
(1.) no risk factors for prostate cancer; age, race, and cryptorchidism (undescended
testicle) are all risk factors for testicular cancer
(2.) no risk factors for prostate cancer; inflammatory bowel diseases such as Crohn
disease or ulcerative colitis are risk factors for colorectal cancer, especially if disease
course has been long and severe
(3.) CORRECT—three major risk factors: age, race, employment; prostate cancer is
found most commonly in men age 50 and over; African Americans are affected more
than other ethnic groups; occupation and environment are other definite risk factors,
particularly exposure to carcinogens found in urban areas (higher incidence of prostate
cancer) and in occupations such as fertilizer, rubber, and textile industries, as well as in
places with heavy metals such as cadmium; cadmium used in low-friction, fatigue-
resistant alloys, in nickel-cadmium batteries, and in rustproof electroplating
(4.) risk factors are for lung or bladder cancer
The home health nurse completes an assessment of a newborn. The nurse expects to
assess which of the following?
1. “Machine-like” heart murmur.
2. Occipital frontal circumference 40
cm.
3. Bulging anterior fontanel at rest.
4. Extrusion reflex.
1) indicates patent ductus arteriosus, acyanotic heart problem
2) normal circumference is 33–35 cm
3) should not bulge at rest, may bulge when infant crying
4) CORRECT— normal neonate reflex that disappears between 3–4 months of age;
extrusion reflex is the tongue moving outward when the tongue is touched
The nurse makes rounds on the medical unit to assess the care given by the nursing
assistants. Which of the following observations requires an intervention by the nurse?
1. The nursing assistant places the fingers of one hand on the wrist of a patient in
order to evaluate the respirations.
2. The nursing assistant prepares to take a blood pressure in the left arm of a
patient recovering from a right mastectomy.
3. The nursing assistant weighs a patient on a standing scale while the patient is
balanced on crutches.
4. The nursing assistant prepares to take an oral temperature on a patient
recovering from a rhinoplasty.
Strategy: "Requires an intervention by the nurse" indicates that something is wrong.
(1.) appropriate action; best if patients are not aware when respirations are being
counted, because if they are aware it is hard for them to maintain a normal breathing
pattern; fingers on the wrist makes it seem like the pulse is being taken
(2.) appropriate action; lymphedema of the arm occurs after mastectomy; taking blood
pressure on that arm would be painful and decrease the already compromised lymph
circulation
(3.) appropriate action; if a patient uses crutches, weight should be taken with crutches
in place so patient can support weight during the process; afterward, the crutches
should be weighed and their weight then subtracted from the total to conclude the
weight of the patient
(4.) CORRECT—rhinoplasty compromises ability of patient to breathe through the nose
due to the packing in both nostrils
The nurse prepares for the admission of a patient diagnosed with diabetes and a latex
allergy. The only private room on the unit is occupied by a patient diagnosed with
tuberculosis. The nurse should take which of the following actions when assigning the
new patient to a room on the unit?
1. Transfer a patient diagnosed with tuberculosis to a room with a patient
diagnosed with bronchitis, and then clean the private room for the patient with
latex allergy.
diagnosed with Parkinson’s disease, and treat both patients as being latex-
sensitive.
diagnosed with diverticulitis, and keep the beds and all equipment at least 3
feet apart.
diagnosed with diabetes who has a Foley catheter and is receiving oxygen.
(1.) private room is best for a patient with latex allergy; however, a patient with active
tuberculosis must be placed on airborne precautions in a private, negative air-pressure
room with the door closed; the air is vented directly to the outside of the building or
filtered before it is recirculated
(2.) CORRECT—private room is best for a patient with latex allergy; if a private room is
not available, then all patients in the room with the patient with latex allergy must be
treated as though they too were latex-sensitive; latex-free environment is essential for
treatment of patients having latex allergy
(3.) 3 feet separation between patient and others is appropriate for droplet precautions,
not latex allergy
(4.) not safe; although both patients have diabetes and might have something in
common, the Foley catheter and the oxygen equipment are usually latex; also, staff
caring for the catheter are likely to use latex gloves and other supplies for that patient
and for others they care for; patient with latex allergy requires a latex-free environment
The nurse cares for clients in the Emergency Department (ED). The nurse is approached
by transport personnel asking the nurse to sign out a client for transport for magnetic
resonance imaging (MRI). The client states “I was in a car accident and there is
something wrong with my left eye.” Which of the following responses by the nurse to
the transport personnel is MOST appropriate?
1. “I’ll call to make sure that they are ready for the client.”
2. “Is there a family member who can go with the client to the MRI?”
3. “I’ll locate the chart to make sure that the physician has ordered
the MRI.”
4. “You have to talk with the nurse assigned to the client.”
question.
1) immediate concern is contacting the nurse assigned to the client
2) appropriate for family to accompany the client, but client safety takes priority
3) should be completed by the nurse assigned to the client
4) CORRECT— MRI is contraindicated for clients with actual or suspected metallic
foreign body in the eye; client was in an auto accident and has the potential for eye
injury that involves metal; assigned nurse would know if prior tests have eliminated a
possible metal object
The nurse supervises care of clients at the local eye care center. The nurse determines
that care of a client immediately after intracapsular cataract extraction is appropriate if
the unlicensed assistive personnel (UAP) performs which of the following activities
FIRST?
1. Raises the head of the client’s bed 35°.
2. Places an emesis basin at the client’s
bedside.
3. Tapes the eye shield securely with paper
tape.
4. Measures the client’s intake and output
1) CORRECT— prevents significant, sustained increased intraocular pressure, which is
a major complication
2) vomiting increases intraocular pressure and should be reported to the health care
provider; do not place head in dependent position
3) not within the scope of practice of the UAP
4) priority is placing the client in semi-Fowler’s position to prevent increased intraocular
pressure
The nurse in the outpatient clinic receives a phone call from a 16-year-old boy who
states, “There is no reason to live. I am going to shoot myself.” Which of the following
1. “Do you have access to a gun?”
2. “Why do you want to shoot yourself?”
3. “Think about how this will affect your
family.”
4. “Share with me what happened to you
today.”
1) CORRECT— nurse should ensure the client’s safety; determine if client has a plan
and the means to carry out the plan
2) “why” is not relevant at this time; more important to determine if teen has the means
to carry out the suicide
3) priority is teen’s safety
4) nurse should offer teen the security that the nurse is concerned about the teen’s
safety
The nurse supervises care for a patient on the hospice unit who practices orthodox
Judaism. The nurse determines care is appropriate if which of the following is
observed?
1. An unleavened wafer is placed on the tongue of the
patient.
2. The patient has a continuous intravenous morphine
infusion.
3. The patient is turned to face east as signs of death
appear.
4. The patient’s forehead is anointed with oil.
Strategy: "Care is appropriate" indicates correct nursing actions.
(1.) wafer known as the Eucharist is offered to Roman Catholic patients and may be
given by lay persons; not appropriate for an orthodox Jewish patient
(2.) CORRECT—control of pain (palliative treatment) during end of life is most important
to Jewish persons
(3.) end of life care in the Islam religion requires the dying to face east towards Mecca
(4.) anointing with oil is performed in many Christian religions
The psychiatric home health nurse visits the home of a patient diagnosed with middle-
stage Alzheimer’s disease. The patient lives with his daughter and son-in-law, who both
insist he stay with them for as long as possible. Which of the following observations
MOST concerns the nurse?
1. There are extension cords on the floors behind
furniture.
2. There is a bowl of artificial fruit on a glass coffee
table.
3. There is a blow-dryer on a hook on the bathroom
wall.
4. The door locks are at the tops of the doors.
(1.) appropriate action; prevents tripping hazard in any home, especially one with
elderly residents who may have visual and musculoskeletal conditions predisposing
them to fall; telephone and other cords should be put behind furniture, not across open
spaces
(2.) concerning but not priority; patient may think the artificial fruit is real and try to eat
it; also, glass coffee table could present an injury hazard due to its height (can be
bumped into) and substance (glass); if kept, the table could be put out of the way of any
traffic, have its edges padded, and be covered with lightweight objects
(3.) CORRECT—the dryer itself could be hazardous to this patient in terms of
misperceptions of what it is—e.g., a gun—or in terms of improper use causing burns or
other injuries; also, having it in bathroom can increase potential for electric shock by
patient having contact with water while holding the device when it is turned on
(4.) appropriate action; wandering is a frequent behavior of Alzheimer’s patients; by the
time patients are in the middle to late stages of the disorder, are unable to look up and
reach upward; door locks that are complex are best for Alzheimer’s patients at any time
A 45-year-old patient with a 10-year history of rheumatoid arthritis is being prepared for
discharge from the hospital. Which of the following instructions is essential for the
nurse to include?
1. “If it hurts to perform an activity, don’t do it.”
2. “Move your joints as much as you can each day.”
3. “Eat a diet high in complex carbohydrates and
calcium.”
4. “Return to work on Monday.”
1) take prescribed medications as ordered and on time; balance rest and activity
2) CORRECT— maintaining mobility is a physical need; most important; achieved by
exercises and independent ADLs; take warm shower or tub bath to increase blood flow,
decrease pain and increase joint mobility; walking and swimming are good exercises
3) physical need but not most important; should eat a balanced diet and maintain weight
4) important to balance rest and activity
The pediatric nurse evaluates a group of children for risk factors for dental caries. The
nurse identifies which of the following children as having the highest risk for dental
caries?
1. A 16-year-old who subsists on a fast-food diet.
2. A 5-year-old whose maternal grandparents both wore
dentures.
3. A 3-year-old whose teeth are not in anatomically correct
alignment.
4. A 2-year-old who takes a bottle of milk to bed each night.
(1.) such a diet can cause a variety of health problems, including dental
(2.) not highest risk; while some aspects of dental health have hereditary components, it
cannot be assumed that the grandparents’ need for dentures was due to cavities
(3.) not highest risk; misalignment can have many causes and can result in need for
orthodontic treatment
(4.) CORRECT—called nursing caries (bottle-mouth caries); results from the teeth being
consistently bathed for hours in a carbohydrate-rich, sweet liquid that is obtained by
sucking; the liquid may be juice or milk, or honey on a pacifier; if a bottle is permitted in
bed, it should contain only water
The nurse evaluates care provided by the staff on the medical/surgical unit. The nurse
determines that care of a patient diagnosed with HIV is appropriate if which of the
1. The LPN wears a protective gown when entering the patient’s room.
2. The nursing assistant uses sterile sheets to make the patient’s bed.
3. The nursing staff wears gloves when exposed to the patient’s
secretions.
4. The family wears gown, gloves, and mask when entering the
patient’s room.
1) not necessary to wear gown into room; use nonsterile gowns if patient care activities
are likely to generate splashes and sprays
2) no reason to use sterile sheets
3) CORRECT— use standard precautions when caring for client
4) not necessary
After a major power outage, a confused client with an unsteady gait arrives at a portable
emergency response station. Which of the following actions should the nurse take
FIRST?
1. Determine where the client lives.
2. Assess the client’s level of
consciousness.
3. Assist the client to the nearest chair.
4. Assign the client a triage number.
1) demographic data not first priority
2) assessment appropriate after nurse ensures client’s safety
3) CORRECT— client is at risk for falling; ensure safety before beginning assessment
A nurse driving home from work observes a car go off the road into a shallow
embankment. When an ambulance arrives, the nurse advises the paramedics to
transport which of the following patients to the hospital FIRST?
1. A crying infant restrained in a rear-facing child safety seat.
2. The restrained front seat passenger who has a laceration to the right side of
his head.
3. The restrained rear seat adult passenger who has a deformity of the right
forearm and who complains of pain at the site.
4. The restrained driver who has faint discoloration around the umbilicus and
complains of abdominal pain.
1) infant properly restrained; crying indicates adequate respiratory function; requires
evaluation, however, actual risk takes precedence over potential risk
2) requires evaluation; however, any bleeding that may occur can be controlled with
pressure and risk for hemorrhage takes precedence over risk for neurological deficit
related to a head injury
3) likely to have a fracture; risk of hemorrhage takes precedence
4) CORRECT— ecchymosis around the umbilicus or in either flank indicates
retroperitoneal bleeding
The mother of a 10-year-old boy with the mental age of 4 asks the clinic nurse, “What
should I expect my child to be able to do?” Which of the following is the BEST response
by the nurse?
1. “Your child should be able to choose his clothes and dress himself with
assistance.”
2. “Your child should be able to take care of his dog by himself.”
3. “Your child should be able to join the local soccer team.”
4. “Your child should be able to load and start the dishwasher after dinner.”
Strategy: Think about each answer choice. Is it an appropriate activity for a 4-year-old?
Don’t memorize IQ ranges, just get an idea of education/training potential.
1) CORRECT— should be able to perform activities of daily living with supervision;
moderate level of mental retardation: IQ ranges 35–40 to 50–55; can learn self-help
activities and simple manual skills
2) probably will need supervision to perform tasks that are this complicated
3) because of the rules of the game, the child would have difficulty with this activity
4) probably will need supervision to perform tasks as complicated as this one
The nurse cares for patients in the emergency department (ED). Which of the following
1. A patient complaining of a dry cough for several weeks with frequent night
sweats.
2. A patient who complains of vaginal spotting and reports that her last menstrual
period was 2 weeks ago.
3. A patient complaining of right upper quadrant abdominal pain with nausea and
vomiting.
4. A patient complaining of burning epigastric pain that radiates to the mid-chest
when the patient is lying flat.
(1.) CORRECT—classic symptoms of tuberculosis; place in room with negative air
pressure or fit with an appropriate mask to prevent spread of the disease until
evaluation confirms that patient is free of disease
(2.) likely experiencing breakthrough bleeding at ovulation, though other possibilities
range from an infectious process to cervical cancer; no emergent intervention is
required at this time
(3.) important to alleviate patient’s symptoms; preventing spread of infection to other
patients, visitors, and staff takes precedence
(4.) likely experiencing symptoms of acid reflux; instruct patient to keep the head of the
bed elevated; possibly offer medication intervention
A client involved in a homosexual relationship is scheduled for abdominal surgery.
During surgery, the client’s partner requests information regarding the client’s status.
1. “The physician will be out to talk with you after the surgery is
complete.”
2. “I am sorry. I can only give out information to family members.”
3. “Let me go back and get an update. I will be right back.”
4. “I’m sure she is doing fine, so just sit back and relax.”
1) passing the buck; nurse should respond to client
2) nurse can share information with significant other
3) CORRECT— important to respect client’s personal lifestyle choice; nurse acts as the
client’s advocate when providing partner with accurate information
4) false reassurance
A woman comes to the outpatient clinic in the 16th week of her pregnancy. The client
asks the nurse why she is going to receive RhoGAM (Rho [D] globulin) during her
pregnancy. Which of the following is the BEST response by the nurse?
1. “It resolves the incompatibility between your blood type and your infant’s
blood type.”
2. “It prevents your infant from developing jaundice due to blood
incompatibility.”
3. “It prevents your body from manufacturing antibodies to your infant’s blood
type.”
4. “It prevents your blood from mixing with the blood of your infant.”
Strategy: Think about the action of RhoGAM.
1) isoimmunization occurs when an Rh-negative mother becomes pregnant with and
gives birth to an Rh-positive infant; the problem is with Rh incompatibility, not blood-
type incompatibility
2) if mother forms antibodies; causes hemolysis and jaundice in the infant; jaundice
within the first 24 hours of life indicates hemolytic disease of the newborn; physiologic
jaundice occurs after 24 hours
3) CORRECT— it prevents the mother from forming antibodies to the Rh+ blood;
sensitization may occur during pregnancy, birth, abortion, or amniocentesis
4) is not the action of RhoGAM
As the night nurse makes rounds, an elderly client complains of cold feet. Which of the
1. Palpate pedal pulses.
2. Elevate the foot of the bed.
3. Place a heating pad on the client’s
feet.
4. Offer the client a warm drink.
1) CORRECT— assess before implementing; client may have decreased circulation
3) contraindicated for decreased circulation
4) may be helpful, but it is important to assess the circulation in the client’s feet
The nurse on the medical/surgical unit has just received report. Which of the following
1. A client 1 day postop after an appendectomy.
2. A client who had a detached retina surgically repaired 4
hours ago.
3. A client with an esophagogastric tube inserted.
4. A client 2 days postop after a laminectomy with spinal
fusion.
1) stable client
2) administer analgesics and antiemetics as prescribed; report increase in pain and
instruct client not to bend from waist, cough or sneeze, or strain to have a bowel
movement
3) CORRECT— used to treat bleeding esophageal varices; assess vital signs for
decreased blood pressure and elevated pulse; ensure that balloon pressure and volume
is maintained
4) maintain body alignment; assess for sensation and circulatory status of lower
extremities
state.”
adequately?”
The charge nurse learns that two staff members are requesting a 12-month leave of
absence. One staff member has 5 years of service and is requesting the leave because
of an adoption. The other staff member has 2 years of service and will care for a family
member diagnosed with terminal cancer. The charge nurse is informed that only one
staff member can receive the leave of absence. Which of the following actions should
1. After consulting agency policy, grant the leave to the nurse with the greatest
seniority.
2. Schedule a meeting with the two staff members to discuss the available
options.
3. Grant leave to the nurse with the terminally ill husband.
4. Persuade the staff member adopting the baby to waive her rights.
1) may resort to strict rule enforcement after other options have been explored
2) CORRECT— first step in problem resolution is to identify the problem and generate
possible solutions
3) after generating possible solutions, the staff members should evaluate the possible
solutions; don’t base decision on personal issues such as terminal illness
4) many times a combination of suggestions is the best solution; assess before
implementing
The triage nurse in an urgent care center assesses a 9-month-old infant. It is MOST
important for the nurse to approach the infant in which of the following ways?
1. Sit the infant on the exam table with the parent in the infant’s complete line of
sight.
2. Ask the parent to leave the room during the exam and return when the
assessment is complete.
3. Encourage the parent to hold the infant during the assessment.
4. Request another nurse to hold the infant during the assessment.
question.
1) encourage the parent to hold the infant in her/his lap
2) at this age, infant likely to experience separation and/or stranger anxiety
3) CORRECT— infant likely to experience separation anxiety; allowing the parent to sit
the child in her/his lap allows the infant to feel more secure
4) should only be used to prevent the necessity of repeating an invasive procedure such
as placing an IV; infant more likely to experience stranger anxiety with more than one
unfamiliar individual at a time
The office nurse meets with a high-school graduate who will be starting at a residential
college in the fall. It is MOST important for the nurse to address which of the following
immunizations?
1. DTaP.
2. Pneumococcal.
3. Meningitis.
4. Varicella.
question.
(1.) diphtheria, tetanus toxoid, and attenuated pertussis vaccine; 10 years after
kindergarten need booster of tetanus and diphtheria (Td) vaccine
(2.) pneumococcal vaccine available since 1983 to prevent pneumonia; in terms of age
group, the highest risk is with older adults; the other risk factors are unlikely in a
college-bound student
(3.) CORRECT—the meningitis vaccine is not currently required for college freshmen,
but information about the importance and reasons for vaccinations against
meningococcal disease should be given to all adolescents who are bound for college
and to their parents, especially if the students will be living on campus in residence
halls or dormitories
(4.) chickenpox vaccine given to people over 13 years of age if they are susceptible
because they have not had the disease and have not been immunized
The nurse on the medical/surgical unit administers digoxin 0.125 mg by direct IV. During
the administration of the digoxin, the unit secretary informs the nurse that a client with
extensive head and facial injuries has arrived on the unit. Which of the following actions
1. Note the time and place the syringe with the remaining medication on the
medication cart.
2. Instruct the unit secretary to find another nurse to admit the client.
3. Ask the unit secretary to obtain the sheet containing the staff’s pager numbers.
4. Request that the LPN continue the administration of the medication.
1) nurse is responsible for administering medication; cannot administer medication that
is not under the constant supervision of the nurse
2) inappropriate delegation; nurse’s responsibility to determine the appropriate person
to admit the client
3) CORRECT— enables nurse to safely administer the medication, and nurse
determines the appropriate person to care for the clients; when administering digoxin
by direct IV, infuse over a minimum of 5 minutes; use diluted solution immediately;
observe IV site; extravasation can lead to tissue irritation and sloughing
4) nurse is responsible for administering the medication
While interviewing a young adult as part of the job application process, the nurse learns
that the individual has a history of frequent nosebleeds that require health care
intervention. Which of the following responses by the nurse is BEST?
1. “Have you been diagnosed with
allergies?”
2. “Do you smoke cigarettes?”
3. “Do you take aspirin on a regular basis?”
4. “Have you been diagnosed with nasal
polyps?”
1) CORRECT— frequent use of nasal sprays to relieve allergic symptoms can result in
vasoconstriction that causes atrophy of nasal membranes resulting in decreased
integrity of blood vessels
2) not likely to cause nosebleeds
3) causes increased bleeding time; not likely to be a contributing factor
4) grape-like swellings in the mucus membranes of the sinuses; may cause obstruction
and chronic infections
The nurse makes a prenatal visit to the home of a woman who is pregnant with her first
child. It is MOST important for the nurse to intervene if which of the following is
observed?
kitchen sink.
(1.) CORRECT—cat presents a toxoplasmosis risk to the pregnant woman and her
unborn/newborn infant; toxoplasmosis is a parasitic disease transmitted in the feces of
cats who have eaten infected mice and animals; preventive measures include
handwashing after touching cats, have the litter box changed daily (it takes about 48
degrees for the cat’s feces to become infectious) by someone other than the pregnant
woman, prevent cats from eating raw meat or wild animals, wear gloves when
gardening, do not garden in areas frequented by cats, avoid undercooked meat and
contact with stray animals
(2.) will be an issue for future teaching prior to yet-unborn infant becoming a toddler
schizophrenia?"
dreaming."
to take."
implications
The nurse in the diabetic specialty unit has just received report. Which of the following
1. A 17-year-old boy with pale, cool skin complaining of a headache.
2. A 28-year-old woman with fruity breath smell complaining of thirst.
3. A 38-year-old man with a B/P of 120/50 complaining of frequent urination
and thirst.
4. A 45-year-old woman with a B/P of 90/60 and skin is hot and dry to touch.
1) indicates hypoglycemia
2) CORRECT— indicates metabolic acidosis from ketosis
3) symptoms of diabetes
4) indicates dehydration caused by hyperglycemia; first stage of diabetic ketoacidosis
The nurse admits a client diagnosed with chronic adrenal insufficiency. The nurse
should intervene if the client is placed in a room with which of the following patients?
1. An elderly client diagnosed with a cerebrovascular
accident (CVA).
2. A middle-aged client diagnosed with pneumonia.
3. A young adult diagnosed with type 1 diabetes.
4. A teen diagnosed with a fractured femur.
Strategy: “Should intervene” indicates something is wrong.
2) CORRECT— exposure to infection, cold, or excessive fatigue can cause circulatory
collapse for a client with chronic adrenal insufficiency
4) appropriate placement
The nurse counsels the parents of school-age children. One of the parents asks the
nurse how they should teach their children about human sexuality. Which of the
1. “Find out what your children know before answering their questions.”
2. “Remember, your words have more influence than your actions.”
3. “Avoid correct anatomic terms because they are difficult for the child to
comprehend.”
4. “Playing ‘ doctor’ satisfies the child’s curiosity.”
1) CORRECT— first assess; children often have misinformation about human sexuality;
if the misinformation is not identified, child will incorporate the misinformation into the
parent’s answer
2) actions are more influential than words
3) using correct terminology is appropriate
4) parents’ responsibility to answer their child’s questions
The nurse cares for clients on an acute pulmonary unit. The nurse prepares a written
report for the next shift. It is critical to communicate which of the following to the next
shift?
1. Laboratory work drawn on the client, arterial blood gas reports, nutritional
intake, and vital signs for the shift.
2. Any respiratory difficulty client has experienced, activity tolerance, sputum
production, and significant variances in vital signs during the shift.
3. Name of client’s physician, date client was admitted, dietary intake, and client’s
general condition.
4. Urinary output, fluid intake, visits by the attending physician, vital signs, any
respiratory problems encountered.
2) CORRECT— report should include client’s status, current care plan, response to
current care, and care that requires further teaching
The nurse cares for clients in the local eye-care center. The nurse returns to the desk to
find four phone messages from clients who are 24 hours postoperative after
intracapsular cataract extraction. Which of the phone messages should the nurse
answer FIRST?
1. A client asks if it is appropriate to take acetaminophen (Tylenol) for discomfort
in the operative eye.
2. A client reports that he feels light-headed when assuming a standing position.
3. A client reports mild itching in the operative eye.
4. A client states that her eyelid is swollen and she has difficulty seeing with the
affected eye.
1) expected outcome; encourage client to take mild analgesic, avoid aspirin
2) instruct client to change positions slowly
3) expected due to stitches in eyes; encourage use of cool compresses
4) CORRECT— may indicate bacterial infection; assess for yellow or green drainage
The nurse performs a physical assessment of a newborn. It is MOST important for the
nurse to report which of the following findings?
1. Head circumference of 40 cm.
2. Chest circumference of 32 cm.
3. Acrocyanosis and edema of the scalp.
4. Heart rate of 160 bpm and respirations of
40/min.
question.
1) CORRECT— average head circumference is 33–35 cm; increased size may indicate
hydrocephaly or increased intracranial pressure
2) normal finding; chest is usually 1 inch less than head circumference (30.5–33 cm)
3) normal finding
4) within normal limits; heart rate ranges from 120 (sleeping) to 180 (crying);
respirations range from 30–60 breaths/min
A 55-year-old woman comes to the outpatient clinic. The client has been receiving
estrogenic substances, conjugated (Prem Pro), for 3 months. Which statement, if made
by the client to the nurse, requires immediate follow-up?
1. “I frequently have trouble falling asleep at night.”
2. “I have gained 5 pounds since I have started taking this
medication.”
3. “My left leg is sore behind the knee.”
4. “I am still having hot flashes several times a week.”
Strategy: “requires immediate follow-up” indicates a complication.
1) assessment; insomnia is a common complaint during menopause
2) assessment; weight gain is a common side effect
3) CORRECT— assessment could indicate thrombophlebitis; other side effects include
nausea, skin rashes, pruritus, breast secretion
4) assessment; symptoms of menopause may persist with use of ERT; symptoms
related to hormone changes: vasomotor instability, emotional disturbances, atrophy of
genitalia, uterine prolapse
The nurse manager observes the new graduate nurse apply a transdermal patch on a
patient. The nurse manager determines that care is appropriate if which of the following
is observed?
1. The nurse wears sterile gloves when applying the patch.
2. The nurse cleanses the skin with alcohol before applying the
patch.
3. The nurse places a heat lamp over the patch for 20 minutes.
4. The nurse folds the old patch in half with sticky sides
together.
1) clean gloves are used; prevents the nurse from absorbing medications through the
fingertips
2) use clear water; do not use soaps, lotions, oils, or alcohol; may cause irritations or
prevent adhesion
3) heat increases absorption of medication and can lead to toxicity
4) CORRECT— patches retain enough medication to be hazardous to pets and children;
folding in this manner ensures medication is sealed inside before disposal
Four patients arrive in the emergency department within minutes of one another. Which
1. A patient, pale and diaphoretic, who is complaining of sudden and severe pain
radiating from the flank to the scrotum.
2. A patient with right lower quadrant (RLQ) abdominal pain of 24 hours’ duration
and which is relieved by drawing the legs up and remaining still.
3. A patient, jaundiced and nauseated, who is complaining of pain in the right
shoulder and has a temperature of 100°F (37.8°C).
4. A patient with sudden epigastric pain and nausea who reports vomiting blood
and has an odor of alcohol on the breath.
(1.) symptoms of renal colic; requires quick attention to diagnose and manage the pain;
not first patient to see
(2.) symptoms of probable appendicitis; confirm with physical assessment (especially
abdomen and temperature) and diagnostic tests; appendectomy should be done within
24 to 48 hours of symptom onset; delay usually causes rupture of the appendix and
results in peritonitis
(3.) symptoms of chronic cholecystitis; insidious symptoms may occur with this
disorder, resulting in patient not seeking medical help until late symptoms appear, such
as jaundice, dark urine, clay-colored stools
(4.) CORRECT—symptoms of acute gastritis; vomiting and hematemesis may be seen
with gastritis stemming from alcohol abuse; other symptoms are epigastric pain or
discomfort, cramping, nausea and vomiting
The nurse cares for a client diagnosed with tuberculosis. The nurse should follow which
of the following transmission-based precautions?
1. Standard
precautions.
2. Airborne
precautions.
4) contact precautions required for all client care activities that require physical skin-to-
skin contact or those that require contact with contaminated inanimate objects in the
client’s environment
Which of the following patients on the pediatric unit MOST requires the immediate
attention of the nurse?
1. A child diagnosed with epilepsy who has a loose tooth.
2. A child diagnosed with sickle-cell anemia who is complaining of
diarrhea.
3. A child with a newly casted arm who says the cast feels too tight.
4. A child who is blind and has a nosebleed.
Strategy: Determine the MOST unstable child.
(1.) loose tooth can be an aspiration hazard if the child has a seizure; potential problem
(2.) may indicate infection and/or dehydration, either of which can contribute to sickle-
cell crisis occurring; potential problem
(3.) CORRECT—may indicate compartment syndrome, priority patient
(4.) may be frightened or unaware; requires evaluation and support
The new graduate registered nurse emerging from a patient’s room is asked by the
preceptor why the time spent with the patient was longer than expected. The new
graduate replies "I taught the patient how to use the incentive spirometer. She did not
understand that you have to inhale and hold your breath." The preceptor responds, "It’s
not inhale with an incentive spirometer, it’s exhale." Which of the following actions
should the new graduate take FIRST?
1. Return to the patient and explain that the patient should hold the breath on
exhalation, not inhalation.
2. Suggest that the preceptor join the new graduate in reviewing the unit’s policy
and procedure manual and also the manufacturer’s guidelines for use of the
machine.
3. Remind the preceptor that the new graduate just left school and it was stressed
that inhalation, not exhalation, was appropriate for the incentive spirometer.
4. Tell the preceptor that this erroneous information is shocking and is not
appreciated, and that the matter obviously needs to be taken to the nurse
manager for resolution.
(2.) CORRECT—referral to supporting legitimate and respected documents defuses
emotional nature of the situation and enables resolution; incentive spirometry requires
inhalation or holding of the breath 3 to 5 seconds; deep inhalations expand alveoli and
therefore prevent atelectasis and other lung complications
(3.) does not refer to written objective documents; also somewhat implies preceptor is
not up-to-date
proceeding up the chain of command for resolution may be necessary, but not initially
The nurse cares for a client taking oral contraceptives. History reveals that the client
smokes 1 pack of cigarettes per day. It is MOST important for the nurse to observe for
1. Weakness.
2. Irritability.
3. Chest pain.
4. Abdominal
cramping.
1) not a side effect of oral contraceptives
2) may cause depression and migraine headaches
3) CORRECT— increased risk for cardiovascular or thromboembolic disease
4) may cause abdominal cramping and bloating
The nurse cares for clients on the postpartum unit. The nurse determines which of the
following clients is at GREATEST risk for developing postpartum hemorrhage?
1. The nurse notes the client has a distended
bladder.
2. The client has had an episiotomy.
3. The client complains of engorged breasts.
4. The nurse massages the client’s fundus.
Strategy: "GREATEST risk" indicates discrimination is required to answer the question.
(1.) CORRECT—likely to displace uterus to left or right and interferes with uterine
contraction
(2.) can cause discomfort; not risk factor for hemorrhage
(3.) breasts filled with milk; not risk factor for hemorrhage
(4.) fundal massage expels blood clots and helps uterine blood vessels to contract; not
a risk factor
The nurse performs a physical assessment of the precordium on an adult male. Identify
where the nurse should place the stethoscope to auscultate the pulmonic area.
Strategy: Locate landmarks.
The pulmonic area is located in the second intercostal space just to the left of the
sternum; auscultate for S2, caused by closure of the semilunar valves.
The nurse performs a physical assessment of the precordium on an adult male. Identify
where the nurse should place the stethoscope to auscultate the pulmonic area.
Strategy: Locate landmarks.
The pulmonic area is located in the second intercostal space just to the left of the
sternum; auscultate for S2, caused by closure of the semilunar valves.
The nurse observes a nursing assistant care for patients on the rehabilitation unit.
Which of the following observations by the nurse requires an intervention?
1. A small pillow is placed under the thighs of a patient with shortness of breath
and the head of the bed is elevated 60 degrees.
2. A pillow is placed under the head and neck of a patient who is lying on his right
side after a liver biopsy.
3. A patient with hemiplegia lies prone with the lower legs placed on a pillow.
4. A patient with sacral decubitus lies on the left side with the right leg extended
and resting on the mattress.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it
desired?
(1.) appropriate action; HOB elevation of 60 degrees is a Fowler’s position; one common
potential trouble area is extension of the knees, which contributes to patient sliding to
foot of bed; small pillow or roll under thighs prevents knee hyperextension by flexing
knees; pillow also prevents pressure from body weight occluding popliteal artery
(2.) appropriate action; one common potential trouble area of the side-lying position is
lateral neck flexion; pillow under head and neck prevents this; positioning on the right
side is appropriate after a liver biopsy
(3.) appropriate action; two common potential trouble areas of the prone position are
plantar flexion of feet (footdrop) and pressure points on toes; pillow under lower leg
allows for dorsiflexion of ankle and foot and keeps pressure off toes
(4.) CORRECT—this is an incorrect action; among potential trouble areas of the side-
lying position are hip joints that are internally rotated, adducted, and unsupported; to
prevent this, upper leg should be mildly flexed and rest on a pillow from groin to feet
hypotension.”
of heath care
members
A client with rheumatoid arthritis is taught by the nurse to perform range-of-motion
(ROM) exercises. In implementing her care, the nurse should include which of the
following actions?
1. Allow the client long rest periods between exercises.
2. Point out small accomplishments that the client makes.
3. Praise her when she makes significant progress.
4. Show appreciation of the client’s efforts by doing a few ROM exercises
for her.
1) causes reverse of gains; balance rest and activity, use after long periods of inactivity
2) CORRECT— encourages patient to continue; help client identify elements of control
over disease and treatment
3) gains will be incremental; should praise with small gains; encourage client to
verbalize feelings
4) encourage to be independent; provide assistive devices; allow patients to control
timing of self-care activities; explore energy conservation
The nurse uses a trochanter roll to position an unconscious patient. Which of the
following most accurately describes the correct location for a trochanter roll?
1. From the iliac crest to the knee.
2. From the lateral aspect of the hip to the mid-
thigh.
3. From the mid-thigh to the ankle.
4. From the medial aspect of the hip to the mid-
calf.
Strategy: Determines the outcome of each answer. Is it desired?
1) positioned too low; trochanter roll is a positioning device that functions as a
mechanical wedge under the greater trochanter, prevents external rotation of the hip
joint and prevents the femur from rolling
2) CORRECT— hip joint lies between these points; hip tends to rotate externally when
the patient is positioned on back if hip in correct alignment, patella faces upward
3) positioned too low; it will not prevent hip rotation
4) this is positioned too low and will not prevent hip rotation; trochanter roll should be
placed laterally, not medially
The nurse performs dietary teaching for a client diagnosed with acute inflammatory
bowel disease. The nurse determines that further teaching is required if the client states
1. "I like to make my sandwiches with white
bread."
2. "My favorite dessert is tapioca pudding."
3. "My family likes to eat roasted chicken."
4. "I drink red wine with dinner."
Strategy: "Further teaching is required" indicates incorrect information.
(1.) appropriate action; should avoid whole-grain breads; during acute phase, diet
should be low-residue, high-protein, and high-calorie
(2.) acceptable food on a low-residue diet
(4.) CORRECT—may exacerbate the inflammatory conditio
The nurse in the clinic is teaching a 65-year-old woman with osteoporosis. It is MOST
important that the nurse recommend which of the following?
1. Take a half-hour walk three times a week.
2. Attend a support group for people with
osteoporosis.
3. Perform isometric exercises four times a day.
4. Attend Weight Watchers weekly to reduce her
weight.
1) CORRECT— exercise stimulates bone production, weight bearing on the long bones
prevents calcium from leaving the bones
2) not most important; psychosocial need; should quit smoking and decrease intake of
alcohol and caffeine
3) regular weight-bearing exercise will stimulate bone production
4) small-framed, non-obese Caucasian women are at the greatest risk to develop
osteoporosis; adequate intake of calcium and vitamin A
The nurse supervises care of a client who is receiving enteral feeding via a nasogastric
tube. The nurse determines that care is appropriate if which of the following is
observed?
1. The nursing assistant aspirates and measures the amount of the gastric
aspirate.
2. The nursing assistant elevates the head of the client’s bed 30 degrees.
3. The nursing assistant warms the formula to room temperature.
4. The nursing assistant measures the pH of the gastric aspirate.
5. The nursing assistant infuses the intermittent feeding in 20 minutes.
6. The nursing assistant clamps the proximal end of the feeding tube at the end of
the feeding.
1) verifies placement of the tube and should be performed by the RN
2) CORRECT— prevents aspiration
3) CORRECT— prevents cramping
4) should be performed by a professional nurse
5) should infuse for a minimum of 30 minutes
6) CORRECT— prevents air from entering the stomach
The nurse on the medical/surgical unit cares for an elderly client diagnosed with cancer.
The nurse notes that the client is disoriented to person, place, and time. The nurse
walks into the client’s room and discovers that the client is incontinent of urine. Which
of the following statements by the nurse is MOST appropriate?
1. “I guess you are going to need an indwelling
catheter.”
2. “Why didn’t you call us?”
3. “Please go the bathroom and put on dry clothes.”
4. “Let’s get you some dry clothes.”
question.
1) use least invasive treatment; encourage client to go to the toilet according to a
schedule
2) don’t ask “why” questions; nontherapeutic
3) nurse should assist the client
4) CORRECT— conveys warmth and concern for the client
The nurse instructs a client diagnosed with diverticulosis. The nurse determines that
teaching is effective if the client selects which of the following menus?
1. Baked chicken breast with rice, and a lettuce, tomato, and cucumber salad with
Italian dressing.
2. Broiled cod with sliced almonds and cooked beets.
3. Lean roast beef with low-fat gravy and corn on the cob.
4. Tuna sandwich on whole-wheat toast with carrot sticks.
1) tomato and cucumber contain seeds and may block diverticulum
2) should not eat nuts
3) should not eat corn or popcorn
4) CORRECT— tuna is nutritious and relatively low in fat; whole-wheat toast provides
fiber that will increase bulk in stools
The home care nurse instructs a client recovering from full-thickness burns of the right
leg. The nurse determines that teaching is effective if the client selects which of the
following menus?
1. Tossed salad, French bread, and coffee.
2. Peanut butter and banana sandwich, chips, and
lemonade.
3. Ham sandwich with Swiss cheese, pasta salad, and
tea.
4. Broiled pork chop, cream of potato soup, and
pudding.
Strategy: Determine what type of diet is required.
1) clients with full-thickness burns require high-calorie, high-protein diets; this menu is
low in protein
2) peanut butter contains protein, other foods do not
3) ham and Swiss cheese contain protein, pasta contains small amounts of protein
4) CORRECT— all foods contain protein; creamed soup and pudding also contain
increased calorie
The nurse cares for an elderly client after a left total hip replacement due to
degenerative joint disease. The nurse is MOST concerned if which of the following is
observed?
1. The client is positioned with a pillow between the
legs.
2. The client moves slowly when getting out of bed.
3. The client’s heels are on the bed with toes pointed
upward.
4. The client uses an incentive spirometer every 2 hours.
Strategy: “MOST concerned” indicates something is wrong.
1) position prevents dislocation of prosthesis
2) prevents orthostatic hypotension
3) CORRECT— keep heels of elderly clients off the bed to prevent pressure sores
4) prevents atelectasis
The nurse cares for a client in the outpatient clinic with a diagnosis of myxedema.
During the initial assessment, the nurse should carefully observe for which of the
following symptoms?
1. Tachycardia, fatigue, and intolerance to
heat.
2. Polyphagia, nervousness, and dry hair.
3. Lethargy, weight gain, and intolerance to
cold.
4. Tachycardia, hypertension, and
tachypnea.
Strategy: Think about each symptom and how it relates to hypothyroidism.
1) signs of hyperthyroidism
2) indicates hyperthyroidism; even though appetite is increased, weight loss occurs;
other emotional manifestations include decreased attention span, irritability, manic
behavior
3) CORRECT— signs and symptoms of hypothyroidism; other assessments include dry
hair, mask-like facial expression, thickened skin, enlarged tongue, and drooling
The nurse reviews the history obtained from a client with degenerative joint disease
(DJD) of the right hip. The nurse identifies which of the following as risk factors for
developing degenerative joint disease?
1. Client had a transurethral resection of the prostate (TURP) 2
years ago.
2. Client worked as a carpet installer for 40 years.
3. Client is a 65-year-old male, height 6 ft, weight 280 lb.
4. Client was diagnosed with diabetes mellitus 10 years ago.
5. Client had a myocardial infarction at age 37.
Strategy: Determine how each answer relates to degenerative joint disease.
1) no relationship with prostatic hypertrophy and joint disease
2) CORRECT— occupation that causes increased mechanical stress to joints, also
would be 60+ years old
3) CORRECT— seen after age 60 years, obesity causes stress to weight-bearing joints
4) CORRECT— metabolic diseases (diabetes mellitus, Paget’s disease) and blood
disorders (hemophilia) can cause joint degeneration
5) myocardial infarction is caused by coronary artery disease
The nurse observes a nursing assistant care for a client after abdominal surgery. The
nursing assistant supports the client’s leg as the client flexes and bends the knee. The
nurse identifies that the client is engaged in which of the following therapeutic
exercises?
1. Passive.
2. Active-assistive.
3. Active.
4. Resistive.
1) exercise is carried out by nurse without help from the client
2) CORRECT— nurse supports distal part while client actively takes the joint through
range-of-motion
3) exercise is carried out by the client without help from the nursing staff; will increase
muscle strength
4) active exercise that is carried out independently by client; client works against
resistance to increase muscle power
A woman is admitted to the hospital with a diagnosis of multiple myeloma. Her husband
states she has been complaining of persistent lower back pain. The nurse should
position the patient in which of the following positions?
1. In bed with her head elevated 45 degrees and her hips and knees moderately
flexed.
2. In bed with her head elevated 60 degrees and her arms resting on the
overhead table.
3. In bed with the head of the bed elevated 15 degrees and her legs extended.
4. In a straight-backed chair with her feet resting on the floor.
1) CORRECT— flexing knees relieves pressure on sciatic nerve and disk
2) position for orthopnea; would put pressure on lumbosacral region
3) knees should be flexed for comfort
4) knees should be higher than hips for comfort; encourage client to alternate lying,
sitting, and walking
The nurse instructs a client diagnosed with chronic renal failure about the appropriate
diet. The nurse determines that teaching is successful if the client chooses which of the
following foods?
1. Half cup beets.
2. 1 orange.
3. 2 tbsp peanut butter.
4. 3 oz chicken breast.
Strategy: Recall foods allowed on a renal diet.
1) renal diet should contain increased calories, high biological protein, low potassium,
low sodium; beets are a high-potassium vegetable
2) orange is a high-potassium fruit
3) incomplete protein sources are low biological value; peanut butter, nuts, vegetables
are considered protein sources of low biological value
4) CORRECT— eggs, lean meat, fish, and poultry are high biological protein sources
that contain sufficient amounts of all the amino acids
The nurse observes a nursing student assess a client’s mobility. The client is lying in
the bed and the nursing student asks the client to sit in the chair so the nursing student
can complete the assessment. Which of the following responses by the nurse is BEST?
1. Instruct the nursing student to continue the assessment.
2. Ask the nursing student to report any difficulties the client may have sitting
in a chair.
3. Tell the nursing student to begin the assessment while the client is lying in
bed.
4. Talk with the nursing student at the completion of the assessment.
Strategy: “BEST” indicates that discrimination is required to answer the question.
1) should begin the assessment with the client in the most supportive position
2) to ensure client safety, begin assessment with client lying in bed; should anticipate
difficulties
3) CORRECT— to ensure client safety, begin assessing client’s movement when the
client is lying in bed, then ask client to sit on side of bed, transfer to the chair, and then
observe the client’s gait
4) client safety is priority, nurse should intervene immediately
The nurse cares for a client 24 hours post surgery after a thyroidectomy. Which of the
following statements if made by the client to the nurse requires an immediate
intervention?
1. “I have been having some muscle spasms in my legs and my lips are
tingling.”
2. “I think I am getting a cold because I have been coughing and sneezing
all night.”
3. “I am still having pain around the incision.”
4. “My voice is still hoarse.”
Strategy: “Immediate intervention” indicates a complication.
1) CORRECT— client is at risk for hypocalcemia, which may be manifested by tetany
and result in airway obstruction, respiratory arrest, cardiac dysrhythmias, and cardiac
arrest
2) though the nurse should reinforce the need to protect the suture line and possibly
obtain an order for medication, circulation takes precedence over the surgical incision
3) though it is important to offer effective pain management, it is not unusual for a
patient to experience pain 24 hours post surgery; hypocalcemia takes precedence over
pain
4) not uncommon for a patient to experience hoarseness post surgery and is initially
likely secondary to edema or the use of an endotracheal tube. If the hoarseness was
persistent it could indicate laryngeal nerve damage, but is not likely a concern 24 ho
FIRST?
1. Call 911.
arm.
At 4 pm a client with severe back pain receives a head wound while en route to the
emergency department. The client is admitted to the hospital after the head wound is
sutured and covered with a sterile dressing. Exhausted from the ordeal, the client
sleeps for several hours. At 3 am the client turns on the nurse call light and requests
pain medication for severe back pain. The unit secretary answers the light and is
suspicious of the sudden report of severe pain. Which of the following responses by the
nurse to the unit secretary is BEST?
1. “Your job is to report client requests to nursing personnel. Don’t interpret what
the client is saying.”
2. “I am surprised as well; earlier this evening, I helped him to the bathroom.”
3. “Tell me exactly what he said. In cases like this, careful documentation is
important.”
4. “Anxiety and fatigue are pain distracters; when they are reduced, the back pain
returns.”
1) relinquishes an opportunity to educate the unit secretary
2) nurse’s knowledge of the pain process should guide comments made to support
personnel; gossiping about clients is prohibited; should be role model to secretary
3) purpose of documentation is to communicate needs to other health professionals;
implies documenting with regard to an anticipated external activity
4) CORRECT— body does not respond to significant levels of pain in two different areas
of the body at one time; the more education the unit secretary has, the better she can
contribute to quality management of client needs
A patient is discharged from the orthopedic unit after receiving treatment for low-back
pain. The nurse counsels the patient about how to prevent further back injury. Which of
the following statements, if made by the patient to the nurse, indicates correct
understanding of appropriate preventive measures?
1. "It is all right to reach up for things, but if I am picking something up from the
floor, I will squat rather than bend and reach down."
2. "I will sleep on my side or abdomen rather than lie flat on my back."
3. "If my back starts to hurt, I will immediately stop what I am doing."
4. "I will sit as far back from the pedals on my car as my legs can comfortably
stretch, and I will use a firm backrest."
Strategy: All parts of the answer must be correct for the answer to be correct.
(1.) partially correct; it is not safe to strain to reach things
(2.) prone (abdomen) position should be avoided in order to maintain proper body
alignment
(3.) CORRECT—pain is the body’s signal that there is a potential for physical harm and
that the patient needs to withdraw from the pain-producing situation
(4.) to prevent back strain when driving a car, patient should sit close to the pedals, in
part to avoid knee and hip extension; a seat belt and firm backrest should be used for
back support
The home care nurse visits a client receiving enteral feeding through a gastrostomy
tube. The client’s wife says that the client has been having frequent loose stools. The
nurse is MOST concerned if the wife states which of the following?
1. “I give him 300 ml of formula in 45 minutes.”
2. “The formula is warmed in a basin of hot water.”
3. “I use a new bag and tubing every day.”
4. “It’s so easy to give liquid medicine through the
tube.”
1) appropriate rate; if volume too great, will cause dumping syndrome
3) appropriate action; if contaminated by bacteria, will cause diarrhea
4) CORRECT— liquid medication may contain sorbitol; if client has allergy to sorbitol,
will cause diarrhea; nurse should further assess
he home care nurse visits a 52-year-old man with an above-knee amputation (AKA). The
nurse reviews with him how to care for his stump. Which of the following instructions
1. Apply cream to the stump every day.
2. Cover the stump with a nylon sock while
awake.
3. Keep the stump elevated on a pillow at
night.
4. Expose the stump to air daily.
1) may predispose to infection of stump; stump skin needs to be firm; wash and dry
gently twice each day
2) precipitates moisture and warmth that may predispose to infection; use only cotton
or wool stump socks; change daily and ensure the sock fits smoothly
3) do not elevate after the first 24 h, may result in flexion contracture
4) CORRECT— facilitates healing of stump; inspect daily for pressure areas, dermatitis,
and blisters
A client with a possible fracture of the right femur comes to the emergency department.
The nurse supervises the transfer of the client from the car to a stretcher. Which of the
actions by the nurse is BEST?
1. Instruct the client to stand on her left leg and ease herself onto the
stretcher.
2. Determine if the client fell from a high place.
3. Support the right leg above and below the right femur.
4. Ask the client if she can move her right hip or right knee.
1) if fracture is suspected, immobilize the body part before moving the client; symptoms
include enlarged, deformed, painful thigh
2) most fractured femurs seen in young adults are from car accidents or falls; may have
multiple trauma; immobilize body part before moving client
3) CORRECT— appropriate if client must be moved before splinting fracture; support
prevents rotation and angular motion
4) Splint extremity; assess for shock and perform frequent neurovascular checks
The home care nurse visits a client with a long leg cast on the right leg due to a fracture
of the tibia. The client complains of feeling a hot spot under the cast. Which of the
1. Assess the circulation in the right
leg.
2. Suggest that the client change
position.
3. Obtain the client’s temperature.
4. Apply ice over the area that is hot.
1) CORRECT— heat is a sign of pressure; nurse should perform neurovascular
assessment before choosing a course of action
2) changing position may relieve the pressure but nurse should first assess
3) follow the ABCs, assess circulation
4) ice is applied directly over fracture site for first 24 hours; heat indicates pressure
The nurse knows that which of the following clients is at highest risk for developing
Dupuytren contracture?
1. A 75-year-old woman from Russia diagnosed with osteoarthritis.
2. A 54-year-old man from Norway diagnosed with diabetes.
3. A 34-year-old woman from Haiti diagnosed with a fractured femur.
4. An 11-year-old boy from Poland diagnosed with Duchenne muscular
dystrophy.
1) Dupuytren contracture is a slow progressive contracture of the palmar fascia causing
flexion of the fourth and fifth fingers; results from inherited autosomal dominant trait;
occurs most often in men over 50 years of age, of Scandinavian or Celtic descent, and
is associated with diabetes, gout, arthritis, and alcoholism; age and diagnosis are risk
factors
2) CORRECT— age, origin, gender, and diabetes are risk factors
3) no risk factors
4) no risk factors
A university sponsors a trip abroad for students majoring in international law. At 0300, a
student awakens the nurse to report that the student has frequency, urgency, and
dysuria. Because of safety concerns, night travel is prohibited. Which of the following
1. Ask the student if she has experienced this problem
previously.
2. Obtain the student’s temperature.
3. Encourage the student to drink large volumes of fluid.
4. Insist that the police override the curfew and allow travel.
1) health history is relevant but not the first action, does nothing to relieve the
discomfort; nurse cannot use the information to assist her in managing the health
problem now
2) fever is a rare manifestation of a urinary tract infection
3) CORRECT— will help flush the system; encourage client to take a warm sitz bath;
treatment of choice for UTI is antibiotics
4) situation not life-threatening
he nurse discusses diet with the mother of a child being treated for deep partial
thickness burns on her legs. Which of the following meals should the nurse suggest?
1. Chicken leg, broccoli, Jell-O, and lemonade.
2. Cheeseburger, fruit-flavored yogurt, carrots, and milk.
3. Cottage cheese, canned peaches, crackers, and apple juice.
4. Scrambled eggs, hashed brown potatoes, banana, and
orange juice.
1) chicken leg and broccoli contain protein
2) CORRECT— all foods contain protein except for carrots; burn injury requires high-
protein diet
3) only cottage cheese contains some protein
4) eggs contain protein, potatoes contain some protein
A patient diagnosed with myasthenia gravis prepares for discharge from the
rehabilitation unit to living at home with her daughter. The nurse reviews with the
daughter necessary home modifications, as well as ambulation issues. Which of the
following statements by the daughter indicates to the nurse that further teaching is
necessary?
1. "I will go forward in and out of elevators, pushing Mother’s wheelchair carefully
in front of me."
2. "I will fold the footrests away when my mother is getting in and out of the
wheelchair."
3. "If we are somewhere with an electric self-closing glass door, I will back myself
into it as we go through."
4. "I will be sure my mother is sitting as far back in the wheelchair as is possible."
(1.) CORRECT—when wheelchair is being pushed, backing into and out of elevators is
the correct procedure to ensure patient safety; allows person pushing to exert any
necessary control over doors manually or via the control panel
(2.) prevents patient bumping into them and bruising self, or trying to avoid them and
losing balance, tripping, or falling
(3.) the back of the person pushing the wheelchair can keep the door open while the
wheelchair is then guided through
(4.) ensures the broadest and consequently safest base of support and provides back
support
The nurse cares for a client who has an immediate prosthetic fitting after an above-the-
knee amputation. Which of the following actions by the nurse takes priority?
1. Observe drainage from surgically placed
drains.
2. Provide cast care to the affected extremity.
3. Observe the dressing for excessive
bleeding.
4. Elevate the residual limb for 72 hours.
1) drains are used to control formation of hematoma if soft dressing is used
2) CORRECT— closed, rigid cast prevents bleeding and controls pain; because rigid
plaster cast is used, cast care is required
3) closed rigid cast prevents bleeding
4) will cause contractures
The nurse counsels a group of senior citizens about how to prevent constipation. It is
MOST important for the nurse to include which of the following suggestions?
1. “Increase your intake of fiber
supplements.”
2. “Eat apples, oranges, or bananas every
day.”
3. “Drink at least four glasses of fluid every
day.”
4. “Decrease the fat in your diet.”
1) fiber pills taken in large quantities with inadequate fluid can cause constipation;
client should increase intake of fiber from dietary sources
2) CORRECT— increase intake of soluble and insoluble dietary fiber; eat two to four
servings of fruit per day as well as three to five servings of vegetables
3) should drink eight to ten glasses of fluid daily
4) fat may have laxative effect
The nurse supervises care of for a client who just had a short leg cast applied. The
nurse determines that care is appropriate if which of the following is observed?
1. The cast is covered with a light sheet.
2. The staff handles the cast using the palms of their hands.
3. The affected limb is elevated to the level of the heart.
4. The nurse compares the toes of the casted leg with the
opposite leg.
5. The staff places a fan in the client’s room.
6. The staff turns the client every 4 hours.
1) leave cast uncovered and exposed to the air
2) CORRECT— prevents development of pressure area
3) CORRECT— decreased edema
4) CORRECT— assess for neurovascular functioning; also assess circulation, motion,
and sensation in the casted extremity
5) CORRECT— increases circulation of air in room to facilitate drying the cast
6) turn the client every 2 hours to facilitate drying the cast, support major joints when
turning
The nurse observes the home health aide transfer a patient with right-sided paralysis
from the hospital bed to a chair using a hydraulic lift. The nurse should intervene if
which of the following is observed?
1. The home health aide lowers the patient’s bed before the transfer is
initiated.
2. A canvas sling is positioned under the center of the patient’s body.
3. The patient’s arms are folded over her chest before the transfer.
4. The home health aide pumps the hydraulic handle using long, slow
strokes.
1) CORRECT— bed should be raised so the home health aide uses proper body
mechanics during the transfer; lowered bed puts aide at risk for injury
2) patient should be centered in sling; provides support for patient’s body during
transfer
3) prevents injury to arms, especially paralyzed side, and provides for patient safety
4) ensures safe support for patient during elevation of slings
The home health nurse receives a phone call from the wife of a client diagnosed with
Parkinson’s disease. The wife states that her husband is having more difficulty
speaking. The nurse responds that she will see the client immediately. The nurse’s
judgment to see the client immediately is based on which of the following?
1. The client has weak facial muscles that can be strengthened with proper
exercise.
2. The client has communication difficulties caused by depression.
3. The client requires a medication change.
4. The client is at risk for aspiration.
1) facial muscle weakness will not be alleviated by exercises
2) client may be depressed, but physical problems take priority
3) may be true but client’s risk for aspiration is the priority
4) CORRECT— the same muscles are used for speaking and swallowing; if client is
having trouble speaking, needs to be assessed immediately for the ability to swallow
The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about
how to move from a supine position to standing at the left side of the bed with a walker.
Which of the following directions by the nurse is BEST?
1. Raise the head of the bed so you are sitting straight up, bend your knees, and
swing your legs to the side and then to the floor.
2. Rock your body from side to side, going further each time until you build up
enough momentum to be lying on your right side, and then raise your trunk
toward your toes.
3. Reach over to the left side rail with your right hand, pull your body onto its left
side, bend your upper leg so the foot is on the bed, and push down to elevate
your trunk.
4. Focus on using your arms, the left elbow as a pivot with the left hand grasping
the mattress edge and the right hand pushing on the mattress above the elbow,
then slide your legs over the side of the mattress.
1) entire spine must be kept straight throughout the transfer, bending knees and
swinging legs to the side would cause spinal twisting
2) should lie on left side, not right side; rocking can be stressful to the spine
3) back must be kept in straight alignment; do not use side rails after spinal surgery
because will cause spine to twist
4) CORRECT— maintains spinal alignment and prevents injury; relatively easy to
accomplish
The nurse on the medical/surgical unit reviews lab results. The nurse notes that a
client’s serum albumin level is 2.5 g/dL, fasting blood sugar is 110 mg/dL, potassium is
4.2 mEq/L, and sodium is 140 mEq/L. It is MOST important for the nurse to assess for
1. Edema.
2. Nausea.
3. Muscle weakness.
4. Blurred vision.
1) CORRECT— normal serum albumin is 3.5 to 5.0 g/dL; albumin deficit decreases
oncotic pressure and fluids shift from vascular area to tissue
2) can be caused by hypokalemia or hyponatremia; sodium, 135 to 145 mEq/L;
potassium, 3.5 to 5.0 mEq/L
3) caused by changes in potassium level
4) caused by hypoglycemia, normal FBS is 60 to 110 mg/dL
the skin.
4. The nurse asks the client to dorsiflex the foot on the affected leg.
pain.
The nurse cares for an elderly client 24 hours after an abdominal hysterectomy. The
nurse asks the client if she is experiencing any pain. The client states, “No, I am just
fine.” Which of the following responses by the nurse is BEST?
1. “That’s good. Please let me know if your abdomen starts hurting.”
2. “I see that you have not used your PCA pump. Are you sure that you aren’t
in pain?”
3. “You are doing such a good job. If it were me, I would be using the pain
medication.”
4. “Look at this faces pain scale. Point to the picture that shows how you feel
now.”
1) should validate client’s statement; client may be denying pain
2) second best answer; nurse is making observation about client’s use of PCA pump,
but validates by asking a yes/no question
3) focus is on nurse and not client
4) CORRECT— allows nurse to assess client’s perception of pain and validate client’s
denial of pain
After being diagnosed with advanced chronic renal failure (CRF), an elderly client
receives her food tray. It is MOST important for the nurse to remove which of the
following items from the client’s food tray?
1. 1 slice of wheat
toast.
2. 6 oz of orange juice.
3. 1/2 cup of grits.
4. One scrambled egg.
Strategy: Think about each food.
1) permitted on renal restrictive diet
2) CORRECT— high in potassium; client with this disease has hyperkalemia or is at risk
for hyperkalemia
3) a hot cereal; is not threatening to client
4) protein of high biological value; allowed on diet
The home care nurse instructs a client diagnosed with multiple sclerosis. The client
relates to the nurse that she has poor concentration and has difficulty pronouncing
words. The nurse notes that the client’s speech is slow and slurred. Which of the
following statements, if made by the client to the nurse, indicates further teaching is
necessary?
1. “I will sit up straight when I talk and will feel confident.”
2. “I will turn off the TV when speaking and look at the person with whom I am
talking.”
3. “During a conversation, I will carefully build up to my most important
points.”
4. “If words fail me, I will draw a picture.”
Strategy: “Further teaching is necessary” indicates an incorrect action.
1) appropriate action; erect posture assists breathing and speech; positive affirmations
and self-image are calming and will assist with self-expression
2) appropriate action; reducing background noise eliminates distractions, competing
sounds and stress; maintaining eye contact helps both parties focus on the moment
and enables feedback cues to be noticed
3) CORRECT— building up can lead to confusion and frustration caused by difficulty
concentrating and fatigue; most important points should be communicated at the
beginning of the sentence
4) appropriate action; may assist with expression and help meet the client’s need to
communicate
The nurse cares for a patient diagnosed with a fractured left femur. The patient
describes how to walk with crutches. Which of the following statements by the patient
indicates to the nurse that further teaching is necessary?
1. "The crutches and my weak leg will go forward first when I walk on flat
surfaces."
2. "My strong leg will lead the way going up and down stairs."
3. "I will use a backpack instead of a briefcase when I go to work."
4. "I will look at the crutch tips and feel them every day."
(1.) appropriate understanding; affected leg is moved forward at the same time as the
crutches, followed by the strong leg; describes the three-point crutch-walking gait,
which is the appropriate gait when partial or no weight-bearing is allowed on one leg
(2.) CORRECT—the strong leg leads the way going up stairs; when going down stairs,
the crutches are advanced to the lower step, the weaker leg is advanced, and then the
stronger leg follows
(3.) appropriate; hands and arms need to be unencumbered to effectively manage the
crutches
(4.) appropriate; crutch tips are rubber and provide stability and prevent slippage;
inspect regularly for cracks, wear, and tightness of fit, and replace immediately if any
problems are found
The nurse cares for a 4-year-old who sustained a fractured wrist from a fall. The nurse
prepares the child for the application of a plaster cast. Which of the following actions by
1. Tell the child the cast will feel cold when it is first applied.
2. Allow the child to play with a doll wearing a cast on the
arm.
3. Tell the child the application of the cast will not hurt.
4. Ask the child if she would like to meet another child with
a cast.
question.
1) may feel a warm sensation as the cast dries
2) CORRECT— preschoolers need to see and play with the equipment; this is the age of
the greatest number of fears
3) describe to the child what she will be feeling and experiencing in words that are not
frightening
4) allow child to play with doll with cast
A client comes to the clinic complaining of muscle weakness, breathlessness, and bone
pain. The nurse notes that the patient takes phenytoin (Dilantin) 100 mg 3 times a day.
When providing nutritional counseling, the nurse should include which of the following
foods in the patient’s diet?
1. Bananas, mushrooms, yams.
2. Oranges, broccoli, papayas.
3. Milk, cantaloupe, kale.
4. Soybeans, spinach, pumpkin
seeds.
Strategy: In order for an answer to be correct, all parts of the answer must be correct.
(1.) does not have increased folate or vitamin D
(2.) high vitamin C, potassium
(3.) CORRECT—anticonvulsants can cause folate and vitamin D deficiencies; folate
deficiency can cause anemia, symptoms reflective of these nutritional deficiencies;
good sources of folate are green leafy vegetables, legumes, tomatoes, and various
fruits such as oranges and cantaloupe; good sources of vitamin D include milk
(4.) contains protein
The nurse provides discharge teaching to the family of a child who had a cleft palate
repair. Which of the following statements, if made by the family to the nurse, indicates
the need for further teaching?
1. “My child can use a straw for drinking milk.”
2. “It’s going to be hard keeping my child from sucking his
fingers.”
3. “I cannot give my child cookies.”
4. “My child should eat in a sitting position.”
Strategy: “need for further teaching” indicates incorrect information.
1) CORRECT— usually repaired around 18 months to allow for bone growth; do not use
suction or place objects in the child’s mouth such as a tongue depressor, thermometer,
small spoon, or straws; restrict for about 6 weeks until palate heals
2) allows palate to heal
3) cookies, toast, and other hard foods are discouraged to prevent damage to newly
repaired palate
4) prevents aspiration
The nurse cares for a client after a left below-the-knee amputation. Which of the
following observations by the nurse requires immediate follow-up?
1. The client eats about half the food on his meal tray.
2. The client complains about inability to concentrate when reading
a book.
3. Pulses are palpable above the operative site.
4. The client complains of persistent pain after receiving pain
medication.
Strategy: “Requires immediate follow-up” indicates something is wrong.
1) not unusual during postoperative period; offer the client small, frequent feedings of
favorite foods
2) may be due to stress of amputation; nurse should further assess, but this is not the
priority
3) expected outcome; assess the closest proximal pulse and compare with the other
extremity
4) CORRECT— may indicate inflammation or infection
The nurse cares for an older woman 12 hours after a right total hip replacement. The
client appears disoriented to person, place, and time. It is MOST important for the nurse
to take which of the following actions?
1. Place an abductor pillow between the patient’s legs.
2. Frequently orient the client to person, place, and time.
3. Limits the client’s fluid intake.
4. Encourage the client to use the incentive spirometer every 4
hours.
1) CORRECT—abduction prevents dislocation of the hip while turning; important to use
because client is confused; assess for pain, rotation, and/or extremity shortening
2) appropriate because client is confused; not unusual that older clients become
confused by surgery and hospitalization; preventing dislocation of replaced joint is
priority
3) encourage fluids to prevent DVT; instruct client to wear elastic stockings and to
perform leg exercises; assess for redness, swelling, or pain
4) encourage to cough and deep breath or use the incentive spirometer Q 2 h

The nurse on the medical/surgical unit prepares several clients for discharge today.
Which of the following statements, if said by one of the clients to the nurse, indicates
1. "Because my colostomy is pink and moist, I can take a relaxing bath."
2. "Now that I’ve had this old hip replaced, I can get back on the tennis court."
3. "In about a week, I’ll need to have the stitches removed from my head. Perhaps
I should wear a hat while I’m outdoors."
4. "I can’t wait to go for a walk in the park. My knee feels so much better with the
new joint in place."
Strategy: "Need for further teaching" indicates incorrect information.
(1.) may resume hygiene
(2.) CORRECT—playing tennis would put the patient at risk for dislocation of the new
hip prosthesis
(3.) wearing a hat may help patient’s self-image by hiding suturesand protect surgical
site from weather conditions
(4.) client with a joint replacement is encouraged to walk to establish joint mobility
The nurse in the outpatient clinic receives a phone call from a young adult who says
that her friend has overdosed. Which of the following actions should the nurse take
FIRST?
1. Ask if the client has any vomiting or diarrhea.
2. Instruct the friend to call the Poison Control
Center.
3. Find out what the client took.
4. Determine if the client is responsive.
1) appropriate after assessing ABCs
2) nurse should complete assessment before implementing; don’t pass the buck
3) important information but priority is determining client’s current condition
4) CORRECT— ask friend if client conscious, if there are breathing difficulties, and what
the respiratory rate is; contact 911
The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants.
The nurse determines that assignments are appropriate if the LPN/LVN is assigned to
which of the following clients?
1. A client 2 days postop after abdominal hysterectomy asking to ambulate in the
hall.
2. A client with a colostomy requiring assistance with an irrigation.
3. A client with a right-sided cerebrovascular accident (CVA) requiring assistance
with bathing.
4. A client refusing medication for treatment of cancer of the colon.
1) assign to nursing assistant; give clear directions as to how far to ambulate client and
any untoward effects that should be reported to the RN
2) CORRECT— stable client with an expected outcome
The nurse observes the nursing assistant perform mouth care on an elderly client
admitted to the hospital with fever of unknown origin. Which of the following actions, if
performed by the nursing assistant, requires an intervention by the nurse?
1. The nursing assistant applies petrolatum jelly to the client’s lips.
2. The nursing assistant flushes the client’s mouth with a 50:50 dilution of
hydrogen peroxide and normal saline.
3. The nursing assistant rinses the patient’s mouth with a glycerin-based
mouthwash.
4. The nursing assistant uses a soft bristled toothbrush to clean the client’s teeth.
Strategy: “Requires an intervention” indicates an incorrect action.
1) prevents drying, cracking, and the formation of encrustations
2) used to remove debris and helps keeps the mucosa clean and moist
3) CORRECT— causes dehydration and irritation of tissues
4) used to prevent trauma to the mucosa
The nurse who is caring for patients in the outpatient clinic receives four phone calls.
Which of the following calls should the nurse return FIRST?
1. A patient reports a headache that is unrelieved by medications. The patient
reports taking two propoxyphene napsylate acetaminophen (Darvocet-N) and
two acetaminophen (Tylenol) every 4 hours for 3 days.
2. A patient complains of left ankle pain and swelling that is reddened and warm
to the touch. The patient states the redness and swelling occurred
spontaneously and denies injury to the ankle.
3. The mother of a toddler calls to report that her child has a rash and a sore
throat.
4. The father of a toddler calls to report that his child swallowed a dime.
(1.) both contain acetaminophen which is 90 to 95% metabolized by the liver; at risk for
damage to the liver as a result of overdose
(2.) the possibility of an infectious process requiring evaluation and treatment exists; an
overdose takes precedence
(3.) probably Streptococcus A infection; not emergent unless patient is having
(4.) CORRECT—nurse should immediately evaluate to determine if the toddler is having
schizophrenia?"
dreaming."
to take."
implications
The nurse receives a report from the previous shift. Which of the following patients
1. A patient who had a lobectomy 24 hours ago and has a
chest tube.
2. A patient who had a laryngectomy 12 hours ago.
3. A patient complaining of a headache.
4. A patient in Buck’s traction for a fracture of the R femur.
1) no indication that patient is unstable
2) CORRECT— postop complications include respiratory difficulties
3) stable patient
4) assess for fat embolism; postop laryngectomy patient is priority
A client involved in a homosexual relationship is scheduled for abdominal surgery.
During surgery, the client’s partner requests information regarding the client’s status.
1. “The physician will be out to talk with you after the surgery is
complete.”
2. “I am sorry. I can only give out information to family members.”
3. “Let me go back and get an update. I will be right back.”
4. “I’m sure she is doing fine, so just sit back and relax.”
1) passing the buck; nurse should respond to client
2) nurse can share information with significant other
3) CORRECT— important to respect client’s personal lifestyle choice; nurse acts as the
client’s advocate when providing partner with accurate information
4) false reassurance
The staff members caring for clients on a large medical-surgical area learn that
mandatory flu vaccinations are available. One week later, the nurse receives a written
abstention from a staff member citing religious reasons. Which of the following actions
1. Inform the staff member that he has 30 days to comply with the regulation or
face suspension or termination.
2. Inform the staff member in writing that immunization is required by agency
policy.
3. Verbally inform the staff member that not being immunized may determine
where the staff member will be allowed to work.
4. Inform staff member in writing that protective gear is required when providing
client care.
1) required to respect the staff member’s religious rights; places the agency in a
possible libelous position
2) staff member aware of agency policy; does not respect the staff member’s religious
rights
3) CORRECT— acknowledges the staff member’s rights but emphasizes the clients’
right to a safe environment
4) transmission-based precautions are related to the nature of the client’s illness
color.
anesthesia
The nurse works on a newly created unit formed by combining two units. Because one
of the former units was a research unit and the other unit was a general
medical/surgical unit, the staff on the new unit does not agree about how to best
manage the clients on the combined unit. Despite meetings held for staff to voice
concerns about the merger, the nurse notes that there is much divisiveness among the
staff that has compromised patient care. It is MOST appropriate for the nurse to make
which of the following suggestions to the charge nurse?
1. Assign staff members to patients on both sides of the
unit.
2. Hold an in-service about the benefits of merging the two
units.
3. Institute disciplinary action for negative talking by the
staff.
4. Require all staff to listen to reports on all of the patients.
Strategy: "MOST appropriate" indicates discrimination is required to answer the
question.
(1.) CORRECT—because meetings allowing staff to voice concerns have not
ameliorated the situation, assigning staff to patients on both sides of the unit will force
the teams to work together and to experience all of the new unit
(2.) because previous meetings have not effected change in staff behavior, more
meetings are unlikely to change the staff’s feelings
(3.) negative talking will impact patient care; assigning staff to care for patients on both
sides of the unit will allow staff to better understand the needs of all the patients
(4.) will expose staff to all patients and their needs, but assigning staff to care for
patients on both sides of the unit is the best option
A 45-year-old patient with a 10-year history of rheumatoid arthritis is being prepared for
discharge from the hospital. Which of the following instructions is essential for the
nurse to include?
1. “If it hurts to perform an activity, don’t do it.”
2. “Move your joints as much as you can each day.”
3. “Eat a diet high in complex carbohydrates and
calcium.”
4. “Return to work on Monday.”
1) take prescribed medications as ordered and on time; balance rest and activity
2) CORRECT— maintaining mobility is a physical need; most important; achieved by
exercises and independent ADLs; take warm shower or tub bath to increase blood flow,
decrease pain and increase joint mobility; walking and swimming are good exercises
3) physical need but not most important; should eat a balanced diet and maintain weight
4) important to balance rest and activity
The nurse on the medical/surgical unit notes a graduate nurse often seems rushed
during the shift and is staying overtime without pay to complete work. The graduate
nurse approaches the nurse and says, "I am having difficulty with time management."
Which of the following INITIAL responses by the nurse is BEST?
1. "I have some ideas to help you better manage your time."
2. "How much practice did you get in school taking care of groups of
patients?"
3. "What ideas do you have as to the reasons for your time management
difficulties?"
4. "Tell me how you feel about time in general."
(1.) assess before implementing
(2.) relevant, but more important to first determine graduate’s perception about why
there is a time management problem
(3.) CORRECT—best to initially assess graduate’s perception of difficulty before
offering solutions; conveys respect, allows for free expression and analysis of problem
(4.) relevant but not best initial response; obtains information about larger framework
and possible cultural issues; assessment should be focused
At 5:00 pm, the nurse notes that the last entry in a patient’s chart was at 9:00 am. The
nurse on the previous shift did not complete the chart and did not sign the nurses’
notes. Which of the following actions by the nurse is BEST?
1. Leave a note on the front of the chart asking the nurse to make a late entry and
begin charting on the line below the last entry in the nurses’ notes.
2. Leave enough space for the previous nurse to complete charting when the
nurse returns the next day.
3. The evening nurse withholds all charting until the previous nurse returns to
complete charting for care delivered.
4. Contact the nurse from the previous shift and ask for a report so the evening
nurse can complete the charting.
1) CORRECT— charting should be timely and accurate; begin charting on the next line
3) charting should be timely
4) nurse should begin charting on the next line; should document date and time that
care provided
following?
examination.”
examination.”
health
2) usually normal
The nurse assigns the care of a client after a left mastectomy to an LPN/LVN. The RN
reminds the LPN/LVN to take the client’s blood pressure on the right arm. Later in the
shift, the RN notes that the deflated blood pressure cuff is on the client’s left arm. Which
1. Talk with the LPN after the shift is over.
2. Ask the LPN why she did not follow directions.
3. Review with the LPN the importance of taking the blood pressure on the
right side.
4. Write a report about the incident and place it in the LPN/LVN’s personnel
folder.
1) would cause continued harm to client
2) do not ask “why” on the licensure exam
3) CORRECT— NCLEX ® -RN exam is a “here and now” test; take care of problem now
to prevent harm to client
4) priority action is protecting the safety of the client
The nurse in a small rural community performs screening for glaucoma. Tonometry
indicates that four residents have elevated intraocular pressure (IOP). The nurse
contacts the local ophthalmologist and learns that only one appointment is available
during the next 7 days. It is MOST important for the nurse to refer which of the following
residents?
1. A resident with type 1 diabetes and an IOP of 26 mm Hg.
2. An 80-year-old resident with an IOP of 20 mm Hg.
3. A resident complaining of seasonal allergies with an IOP of 22
mm Hg.
4. A resident with a L-sided CVA and an IOP of 21 mm Hg.
1) CORRECT— diabetes is associated with glaucoma; normal pressure is 10 to 21 mm
Hg; this client should be the first to see the physician
2) aging is a common cause of glaucoma; this IOP is within the upper limits of normal;
client should be rescreened; obtain readings at various times of the day
3) IOP is elevated but no other common causes of glaucoma are mentioned; requires
rescreening
4) neurovascular disorders can cause secondary glaucoma; IOP at upper limits of
normal; client should be rescreened; obtain readings at various times of day
The nurse in the pediatrician’s office receives the following phone messages. Which of
the phone messages should the nurse return FIRST?
1. The mother of a 2-day-old infant states that her infant’s extremities extend and
return to their previous position when the crib is bumped.
2. The mother of a 3-day-old infant states that her son’s circumcision is covered
with yellowish exudate.
3. The mother of a 4-day-old infant states that her infant has had one stool per
day for the past 2 days.
4. The mother of a 5-day-old infant states that the stump of her infant’s umbilical
cord is moist at the base and slightly red.
1) describes Moro reflex, which is normal; also known as startle reflex
2) indicates normal healing
3) normal stool pattern
4) CORRECT— indicates infection; cord should be dry with no redness
include?
question requires."
time
The nurse supervises care of clients at the local eye care center. The nurse determines
that care of a client immediately after intracapsular cataract extraction is appropriate if
the unlicensed assistive personnel (UAP) performs which of the following activities
FIRST?
1. Raises the head of the client’s bed 35°.
2. Places an emesis basin at the client’s
bedside.
3. Tapes the eye shield securely with paper
tape.
4. Measures the client’s intake and output
1) CORRECT— prevents significant, sustained increased intraocular pressure, which is
a major complication
2) vomiting increases intraocular pressure and should be reported to the health care
provider; do not place head in dependent position
3) not within the scope of practice of the UAP
4) priority is placing the client in semi-Fowler’s position to prevent increased intraocular
pressure
The nurse cares for clients on an acute pulmonary unit. The nurse prepares a written
report for the next shift. It is critical to communicate which of the following to the next
shift?
1. Laboratory work drawn on the client, arterial blood gas reports, nutritional
intake, and vital signs for the shift.
2. Any respiratory difficulty client has experienced, activity tolerance, sputum
production, and significant variances in vital signs during the shift.
3. Name of client’s physician, date client was admitted, dietary intake, and client’s
general condition.
4. Urinary output, fluid intake, visits by the attending physician, vital signs, any
respiratory problems encountered.
2) CORRECT— report should include client’s status, current care plan, response to
current care, and care that requires further teaching
Six months ago a nursing assistant was injured in an automobile accident. Her right leg
was badly damaged and, after rehabilitation, the nursing assistant walks with an
extreme limp and a slow, unstable gate. The nursing assistant prepares to return to
work on an acute care surgical unit. When planning for the return of the nursing
assistant, the nurse should take which of the following actions?
1. Survey other units for positions that are more suitable for the nursing
assistant.
2. Recommend the nursing assistant take a leave of absence without pay until the
nursing assistant receives disability benefits.
3. Transfer the nursing assistant to a shift during which the work on the surgical
unit is less demanding.
4. Transfer a major portion of the nursing assistant’s duties to the other nursing
assistants.
Strategy: Topic of question unstated.
1) CORRECT— ADA recommends that the nursing assistant be offered a position that is
appropriate
2) ADA requires reasonable accommodations; if nursing assistant is returning to work
after 6 months, either there are no disability benefits or the nursing assistant does not
want them
3) regardless of shift, nursing assistant has to be able to perform the care required by
surgical patients; unsteady gait makes nursing assistant unsafe
4) may jeopardize patient safety and reduce staff morale
A 75-year-old man is admitted with altered mental status and a urinary tract infection.
The physician writes an order for use of a Posey vest restraint. Which of the following
actions by the nurse is BEST?
1. Perform some of the patient’s care so he doesn’t feel that the restraint is a
punishment.
2. Ask the physician to change the order to wrist restraints to allow the patient
some movement in bed.
3. Explain the use of the restraint to the patient and ask for permission to apply it.
4. Reevaluate the need for the restraint every 4 hours.
Strategy: The answer choices are a mix of assessments and implementations. Is
validation required? Yes.
1) should encourage independent functioning; try less restrictive alternative first
2) would increase agitation more than a vest restraint; nurse must try less restrictive
alternatives
3) should explain use of restraint to patient, but should not ask patient for permission to
apply restraints due to patient’s altered mental status; if client is unable to consent to
use of restraints, then consent of proxy must be obtained after full disclosure of risks
and benefits
4) CORRECT— nurse should assess for and document need for continue use of
restraints; order for restraint is time-limited to 4 hours
A client in a semiprivate room is visiting with his roommate. An employee from the
hospital business office enters the room and discusses with the client his inability to
pay for services. The client is an investment banker and his company filed for
bankruptcy two weeks ago. After the business employee leaves, the client goes to the
nurse’s station to complain that his right to privacy was violated. Which of the following
1. Escort the client to a private setting.
2. Tell the client that his roommate was probably not listening.
3. Inform the client that the business office had to straighten out his
account.
4. Contact the business office so the client can talk with the
employee.
1) CORRECT— prevents further violation of privacy
2) “don’t worry” response; does not address the client’s concerns
3) nurse is responsible for protecting client’s rights
4) should talk with client in private setting; follow chain of command and contact the
nursing supervisor
Because of budgetary constraints, the head nurse on a large medical/surgical unit is
required to redesign the nursing positions on the second shift. The nurse plans to meet
with the staff to discuss the required changes. Which of the following actions by the
head nurse is MOST appropriate?
1. Inform the staff that they will redesign the positions with input as needed from
the head nurse.
2. Ask the staff nurses for input; redesign the positions and forward it to the
supervisor.
3. Direct the nurses to redesign the position according to agency guidelines.
4. Gather data from the staff nurses, redesign the positions, ask the nurses to
review final draft, and submit the proposal to the supervisor.
1) laissez-faire leadership not appropriate for resolving formal, structured elements
such as fiscal matters
2) if the staff is to effectively implement the change, they need to be involved as much
as possible; head nurse not as familiar with the day-to-day elements associated with the
position
3) usually this is a very trying process for nurses; they need the support and input of
the head nurse
4) CORRECT— should use the expertise of all staff members
The mother of a 28-day-old baby diagnosed with tetralogy of Fallot (TOF) is seen
pumping her breasts at the infant’s bedside. The nursing assistant comes out of the
room and says to the nurse, "She should breast feed that baby instead of sitting there
with a breast pump under her shirt all the time. What’s wrong with her?" Which of the
following is the BEST response for the nurse to make?
1. "You sound upset."
2. "Why don’t you ask her?"
3. "What do you understand about her baby’s
illness?"
4. "It’s not our business to judge the decisions of
others."
(1.) not best; does acknowledge expressed emotion, which can help the person feel
understood and want to talk further
(2.) not therapeutic; is a "why" question
(3.) CORRECT— non-judgmental response; provides opportunity and starting point for
probably needed staff teaching; infants with congenital heart diseases, including TOF,
are weak, fatigue easily, and need to be fed carefully and with the least amount of
required effort on their part
(4.) blocks nursing assistant’s expression of feelings, subtly conveying a judgment, and
also misses opportunity to further assess and to educate staff
urination.
respirations.
The nurse observes that a physician has ordered 100 cc D 5 W with KCl 80 mEq to
infuse in 0.5 hour. Which of the following actions should the nurse take FIRST?
1. Assess the client’s urinary
output.
2. Ensure the patency of the client’s
IV.
3. Request an order for IV Lidocaine.
1) decreased renal function can cause hyperkalemia
2) severe pain and tissue necrosis may occur because of extravasation
3) lidocaine used for treatment of ventricular dysrhythmia
4) CORRECT— rate of IV administration should be no faster than 20 mEq/h; contact
physician to clarify order

A mother brings her 2-year-old girl to the clinic. The nurse notes that the child has
honey-colored crusts, vesicles, and reddish macules around her mouth. Which
statement, if made by the nurse, is BEST?
1. Your child has developed an irritation because she continues to use a
pacifier.
2. Your child has an infection that can be treated with antibiotics.
3. Your child has developed a food allergy and you should restrict her diet.
4. Your child has been exposed to a sick child and should be isolated for a
few days.
1) describes impetigo, not an irritation
2) CORRECT— describes the skin eruptions found with impetigo; symptoms of impetigo
include reddish macule becoming vesicle, then crusts, pruritus; caused by
Staphylococcus , Streptococcus
3) symptoms suggestive of impetigo, not food allergy
4) unnecessary to isolate child; should use skin isolation and good handwashing
techniques; antibiotics: may be topical ointment (Garamycin, Neosporin) and/or PO;
loosen scabs with Burow solution compresses, remove gently, restraints if necessary;
mitts for infants to prevent secondary infection; monitor for acute glomerulonephritis
(complication of untreated impetigo)
The nurse admits a client to the outpatient surgical unit for a mastoidectomy due to
chronic otitis media. Which of the following questions should the nurse ask FIRST?
1. “When did you begin having problems with your
ears?”
2. “Do you have problems with vertigo?”
3. “Do you have any questions about the procedure?”
4. “What are your concerns about the postoperative
period?”
1) nurse will obtain a health history, including questions about infection, otorrhea,
hearing loss and vertigo; because vertigo is a common occurrence with ear problems, it
is priority that nurse establishes client’s safety
2) CORRECT— nurse anticipates problems with vertigo and asks about it first to prevent
injury to the client
3) nurse should reinforce information presented by the surgeon; not the first action the
nurse should take
4) appropriate discussion for the nurse; safety takes priority
The nurse prepares a client for a contrast enhancement CT scan. It is MOST important
for the nurse to ask which of the following questions?
1. “Do you have a history of respiratory
disease?”
2. “Do you have any allergies to food or
medication?”
3. “Have you ever smoked?”
4. “What x-ray tests have you had before?”
1) does not place the client at risk for the test
2) CORRECT— contrast enhancement performed with iodine contrast media; ask about
allergies to seafood, iodine, and other contrast dyes
3) not the priority question
4) priority is asking directly about allergies
The nurse instructs a client diagnosed with type 2 diabetes about disease management
during an illness. The nurse determines that further teaching is necessary if the client
1. "I will monitor my blood glucose levels more frequently."
2. "I should contact the physician if I cannot eat for more than 24 hours."
3. "I should stop taking insulin during the time I am sick."
4. "I should notify the physician if I have vomiting and diarrhea for more than 24
hours."
(1.) appropriate action; changes in dietary intake and metabolic processes during an
illness may result in significant fluctuations in blood glucose levels
(2.) appropriate action; important to maintain adequate nutritional intake and prevent
dehydration
(3.) CORRECT—should take usual dose and substitute easily digested foods and fluids
to provide adequate nutrition and prevent dehydration
(4.) encourage patient to notify physician of persistent vomiting and diarrhea because
intervention may be required to prevent dehydration
The nurse assumes care of a patient just returning from surgery after a total abdominal
hysterectomy. When the nurse questions the patient about her pain, the patient rates
her pain as 4 out of 10 on the pain scale. Which of the following interventions by the
1. Assist the patient to a more comfortable position and encourage her
to sleep.
2. Administer narcotic pain medications as ordered.
3. Encourage the patient to watch television or read a book.
4. Continue to monitor the patient for pain.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it
desired?
1) nonpharmacologic interventions such as repositioning and rest are appropriate
alternatives; however, moderate pain should be more aggressively addressed
2) CORRECT— there is a known etiology for the pain (surgery), so it is most appropriate
to provide pain medications immediately for moderate pain and use other methods as
adjunct therapy
3) distraction may be appropriate adjunct therapy; unrealistic intervention immediately
post anesthesia
4) providing no intervention for the patient’s report of moderate pain is an unacceptable
solution
A woman is scheduled to have a transabdominal pelvic ultrasound for evaluation of a

uterine mass. The office nurse knows that which of the following statements is MOST
important to include when preparing the patient for the procedure?
1. "Do not eat anything for at least 8 hours before the test."
2. "You may feel a stinging sensation as the machine moves over
your skin."
3. "Drink four glasses of water 1 hour before the test and do not
urinate."
4. "Be prepared for the test to take about 1 hour."
Strategy: "MOST important" indicates that discrimination is required when answering
the question.
(1.) does not require fasting
(2.) no discomfort or pain with this test
(3.) CORRECT—a full bladder is necessary for this test for several reasons; included in
these are that it serves as a window for the ultrasound beam transmission and that it
provides a less obstructed view by pushing the uterus away from the pubic symphysis
and by pushing the intestine out of the pelvis
(4.) examination time is approximately one-half hour; most ultrasounds take 20 to 45
minutes, not including preparation and waiting times
When assessing the incision of a client 2 days postoperatively, the nurse notes a shiny
pink area with underlying bowel visible. Which of the following actions should the nurse
take FIRST?
1. Cover the area with sterile gauze soaked in normal saline.
2. Cleanse the wound with hydrogen peroxide and apply a sterile
dressing.
3. Pack the opened area with sterile 3/4 inch gauze soaked in normal
saline.
4. Apply Neosporin ointment and cover with Tegaderm dressing.
1) CORRECT— describes evisceration; immediately cover with sterile dressing soaked
with normal saline and contact the physician
2) cover with sterile dressing soaked in normal saline
As a nurse prepares to assist a physician with an epidural patch for a client with a
postlumbar puncture headache, the client tells the nurse he is an illegal alien. Which of
the following actions should the nurse perform NEXT?
1. Position the client in a side lying position.
2. Notify immediate supervisor of the client’s citizenship
status.
3. Notify the appropriate federal officials.
4. Place client in upright position.
1) CORRECT— appropriate position for procedure; citizenship status is not the priority
2) staff nurse does not address citizenship status; current need is proper position for
procedure, along with equipment/supplies
3) agency would need to decide who should make contact; questions of privacy and
confidentiality exist
4) more likely to result in severe headache; headache represents excessive loss of
cerebral spinal fluid, resulting in brain settling while in upright position
The nurse cares for a client receiving spinal anesthesia. It is MOST important for the
nurse to take which of the following actions?
1. Ensure that the client is adequately hydrated before the
procedure.
2. Assess for allergies to iodine.
3. NPO for 12 hours before the procedure.
4. Determine the specific gravity of the client’s urine.
1) CORRECT— will prevent hypotensive problems after the anesthesia is initiated
2) iodine preparations are not used in spinal anesthesia
3) not necessary; encourage fluids to ensure that the client is well hydrated
4) irrelevant to the procedure
The nurse instructs a patient about how to use an incentive spirometer. The nurse
should include which of the following instructions?
1. “Hold the spirometer at a 45° angle while breathing in.”
2. “Exhale into the spirometer for 3 seconds.”
3. “Inhale through the mouthpiece and hold breath for 3
seconds.”
4. “Hold the spirometer straight to allow aerosol to enter
lungs.”
1) spirometer is held upright at eye level so patient can observe the ball purpose is to
promote complete lung expansion and prevent respiratory complications in the post-op
patient
2) should inhale and hold breath for 3 seconds
3) CORRECT — allows sustained maximal inspriation to prevent atelectasis; patient is
able to see efforts registered on spirometer
4) when awake; encourage patient to cough after using spirometer
The nurse in the prenatal clinic monitors the condition of a pregnant woman at 30
weeks’ gestation who is diagnosed with gestational diabetes mellitus (GDM). Which of
the following testing results MOST concerns the nurse?
1. Hemoglobin (Hgb) 11.5 mg/dL and hematocrit (Hct)
33%.
2. Glycosylated hemoglobin (HbA1c) 7%.
3. Urine dipstick testing is positive for ketones.
4. One-hour glucose tolerance test (GTT) result is 140
mg/dL.
(1.) probably reflects physiologic anemia of pregnancy, a normal response that occurs
because of plasma volume expansion to a volume 3 times more than the RBC mass
(2.) glycosylated Hgb reflects blood sugar control over the preceding 120 days; 7% is
within normal range
(3.) CORRECT—ketones result from fatty acid metabolism, and usually are completely
metabolized by the liver; ketone bodies in the urine (ketonuria) are a sign of
ketoacidosis which, in pregnancy, is a major factor contributing to intrauterine death
(4.) result of 140 mg/dL or over is seen as abnormal and requires further evaluation with
a 3-hour GTT
The nurse in the outpatient clinic cares for a client complaining of anorexia, belching,
heartburn, and a sour taste in the mouth. The physician orders a battery of tests. The
nurse is MOST concerned about the timing of which of the following tests?
1. Upper GI.
2. Colonoscopy.
3. Abdominal
ultrasound.
4. Electrocardiogram.
1) CORRECT— barium radiography can interfere with x-rays, ultrasound, tests using
iodine, proctoscopy, and colonoscopy and should be scheduled after these tests
2) should be performed before the upper GI to ensure that colon is thoroughly cleansed
3) barium interferes with the transmission of sound waves and should be scheduled
after this test
4) EKG is not affected by other tests
The nurse counsels a client diagnosed with a seizure disorder. The client has just won a
national beauty pageant and will be frequently traveling during the next year. It is MOST
important for the nurse to include which of the following instructions?
problems.”
2) CORRECT— take medication as prescribed to keep drug levels constant to prevent
seizures; should carry medication because luggage can get lost
The nurse on the medical/surgical unit receives an informal mid-shift report from the
nursing assistants. The nurse should respond FIRST to which of the following reports?
1. The nursing assistant caring for a patient diagnosed with lung cancer says,
"He keeps coughing, is on oxygen, and can hardly breathe, but he asked me
for a cigarette. It makes me so mad that the patient is sick because of smoking
and he still wants to smoke."
2. The nursing assistant caring for a patient after a Billroth II procedure
(gastrojejunostomy) says, "After she ate lunch, the patient said she wanted to
lie down. I told her that she should sit up for at least half an hour to let her food
digest properly."
3. The nursing assistant caring for a patient recovering from a myocardial
infarction says, "When I was combing her hair, the patient started crying and
said she knew she should be grateful but she is terrified. She can’t help
thinking, ‘what if it happens again?’"
4. The nursing assistant caring for a patient after a right-below-the-knee
amputation says, "The patient keeps complaining of pain in the toes and calf of
his right leg. I have reminded him that they are no longer there, but he insists
that they hurt."
(1.) nurse should allow nursing assistant to further express feelings; often difficult for
health care providers to deal with patients who seem addicted to or intent on self-
destruction when providers are intent on saving lives; such expression should be
followed with discussion of ways to be objective and avoid judgment
(2.) CORRECT—requires immediate intervention; after gastrojejunostomy, dumping
syndrome can occur; lying down after eating is recommended in order to delay the
gastric emptying process; eating lying down or semirecumbent is another measure that
can be taken; desire to lie down may also be one of the early manifestations of dumping
syndrome, which also includes vasomotor disturbances of syncope, symptom
manifestations (90 minutes to 3 hours after eating); the patient needs evaluation and
clarification of proper procedure, and the nursing assistant needs to be taught that this
patient situation is the exception to the rule of not lying down after eating
(3.) psychosocial need; needs to express feelings and fears and have them
acknowledged by staff, particularly professional staff or registered nurse and physician,
so that appropriate teaching, guidance, and support can be given
(4.) instruct nursing assistant about phantom limb pain; assess patient to determine if
pain intervention required, such as medication and complementary and alternative
therapy; not therapeutic to remind patient that because the limb is missing it cannot be
hurting
The community health nurse obtains laboratory test results for four clients. After
evaluating the lab results, the nurse determines that which of the clients should be
contacted FIRST?
1. Urine culture and sensitivity with colonization of E.
coli .
2. Urinalysis with leukocytes.
3. Elevated serum antistreptolysin O (ASO) titer.
4. Cystourethrogram reveals vesicoureteral reflux.
1) validates urinary tract infection; not as threatening to health as glomerulonephritis
2) reflects urinary tract infection or contamination during specimen collection; no
immediate significant threat to health
3) CORRECT— indicates glomerulonephritis, damage to glomerulus caused by an
immunological reaction that results in proliferative and inflammatory changes within the
glomerular structure
4) X-ray study of bladder and urethra; radiopaque dye injected, patient voids, x-rays
taken during voiding
The nurse cares for a patient just returned from surgery after a right total knee
replacement. It is MOST important for the nurse to take which of the following actions?
1. Change the surgical dressing immediately.
2. Assist the patient to ambulate in the room.
3. Encourage the patient to use the incentive spirometer three times
per day.
4. Apply a sequential compression device to the patient’s lower
extremities.
(1.) dressing is usually not changed for 24 to 48 hours; if becomes saturated or loosens
during this time, it should simply be reinforced
(2.) placed on bedrest initially and then activity will be increased as ordered by
physician and tolerated by patient
(3.) instruct to use the incentive spirometer every 1 to 2 hours
(4.) CORRECT—improves circulation and prevents clot formation
While running a mountainous marathon, a runner falls over a cliff and hits her head. The
runner is admitted to the local hospital. The physician asks the nurse to prepare the
client for a lumbar puncture. Which of the following actions should the nurse take
FIRST?
1. Obtain informed consent.
2. Obtain the client’s vital
signs.
3. Explain procedure to client.
4. Procure lumbar puncture
tray.
1) responsibility of the physician
2) CORRECT— change in vital signs could indicate increased intracranial pressure
(ICP), which is contraindicated in lumbar puncture
3) physical needs take priority over psychosocial needs
4) priority is completing the assessment
The nurse instructs a client about how to collect a 24-hour urine specimen for a
creatinine clearance test. The nurse should intervene if the client states which of the
following?
1. “I will have to have my blood drawn during the
test.”
2. “I will go to the lab after I work out in the gym.”
3. “I will drink at least one cup of water hourly.”
4. “I will void and discard the urine before the test
begins.”
1) appropriate action; almost all creatinine in the blood is excreted by the kidneys;
creatinine clearance is most accurate indicator of renal function
2) CORRECT— creatinine is waste product of muscle breakdown; should not engage in
strenuous exercise during the test
3) appropriate action; produces urine
4) appropriate action; after discarding urine, time is noted and all urine is saved for 24
hours
Because of persistent absenteeism and decreased performance, a 35-year-old African
American woman who works at a national cell telephone company is referred to the
occupational nurse’s office. The client tells the nurse that she feels tired all of the time
and has headaches unrelieved by acetaminophen (Extra Strength Tylenol) tab ii. It is
2. Schedule an appointment with the nephrologist.
3. Ask the client when she last saw her personal physician.
4. Instruct the client to schedule an appointment with her personal
physician.
1) CORRECT— race, age, gender, and signs/symptoms are reflective of hypertension;
fatigue may indicate early development of renal disease
2) requires more data
3) important question; priority is to complete the assessment
The nurse reviews dietary guidelines with a client diagnosed with gastroesophageal
reflux disease (GERD). The nurse determines teaching is successful if the client states
2. “I will switch from orange juice to tomato juice at breakfast.”
3. “I will eat three meals per day and not snack between meals.”
inches.”
2) both juices are acidic and exacerbate reflux; apple juice is an appropriate alternative
3) big meals exacerbate reflux by increasing volume and pressure in the stomach as
well as delay gastric emptying
4) CORRECT— recumbent position significantly impairs esophageal clearance; head
should be elevated 6 to 12 inches to prevent nighttime reflux
The nurse cares for clients in the pediatric clinic. The nurse reviews charts of school-
aged children receiving care for chronic conditions. The nurse determines which of the
following children is MOST at risk for crippling knee and joint deformities?
1. A child diagnosed with
hemophilia.
2. A child diagnosed with epilepsy.
3. A child diagnosed with cystic
fibrosis.
4. A child diagnosed with celiac
disease.
Strategy: "MOST at risk" indicates discrimination is required to answer the question.
(1.) CORRECT—most frequent site of bleeding is into muscles and joints; repeated
bleeding episodes cause changes in bone and muscles
(2.) no risk for joint deformity
(3.) no musculoskeletal deformities associated with this respiratory and gastrointestinal
disease
(4.) malabsorption disorder; nonmusculoskeletal deformities
observations requires an IMMEDIATE intervention by the nurse?
1. The new resident physician prepares to insert the needle for a lumbar puncture
at the level of the posterior iliac crest.
2. The staff nurse leaves a patient’s isolation room, mask on, and is folding the
gown inside out before disposing of it.
3. The nursing assistant feeds a patient who had a cerebrovascular accident
(CVA) while the patient’s neck and head are flexed slightly forward.
4. The licensed practical nurse (LPN/LVN) removes the weight of a patient in
Buck’s extension traction before repositioning the patient.
Strategy: Determine the MOST unstable situation.
(1.) appropriate action; the posterior iliac crest is at the level of L3 through L4, which is
the usual level at which the spinal tap needle is inserted
(2.) appropriate action; decreases microorganism spread and protects clothing from
contamination; waist ties are first untied, then gloves off, then neck ties untied; gown is
allowed to fall forward from shoulders, arms are slid out working from the inside, then
gown is folded while being held away from body; after gown is discarded, mask is
removed and discarded
(3.) appropriate action; head should be in midline and flexed slightly forward to facilitate
swallowing and to prevent aspiration
(4.) CORRECT—skeletal traction weights should never be removed without an order,
including when repositioning the patient; such an action would be very painful for the
patient and would interrupt the line of pull
The nurse cares for a 72-year-old client diagnosed with bilateral cataracts. The client
repeatedly asks the nurse “Why did this happen to me?” Which of the following
statements by the nurse is BEST?
1. “As you age, the lenses of the eyes gradually lose moisture and their density
increases.”
2. “The pressure within the eye increases, causing the eye’s reduced ability to
focus.”
3. “The lenses in your eyes become hardened and inflexible.”
4. “This happened because your retina detached from the inner part of the eye.”
1) CORRECT— cataracts are partial or total opacity of the normally transparent
crystalline lens; occurs because lens becomes less hydrated and more dense
2) increased pressure within the eye is glaucoma
3) flexibility not related to transparency of the lens
4) cataract is not a detached retina
The nurse cares for a 72-year-old client diagnosed with bilateral cataracts. The client
repeatedly asks the nurse “Why did this happen to me?” Which of the following
statements by the nurse is BEST?
1. “As you age, the lenses of the eyes gradually lose moisture and their density
increases.”
2. “The pressure within the eye increases, causing the eye’s reduced ability to
focus.”
3. “The lenses in your eyes become hardened and inflexible.”
4. “This happened because your retina detached from the inner part of the eye.”
crystalline lens; occurs because lens becomes less hydrated and more dense
2) increased pressure within the eye is glaucoma
3) flexibility not related to transparency of the lens
4) cataract is not a detached retina
The nurse in the outpatient surgical center instructs a client preparing for surgical
removal of a cataract of the left eye with a lens implant. The nurse determines teaching
is effective if the client states which of the following?
1. “My eyelid will be swollen shut for 3 days.”
2. “I am happy that I will only need reading glasses.”
3. “I can return to normal activities without
restrictions”
4. “I will have severe pain that will be relieved by
narcotics”
1) indicates a serious complication
2) CORRECT— replacement lens implants are selected to allow correction of refraction
for distant vision; client may not require glasses to see distances, but may still require
glasses for reading or for close work
3) multiple activity restrictions required to prevent increased intraocular pressure; avoid
straining, no heavy lifting; bend from knees to pick up objects
4) severe pain is a complication of the procedure related to increased intraocular
pressure
The nurse assesses a client for signs and symptoms of carpal tunnel syndrome. It is
1. “Put the back of your hands together and bend both wrists at the same time.”
2. “Place the fingernails of your ring fingers together and hold them up to the
light.”
3. “Hold your arms out straight in front of you and push with your hands and
wrists against the wall.”
4. “Put your hands with palms up and then palms down on each thigh, repeating
as fast as you can.”
1) CORRECT— describes Phalen’s maneuver; produces paresthesia of the median
nerve distribution within 60 seconds; 80% of clients diagnosed with carpal tunnel
syndrome have a positive result
2) Schamroth method to detect clubbing; if diamond shape is visible between the nails,
there is no clubbing; clubbing indicates oxygen deprivation from respiratory or
cardiovascular conditions
3) isometric exercise not related to assessment of carpal tunnel syndrome
4) assesses cerebellar function, fine coordination of muscle activity
The nurse assesses a client for signs and symptoms of carpal tunnel syndrome. It is
1. “Put the back of your hands together and bend both wrists at the same time.”
2. “Place the fingernails of your ring fingers together and hold them up to the
light.”
3. “Hold your arms out straight in front of you and push with your hands and
wrists against the wall.”
4. “Put your hands with palms up and then palms down on each thigh, repeating
as fast as you can.”
1) CORRECT— describes Phalen’s maneuver; produces paresthesia of the median
nerve distribution within 60 seconds; 80% of clients diagnosed with carpal tunnel
syndrome have a positive result
2) Schamroth method to detect clubbing; if diamond shape is visible between the nails,
there is no clubbing; clubbing indicates oxygen deprivation from respiratory or
cardiovascular conditions
3) isometric exercise not related to assessment of carpal tunnel syndrome
4) assesses cerebellar function, fine coordination of muscle activity
An elderly client is admitted for removal of a cataract on his right eye. The nurse should
anticipate which of the following during the initial nursing assessment?
1. The client states that objects appear distorted and blurred.
2. The client uses thick glasses for activities of daily living.
3. The client complains of increased eye pain with quick
movements.
4. The client has a history of frequent conjunctivitis.
Strategy: Determine how each answer relates to a cataract.
crystallin lens; there is a general decrease in ability of client to see environment clearly,
there is an annoying glare; pupil changes from black to gray to milky white
2) client may need glasses after the surgery unless a lens implant is performed
3) relates to increased intraocular pressure
4) describes an eye infection
The nursing assistant reports to the nurse that a client diagnosed with type 1 diabetes
complains, “The room is spinning around me.” Which of the following responses by the
nurse is MOST important?
1. “Did the client eat breakfast?”
2. “Has the client experienced episodes of
vomiting?”
3. “Is the client in bed?”
4. “Has the client had this problem before?”
1) moderate hypoglycemia can cause headache, light-headedness, and confusion;
appropriate question to ask, but client safety takes priority
2) vertigo may cause vomiting; priority is client safety
3) CORRECT— priority is client safety; client should sit down to prevent falling
4) nurse should focus on current situation; not appropriate question for the nursing
assistant
The clinic nurse instructs a young adult scheduled in 2 days for surgery. It is MOST
important for the nurse to report which of the following client statements to the
physician?
1. "Sometimes I feel so claustrophobic I want to run."
2. "I have heard about near-death experiences occurring in the operating room.
Have you heard about it?"
3. "I had my will finalized last week just in case anything happens."
4. "I hope they keep the operating room cool. My grandfather died during surgery
when he got very hot."
Strategy: "MOST important" indicates priority.
(1.) indicates need for some anxiety-reduction methods; not priority
(2.) may indicate client fears death during surgery or is curious about this phenomenon;
nurse should respond; not priority
(3.) requires further exploration; may be realistic action, may indicate anxiety about
surgical procedure; not priority
(4.) CORRECT—may indicate potential for malignant hyperthermia, which is genetic
predisposition disorder transmitted as autosomal dominate trait; life-threatening
complication of general anesthesia; indications include tachycardia, dysrhythmias,
tachypnea, hyperthermia, hypotension; treatment includes dantrolene sodium
(Dantrium)
The nurse is called to the room of a patient one day after abdominal surgery. The nurse
observes that the edges of the incision have been separated and a small loop of the
bowel protrudes through the incision. The nurse should take which of the following
actions?
2. Determine what caused the incision to separate.
3. Cover the wound with a sterile dressing soaked with normal
saline.
4. Irrigate the wound with sterile normal saline.
1) implementation; describes evisceration; contact physician after covering wound
2) assessment; cover wound and contact physician; surgical emergency
3) CORRECT— implementation; keep intestines moist until patient can be returned to
surgery; place in low Fowler position, instruct not to cough
4) implementation; should be covered with dressing soaked in sterile saline
The nurse obtains a health history from a 72-year-old Caucasian female. It is MOST
1. “What kind of coffee do you drink?”
2. “When did your mother go through
menopause.”
3. “Is there a family history of osteoporosis?”
4. “Do you take calcium supplements?”
1) client at risk to develop osteoporosis; excessive caffeine intake is a risk factor;
caffeine should be ingested in moderation
2) primary osteoporosis occurs in woman after menopause; prevention is the key
3) no known familial relationship
4) CORRECT— small-framed non-obese Caucasian women are at risk; not only has a 72-
year-old woman lost bone mass, but the elderly also absorb calcium less efficiently;
should take regular calcium supplements
The medical surgical nurse knows that which of the following patients is MOST at risk
for wound dehiscence and evisceration?
1. A patient diagnosed with Parkinson’s Disease who is 5 feet 8 inches tall,
weighs 150 lb, and had stereotactic pallidotomy 2 days ago.
2. A patient diagnosed with type 2 diabetes mellitus who is 5 feet 5 inches tall,
weighs 195 lb, and had an appendectomy 6 days ago.
3. A patient with history of mitral stenosis who is 5 feet 2 inches tall, weighs 130
lb, and had open-heart surgery for mitral valve reconstruction 10 days ago.
4. A patient with a fractured femur who is 6 feet 1 inch tall, weighs 170 lb, and is
in balanced suspension traction after having open reduction and internal
fixation surgery 4 days ago.
Strategy: Discrimination is required to answer the question.
(1.) decreases tremor and rigidity via making a permanent lesion in the brain
(2.) CORRECT—patient is overweight (possibly with weak or pendulous abdominal wall),
probably has poor wound healing due to both the diabetes and the weight, and is 6 days
post abdominal surgery, which is the most frequent type of surgery in which wound
dehiscence and evisceration appear
(3.) less risk; incision located on chest
(4.) more risk with abdominal surgery
A male patient is discharged from the emergency department after being diagnosed
with a concussion sustained in a fall. Which of the following statements, if made by the
patient’s wife to the nurse, indicates that further teaching is necessary?
1. "I will wake my husband up every 3 hours whenever sleeping and ask him his
name, my name, and where he is."
2. "If my husband complains of a headache and needs aspirin, I will give it to him
no more than every 4 hours."
3. "If my husband complains of blurry vision or has difficulty walking, I will bring
him to the emergency department right away."
4. "I will talk to my husband’s friend about doing the coaching for the soccer
team tomorrow."
(1.) appropriate action; provides patient’s spouse with essential information as to
whether complications or deterioration are occurring and if patient thus needs to be
returned immediately to the hospital
(2.) CORRECT—wrong action; patient should not receive aspirin, as it can prolong any
bleeding that might occur; acetaminophen (Tylenol) every 4 hours as needed is what
should be given
(3.) appropriate action; visual disturbance such as blurred or double vision, difficulty
walking, weakness, numbness, clumsiness are symptoms that require immediate return
of patient to the hospital
(4.) appropriate action; patient should not be involved in strenuous activity for at least 2
days; even coaching and not playing can be strenuous; driving, contact sports,
swimming, use of power tools are examples of strenuous activities; resting and eating
lightly should be encouraged
The nurse prepares a client for a bone scan. Which of the following statements by the
nurse to the client is MOST important?
1. “Be sure to drink lots of fluid in the time between the tracer injection and
the test.”
2. “You will feel some discomfort as the tracer is injected into your muscle.”
3. “You will have to assume various positions on a tilting x-ray table.”
4. “The scan is painless and will be over before you know it.”
1) CORRECT— interval between injection of the tracer and the actual scanning is
usually 1 to 3 hours; large amounts of fluid maintain hydration and decrease radiation
dose to the bladder; client should void immediately before scan to prevent a distended
bladder
2) tracer is administered IV, not IM
3) client does not change position; must lie still for bone scan
4) scan is painless, but may take about 1 hour; client required to lie still throughout the
scan
The nurse cares for clients on the medical/surgical unit. A nursing assistant reports to
the nurse that a comatose client receiving oxygen through a tracheostomy has “lots of
water in the tubing.” Which of the following actions should the nurse take FIRST?
1. Ask the nursing assistant to clarify “lots of water.”
2. Instruct the nursing assistant to empty the fluid from the
tubing.
3. Contact respiratory therapy.
4. Empty the fluid from the tubing.
1) nursing assistant has reported the problem; nurse should assess situation
2) not within the scope of practice for the nursing assistant
3) passing the buck; nurse should respond to the problem
4) CORRECT— client at risk for aspiration; caring for the tracheostomy is within the
scope of nursing practice
The physician has ordered antibiotic eye drops for a client recovering from outpatient
cataract surgery. Which of the following statements, if made by the client, indicates to
the nurse that further teaching is necessary?
1. “The drops should go into the center of the lower
eyelid.”
2. “I should not let the drops flow from one eye into the
other.”
3. “I should squeeze my eye tightly after I put in the
drop.”
4. “I should tilt my head back to put in the drops.”
Strategy: “Further teaching” indicates an incorrect response.
1) appropriate placement of drops into the lower conjunctival sac; wash hands before
instilling drops; look up, pull lower lid down
2) drops should not be permitted to flow across the nose into the opposite eye; do not
touch dropper to eye
3) CORRECT— should blink between drops but should not squeeze eye tightly because
it would cause the drop to be expelled; press inner angle of eye after instillation to
prevent systemic absorption
4) helps position for proper placement of eye drops
The nurse observes a student nurse care for a client diagnosed with cerebrovascular
accident (CVA). The nurse should intervene if which of the following is observed?
1. The student nurse places the client in an upright position
to eat.
2. The student nurse auscultates breath sounds bilaterally.
3. The student nurse simultaneously palpates the carotid
pulses.
4. The student nurse faces the client and speaks clearly.
1) appropriate action; in addition to sitting upright, encourage client to flex head slightly
3) CORRECT— palpating the carotid pulses together can cause a vagal response and
slow the client’s heart rate
4) appropriate action; facilitates communication, allow client enough time to respond
The home care nurse visits a client diagnosed with cardiomyopathy. The client asks the
nurse how he will know if he is “overdoing it.” Which of the following responses by the
nurse is BEST?
1. “If you feel fatigued, you have done too much.”
2. “Follow the list that your physician gave you.”
3. “Coughing up more sputum is a good indication.”
4. “To prevent doing too much, allow your family to help
you.”
1) CORRECT—fatigue is a useful guide in gauging activity tolerance in patients with
decreased cardiac output; cardiomyopathy is subacute or chronic enlargement of heart
2) does not answer client’s question
3) may indicate pulmonary edema; client should discontinue activities at this point
4) encourage client to be as independent as possible
The nurse is feeding a woman resident in the dining room of a long-term care facility.
Suddenly, the resident starts to choke and becomes cyanotic. Which of the following is
the BEST action for the nurse to take?
1. Start behind the resident and deliver a quick blow to the middle of her back
with the palm of the hand.
2. Embrace the resident from behind and with a fist quickly thrust upward into her
abdomen.
3. Check the resident’s mouth and throat for food, and perform a finger sweep.
4. Lay the resident on the floor and prepare to initiate cardiopulmonary
resuscitation.
1) implementation; should do Heimlich maneuver
2) CORRECT— implementation; description of Heimlich maneuver, expels remaining air
in victim’s lungs, along with foreign body
3) assessment; need to clear airway; will not be able to reach obstruction
4)implementation; need to clear airway immediately
The nurse is feeding a woman resident in the dining room of a long-term care facility.
Suddenly, the resident starts to choke and becomes cyanotic. Which of the following is
the BEST action for the nurse to take?
1. Start behind the resident and deliver a quick blow to the middle of her back
with the palm of the hand.
2. Embrace the resident from behind and with a fist quickly thrust upward into her
abdomen.
3. Check the resident’s mouth and throat for food, and perform a finger sweep.
4. Lay the resident on the floor and prepare to initiate cardiopulmonary
resuscitation.
1) implementation; should do Heimlich maneuver
2) CORRECT— implementation; description of Heimlich maneuver, expels remaining air
in victim’s lungs, along with foreign body
3) assessment; need to clear airway; will not be able to reach obstruction
implementation; need to clear airway immediately
A patient is admitted with a diagnosis of Addison’s disease. The nurse expects the
patient to exhibit which of the following?
1. Muscle cramps, fatigue, and hypotension.
2. Shortness of breath, pallor, and hirsutism.
3. Rales, maculopapular rash, and weight loss.
4. Hypertension, peripheral edema, and
petechiae.
Strategy: Thank about each answer.
1) CORRECT— symptoms of hyponatremia; Addison is hyposecretion of the adrenal
hormones
2) not seen with Addison’s disease; symptoms of Addison’s disease include fatigue,
weakness, dehydration, decreased BP, “eternal tan,” decreased resistance to physical
stress, alopecia
3) patients with Addison’s disease show symptoms of dehydration and “eternal tan,”
not a rash
4) hypertension and edema are symptoms of Cushing’s disease, which is
hypersecretion of the adrenal hormones
The nurse cares for a patient who has just been intubated in preparation for mechanical
ventilation. Which of the following actions should the nurse take NEXT?
1. Assess lung sounds.
2. Call for a stat x-ray.
3. Obtain arterial blood gasses.
4. Suction the endotracheal
tube.
1) CORRECT— priority is to assess for bilateral lung sounds and bilateral chest
excursions; assess before implementing
2) more important to assess lung sounds
3) more important to determine that there are bilateral breath sounds
4) priority is to determine if client has a patent airway
The nurse cares for a patient who has just been intubated in preparation for mechanical
ventilation. Which of the following actions should the nurse take NEXT?
1. Assess lung sounds.
2. Call for a stat x-ray.
3. Obtain arterial blood gasses.
4. Suction the endotracheal
tube.
1) CORRECT— priority is to assess for bilateral lung sounds and bilateral chest
excursions; assess before implementing
2) more important to assess lung sounds
3) more important to determine that there are bilateral breath sounds
4) priority is to determine if client has a patent airway
The home care nurse is caring for a 60-year-old client with gastric cancer. The nurse
would be MOST concerned if which of the following is observed?
1. The client complains of indigestion.
2. The client has lost a pound in the past two
weeks.
3. The client’s skin develops a yellow cast.
4. The client is fatigued after radiation
treatments.
Strategy: Determine the outcome of each answer and how it relates to the gastric
cancer.
1) common symptom of gastric cancer; other early symptoms include abdominal
discomfort, feeling of fullness, and epigastric pain
2) weight loss may be a result of poor appetite, this weight lost is small; in advanced
gastric cancer, progressive weight loss, nausea, and vomiting occur
3) CORRECT— jaundice is a sign of liver involvement; may signal metastatic disease
4) common side effect; gastric cancer also causes anemia, which contributes to fatigue
The home care nurse is planning care for a 67-year-old client with pernicious anemia.
Which of the following is the MOST important goal for the client?
1. The client will obtain household help during recuperative period.
2. The client will increase dietary intake of green leafy vegetables.
3. The client will return to the clinic to receive monthly vitamin B 12
injections.
4. The client will begin a program of moderate exercise.
1) although rest is important, it is not the most important goal; symptoms: pallor, slight
jaundice, glossitis, fatigue, weight loss, paresthesias of hands and feet, disturbances of
balance and gait
2) pernicious anemia is caused by failure to absorb B12 because of a deficiency of
intrinsic factor from the gastric mucosa
3) CORRECT— vitamin B 12 is given on a monthly basis; without it, death will occur in
1–3 years
4) important that client balances rest and activity; more important to receive vitamin B
12 injections
The nurse cares for a patient admitted for an adrenalectomy for treatment of Cushing’s
syndrome. It is MOST important for the nurse to take which of the following actions?
1. Evaluate the patient’s mood.
2. Monitor the patient’s blood
glucose.
3. Take the patient’s temperature.
4. Obtain the patient’s weight.
1) mood swings do occur with Cushing’s syndrome; more important to assess physical
problems
2) CORRECT— hypercortisolism causes hyperglycemia; other symptoms include
fatigue, weakness, osteoporosis, cramps, edema, hypertension, decreased resistance to
infection, truncal obesity, buffalo hump, moon face
3) not a problem for patients with Cushing’s syndrome
4) more important to monitor blood sugar
An adult comes to the emergency room in acute respiratory distress. The client has a
20-year history of asthma. The nurse considers which of the following as an ominous
sign in this patient?
1. Absence of wheezing on auscultation.
2. Crackles are heard on auscultation.
3. Bilateral rales are absent on
auscultation.
4. Coarse rhonchi are present on
auscultation.
Strategy: Think about the causes of each sign.
1) CORRECT— indicates acute respiratory distress; small airways completely
constricted; patient requires immediate intervention
2) crackles: rales; abnormal breath sounds caused by air through fluid; not usually seen
with asthma
3) not expected with asthma; symptoms of asthma include dyspnea, wheezing,
nonproductive cough, tachycardia, tachypnea
4) continuous grating sounds; indicates disease of bronchi; not expected with asthma
The nurse plans care for a one-week-old child with tetralogy of Fallot. It is MOST
1. Offer the infant water every four hours.
2. Enlarge the hole in the nipple of the formula
bottle.
3. Position the infant on his stomach after bottle-
feeding.
4. Gradually increase the time between bottle
feedings.
1) should offer formula to meet nutritional needs; has increased calorie needs due to
increased metabolic rate
2) CORRECT— allows the child to obtain nourishment easily; feed on a 3-hour schedule
and feed soon after awakening so infant doesn’t cry
3) support infant and feed in a semi-upright position
should offer feeding every 3 hours; stroke infant’s jaw and cheek to encourage suc
The nurse on the medical/surgical unit admits a client with a hemoglobin level of 6.8
g/dL. Which of the following interventions should the nurse perform FIRST?
1. Draw a type and cross for 2 units packed red blood
cells.
2. Place the client on 2 L of oxygen per nasal
cannula.
3. Start an IV with at least a 20-gauge IV catheter.
4. Place the client on a cardiac monitor.
1) appropriate action but nurse should follow ABCs; do not delay oxygen or a cardiac
monitoring to draw labs
2) CORRECT— critically low hemoglobin indicates less circulating oxygen; important
that the hemoglobin available is well oxygenated
3) appropriate action but nurse should follow ABCs; likely to draw the type and cross as
well as other labs at the same time the IV is started
4) appropriate action because of a possible decrease in available oxygen to tissues and
risk for cardiac dysrhythmia, but the nurse should follow ABCs
The home care nurse visits a client diagnosed with a cerebrovascular accident with an
uninhibited bladder. Which of the following actions by the nurse is MOST appropriate?
1. Encourage the client to drink 2000 mL per day.
2. Determines the client’s voiding habits before the CVA.
3. Instruct the client how to perform intermittent
catheterization.
4. Ask the client to void before and after meals.
1) appropriate action unless medical condition contraindicates
2) CORRECT— when retraining the bladder, important to mimic the client’s usual
voiding pattern
3) appropriate action for flaccid bladder; client with uninhibited bladder has little control
and is unable to wait to get to the commode to void
4) appropriate action; assess before implementing
The nurse cares for a client receiving aluminum hydroxide gel (Amphojel). The nurse
1. I will only take this medication before bedtime.
2. I will decrease side effects by taking this medication before
meals.
3. I will take the medication 1 hour after meals.
4. I will take the medication when I feel epigastric pain.
1) antacids are taken several times per day to be effective
2) most effective when taken after digestion has begun but before the stomach has
emptied
3) CORRECT— antacids neutralize gastric acids, increase gastric pH, and inactivate
pepsin; contains sodium, check if patient is on sodium-restricted diet
4) take medication to prevent epigastric pain
The nurse in the pediatric clinic receives a call from the mother of an adolescent girl.
The girl fell off a balance beam while performing a gymnastic activity two days ago and
briefly lost consciousness. The adolescent was hospitalized overnight and discharged
home yesterday. The mother reports the adolescent’s headache is unrelieved by
multiple doses of acetaminophen (Extra Strength Tylenol). Which of the following
1. Instruct the mother to darken the adolescent’s room.
2. Determine when the client can receive another dose of
medication.
4. Reassure the mother that this is expected.
1) more assessment is required
2) if a client has a severe headache after a concussion, should be evaluated by the
physician
3) CORRECT— persistent localized pain suggests a skull fracture; should be evaluated
4) should be reported
The parents bring their 18-month-old into the emergency room. The nurse notes that the
child is having difficulty breathing and appears to be wheezing on inspiration. It is
MOST important for the nurse to ask the parents which of the following questions?
1. “Is your child’s immunization schedule current?”
2. “Do you or the child’s brothers or sisters have a history of asthma?”
3. “What toy does your child like playing with the most?”
4. “Was your child eating a hot dog immediately before developing breathing
problems?”
1) important information, but not the first question the nurse should ask
2) wheezing usually occurs with expiration
3) ensure that child’s toys be large and sturdy, with no sharp edges or removable parts
4) CORRECT— toddlers are in danger of aspirating large pieces of meat and hot dogs,
as well as nuts, dried beans, chewing gum; if children offered hot dogs, cut into small,
irregular shapes
problems?”
irregular shapes
problems?”
irregular shapes
The nurse discharges a client with a permanent pacemaker. It is MOST important for the
nurse to include which of the following instructions?
1. “Take your pulse every day.”
2. “Eat foods that are low in sodium.”
3. “Weigh yourself on the same scale
weekly.”
4. “Measure your abdominal girth daily.”
1) CORRECT— change in heart rhythm or rate can signal a malfunction of the
pacemaker; instruct client to take pulse for 1 full minute at the same time each day and
record; should also take pulse if feeling any symptoms
2) pacemaker inserted to treat dysrhythmia; low sodium diet useful to treat heart failure,
hypertension, or cirrhosis
3) not necessary; avoid tight clothing over pacemaker
4) measures ascites; this client has a dysrhythmia
The nurse prepares a client for discharge from the rehabilitation center for spinal cord
injuries. The client fell from a tree and suffered a spinal cord injury at the level of T4,
resulting in paralysis below the injury. It is MOST important for the nurse to include
which of the following in the discharge instructions?
1. Signs/symptoms of urinary tract infection.
2. Daily assessment of skin.
3. Perform range-of-motion exercises 4
times/day.
4. Observe respiratory function.
1) common problem in paraplegics, but not most significant
2) instruct to change positions every 2 hours
3) prevents contractures; important to stretch Achilles tendon
4) CORRECT— injuries at level of T1 through T6 result in decreased respiratory reserve;
should be fully independent in self-care and in wheelchair
The nurse prepares a client for discharge from the rehabilitation center for spinal cord
injuries. The client fell from a tree and suffered a spinal cord injury at the level of T4,
resulting in paralysis below the injury. It is MOST important for the nurse to include
which of the following in the discharge instructions?
1. Signs/symptoms of urinary tract infection.
2. Daily assessment of skin.
3. Perform range-of-motion exercises 4
times/day.
4. Observe respiratory function.
1) common problem in paraplegics, but not most significant
2) instruct to change positions every 2 hours
3) prevents contractures; important to stretch Achilles tendon
4) CORRECT— injuries at level of T1 through T6 result in decreased respiratory reserve;
should be fully independent in self-care and in wheelchair
The nurse finds a visitor slumped to the floor of a patient’s room during visiting hours
at the hospital. INITIALLY, the nurse should take which of the following actions?
1. Start rescue breathing and chest
compressions.
2. Call for help.
3. Shake the patient and shout, “Are you all
right?”
4. Listen for breath sounds.
Strategy: Remember the nursing process.
1) implementation; need to assess first
2) implementation; need to assess first
3) CORRECT— assess unconsciousness; open airway with head tilt of chin lift (jaw
thrust if neck injury is suspected); look, listen, and feel for signs of breathing
4) assessment, but should not be done first
A patient developed acute respiratory distress syndrome (ARDS) after an auto accident
and is being weaned from the ventilator. The nurse knows the best mode to wean the
patient from the ventilator is
1. synchronized intermittent mandatory ventilation
(SIMV).
2. controlled ventilation.
3. assist-control ventilation.
4. positive end expiratory pressure (PEEP).
1) CORRECT— allows for spontaneous breaths at his own rate and tidal volume
between ventilator breaths
2) delivers a set volume at a set rate; does not allow patient-initiated respirations
3) rate is variable but the tidal volume is preset so each breath is delivered at a set
volume regardless of patient’s needs
4) delivers positive pressure during expiration to keep airways constantly open; used
with seriously ill patients
A patient developed acute respiratory distress syndrome (ARDS) after an auto accident
and is being weaned from the ventilator. The nurse knows the best mode to wean the
patient from the ventilator is
(SIMV).
3) rate is variable but the tidal volume is preset so each breath is delivered at a set
volume regardless of patient’s needs
4) delivers positive pressure during expiration to keep airways constantly open; used
with seriously ill patients
A nurse is eating lunch in a restaurant. Suddenly, a woman at the next table gasps for
breath and grabs her throat. Which of the following actions should the nurse take
FIRST?
1. Lean the woman forward and administer back
blows.
2. Offer the woman sips of water.
3. Ask the woman if she can speak.
4. Perform a finger sweep of the woman’s mouth.
1) intervention; back blow not used
2) intervention; will not clear airway
3) CORRECT— if cannot speak, indicates airway obstruction; perform Heimlich
maneuver
4) intervention; first assess
During the initial period following a spinal cord injury, it is MOST important for the
1. Prevent contractures and atrophy.
2. Prevent urinary tract infections.
3. Promote rehabilitation.
4. Prevent flexion or hyperextension of the
spine.
1) although important, not a priority in the immediate post-injury period
2) infection generally occurs as a result of prolonged immobility; important, but not the
priority
3) safety and surviving injury take priority; begin when client’s condition stabilizes
4) CORRECT— primary goal is to protect spine from strain and further damage while
injury heals
The nurse in the medical clinic performs a chart review. The nurse identifies that which
of the following clients have modifiable risk factors for coronary artery disease?
1. A 32-year-old African American.
2. A 44-year-old who has smoked for 25 years.
3. A 49-year-old who is 5'8" tall and weighs 242 pounds.
4. A 53-year-old whose father died at age 61 of a myocardial
infarction.
5. A 66-year-old with a blood cholesterol of 255 mg/dL.
6. A 70-year-old who plays golf four times per week.
1) incidence of heart disease is higher in African Americans but is a nonmodifiable risk
factor
2) CORRECT— smoking is a modifiable risk factor
3) CORRECT— obesity is a modifiable risk factor
4) increasing age and family history are nonmodifiable risk factors
5) CORRECT— normal cholesterol is 150 to 200 mg/dL; elevated cholesterol is a
modifiable risk factor
6) increasing age is a nonmodifiable risk factor; physical inactivity is a modifiable risk
factor; playing golf four times per week is acceptable physical activity
The nurse plans care for an adult woman admitted with toxic shock syndrome. The
nurse is MOST concerned if the client states which of the following?
1. “I am very frightened of doctors and
hospitals.”
2. “I vomited 12 times in the past 24 hours.”
3. “I have abdominal pain and pressure.”
4. “I use extra-absorbent tampons.”
Strategy: Remember Maslow.
1) psychosocial need; not most important
2) CORRECT— physical need; would lead to fluid volume deficit; fluids lost due to
vomiting and diarrhea; symptoms of toxic shock syndrome include fever of sudden
onset, hypotension, rash
3) psychosocial need; not most important; fluid volume deficit priority
4) teaching need; not most important; instruct about prevention: change tampon every
3-6 hours, don’t use extra-absorbent tampons, use sanitary napkins at night; fluid
volume deficit takes priority
The nurse cares for a patient on a mechanical ventilator. Which of the following findings
suggests to the nurse that the patient is experiencing hypoxia?
1. The patient’s Babinski response changes from negative to
positive.
2. The patient’s pulse changes from 80 bpm to 70 bpm.
3. The patient’s extremities are twitching.
4. The patient is moving about restlessly in bed.
Strategy: Think about the answers and how they relate to hypoxia.
1) seen with CNS involvement, not hypoxemia
2) pulse will increase with hypoxemia
3) not related to hypoxemia; seen with electrolyte imbalances, especially calcium
4) CORRECT— confusion and agitation suggest hypoxemia; nurse should assess for
hypoxemia and manually ventilate with 100% oxygen; other indications include
cyanosis, anxiety, tachycardia, and increased respiratory rate
The clinic nurse instructs a client about ambulatory electrocardiography. The nurse
should intervene if the client states which of the following?
1. “I will have to use a safety razor while the monitor is in
place.”
2. “I will keep a log of all of my activities during monitoring.”
3. “I will wrap the device with plastic wrap before taking a
shower.”
4. “I will contact the physician if I experience
lightheadedness.”
5. “I will decrease my roughage during the monitoring.”
1) ambulatory electrocardiography continuously records cardiac activity during a 24-
hour period; client should not use an electric razor or hairdryer while monitor is in place
2) allows the health care provider to correlate cardiac events with client’s activities or
symptoms
3) CORRECT— do not bathe or take a shower during monitoring; sponge bath meets the
client’s need for hygiene
4) CORRECT— should record event in daily log
5) CORRECT— no reason to change diet
The nurse in the pediatric clinic instructs the mother of a child diagnosed with asthma
about preventative care. The nurse determines that further teaching is necessary if the
child’s mother states which of the following?
1. “My child likes sleeping on the bottom bunk.”
2. “My child sleeps on a foam pillow and
mattress.”
3. “I wash my child’s hair almost every night.”
4. “My child wears a mask while I vacuum the
carpets.”
Strategy: “Further teaching is necessary” indicates wrong information.
1) CORRECT— dust mites are a trigger for asthma; fabric from bedding on upper bunk
can harbor dust mites; do not sleep or lie down on upholstered furniture, use furniture
that can be wiped with a damp cloth (wood, plastic, vinyl, or leather)
2) appropriate action; encase mattress, box springs, and pillow in zippered, allergen-
impermeable covers
3) appropriate action if child plays outside and pollen count is high; child should
change clothes after playing outside
4) appropriate action; child should not be in the room when cleaning occurs; preferable
to remove carpets; if not possible, vacuum once or twice per week
The nurse in the pediatric clinic instructs the mother of a child diagnosed with asthma
about preventative care. The nurse determines that further teaching is necessary if the
child’s mother states which of the following?
1. “My child likes sleeping on the bottom bunk.”
2. “My child sleeps on a foam pillow and
mattress.”
3. “I wash my child’s hair almost every night.”
4. “My child wears a mask while I vacuum the
carpets.”
Strategy: “Further teaching is necessary” indicates wrong information.
1) CORRECT— dust mites are a trigger for asthma; fabric from bedding on upper bunk
can harbor dust mites; do not sleep or lie down on upholstered furniture, use furniture
that can be wiped with a damp cloth (wood, plastic, vinyl, or leather)
2) appropriate action; encase mattress, box springs, and pillow in zippered, allergen-
impermeable covers
3) appropriate action if child plays outside and pollen count is high; child should
change clothes after playing outside
4) appropriate action; child should not be in the room when cleaning occurs; preferable
to remove carpets; if not possible, vacuum once or twice per week
The nurse cares for a client diagnosed with full-thickness burns. In planning the d é
bridement of the burn, the nurse should give priority to which of the following actions?
1. Assemble all necessary supplies and medications.
2. Organize time for the dressing change and provide emotional support.
3. Prepare the client and family for the pain the client will experience during and
4. Limit visitors before the procedure.
1) take care of the patient first, not the equipment; important to organize and assemble
all that is required; more important to offer support to client
2) CORRECT— administer analgesic 30 minutes before wound care; d é bridement is the
removal of nonviable tissue; may be preceded by hydrotherapy; encourage expression
of feelings and demonstrate acceptance of the client
3) appropriate, but more important to carefully plan time for the dressing change
4) assist client’s family to adjust to changed appearance
The nurse supervises care for a client diagnosed with increased intracranial pressure.
The nurse determines that care is appropriate if which of the following is observed?
1. The LPN encourages the client to cough and breathe deeply.
2. The RN suctions the client every 2 hours.
3. The nursing assistant positions the client in a prone position.
4. The nurse assesses for the cough reflex and ability to swallow before
administering oral fluids.
1) increases intracranial pressure
2) increases intracranial pressure
3) elevate head of the bed 15–30 to promote venous drainage
4) CORRECT— increased intracranial pressure can adversely affect the cough and gag
reflex and increase the possibility of aspiration
The nurse conducts a class on skin cancers at a local community center. The nurse
explains the danger signs of malignant melanoma, which include which of the
following?
1. A lesion with an irregular surface and variegated
colors.
2. A flat, red lesion that is nonpalpable.
3. A circumscribed lesion filled with fluid.
4. A lesion that is shiny and translucent.
1) CORRECT— may see shades of red, white, and blue; blue color is ominous;
commonly found on upper back and lower legs
2) definition of a macule
3) definition of a vesicle
4) description of atrophy
The nurse cares for a 4-month-old infant diagnosed with meningitis. Which assessment
indicates increased intracranial pressure?
1. A positive Babinski reflex.
2. High-pitched cry.
3. Bulging posterior
fontanelle.
4. Pinpoint pupils.
1) positive during the first 6 months of life; dorsiflexion of great toe when sole of foot is
stroked
2) CORRECT— one of the first signs of increased intracranial pressure; other signs
include irritability, poor feeding, increased frontal occipital circumference
3) posterior fontanelle closes at 2 months
4) pupils respond slowly to light
A nurse in a small rural community assesses residents for risk factors for heart disease.
The nurse determines that which of the following residents is at greatest risk to develop
heart disease?
1. A resident who participates in a competitive weight lifting
program.
2. A resident diagnosed with type 1 diabetes that is poorly
controlled.
3. A resident whose grandfather died of heart failure at age 72.
4. A resident with a history of alcoholism.
1) obesity and physical inactivity are risk factors for heart disease
2) CORRECT— elevated blood glucose level places a client at risk for heart disease
3) positive family history for premature coronary artery disease is a nonmodifiable risk
factor
4) not a risk factor
During an admission interview, a patient tells the nurse about a six-year history of heart
failure. Which of the following requires an immediate intervention by the nurse?
1. The patient’s feet are cool with 2+ pitting edema.
2. The patient complains of abdominal pain.
3. The patient has a productive cough of pink-tinged
sputum.
4. The patient’s abdomen is bloated and tympanic.
Strategy: “Requires an immediate intervention” indicates a complication.
1) suggestive of right-sided heart failure; edema may be a chronic problem
2) may indicate right-sided failure; does not require an immediate intervention
3) CORRECT— indicates fluid in lungs, which will decrease respiratory ability; may be
life-threatening; administer cardiac glycosides and diuretics, record I and O, oxygen
therapy
4) may indicate right-sided failure
A client, walking down the hall in the outpatient clinic, suddenly collapses. The nurse
notes that he does not move his extremities. Which of the following actions should the
nurse take FIRST?
1. Check the client’s carotid pulse.
2. Call for help.
3. Determine if the client is
responsive.
4. Begin cardiopulmonary
resuscitation.
1) assessment; first determine responsiveness
3) CORRECT— determine responsiveness before intervening
4) assess first
An older client suffers a left-sided cerebral infarct. The nurse expects the client to
exhibit which of the following?
1. Weakness of the left arm.
2. Impulsive behavior.
3. Disorientation to person, place, and
time.
4. Impaired speech.
1) unaffected; nerve fibers cross in the spinal canal, result in disabilities on opposite
(contralateral) side
2) seen with right hemisphere CVA
4) CORRECT— left hemisphere controls speech, math skills, analytical thinking
The nurse cares for a 4-year-old child diagnosed with epiglottitis. It is MOST important
1. Instruct a nursing assistant to take the child to the x-ray
department.
2. Use a padded tongue blade to assess the child’s gag reflex.
3. Obtain a blood culture and arterial blood gases (ABGs) as
ordered.
4. Apply a pulse oximeter and start an IV.
1) epiglottitis is inflammation of the epiglottis and can be life-threatening; a professional
should be with the child at all times
2) Never insert a tongue blade into the mouth of a child diagnosed with epiglottitis; gag
reflex can cause complete obstruction of the airway
3) crying can cause obstruction of airway
4) CORRECT— treatment includes moist air and IV antibiotics to decrease epiglottal
swelling; pulse oximeter measures oxygen saturation to determine the need for
supplemental oxygen
The home care nurse assesses a client diagnosed with heart failure. The nurse is MOST
concerned if the client states which of the following?
1. “My ankles and hands become swollen at the end of the
day.”
2. “I have trouble catching my breath after taking out the
garbage.”
3. “I don’t feel hungry and my stomach feels bloated.”
4. “I have pain in my chest each time I cough.”
Strategy: Determine the significance of the patient’s words.
1) symptoms indicate right-sided failure; heart failure is the failure of the cardiac muscle
to pump sufficient blood to meet the body’s metabolic needs; indications of right-sided
failure include dependent edema, liver enlargement and abdominal girth, anorexia,
nausea, bloating, anxiety, fear, and depression
2) CORRECT— pulmonary edema is manifested as dyspnea; fluid remains in the vessels
of the lung instead of going into the left side of the heart; decreased cardiac output
results in tissue congestion; fluid passes from the pulmonary capillaries to the alveoli,
causing cough and shortness of breath; dyspnea may occur or become worse with
physical exertion
3) indicates right-sided failure; symptoms of left-sided failure take priority
4) may indicate irritation of the parietal pleura or pericarditis
The nurse counsels an older client about peripheral vascular disease (PVD). Which of
the following statements, if made by the client to the nurse, indicates that further
teaching is needed?
1. “I should not smoke since it makes my symptoms
worse.”
2. “I should exercise, even if it causes pain.”
3. “I should use warm packs if my hands and feet get
cold.”
4. “I should stay inside during extreme weather.”
1) causes vasoconstriction of extremities; emotional stress and caffeine also cause
vasoconstrictions
2) increases collateral circulation; client should walk until pain begins, rest, and then
walk a little farther
3) CORRECT— decreased sensitivity may result in burns, should use gloves and socks
instead
4) body can’t adjust to temperature extremes; wear socks or insulated shoes at all
times; keep home warm
The nurse finds a 5-year-old boy having a grand mal seizure. What action should the
nurse take FIRST?
1. Call for help.
2. Place a padded tongue blade between his
teeth.
3. Place a pillow under his head.
4. Straddle his legs and hold his arms.
1) must protect patient; should call for help but should not be first action; raise side
rails or ease client to floor
2) do not try to insert a bite block, padded tongue blade, or oral airway
3) CORRECT— need to protect him from injury using padded side rails, airway at
bedside, pillow under head, loosen clothing, clear space
4) attempts to restraint him could cause fracture, dislocation; nurse should protect from
the patient’s flailing arms

The nurse prepares for discharge a patient with newly diagnosed diabetes. The client is
on a regimen of regular and NPH insulin. Which of the following statements, if made by
the patient to the nurse, indicates that teaching is successful?
1. "I will take the bottles out of the refrigerator and shake them thoroughly before
I withdraw the medication."
2. "I will stick with the same types and sources of insulin, but I will stock up
whatever insulin syringes I can find on sale."
3. "If I see that the injection site becomes red, itchy, and swollen, I will contact
the physician immediately."
4. "I will put tape with a ‘1’ on it on the regular insulin bottle and tape with a ‘2’ on
it on the NPH insulin bottle."
(1.) regular insulin bottles do not need to be manipulated; NPH insulin bottle should not
be shaken; should be gently rolled in the palms of the hands to warm the insulin and to
resuspend or mix the insulin
(2.) should stay with the same insulin types and species because changing insulins may
affect blood glucose control; syringe brands are interchangeable; serious changes in
blood glucose control can occur due to inaccurate measurement of insulin because of
manufacturing variations
(3.) not necessary; redness, itching, and swelling at the injection site indicate an allergic
reaction which is common in patients taking insulin; spontaneous desensitization
usually occurs in a few weeks; if local irritation persists or is severe, physician should
be contacted
(4.) CORRECT—if insulins are to be mixed, the regular or short-acting insulin should be
withdrawn first and then the NPH or intermediate-acting; "1" and "2" will remind of the
order in which the insulins should be withdrawn
Upon assessment of a patient admitted for dehydration, the nurse observes that the
patient appears restless and complains of difficulty breathing. Upon auscultation of the
patient’s lungs, the nurse notes bibasilar crackles. Which of the following actions
1. Place the patient on 2 liters of oxygen per nasal cannula and auscultate
the lungs.
2. Elevate the head of the bed and stop the infusion.
3. Decrease the IV flow rate and administer Lasix as ordered.
4. Stop the infusion and notify the physician.
(1.) appropriate action; however, by immediately positioning patient for maximum lung
expansion with minimal effort, more rapid improvement of ventilation will occur while
preparing other interventions
(2.) CORRECT—signs and symptoms suggest fluid overload; elevating the head of the
bed maximizes respiration; stopping the infusion prevents further overload and
progressive complications
(3.) inadequate response; will likely stop IV fluids and administer a diuretic, but first
elevate the head of the bed
(4.) appropriate action; elevate the head of the bed before contacting physician
The nurse assesses an elderly client receiving dexamethasone (Decadron) 1.5 mg PO
tid. The nurse is MOST concerned if the client states which of the following?
1. “I take my medication with meals.”
2. “I have this little sore on my leg that won’t go
away.”
3. “I should take a brisk walk several times a
week.”
4. “I avoid public places during the flu season.”
Strategy: “Nurse is MOST concerned” indicates a potential complication.
1) appropriate action; given with meals to decrease gastrointestinal irritation
2) CORRECT— steroids suppress the immune response; should report non-healing
sores
3) elderly more susceptible to osteoporosis, which is exacerbated by oral steroids;
encourage exercise
4) corticosteroids cause immunosuppression
The nurse cares for patients on the medical/surgical unit. After receiving report, which
of the following patients should the nurse see FIRST?
1. A 22-year-old admitted 8 hours ago with viral gastroenteritis who is
complaining of nausea, vomiting, and diarrhea.
2. A 42-year-old 24 hours post-thyroidectomy who is complaining of a headache
and pain at the incision site.
3. A 50-year-old admitted 72 hours ago for chronic renal failure with a urinary
output of 220 mL in 8 hours and hands and feet that are edematous.
4. A 64-year-old admitted yesterday for hypertension, congestive heart failure,
and digitalis toxicity with frequent PVCs (premature ventricular complexes).
Strategy: Determine the LEAST stable patient.
(1.) potential electrolyte imbalance; need to monitor
(2.) pain at incision site is expected outcome; headache needs further investigation; not
priority
(3.) indicates sodium retention, which is an expected finding in chronic renal failure;
output needs to be evaluated but is not an immediate threat
(4.) CORRECT—indicates potassium imbalance (hypokalemia); dysrhythmias
(cardiac/circulatory problem) can rapidly deteriorate to ventricular tachycardia or
sudden death
A patient is brought to the emergency department by a family member, who reports that
the patient had a sudden onset of decreased level of consciousness, blurred vision,
headache, and slurred speech. Before sending the patient for a stat head CT scan,
which of the following actions should the nurse take FIRST?
1. Elevate the head of the bed 90
degrees.
2. Obtain a finger-stick blood glucose
level.
3. Pad the side rails of the patient’s bed.
4. Obtain a urine specimen from the
patient.
Strategy: Does this situation require validation? Yes.
(1.) unlikely to tolerate this position with these symptoms; may also be at risk for injury
if unable to self-support this position
(2.) CORRECT—symptoms are suggestive of a possible TIA or CVA; assessment of
other possible underlying causes that can be quickly and easily corrected should be
ruled out; patient with hypoglycemia may present with similar symptoms
(3.) not indicated because there has been no report of seizure activity
(4.) no evidence to suggest this is indicated
The nurse cares for a client receiving cimetidine (Tagamet) by continuous IV infusion.
The physician has ordered 900 mg infused over 24 hours. The medication is mixed in
500 cc of D 5 W and the IV unit delivers 60 drops per ml. The nurse should adjust the
flow rate to deliver how many drops per minute? Type the correct answer into the blank.
Your Response: 123
Correct 21
Response:
Strategy:
Correct answer: 21
A client diagnosed with Addison disease comes to the emergency room complaining of
nausea, vomiting, diarrhea, and abdominal pain. The nurse expects the physician to
order which of the following?
1. IV administration of D 5 NS, and steroid in high doses.
2. IM injections of ACTH, normal saline solution, and
potassium.
3. SQ administration of insulin according to blood sugar.
4. Oral administration of NaCl, KCl, and steroids.
1) CORRECT— exhibiting symptoms of Addisonian crisis; increases fluid volume;
provides steroids
2) ACTH stimulates adrenal cortex; does not help with Addison’s; patients have
hyperkalemia
3) insulin treatment for diabetes
4) NaCl given IV; KCl not given
The nurse provides postoperative care for a patient after an ileal conduit procedure.
Which of the following observations of the patient MOST concerns the nurse?
1. There is bleeding from the stoma when the appliance is
changed.
2. The skin under the ostomy pouch is irritated.
3. The patient has abdominal pain and a temperature of 100.4°F
(38°C).
4. Bowel sounds are absent in all four quadrants.
Strategy: "MOST concerns the nurse" indicates a complication.
(1.) not of most concern; the intestinal mucosa is very fragile and it is common that it
bleeds at this stage during changing of the appliance or due to the collection pouch not
fitting properly
(2.) of definite concern but not most; interventions would include decreasing frequency
of pouch changing, using a non-karaya skin barrier (urine erodes karaya), leaving skin
open to air when possible as changing pouch, promoting acid urine (alkaline urine
irritates the skin), using Nystatin cream or powder if yeast infection
(3.) CORRECT—fever and abdominal rigidity and pain are two indications of peritonitis;
urine may have entered the peritoneal cavity from anastomosis site leakage or from
separation of the ureter from the ileal segment (the conduit); there may have been
spillage from the intestine during the surgery; physician should be notified at once;
requires immediate medical intervention
(4.) not of concern at this time; due to the bowel manipulation and resection; there will
be no peristalsis for several days; patient will remain NPO and has IV lines and an NG
tube in place until peristalsis is reestablished; bowel sounds do need to be assessed
What is the MOST effective way for the nurse to prevent unnecessary complications for
a patient receiving medications in the acute care setting?
1. Encourage the patient to report any new or unusual symptoms to the nurse or
physician immediately.
2. Obtain information regarding the patient’s allergies and document in the chart
and an allergy armband.
3. Monitor the patient’s response to prescribed medications.
4. Offer patient information regarding medications before administration.
Strategy: “MOST effective” indicates discrimination is required to answer the question.
1) appropriate action; however, an allergic reaction is completely preventable if
appropriate history is obtained and documented correctly
2) CORRECT— first line defense in preventing unnecessary reactions
3) appropriate action; however, must first know patient allergies
What is the MOST effective way for the nurse to prevent unnecessary complications for
a patient receiving medications in the acute care setting?
1. Encourage the patient to report any new or unusual symptoms to the nurse or
physician immediately.
2. Obtain information regarding the patient’s allergies and document in the chart
and an allergy armband.
3. Monitor the patient’s response to prescribed medications.
4. Offer patient information regarding medications before administration.
Strategy: “MOST effective” indicates discrimination is required to answer the question.
1) appropriate action; however, an allergic reaction is completely preventable if
appropriate history is obtained and documented correctly
2) CORRECT— first line defense in preventing unnecessary reactions
An order is written for "3,000 mL 5% D5NS every 24 hours by gravity infusion." The
administration set delivers 15 drops/mL. What is the correct infusion rate/min for this
solution?
1. 21 drops/min.
2. 31 drops/min.
3. 50 drops/min.
4. 96 drops/min.
Strategy: Total volume to infuse (mL) × drop factor / time (min) = drops per min.
(1.) drop factor is 15, not 10; this incorrect number is obtained by dividing 30,000 by
1,440
(2.) CORRECT—3,000 mL × 15 drops/mL/(24 × 60) = 45,000/1,400 = 31.25 = 31 drops/min
(3.) incorrect number is obtained by dividing 3,000 ml by 60 minutes
(4.) solution volume needs to be included in calculation; this incorrect number is
obtained by dividing 1,440 by the drop factor of 15
The nurse on the psychiatric unit is caring for a patient who is taking fluvoxamine
(Luvox) 100 mg PO at HS. Stat A.M. laboratory results reveal Na+ 124 mEq, K+ 4.6 mEq,
Cl– 96 mEq, and serum osmolality 275 mOsm. Which of the following actions should the
nurse take FIRST?
1. Place the patient on one-to-one suicide precautions.
2. Prepare to administer NaCl 0.45% IV.
3. Initiate seizure precautions with constant observation.
4. Ask the patient about side effects experienced during
the night.
(1.) must assess for suicide before implementing precautions; fluvoxamine (Luvox) for
OCD, side effect of dry mouth; although patient may be at risk for self-harm, no
evidence that patient is intentionally harming self
(2.) patient has hypo-osmolar imbalance; hypotonic fluids will worsen medical condition
(3.) CORRECT—lab results suggest dilutional hyponatremia from obsessive-compulsive
water intake (aka psychogenic polydipsia); at high risk for convulsions and cerebral
edema; also needs monitoring to prevent further water intake
(4.) safety needs must be met first
The nurse on the psychiatric unit is caring for a patient who is taking fluvoxamine
(Luvox) 100 mg PO at HS. Stat A.M. laboratory results reveal Na+ 124 mEq, K+ 4.6 mEq,
Cl– 96 mEq, and serum osmolality 275 mOsm. Which of the following actions should the
nurse take FIRST?
4. Ask the patient about side effects experienced during
the night.
(1.) must assess for suicide before implementing precautions; fluvoxamine (Luvox) for
OCD, side effect of dry mouth; although patient may be at risk for self-harm, no
evidence that patient is intentionally harming self
(2.) patient has hypo-osmolar imbalance; hypotonic fluids will worsen medical condition
(3.) CORRECT—lab results suggest dilutional hyponatremia from obsessive-compulsive
water intake (aka psychogenic polydipsia); at high risk for convulsions and cerebral
edema; also needs monitoring to prevent further water intake
An infant is treated in the newborn nursery for hyperbilirubinemia using phototherapy
lights. It is MOST important for the nurse to intervene in which of the following
situations?
1. The mother turns off the phototherapy lights and removes the infant’s eye
patches in preparation for feeding.
2. The mother is worried because the infant experiences frequent loose, greenish
stools and increased urine output.
3. A laboratory technician turns off the phototherapy lights to draw blood.
4. The jaundice observed around the infant’s eyes has begun to disappear.
question.
(1.) no intervention required; turning off the light and removing the eye patches before
oral feeding is appropriate
(2.) loose, greenish stools and increased urine output reflect increased excretion of
bilirubin and are possible minor side effects
(3.) appropriate action; phototherapy lights must be turned off when blood is drawn to
ensure accurate bilirubin levels
(4.) CORRECT—indicates that the eye patches are not adequately placed or are not of
adequate opaqueness and are allowing light to enter; with phototherapy, eyes must be
completely shielded with patches or an opaque mask in order to prevent exposure to
the light, which could result in eye damage, especially of the retina
A 62-year-old man suffers a pulmonary embolism in the recovery room following
abdominal surgery. Which of the following conditions, if found by the nurse in the
patient’s history, contraindicates the use of thrombolytic therapy?
1. The patient was diagnosed with type 2 non-insulin-dependent diabetes mellitus
(NIDDM) two years ago.
2. The patient takes medication as needed for angina pectoris.
3. The patient suffered a concussion in a car accident three weeks ago.
4. The patient uses an inhaler for treatment of asthma.
1) not contraindicated
3) CORRECT— contraindicated with trauma in last two months, active internal bleeding,
history of hemorrhagic stroke, intracranial or intraspinal surgery, intracranial neoplasm,
arteriovenous malformation, aneurysm, severe uncontrolled hypertension
The physician orders propranolol (Inderal) for a client with type 1 diabetes mellitus
(IDDM). The client asks the nurse if there is anything special she needs to know about
this medication since she takes NPH and regular insulin each morning. Which of the
1. “Inderal potentiates the action of insulin and may increase the number of
episodes of hypoglycemia you experience.”
2. “Inderal interferes with the action of the insulin and may cause you to
experience hyperglycemia.”
3. “Inderal may mask symptoms of hypoglycemia, removing your body’s early
warning system.”
4. “Inderal has no effect on your body’s metabolism other than to lower your
blood pressure.”
3) CORRECT— beta-blockers bind beta-adrenergic receptor sites, which prevents
adrenaline from causing symptoms and glycogenolysis
4) will lower BP, but also interferes with body’s response to hypoglycemia
A 65-year-old woman is receiving albuterol (Proventil) two puffs, and beclomethasone
(Vanceril) two puffs, through inhalers. The client asks the nurse if it matters which
inhaler she uses first. Which of the following is the BEST response by the nurse?
1. Use the Proventil inhaler then the Vanceril inhaler.
2. Use the Vanceril inhaler and then the Proventil inhaler.
3. You should take one puff of each inhaler, wait a minute, and then repeat
the process.
4. Either inhaler can be used first as long as you wait two minutes between
puffs.
1) CORRECT— Proventil is a bronchodilator that will open the passageways so the
steroid medication (Vanceril) can get into bronchioles; side effects of Proventil include
tremors, headache, hyperactivity, tachycardia; nursing considerations: monitor for
toxicity if using tablets and aerosol, teach how to use inhaler correctly
2) should use the bronchodilator (Proventil) to open the passageways so the steroid
(Vanceril) can get into the bronchioles; side effects of Vanceril include fungal infections,
dry mouth, throat infections
3) should use the bronchodilator (Proventil) to open the passageways so the steroid
(Vanceril) can get into the bronchioles, and should wait one minute between puffs of the
inhalers for best effect; gargle or rinse mouth after using Vanceril
4) it does matter which inhaler is used first; should use the bronchodilator (Proventil) to
open the passageways so the steroid (Vanceril) can get into the bronchioles
The clinic nurse assesses a patient who is presenting with a documented history of a
gastric ulcer and current symptoms of nausea, vomiting, and diarrhea of 2 days’
duration. It is MOST important for the nurse to follow up on which of the following
statements made by the patient?
1. "I take aspirin for headaches and arthritis pain, and antacids for this ulcer of
mine."
2. "I have been drinking more fluids to keep from getting dehydrated. It’s odd, but
I’m urinating less than I thought I would."
3. "On my last visit to the doctor, I was told I may be developing cataracts."
4. "When this first began, I didn’t know what had hit me. I knew I had been under
a lot of stress at work but I thought I was coping well, considering the
circumstances."
question.
(1.) concerning, but not priority; aspirin and other NSAIDs can contribute to gastric
ulcer development and worsening; potential problem
(2.) CORRECT—it is particularly important to assess urine output because of the
potential for fluid volume deficit causing shock; in the first stages of shock there is
decreased urine output, even when there is normal fluid intake; it is especially important
for the nurse to elicit information about fluid intake and output during the preceding 24
hours; this patient has an ulcer, which might be bleeding or for which he might be
taking medications that could lead to hypovolemic shock; loss of fluid from vomiting
and diarrhea could cause dehydration and hypovolemia
(3.) not a concern at this time
(4.) may need recommendations for counseling about stress management; priority is to
follow up on comments about urine output
Miconazole (Monistat 7) cream is ordered by the gynecologist for a patient. Which of the
following statements, if made by the patient to the office nurse, indicates that teaching
is successful?
1. "I will go to the store and stock up on sanitary pads, pantyhose, and cotton
underpants."
2. "I will continue to insert the cream every day, even during my menstrual
period."
3. "Once the symptoms have been gone for 3 full days, I will stop using the
medication."
4. "I will use a diaphragm and have my boyfriend use a condom when we have
sex."
Strategy: Every part of the answer has to be correct in order for the answer to be
correct.
(1.) nylon pantyhose provide a dark, moist environment conducive to vaginal infections;
sanitary pads may be used to protect clothing while the medication is being used; the
pads may also be used to replace tampons, which can contribute to vaginal infections;
cotton underpants help create a clean, healthy vaginal environment by allowing air to
circulate, and should be changed daily
(2.) CORRECT—the full number of doses prescribed should be taken, even if
menstruation occurs or symptoms resolve; given for vulvovaginal candidiasis
(3.) full number of doses prescribed should be taken, even if symptoms disappear
(4.) both devices—especially the diaphragm, which is reused—can become
contaminated with the fungal infection and harbor it; avoiding sex until the infection is
completely resolved is best
The nurse cares for a client receiving gentamycin (Garamycin) IV. The physician orders
the medication to be administered IV piggyback in 100 mL D 5 W over 30 minutes. The
IV set delivers 15 drops per mL. Record the number of drops per minute the client
should receive.
Your Response: 12
Correct 50
Response:
Strategy:
Correct answer: 50
After a patient receives naloxone hydrochloride (Narcan) 0.2 mg IV, which of the
following actions is ESSENTIAL for the nurse to perform?
1. Decrease external stimuli.
2. Encourage oral fluids.
3. Place the patient in lateral recumbent
position.
4. Monitor the patient’s rate of respirations.
Strategy: “ESSENTIAL” indicates priority.
1) implementation; unnecessary for patient experiencing narcotic-induced respiratory
depression
2) implementation; patient may have lowered level of consciousness; don’t give
anything PO
3) implementation; should position patient with head of bed elevated
4) CORRECT— assessment; used to reverse narcotic-induced respiratory depression;
should frequently monitor BP, rate and depth of respirations, and pulse
A patient is started on metformin (Glucophage). It is MOST important for the nurse to
respond to which of the following statements by the patient?
1. "I will be sure to carry a chocolate candy bar with me at all times."
2. "If I get abdominal cramps and a metallic taste in my mouth, I will call the
physician."
3. "I am glad this medication will not cause me to gain weight."
4. "I will take the Glucophage when I first get up and just before I go to bed."
question.
(1.) further teaching needed, but not most important; Glucophage is a biguanide oral
hypoglycemic agent, does not cause hypoglycemia; does not increase insulin secretion
from the pancreas but helps tissues respond to insulin, decreases gluconeogenesis,
and increases glucose uptake into muscles and fat
(2.) further teaching is needed, but not most important; bitter or metallic tastes and
abdominal cramps are two common side effects of this drug, which can be addressed
by the physician possibly adjusting the dose and/or patient taking the medication with
meals
(3.) appropriate understanding, does not cause weight gain
(4.) CORRECT—take with meals to reduce side effects of the drug–-e.g., nausea,
vomiting, anorexia, abdominal cramps, fatigue; these effects tend to be mild and to
resolve as therapy continues
The nurse prepares a patient diagnosed with cervical cancer for the insertion of an
internal radiation implant. The nurse knows that it is MOST important to respond to
which of the following patient statements?
1. "Unless I have a bowel movement every day, I just do not feel right."
2. "I am glad this whole process is only going to last 3 days."
3. "I will get up only when I have to urinate, and then I will go right
back to bed."
4. "If it were not for my children, I would not be going through all of
this."
(1.) of concern, but not priority; prior to patient receiving implant, an enema is given so
rectum is empty in order to facilitate placing the implant through the vagina and into
uterus; bowel movement during the implantation period (1–3 days) is avoided in order
to prevent the implant from dislodging
(2.) internal radiation treatment for this condition is 1–3 days
(3.) CORRECT—patient will be on strict bedrest on her back with head of bed elevated
no more than 20 degrees; movement is restricted; a Foley catheter is inserted into
bladder in order to prevent the implant from being dislodged by a full bladder or by
voiding attempts; severe radiation burns can result from a distended bladder
(4.) indicates probable depression; requires further exploration but is not priority
A community experiences a prolonged heat wave. The emergency department nurse
expects to see which of the following indications if a patient is admitted with a
diagnosis of heat stroke?
1. Elevated temperature, diaphoresis,
nystagmus.
2. Hypotension, tachypnea, tachycardia.
3. Hemiplegia, diplopia, dysarthria.
4. Headache; hot, dry skin; hypertension.
Strategy: Remember the "comma, comma, and" rule.
(1.) anhydrosis (absence of sweating or diaphoresis) is usually present in heat stroke,
so skin is hot and dry; elevated temperature is the primary symptom—105°F (40.6°C) or
above; nystagmus (involuntary eye movements) is not a symptom of heat stroke
(2.) CORRECT—temperature of 105°F (40.6°C) or above; skin is hot and dry; behavior is
bizarre, confused, delirious, or comatose
(3.) symptoms of a cerebrovascular accident/CVA/stroke/brain attack, not of heat stroke
(4.) hypotension present in heat stroke; headache may be initial symptom of
hyperthermia; skin is hot and dry in heat stroke
The nurse cares for a client receiving ranitidine (Zantac) 150 mg PO BID. The nurse
should further assess if the client states which of the following?
1. “I am going to have allergy testing tomorrow.”
2. “I have increased my intake of whole grains and fresh
vegetables.”
3. “I like to smoke a cigarette immediately before bedtime.”
4. “I take an occasional Advil if my knees hurt.”
5. “I will take all of the medication in the bottle.”
6. “I drink a glass of red wine every night.”
Strategy: “Should further assess” indicates something is wrong.
1) CORRECT— may cause false-negative results on allergy skin testing; client should
avoid medication for 24 hours before testing
2) appropriate action, minimizes constipation; Zantac is histamine H 2 antagonist used
to treat active duodenal ulcers or benign gastric ulcers
3) CORRECT— smoking interferes with histamine antagonist; client should not smoke
when taking medication; if client continues to smoke, should not smoke after the last
dose of the day
4) CORRECT— should avoid NSAIDs because of increased gastric irritation
6) CORRECT— should avoid alcohol because it may increase gastrointestinal irritation
The public health nurse visits an older Asian American patient who has been taking
isoniazid (INH) for 4 months. The patient complains of nausea and anorexia. Which of
1. Obtain a sputum specimen.
2. Inspect the hard palate.
3. Assess skin color on the abdomen.
4. Instruct the client to stop the
medication.
(1.) complaints are gastrointestinal-related, must assess for signs of drug-induced
hepatitis
(2.) CORRECT—due to biocultural skin variations, signs of early jaundice best observed
on posterior hard palate in Asians. Even sclera may contain carotene pigments that
mimic jaundice in Asians.
(3.) Asians tend to have yellow undertones to skin, early jaundice difficult to identify
(4.) need to assess and validate signs of hepatotoxicity first
The nurse cares for an elderly client receiving phenytoin (Dilantin). The nurse knows
which of the following client conditions may precipitate a toxic reaction to this
medication?
1. Impaired liver function.
2. Decreased hemoglobin and hematocrit.
3. White blood count of 10,000 mm 3 and serum sodium of 140
mEq/L.
4. Depressed neurological functioning.
Strategy: Determine how each answer might relate to Dilantin.
1) CORRECT— phenytoin (Dilantin) is metabolized and excreted by liver; elderly clients
frequently have some degree of liver impairment, and are at high risk for this problem
2) not affected by Dilantin
3) not affected by Dilantin
4) client with seizures is most likely to receive this medication
The nurse cares for a client receiving lithium (Lithane). It is MOST important for the
nurse to include which of the following dietary instructions?
1. Restricted sodium diet with increased fluid
intake.
2. High-calorie diet with restricted potassium
intake.
3. Regular sodium intake with adequate fluid
intake.
4. Decreased caloric intake with decreased fluid
intake.
1) lithium is a salt preparation and replaces sodium in the cells; low-sodium diet will
precipitate lithium toxicity
2) no reason to increase calories and decrease potassium intake
3) CORRECT— should drink 2 to 3 liters per day and ingest adequate amounts of
sodium; side effect include dizziness, headache, impaired vision, fine hand tremors, and
reversible leukocytosis
4) should drink 2 to 3 liters per day; caloric intake does not impact lithium levels
The pediatric home health nurse has just completed the physical assessment of a 3-
year-old child diagnosed with acute diarrhea related to gastroenteritis. There is no
evidence of significant dehydration. It is MOST important for the nurse to make which of
the following recommendations to the child’s mother?
1. "Encourage your child to drink clear fluids such as fruit juices, gelatin, and
carbonated drinks."
2. "Offer your child beef broth or chicken broth as tolerated."
3. "Bananas, rice, and toast are effective for decreasing diarrhea."
4. "It is best to start your child on the usual diet right away, offering food as
tolerated."
Strategy: "MOST important" indicates discrimination is required to answer the question.
(1.) clear fluids by mouth are not recommended for managing diarrhea; these fluids
usually are high in simple sugars or simple carbohydrates, are very low in electrolytes,
and have a high osmolality, which can exacerbate vomiting and diarrhea
(2.) beef or chicken broth should not be given in diarrhea because it is inadequate in
carbohydrates and has too much sodium
(3.) BRAT (bananas, rice, apples, toast and tea) diet not recommended for a child with
acute diarrhea because it has very low nutritional value (low in protein and energy), is
low in electrolytes, and is high in carbohydrates
(4.) CORRECT—once rehydration has occurred, or if dehydration is not evident, the
child’s normal diet should be resumed; continued feeding or early reintroduction of
nutrients as in a normal diet is without adverse effects, decreases the duration and
severity of the illness, and improves weight gain compared to gradually reintroducing
foods
A patient diagnosed with type 2 diabetes mellitus is treated for hypertension with
propanolol (Inderal). History reveals that the patient is diagnosed with glaucoma and is
allergic to sulfa. The nurse is MOST concerned if an order was written for which of the
following medications?
1. Glycerin (Osmoglyn).
2. Pilocarpine (Isopto-
Carpine).
3. Acetazolamide (Diamox).
4. Timolol maleate
(Timoptic).
Strategy: "Nurse is MOST concerned" indicates a complication.
(1.) should be questioned but not of most concern; osmotic agent; diuretic; increases
osmolarity of the blood, extracting fluid from extracellular space into the bloodstream,
including aqueous humor and vitreous humor from the anterior chamber of the eye,
thus decreasing intraocular pressure; glycerin needs to be used with caution in
diabetics because it can cause hyperglycemia
(2.) no need to question this order; direct-acting parasympathetic function causing
miosis
(3.) CORRECT—contraindicated; cross-sensitivity can occur due to allergy to
antibacterial sulfonamides and sulfonamide derivatives
(4.) should be questioned, but not priority; beta blockers given for systemic use, such
as propanolol and atenolol, can enhance the therapeutic and toxic effects of beta
blockers prescribed for ophthalmic use
A patient diagnosed with type 2 diabetes mellitus is treated for hypertension with
propanolol (Inderal). History reveals that the patient is diagnosed with glaucoma and is
allergic to sulfa. The nurse is MOST concerned if an order was written for which of the
Carpine).
4. Timolol maleate
(Timoptic).
(1.) should be questioned but not of most concern; osmotic agent; diuretic; increases
osmolarity of the blood, extracting fluid from extracellular space into the bloodstream,
including aqueous humor and vitreous humor from the anterior chamber of the eye,
thus decreasing intraocular pressure; glycerin needs to be used with caution in
diabetics because it can cause hyperglycemia
(2.) no need to question this order; direct-acting parasympathetic function causing
miosis
(4.) should be questioned, but not priority; beta blockers given for systemic use, such
as propanolol and atenolol, can enhance the therapeutic and toxic effects of beta
blockers prescribed for ophthalmic use
The nurse cares for clients in the outpatient clinic. During the nursing assessment, the
nurse learns that the client takes garlic capsules daily. After completing the history, it is
MOST important for the nurse to follow up on which of the following client information?
1. The client was diagnosed with hypertension 2 years
ago.
2. The client takes insulin for type 1 diabetes.
3. The client is CEO of a large real-estate company.
4. The client’s father died at age 42 of a myocardial
infarction.
question.
(1.) garlic taken for hypertension; side effects include heartburn, flatulence, gastric
irritation
(2.) CORRECT—can have direct hypoglycemic effect; may potentiate action of diabetic
drugs; information should be reported to physician
(3.) may add to stress level; hypoglycemic effect of garlic takes priority
(4.) unmodifiable risk factor for coronary artery disease; should control hypertension,
maintain appropriate body weight, monitor fats in diet, exercise regularly
The nurse cares for a patient 1 day postop after a hemorrhoidectomy. Which of the
following assessments MOST concerns the nurse?
1. The patient complains of severe pain in the anorectal area.
2. The patient complains of feeling lightheaded and dizzy during a sitz
bath.
3. The patient’s lower abdomen is enlarged and sounds dull on
percussion.
4. The patient states there are laxatives which will prevent further
hemorrhoids.
Strategy: "MOST concerned" indicates that discrimination is required to answer the
question about a complication.
(1.) expected outcome; pain in the surgical area after a hemorrhoidectomy is most
common postoperative problem; encourage a side-lying position, place ice packs over
dressing until packing is removed, sitz baths help decrease pain
(2.) not most concerning; feelings of faintness can occur as the moist heat of sitz bath
redirects blood to the rectal area; an ice bag on the head during the bath may prevent
faintness feelings; sitz baths should be taken three or four times per day beginning after
12 hours postop to manage pain
(3.) CORRECT—indicates probable urinary retention; after a hemorrhoidectomy, should
be monitored for urinary retention; occurs because of closeness of bladder to the
surgical site and occurrence of rectal spasms and anorectal tenderness; catheterize to
empty bladder
(4.) stimulant laxatives are habit-forming and should be avoided; encourage high-fiber,
high-fluid diet to facilitate regular bowel patterns
The nurse cares for a client receiving 1,800 ml of IV fluid daily. The IV set delivers 60
drops per ml. The nurse should adjust the IV flow rate so that the client receives how
many drops of fluid per minute? Type the correct answer into the blank.
Your Response: 1
Correct 75
Response:
Strategy: If the IV set delivers 60 drops per min, ml per hour equals drops per minute.
Correct answer: 75
The nurse cares for a patient 2 months after suffering a spinal cord injury at the level of
T-2. The nurse enters the room and notes that the client’s face is flushed, he is sweating
profusely, and his blood pressure is 260/160 mm Hg. The nurse should prepare to
administer which of the following medications?
1. Docusate sodium (Colace) 100 mg PO.
2. Prochlorperazine (Compazine) 10 mg IM.
3. Hydralazine hydrochloride (Apresoline) 10
mg IV.
4. Diazepam (Valium) 20 mg IV.
Strategy: Think about the action of each drug.
1) stool softener; symptoms indicate autonomic dysreflexia; check for and remove
impaction
2) antiemetic used to control nausea and vomiting, anxiety; nausea is a symptom of
autonomic dysreflexia; blood pressure is priority
3) CORRECT— symptoms indicate autonomic dysreflexia; Apresoline is a fast acting
antihypertensive; relaxes smooth muscle; side effects include headache, angina,
tachycardia, palpitations, sodium retention, anorexia, lupus erythematosus-like
syndrome (sore throat, fever, muscle-joint aches, rash)
4) treatment for seizures; untreated autonomic dysreflexia can cause seizures, CVA, MI
The nurse who is caring for clients in the outpatient clinic identifies that which of the
following clients is at risk to develop hearing problems?
1. A client receiving cisplatin (Platinol-
AQ).
2. A client receiving propranolol
(Inderal).
3. A client receiving flurazepam
(Dalmane).
4. A client receiving cimetidine
(Tagamet).
1) CORRECT— antineoplastic that is ototoxic; other side effects include hepatotoxicity,
bone marrow suppression, tremors, and confusion
2) beta-blocker that is used as an antianginal, antiarrhythmic, and antihypertensive; side
effects include weakness, hypotension, bronchospasm, and depression
3) sedative/hypnotic used for short-term management of insomnia; side effects include
confusion, daytime drowsiness, blurred vision
4) histamine H 2 antagonist; side effects include diarrhea, dizziness, hirsutism
A patient diagnosed with alcoholism is scheduled to take disulfiram (Antabuse). Which
of the following statements, if made by the patient to the clinic nurse, MOST concerns
the nurse?
1. "I will take it at night so it helps me sleep."
2. "I like to work on crafts, especially unfinished
furniture."
3. "I understand that Antabuse loses its effectiveness
over time."
4. "I hope this works. I’m tired of being drunk."
Strategy: "MOST concerns the nurse" indicates incorrect information.
(1.) correct action, although reason is not fully accurate; taking Antabuse at night helps
to minimize complications from the sedative effects of the drug
(2.) CORRECT—potential contact with alcohol both by inhalation of paint or wood stain
fumes as well as by skin contact with these substances; any contact with any amount or
any form of alcohol, even a very small amount, like 7 to 15 mL, will cause an alcohol–
disulfiram reaction, which is extremely uncomfortable and may even lead to shock and
cardiac dysrhythmias
(3.) inaccurate statement, but not most important to correct at this time; tolerance does
not develop with Antabuse; in fact, the longer a person takes Antabuse, the more
sensitive s/he will be to alcohol
(4.) no intervention required; this is a positive statement, indicating that patient is
motivated for alcohol abstinence and appropriate use of Antabuse
The nurse assists a patient who is diagnosed with oral candidiasis (moniliasis, thrush)
secondary to antibiotic treatment in preparing for discharge to home. Which of the
following statements, if made by the patient to the nurse, indicates that teaching is
successful?
1. "I will stop on the way home to get some mouthwash at the store."
2. "I will swish the Mycostatin around in my mouth thoroughly before I
spit it out."
3. "I think I will take it easy for a while by reading some books."
4. "I will start cooking with some strong spices that I know have healing
properties."
Strategy: "Teaching is successful" indicates correct information.
(1.) commercial mouthwash should be avoided because of high alcohol level that
causes a burning feeling in the irritated oral mucosa; warm saline or hydrogen peroxide
are mouthwashes that can be used instead
(2.) nystatin (Mycostatin) is an antifungal agent in oral suspension; should be swished
around in the mouth and then swallowed
(3.) CORRECT—relaxation can help immune system repair itself, and engaging in an
enjoyable activity can be a distraction from the pain of the stomatitis
(4.) soft, bland, nonacidic, and cool liquids and foods will help eating process be more
comfortable; spicy foods, hot liquids, and citrus juices cause mucosal irritation
A 54-year-old client tells the nurse in the outpatient clinic that she stopped taking
atenolol 100 mg several days ago because it didn’t make her feel better. It is MOST
important for the nurse to assess which of the following?
1. Palpations and diaphoresis
2. Urinary frequency and
dysuria
3. Increased hunger and thirst
4. Confusion and tremors
Strategy: Read answer choices to determine the topic.
1) CORRECT— atenolol is a beta-blocker that decreases excitability of the heart;
reduces cardiac workload and oxygen consumption; decreases release of rennin;
lowers blood pressure by reducing SNS stimuli; should not be discontinued abruptly;
may develop tachycardia, diaphoresis, malaise
2) symptoms of UTI; other symptoms include urgency, nocturia, incontinence, and
suprapubic or pelvic pain; treat with antibacterial
3) symptoms of use of amphetamines; a central nervous system stimulant; other
symptoms: dilated pupils, increased motor activity, mental alertness, decreased fatigue,
and increased spirit
4) symptoms of hypoglycemia; other symptoms include headache, lightheadedness,
slurred speech, impaired coordination
A cast is applied to a 9-month-old girl for the treatment of talipes equinovarus
(clubfoot). Which of the following instructions is essential for the nurse to give the
child’s mother regarding her care at home?
1. Provide blocks for the child during
playtime.
2. Bring her back to the clinic in 7 days.
3. Give her Tylenol liquid as needed.
4. Evaluate the color of her feet.
Strategy: Determine whether it is time to assess or time to implement.
1) implementation; toys — ball, blocks, large push-pull toys
2) implementation
3) implementation; on NCLEX-RN ® , pain is considered a psychological need
4) CORRECT— assessment; check temperature, color, sensation; immediate nursing
care for plaster cast: don’t cover cast until dry (48 hours), handle with palms, not
fingertips; don’t rest on hard surfaces; elevate affected limb above heart on soft surface
until dry; don’t use heatlamp; check for blueness or paleness, pain, numbness or
tingling sensations on affected area; if present, elevate casted area; if it persists,
contact physician; child should remain inactive while cast is drying
A cast is applied to a 9-month-old girl for the treatment of talipes equinovarus
(clubfoot). Which of the following instructions is essential for the nurse to give the
child’s mother regarding her care at home?
1. Provide blocks for the child during
playtime.
2. Bring her back to the clinic in 7 days.
3. Give her Tylenol liquid as needed.
4. Evaluate the color of her feet.
Strategy: Determine whether it is time to assess or time to implement.
1) implementation; toys — ball, blocks, large push-pull toys
2) implementation
3) implementation; on NCLEX-RN ® , pain is considered a psychological need
4) CORRECT— assessment; check temperature, color, sensation; immediate nursing
care for plaster cast: don’t cover cast until dry (48 hours), handle with palms, not
fingertips; don’t rest on hard surfaces; elevate affected limb above heart on soft surface
until dry; don’t use heatlamp; check for blueness or paleness, pain, numbness or
tingling sensations on affected area; if present, elevate casted area; if it persists,
contact physician; child should remain inactive while cast is drying
A patient newly diagnosed with Ménière’s disease is counseled by the office nurse as to
important dietary modifications. Which of the following comments, if made by the
patient to the nurse, BEST indicates that teaching is successful?
1. "I have seen a lot of dietetic foods in the store. I will focus on buying them."
2. "I will avoid Chinese restaurants and fast-food places when I go out to eat."
3. "I will buy one of those commercial salt substitutes to use when I have a
craving for salt."
4. "I understand that I can have corned beef and smoked fish, but not pickles or
creamed sauces."
(1.) not best; not all dietetic foods are low in sodium; labels need to be read
(2.) CORRECT—patients with Ménière’s disease require a low-sodium diet to decrease
fluid retention (endolymphatic fluid, which is clear, intracellular fluid located in the
labyrinth of the inner ear); many Chinese restaurants use MSG and soy sauce, both of
which are high in sodium; fast-food places and products also have a tendency to be
high in sodium
(3.) spices and herbs would be better substances for flavor enhancement
(4.) meat and fish products that are canned, smoked, pickled, or cured should be
avoided because they are high in sodium, as are pickles and, often, creamed sauces
1. The client has weak facial muscles that can be strengthened with
proper exercise.
he home health nurse receives a phone call from the wife of a client diagnosed with
proper exercise.
The home care nurse visits a client diagnosed with ulcerative colitis. The nurse
instructs the client about an appropriate diet. The nurse determines that teaching is
effective if the client selects which of the following menus?
1. White chili, crackers, applesauce, and tea.
2. Grilled cheese sandwich on white bread, bouillon, an orange,
and coffee.
3. Raisin Bran cereal, milk, white toast, and coffee.
4. Baked fish, cream of potato soup, cooked baby carrots, and tea.
Strategy: Recall the diet required for ulcerative colitis.
1) ulcerative colitis is inflammation and ulceration of the colon and rectum; requires
high-calorie, high-protein, low-residue diet; chili contains beans, which are not allowed;
crackers made with white flour and applesauce are allowed
2) raw fruit is not allowed; grilled cheese sandwich and bouillon are allowed
3) Raisin Bran not allowed
4) CORRECT— all of these foods are allowed on diet
An 89-year-old man with Alzheimer’s disease wanders around the unit disturbing other
patients. Which of the following actions by the nurse would be MOST appropriate?
1. Call the physician for an order for a tranquilizer.
2. Place the patient in a geri chair with a clipboard to complete a
puzzle.
3. Allow the patient to assist the staff to sort the linen.
4. Explain to the patient that he may not leave his room.
1) “passing the buck” and a premature action; use least restrictive measures
2) patient will be unable to complete puzzle due to cognitive dysfunction; will increase
confusion and possibly combativeness; form of restraint
3) CORRECT— keeps patient active and independent, structures his environment,
promotes socialization, orients him and preserves his dignity; does not block his
wandering behaviors but uses them constructively; it also protects others from
intrusion
4) the patient may be unable to understand and/or control his behavior; provide calm,
predictable environment with regular routine; give clear and simple explanations
Italian dressing.
The nurse cares for a newborn diagnosed with a myelomeningocele. The nurse
identifies that which of the following actions is MOST important?
1. Monitor for elevated temperature, irritability, and lethargy.
2. Perform range-of-motion exercises to feet, ankles, and
knee joints.
3. Apply lotion to healthy skin and gently massage skin.
4. Measure occipitofrontal circumference daily.
1) CORRECT— infant is at risk to develop infection (meningitis) because of
myelomeningocele sac; change dressing every 2–4 hours using aseptic technique
2) prevents contractures; risk for infection takes priority
3) prevents skin irritation; keep perineal area clean and dry; place on pressure-reducing
surface; risk for infection takes priority
4) at risk for impaired circulation of cerebrospinal fluid; risk for infection takes priority
the skin.
4. The nurse asks the client to dorsiflex the foot on the affected
leg.
pain.
At 4 pm a client with severe back pain receives a head wound while en route to the
emergency department. The client is admitted to the hospital after the head wound is
sutured and covered with a sterile dressing. Exhausted from the ordeal, the client
sleeps for several hours. At 3 am the client turns on the nurse call light and requests
pain medication for severe back pain. The unit secretary answers the light and is
suspicious of the sudden report of severe pain. Which of the following responses by the
nurse to the unit secretary is BEST?
1. “Your job is to report client requests to nursing personnel. Don’t interpret what
the client is saying.”
2. “I am surprised as well; earlier this evening, I helped him to the bathroom.”
3. “Tell me exactly what he said. In cases like this, careful documentation is
important.”
4. “Anxiety and fatigue are pain distracters; when they are reduced, the back pain
returns.”
1) relinquishes an opportunity to educate the unit secretary
2) nurse’s knowledge of the pain process should guide comments made to support
personnel; gossiping about clients is prohibited; should be role model to secretary
3) purpose of documentation is to communicate needs to other health professionals;
implies documenting with regard to an anticipated external activity
4) CORRECT— body does not respond to significant levels of pain in two different areas
of the body at one time; the more education the unit secretary has, the better she can
contribute to quality management of client needs
The nurse knows that which of the following clients is at highest risk for developing
Dupuytren contracture?
1. A 75-year-old woman from Russia diagnosed with osteoarthritis.
2. A 54-year-old man from Norway diagnosed with diabetes.
3. A 34-year-old woman from Haiti diagnosed with a fractured femur.
4. An 11-year-old boy from Poland diagnosed with Duchenne muscular
dystrophy.
1) Dupuytren contracture is a slow progressive contracture of the palmar fascia causing
flexion of the fourth and fifth fingers; results from inherited autosomal dominant trait;
occurs most often in men over 50 years of age, of Scandinavian or Celtic descent, and
is associated with diabetes, gout, arthritis, and alcoholism; age and diagnosis are risk
factors
2) CORRECT— age, origin, gender, and diabetes are risk factors
3) no risk factors
4) no risk factors
The nurse observes the home health aide transfer a patient with right-sided paralysis
from the hospital bed to a chair using a hydraulic lift. The nurse should intervene if
1. The home health aide lowers the patient’s bed before the transfer is
initiated.
2. A canvas sling is positioned under the center of the patient’s body.
4. The home health aide pumps the hydraulic handle using long, slow
strokes.
transfer
3) prevents injury to arms, especially paralyzed side, and provides for patient safety
supplements.”
day.”
day.”
The home care nurse visits an elderly Asian woman diagnosed with hypertension and
heart failure. It is MOST important for the nurse to follow up on which of the following
observations?
1. The client is 5 feet tall and weighs 100 pounds.
2. The client eats whole grains and fresh fruits and
vegetables.
3. The client walks 2 miles three times per week.
4. The client abstains from alcohol.
Strategy: Topic of the question is unstated.
1) CORRECT— client is at risk for developing osteoporosis because of gender, age,
ethnicity, and small body frame; encourage client to increase foods high in calcium,
take prescribed medication (Fosamax and Evista), and exercise regularly
2) appropriate diet for hypertension; instruct client to include foods high in calcium
3) appropriate action; weightbearing exercises increase bone density; encourage clients
with osteoporosis to avoid bowling or other high impact forms of activity
4) promotes acidosis, which increases bone reabsorption
The nurse receives verbal patient care reports from the home health aide. Which of the
following situations requires an intervention by the nurse?
1. A Mexican American female refuses to bathe because she is
menstruating.
2. The family of a terminally ill Hindu man places him on the floor after the
bed bath.
3. An African American female’s hair is shampooed every third day.
4. A Pakistani male on bedrest genuflects on the floor several times
during the day.
Strategy: "Requires and intervention" indicates an incorrect action.
(1.) traditional cultural practice; females do not shower or bathe while menstruating
(2.) cultural end-of-life ritual
(3.) CORRECT—hair and scalp tend to be dry and need oil application rather than
common shampoo, which will further dry out the scalp and make hair brittle
(4.) Islamic ritual prayer done five times per day; nurse should accommodate this
practice to the best of the patient’s ability
The home care nurse instructs a client receiving digoxin (Lanoxin) 0.125 mg PO OD and
furosemide (Lasix) 40 mg PO OD. The nurse determines teaching is effective if the client
1. “I will eat alfalfa sprouts on my salad.”
2. “I will eat more cabbage with my
meals.”
3. “I will eat half a grapefruit every
morning.”
4. “I will eat bananas every day.”
1) client vulnerable to develop hypokalemia from digoxin and Lasix (potassium-wasting
diuretic); should increase potassium in the diet; alfalfa sprouts and lettuce are low in
potassium
2) cabbage is a vegetable low in potassium; high potassium vegetables include
broccoli, spinach, and potatoes
3) low in potassium
4) CORRECT— high in potassium, other fruits high in potassium include cantaloupe and
oranges
he nurse obtains a health history from a teen admitted with acute glomerulonephritis.
4. The teen had an untreated bladder infection 2
months ago.
The nurse performs diet teaching for a client diagnosed with heart failure. Which of the
following statements by the client indicates that further teaching is necessary?
1. "I will increase the amount of fresh vegetables I eat
daily."
2. "I eat salami sandwiches for lunch each day."
3. "I enjoy wheat bread toast in the morning."
4. "I drink low-fat milk at every meal."
(1.) recommend decreased-salt diet for heart failure; fresh vegetables naturally low in
sodium
(2.) CORRECT—processed meats such as cold cuts, sausage, and bacon are high in
added sodium
(3.) appropriate food for low-sodium diet
(4.) naturally low in sodium
The adult granddaughter of a patient diagnosed with moderate Parkinson’s disease tells
the nurse about the ideas she has come up with for gifts for her grandmother’s birthday
in 2 weeks. The granddaughter asks the nurse which idea is best. Which of the following
is the BEST gift for the nurse to support?
1. Perfume and make-up.
2. Hearing aid with
batteries.
3. Warming tray for food.
4. Quilt and soft pillow.
(1.) esthetically pleasing and could boost morale, body image, and self-esteem; not
priority
(2.) hearing loss is not usually a problem with Parkinson’s disease itself; problems that
Parkinson’s patients have with communication primarily relate to speaking so that
others can hear and understand
(3.) CORRECT—warming trays can keep food hot, safe, and appealing during the slow
eating process of the Parkinson’s patient; eating is slow because of overall slowed
body movement, tremors, difficulty chewing and swallowing, fatigue, need for rest
periods; this choice directly addresses a physiologic need
(4.) patients with Parkinson’s disease should keep good posture and avoid flexion of
neck and shoulders; sleep on a firm mattress without a pillow to prevent flexion of the
spine
The pediatric nurse cares for a 3-month-old infant diagnosed with developmental
dysplasia of the left hip. The physician orders the infant to be placed in a Pavlik
harness, and the nurse instructs the mother about how to care for the infant. Which of
the following statements, if made by the infant’s mother to the nurse, indicates further
teaching is necessary?
1. “My baby should always wear an undershirt under the chest straps.”
2. “I should check for reddened areas under the straps several times each
day.”
3. “I should place my baby’s diaper over the straps.”
4. “We should adjust the harness every couple of weeks because of the
baby’s growth.”
5. “I should massage under the straps once a day.”
6. My baby will always wear knee socks.”
1) appropriate action; prevents skin breakdown; symptoms of developmental dysplasia
of the hip include uneven gluteal folds and thigh creases, Ortolani sign, shortened limb
on affected side
2) appropriate action; prevents skin breakdown
3) CORRECT— diaper should be placed under the straps; Pavlik harness is an
abduction device; infant wears it for 3–5 months
4) CORRECT— the straps of the harness may require adjustment every 1–2 weeks
because of infant’s growth, but this should be done by a health care professional; some
harnesses are not removed, even for bathing
5) appropriate action; do not use lotions or powders because they can cause irritation
to the skin
6) appropriate action; prevent skin breakdown
he pediatric nurse cares for a 3-month-old infant diagnosed with developmental
dysplasia of the left hip. The physician orders the infant to be placed in a Pavlik
harness, and the nurse instructs the mother about how to care for the infant. Which of
the following statements, if made by the infant’s mother to the nurse, indicates further
1. “My baby should always wear an undershirt under the chest straps.”
2. “I should check for reddened areas under the straps several times each
day.”
3. “I should place my baby’s diaper over the straps.”
4. “We should adjust the harness every couple of weeks because of the
baby’s growth.”
5. “I should massage under the straps once a day.”
6. My baby will always wear knee socks.”
1) appropriate action; prevents skin breakdown; symptoms of developmental dysplasia
of the hip include uneven gluteal folds and thigh creases, Ortolani sign, shortened limb
on affected side
2) appropriate action; prevents skin breakdown
3) CORRECT— diaper should be placed under the straps; Pavlik harness is an
abduction device; infant wears it for 3–5 months
4) CORRECT— the straps of the harness may require adjustment every 1–2 weeks
because of infant’s growth, but this should be done by a health care professional; some
harnesses are not removed, even for bathing
5) appropriate action; do not use lotions or powders because they can cause irritation
to the skin
6) appropriate action; prevent skin breakdown
The nurse on a medical/surgical unit admits a young adult suspected of having acute
glomerulonephritis. Which of the following questions should the nurse ask FIRST?
1. “Have you had a sore throat within the last few weeks?”
2. “Have you noticed a significant weight gain?”
3. “Has your appetite decreased within the last few weeks?”
4. “Have you noticed an increase in fatigue over the last few
weeks?”
1) CORRECT— infection often occurs before the onset of acute glomerulonephritis; sore
throat caused by group A beta-hemolytic Streptococcus is a common cause; infections
2) sodium retention resulting in weight gain does occur; during admission, nurse is
obtaining as much information as possible to validate possible cause
3) common sign/symptom but not the first question asked
4) common sign/symptom but not the first data needed to validate diagnosis
previously.
4. Insist that the police override the curfew and allow
travel.
problem now
previously.
4. Insist that the police override the curfew and allow
travel.
problem now
The community health nurse cares for a patient who is taking multiple medications for
constipation. The nurse would be LEAST concerned about the patient taking which of
the following medications regularly?
1. Psyllium hydrophilic mucilloid
(Metamucil).
2. Docusate sodium (Colace).
3. Magnesium hydroxide (Milk of
Magnesia).
4. Bisacodyl (Dulcolax).
Strategy: "LEAST concerned" indicates that there is no problem.
(1.) CORRECT—bulk-forming laxative, the category of laxative that is usually seen as
the safest, even when taken on a routine basis; works by increasing water absorption or
retention within the stool, increasing bulk and stimulating peristalsis
(2.) possible problems with regular use could include laxative dependency, bowel
damage, electrolyte imbalance; Colace is an emollient laxative of the fecal-softener type
(3.) saline laxative; hypertonic and works osmotically by drawing water into the intestine
from surrounding tissues; stool consistency is affected, becoming watery, and bowel
distention causes peristalsis; chronic use of saline laxatives can significantly alter
electrolyte balance, cause dehydration, and lead to dependence
(4.) stimulant laxative; achieves its effects by causing an irritation via nerve stimulation
directly on the wall of the intestine, thus stimulating peristalsis and evacuation
The nurse cares for an older woman 12 hours after a right total hip replacement. The
client appears disoriented to person, place, and time. It is MOST important for the nurse
to take which of the following actions?
1. Place an abductor pillow between the patient’s legs.
2. Frequently orient the client to person, place, and time.
3. Limits the client’s fluid intake.
4 hours.
1) CORRECT—abduction prevents dislocation of the hip while turning; important to use
because client is confused; assess for pain, rotation, and/or extremity shortening
2) appropriate because client is confused; not unusual that older clients become
confused by surgery and hospitalization; preventing dislocation of replaced joint is
priority
3) encourage fluids to prevent DVT; instruct client to wear elastic stockings and to
perform leg exercises; assess for redness, swelling, or pain
4) encourage to cough and deep breath or use the incentive spirometer Q 2 h
Diagnostic testing indicates that a bottle-fed infant is allergic to cow’s milk. The nurse
discusses with the mother the adaptive measures to take. Which of the following
statements by the infant’s mother to the nurse indicates that the mother has a correct
understanding of how to proceed?
1. "I am glad there are so many varieties of soy-based formulas
available."
2. "Goat’s milk is supposed to be very gentle on the stomach."
3. "Those predigested formulas sound like they would be a good
choice."
4. "The store near my house is always having sales on fresh
yogurt."
Strategy: "Correct understanding" indicates correct information.
(1.) soy-based formulas are not recommended for infants with cow’s milk allergy due to
cross-reactivity to soy
(2.) goat’s milk is not recommended for infants with cow’s milk allergy; has cross-
reactivity with cow’s milk protein, is deficient in folic acid, is inadequate as the only
caloric source
(3.) CORRECT—formulas that use enzymatic hydrolysis to break down or predigest the
casein protein into its amino acids are recommended for infants with cow’s milk
allergies
(4.) fresh yogurt can be used in situations of lactose intolerance because it has a
lactase enzyme, but it is not suitable for infants with a cow’s milk allergy
The school nurse attends a class outing with a group of sixth-graders. One of the
children falls from a tree, and the nurse suspects that the child’s leg is broken. Which of
1. Contact the child’s parent.
2. Instruct the child to not move.
3. Send a teacher to obtain padded
splints.
4. Bandage the child’s legs together.
1) priority is to prevent any further damage to the leg
2) it is important to prevent movement that may cause further injury to the leg; priority
is splinting the leg
3) uninjured leg can be used as a splint
4) CORRECT— priority is to prevent further injury to the leg; adequate splinting
includes splinting the joint above and below the fracture; uninjured leg can be used as a
splint
bread."
(4.) CORRECT—may exacerbate the inflammatory condition
The nurse on the medical/surgical unit cares for an elderly client diagnosed with cancer.
catheter.”
3. “Please go the bathroom and put on dry
clothes.”
question.
schedule
he nurse on the medical/surgical unit cares for an elderly client diagnosed with cancer.
catheter.”
3. “Please go the bathroom and put on dry
clothes.”
question.
schedule
The industrial nurse receives a visit from a worker diagnosed in the early stages of
chronic renal failure. The client relates to the nurse that he does not understand why the
physician thinks he is “having trouble” with his kidneys when they are working better
than they have in the past. He states that he urinates large volumes of urine all day and
gets up to go to the bathroom all through the night. Which of the following response by
the nurse is BEST?
1. “Did you tell the physician you are putting out lots of urine?”
2. “If you manage your diabetes well, there should be no further
damage.”
3. “You seem to be very upset about this.”
4. “A high volume of urine indicates your kidneys are releasing too
much fluid.”
1) yes/no question; nontherapeutic
2) does not address the client’s misunderstand about the symptoms
3) can be appropriate lead statement when exploring subject; has enough information to
have structured discussion
4) CORRECT— hypertrophy of renal tissue results in increased surface available for
urinary excretion
The nurse counsels a client diagnosed with iron deficiency anemia. The nurse
determines that teaching is effective if the client selects which of the following menus?
1. Roast beef, brown rice, green beans, carrot and raisin salad, and
milk.
2. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and
lemonade.
3. Two scrambled eggs, bacon, white toast with strawberry jam,
and coffee.
4. Corn flakes with milk, whole wheat toast, and orange juice.
1) CORRECT— beef is good source of organic iron, brown rice and raisins are good
sources of inorganic iron; green beans also contain inorganic iron; total iron, 8.4 mg
2) cheese pizza contains small amount of iron, oatmeal-raisin cookie is best source of
iron in this selection (2.7 mg); total iron, 4.8 mg
3) total iron, 2.5 mg (1.4 mg from scrambled eggs); coffee contains tannin, which
combines with nonheme iron and prevents it from being absorbed; nonheme iron
comes from inorganic sources
4) total iron, 4 mg from nonorganic sources; vitamin C enhances the absorption of
inorganic iron
The nurse cares for a client on bedrest with an order to immobilize the right leg because
of tenderness, increased warmth, and diffuse swelling. Which of the following nursing
actions is MOST appropriate?
1. Install a trapeze to the client’s bed.
2. Assess bony prominences every 12
hours.
3. Apply granular spray to bony
prominences.
4. Turn the client every 2 hours.
1) encourages the client to move independently, but does not relieve pressure on bony
prominences
2) should assess frequently
3) does not protect the bony prominences from pressure
4) CORRECT— turning client at frequent intervals prevents skin breakdown caused by
pressure, friction, or shearing forces; client is immobilized because of symptoms of
DVT
The nurse instructs a client about care of a colostomy. The client is especially
concerned about controlling odor and gas. The nurse should include which of the
following instructions to the client?
1. “Place a breath mint inside the colostomy pouch.”
2. “Eat onions, beans, and cucumbers.”
3. “Drink cranberry juice and buttermilk.”
4. “Eat crackers, toast, and yogurt.”
5. “Use a commercially prepared deodorizer inside the
pouch.”
6. “Do not skip meals or chew gum.”
1) CORRECT— eliminates odors in the pouch
2) avoid these foods because they contribute to gas production
3) CORRECT— helps prevent odor; eating parsley and yogurt is also helpful
4) CORRECT— helps prevent gas
5) CORRECT— helps eliminate odors
6) CORRECT— chewing gum, skipping meals, drinking beer, and smoking contribute to
the production of flatus
further teaching is needed if the client states which of the following?
1. “I will eat fruits and vegetables with every
meal.”
2. “I will select meats that are low in fat.”
3. “I will add nuts and corn to my diet.”
4. “I will drink milk at least once per day.”
Strategy: “Further teaching is needed” indicates incorrect information.
1) appropriate action; will add fiber to diet which increases bulk in stool; avoid fiber if
diverticulitis develops
2) good heath habit; no more than 30% of daily calories should come from fat
3) CORRECT— diverticulosis is diverticula in the colon without inflammation; foods
with seeds or indigestible material may block a diverticula; should avoid seeds, nuts,
corn, popcorn, cucumbers, tomatoes, figs, strawberries, and caraway seeds
The nurse prepares to move a patient from bed to chair using a hydraulic lift. It is MOST
important for the nurse to perform which of the following actions?
1. While lowering the patient to the chair, ask the patient to extend the legs
forward.
2. Remove the sling from the patient once the patient is seated in the chair.
3. Suspend the patient in the sling above the bed prior to moving the lift.
4. Set the adjustable base of the lift to its most space-conserving position.
(1.) when lowing patient, push gently on knees in order to maintain the proper sitting
position
(2.) leave sling in place under the patient to facilitate transfer and promote comfort for
the patient
(3.) CORRECT—lift supports weight safely and will not tip over; suspending the patient
briefly above the bed prior to moving away from it provides reassurance and increases
patient’s feelings of security
(4.) lift base should be set at its widest position in order to ensure greatest stability
The nurse on the surgical unit is aware that protein-calorie malnutrition contributes to
postoperative infections. Which of the following observations BEST informs the nurse
that the client’s protein intake is adequate?
1. The client eats 1/2 to 3/4 of the food on each meal
tray.
2. The client has dry, flaking skin.
3. The client complains of being cold.
4. The client’s serum albumin is 4.0 g/dL.
1) protein-calorie malnutrition affects the immune system; nurse should weigh client on
admission and weigh at least weekly; eating 1/2 to 3/4 of meal tray indicates that the
client is taking in food, but albumin level is the most objective measure
2) can be caused by malnutrition, but also can be caused by dehydration,
hypothyroidism
3) can be caused by malnutrition, but also can be caused by hypothyroidism
4) CORRECT— normal serum albumin is 3.5 to 5.0 g/dL; albumin deficit decreases
oncotic pressure and fluids shift from vascular area to tissue
FIRST?
1. Call 911.
arm.
he nurse in the clinic is teaching a 65-year-old woman with osteoporosis. It is MOST
osteoporosis.
weight.
The nurse assesses a patient 48 hours after a total joint replacement of the right hip.
Which of the following findings should the nurse report to the physician?
1. The patient requests analgesics less frequently.
2. The right leg is abducted beyond the body’s midline.
3. The right leg is outwardly rotated.
4. The hip joint is flexed at a 70°angle when the patient sits in
the chair.
1) parenteral pain medication usually is not required after the first 2 days; change to
non-narcotic analgesics according to patient tolerance; if client is confused, offer pain
medication, don’t wait for the client to ask
2) to prevent dislocation, maintain leg in position of abduction for 2–3 months
3) CORRECT— indicates dislocation of prosthesis; may also see shortening of
extremity, inability to move it, altered alignment, abnormal rotation, increased pain
4) flexion is usually limited to 60°for 6–7 days, then limited to 90°for 2–3 months;
instruct patient not to sit or stand for long periods of time, do not cross legs beyond
midline of body, and use assistive device to put on shoes and socks
Diagnostic testing indicates that a bottle-fed infant is allergic to cow’s milk. The nurse
discusses with the mother the adaptive measures to take. Which of the following
statements by the infant’s mother to the nurse indicates that the mother has a correct
understanding of how to proceed?
available."
choice."
yogurt."
(1.) soy-based formulas are not recommended for infants with cow’s milk allergy due to
cross-reactivity to soy
(2.) goat’s milk is not recommended for infants with cow’s milk allergy; has cross-
reactivity with cow’s milk protein, is deficient in folic acid, is inadequate as the only
caloric source
(3.) CORRECT—formulas that use enzymatic hydrolysis to break down or predigest the
casein protein into its amino acids are recommended for infants with cow’s milk
allergies
The nurse observes a nursing assistant care for a client after abdominal surgery. The
nursing assistant supports the client’s leg as the client flexes and bends the knee. The
nurse identifies that the client is engaged in which of the following therapeutic
exercises?
1. Passive.
2. Active-
assistive.
3. Active.
4. Resistive.
1) exercise is carried out by nurse without help from the client
2) CORRECT— nurse supports distal part while client actively takes the joint through
range-of-motion
3) exercise is carried out by the client without help from the nursing staff; will increase
muscle strength
4) active exercise that is carried out independently by client; client works against
resistance to increase muscle power
An adult is undergoing testing for amyotrophic lateral sclerosis (ALS). The nurse would
expect the client to exhibit which of the following symptoms?
1. Incontinence of bowel and
bladder.
2. Difficulty swallowing.
3. Paresthesia of the face.
4. Disorientation to time and
place.
1) retains control of these functions
2) CORRECT— have difficulty with dysphagia and aspiration; other early symptoms
include fatigue with while talking, tongue atrophy, weakness of hands and arms
3) has fasciculations of the face
4) ALS does not cause changes to the mental state
An adult is undergoing testing for amyotrophic lateral sclerosis (ALS). The nurse would
expect the client to exhibit which of the following symptoms?
1. Incontinence of bowel and
bladder.
2. Difficulty swallowing.
3. Paresthesia of the face.
4. Disorientation to time and
place.
1) retains control of these functions
2) CORRECT— have difficulty with dysphagia and aspiration; other early symptoms
include fatigue with while talking, tongue atrophy, weakness of hands and arms
3) has fasciculations of the face
4) ALS does not cause changes to the mental state
When teaching a patient with chronic renal failure about dietary management, the nurse
should recommend which of the following?
1. Increase intake of chicken and
fish.
2. Drink 2 to 3 liters of water each
day.
3. Use salt substitutes rather than
salt.
4. Increase intake of pasta and
breads.
Strategy: All answers are implementations. Determine the outcome of each answer. Is it
desired?
(1.) body unable to store excess proteins; proteins break down into wastes that cannot
be excreted by the compromised kidneys
(2.) 1 to 2 liters recommended to maintain fluid balance and avoid retention of excess
fluid that cannot be excreted by the compromised kidneys
(3.) many salt substitutes are high in potassium, which may not be adequately excreted
by the compromised kidneys
(4.) CORRECT—increasing carbohydrate intake helps patient to maintain energy
requirements
2. “I see that you have not used your PCA pump. Are you sure that you
aren’t in pain?”
medication.”
4. “Look at this faces pain scale. Point to the picture that shows how you
feel now.”
denial of pain
2. “I see that you have not used your PCA pump. Are you sure that you
aren’t in pain?”
medication.”
4. “Look at this faces pain scale. Point to the picture that shows how you
feel now.”
denial of pain
The nurse in the outpatient clinic assesses a female client complaining of “burning with
urination.” It is MOST important for the nurse to take which of the following actions?
1. Ask the client if she has experienced this before.
2. Encourage the client to drink cranberry juice.
3. Examine the urethral meatus and vaginal introitus.
4. Instruct the client to wear loose-fitting cotton
underwear.
1) appropriate question but not the priority action
2) helps to acidify the urine; assess before implementing
3) CORRECT— client may have normal acidic urine that causes burning if labial tissues
are inflamed because of vaginal infection
4) appropriate action to prevent UTI; assess before implementing
The adult granddaughter of a patient diagnosed with moderate Parkinson’s disease tells
the nurse about the ideas she has come up with for gifts for her grandmother’s birthday
in 2 weeks. The granddaughter asks the nurse which idea is best. Which of the following
is the BEST gift for the nurse to support?
2. Hearing aid with
batteries.
(1.) esthetically pleasing and could boost morale, body image, and self-esteem; not
priority
(2.) hearing loss is not usually a problem with Parkinson’s disease itself; problems that
Parkinson’s patients have with communication primarily relate to speaking so that
others can hear and understand
(3.) CORRECT—warming trays can keep food hot, safe, and appealing during the slow
eating process of the Parkinson’s patient; eating is slow because of overall slowed
body movement, tremors, difficulty chewing and swallowing, fatigue, need for rest
periods; this choice directly addresses a physiologic need
(4.) patients with Parkinson’s disease should keep good posture and avoid flexion of
neck and shoulders; sleep on a firm mattress without a pillow to prevent flexion of the
spine
The home care nurse receives a phone call from the wife of a client recovering from a
left above-the-knee amputation. The client awakened screaming with pain in the
amputated portion of the limb. The wife relates to the nurse that she is worried about
her husband’s mental health. Which of the following responses by the nurse is BEST?
1. “Did you have him turn on his abdomen?”
2. “Please try to calm down. There is nothing to be upset about.”
3. “Is the residual limb bleeding or does it have an unusual odor?”
4. “That kind of pain is common after an amputation. Does he have something he
can take for the pain?”
1) flexor spasms may cause pain in residual part of limb; is not related to pain in the
absent portion of the limb
2) negates the wife’s experience; offer specific information; not likely to calm down until
she understands the process
3) assessment of the residual limb is relevant to determine source of pain, can be
relevant under different circumstances; does not address the fact he’s having pain in
the absent portion of the limb
4) CORRECT— nerve endings often become pinched in the scar tissue; brain still has
image of the missing limb
The home care nurse instructs a client receiving digoxin (Lanoxin) 0.125 mg PO OD and
furosemide (Lasix) 40 mg PO OD. The nurse determines teaching is effective if the client
1. “I will eat alfalfa sprouts on my salad.”
2. “I will eat more cabbage with my
meals.”
3. “I will eat half a grapefruit every
morning.”
4. “I will eat bananas every day.”
1) client vulnerable to develop hypokalemia from digoxin and Lasix (potassium-wasting
diuretic); should increase potassium in the diet; alfalfa sprouts and lettuce are low in
potassium
2) cabbage is a vegetable low in potassium; high potassium vegetables include
broccoli, spinach, and potatoes
3) low in potassium
4) CORRECT— high in potassium, other fruits high in potassium include cantaloupe and
oranges
The nurse cares for a patient diagnosed with a fractured left femur. The patient
describes how to walk with crutches. Which of the following statements by the patient
indicates to the nurse that further teaching is necessary?
1. "The crutches and my weak leg will go forward first when I walk on flat
surfaces."
2. "My strong leg will lead the way going up and down stairs."
3. "I will use a backpack instead of a briefcase when I go to work."
4. "I will look at the crutch tips and feel them every day."
(1.) appropriate understanding; affected leg is moved forward at the same time as the
crutches, followed by the strong leg; describes the three-point crutch-walking gait,
which is the appropriate gait when partial or no weight-bearing is allowed on one leg
(2.) CORRECT—the strong leg leads the way going up stairs; when going down stairs,
the crutches are advanced to the lower step, the weaker leg is advanced, and then the
stronger leg follows
(3.) appropriate; hands and arms need to be unencumbered to effectively manage the
crutches
(4.) appropriate; crutch tips are rubber and provide stability and prevent slippage;
inspect regularly for cracks, wear, and tightness of fit, and replace immediately if any
problems are found
The nurse cares for a 4-year-old who sustained a fractured wrist from a fall. The nurse
prepares the child for the application of a plaster cast. Which of the following actions by
1. Tell the child the cast will feel cold when it is first
applied.
arm.
a cast.
question.
2) CORRECT— preschoolers need to see and play with the equipment; this is the age of
the greatest number of fears
3) describe to the child what she will be feeling and experiencing in words that are not
frightening
The nurse cares for a client receiving furosemide (Lasix). The nurse determines that
teaching is effective if the client selects which of the following foods?
1. One medium baked
potato.
2. One slice of white bread.
3. One medium apple.
4. One scrambled egg.
5. 1 1/4 cup of corn flakes.
6. 1 cup of cantaloupe.
Strategy: Think about each food.
1) CORRECT— contains 407 mg of potassium; Lasix is a potassium-wasting diuretic;
client needs to increase intake of potassium
2) contains 27 mg potassium
6) CORRECT— contains 825 mg potassium
The community health nurse cares for a patient who is taking multiple medications for
constipation. The nurse would be LEAST concerned about the patient taking which of
the following medications regularly?
1. Psyllium hydrophilic mucilloid
(Metamucil).
2. Docusate sodium (Colace).
3. Magnesium hydroxide (Milk of
Magnesia).
4. Bisacodyl (Dulcolax).
Strategy: "LEAST concerned" indicates that there is no problem.
(1.) CORRECT—bulk-forming laxative, the category of laxative that is usually seen as
the safest, even when taken on a routine basis; works by increasing water absorption or
retention within the stool, increasing bulk and stimulating peristalsis
(2.) possible problems with regular use could include laxative dependency, bowel
damage, electrolyte imbalance; Colace is an emollient laxative of the fecal-softener type
(3.) saline laxative; hypertonic and works osmotically by drawing water into the intestine
from surrounding tissues; stool consistency is affected, becoming watery, and bowel
distention causes peristalsis; chronic use of saline laxatives can significantly alter
electrolyte balance, cause dehydration, and lead to dependence
(4.) stimulant laxative; achieves its effects by causing an irritation via nerve stimulation
directly on the wall of the intestine, thus stimulating peristalsis and evacuation
supplements.”
day.”
day.”
supplements.”
day.”
day.”
The school nurse is performing health screening for scoliosis on a group of sixth-
graders. The nurse would be MOST concerned if which of the following is observed?
1. A child complains of a painful right knee.
2. A child’s feet turn inward.
3. A child shifts his weight from the right foot to the
left foot.
4. A child’s left shoulder is higher than her right
shoulder.
Strategy: “MOST” concerned indicates something is wrong.
1) usually there is no complaint of pain with scoliosis; there may be a slight limp with
scoliosis
2) does not indicate scoliosis
3) does not indicate scoliosis
4) CORRECT— nurse should also observe for asymmetry or prominence of rib cage and
scapulae, curvature of spine; treatment is bracing and spinal fusion surgery
bread."
(4.) CORRECT—may exacerbate the inflammatory condition
Italian dressing.
months ago.
months ago.
A 1-day-old infant was born with a myelomeningocele. The nurse caring for the neonate
should place the infant in which of the following positions?
1. On her abdomen with her face turned to the
side.
2. Sitting upright in an infant seat.
3. On her back with the head of the crib
elevated.
4. On the left side with a pillow to her back.
1) CORRECT— prevents pressure on sac-like protrusion on back; pressure would result
in increased intracranial pressure, or may rupture sac, leading to infection; cover lesion
with moist, sterile dressing
2) dangerous position due to pressure on sac-like protrusion on back; position on
abdomen or semiprone with sandbags
3) this would put pressure on the sac-like protrusion on back; observe for increased
intracranial pressure, meningitis
4) dangerous position due to pressure on sac-like protrusion on back
The nurse cares for a client diagnosed with myasthenia gravis. Which of the following
clinical manifestations would the nurse expect to see?
1. Rigidity.
2. Muscle weakness that improves with
rest.
3. Paresthesia of the lower extremities.
4. Propulsive gait.
5. Ptosis.
6. Diplopia.
Strategy: Determine how each answer relates to myasthenia.
1) resistance to passive movement of the extremities; seen with Parkinson’s disease
2) CORRECT— caused by acetylcholine deficiency, transmission of nerve impulses is
limited, resulting in difficulty stimulating or initiating muscular movement; muscle
weakness increases with exertion; administer medication on time and plan activities to
follow medication
3) seen with injury to spinal canal
4) seen with Parkinson’s disease; short, hesitant steps
5) CORRECT— drooping eyelids, may also have impaired speech, dysphagia
6) CORRECT— double vision
A client with a history of lupus erythematous is hospitalized following a seizure. A few
minutes after admission, the client asks for something for severe pain in the right hip
joint. Because the client was applying makeup and talking on the phone when the
LPN/LVN enters the room, the LPN/LVN exited the room to confer with the charge nurse.
1. “Hold the pain medication for now. I will report the information to the
physician.”
2. “The pain medication is ordered so please give it.”
3. “Give the medication. People with chronic pain often do not exhibit
signs/symptoms of tissue injury.”
4. “Tell me exactly what you want from me.”
1) statement indicates nurse lacks competency in pain management of clients with
chronic pain; joint pain is very common in clients with lupus erythematous
2) assessment of pain before administration of analgesia is appropriate; response
should be directed at level of pain
3) CORRECT— clients with chronic pain exhibit little or no autonomic hyperactivity
4) inappropriate response; it appears the medication nurse is questioning whether or
not the client is experiencing pain and needs help figuring out what to do about the
conclusion.
The nurse is caring for a patient with a casted left leg. Which of the following exercises
should the nurse recommend?
1. Passive exercise of the affected limb.
2. Quadriceps setting of the affected limb.
3. Active ROM exercises of the unaffected
limb.
4. Passive exercise of the upper
extremities.
1) nurse moves extremity; maintains ROM of joint; can’t do with a cast
2) CORRECT— isometric exercise: contraction of muscle without movement of joint;
maintains strength while in cast
3) not best; more important to maintain muscle strength of casted leg
4) if preparing for walking with crutches, need strengthening, not passive exercises
The nurse is caring for a patient with a casted left leg. Which of the following exercises
should the nurse recommend?
1. Passive exercise of the affected limb.
2. Quadriceps setting of the affected limb.
3. Active ROM exercises of the unaffected
limb.
4. Passive exercise of the upper
extremities.
1) nurse moves extremity; maintains ROM of joint; can’t do with a cast
2) CORRECT— isometric exercise: contraction of muscle without movement of joint;
maintains strength while in cast
3) not best; more important to maintain muscle strength of casted leg
4) if preparing for walking with crutches, need strengthening, not passive exercises
The nurse reviews the principles of correct body mechanics with a nurse aide. Which of
the following suggestions by the nurse is MOST appropriate?
1. “Bend at the waist when you lift objects.”
2. “Carry objects close to your body or above your
head.”
3. “Bend your knees when you lift objects.”
4. “Lean forward when you lift objects.”
1) should bend at the knees to increase body balance and lower center of gravity
2) object should be carried close to body’s center of gravity to help balance, but
shouldn’t carry above head
3) CORRECT— maintains better body balance, moves center of gravity close to object
4) would put unnecessary stress on back; should bend knees when lifting
proper exercise.
A patient newly diagnosed with Ménière’s disease is counseled by the office nurse as to
important dietary modifications. Which of the following comments, if made by the
patient to the nurse, BEST indicates that teaching is successful?
1. "I have seen a lot of dietetic foods in the store. I will focus on buying them."
2. "I will avoid Chinese restaurants and fast-food places when I go out to eat."
3. "I will buy one of those commercial salt substitutes to use when I have a
craving for salt."
4. "I understand that I can have corned beef and smoked fish, but not pickles or
creamed sauces."
(1.) not best; not all dietetic foods are low in sodium; labels need to be read
(2.) CORRECT—patients with Ménière’s disease require a low-sodium diet to decrease
fluid retention (endolymphatic fluid, which is clear, intracellular fluid located in the
labyrinth of the inner ear); many Chinese restaurants use MSG and soy sauce, both of
which are high in sodium; fast-food places and products also have a tendency to be
high in sodium
(3.) spices and herbs would be better substances for flavor enhancement
(4.) meat and fish products that are canned, smoked, pickled, or cured should be
avoided because they are high in sodium, as are pickles and, often, creamed sauces
fingers.”
repaired palate
fingers.”
repaired palate
The nurse instructs a 56-year-old woman with degenerate joint disease. Which of the
following statements, if made by the client, would indicate to the nurse that further
teaching is needed?
1. “I should carry my handbag on my shoulder instead of holding it in my
hands.”
2. “I should hold things with both hands instead of using just one.”
3. “I should bend at the waist, keeping my back straight when I pick things up
off the floor.”
4. “I should sit in a chair that has a high, straight back on it.”
1) should encourage use of large joints instead of smaller joints; encourage client to
balance rest and activity
2) reduce stress on joints of wrist and hand; apply heat prior to beginning day
3) CORRECT— inaccurate, wrong behavior; should bend at knees, not waist, and keep
back straight
4) maintain body in good alignment, prevents bending or stooping
The nursing assistant on an acute urology unit gives the nurse the intake and output
sheet for a client diagnosed with chronic renal failure (CRF). The client’s output was
measured on the day shift but not recorded on the evening shift. Which of the following
actions should the charge nurse take FIRST?
1. Call the nurse assigned to the evening shift and request the
information.
2. Complete an agency incident report.
3. Ask the client if he noticed the output last evening.
4. Notify immediate supervisor of the incident.
1) CORRECT— the goal is to make every effort to retrieve the data; knowledge of output
used to support decision making about most appropriate interventions; nurses often
carry notes home with them or store their work sheets in their lockers; this method
seeks a possible resource
2) last step; information may be available; quality client care is first priority; don’t have
problem yet
3) some clients notice the volume and some do not; is a possible resource, but is not
the best resource; is nurse’s job to record output
4) focus is not maintaining system at this point; focus is on collection of prime data for
management of client health needs
The nursing assistant on an acute urology unit gives the nurse the intake and output
sheet for a client diagnosed with chronic renal failure (CRF). The client’s output was
measured on the day shift but not recorded on the evening shift. Which of the following
actions should the charge nurse take FIRST?
1. Call the nurse assigned to the evening shift and request the
information.
2. Complete an agency incident report.
3. Ask the client if he noticed the output last evening.
4. Notify immediate supervisor of the incident.
1) CORRECT— the goal is to make every effort to retrieve the data; knowledge of output
used to support decision making about most appropriate interventions; nurses often
carry notes home with them or store their work sheets in their lockers; this method
seeks a possible resource
2) last step; information may be available; quality client care is first priority; don’t have
problem yet
3) some clients notice the volume and some do not; is a possible resource, but is not
the best resource; is nurse’s job to record output
4) focus is not maintaining system at this point; focus is on collection of prime data for
management of client health needs
The nurse cares for a client admitted with malnutrition due to disorientation and
confusion. The nurse determines that the client has responded positively to care when
1. The client states that he understands that he does not eat when he is
confused.
2. The client correctly identifies the food groups.
3. The client states that he needs to drink more water.
4. The client feeds himself when the nurse offers cues.
1) not realistic for a client who is confused
4) CORRECT— a disoriented, confused client who is unable to care for himself will
require cues from the nurse in order to eat; goal is for client to feed self
The nurse counsels a client diagnosed with rheumatoid arthritis. The client asks the
nurse why he should perform range-of-motion (ROM) exercises. Which of the following
1. “They help make your muscles
stronger.”
2. “They help prevent contractures.”
3. “They help keep your spirits up.”
4. “They will prevent respiratory
complication.”
1) it is important that the client increases muscle strength; will be done through
isometric and resistive exercises
2) CORRECT— ROM exercises increase joint mobility and decrease pain; important that
client take medication on time to ensure consistent blood levels, balance rest, and
activity
3) if client has decreased pain and greater ROM, will feel better psychologically, but not
the primary reason for ROM exercises; recreational exercise such as walking and
swimming will increase muscle tone and increase psychological well being
4) not accurate; coughing and deep breathing will prevent respiratory complication
FIRST?
1. Call 911.
arm.
The nurse in the clinic is teaching a 65-year-old woman with osteoporosis. It is MOST
osteoporosis.
weight.
The nurse cares for a client after a left below-the-knee amputation. The client complains
of persistent pain after receiving pain medication. Which of the following actions by the
2. Inspect the limb.
3. Turn on the television.
4. Obtain the client’s
temperature.
question.
1) nurse should assess before notifying health care provider
2) CORRECT— observe for redness, swelling, and pain, which may indicate
inflammation and infection
3) assumes that the pain does not indicate a complication; assess before implementing
4) is an appropriate action but the nurse should first inspect the wound
hypotension.”
of heath care
members

The nurse answers a call light for a patient who is complaining of pain at the IV
site. Upon assessment, the nurse notes the IV insertion site is pale, cool to the
touch, and mildly swollen. It is MOST important for the nurse to take which of the
following actions?

1. Slow the infusion rate and monitor the patient’s
response.
3. Remove the IV and apply a pressure dressing.
4. Remove the IV and place the patient’s arm on a

pillow.


the question.
(1.) indicates infiltration of the IV; symptoms will progress if the infusion is
continued
(2.) inadequate intervention; action appropriate, should elevate extremity to
increase rate of re-absorption of the fluid
(3.) should remove IV and elevate arm
(4.) CORRECT—likely infiltrated; discontinue and restart at a new site; elevate
extremity to increase the rate of re-absorption of the fluid
The nurse cares for patients in the emergency department. Four patients come
to the ED at the same time. Which of the following patients should the nurse see
FIRST?

1. A 1-year-old with vomiting and diarrhea.
2. A 2-year-old with a temperature of 101°F (38°C).
3. A 20-year-old at 8 weeks’ gestation who is complaining of

vaginal spotting.
4. A 32-year-old complaining of nausea and vomiting for the past
several hours.

(1.) CORRECT—at significant risk for dehydration, which may result in
electrolyte imbalances, as well as shock, depending on the amount of fluid lost
(2.) obtain an order for an antipyretic and monitor until can be evaluated by
physician
(3.) caused by drop the progesterone level, potential for spontaneous abortion;
encourage patient to rest; offer reassurance until patient evaluated by physician
(4.) average healthy young adult’s body can adequately compensate for
The nurse cares for patients in the emergency department. Four patients come
to the ED at the same time. Which of the following patients should the nurse see
FIRST?

1. A 1-year-old with vomiting and diarrhea.
2. A 2-year-old with a temperature of 101°F (38°C).

vaginal spotting.
4. A 32-year-old complaining of nausea and vomiting for the past
several hours.


(1.) CORRECT—at significant risk for dehydration, which may result in
electrolyte imbalances, as well as shock, depending on the amount of fluid lost
(2.) obtain an order for an antipyretic and monitor until can be evaluated by
physician
(3.) caused by drop the progesterone level, potential for spontaneous abortion;
encourage patient to rest; offer reassurance until patient evaluated by physician
(4.) average healthy young adult’s body can adequately compensate for
The nurse on the orthopedic unit cares for a patient who sustained a T5 spinal
cord injury 4 weeks ago. Upon entering the room, the nurse observes that the
patient is diaphoretic, nauseated, and complaining of a severe headache. Which

1. Place the patient in a sitting position.
2. Have the patient empty his bladder.
3. Examine the rectum.
4. Administer hydralazine hydrochloride (Apresoline) as

ordered.


(1.) CORRECT—symptoms reflect autonomic dysreflexia; emergency life-
threatening condition which can occur with spinal cord injuries above T6 after
spinal shock resolves, which is 1 to 6 weeks after injury; causes include visceral
distension and noxious stimuli such as skin pressure, temperature extremes; a
primary symptom, and of most major concern, is severe rapid hypertension;
other symptoms include bradycardia; placing patient in sitting position should
be done immediately to help decrease the blood pressure and prevent increased
intracranial pressure with cerebral hemorrhage and seizures
(2.) not first; distended bladder is the most common cause of autonomic
dysreflexia and must be assessed very quickly, e.g., right after sitting patient up
(3.) not first; bowel distension can be a cause of autonomic dysreflexia; if fecal
impaction is discovered, a local anesthetic ointment should be used before
impaction removal to block further autonomic stimulation
(4.) not first; used if other means (such as sitting, urinary catheterization and
emptying of the bladder, removal of fecal mass, or removal of skin stimuli) have
not relieved the hypertension and headache; Apresoline is an antihypertensive,
non-nitrate vasodilator
A patient diagnosed with emphysema is brought to the emergency department

by the family. The nurse notes that the patient is breathless and ashen in color.
Vital signs include: temperature 98.8°F (37°C), pulse 114, respirations 36, BP
138/108. Oxygen is started per nasal cannula at 2 L/min. Which of the following
observations MOST concerns the nurse?

1. The patient’s skin color is pink within the first 20 minutes of
oxygen delivery.
2. The pulse oximetry reading is 92%.
3. The spouse begins to sob and says living will be difficult if

patient dies.
4. Blood work reveals hemoglobin 19 g/dL and hematocrit 54%.

Strategy: Remember Maslow.

(1.) CORRECT—COPD patient who has hypercapnia, which is likely in advanced
or exacerbated emphysema, is at risk for oxygen-induced hypoventilation
because stimulus for breathing is low oxygen level, not high CO2 level as in
average people; signs of hypoventilation will appear in the first 30 minutes of
oxygen administration; color will improve due to the increase in PaO2 levels;
going from gray or ashen to pink before becoming apneic or going into
respiratory arrest; careful monitoring of these patients is critical
(2.) due to the risk of oxygen-induced hypoventilation in COPD, patients on 02
therapy, should initially be maintained at an oxygen saturation between 90 and
92% until ABGs are available to guide therapy further
(3.) psychosocial; needs to be addressed by health care staff; including possible
referral to social services or pastoral care
(4.) polycythemia is a compensatory mechanism of an increase in RBCs in
people who are chronically hypoxic; for adult male: hemoglobin range is 14.0 to
17.4 g/dL, hematocrit is 42 to 52%
After a patient receives naloxone hydrochloride (Narcan) 0.2 mg IV, which of the
following actions is ESSENTIAL for the nurse to perform?

1. Decrease external stimuli.
3. Place the patient in lateral recumbent

position.
4. Monitor the patient’s rate of respirations.
Strategy: “ESSENTIAL” indicates priority.

1) implementation; unnecessary for patient experiencing narcotic-induced
respiratory depression
2) implementation; patient may have lowered level of consciousness; don’t give
anything PO
3) implementation; should position patient with head of bed elevated
4) CORRECT— assessment; used to reverse narcotic-induced respiratory
depression; should frequently monitor BP, rate and depth of respirations, and
pulse
The nurse cares for a client receiving albuterol (Proventil) 2 puffs, and
beclomethasone (Vanceril) 2 puffs through inhalers. The nurse should include
which of the following statements when counseling the client?

1. “Use the Proventil inhaler and then use the Vanceril inhaler.”
2. “Use the Vanceril inhaler and then the Proventil inhaler.”
3. “You should take 1 puff of each inhaler, wait a minute, and then
repeat the process.”
4. “Either inhaler can be used first as long as you wait 2 minutes
between puffs.”


1) CORRECT— Proventil is a bronchodilator that opens the passageways so the
steroid medication (Vanceril) can get into the bronchioles
2) steroids won’t be able to penetrate unless the bronchioles are opened by the
bronchodilator
3) dilate the bronchioles first; side effects of Proventil include tremors,
headache, hyperactivity, tachycardia; teach client correct use of inhaler
4) incorrect action; side effects of Vanceril include fungal infections, dry mouth,
throat infections; taper slowly, check growth and development with high-dose
and prolonged use in children, during times of stress systemic steroids may be
needed, gargle or rinse mouth after each use
The nurse cares for a client receiving albuterol (Proventil) 2 puffs, and
beclomethasone (Vanceril) 2 puffs through inhalers. The nurse should include
which of the following statements when counseling the client?

1. “Use the Proventil inhaler and then use the Vanceril inhaler.”
2. “Use the Vanceril inhaler and then the Proventil inhaler.”
3. “You should take 1 puff of each inhaler, wait a minute, and then
repeat the process.”
4. “Either inhaler can be used first as long as you wait 2 minutes
between puffs.”


1) CORRECT— Proventil is a bronchodilator that opens the passageways so the
steroid medication (Vanceril) can get into the bronchioles
2) steroids won’t be able to penetrate unless the bronchioles are opened by the
bronchodilator
3) dilate the bronchioles first; side effects of Proventil include tremors,
headache, hyperactivity, tachycardia; teach client correct use of inhaler
4) incorrect action; side effects of Vanceril include fungal infections, dry mouth,
throat infections; taper slowly, check growth and development with high-dose
and prolonged use in children, during times of stress systemic steroids may be
needed, gargle or rinse mouth after each use
The nurse makes rounds of patients on the medical/surgical unit. It is MOST

important for the nurse to intervene if which of the following is observed?

1. A patient 10 hours post-tonsillectomy sits in a bedside recliner
watching television.
2. A patient admitted 4 hours ago with a closed head injury lies flat
in bed with legs elevated.
3. A patient 3 days post–below knee amputation (BKA) lies prone
in bed.
4. A patient admitted yesterday with COPD lies in bed with the
head of the bed elevated 45 degrees.


(1.) proper positioning; assess for postop bleeding
(2.) CORRECT—patients with closed head injury prone to increased intracranial
pressure; elevate head of bed 30 to 45 degrees to promote venous drainage
(3.) 72 hours post-BKA would start to be concerned with development of
contractures; prone position will stretch the hip flexors/quadriceps muscle and
help to prevent contractures
(4.) although usually most comfortable in a 60- to 90-degree position, a 45-
degree position is acceptable (the patient is not flat)
A client receives theophylline (aminophylline) IV for an acute respiratory

problem. Which of the following observations alerts the nurse to withhold the
medication and notify the doctor?

1. Hypertension.
2. Unresponsiveness.
3. Polyuria.
4. Tachycardia.
Strategy: Think about each answer and how it relates to aminophylline.

1) does not result from an aminophylline overdose
4) CORRECT— side effect of aminophylline; levels above 20 mcg/L are
considered toxic; after long-term use, clients may tolerate higher blood
concentration; other side effects include hypotension, nausea, vom
The physician has ordered digoxin (Lanoxin) 0.02 mg/kg PO in divided doses for
a 4-month-old infant. When the nurse checks the sleeping child’s heart rate, it is
regular at 80 bpm. The nurse should take which of the following actions?

1. Stimulate sole of the infant’s foot to recheck heart rate.
2. Give the medication as ordered and document the heart rate in

the chart.
3. Withhold the medication and immediately notify the physician.
4. Ask another nurse to recheck the infant’s heart rate.

1) medication is given according to resting heart rates; should not stimulate
child
2) normal heart rate for an infant is 120–140 (resting); bradycardia is rate below
80–100; withhold medication if rate is below 90–110; excessive slowing of beats
may indicate digitalis toxicity
3) CORRECT— withhold med if rate is below 90–110 for child; excessive slowing
of beats may indicate digitalis toxicity
4) unnecessary; should not give medication
The clinic nurse examines the fingernails of a new patient who presents with
pallor and complaints of fatigue, weakness, and dyspnea on exertion. Which of
the following findings MOST concerns the nurse?

1. There are multiple small pits in the nail plate.
2. There are 1-mm-wide horizontal depressions in the nail plates.
3. The nail plate is concave, curving up from the nailbed and

appearing spoon-shaped.
4. The angle between the nail plate and the proximal nail fold is
straightened to 180 degrees.


(1.) seen in psoriasis
(2.) not of most concern; these are Beau’s lines; might occur singly or in
multiples; reflect temporary disturbance of nail growth related to acute severe
illness, such as infection, to isolated periods of severe malnutrition, or to direct
nail root injury
(3.) not of most concern; spoon nails are usually indicative of iron deficiency
anemia; can also indicate use of strong detergents or other chemicals; formal
name for these nails is koilonychias
(4.) CORRECT—indicates early clubbing, a sign of hypoxia; with early clubbing,
the nail base is also spongy upon palpation; there is normally a 160-degree
angle between nail plate and proximal nail fold, and nail shape is normally
convex; straightening or flattening beyond 180 degrees indicates late clubbing
The home care nurse performs an initial visit to the home of a client diagnosed
with a myocardial infarction. The client’s nose is bleeding, and he reports that he
is unable to stop the bleeding. It is MOST important for the nurse to ask which of
the following questions?

1. “Are you allergic to any medication?”
2. “Are you taking any anticoagulant medication?”

3. “Do you regularly use nasal sprays for
congestion?”
4. “Are you taking ibuprofen or aspirin?”

question.
1) important to obtain during history but is not relevant to the nose bleed
2) CORRECT— side effect of anticoagulants is bleeding; client may be taking
anticoagulant due to heart disease; instruct client to pinch nose closed for 5-10
min with an ice-cold washcloth
3) vasoconstriction related to nasal sprays can result in thinning of mucus
membranes and cause nosebleeds; more important to find out if client on
anticoagulants
4) may cause gastric distress
The psychiatric nurse on the inpatient unit identifies which of the following
patient situations as MOST requiring the nurse’s immediate attention?

1. A patient taking clozapine (Clozaril) for 2 months comes to the
nursing station and complains of feeling hot and having a sore
throat.
2. A patient taking diazepam (Valium) PRN for anxiety asks for the
medication on an increasingly regular basis.
3. A patient taking lithium carbonate (Eskalith) for 10 days is
observed to be thirsty and has fine hand tremors, mild nausea,
and frequent urination.
4. A patient taking haloperidol (Haldol) for 4 days has a
temperature of 102°F (38.9°C).


(1.) is of very definite concern, but not first; may indicate flu, but may also
indicate the very serious adverse effect of this drug, which is agranulocytosis
(2.) may indicate that the Valium and/or other medications being taken for
anxiety are not being effective; may also indicate beginning dependence on the
drug, which is a benzodiazepine
(3.) fine hand tremors, polyuria, and polydipsia are expected minor side effects
from therapeutic levels of lithium; therapeutic levels are usually reached in 7 to
14 days
(4.) CORRECT—may indicate impending neuroleptic malignant syndrome (NMS);
NMS is a potentially lethal side effect of antipsychotic medications, especially
high-potency drugs such as Haldol; medical emergency
The nurse cares for a client receiving a continuous infusion of heparin. The
client’s aPTT is greater than 150 seconds. Which of the following actions by the

1. Stop the heparin and administer protamine
sulfate.
2. Stop the heparin and notify the physician.
3. Maintain the heparin at the current infusion

rate.
4. Increase the infusion rate and notify the
physician.

Strategy: All answer choices are implementations. Determine the outcome of

each. Is it desired?
1) may occur, but the nurse cannot administer protamine sulfate without
consulting with the physician
2) CORRECT— heparin is an anticoagulant; normal aPTT is 20 to 45 seconds;
therapeutic level is 1.5 to 2.5 times control; maximum aPTT is 112 seconds
3) at risk for bleeding
4) at risk for bleeding; should notify the physician
The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4
days. The antibiotic is mixed in D 5 W. The nurse determines that a post-infusion
phlebitis has occurred if which of the following is observed?

1. Tenderness at the IV site.
2. Increased swelling at the insertion site.
3. Area around the IV site is reddened with red

streaks.
4. Fluid is leaking around the IV catheter.

1) tenderness occurs with phlebitis but is not specific to it
2) may indicate either infiltration or phlebitis
3) CORRECT— reddened, warm area noted around insertion site or on path of
vein; discontinue IV, apply warm, moist compresses, restart IV at new site
4) not indicative of phlebitis

The nurse obtains a history from a client scheduled to undergo
electroconvulsive therapy. It is MOST important for the nurse to report which of
the following findings to the physician?

1. The client takes alendronate (Fosamax) once a day.
2. The client complains of lethargy and fatigue.
3. The client has received electroconvulsive therapy in the

past.
4. The client walks for 30 minutes three times per week.
Strategy: “report finding to physician” indicates a contraindication to the

procedure.
1) CORRECT— Fosamax is used to treat osteoporosis, which places the client at
risk for ECT; should be reported to the physician
2) symptoms of depression; ECT used to treat depression
3) not a contraindication
4) appropriate to prevent osteoporosis
The nurse performs an initial assessment on a middle-aged male. It is MOST

important for the nurse to follow up on which of the following client statements?

1. "My brother was just diagnosed with prostate cancer."
2. "I take enalapril maleate (Vasotec) 5 mg po daily."
3. "I had a lumbar laminectomy 2 years ago but still have some low
back pain."
4. "Lately, I just don’t have as much desire to engage in sex."

question.
(1.) CORRECT—middle-aged male is at risk for prostate cancer; having a father
or brother with this cancer increases the client’s risk by 50%
(2.) used to treat mild hypertension, no problem indicated
(3.) may be experiencing chronic pain; usually not life-threatening, requires
further assessment
(4.) requires further assessment of underlying cause; may be physical or
psychosocial
The nurse answers a call light for a patient complaining of pain at the IV site. The
nurse observes that the IV insertion site is pale, cool to the touch, and mildly
swollen. Which of the following interventions is the nurse MOST likely to
perform?

1. Slow the infusion rate and monitor the patient’s
response.
3. Remove the IV and apply a pressure dressing.
4. Remove the IV and place the patient’s arm on a pillow.

1) symptoms likely caused by infiltration of the IV and will progress if the
infusion is continued
2) should stop the infusion and elevate the extremity
3) appropriate to remove the IV, should also elevate the extremity to increase
reabsorption of the fluid
4) CORRECT— IV likely infiltrated and should be discontinued and restarted at a
new site; elevating the extremity may increase the rate of reabsorption of the
fluid
Which of the following statements if made by the client BEST indicates to the
nurse the client understands teaching to prevent hypokalemia?

1. “I should take the potassium supplements on an empty
stomach.”
2. “I should crush the potassium tablets if I can’t swallow them.”
3. “I should eat more bananas as well as take the potassium

supplement.”
4. “I should avoid salt substitutes while taking the potassium
supplement.”


1) potassium supplements should be taken with meals
2) do not crush, may affect the potency or action of the drug
3) bananas are a good source of potassium; increasing natural potassium intake
while on a potassium supplement may result in hyperkalemia
4) CORRECT— many salt substitutes are potassium-based, which combined
with the prescribed potassium supplement may result in hyperkalemia
Which of the following statements if made by the client BEST indicates to the
nurse the client understands teaching to prevent hypokalemia?

1. “I should take the potassium supplements on an empty
stomach.”
2. “I should crush the potassium tablets if I can’t swallow them.”
3. “I should eat more bananas as well as take the potassium

supplement.”
4. “I should avoid salt substitutes while taking the potassium
supplement.”


1) potassium supplements should be taken with meals
2) do not crush, may affect the potency or action of the drug
3) bananas are a good source of potassium; increasing natural potassium intake
while on a potassium supplement may result in hyperkalemia
4) CORRECT— many salt substitutes are potassium-based, which combined
with the prescribed potassium supplement may result in hyperkalemia
The nurse monitors a client receiving the first of two units of packed red blood
cells. Each unit is to be administered over 4 hours. The client complains of a
headache and lower backache approximately 2 hours into transfusion of the first
unit. Which of the following interventions should the nurse perform FIRST?

1. Assess the patient’s vital signs and respiratory status.
2. Administer acetaminophen (Tylenol) as ordered and monitor

response.
3. Stop the transfusion.

1) appropriate action; however, must stop the transfusion immediately to
prevent additional administration of this blood product that may worsen reaction
2) continuing transfusion may result in death
3) CORRECT— symptoms indicate a possible hemolytic reaction, continuing the
transfusion may result in death
4) appropriate action; however, must first stop transfusion to prevent further
administration of this blood product that may worsen reaction
The nurse responds to a call light and finds the patient’s IV tubing disconnected
from the patient’s central line. The patient is restless and complains of difficulty
breathing. After the nurse locks the open catheter, which of the following series
of interventions is the nurse MOST likely to perform FIRST?

1. Place the patient in a flat supine position, initiate oxygen
therapy, and notify the physician.
2. Place the patient in a high Fowler’s position, initiate oxygen
therapy, and notify the physician.
3. Place the patient on the left side in Trendelenburg position,
initiate oxygen therapy, and notify the physician.
4. Place the patient on the left side with the lower extremities
elevated, initiate oxygen therapy, and notify the physician.


1) signs and symptoms likely caused by an air embolism; placing the patient in
this position increases the risk for the embolism moving to the heart or brain
2) position increases the risk for the embolism moving to the brain
3) CORRECT— placing the patient in this position increases the likelihood that
the air will pass into the right atrium and be dispersed by way of the pulmonary
artery
4) placing the patient in this position increases the risk for the embolism moving
to the heart or brain
The nurse works in the cardiac clinic of a major medical center teaching
hospital. The patients are African American, and the medical house staff is of
various ethnicities. The nurse should question a written order for which of the

1. Hydralazine hydrochloride
(Apresoline).
2. Atenolol (Tenormin).
3. Chlorothiazide (Diuril).
4. Nifedipine (Procardia).
Strategy: "Should question a written order" indicates that something is wrong.

(1.) no need to question this order; direct vasodilator; relaxes smooth muscles,
especially on arteries and arterioles and decreases peripheral resistance and
lowers blood pressure
(2.) CORRECT—beta blocker; beta-adrenergic inhibitor that slows heart rate and
decreases cardiac contractility and cardiac output, thereby lowering blood
pressure; beta blockers are less effective in African Americans than they are in
Caucasians; the same is true for angiotensin-converting enzyme (ACE)
inhibitors, such as captopril (Capoten)
(3.) thiazide diuretic; promotes water and sodium excretion, thereby lowering
blood pressure; there is no need to question this order; diuretics are especially
effective with African Americans, especially if only one drug is used (single
agent)
(4.) no need to question this order; calcium channel blocker; stops calcium
movement into cells, thereby relaxing smooth muscle and causing vasodilation;
calcium channel blockers are found to be particularly effective in older patients
and in African Americans
The triage nurse prioritizes patients to be evaluated in the emergency

department (ED). Which of the following patients should the nurse see FIRST?

1. A 3-year-old complaining of an earache.
2. A 5-year-old complaining of leg pain after falling off a bicycle.

vaginal spotting.
4. A 50-year-old who is complaining of nausea and is diaphoretic.

(1.) monitor patient until patient can be evaluated by physician
(2.) assess the neurovascular status of the affected extremity, then ice, splint,
and elevate it until evaluation by physician
(3.) ask patient to rest and offer her reassurance until evaluated by physician;
can be related to engaging in intercourse, drop in progesterone level, potential
spontaneous abortion
(4.) CORRECT—even though not complaining of chest pain, should be treated as
a potential MI; a cardiac workup should be performed immediately

The nurse cares for a client receiving 40 drops per minute of D 5 W. The IV set
delivers 10 drops per ml. If the nurse begins infusing 1,000 ml of D 5 W at 12
noon, how many milliliters of D 5 W will be remaining at 3:30 PM? Type the
correct answer into the blank.

Your Response: 476
Correct 160
Response:

Strategy: Do the math.
Correct answer: 160
3.5 hr × 60 min/hr = 210 min

210 min × 4 ml/min = 840 ml
1,000 ml – 840 ml = 160 ml left at 3:30 PM
A patient comes to the medical clinic for re-evaluation of primary lymphedema,
the praecox type, affecting the left leg and ankle. Which of the following
statements by the patient MOST concerns the clinic nurse doing the initial
assessment?

1. "I could hardly get my shoes on this morning."
2. "My leg hurts, and it’s red and warm to the

touch."
3. "Sometimes my legs feel numb and tingly."
4. "Sometimes I wish that my leg could just be cut

off."

Strategy: "MOST concerns the clinic nurse" indicates a complication.

(1.) may indicate a worsening of the lymphedema; the foot itself is not usually
affected by the lymphedema, although the leg and ankle are
(2.) CORRECT—redness, warmth, and pain of the affected leg can indicate
infection, a condition for which patients with lymphedema are at high risk
(3.) concern but not priority; potential problem that may indicate neurologic
and/or vascular compromise; may be related or unrelated to the lymphedema
(4.) psychosocial; physical takes priority; may indicates anger, depression
related to disease condition

The nurse on the psychiatric unit is caring for a patient who is taking
fluvoxamine (Luvox) 100 mg PO at HS. Stat A.M. laboratory results reveal Na+
124 mEq, K+ 4.6 mEq, Cl– 96 mEq, and serum osmolality 275 mOsm. Which of

4. Ask the patient about side effects experienced during the

night.


(1.) must assess for suicide before implementing precautions; fluvoxamine
(Luvox) for OCD, side effect of dry mouth; although patient may be at risk for
self-harm, no evidence that patient is intentionally harming self
(2.) patient has hypo-osmolar imbalance; hypotonic fluids will worsen medical
condition
(3.) CORRECT—lab results suggest dilutional hyponatremia from obsessive-
compulsive water intake (aka psychogenic polydipsia); at high risk for
convulsions and cerebral edema; also needs monitoring to prevent further water
intake

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The nurse cares for a client diagnosed with Clostridium difficile . The nurse
should follow which of the following transmission-based precautions?

1. Standard
precautions.
2. Airborne
precautions.
4. Contact
precautions.


4) CORRECT— causes pseudomembranous colitis; contact precautions required
for all client care activities that require physical skin-to-skin contact or those
that require contact with contaminated inanimate objects
The fire alarm sounds in the general hospital that houses a locked acute
inpatient psychiatric unit on the eighth floor. The alarm code indicates that the
fire is in the third-floor medical unit. Which of the following actions should the
eighth-floor nurse take FIRST?

1. Ensure that all patients are out of their rooms and in the
dayroom.
2. Assign a staff member to each of the unit’s locked doors.
3. Explore with patients their past experiences with fire and their
current concerns.
4. Prepare for evacuation of the unit using the stairs.

(1.) CORRECT—priority is direct patient care (think RACE, even though fire is
not on this unit); psychiatric patients are usually mobile versus confined to bed,
and the unit usually has a central gathering area; staff should be assigned to
check all rooms and direct patients to leave their rooms and go to the dayroom
(2.) priority is locating and centralizing patients; locked doors do need to be
staffed, particularly since fire alarms in a large institution often automatically
unlock all locked doors in the building
(3.) priority is safety of patients
(4.) not first; if evacuation is necessary, use of stairs (versus elevators) is the
correct method
The nurse cares for a client after abdominal surgery, and the client complains of
gas pains. Which of the following suggestions by the nurse is BEST?

vegetables.


2) CORRECT— increases the return of peristalsis and facilitates the expulsion of
flatus
The nurse assesses a client diagnosed with M é ni è re’s disease. The client
reports that even though he takes the prescribed medications regularly, he
continues to have episodes of vertigo. It is MOST important for the nurse to ask
which of the following questions?

1. “Tell me about your diet.”
2. “How are things going at work?”
3. “When was M é ni è re’s disease

diagnosed?”
4. “What were the results of your last blood
test?”


the question.
1) CORRECT— symptoms are usually controlled by adhering to a low-sodium
diet (2000 mg/day); nurse should assess if client following diet
2) a psychological evaluation may be warranted if client anxious, fearful, or
depressed; more important for nurse to determine if client adhering to medical
regimen
3) priority is to determine if client is following the low-sodium diet
4) M é ni è re diagnosed through history and evaluation of cranial nerve VIII
A patient is brought to the emergency department by EMS with a blood glucose
level of 32 mg/dL. The patient received 25 cc of 50% dextrose in water before
arrival. While assessing the patient, the nurse instructs the patient care tech to
do which of the following?

1. Recheck the patient’s blood
glucose.
2. Obtain orange juice for the
patient.
3. Pad the side rails of the
stretcher.
4. Obtain an EKG on the patient.

1) although this is an appropriate action, the patient is at increased risk for
seizures as a result of hypoglycemia; seizure precautions should be initiated
2) blood sugar will not be helped immediately with orange juice; patient is likely
to have an altered mental status at this critically low level and should remain
NPO until mental status resumes baseline or until ordered by the physician
3) CORRECT— patient is at risk for seizures, precautions should be initiated
4) should take seizure precautions
The nurse makes a prenatal visit to the home of a woman who is pregnant with
her first child. It is MOST important for the nurse to intervene if which of the


kitchen sink.

(1.) CORRECT—cat presents a toxoplasmosis risk to the pregnant woman and
her unborn/newborn infant; toxoplasmosis is a parasitic disease transmitted in
the feces of cats who have eaten infected mice and animals; preventive
measures include handwashing after touching cats, have the litter box changed
daily (it takes about 48 degrees for the cat’s feces to become infectious) by
someone other than the pregnant woman, prevent cats from eating raw meat or
wild animals, wear gloves when gardening, do not garden in areas frequented by
cats, avoid undercooked meat and contact with stray animals
(2.) will be an issue for future teaching prior to yet-unborn infant becoming a
toddler
The nurse makes a prenatal visit to the home of a woman who is pregnant with
her first child. It is MOST important for the nurse to intervene if which of the


kitchen sink.

(1.) CORRECT—cat presents a toxoplasmosis risk to the pregnant woman and
her unborn/newborn infant; toxoplasmosis is a parasitic disease transmitted in
the feces of cats who have eaten infected mice and animals; preventive
measures include handwashing after touching cats, have the litter box changed
daily (it takes about 48 degrees for the cat’s feces to become infectious) by
someone other than the pregnant woman, prevent cats from eating raw meat or
wild animals, wear gloves when gardening, do not garden in areas frequented by
cats, avoid undercooked meat and contact with stray animals
(2.) will be an issue for future teaching prior to yet-unborn infant becoming a
toddler

The nurse cares for clients on the cardiovascular unit. As the nurse is
administering medications to the clients, a nursing assistant approaches the
nurse to report that a client has a large amount of thick, dry mucus on one side
of the tracheostomy tube. Which of the following responses by the nurse to the
nursing assistant is MOST appropriate?

1. “Please take this tray of medications into the medication room
for me.”
2. “Is the client having difficulty breathing?”
3. “Take a sterile cotton swab and remove the mucus using sterile
technique.”
4. “Please find another nurse to take care of the client.”

1) passing medication is the nurse’s responsibility; nurse is responsible for
managing tray of medications
2) CORRECT— nursing assistant can observe whether or not client is in
distress; many cardiovascular drugs require administration in a timely manner;
assess before implementing
3) sterile procedures not within the scope of practice for a nursing assistant; risk
pushing the mucus into the airway
4) inappropriate delegation
A patient and spouse are visiting the outpatient neurology clinic for the first
time. The patient denies any seizure activity, but the spouse states that the
patient has "fits." As part of the workup for evaluation of seizure activity, an
electroencephalogram (EEG) is ordered for the next day. Which of the following
statements is MOST important for the nurse to include when preparing the
patient for the test?

1. "Set your alarm for 2 A.M. and force yourself to stay awake for
the rest of the night."
2. "You will need to wash your hair after the test, so do not bother
washing it beforehand."
3. "Be careful not to eat or drink anything for at least 6 hours
before the test."
4. "There will be harmless pricking sensations during the test as
the electricity enters your brain."

the question.
(1.) CORRECT—patient usually needs to be sleep-deprived (from 2 or 3 A.M.
onward) in order for one part of the test to be most effectively carried out; it is
during sleep that some abnormalities are most evident
(2.) hair is washed after the test, usually with acetone and shampoo, in order to
remove the electrode gel and glue or paste from the scalp and hair; however,
hair should also be shampooed clean before the test, with no spray, oils, or
hairpins used, to ensure that EEG patches or electrodes remain firmly in place
during the test
(3.) because hypoglycemia affects brain activity, food and fluids can be
consumed beforehand; caffeine-containing fluids such as tea or coffee should
be avoided for 24 to 48 hours before the test
(4.) no pricking sensations, and the electricity does not enter the brain or give a
shock
During a flood, two ambulances arrive at an emergency substation at the same
time. One contains a 2-year-old near drowning victim on a ventilator. The other
contains an 80-year-old client with a left-sided CVA who is conscious and has a
blood pressure of 220/130. Which patient should the nurse see INITIALLY?

1. The 2-year-old because she is on a ventilator.
2. The 80-year-old because he is hypertensive.
3. The 2-year-old because she is a victim of the

flooding.
4. The 80-year-old because he is older.

1) even though patient is on a ventilator, there is no indication that she is
unstable
2) CORRECT— blood pressure is an obvious threat to health status and is an
emergent problem
3) no indication that patient is unstable; cause of condition is not a
consideration
4) age is not a consideration to determine instability
The nurse cares for a client diagnosed with tuberculosis. The nurse should
follow which of the following transmission-based precautions?

1. Standard
precautions.
2. Airborne
precautions.
4. Contact
precautions.


4) contact precautions required for all client care activities that require physical
skin-to-skin contact or those that require contact with contaminated inanimate
objects in the client’s environment
The nurse counsels a client diagnosed with a seizure disorder. The client has
just won a national beauty pageant and will be frequently traveling during the
next year. It is MOST important for the nurse to include which of the following
instructions?

problems.”

question.
2) CORRECT— take medication as prescribed to keep drug levels constant to
prevent seizures; should carry medication because luggage can get lost
The nurse in the pediatric clinic receives a phone call from a mother who says,
“My 10-year-old has a nosebleed that won’t stop bleeding even though I have
applied pressure.” Which of the following responses by the nurse is MOST
important?

1. “Place pressure on the nose using an ice-cold
washcloth.”
2. “How much bleeding has occurred?”
3. “Instruct your child not to blow his nose.”
4. “How long have you applied pressure?”

1) appropriate action; nurse needs to first complete assessment
2) difficult for lay person to estimate
3) appropriate action; first complete assessment
4) CORRECT— assess before implementing; initially, should apply direct
pressure for 5–10 minutes continuously; if this is ineffective, may require
treatment with silver nitrate applicator and Gelfoam
As the health care provider removes the peripherally inserted central catheter
(PICC) from a patient, a portion of the catheter breaks. Which of the following

1. Check the patient’s radial pulse.
2. Turn the patient to the right side.
3. Apply a tourniquet to the upper right arm.
4. Instruct the unit secretary to call for a STAT

x-ray.

1) second action; if tourniquet is too tight, a radial pulse will not be detected
2) do not move client to prevent movement of broken catheter piece
3) CORRECT— place close to axilla; prevents catheter piece from advancing into
right atrium; after tourniquet is applied, check for presence of radial pulse; keep
in place until x-ray obtained and surgical retrieval attempted
4) will x-ray; priority is to prevent catheter from advancing
The nurse cares for a client after abdominal surgery, and the client complains of
gas pains. Which of the following suggestions by the nurse is BEST?

vegetables.

2) CORRECT— increases the return of peristalsis and facilitates the expulsion of
flatus
The nurse receives report on a patient admitted to the unit with a new diagnosis
of abdominal aortic aneurysm (AAA). When teaching the patient measures to
reduce the risk of complications associated with AAA, the nurse should include

1. Elevate the lower extremities above the level of the
heart.
2. Encourage the patient to increase fluid intake and
dietary fiber.
3. Teach the patient to utilize proper lifting techniques.
4. Advise the patient not to wear a seatbelt while driving.

(1.) contraindicated; increases pressure in the aortic artery, which may increase
the risk of rupture
(2.) CORRECT—prevents constipation and the need for straining with bowel
movements that may cause increased intra-abdominal pressure and risk of
rupture
(3.) instruct to not lift heavy objects which may increase intra-abdominal
pressure and lead to rupture of the aneurysm
(4.) never instruct a patient not to wear a seatbelt; increases likelihood of a
fatality should the patient be involved in a motor vehicle collision
A staff nurse reviews the chart of a patient who is 24 hours post surgery. Which
of the following assessments if documented in the patient’s record requires an
immediate intervention by the nurse?

1. The patient has requested pain medicine every 6 hours since
returning from surgery.
2. The patient’s urine output is 240 mL during the previous 12-hour
shift.
3. The patient ambulates frequently in the hall.
4. The patient has not had a bowel movement since surgery.
Strategy: “Requires an immediate intervention” indicates a complication.

1) pain medicine often is given every 4 to 6 hours after surgery; not uncommon
for the patient to be requesting pain medicine every 6 hours 24 hours after
surgery
2) CORRECT— urine output of less than 30 mL per hour requires further
evaluation
3) early ambulation encouraged in the postsurgical patient to prevent
complications
4) not uncommon for patient not to have a bowel movement within this time
frame, though this may require further consideration if the patient has not
passed flatulence or if either persists
After the recent delivery of an infant girl, a women’s organization held a baby
shower for the department head. During the opening of the gifts, the department
head began sobbing and informed the group that the baby has polycystic kidney
disease. The department head announces that because she is so afraid that the
baby is going to die, she does not know how she can return to work. While the
rest of the group is setting up the refreshments in the next room, the nurse and
the grieving mother discussed the problem. Which of the following responses by
the nurse is BEST?

1. “Finding out your baby has a serious health problem has to be
very painful.”
2. “How does your husband feel about this problem?”
3. “How is the baby doing now?”
4. “What you need to do is to focus on the present.”

1) CORRECT— acknowledges her pain; gives her an opportunity to talk more
about her feelings privately; polycystic kidney disease is one of the most
common inherited disorders
2) redirecting the conversation does not show sensitivity, is not the best
response; perhaps later in the conversation could discuss available support
systems
3) after addressing her feelings, could lead conversation to present positive
things about the baby’s status
4) nontherapeutic; does not allow the client to verbalize

A woman returns to her room following a myelogram using Pantopaque, an oil-
based dye. It is MOST important for the nurse to take which of the following
actions?

1. Apply ice packs to the puncture
site.
3. Monitor for seizures.

1) no swelling expected; myelogram visualizes spinal column and subarachnoid
space; inspect injection site
2) must remain flat for 12–24 h
3) seen with water-based dye, metrizamide; neurologic assessment q 2–4 h
4) CORRECT— need to replace fluid lost with removal of oil-based dye; offer oral
analgesics for headache
The physician has ordered antibiotic eye drops for a client recovering from
outpatient cataract surgery. Which of the following statements, if made by the
client, indicates to the nurse that further teaching is necessary?

1. “The drops should go into the center of the lower
eyelid.”
2. “I should not let the drops flow from one eye into the
other.”
3. “I should squeeze my eye tightly after I put in the
drop.”
4. “I should tilt my head back to put in the drops.”
Strategy: “Further teaching” indicates an incorrect response.

1) appropriate placement of drops into the lower conjunctival sac; wash hands
before instilling drops; look up, pull lower lid down
2) drops should not be permitted to flow across the nose into the opposite eye;
do not touch dropper to eye
3) CORRECT— should blink between drops but should not squeeze eye tightly
because it would cause the drop to be expelled; press inner angle of eye after
instillation to prevent systemic absorption
4) helps position for proper placement of eye drops
A patient returns to the medical unit after placement of a split-thickness
autograft to a burn on the right arm. The nurse identifies that the highest priority
at this time will need to be given to which of the following interventions?

1. Managing pain at the recipient
site.
2. Immobilizing the graft.
3. Minimizing light exposure.
4. Observing for signs of

rejection.


(1.) not highest priority; donor site is usually more painful than recipient site
because of exposed nerve endings; autograft means a layer of the patient’s own
unburned skin is removed and grafted to the burn wound
(2.) CORRECT—graft adherence to the site is essential for vascularization and
"taking" or survival of the graft; immobilization of the graft is critical; a thin fibrin
network develops quickly after graft placement but it takes 7–10 days for the
graft to really adhere, and longer than that to mature
(3.) no need for minimizing light exposure at this time; patient needs to be taught
that once donor and recipient sites have healed, they should completely avoid
direct sunlight for 1 year because of the skin’s increased sensitivity to ultraviolet
rays
(4.) once pressure dressings are removed (3–5 days), continual assessing of the
graft for healing should be done related to vascularization, such as continued
adherence to the site, absence of necrotic graft tissue, dusky color, or sharp line
of color demarcation
The nurse cares for clients on the medical/surgical unit. A nursing assistant
reports to the nurse that a comatose client receiving oxygen through a
tracheostomy has “lots of water in the tubing.” Which of the following actions

2. Instruct the nursing assistant to empty the fluid from

the tubing.


4) CORRECT— client at risk for aspiration; caring for the tracheostomy is within
the scope of nursing practice
When teaching a client diagnosed with type 1 diabetes about measures to

prevent long-term complications, the nurse should include which of the
following instructions?

1. Wear slippers around the house.
2. Wear shoes made of manmade fibers.
3. Avoid wearing insulated boots in cold

weather.
4. Wear knee-high nylons instead of
pantyhose.


(1.) CORRECT—instruct never to go barefoot; compromise of skin integrity to
the feet may result in wounds that go unnoticed or are slow to heal as a result of
associated neuropathy or peripheral vascular disease
(2.) shoes made with natural fibers allow perspiration to dry, preventing
compromised skin integrity
(3.) decreases the risk of injury from the cold related to neuropathy and
peripheral vascular disease
(4.) patient should avoid wearing nylons altogether because they may
exacerbate circulatory problems
The nurse cares for a toddler diagnosed with pneumonia receiving oxygen in an
oxygen tent. The toddler’s mother reports to the nurse that her toddler’s birthday
is tomorrow and asks if the parents can have a party. It is MOST important for
the nurse to follow up on which of the following statements if made by the
mother?

1. “I plan to bring paper streamers to put on the
wall.”
2. “My child loves to look at Mylar balloons.”
3. “I found the neatest candles to put on the

cake.”
4. “My child’s grandparents are planning to
come.”

Strategy: “MOST important to follow up” indicates a potential complication.

1) no reason to follow up
2) no reason to follow up
3) CORRECT— oxygen is combustible and can cause a fire if it comes in contact
with a spark from an open flame or electrical equipment; inform mother that the
candles cannot be lighted
The nurse counsels a client newly diagnosed with hypertension. Which of the
following statements, if made by the client to the nurse, indicates that teaching
is successful?

1. "If I feel dizzy when I wake up, I will skip my morning blood-
pressure pill."
2. "I will switch from lifting weights at the health club to doing
aerobics."
3. "I will be sure to take chlorothiazide (Diuril) every night before I
go to bed."
4. "I will take hot baths or go to the sauna to relax if I feel tension
coming on."


(1.) medication needs to be taken on a regular basis; instruct to rise slowly from
lying and sitting positions; if severely bothered by dizziness, contact physician
(2.) CORRECT—regular aerobic exercises are usually recommended; isometric
exercises such as heavy weight-lifting and rowing are contraindicated, can
cause a dangerous rise in blood pressure due to a vasovagal response during
intense isometric muscle contraction
(3.) thiazide diuretic; nighttime dosing will interfere with sleep by requiring
frequent urination
(4.) not best; antihypertensives (and diuretics) commonly cause hypotension
and heat can facilitate hypotension
An adult is scheduled for magnetic resonance imaging (MRI) of the upper

abdomen. Which of the following information is MOST important for the nurse to
communicate to the technician prior to the test?

1. Patient has a penicillin allergy.
2. Patient has aortic stenosis.
3. Patient has a history of gastric

ulcers.
4. Patient has a metal hip
prosthesis.


1) not contraindicated for MRI; should receive cephalosporin antibiotics
cautiously
2) not contraindicated; malfunction of aortic valve between left atria and
ventricles results in ventricular hypertrophy, pulmonary congestion, reduced
cardiac output
3) not contraindicated; symptoms: 45 years and older, pain 1 h after meal or
when fasting, pain relived by vomiting, food doesn’t help with pain, hematemesis
4) CORRECT— metal implanted objects contraindication to test; assess the
patient for claustrophobia; remove all metal jewelry and metal objects
The nurse in the outpatient clinic cares for a client who experienced sudden
visual loss in a portion of the visual field. A physician’s examination reveals age-
related macular degeneration (ARMD). It is MOST important for the nurse to
assess which of the following?

1. Allergies to medication and food.
2. Client’s feelings about permanent loss of

vision.
3. History of hypertension.
4. History of smoking.

question.
1) ARMD causes permanent loss of central vision; focus of treatment is
augmenting remaining vision; obtaining information about allergies is not
relevant to ARMD
2) CORRECT— because loss of vision is permanent, it is important for the nurse
to allow the client to verbalize fears about the future and to assist the client to
maximize remaining vision
3) not related to macular degeneration
4) cigarette smokers have significantly higher risk of developing ARMD;
important information to obtain when counseling the public about how to
decrease the risk of developing macular degeneration
The nurse cares for clients in the outpatient clinic. A 45-year-old male client
presents with acute mid-abdominal pain and acute vomiting. It is MOST

1. “How much alcohol do you drink per
day?”
2. “Do you have a family history of
diabetes?”
3. “Do you have a history of peptic ulcer
disease?”
4. “How frequently do you take laxatives?”

1) CORRECT— symptoms indicate acute episode of pancreatitis; pancreatitis
associated with males age 40–45 with a history of heavy drinking or females
ages 50–55 diagnosed with biliary disease
2) priority is asking client about pain and its relationship to either the ingestion
of meals or alcohol
3) not a risk factor
4) pancreatitis causes diarrhea and passage of fatty stools; not relevant
question
The nurse prepares a client for a barium enema. It is MOST important for the

1. “Your stool will be light-colored for 2 to 3 days after the test.”
2. “Once the test is over and you go to the toilet, you will be able to
resume normal activities.”
3. “The x-ray table will be tilted so you can assume various
positions.”
4. “During the test, it is crucial that you take slow, deep breaths
through your mouth.”


1) accurate information but not the most important
2) after the rectal tube is removed and client evacuates the bowels, additional x-
rays are taken; due to the bowel prep and procedure, most clients require a
period of rest after the test
3) accurate information but not the most important; reassure client that he will
be secure on the table during the x-rays
4) CORRECT— for test to be successful, client must retain barium; as barium is
introduced, client may have the urge to defecate; slow, deep breathing will help
ease the discomfort
The nurse cares for a patient just returned from surgery after a right total knee
replacement. It is MOST important for the nurse to take which of the following
actions?

1. Change the surgical dressing immediately.
2. Assist the patient to ambulate in the room.
3. Encourage the patient to use the incentive spirometer three

times per day.
4. Apply a sequential compression device to the patient’s lower
extremities.

(1.) dressing is usually not changed for 24 to 48 hours; if becomes saturated or
loosens during this time, it should simply be reinforced
(2.) placed on bedrest initially and then activity will be increased as ordered by
physician and tolerated by patient
(3.) instruct to use the incentive spirometer every 1 to 2 hours
(4.) CORRECT—improves circulation and prevents clot formation
The nurse cares for a client diagnosed with a draining abdominal abscess. What
is the MOST important information for the nurse to assess?

1. Amount.
2. Character.
3. Consistency.
4. Amount of suction on
system.


1) important to measure amount of drainage
2) CORRECT— assessing whether the drainage is purulent, sanguinous,
serosanguineous, etc.
3) character is most important
4) not relevant to the drainage
The nurse cares for clients on the medical/surgical unit. The nurse instructs a
nursing assistant to put elastic stockings on a client scheduled for surgery. It is
MOST important for the nurse to follow up on which of the following statements
if made by the nursing assistant?

1. “I will apply talcum powder to the client’s feet and legs before
applying the stockings.”
2. “I will elevate the client’s legs before applying the stockings.”
3. “The client has obese thighs.”

4. “I will make sure there are no wrinkles in the stockings.”

question.
1) allows for easier application of the stockings
2) prevents stagnation of blood in the lower extremities
3) CORRECT— may decrease venous return because of constriction around
thighs
4) can cause irritation to the skin
The nurse in the prenatal clinic monitors the condition of a pregnant woman at
30 weeks’ gestation who is diagnosed with gestational diabetes mellitus (GDM).
Which of the following testing results MOST concerns the nurse?

1. Hemoglobin (Hgb) 11.5 mg/dL and hematocrit (Hct)
33%.
2. Glycosylated hemoglobin (HbA1c) 7%.
3. Urine dipstick testing is positive for ketones.
4. One-hour glucose tolerance test (GTT) result is 140

mg/dL.


(1.) probably reflects physiologic anemia of pregnancy, a normal response that
occurs because of plasma volume expansion to a volume 3 times more than the
RBC mass
(2.) glycosylated Hgb reflects blood sugar control over the preceding 120 days;
7% is within normal range
(3.) CORRECT—ketones result from fatty acid metabolism, and usually are
completely metabolized by the liver; ketone bodies in the urine (ketonuria) are a
sign of ketoacidosis which, in pregnancy, is a major factor contributing to
intrauterine death
(4.) result of 140 mg/dL or over is seen as abnormal and requires further
evaluation with a 3-hour GTT
As a nurse prepares to assist a physician with an epidural patch for a client with
a postlumbar puncture headache, the client tells the nurse he is an illegal alien.
Which of the following actions should the nurse perform NEXT?

1. Position the client in a side lying position.
2. Notify immediate supervisor of the client’s citizenship

status.
3. Notify the appropriate federal officials.
4. Place client in upright position.

1) CORRECT— appropriate position for procedure; citizenship status is not the
priority
2) staff nurse does not address citizenship status; current need is proper
position for procedure, along with equipment/supplies
3) agency would need to decide who should make contact; questions of privacy
and confidentiality exist
4) more likely to result in severe headache; headache represents excessive loss
of cerebral spinal fluid, resulting in brain settling while in upright position
A patient is admitted to the medical unit for evaluation of headaches, epigastric

pain that is relieved by food, anorexia, nausea and vomiting, and periods of both
constipation and diarrhea. The physician orders several diagnostic tests. The
nurse knows it is MOST important to schedule which of the following tests
FIRST?

1. Upper GI series.
2. Small bowel
series.
3. Lower GI series.
4. Lumbar puncture.

(1.) upper GI series includes esophagus, stomach, duodenum, and upper portion
of jejunum; patient swallows barium sulfate
(2.) usually, is done in conjunction with upper GI series; sometimes is even
referred to as small bowel follow-through (SBFT); encompasses duodenojejunal
junction to ileocecal valve; patient swallows barium sulfate
(3.) CORRECT—often referred to as a barium enema examination, it is a
radiographic visualization of the large intestine; encompasses rectum, sigmoid,
descending, transverse, and ascending colon, going to the ileocecal valve;
barium is administered through a rectal catheter which has an inflatable balloon;
when both upper and lower GI series are ordered, the lower GI series should be
done first; this is in order to avoid the barium from the upper GI exam traveling
down the GI tract and interfering with the results of the lower GI series;
signs/symptoms consistent with irritable bowel syndrome
(4.) no clear indications that this test is needed
The nurse instructs a client diagnosed with type 2 diabetes about disease
management during an illness. The nurse determines that further teaching is
necessary if the client states which of the following?

1. "I will monitor my blood glucose levels more frequently."
2. "I should contact the physician if I cannot eat for more than 24
hours."
3. "I should stop taking insulin during the time I am sick."
4. "I should notify the physician if I have vomiting and diarrhea for
more than 24 hours."


(1.) appropriate action; changes in dietary intake and metabolic processes
during an illness may result in significant fluctuations in blood glucose levels
(2.) appropriate action; important to maintain adequate nutritional intake and
prevent dehydration
(3.) CORRECT—should take usual dose and substitute easily digested foods and
fluids to provide adequate nutrition and prevent dehydration
(4.) encourage patient to notify physician of persistent vomiting and diarrhea
because intervention may be required to prevent dehydration
The nurse determines that a client’s tracheostomy requires suctioning. Which of

1. Elevate the head of the client’s bed to
90°.
2. Quickly insert the suction catheter.
3. Preoxygenate the client.
4. Put on clean gloves.

1) not necessary to elevate the client’s head
2) must set up sterile field and preoxygenate the client before inserting the
suction catheter
3) CORRECT— prevents hypoxia associated with tracheal suctioning
4) wear sterile gloves
The nurse prepares a client for discharge following repair of a detached retina.
Which of the following statements, if made by the client, indicates to the nurse
that discharge teaching is effective?

1. “I should avoid jarring movements of my
head.”
2. “I should sleep with my head and shoulders
elevated.”
3. “I can resume my usual activities immediately.”
4. “I should stay in well-lighted areas.”

1) CORRECT— implementation; increases intraocular pressure; causes retina to
re-detach; first week avoid rapid eye movements: reading, writing, closer work
such as sewing; avoid stooping or straining at stool; use proper body
mechanics
2) implementation; if gas or oil used to reattach retina, sleep on abdomen with
affected eye down for several days
3) implementation; resume light work after 3 weeks, normal activities after 6
weeks; no hair washing for 1 week; avoid strenuous activity for 3 months; avoid
sneezing, coughing, or straining at stool, bending down
4) implementation; general statement not specific for patients after surgery for
detached retina
The nurse counsels a client diagnosed with a seizure disorder. The client has
just won a national beauty pageant and will be frequently traveling during the
next year. It is MOST important for the nurse to include which of the following
instructions?

problems.”

question.
2) CORRECT— take medication as prescribed to keep drug levels constant to
prevent seizures; should carry medication because luggage can get lost
The nurse examines the abdomen of a client complaining of acute abdominal

pain with nausea and vomiting. The nurse auscultates the abdomen and hears
40 sounds in one minute. The nurse should chart which of the following?

1. “Absent bowel sounds on auscultation.”
2. “Hypoactive bowel sounds heard on

auscultation.”
3. “Normal bowel sounds heard on
auscultation.”
4. “Hyperactive bowel sounds heard on
auscultation.”

1) no sounds heard in 3 to 5 minutes; indicates late intestinal obstruction
2) one or two sounds heard in two minutes; indicates decreased motility of
bowel
3) 5 to 30 sounds per minute
4) CORRECT— greater than 30 sounds per minute; indicates increased motility
due to gastroenteritis, diarrhea, and laxative use
The nurse prepares to assist a physician with a patient requiring a paracentesis.

It is MOST important for the nurse to place which of the following at the patient’s
bedside?

1. A tape measure.
2. An emesis basin.
3. A blood pressure
cuff.
4. A scale.
Strategy: "MOST important" indicates priority.

(1.) measure abdominal girth before and after procedure; not most important
(2.) not needed
(3.) CORRECT—place on patient’s arm prior to procedure and leave in place
through immediate postprocedure time; shock may occur because of removal of
fluid
(4.) patient weighed before and after procedure; blood pressure cuff is priority
After insertion of a central venous catheter (CVC), a patient suddenly starts
coughing. The nurse notes that the client is pale and dyspneic, and has
tachycardia. Which of the following actions should the nurse take FIRST?

1. Turn the patient to the left side and lower the head of
the bed.
4. Instruct the patient to do the Valsalva maneuver.

Strategy: FIRST indicates priority.

1) CORRECT—symptoms consistent with air embolism; position allows air to
enter the right atrium and pulmonary artery; keep in this position for 20–30
minutes
2) notify physician after repositioning patient and administering oxygen
3) turn patient to left side before administering oxygen
4) incorrect action; prevents air embolism but does not treat it; used during
insertion and removal of catheter and during tubing changes
The nurse instructs a client about how to collect a 24-hour urine specimen. The
nurse determines that teaching is effective if the client makes which of the
following statements?

1. “I should discard my first morning specimen, collect all urine for
24 hours, and place the urine in one container.”
2. “I should begin the collection at 8 am, collect all urine voided
between 8 am and 8 pm, and place the urine in one container.”
3. “I should not mix the urine I collect within the 24 hours.”
4. “I will call the nurse to notify the lab about when to begin the
test.”


1) CORRECT— discarding first morning specimen removes residual urine from
the bladder
2) collect urine for 24 hours
3) all urine should be placed in one container
4) should discard urine, note time, and collect all urine specimens during next 24
hours
The nurse instructs a patient about how to use an incentive spirometer. The
nurse should include which of the following instructions?

1. “Hold the spirometer at a 45° angle while breathing in.”
2. “Exhale into the spirometer for 3 seconds.”
3. “Inhale through the mouthpiece and hold breath for 3

seconds.”
4. “Hold the spirometer straight to allow aerosol to enter
lungs.”


1) spirometer is held upright at eye level so patient can observe the ball purpose
is to promote complete lung expansion and prevent respiratory complications in
the post-op patient
2) should inhale and hold breath for 3 seconds
3) CORRECT — allows sustained maximal inspriation to prevent atelectasis;
patient is able to see efforts registered on spirometer
4) when awake; encourage patient to cough after using spirometer
A patient returns to his room following a pyelolithotomy through a flank incision.

The nurse expects to hear which of the following?

1. Breath sounds that are clear on the nonoperative side,
diminished on the operative side.
2. Breath sounds that are diminished on the nonoperative side,
clear on the operative side.
3. Breath sounds that are diminished on both sides.
4. Breath sounds that are clear on both sides.
Strategy: Read answer choices to determine the topic of the question.

1) not expected outcome; normal breathing sounds include vesicular: soft and
low-pitched breezy sounds heard over most of peripheral lung fields;
bronchovesicular: harsh sounds heard over the mainstem bronchi; bronchial:
loud, coarse, blowing sound heard over the trachea
2) not expected outcome
3) not expected outcome; adventitious (abnormal); caused by fluid or
inflammation and include: rales — crackling or gurgling sounds (also known as
crackles) commonly heard on inspiration; rhonchi — musical sounds or
vibrations commonly heard on expiration; wheezes — squeaky sounds heard
during inspiration and expiration; pleural friction rub — grating sound or
vibration heard during inspiration ad expiration
4) CORRECT— need to be able to recognize “normal” ; postop care: narcotics
for pain, splint incision when turn, cough and deep breathe; force fluids 3,000 to
4,000 day, frequent dressing changes, protect skin from urinary drainage
Plasmapheresis is scheduled for a patient diagnosed with Guillain-Barré
syndrome. In planning for the procedure, the nurse knows it is MOST important
to have which of the following items readily available?

1. Warm blankets.
2. Emesis basin.
3. Oxygen administration
set.
4. Crutchfield tongs.

(1.) CORRECT—warm blankets can prevent or manage chills and hypothermia
that may occur during plasmapheresis; plasmapheresis is similar to
hemodialysis; done to remove antibodies that may be causing the symptoms
(2.) useful, but not most important; patient may develop temporary nausea and
vomiting related to the citrated plasma being administered
(3.) respiratory complications are not expected with plasmapheresis and
Guillain-Barré
(4.) Crutchfield tongs used in skeletal traction for cervical spine injury; not
related to plasmapheresis
The nurse performs a wet-to-dry dressing. Place the following steps of the
procedure in the correct order from FIRST step to LAST. All options must be
used.
Strategy:
(1) Assess the client's comfort level: may require pain medication because
removing dressing may be painful
(2) Remove gauze dressings: wear clean disposable gloves; be careful to not
remove drains or tubes; do not moisten dressing if it sticks to wound
(3) Observe the appearance of the wound: inspect wound for color, character of
drainage, and presence of drains
(4) Clean the wound with saline solution: clean from least contaminated to most
contaminated area of the wound to decrease potential for infection
(5) Apply moist gauze in a single layer to the wound: absorbs drainage and
adheres to wound; cover moist dressing with dry sterile dressing
(6) On the tape, record date and time dressing applied: use ink-pen, not a marker
The clinic nurse evaluates a client diagnosed with type 1 diabetes. Which of the
following observations indicates to the nurse that the client is not rotating
insulin injection sites?

1. A wheal develops at the site of the injection.
2. There is increased discomfort at the site of the injection.
3. Glucose levels rise temporarily.
4. There is skin breakdown and ulceration at the site of the

injection.

Strategy: Determine the significance of each answer choice and how it relates to
insulin administration.
1) represents an allergic reaction to insulin
2) repeated injections into same site become less painful rather than more
uncomfortable
3) CORRECT— failure to rotate sites results in poor absorption of insulin, which
increases blood sugar
4) is not a complication of repeated insulin injections in same site
The nurse assesses a client before an intravenous pyelogram. It is MOST


1. “I really cleaned out my bowels last night.”
2. “My face flushes when I eat shrimp.”
3. “I missed my morning cup of coffee.”
4. “They are going to be taking x-rays at multiple

intervals.”

1) procedure requires a bowel prep
2) CORRECT— if sensitive to iodine, patient may develop anaphylaxis; assess
for allergy to shellfish, iodine, chocolate, eggs, milk
3) NPO after midnight
4) X-rays taken at intervals after dye is injected
The nurse cares for a client after a thoracentesis. The nurse should observe the
patient for which of the following symptoms?

1. Severe headache, diaphoresis, nasal congestion, distended
bladder.
2. Shortness of breath (SOB), faintness, chest pain, bloody
sputum.
3. Abdominal pain, rigidity and distention, nausea and vomiting.
4. Muscle spasms, tingling sensations in fingertips and around

mouth, confusion.

Strategy: Determine how each answer relates to thoracentesis.

(1.) related to autonomic hyperreflexia/autonomic dysreflexia, complication of
spinal cord injury
(2.) CORRECT—pulmonary edema, hypoxia, hemothorax, pneumothorax,
subcutaneous emphysema, spleen and liver puncture are all potential
complications of a thoracentesis; report immediately to the physician
(3.) indicate peritonitis, complication of paracentesis
(4.) these symptoms are related to tetany (hypocalcemia)
The nurse cares for a client requiring fluorescein angiography. The nurse
determines that further teaching is required if the client states which of the
following?

1. “I’ll have to wear dark glasses for a while.”
2. “I may notice yellow staining of my skin, but it will

disappear.”
3. “I will have to drink more fluids immediately after the
test.”
4. “The test determines the amount of pressure within my
eyes.”

Strategy: “Further teaching is required” indicates incorrect information.

1) fluorescein is a dye administered IV; fluorescein angiography is a series of
photographs that detail the eye’s circulation; the eyes are dilated with mydriatic
eyedrops before the exam; after exam, client should avoid direct sunlight until
eyes have returned to normal
2) appropriate statement; fluorescein is administered IV; the dye causes
temporary staining of the skin
3) appropriate statement; helps eliminate the dye
4) CORRECT— tonometry measures pressure in eye; fluorescein angiography
measures circulation in the retina
The nurse cares for a client immediately after a cardiac catheterization. It is


1. Place a warm pack on the affected foot.
2. Obtain vital signs every 2 hours.
3. Compare the quality of pulses on both legs.
4. Determine the presence of the radial pulse

bilaterally.


1) no reason to apply warm pack; keep leg straight and assess for bleeding
2) obtain vital signs every 15 minutes for 2 hours
3) CORRECT— compare pain, pulse, pallor, temperature, and capillary refill time
4) assess pulses distal to the insertion site
A male patient is discharged from the emergency department after being

diagnosed with a concussion sustained in a fall. Which of the following
statements, if made by the patient’s wife to the nurse, indicates that further

1. "I will wake my husband up every 3 hours whenever sleeping
and ask him his name, my name, and where he is."
2. "If my husband complains of a headache and needs aspirin, I
will give it to him no more than every 4 hours."
3. "If my husband complains of blurry vision or has difficulty
walking, I will bring him to the emergency department right
away."
4. "I will talk to my husband’s friend about doing the coaching for
the soccer team tomorrow."


(1.) appropriate action; provides patient’s spouse with essential information as
to whether complications or deterioration are occurring and if patient thus needs
to be returned immediately to the hospital
(2.) CORRECT—wrong action; patient should not receive aspirin, as it can
prolong any bleeding that might occur; acetaminophen (Tylenol) every 4 hours
as needed is what should be given
(3.) appropriate action; visual disturbance such as blurred or double vision,
difficulty walking, weakness, numbness, clumsiness are symptoms that require
immediate return of patient to the hospital
(4.) appropriate action; patient should not be involved in strenuous activity for at
least 2 days; even coaching and not playing can be strenuous; driving, contact
sports, swimming, use of power tools are examples of strenuous activities;
resting and eating lightly should be encouraged
The nurse is caring for a patient with a pulse oximeter probe in place. Which of
the following situations requires an intervention by the nurse?

1. The probe is in place on the woman’s ring finger, which has
clear polish on the nail.
2. The emitting and receiving sensors of the probe are directly
opposite each other.
3. The hand with the probe attached is directly beneath a
procedure light to prevent chilling.
4. The SaO 2 alarm for the pulse oximeter is set at 95%.
Strategy: “Requires an intervention” indicates a complication.

1) equipment includes wave of infrared light and sensor placed on finger, nose,
toe, earlobe, or forehead; no intervention needed; measures oxygen saturation
through the skin
2) correct placement of equipment
3) CORRECT— don’t expose the probe to direct sunlight or strong light, gives
inaccurate results, cover with dry washcloths; rotate site every 4 h to prevent
skin irritation
4) normal SaO 2 is 95–100%; measures reserve oxygen attached to hemoglobin;
results below 86–91% considered emergency, below 70% life-threatening
The home health nurse visits the home of a client with a history of kidney
stones. When instructing the client, it is MOST important for the nurse to include
which of the following

1. “Drink at least 2000 to 3000 mL water per
day.”
2. “Avoid drugs that cause elevated calcium
levels.”
3. “Avoid foods that contain calcium.”
4. “Participate in a regular exercise program.”
Strategy: Determine the outcome of each answer choice. Is it desired?

1) CORRECT— high urine output dilutes the concentration of minerals and
flushes them from the body
2) priority is diluting the urine
3) avoid foods that are high in oxalates such as spinach, asparagus, and
cabbage
4) good health promotion habits; should increase fluids to prevent dehydration
The nurse reviews records and determines which of the following clients is at
highest risk for developing pneumonia?

1. A 15-year-old client diagnosed with cystic
fibrosis.
2. A 36-year-old client who has smoked for 18
years.
3. A 57-year-old client diagnosed with
hypertension.
4. A 78-year-old client diagnosed with colon
cancer.


1) risk factors for pneumonia include advanced age, underlying lung disease,
bedridden, and postop; has one risk factor
2) smoking is a risk factor
3) has no risk factors
4) CORRECT— advancing age and immunosuppressed status are risk factors
The nurse observes a student nurse care for a client diagnosed with
cerebrovascular accident (CVA). The nurse should intervene if which of the

1. The student nurse places the client in an upright
position to eat.
2. The student nurse auscultates breath sounds
bilaterally.
3. The student nurse simultaneously palpates the carotid
pulses.
4. The student nurse faces the client and speaks clearly.

1) appropriate action; in addition to sitting upright, encourage client to flex head
slightly
3) CORRECT— palpating the carotid pulses together can cause a vagal response
and slow the client’s heart rate
4) appropriate action; facilitates communication, allow client enough time to
respond
A mother brings her 2-year-old girl to the clinic. The nurse notes that the child
has honey-colored crusts, vesicles, and reddish macules around her mouth.
Which statement, if made by the nurse, is BEST?

1. Your child has developed an irritation because she continues to
use a pacifier.
3. Your child has developed a food allergy and you should restrict
her diet.
4. Your child has been exposed to a sick child and should be
isolated for a few days.


2) CORRECT— describes the skin eruptions found with impetigo; symptoms of
impetigo include reddish macule becoming vesicle, then crusts, pruritus; caused
by Staphylococcus , Streptococcus
4) unnecessary to isolate child; should use skin isolation and good
handwashing techniques; antibiotics: may be topical ointment (Garamycin,
Neosporin) and/or PO; loosen scabs with Burow solution compresses, remove
gently, restraints if necessary; mitts for infants to prevent secondary infection;
monitor for acute glomerulonephritis (complication of untreated impetigo)
The nurse cares for a patient 2 days after the patient took an acetaminophen
(Tylenol) overdose. It is MOST important for the nurse to monitor which of the
following laboratory results?

1. ALT and AST.
2. Blood glucose.
3. BUN and creatinine.
4. Hemoglobin and
hematocrit.


(1.) CORRECT—hepatic toxicity is a serious complication resulting from an
acute Tylenol overdose that manifests approximately 1 to 3 days after initial
ingestion; there is an increase in the serum transaminase liver enzymes ALT and
AST; PT should also be monitored, as Tylenol overdose prolongs it
(2.) no particular relationship with overdose, although Tylenol can interfere with
home glucose monitoring, causing false decreases in glucose
(3.) not most important at this time; renal damage, as well as hepatotoxicity, can
occur with chronic long-term ingestion of large Tylenol doses
(4.) no particular relationship with Tylenol overdose
The nurse on the medical/surgical unit receives an informal mid-shift report from
the nursing assistants. The nurse should respond FIRST to which of the
following reports?

1. The nursing assistant caring for a patient diagnosed with lung
cancer says, "He keeps coughing, is on oxygen, and can hardly
breathe, but he asked me for a cigarette. It makes me so mad
that the patient is sick because of smoking and he still wants to
smoke."
2. The nursing assistant caring for a patient after a Billroth II
procedure (gastrojejunostomy) says, "After she ate lunch, the
patient said she wanted to lie down. I told her that she should sit
up for at least half an hour to let her food digest properly."
3. The nursing assistant caring for a patient recovering from a
myocardial infarction says, "When I was combing her hair, the
patient started crying and said she knew she should be grateful
but she is terrified. She can’t help thinking, ‘what if it happens
again?’"
4. The nursing assistant caring for a patient after a right-below-the-
knee amputation says, "The patient keeps complaining of pain in
the toes and calf of his right leg. I have reminded him that they
are no longer there, but he insists that they hurt."


(1.) nurse should allow nursing assistant to further express feelings; often
difficult for health care providers to deal with patients who seem addicted to or
intent on self-destruction when providers are intent on saving lives; such
expression should be followed with discussion of ways to be objective and
avoid judgment
(2.) CORRECT—requires immediate intervention; after gastrojejunostomy,
dumping syndrome can occur; lying down after eating is recommended in order
to delay the gastric emptying process; eating lying down or semirecumbent is
another measure that can be taken; desire to lie down may also be one of the
early manifestations of dumping syndrome, which also includes vasomotor
disturbances of syncope, symptom manifestations (90 minutes to 3 hours after
eating); the patient needs evaluation and clarification of proper procedure, and
the nursing assistant needs to be taught that this patient situation is the
exception to the rule of not lying down after eating
(3.) psychosocial need; needs to express feelings and fears and have them
acknowledged by staff, particularly professional staff or registered nurse and
physician, so that appropriate teaching, guidance, and support can be given
(4.) instruct nursing assistant about phantom limb pain; assess patient to
determine if pain intervention required, such as medication and complementary
and alternative therapy; not therapeutic to remind patient that because the limb
is missing it cannot be hurting

An LPN/LVN reports to the nurse that a client admitted with persistent chest pain
is experiencing moderate, spastic lower abdominal pain, nausea, and some
vomiting. Which of the following actions should the nurse take FIRST?

1. Determine what medications the client is receiving.
2. Perform a comprehensive abdominal assessment.
3. Ask the client if he has a history of gastrointestinal

problems.

1) nausea and vomiting is a side effect of many medications; priority is
assessing client’s abdomen
2) CORRECT— abdominal pain not usually associated with MI; nurse should
assess GI problem
3) priority is current physical status
The nurse cares for a client injured in a motor vehicle accident (MVA) that
resulted in total blindness. The nurse assists the client with the lunch tray.
Which of the following actions should the nurse take FIRST?

1. Place client’s hand on each food item and describe the
specific foods.
2. Procure utensils specifically designed for visually impaired
clients.
3. Cut up the client’s food.
4. Inform client of location of food items using an imaginary

clock face.


1) most people eat with utensils; there is no value in asking the client to feel the
food
2) familiar utensils more useful; client likely to reject anything that makes
her/him different, especially if it is not necessary
3) priority is helping client locate food on the tray
4) CORRECT— client can use imagery to recall location of each food

When teaching a client diagnosed with type 1 diabetes about measures to
prevent long-term complications, the nurse should include which of the
following instructions?

1. Wear slippers around the house.
2. Wear shoes made of manmade fibers.
3. Avoid wearing insulated boots in cold

weather.
4. Wear knee-high nylons instead of
pantyhose.


(1.) CORRECT—instruct never to go barefoot; compromise of skin integrity to
the feet may result in wounds that go unnoticed or are slow to heal as a result of
associated neuropathy or peripheral vascular disease
(2.) shoes made with natural fibers allow perspiration to dry, preventing
compromised skin integrity
(3.) decreases the risk of injury from the cold related to neuropathy and
peripheral vascular disease
(4.) patient should avoid wearing nylons altogether because they may
exacerbate circulatory problems
An adult is scheduled for magnetic resonance imaging (MRI) of the upper

abdomen. Which of the following information is MOST important for the nurse to
communicate to the technician prior to the test?

1. Patient has a penicillin allergy.
2. Patient has aortic stenosis.
3. Patient has a history of gastric

ulcers.
4. Patient has a metal hip
prosthesis.


1) not contraindicated for MRI; should receive cephalosporin antibiotics
cautiously
2) not contraindicated; malfunction of aortic valve between left atria and
ventricles results in ventricular hypertrophy, pulmonary congestion, reduced
cardiac output
3) not contraindicated; symptoms: 45 years and older, pain 1 h after meal or
when fasting, pain relived by vomiting, food doesn’t help with pain, hematemesis
4) CORRECT— metal implanted objects contraindication to test; assess the
patient for claustrophobia; remove all metal jewelry and metal objects
The home care nurse counsels a client diagnosed with glaucoma. The nurse
determines that teaching is successful if the client makes which of the following
statements?

1. “Because of glaucoma, the correction in my eyeglasses needs
to be changed”
2. “I will schedule appointments with my physician early in the
morning.”
3. “I’m glad that surgery can reverse the damage caused by the
glaucoma.”
4. “I will be happy when I don’t have to use the eyedrops
anymore.”

Strategy: “Teaching is successful” indicates correction information.

1) glaucoma is an obstruction of the outflow of aqueous humor, causing
increased intraocular pressure that causes permanent damage to the optic
nerve; there is decreased visual acuity but it is not corrected by eyeglasses
2) CORRECT— IOP tends to be higher in the early morning hours; an early
morning assessment is likely to be more accurate
3) damage resulting from sustained increased pressure cannot be corrected with
surgery
4) glaucoma is a chronic health problem; blindness can be prevented by lifelong
treatment
The nurse reviews the chart of a client diagnosed with acute renal failure (ARF).
It is MOST important for the nurse to review which of the following lab values?

1. Fasting blood sugar.
2. Serum uric acid.
3. Serum protein.
4. Urine specific
gravity.


question.
1) may be elevated in renal failure, but is not a measure of renal function; normal
is 70 to 110 mg/dL
2) by-product of purine metabolism; elevated in renal failure; normal is 2.5 to 5.5
mg/dL (women) and 4.5 to 6.5 mg/dL (men)
3) decreased in chronic renal failure; normal is 6.0 to 8.0 g/dL
4) CORRECT— inability of kidneys to concentrate urine occurs in acute renal
failure; normal is 1.010 to 1.030
The nurse assumes care of a patient just returning from surgery after a total
abdominal hysterectomy. When the nurse questions the patient about her pain,
the patient rates her pain as 4 out of 10 on the pain scale. Which of the following
interventions by the nurse is MOST appropriate?

1. Assist the patient to a more comfortable position and encourage
her to sleep.
2. Administer narcotic pain medications as ordered.
3. Encourage the patient to watch television or read a book.
4. Continue to monitor the patient for pain.
Strategy: All answers are implementation. Determine the outcome of each

1) nonpharmacologic interventions such as repositioning and rest are
appropriate alternatives; however, moderate pain should be more aggressively
addressed
2) CORRECT— there is a known etiology for the pain (surgery), so it is most
appropriate to provide pain medications immediately for moderate pain and use
other methods as adjunct therapy
3) distraction may be appropriate adjunct therapy; unrealistic intervention
immediately post anesthesia
4) providing no intervention for the patient’s report of moderate pain is an
unacceptable solution
The physician on the medical unit writes orders for heat application for four
patients. The nurse should question which of the following orders?

1. Warm sterile saline compresses for a patient with phlebitis
from an IV.
2. Aquathermia pad for a patient with low back pain.
3. Heat lamp for a patient with a diabetic foot ulcer.
4. Sitz bath for a patient after incision and drainage of an

anorectal abscess.


(1.) appropriate order; the warmth and moisture will dilate the vein and
encourage circulation
(2.) appropriate order; electronic device comprised of a waterproof pad that has
water circulating through it; the moist heat it provides decreases muscle tension
and muscle spasms and decreases inflammation in various musculoskeletal
conditions
(3.) CORRECT—diabetics often have impaired peripheral circulation and
sensation; foot ulcers can be especially dangerous because they can lead to
gangrene and amputation; not only might the diabetic not be able to feel
problems with the feet, but if heat were applied they might well not be able to
detect if the heat were too high; burns and further tissue destruction could occur
(4.) appropriate order; the vasodilation that occurs increases blood flow and
therefore oxygen and nutrients to the area, and helps with waste product
removal; it decreases inflammation
The nurse reviews records and determines which of the following clients is at
highest risk for developing pneumonia?

1. A 15-year-old client diagnosed with cystic
fibrosis.
2. A 36-year-old client who has smoked for 18
years.
3. A 57-year-old client diagnosed with
hypertension.
4. A 78-year-old client diagnosed with colon
cancer.


1) risk factors for pneumonia include advanced age, underlying lung disease,
bedridden, and postop; has one risk factor
2) smoking is a risk factor
3) has no risk factors
4) CORRECT— advancing age and immunosuppressed status are risk factors
The nurse cares for clients on the medical/surgical unit. A nursing assistant
reports to the nurse that a comatose client receiving oxygen through a
tracheostomy has “lots of water in the tubing.” Which of the following actions

2. Instruct the nursing assistant to empty the fluid from
the tubing.

4) CORRECT— client at risk for aspiration; caring for the tracheostomy is within
the scope of nursing practice
A mother brings her 2-year-old girl to the clinic. The nurse notes that the child
has honey-colored crusts, vesicles, and reddish macules around her mouth.
Which statement, if made by the nurse, is BEST?

1. Your child has developed an irritation because she continues to
use a pacifier.
3. Your child has developed a food allergy and you should restrict
her diet.
4. Your child has been exposed to a sick child and should be
isolated for a few days.


2) CORRECT— describes the skin eruptions found with impetigo; symptoms of
impetigo include reddish macule becoming vesicle, then crusts, pruritus; caused
by Staphylococcus , Streptococcus
4) unnecessary to isolate child; should use skin isolation and good
handwashing techniques; antibiotics: may be topical ointment (Garamycin,
Neosporin) and/or PO; loosen scabs with Burow solution compresses, remove
gently, restraints if necessary; mitts for infants to prevent secondary infection;
monitor for acute glomerulonephritis (complication of untreated impetigo)
The nurse prepares a client for a barium enema. It is MOST important for the

1. “Your stool will be light-colored for 2 to 3 days after the test.”
2. “Once the test is over and you go to the toilet, you will be able to
resume normal activities.”
3. “The x-ray table will be tilted so you can assume various
positions.”
4. “During the test, it is crucial that you take slow, deep breaths
through your mouth.”


1) accurate information but not the most important
2) after the rectal tube is removed and client evacuates the bowels, additional x-
rays are taken; due to the bowel prep and procedure, most clients require a
period of rest after the test
3) accurate information but not the most important; reassure client that he will
be secure on the table during the x-rays
4) CORRECT— for test to be successful, client must retain barium; as barium is
introduced, client may have the urge to defecate; slow, deep breathing will help
ease the discomfort
The nurse cares for a comatose client. The nurse is unable to elicit a reaction
after applying the trapezius squeeze, supraorbital pressure, mandibular
pressure, and sternal rub. Which of the following actions should the nurse take
NEXT?

1. Administer diuretics as ordered.
2. Lower the head of the bed.
3. Press a pencil to a finger or toe of each

limb.
4. Begin cardiopulmonary resuscitation.


1) complete assessment first; may help decrease ICP if contributing to comatose
state
2) first, complete assessment; head of bed should be elevated to decrease ICP;
assess before implementing
3) CORRECT— when assessing a client’s response to pain, begin with least
noxious stimulation (speak to client) and proceed to more painful stimulation;
trapezius squeeze, supraorbital pressure, mandibular pressure, and sternal rub
are central stimulation; if no response to central stimulation demonstrating brain
function, apply peripheral stimulus to the extremities; client’s finger or toe
should be braced on nurse’s thumb and pencil placed sideways on top of nail
bed at base of cuticle and pushed down hard; use peripheral assessment only
on extremity that did not move
4) first, complete assessment; not responding to painful stimuli indicates brain
is not responding; does not indicate client has arrested
The office nurse makes a follow-up telephone call to a patient 3 days after
extracapsular cataract extraction with intraocular lens implantation. Which of the
following patient statements MOST concerns the nurse?

1. "I am going to the beauty shop to get my hair done tomorrow. It
will be kind of like a celebration—getting my whole head back in
shape!"
2. "I am feeling really good. As soon as I get off the phone I am
going to do the vacuuming and then go out for a round of golf
with my friends."
3. "My eye is itching a little, especially at night. There is also a dry,
crusty white drainage on the eyelids and lashes."
4. "It may be hard for me to get a ride to my doctor follow-up visit
next week because all my friends are busy that day."

Strategy: "MOST concerns the nurse" indicates a complication.

(1.) hair can be shampooed 1–2 days after surgery as long as head is tilted back;
does not affect intraocular pressure (IOP), which is major complication during
the post-op period
(2.) CORRECT—for the first several weeks light housekeeping is acceptable, but
vacuuming involves too much forward flexion and jerky, rapid movement; golf
also involves too much flexion, potential for strained rapid movement, and
possibly excessive lifting related to equipment
(3.) mild itching caused by the stitches that are in place to close the incision and
is normal; acetaminophen (Tylenol) used as a mild analgesic if necessary;
aspirin should be avoided because of its effect on blood coagulability; eyes
should not be rubbed or pressed
(4.) cataract surgery is usually done on an outpatient basis; patient returns to
the ophthalmologist the next morning and then again at 1 week and 1 month;
exploration of transportation options for patient can be done and/or the
appointment date or time can be adjusted
The nurse prepares a client for surgery. Place the following preoperative
activities in the correct sequence from FIRST action to LAST. All options must
be used.
trategy:
Determine the outcome of each answer when determining the order of nursing
actions.
(1) Verify that operative permit is signed: perform first before continuing
preparation; confirm that lab results are posted
(2) Obtain and record the vital signs: provides baseline for anesthesiologist
(3) Ask the client to empty the bladder: do not allow client to ambulate after
receiving preoperative medication
(4) Instruct the client to remain in bed: safety measure; raise side rails and put
bed in low position
(5) Administer preoperative medication: provide all nursing care prior to
administering preoperative medication
The nurse in the outpatient surgery prepares a 2-year-old child for a

myringotomy for placement of tympanostomy tubes. It is MOST important for the

1. Use bright objects to distract the toddler during the
preoperative assessment.
2. Allow the toddler to play with a toy stethoscope before
auscultation.
3. Demonstrate the use of the stethoscope before auscultation.
4. Give the toddler choices when possible during the preoperative

assessment.

1) more appropriate for an infant than a toddler
2) CORRECT— allows the child to become familiar with equipment; decreases
fear of the unfamiliar objects; explain procedures by telling toddler what she/he
will see, hear, taste, and feel
3) ineffective because of developmental age; more appropriate for preschool age
child
4) appropriate for a school age child
As the health care provider removes the peripherally inserted central catheter
(PICC) from a patient, a portion of the catheter breaks. Which of the following

1. Check the patient’s radial pulse.
2. Turn the patient to the right side.
3. Apply a tourniquet to the upper right arm.
4. Instruct the unit secretary to call for a STAT

x-ray.


1) second action; if tourniquet is too tight, a radial pulse will not be detected
2) do not move client to prevent movement of broken catheter piece
3) CORRECT— place close to axilla; prevents catheter piece from advancing into
right atrium; after tourniquet is applied, check for presence of radial pulse; keep
in place until x-ray obtained and surgical retrieval attempted
4) will x-ray; priority is to prevent catheter from advancing
The nurse discusses skateboard safety with a group of parents. It is MOST
important for the nurse to include which of the following statements?

1. “If your children are younger than 5, always observe them while
they are skateboarding.”
2. “Carefully check the surface where your child will be
skateboarding.”
3. “It does not matter what type of skateboard you get for your
child.”
4. “Instruct your child to keep as close to the curb as possible.”


1) children younger than 5 should not skateboard; developmentally they have
difficulty protecting themselves from injury
2) CORRECT— check for holes, bumps, rocks, and debris
3) skateboards are designed for various uses (slalom, freestyle, or speed); know
how you child plans to use the skateboard
4) never ride a skateboard in the street
The nurse admits an elderly man to the medical unit. The nurse assesses the
client and establishes a nursing diagnosis of “fluid volume deficit related to
decreased intake and fever.” Which of the following symptoms substantiates
this nursing diagnosis?

1. The client’s temperature is 102°F (38.4°C), pulse 120 bpm, BP
90/60, respirations 22 and deep.
2. The client has difficulty breathing in the supine position or with
minimal activity.
3. The client’s skin is pale and cool to touch with pitting edema in
dependent areas.
4. There is a decrease in the client’s level of consciousness and
moderate ascites.


1) CORRECT— will see increased pulse rate with thready quality, decreased BP,
fever, and increased rate and depth of respirations
2) indicates fluid volume overload
Diagnostic testing indicates that a bottle-fed infant is allergic to cow’s milk. The
nurse discusses with the mother the adaptive measures to take. Which of the
following statements by the infant’s mother to the nurse indicates that the
mother has a correct understanding of how to proceed?

available."

choice."
yogurt."


(1.) soy-based formulas are not recommended for infants with cow’s milk allergy
due to cross-reactivity to soy
(2.) goat’s milk is not recommended for infants with cow’s milk allergy; has
cross-reactivity with cow’s milk protein, is deficient in folic acid, is inadequate
as the only caloric source
(3.) CORRECT—formulas that use enzymatic hydrolysis to break down or
predigest the casein protein into its amino acids are recommended for infants
with cow’s milk allergies
The nurse prepares a 50-year-old man for discharge following treatment for
myocardial infarction (MI). The patient asks the nurse when he can resume
sexual activity with his wife. Which of the following responses by the nurse is
the BEST?

1. “You can resume your usual sexual activity anytime during the
next week as long as you continue to take your medications.”
2. “Because you have been through a crisis, you should get
comfortable at home before you consider having sexual
relations.”
3. “You can resume your usual sexual activity when you can walk
one city block without having chest pain.”
4. “Because sexual activity requires strenuous activity and intense
emotions, it will be some time before you can resume your usual
activity.”


1) should continue to take medications, but is too early to resume sexual activity
2) does not provide information patient is seeking; provides advice
3) CORRECT— sexual activity can be resumed when patient can tolerate the
physical activity of climbing two flights of stairs or walking one city block
without SOB or chest pain; should maintain a supine position and not have
intercourse after a heavy meal
4) does not provide information the patient is seeking
A client tells the nurse that he is a lactovegetarian. It is MOST important for the
nurse to suggest which of the following?

1. Limit the intake of eggs to three per week.
2. Increase consumption of breads and pastas.
3. Increase intake of beans, legumes, and nuts.
4. Supplement diet with calcium and magnesium

tablets.

Strategy: Determine which answer choice has items with the most protein.
1) lactovegetarians do consume milk and dairy products, but do not eat eggs
2) increasing this food group will not increase amino acids and protein stores in
the client’s diet
3) CORRECT— the client should take in adequate amounts of protein from other
sources, such as seeds, tofu, dark green vegetables
4) client consumes dairy products; therefore, calcium and magnesium
consumption should not be a problem
The nurse interacts with a client diagnosed with a phobic disorder. It is MOST
important for the nurse to recommend which of the following interventions?

1. Refer the client for psychopharmacological
intervention.
2. Group therapy.
3. Systematic desensitization.
4. Biofeedback.

1) can be used, but behavior modification is more effective
2) can be used, but behavior modification is more effective
3) CORRECT— form of behavior modification; used in conjunction with deep
muscle relaxation designed to decrease the extreme response to anxiety-
producing situations
4) more useful for reducing stress associated with physiologically based
disorders
The nurse cares for clients on the psychiatric unit. Before administering
medication to a client, the nurse asks him to state his name. The client
responds, “I am Jesus Christ.” Which of the following actions should the nurse
take FIRST?

1. Ask two nursing assistants to stand by in the
area.
2. Request that the hospital chaplain speak to the
client.
3. Look at the client’s armband.
4. Determine if the client ate his lunch.

1) nursing assistants not needed; priority is identifying client before giving
medications
2) passing the buck
3) CORRECT— remember the five rights of medication administration
4) some medications have to be given before or after meals; priority is
identifying the client so medications can be given
The adult granddaughter of a patient diagnosed with moderate Parkinson’s

disease tells the nurse about the ideas she has come up with for gifts for her
grandmother’s birthday in 2 weeks. The granddaughter asks the nurse which
idea is best. Which of the following is the BEST gift for the nurse to support?

2. Hearing aid with

batteries.

question.
(1.) esthetically pleasing and could boost morale, body image, and self-esteem;
not priority
(2.) hearing loss is not usually a problem with Parkinson’s disease itself;
problems that Parkinson’s patients have with communication primarily relate to
speaking so that others can hear and understand
(3.) CORRECT—warming trays can keep food hot, safe, and appealing during the
slow eating process of the Parkinson’s patient; eating is slow because of overall
slowed body movement, tremors, difficulty chewing and swallowing, fatigue,
need for rest periods; this choice directly addresses a physiologic need
(4.) patients with Parkinson’s disease should keep good posture and avoid
flexion of neck and shoulders; sleep on a firm mattress without a pillow to
prevent flexion of the spine
The nurse cares for a client before and after electroconvulsive therapy. Arrange
the following nursing responsibilities in the correct order from FIRST to LAST.
All options must be used.
(1) Explain the procedure: client will have convulsions similar to grand mal
seizures; explain about potential temporary memory loss and confusion
(2) Ask the client to void: void, and remove dentures, glasses, and jewelry about
1 hour before procedure
(3) Administer atropine about 30 minutes before treatment to decrease
secretions
(4) Orient the client: client will be confused after treatment; stay with client
during confusion and frequently orient client; obtain client’s vital signs
The nurse on the burn unit is orienting new staff to infection control issues on
the unit. Which of the following measures is MOST important to emphasize for
this particular type of unit?

1. Wear gowns, gloves, masks, and shoe and hair covers.
2. Ensure that no equipment is shared between patients.
3. Assign patients diagnosed with infection to private rooms with

negative-pressure air flow.
4. Wash hands using a thorough and consistent approach.

the question.
(1.) some burn units recommend that staff and visitors wear all this equipment
because patients are immunosuppressed; other units do not, as there is no
conclusive evidence to support this approach; wearing of gloves by staff during
all contract with open wounds is essential
(2.) not most important; disposable items such as pillows and dishes are used
as much as possible; equipment such as thermometers, blood pressure cuffs,
and stethoscopes are actually assigned to each patient and cleaned daily
(3.) private rooms with negative-pressure air flow are used for airborne
precautions such as TB
(4.) CORRECT—correct and consistent handwashing is the single most effective
technique for preventing infection transmission on burn units
Four patients arrive in the emergency department within minutes of one another.
Which patient should the nurse see FIRST?

1. A patient, pale and diaphoretic, who is complaining of sudden
and severe pain radiating from the flank to the scrotum.
2. A patient with right lower quadrant (RLQ) abdominal pain of 24
hours’ duration and which is relieved by drawing the legs up and
remaining still.
3. A patient, jaundiced and nauseated, who is complaining of pain
in the right shoulder and has a temperature of 100°F (37.8°C).
4. A patient with sudden epigastric pain and nausea who reports
vomiting blood and has an odor of alcohol on the breath.


(1.) symptoms of renal colic; requires quick attention to diagnose and manage
the pain; not first patient to see
(2.) symptoms of probable appendicitis; confirm with physical assessment
(especially abdomen and temperature) and diagnostic tests; appendectomy
should be done within 24 to 48 hours of symptom onset; delay usually causes
rupture of the appendix and results in peritonitis
(3.) symptoms of chronic cholecystitis; insidious symptoms may occur with this
disorder, resulting in patient not seeking medical help until late symptoms
appear, such as jaundice, dark urine, clay-colored stools
(4.) CORRECT—symptoms of acute gastritis; vomiting and hematemesis may be
seen with gastritis stemming from alcohol abuse; other symptoms are epigastric
pain or discomfort, cramping, nausea and vomiting
The nurse cares for a client in the outpatient clinic with a diagnosis of
myxedema. During the initial assessment, the nurse should carefully observe for
which of the following symptoms?

1. Tachycardia, fatigue, and intolerance to
heat.
2. Polyphagia, nervousness, and dry hair.
3. Lethargy, weight gain, and intolerance to

cold.
4. Tachycardia, hypertension, and
tachypnea.

Strategy: Think about each symptom and how it relates to hypothyroidism.

2) indicates hyperthyroidism; even though appetite is increased, weight loss
occurs; other emotional manifestations include decreased attention span,
irritability, manic behavior
3) CORRECT— signs and symptoms of hypothyroidism; other assessments
include dry hair, mask-like facial expression, thickened skin, enlarged tongue,
and drooling
The nurse reviews the chart of a client diagnosed with acute renal failure (ARF).
It is MOST important for the nurse to review which of the following lab values?

1. Fasting blood sugar.
2. Serum uric acid.
3. Serum protein.
4. Urine specific
gravity.


question.
1) may be elevated in renal failure, but is not a measure of renal function; normal
is 70 to 110 mg/dL
2) by-product of purine metabolism; elevated in renal failure; normal is 2.5 to 5.5
mg/dL (women) and 4.5 to 6.5 mg/dL (men)
3) decreased in chronic renal failure; normal is 6.0 to 8.0 g/dL
4) CORRECT— inability of kidneys to concentrate urine occurs in acute renal
failure; normal is 1.010 to 1.030
The nurse cares for a 4-year-old who sustained a fractured wrist from a fall. The
nurse prepares the child for the application of a plaster cast. Which of the

1. Tell the child the cast will feel cold when it is first
applied.
arm.
a cast.


question.
2) CORRECT— preschoolers need to see and play with the equipment; this is the
age of the greatest number of fears
3) describe to the child what she will be feeling and experiencing in words that
are not frightening
The nurse on the neurology unit prepares a patient for discharge. The patient
has been treated for an exacerbation of multiple sclerosis. Which of the
is successful?

1. "When I am exercising, I will push a little beyond when I start to
feel tired and then stop."
2. "When my muscles seem especially spastic, I will take hot baths
to relieve them."
3. "I will sleep on my stomach as much as I can."
4. "I will be firm and steady when I pull a spastic leg open."

(1.) overexertion must be avoided because it will cause fatigue and exacerbate
symptoms; exercises for muscle strengthening done to the point of fatigue can
actually cause further paresis or weakness, numbness, incoordination
(2.) heat and humidity, whether environmental or a hot bath or shower, can
aggravate the fatigue which is so much a part of multiple sclerosis; fatigue can
precipitate and/or intensify multiple sclerosis symptoms
(3.) CORRECT—may minimize spasm of the flexor muscles of the hips and knees
of a person with multiple sclerosis; if these spasms are not relieved, joint
contractions will occur as well as pressure ulcers on the sacrum and hips from
difficulty positioning the patient correctly
(4.) spastic extremity should not be forced open; instead it should be gently
rotated in the direction it is being pulled and then gradually rotated in the
opposite direction, which is usually outward since spasticity usually is into an
adducted position; these rotations are repeated, going a little farther each time
An order is written for "3,000 mL 5% D5NS every 24 hours by gravity infusion."

The administration set delivers 15 drops/mL. What is the correct infusion
rate/min for this solution?

1. 21 drops/min.
2. 31 drops/min.
3. 50 drops/min.
4. 96 drops/min.

Strategy: Total volume to infuse (mL) × drop factor / time (min) = drops per min.
(1.) drop factor is 15, not 10; this incorrect number is obtained by dividing 30,000
by 1,440
(2.) CORRECT—3,000 mL × 15 drops/mL/(24 × 60) = 45,000/1,400 = 31.25 = 31
drops/min
(3.) incorrect number is obtained by dividing 3,000 ml by 60 minutes
(4.) solution volume needs to be included in calculation; this incorrect number is
obtained by dividing 1,440 by the drop factor of 15
As a part of a diaster drill, the school nurse reacts to an announcement that a

“dirty” bomb exploded 4 miles away. According to the diaster plan, which of the

1. Move food and water to an interior area in the
school.
2. Contact parents to immediately pick up their
children.
3. Turn off the air conditioners and forced-air
heating units.
4. Encourage the staff and children to remain calm.

1) a radiological dispersion device (dirty bomb) is a chemical explosive
containing radioactivity; principles are distance, shielding, and time; food and
water should already be stored in a safe area
2) decision not made by the nurse; local authorities will determine whether to
“shelter in place” or evacuate
3) CORRECT— turn off all units that bring fresh air in from the outside; close
and lock all doors and windows; move to an inner room or basement
4) priority is protecting the environment
A Buddhist patient dies on the medical unit in a private room after a protracted
battle with cancer. Family and friends have gathered around the bedside. Which
of the following actions by the nurse is BEST?

1. Provide a basin of warm water and a washcloth.
2. Hand the closest family members a clean white sheet.
3. Close the door to provide privacy for chanting around the

bedside.
4. Call the hospital chaplain to tie a thread around the neck
or waist.


question.
(1.) useful if patient were Hindu; priest pours water into the mouth of the corpse
and the family washes the body before cremation
(2.) no particular need for this; the color white means death in this religion
(3.) CORRECT—in Buddhism, those at the bedside after the death often perform
last rites of chanting; a Buddhist priest should be contacted by the nurse or
family
(4.) not appropriate; in Hinduism, a Hindu priest may be called when death has
occurred and, as a blessing, might tie a string around the waist or neck of the
deceased
The nurse reviews circumcision site care with the parents of a boy who had a
circumcision using a circumcision clamp. Which of the following statements by
the mother to the nurse indicates that teaching is successful?

1. "I will wipe off any discharge that appears, using warm water
and a gentle circular motion."
2. "I will put Vaseline on a gauze pad and put that over the
circumcision area before I diaper him."
3. "I will be sure the diaper fits snugly but not too tightly, and that
it is changed when wet."
4. "I understand that it is normal for the first few days for the penis
to look red or swollen and for my son not to be urinating much."


(1.) yellowish-white exudates appears on the second day; part of the granulation
process; do not remove or disrupt during cleaning of the area
(2.) CORRECT—correct action; a 4 × 4 gauze pad with either petroleum jelly
(Vaseline) or A & D ointment on it is placed on the circumcision site as a
dressing to prevent the wound from adhering to the dressing or diaper; the
dressing changes occur for 3 days after procedure
(3.) diaper should be loosely fastened to prevent friction, rubbing, or pressure
against the tender penis; mother is correct that it should be changed when wet
(4.) signs of infection; the difficulty voiding and/or failure to void sufficiently may
result from edema at the circumcision site blocking the urethra or urethral
meatus; report to physician immediately
The nurse in the neurology unit cares for a patient diagnosed with a
cerebrovascular accident (CVA) with hemiplegia and dysphagia. As discharge
approaches, the nurse discusses nutritional planning with the patient’s wife.
Which of the following statements, if made by the wife to the nurse, indicates
that further teaching is necessary?

1. "I will have him sit up for 20 minutes before he eats and about
an hour afterward."
2. "Casseroles are one of my favorite things to make, and he loves
them."
3. "I will plan to prepare six meals a day rather than our usual
three."
4. "A peanut butter sandwich and glass of milk at midday is easy
and nutritious."


(1.) appropriate action; sitting, particularly in high Fowler’s position at 90
degrees, lessens aspiration risk by utilizing the pressure of gravity to pass food
through the stomach and into the duodenum; sitting before a meal allows for a
rest period before eating, which helps minimize fatigue and therefore helps the
patient’s desire to eat and enhances swallowing efforts
(2.) appropriate action; swallowing usually easiest with semisolid foods of
medium consistency
(3.) appropriate action; six small meals versus three large ones can increase
swallowing-muscle strength and are easier to digest
(4.) CORRECT—incorrect action; peanut butter is to be avoided because it is
sticky in the mouth and the throat; most milk products are avoided because they
produce mucus
A 10-year-old girl is receiving Amoxicillin 250 mg PO. Which of the following

statements, if made by the nurse, is MOST likely to elicit cooperation from the
child?

1. “Amoxicillin is an antibiotic to help you get well.”
2. “This medicine tastes good. Would you like

some?”
3. “Would you like to take this medicine with milk or
juice?”
4. “Do you want to go play after you take your
medicine?”

Strategy: All answers are implementation. Determine the outcome of each

1) CORRECT— discussion of facts is appropriate with school-age child
2) don’t compare medication to food
3) offers child a choice, gives some control over behavior, suitable for younger
child
4) bargaining, not based on Erikson’s developmental tasks
The nurse observes the home health aide transfer a patient with right-sided
paralysis from the hospital bed to a chair using a hydraulic lift. The nurse should
intervene if which of the following is observed?

1. The home health aide lowers the patient’s bed before the
transfer is initiated.
2. A canvas sling is positioned under the center of the patient’s
body.
4. The home health aide pumps the hydraulic handle using long,
slow strokes.


transfer
3) prevents injury to arms, especially paralyzed side, and provides for patient
safety
The nurse performs discharge teaching for a patient receiving ethacrynic acid
(Edecrin). The nurse determines that further teaching is needed if the client

1. I will take the medication early in the
day.
2. I will contact the physician if I feel
dizzy.
3. I will take the medication with meals.
4. I will avoid orange juice and

bananas.


1) appropriate action, sleep will not be disturbed by increased urination
2) loop diuretic that may cause orthostatic hypotension; instruct client to rise
slowly
3) minimizes GI upset
4) CORRECT— loop diuretics are potassium wasting; encourage client to
increase intake of potassium-rich foods
The nurse performs an initial assessment on a middle-aged male. It is MOST


1. "My brother was just diagnosed with prostate cancer."
2. "I take enalapril maleate (Vasotec) 5 mg po daily."
3. "I had a lumbar laminectomy 2 years ago but still have some low
back pain."
4. "Lately, I just don’t have as much desire to engage in sex."

question.
(1.) CORRECT—middle-aged male is at risk for prostate cancer; having a father
or brother with this cancer increases the client’s risk by 50%
(2.) used to treat mild hypertension, no problem indicated
(3.) may be experiencing chronic pain; usually not life-threatening, requires
further assessment
(4.) requires further assessment of underlying cause; may be physical or
psychosocial
The nurse in the medical clinic performs an initial assessment for an older adult.
The client states that she does not want to be kept alive by feeding tubes or
other artificial methods. Which of the following initial responses by the nurse is
BEST?

1. "How do you feel about hospice care?"
2. "Do you have an advanced directive?"
3. "Have you told your children about how you

feel?"
4. "Tell me about your meal plan."
Strategy: "BEST" indicates discrimination may be required to answer the

question.
(1.) may want to explore how client feels about hospice, but is not the best initial
response
(2.) CORRECT—living will, durable power of attorney for health care allows client
to state wishes about life-sustaining treatment and is legally binding
(3.) important to discuss but finding out if client has advanced directive is
priority
(4.) assumes that client doesn’t want to eat; nurse should find out about
advanced directive
The nurse in the outpatient clinic identifies that which of the following clients
has the LOWEST risk for developing pneumonia?

1. A 43-year-old homeless man consumes a quart of wine daily.
2. A 56-year-old woman NPO due to perforated bowel.

3. A 60-year-old woman diagnosed with mitral valve prolapse.
4. A 76-year-old man with dysphagia following a cerebrovascular

accident.

Strategy: Eliminate patients at risk to develop pneumonia.

1) alcohol suppresses body reflexes, ciliary motion, and white blood cell
mobilization
2) surgery increases pharyngeal colonization of organisms; should promote oral
hygiene
3) CORRECT— lowest risk for developing pneumonia
4) persons with swallowing difficulties are at risk for bronchial pneumonia;
suctioning and frequent position change will help to prevent pneumonia
The home care nurse visits a client diagnosed with a CVA who uses a condom
catheter because of incontinence. The nurse is MOST concerned if which of the

1. The penis and surrounding skin are red and
irritated.
2. The urine output for 8 hours is 500 cc.
3. The penis appears swollen and dark in color.
4. The condom keeps slipping off the penis.
Strategy: “MOST concerned” indicates a complication.

1) may indicate allergy to the latex; remove condom, notify health care provider,
allow skin to heal before reapplying
2) appropriate output
3) CORRECT— indicates impaired circulation; condom was applied improperly,
adhesive was applied too tightly, or condom is too small; assess circulation 30
minutes after catheter is applied and then every 4 hours
4) not the priority; should be reapplied as necessary
The home care nurse makes an initial visit to a client diagnosed with nephrotic
syndrome caused by acute poststreptococcal glomerulonephritis (ASGN). After
obtaining a client history, it is MOST important for the nurse to instruct the client
about which of the following?

1. Take the blood pressure daily.
2. Low fat diet.
3. Signs and symptoms of venous

thrombosis.
4. Low sodium diet.

question.
1) hypertension is part of disease process, but is not the first priority for this
client; can be managed with medication
2) necessary in renal failure but is not urgent
3) CORRECT— common complication of nephrotic syndrome
4) because disease results in edema and fluid retention is needed for
management of disease, but lacks urgency of the risk for clot formation in vital
organs
A male patient is brought to the emergency department by friends who state that
he has been "hanging with the wrong crowd" and they are worried he is using
drugs. The nurse notes that the patient stares blankly and has an unsteady gait,
stiff muscles, and eyes that are moving rapidly side to side and up and down. It
is MOST important for the nurse to plan for which of the following?

1. Increased adventitious breath sounds.
2. Decreased blood pressure, temperature, and

pulse.
3. Aggressive behaviors.
4. Nausea, vomiting, abdominal cramping.

(1.) patient’s symptoms indicate phencyclidine piperidine (PCP) intoxication;
breath sounds important to assess with any new patient but not priority;
respiratory arrest can occur with PCP overdose
(2.) with PCP, blood pressure, temperature, and pulse are expected to increase,
not decrease; overdose could even lead to a hypertensive crisis; hyperthermia
can also occur
(3.) CORRECT symptoms of blank stare, rigid muscles, ataxia, and nystagmus
that is both vertical and horizontal indicate probable phencyclidine piperidine
(PCP) intoxication; another name for PCP is angel dust; aggression in all forms
is another symptom that manifests with PCP; can take the form of assault,
belligerence, impulsiveness, and/or suicidality, and is very often bizarre in
nature; often occurs in unpredictable outbursts; interventions should be
planned to monitor for aggressive symptoms, to prevent them, and to manage
them should they occur; decreasing stimuli, avoiding trying to "talk the person
down," securing potential injurious objects in the environment, having chemical
and physical restraints (along with sufficient staff) available are all measures
that can be planned in advance and utilized; PCP is used by itself, but is also
frequently used as an adulterant with other drugs
(4.) no particular association with PCP; these are symptoms that occur with
opiate withdrawal.
An 8-year-old with a history of asthma is brought to the emergency department

by his mother. The child tells the nurse that he was wheezing earlier and now
feels worse. The nurse should be MOST concerned with which of the following
findings?

1. The child states that his chest feels tight.
2. The nurse auscultates wheezing at the end of each

expiration.
3. The nurse auscultates decreasing breath sounds.
4. The child coughs while lying on the stretcher.
Strategy: “MOST concerned” indicates a complication

1) common complaint with asthma, but does not necessarily indicate severe
respiratory impairment
2) indicates mild respiratory impairment; asthma attack produces dyspnea,
audible wheezing, coughing, chest tightness, feeling of suffocation
3) CORRECT— with severe spasm or obstruction, breath sounds and crackles
may become inaudible
4) indicates ability to breathe in the recumbent position
The nurse in the emergency department (ED) assesses a client diagnosed with
burns. The nurse is MOST concerned if which of the following is observed?

1. Redness and swelling with fluid-filled vesicles noted on
right arm.
2. Charred, waxy, white appearance of skin on left leg.
3. Reddened blotchy painful areas noted on the face.
4. Blistering and blanching of the skin noted on the back.
Strategy: “MOST concerned” indicates a serious situation.

1) partial-thickness burn; only part of skin is damaged or destroyed; large, thick-
walled blisters develop; underlying tissue is deep red, appears wet and shiny;
painful with increased sensitivity to heat; healing occurs by evolution of
undamaged basal cells, takes about 21–22 days
2) CORRECT— describes full-thickness burn; all skin is destroyed and muscle
and bone may be involved; substance that remains is called eschar, dry to
touch, doesn’t heal spontaneously, requires grafting
3) superficial burn; skin appears pink, increased sensitivity to heat, some
swelling, healing occurs without treatment
4) partial-thickness burn
The nurse in the outpatient clinic cares for a client diagnosed with peptic ulcer
disease (PUD) and gout. Which of the following orders, if written by the
physician, should the nurse question?

1. “Colchicine (Colsalide) 1 mg q 2 hours until cumulative dose of
8 mg achieved.”
2. “Allopurinol (Aloprim) 100 mg daily.”
3. “Probenecid (Benemid) 250 mg BID.”
4. “Indomethacin (Indocin) 50 mg QID.”
Strategy: Think about the side effects of each drug.

1) appropriate order; drug given to treat acute attack of gout
2) appropriate order; inhibits production of uric acid
3) appropriate order; prevents the reoccurrence of gouty arthritis
4) CORRECT— nonsteroidal anti-inflammatory; use cautiously in clients with
peptic ulcer disease
The nurse asks the nursing assistant to perform soapsuds enemas for a patient
scheduled for a diagnostic test. The nurse should

1. observe the returns from the enemas in the patient’s bedside
commode.
2. ask the nursing assistant to describe the returns from the
enemas.
3. ask the patient to describe the returns from the enemas.
4. palpate the patient’s abdomen, noting firmness and

tenderness.


1) performing an enema is a standard, unchanging procedure that can be
delegated to the nursing assistant; responsibility and authority for performing
the task (function, activity, decision) is transferred to another individual; it is the
nurse’s responsibility to describe clear outcomes; observing returns is a part of
the task delegated and should be performed by the nursing assistant
2) CORRECT— describing returns from the enema is a part of the
responsibilities delegated; nurse should monitor performance and results
according to established goals
3) inappropriate; this information should be reported by the nursing assistant
4) should be performed by the RN if patient complains of tenderness or the
nursing assistant identifies a problem with the procedure
The nurse cares for a patient after a laminectomy and spinal fusion. The patient
receives both continuous IV infusion and PCA-mediated demand dosing of
morphine. As the nurse takes vital signs, the patient, who appears to be sleeping
comfortably, suddenly looks startled and says "Whoops, I keep forgetting to
push this," and pushes the PCA pump button. Which of the following responses

1. "Good. The more you can keep the morphine at an even level,
the better."
2. "Tell me where you are feeling pain and show me on this pain
chart the level of pain you are feeling."
3. "You seem very comfortable using the pump."
4. "The combination of the surgery and the medication can

temporarily affect the memory."


question.
(1.) continuous infusion of morphine should maintain an even level; PCA pump
manages breakthrough pain
(2.) CORRECT—assessment of pain status and apparent discrepancy between
patient’s having appeared comfortable and relaxed and suddenly "remembering"
pain; patient’s response to nurse’s question may lead to needed patient teaching
(3.) patient may seem comfortable and knowledgeable about what to do
mechanically, but may have faulty, even dangerous, understanding of the basic
purpose of the pump
(4.) accurate, but does not address the patient’s possibly dangerous
misunderstanding of how to use the pump
Plasmapheresis is scheduled for a patient diagnosed with Guillain-Barré

syndrome. In planning for the procedure, the nurse knows it is MOST important
to have which of the following items readily available?

1. Warm blankets.
2. Emesis basin.
3. Oxygen administration
set.
4. Crutchfield tongs.

(1.) CORRECT—warm blankets can prevent or manage chills and hypothermia
that may occur during plasmapheresis; plasmapheresis is similar to
hemodialysis; done to remove antibodies that may be causing the symptoms
(2.) useful, but not most important; patient may develop temporary nausea and
vomiting related to the citrated plasma being administered
(3.) respiratory complications are not expected with plasmapheresis and
Guillain-Barré
(4.) Crutchfield tongs used in skeletal traction for cervical spine injury; not
related to plasmapheresis
The nurse cares for a client receiving sulfasalazine (Azulfidine). The nurse
should include which of the following in the client’s teaching plan?

1. Restrict fluids to 1,500 cc per day.
2. Explain to the client that the stools may become clay-

colored.
3. The medication should be continued, even after symptoms
subside.
4. If diarrhea occurs, the client should discontinue the
medication.


1) sulfonamides used to treat inflammatory bowel disease; increase fluids to
prevent crystallization in the kidney tubules
2) may turn the urine an orange-red color temporarily; does not discolor stool
3) CORRECT— decreases bowel inflammation; administer after meals or with
food
4) diarrhea is symptom of ulcerative colitis; should continue taking the
medication
The assigned nurse is preparing a nursing home unit for a male client who had a
cerebrovascular accident resulting in right-sided paralysis. Which of the

1. Post a sign stating, “Keep floor dry and free of
debris.”
2. Post a sign stating, “Do not use client’s right arm for
lifting.”
3. Post a sign stating, “Client is hard of hearing.”
4. Post a sign stating, “Client is paralyzed on the right

side.”


question.
1. is appropriate for any client; is not specific for this client
2) CORRECT— is common injury in clients with paralysis; because paralyzed
muscles cannot offer resistance, shoulder can be dislocated
3. is appropriate, but is not as significant as the risk for a dislocated shoulder
4. may help personnel address client’s specific needs; does not directly provide
specific directions for client management
The nurse admits a client diagnosed with chronic lung disease to the acute
pulmonary unit. The nursing assessment reveals respiratory rate of 50, pulse
140 and irregular, skin pale and cool to touch, and client confused to person,
place, and time. Orders include oxygen per nasal cannula at 4 L/min, bedrest,
soft diet, and pulmonary function tests in the A.M. Place the following nursing
activities in the proper sequence beginning with MOST important. All options
must be used.
Strategy:
Determine the outcome of each answer.
(1) Place the client in semi-Fowler position: allows for maximal lung expansion
(2) Ask a staff member to stay with the client: do not leave the client alone
(3) Contact the physician: client appears unstable; support respiratory function
first
(4) Administer oxygen at 4 L/min: oxygenates the client
The nurse should question the order if propanolol (Inderal) is ordered for which
of the following patients?

1. A 39-year-old woman with type 1 diabetes.
2. A 45-year-old woman with peptic ulcer disease.
3. A 49-year-old man with a history of bronchial

asthma.
4. A 60-year-old man with atrial tachycardia.
Strategy: “Should question” indicates a contraindication.

1) propanolol use not contraindicated for this patient; propanolol is a beta-
adrenergic blocker used as antihypertensive
2) propanolol use not contraindicated for this patient
3) CORRECT—may cause bronchospasm; other side effects include bradycardia
and depression; nursing care includes taking pulse before administering
medication; dosage should be gradually reduced before discontinued
4) propanolol use not contraindicated for this patient
Following a left above-knee amputation with delayed prosthesis fitting, the nurse
instructs the client about the importance of lying prone. Which of the following
responses by the client indicates to the nurse that teaching is successful?

1. “I need to lie on my stomach to keep from getting a flexion
contracture of my left hip.”
2. “Lying flat keeps my blood flowing and prevents my stump from
swelling.”
3. “I need to lie on my stomach to prevent a pressure sore on my
hips.”
4. “I will always elevate my stump when I am in a chair to keep it
from swelling.”


1) CORRECT— prone position provides maximum extension of the hip joint and
prevents hip flexion contracture; if hip flexion contracture occurs, it is very
difficult to correctly fit or use a prosthesis
2) lying prone prevents hip contracture; wrap stump with elastic bandage to
shape; reduce edema and keep dressing in place; encourage client to roll from
side to side
3) not the reason for the prone position; begin active range of motion and
strengthening exercises for arms
4) lie prone to prevent hip contracture; instruct about stump care
The nurse is called to a neighbor’s house during a snowstorm. The neighbor
states she is in the 40th week of gestation with her second baby, and has been
having contractions for several hours. The woman has been unable to obtain
assistance because the roads are impassable. Which of the following signs
would indicate to the nurse that the woman is in the transition phase of labor?

1. The woman asks for help to go to the
bathroom.
2. The woman’s contractions become
stronger.
3. The woman’s contractions are more
frequent.
4. The woman becomes flushed and
diaphoretic.

Strategy: Determine how each answer relates to transition phase of labor.

1) CORRECT— transition phase; cervix is 8–10 cm dilated with complete
effacement; increased pressure in pelvis causes intense desire to urinate
2) difficult to differentiate strength of contractions during labor
3) may see during entire labor
4) may see during entire labor
Prior to the patient’s discharge, the nurse in the cardiac unit reviews dietary
management with a patient diagnosed with hypertension. Which of the following
statements, if made by the patient to the nurse, indicates further teaching is
necessary?

1. "I will use a rack whenever I cook meats."
2. "I will ask for some nice pans with nonstick coating for my
birthday."
3. "I will make stews and soups in advance and refrigerate
them."
4. "I will use vegetable oils instead of butter to fry my foods."

(1.) allows the fat to drip off; lean cuts of meat are best and all visible fat should
be trimmed first
(2.) decreases the need for shortening or oil
(3.) allows the fat to harden and then be skimmed off
(4.) CORRECT—low-fat, low-cholesterol diet is recommended for patients with
hypertension, fried foods should be avoided; baking, roasting, boiling, or
broiling are appropriate cooking methods
The home care nurse assesses a client receiving doxorubicin hydrochloride

(Adriamycin) IV. The nurse is MOST concerned if which of the following is
observed?

1. Ulceration in
mouth.
2. Red urine.
3. Alopecia.
4. Fever.
Strategy: “MOST concerned” indicates a complication.

1) stomatitis may occur 5 to 10 days after receiving medication; encourage client
to use a sponge brush, rinse mouth with water after eating and drinking
2) medication causes urine to turn red for 1 to 2 days; inform client of
occurrence
3) avoid brushing hair, blow-drying, and frequent shampooing
4) CORRECT— causes bone marrow depression; promptly report fever, sore
throat, and signs of infection
The home care nurse visits an elderly Asian woman diagnosed with
hypertension and heart failure. It is MOST important for the nurse to follow up on
which of the following observations?

1. The client is 5 feet tall and weighs 100 pounds.
2. The client eats whole grains and fresh fruits and

vegetables.
3. The client walks 2 miles three times per week.
4. The client abstains from alcohol.

1) CORRECT— client is at risk for developing osteoporosis because of gender,
age, ethnicity, and small body frame; encourage client to increase foods high in
calcium, take prescribed medication (Fosamax and Evista), and exercise
regularly
2) appropriate diet for hypertension; instruct client to include foods high in
calcium
3) appropriate action; weightbearing exercises increase bone density;
encourage clients with osteoporosis to avoid bowling or other high impact forms
of activity
4) promotes acidosis, which increases bone reabsorption
A 10-week-old infant is admitted for recurrent pyloric stenosis. The parents have
gone to get something to eat and the grandparents are with the child. When the
nurse enters the room and prepares to insert a nasogastric (NG) tube prior to the
surgery, the grandparents say, "Don’t you need a consent for that?" Which of

1. "Thanks for reminding me. I will get the form and have you sign
it before I go any further."
2. "Consent is not needed for inserting this type of tube in any
patient."
3. "You sound worried. Let me explain how this tube works and
why it is needed before this type of surgery."
4. "This is in preparation for the surgery, and the consent for the
surgery has been signed."


question.
(1.) no consent is required for NG tube insertion; even if it were, it is not the role
of the nurse to get the consent signed, and it is not the grandparents who would
be eligible to sign it
(2.) accurate, but not best; by itself, does not get to the deeper concern being
expressed
(3.) CORRECT—answers the question directly and proceeds to make an
empathic response followed by education to address the grandparents’
underlying concern; is clear and conveys caring and respect; the consent-to-
treatment forms signed when a patient is admitted to a hospital give general
consent to routine types of procedures or treatments; routine usually implies
noninvasive and low risk for injury; invasive surgery needs specific informed
consent
(4.) accurate but does not address grandparents’ concern
The school nurse attends a class outing with a group of sixth-graders. One of
the children falls from a tree, and the nurse suspects that the child’s leg is
broken. Which of the following actions should the nurse take FIRST?

1. Contact the child’s parent.
2. Instruct the child to not move.
3. Send a teacher to obtain padded

splints.
4. Bandage the child’s legs together.

1) priority is to prevent any further damage to the leg
2) it is important to prevent movement that may cause further injury to the leg;
priority is splinting the leg
3) uninjured leg can be used as a splint
4) CORRECT— priority is to prevent further injury to the leg; adequate splinting
includes splinting the joint above and below the fracture; uninjured leg can be
used as a splint
The nursing team at the home care agency consists of an RN, an LPN, and a
nursing assistant. The RN should assign the LPN/LVN to which of the following
clients?

1. A client just discharged from the hospital with a diagnosis of
hypertension and hypothyroidism.
2. A client recovering from a kidney transplant complaining of
fever and tenderness over the transplant site.
3. A client diagnosed with regional enteritis requiring a dressing
change for an abdominal abscess.
4. A client recovering from a hip fracture requiring assistance with
a bath and hair washing.


1) requires the assessment and teaching skills of the RN
2) could indicate rejection or infection; requires the assessment skills of the RN
3) CORRECT— LPN/LVN recognizes normal from abnormal and can perform
dressing change
A client is placed on gentamicin sulfate (Garamycin) IV q 8 hours. It is MOST
important for the nurse to respond to which of the following statements made by
the client?

1. “My wife tells me my hearing has
changed.”
2. “My vision is blurred when I read the
paper.”
3. “Food just doesn’t taste as good to
me.”
4. “Look at this rash on my arms.”
Strategy: “MOST important to respond” indicates a potential complication.

1) CORRECT— decreased hearing and vertigo occur as a result of involvement
of the eighth cranial nerve, which is caused by gentamicin (Garamycin) toxicity
2) gentamicin is an aminoglycoside; nephrotoxic
3) not toxic effect of this antibiotic
4) rash may indicate hypersensitivity reaction; more important to respond to
changes in hearing
A client is placed on gentamicin sulfate (Garamycin) IV q 8 hours. It is MOST

important for the nurse to respond to which of the following statements made by
the client?

1. “My wife tells me my hearing has
changed.”
2. “My vision is blurred when I read the
paper.”
3. “Food just doesn’t taste as good to
me.”
4. “Look at this rash on my arms.”
Strategy: “MOST important to respond” indicates a potential complication.

1) CORRECT— decreased hearing and vertigo occur as a result of involvement
of the eighth cranial nerve, which is caused by gentamicin (Garamycin) toxicity
2) gentamicin is an aminoglycoside; nephrotoxic
3) not toxic effect of this antibiotic
4) rash may indicate hypersensitivity reaction; more important to respond to
changes in hearing
A newly admitted client has been taking lithium carbonate (Lithane) for 2 years.
The client’s serum lithium level is 1.5 mEq/L. Which of the following actions

1. Administer the next dose on time.
2. Increase the client’s oral fluid

intake.
4. Encourage the client to rest.

1) should be withheld
2) does not address issue of toxic level of medication; encourage client to drink
2,000–3,000 cc and have a moderate sodium intake
3) CORRECT—therapeutic level of lithium is 0.5–1.2 mEq/L; toxic manifestations
may occur at levels greater than 1.5 mEq/L; physician should be notified
4) does not address issue of toxic level of medication; observe for vomiting,
diarrhea, slurred speech, decreased coordination, drowsiness, muscle twitching
The nurse prepares to administer medication into an established IV line by IV

push. Which of the following is the MOST important action for the nurse to take?

1. Select the port farthest from the insertion site.
2. Ensure that the tubing above the injection port is

patent.
3. Time the medication administration with a watch.
4. Explain the procedure to the patient.


the question.
(1.) incorrect action; port selected should be the one closest to the IV insertion
site for three reasons; less dilution of the medication will occur, the medication
will move into the vascular system more readily, and it is easier to assess if
catheter placement is correct by blood return
(2.) tubing above the port should be occluded by pinching the tubing gently,
thus stopping the IV solution flow while the medication is administered
(3.) CORRECT—this ensures safe drug infusion; ideally, the watch should have a
second hand or digital readout; many medications which are ordered as IV push
or bolus need to be given slowly over several minutes
(4.) not most important; patient teaching should be done regarding purpose of
the medication and side effects to report
The nurse in the outpatient clinic cares for a client who only travels by train
because he is terrified of flying. The nurse understands that the phobic client is
MOST likely to respond to which form of treatment?

1. Major tranquilizers.
2. Insight-oriented
therapy.
3. Crisis intervention.
4. Systemic
desensitization.


1) used to treat psychosis
2) phobic clients respond well to desensitization
3) a crisis is a temporary state of disequilibrium
4) CORRECT— enables client to encounter phobic object gradually while using
relaxation techniques
The charge nurse implements a change in the nursing assistant’s job

description. The change increases the nursing assistants’ responsibilities and
independence. A nurse with 15 years of service on the unit verbally agrees to the
change, but her behaviors indicate that she does not agree with the new job
description. Which of the following actions by the charge nurse is MOST
appropriate?

1. Inform the nurse that there is a conflict between her verbal
statements and behaviors.
2. Schedule an appointment with the nurse.
3. Ask the nursing assistants to accommodate the nurse.
4. Facilitate an open discussion during a prescheduled meeting.

question.
1) nurse is probably aware of actions; may make the nurse defensive
2) confrontation inappropriate when emotions are high
3) nursing assistant cannot perform under two different job descriptions
4) CORRECT— indirect approach; nurse not confronted directly about
behaviors; peer pressure can be effective in dealing with situation
The nurse dilutes a 2-g vial of cefazolin (Ancef) with 3 mL of diluent to yield a
volume of 3.2 mL. How many mL should the nurse administer if the physician
orders 550 mg IM? Type the correct answer in the blank.

Your Response: 0.88
Correct 0.88
Response:

Strategy: 1 g = 1,000 mg.

Correct answer: 0.88
The industrial nurse supervises the health care needs at a local plant. It is
announced on the news that a device has exploded in a heavily populated area
away from the plant and that individuals near the site have become ill. Several
hours later, workers at the plant come to the nurse and demand antibiotics to
protect them against potential effects of the device. Which of the following
responses by the nurse is MOST appropriate?

1. “I cannot administer medication without a physician’s
order.”
2. “Tell me about how you are feeling.”
3. “The cause of the illness has not been identified.”
4. “Do you have any allergies to medications?”
Strategy: “MOST appropriate” indicates priority.

1) true statement, but nurse should assess before implementing
2) CORRECT— nurse needs to find out more information before determining the
appropriate course of action
3) need to assess before responding to the workers
4) inappropriate assessment
The nurse cares for clients in the outpatient surgical center. Four clients
scheduled for surgery present to the surgical center at the same time. Which of
the following clients should the nurse see FIRST?

1. A 19-year-old scheduled for a tonsillectomy.
2. A 25-year-old scheduled for an inguinal hernia

repair.
3. A 32-year-old scheduled for a mastoidectomy.
4. A 39-year-old scheduled for removal of nasal

polyps.


1) not the priority client
2) stable client; not the priority
3) CORRECT— chronic ear infections often cause vertigo, priority client due to
safety
4) stable client
The nurse cares for a 2-year-old who received ipecac syrup after accidental
ingestion of a poisonous plant. It is MOST important for the nurse to report
which of the following to the next shift?

1. No vomiting occurred after administration of the
ipecac syrup.
2. An antiemetic was ordered and administered.
3. A slight increase in the client’s temperature is noted.
4. The client is to remain NPO until the following day.

1) CORRECT— if no vomiting occurs, may repeat dose in 20 minutes; notify next
shift so further action can be taken
2) priority is reporting the lack of vomiting
3) not a priority
4) not a high priority
A patient is brought to the emergency department by a family member, who

reports that the patient had a sudden onset of decreased level of consciousness,
blurred vision, headache, and slurred speech. Before sending the patient for a
stat head CT scan, which of the following actions should the nurse take FIRST?

1. Elevate the head of the bed 90
degrees.
2. Obtain a finger-stick blood glucose
level.
3. Pad the side rails of the patient’s
bed.
4. Obtain a urine specimen from the
patient.

Strategy: Does this situation require validation? Yes.

(1.) unlikely to tolerate this position with these symptoms; may also be at risk for
injury if unable to self-support this position
(2.) CORRECT—symptoms are suggestive of a possible TIA or CVA; assessment
of other possible underlying causes that can be quickly and easily corrected
should be ruled out; patient with hypoglycemia may present with similar
symptoms
(3.) not indicated because there has been no report of seizure activity
(4.) no evidence to suggest this is indicated
The nurse discharges a client with a permanent pacemaker. It is MOST important


1. “Take your pulse every day.”
2. “Eat foods that are low in sodium.”
3. “Weigh yourself on the same scale

weekly.”
4. “Measure your abdominal girth daily.”

1) CORRECT— change in heart rhythm or rate can signal a malfunction of the
pacemaker; instruct client to take pulse for 1 full minute at the same time each
day and record; should also take pulse if feeling any symptoms
2) pacemaker inserted to treat dysrhythmia; low sodium diet useful to treat heart
failure, hypertension, or cirrhosis
3) not necessary; avoid tight clothing over pacemaker
4) measures ascites; this client has a dysrhythmia
The physician orders streptomycin sulfate 0.4 g IM BID. After reconstituting a 1-g
vial of streptomycin sulfate with 3.5 mL of water for injection, the vial contains
250 mg/mL. How many mL per dose should the nurse administer? Type the
correct answer in the blank.

Your Response: 1.6
Correct 1.6
Response:

Strategy: 1 g = 1,000 mg.
Correct answer: 1.6
The home care nurse visits an older man diagnosed with a cerebrovascular
accident with an uninhibited bladder. The client is incontinent and has
developed repeated urinary tract infections. Which of the following actions by

1. Teach the client exercises to strengthen the pelvic floor.
2. Perform an intermittent catheterization for residual urine

volume.
3. Teach the client about self-catheterization.
4. Instruct client to clean perineum from front to back.

question.
1) appropriate for stress incontinence; uninhibited bladder is caused by damage
to the cortical bladder center in the frontal lobe of the brain
2) CORRECT— even though client with uninhibited bladder is incontinent, the
bladder may not empty completely; residual urine can cause UTI
3) clean procedure used for a flaccid bladder
4) appropriate instructions for a female; priority is to determine if residual urine
is the cause of UTI
The nurse performs teaching for a patient receiving amitriptyline hydrochloride

(Elavil). The nurse should intervene if the patient makes which of the following
statements?

1. “I will take Elavil at bedtime.”
2. “I always forget to wear sunscreen.”
3. “I will stop eating cheese and yogurt.”
4. “It may be 3 to 4 weeks before I feel better.”
5. “When I start to feel better, I can adjust the dosage of

Elavil.”
6. “I can exercise as soon as I wake up in the morning.”

1) appropriate action; has a sedative effect; other side effects include blurred
vision, dry mouth, diaphoresis, postural hypotension, palpitations, constipation,
urinary retention, increased appetite
2) CORRECT— sunblock required
3) CORRECT— true of MAO inhibitors (Nardil, Marplan); foods containing
tyramine may cause hypertension
4) true statement; takes 3-4 weeks to achieve therapeutic level and see changes
in mood
5) CORRECT— patient should never adjust dosage of medication without
consulting a physician
6) CORRECT— may cause orthostatic hypotension; instruct client to sit on side
of bed before arising in the morning
The nurse interacts with a client verbalizing a cocaine craving. The nurse
acknowledges the client’s discomfort and suggests the client walk around the
exercise track in the gym. The nurse understands that walking on the track may
be helpful because of which of the following reasons?

1. The client is more comfortable being alone.
2. The client likes to be mentally challenged.
3. Increased physical activity will decrease the client’s feelings

of guilt.
4. Decreasing physical tension will reduce the craving for
cocaine.


1) encourage client to engage in activities that dissipate anxiety and increase
self-esteem; being alone does not increase self-esteem
2) may be true, but walking helps physically
3) will increase self-esteem
4) CORRECT— low-impact physical activity will dissipate anxiety; will help avoid
weight gain that may occur with recovery, stimulates release of endorphins
A 55-year-old client is seen in the outpatient clinic for complaints of perineal

irritation due to frequent incontinence. Which of following measures, if
suggested to the client by the nurse, is BEST?

1. Apply Betadine ointment to the perineum.
2. Gently cleanse the perineum with warm water 2–3

times/day.
3. Use extra large incontinence briefs during the day.
4. Expose the perineum to the air for 20 minutes each

day.


1) not best; topical antibacterial medication
2) CORRECT— warm water and gentle stroking stimulate circulation, promote
good hygiene; barrier creams may be used
3) not best; would increase perineal irritation
4) not best; keep area clean and dry
The nurse in the emergency department cares for a client diagnosed with a
possible cervical spinal cord injury. It is MOST important for the nurse to assess
for which of the following?

1. How the accident occurred.
2. Status of neurological
functioning.
3. Respirations and heart rate.
4. Pre-existing medical condition.

1) least important
2) important assessment; remember the ABCs
3) CORRECT— assessing respiratory functioning is priority, especially due to
cervical injury
4) first, assess client’s condition
A patient diagnosed with type 2 diabetes mellitus is treated for hypertension

with propanolol (Inderal). History reveals that the patient is diagnosed with
glaucoma and is allergic to sulfa. The nurse is MOST concerned if an order was
written for which of the following medications?

Carpine).
4. Timolol maleate
(Timoptic).


(1.) should be questioned but not of most concern; osmotic agent; diuretic;
increases osmolarity of the blood, extracting fluid from extracellular space into
the bloodstream, including aqueous humor and vitreous humor from the anterior
chamber of the eye, thus decreasing intraocular pressure; glycerin needs to be
used with caution in diabetics because it can cause hyperglycemia
(2.) no need to question this order; direct-acting parasympathetic function
causing miosis
(4.) should be questioned, but not priority; beta blockers given for systemic use,
such as propanolol and atenolol, can enhance the therapeutic and toxic effects
of beta blockers prescribed for ophthalmic use
The nurse cares for a client receiving ranitidine (Zantac) 150 mg PO BID. The
nurse should further assess if the client states which of the following?

1. “I am going to have allergy testing tomorrow.”
2. “I have increased my intake of whole grains and fresh

vegetables.”
3. “I like to smoke a cigarette immediately before bedtime.”
4. “I take an occasional Advil if my knees hurt.”
5. “I will take all of the medication in the bottle.”
6. “I drink a glass of red wine every night.”
Strategy: “Should further assess” indicates something is wrong.

1) CORRECT— may cause false-negative results on allergy skin testing; client
should avoid medication for 24 hours before testing
2) appropriate action, minimizes constipation; Zantac is histamine H 2
antagonist used to treat active duodenal ulcers or benign gastric ulcers
3) CORRECT— smoking interferes with histamine antagonist; client should not
smoke when taking medication; if client continues to smoke, should not smoke
after the last dose of the day
4) CORRECT— should avoid NSAIDs because of increased gastric irritation
6) CORRECT— should avoid alcohol because it may increase gastrointestinal
irritation
The nurse develops a plan of care for a client diagnosed with dementia. It is
MOST important for the nurse to include which of the following?

1. Reinforce the client’s thought patterns.
2. Use simple, short phrases when speaking with

the client.
3. Administer antianxiety medication.
4. Plan a regular exercise program.

1) reality orientation is important, don’t reinforce client’s altered thought
processes
2) CORRECT— enhance client’s ability to process information
3) may increase confusion
4) appropriate strategy to decrease anxiety
The nurse cares for an elderly client scheduled for a CT scan with and without
contrast. The client is diagnosed with type 1 diabetes and hypertension. The
nurse notes that the client’s BUN is 2.1 mg/dL and the creatinine is 2.1 mg/dL.
Which of the actions by the nurse is MOST appropriate?

1. Hydrate well before the procedure.
2. Monitor blood pressure before and after the

procedure.
3. Instruct client to be NPO for 6 hours before the
procedure.
4. Question whether the scan be done with contrast.

1) offer fluids after procedure
2) not necessary
3) if contrast dye used, NPO 8 hours before test
4) CORRECT— normal creatinine is 0.5 to 1.5 mg/dL; elevated levels indicate
acute and chronic renal failure; client also has decreased glomerular filtration
rate due to advanced age; contrast dye not safe due to renal status; normal BUN
is 5 to 25 mg/dL, decreased levels caused by severe liver damage, low-protein
diet, overhydration, and malnutrition
The nurse cares for a client who has been raped. Which of the following actions
by the nurse is MOST appropriate?

1. Focus on the here and now.
2. Refer the client for crisis counseling.
3. Determine how the rape occurred.
4. Determine how the client previously responded to

trauma.


question.
1) CORRECT— first action is to assist client to identify immediate needs and
concerns
2) appropriate action, but it isn’t the nurse’s first action
3) focus on the here and now
4) appropriate to find out how clients responded to crisis in the past; not the
priority action
The nurse cares for a client receiving spinal anesthesia. It is MOST important for
the nurse to take which of the following actions?

1. Ensure that the client is adequately hydrated before the
procedure.
2. Assess for allergies to iodine.
3. NPO for 12 hours before the procedure.
4. Determine the specific gravity of the client’s urine.

1) CORRECT— will prevent hypotensive problems after the anesthesia is
initiated
2) iodine preparations are not used in spinal anesthesia
3) not necessary; encourage fluids to ensure that the client is well hydrated
4) irrelevant to the procedure
The nurse cares for a client receiving haloperidol (Haldol) by intramuscular

injection. The client develops a fever of 103.6°F (40°C), pulse 110, muscle
rigidity, and incontinence. The nurse knows that the client is experiencing which
of the following?

1. Tardive dyskinesia.
2. Pseudoparkinsonism.
3. Acute dystonic reaction.
4. Neuroleptic malignant
syndrome.


1) characterized by abnormal facial and tongue movements
2) characterized by tremors, rigidity, and shuffling gait; administer an
anticholinergic agent
3) characterized by severe muscle contractions of the head and neck; administer
diphenhydramine hydrochloride (Benadryl)
4) CORRECT— severe reaction to antipsychotic medication as a result of
dopamine blockade in the hypothalamus; fatal in approximately 10% of cases;
stop medication; transfer to medical unit, cool body; administer bromocriptine
(Parlodel) to treat muscle rigidity and dantrolene (Dantrium) to reduce muscle
spasms
The nurse cares for an elderly client who requires bilateral eye patches. It is

1. Sedate the client until the eye patches are
removed.
2. Place the client in a private room.
3. Maintain a calm, dark environment.

4. Frequently touch the client while speaking to
him.


1) an elderly client with eye patches may experience sensory deprivation;
sedating elderly clients will make them more confused
2) private room would increase isolation
3) client requires stimulation
4) CORRECT— always speak to client when entering room; frequently reorient to
surroundings
The home care nurse instructs a client recovering from full-thickness burns of
the right leg. The nurse determines that teaching is effective if the client selects
which of the following menus?

1. Tossed salad, French bread, and coffee.
2. Peanut butter and banana sandwich, chips, and

lemonade.
3. Ham sandwich with Swiss cheese, pasta salad,
and tea.
4. Broiled pork chop, cream of potato soup, and
pudding.

Strategy: Determine what type of diet is required.

1) clients with full-thickness burns require high-calorie, high-protein diets; this
menu is low in protein
2) peanut butter contains protein, other foods do not
3) ham and Swiss cheese contain protein, pasta contains small amounts of
protein
4) CORRECT— all foods contain protein; creamed soup and pudding also
contain increased calories
The nurse reviews dietary guidelines with a client diagnosed with

gastroesophageal reflux disease (GERD). The nurse determines teaching is
successful if the client states which of the following?

2. “I will switch from orange juice to tomato juice at
breakfast.”
3. “I will eat three meals per day and not snack between
meals.”
inches.”


2) both juices are acidic and exacerbate reflux; apple juice is an appropriate
alternative
3) big meals exacerbate reflux by increasing volume and pressure in the
stomach as well as delay gastric emptying
4) CORRECT— recumbent position significantly impairs esophageal clearance;
head should be elevated 6 to 12 inches to prevent nighttime reflux
The home care nurse instructs a client diagnosed with Bell’s palsy. Which of the
following statements, if made by the client to the nurse, indicates further

1. “I should place an eye shield over the affected eye at
bedtime.”
2. “I should avoid sudden movement when bending
over.”
3. “I should not go out when there is a cold wind.”
4. “I should use heat on the affected side of my face.”
Strategy: “further teaching is necessary” indicates an incorrect statement.

1) appropriate action; prevents corneal irritation; use artificial tears
2) CORRECT— required if client has problems with increased intraocular
pressure
3) appropriate action due to sensitivity of nerve endings
A patient developed acute respiratory distress syndrome (ARDS) after an auto
accident and is being weaned from the ventilator. The nurse knows the best
mode to wean the patient from the ventilator is

(SIMV).

3) rate is variable but the tidal volume is preset so each breath is delivered at a
set volume regardless of patient’s needs
4) delivers positive pressure during expiration to keep airways constantly open;
used with seriously ill patients
The medical surgical nurse knows that which of the following patients is MOST
at risk for wound dehiscence and evisceration?

1. A patient diagnosed with Parkinson’s Disease who is 5 feet 8
inches tall, weighs 150 lb, and had stereotactic pallidotomy 2
days ago.
2. A patient diagnosed with type 2 diabetes mellitus who is 5 feet 5
inches tall, weighs 195 lb, and had an appendectomy 6 days ago.
3. A patient with history of mitral stenosis who is 5 feet 2 inches
tall, weighs 130 lb, and had open-heart surgery for mitral valve
reconstruction 10 days ago.
4. A patient with a fractured femur who is 6 feet 1 inch tall, weighs
170 lb, and is in balanced suspension traction after having open
reduction and internal fixation surgery 4 days ago.

Strategy: Discrimination is required to answer the question.
(1.) decreases tremor and rigidity via making a permanent lesion in the brain
(2.) CORRECT—patient is overweight (possibly with weak or pendulous
abdominal wall), probably has poor wound healing due to both the diabetes and
the weight, and is 6 days post abdominal surgery, which is the most frequent
type of surgery in which wound dehiscence and evisceration appear
(3.) less risk; incision located on chest
(4.) more risk with abdominal surgery
The nurse cares for a patient receiving haloperidol (Haldol) for 3 days. The
results of the nurse’s most recent assessment include: temperature 103.5°F
(39.7°C), BP 200/100, pulse 122. The nurse notes the patient is pale and sweating
excessively, and his arms are rigid. Which of the following actions should the
nurse take FIRST?

1. Monitor vital signs every 15 minutes.
3. Administer haloperidol (Haldol) as

ordered.
4. Administer bromocriptine (Parlodel) as
ordered.


1) symptoms consistent with neuroleptic malignant syndrome, which is a
serious complication of antipsychotic drugs; symptoms include sudden high
fever, rigidity, tachycardia, hypertension, and decreased LOC; contact physician
and monitor vital signs every 15 minutes
2) CORRECT— life-threatening complication; manage fluid balance, reduce
temperature, and monitor for complication
3) discontinue antipsychotic medication
4) Antiparkinson medication used to counteract effects of neuroleptic malignant
syndrome
The nurse in the emergency room is assigned to a patient who lost
consciousness while out jogging and was brought in by paramedics. The patient
regains consciousness and says to the nurse, "I saw my wife who died 5 years
ago. She told me we’ll be together soon." Which of the following responses by

1. "Because your wife died 5 years ago, I don’t think you really
saw her."
2. "You were probably in a dream state, but everything is fine
now."
3. "I’ll get the psychiatrist to speak with you about this."
4. "Tell me how you feel about what just happened."

(1.) close-ended; doesn’t allow the patient to verbalize feelings
(2.) false reassurance; response does not address patient’s feelings
(3.) passing the buck
(4.) CORRECT—open-ended response by the nurse allows patient to explore and
express thoughts and feelings
The nurse prepares a client for a bone scan. Which of the following statements
by the nurse to the client is MOST important?

1. “Be sure to drink lots of fluid in the time between the tracer
injection and the test.”
2. “You will feel some discomfort as the tracer is injected into your
muscle.”
3. “You will have to assume various positions on a tilting x-ray
table.”
4. “The scan is painless and will be over before you know it.”

1) CORRECT— interval between injection of the tracer and the actual scanning is
usually 1 to 3 hours; large amounts of fluid maintain hydration and decrease
radiation dose to the bladder; client should void immediately before scan to
prevent a distended bladder
2) tracer is administered IV, not IM
3) client does not change position; must lie still for bone scan
4) scan is painless, but may take about 1 hour; client required to lie still
throughout the scan
An older client suffers a left-sided cerebral infarct. The nurse expects the client
to exhibit which of the following?

1. Weakness of the left arm.
2. Impulsive behavior.
3. Disorientation to person, place, and

time.
4. Impaired speech.

1) unaffected; nerve fibers cross in the spinal canal, result in disabilities on
opposite (contralateral) side
4) CORRECT— left hemisphere controls speech, math skills, analytical thinking
The parents bring their 18-month-old into the emergency room. The nurse notes
that the child is having difficulty breathing and appears to be wheezing on
inspiration. It is MOST important for the nurse to ask the parents which of the
following questions?

2. “Do you or the child’s brothers or sisters have a history of

asthma?”
4. “Was your child eating a hot dog immediately before developing

breathing problems?”


3) ensure that child’s toys be large and sturdy, with no sharp edges or
removable parts
4) CORRECT— toddlers are in danger of aspirating large pieces of meat and hot
dogs, as well as nuts, dried beans, chewing gum; if children offered hot dogs,
cut into small, irregular shapes
The nurse supervises care of a client who is receiving enteral feeding via a
nasogastric tube. The nurse determines that care is appropriate if which of the

1. The nursing assistant aspirates and measures the amount of
the gastric aspirate.
2. The nursing assistant elevates the head of the client’s bed 30
degrees.
3. The nursing assistant warms the formula to room temperature.
4. The nursing assistant measures the pH of the gastric aspirate.
5. The nursing assistant infuses the intermittent feeding in 20

minutes.
6. The nursing assistant clamps the proximal end of the feeding
tube at the end of the feeding.


1) verifies placement of the tube and should be performed by the RN
2) CORRECT— prevents aspiration
3) CORRECT— prevents cramping
4) should be performed by a professional nurse
5) should infuse for a minimum of 30 minutes
6) CORRECT— prevents air from entering the stomach
A 24-year-old woman at 10 weeks’ gestation becomes nauseated each day

around 4 P.M. Which of the following interventions is MOST appropriate for the
nurse to suggest to the client?

1. Limit lunch to soft foods and fruit before 2
p.m.
2. Eat several pretzels around 3:30 p.m.
3. Take an antacid around 3:30 p.m.
4. Lie down and rest around 2 p.m.
Strategy: All the answer choices are implementations. Evaluate the outcome of
each answer choice. Is it desired?
1) implementation; does not provide requirements for healthy pregnancy
2) CORRECT— implementation; should eat dry carbohydrate food 30 minutes to
1 hour before getting out of bed; remain in bed until the feeling of nausea
subsides; alternate dry carbohydrate with fluids such as hot tea, milk, or coffee;
avoid eating fried, spicy, or gas-forming foods; eat small, frequent meals
3) implementation; heartburn due to displacement of stomach by the enlarging
uterus; take low sodium antacid; occurs in second and third trimesters
4) implementation; will not prevent nausea; fatigue common in first trimester
The nurse determines that which of the following patients is MOST likely to need
pyridoxine hydrochloride (vitamin B6) supplementation?

1. A patient diagnosed with tuberculosis.
2. A patient diagnosed with pernicious

anemia.
3. A patient diagnosed with chronic
alcoholism.
4. A patient at 12 weeks’ gestation.

(1.) CORRECT—patient is likely to be taking isoniazid (INH); INH is a mainstay in
prevention and treatment of tuberculosis, used in combination with other
antitubercular drugs if the disease is active; vitamin B6 is given to prevent the
peripheral neuropathy, dizziness, and ataxias that can occur with this drug
(2.) needs supplementation with vitamin B12
(3.) needs supplementation with all B vitamins, especially thiamine (vitamin B1);
thiamine deficiency is the primary cause of alcohol-related changes such as
Wernicke’s encephalopathy and Korsakoff’s syndrome
(4.) needs supplementation with folic acid (vitamin B9) to prevent neural tube
defects in the fetus; supplementation is recommended for all women capable of
becoming pregnant
The nurse in the medical clinic performs a chart review. The nurse identifies that
which of the following clients have modifiable risk factors for coronary artery
disease?

1. A 32-year-old African American.
2. A 44-year-old who has smoked for 25 years.
3. A 49-year-old who is 5'8" tall and weighs 242 pounds.
4. A 53-year-old whose father died at age 61 of a myocardial

infarction.
5. A 66-year-old with a blood cholesterol of 255 mg/dL.
6. A 70-year-old who plays golf four times per week.

1) incidence of heart disease is higher in African Americans but is a
nonmodifiable risk factor
2) CORRECT— smoking is a modifiable risk factor
3) CORRECT— obesity is a modifiable risk factor
4) increasing age and family history are nonmodifiable risk factors
5) CORRECT— normal cholesterol is 150 to 200 mg/dL; elevated cholesterol is a
modifiable risk factor
6) increasing age is a nonmodifiable risk factor; physical inactivity is a
modifiable risk factor; playing golf four times per week is acceptable physical
activity
The nurse cares for clients in the emergency department (ED). A newly married
woman is brought to the ED by her parents, who relate that their son-in-law was
killed 3 days ago in a boating accident. The parents report their daughter has
been uncontrollably screaming and crying since the boating accident. Which of

1. Administer diazepam (Valium).
2. Ask the parents to leave the room.
3. Refer the client and her parents to family

therapy.
4. Offer the client a reassuring hug.

1) may be appropriate at some point, but more important to convey to client that
the nurse understands her loss and will be with the client
2) may be appropriate at some point, but not the nurse’s first action
3) may be appropriate at some point, but not the nurse’s first action
4) CORRECT— important that nurse convey warmth, caring, and empathy with
the client; nurse should structure environment so client can express feelings
about her loss
The nurse observes a nursing student assess a client’s mobility. The client is
lying in the bed and the nursing student asks the client to sit in the chair so the
nursing student can complete the assessment. Which of the following responses

1. Instruct the nursing student to continue the assessment.
2. Ask the nursing student to report any difficulties the client may
have sitting in a chair.
3. Tell the nursing student to begin the assessment while the client
is lying in bed.
4. Talk with the nursing student at the completion of the
assessment.

Strategy: “BEST” indicates that discrimination is required to answer the

question.
1) should begin the assessment with the client in the most supportive position
2) to ensure client safety, begin assessment with client lying in bed; should
anticipate difficulties
3) CORRECT— to ensure client safety, begin assessing client’s movement when
the client is lying in bed, then ask client to sit on side of bed, transfer to the
chair, and then observe the client’s gait
4) client safety is priority, nurse should intervene immediately

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The home care nurse visits a client in a large apartment complex.

During the visit,

2. An unconscious client with left-sided tracheal shift from midline.

3. A client complaining of excruciating pain with an obvious

Strategy: Determine the most unstable client.

4. A 75-year-old male complains of insomnia and irritability after the death

Strategy: Determine the most unstable client.

Strategy: Determine the most unstable client.

3. A 21-year-old with a history of chronic sinus

Strategy: Determine the most unstable client.

3. An unconscious client with a regular heart rhythm at 64 bpm with even

Strategy: Determine the most unstable client.

Strategy: Determine the most unstable patient.

3. A patient with a short arm cast on the left arm.

4. A patient diagnosed with hypothyroidism requiring TSH level.

Strategy: Determine the most unstable patient.

2. A 35-year-old who had a hysterosalpingogram is experiencing

4. A 25-year-old scheduled for a Pap smear.

Strategy: Determine the most unstable client.

3. A 6-year-old with small lacerations to the

Strategy: Determine the most unstable patient.

3. A patient who will be discharged this afternoon.

4. A patient with a fasting blood glucose of 517 mg/dL.

Strategy: Determine the most unstable patient.

Strategy: Determine the most unstable patient.

2. A patient diagnosed with Wilms tumor complaining of thirst.

3. A patient diagnosed with hemophilia complaining of joint pain.

4. A patient diagnosed with gastroesophageal reflux complaining of

Strategy: Determine the most unstable patient.

3. A client with a tonometer reading of 21 mm Hg.

4. A client with a laryngectomy who is complaining of a greenish-yellow

Strategy: Determine the most unstable patient.

3. A client receiving lorazepam (Ativan) and experiencing abdominal

3. A child diagnosed with gastroenteritis with five diarrheal stools in the

Strategy: Determine the most unstable patient.

A nurse working in an emergency department performs a yearly ride-along with a

2. A child who is crying that her leg is broken.

Strategy: Determine the most unstable patient.

Strategy: Determine the most unstable patient.

Strategy: Determine the most unstable patient.

2. A client who is scheduled to receive the prescribed metered dose

Strategy: Determine the most unstable client.

Strategy: Determine the most unstable patient.

Strategy: Determine the most unstable client.

2. "My face gets red when I eat shrimp."

3. "I get claustrophobic when I am in a

Strategy: Determine the most unstable client.

4. An infant with vomiting and diarrhea.

Strategy: Determine the most unstable patient.

Strategy: Determine the most unstable client.

Strategy: Determine the most unstable client.

A psychiatric nurse is presented with a group of patients in the emergency

4. A middle-aged adult who is fearful after witnessing a murder.

Strategy: Determine the most unstable patient.

Strategy: “FIRST” indicates priority.

The nurse in a small town is called to a neighbor’s house in the middle of a

2. Tell the emergency management team they will have to re-

4. Inform the emergency department nurses they must work

Strategy: “FIRST” indicates priority.