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Questions D. Nonsteroidal antiinflammatory agents.

6. 6 59
1. 1 98 A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID).
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which The client asks the nurse, "How is this medication different from the acetaminophen I have been
prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma? taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?
A. Pindolol (Visken). A. Are less expensive.
B. Carteolol (Ocupress). B. Provide antiinflammatory response. Correct
C. Metoprolol tartrate (Lopressor). Correct C. Cause gastrointestinal bleeding.
D. Propranolol hydrochloride (Inderal). D. Increase hepatotoxic side effects.
2. 2 22 7. 7 62
A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain.
provider discontinued the medication because his blood pressure has been normal for the past three Which organ function is most important for the nurse to monitor?
months. Which instruction should the nurse provide?
A. Liver. Correct
A. Report any uncomfortable symptoms after stopping the medication.
B. Kidney.
B. Stop the medication and keep an accurate record of blood pressure.
C. Sensory.
C. Ask the healthcare provider about tapering the drug dose over the next week. Correct
D. Cardiorespiratory.
D. Obtain another antihypertensive prescription to avoid withdrawal symptoms. 8. 8 10
3. 3 04 The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
should the nurse make?
A. Administer the dose as prescribed. Correct
A. How long has the client been taking the medication? Correct
B. Withhold the drug and notify the healthcare provider.
B. Does the client use any tobacco products?
C. Give intravenous (IV) calcium gluconate.
C. Has the client experienced constipation recently?
D. Recheck the vital signs in 30 minutes and then administer the dose.
D. Did the client miss any doses of the medication? 9. 9 83
4. 4 90 A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which
The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a categories of illness should the nurse develop goals for the client's plan of care?
cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What
A. Two acute illnesses.
response is best for the nurse to provide?
B. Two chronic illnesses.
A. Provide a more rapid induction of anesthesia.
C. One chronic and one acute illness. Correct
B. Decrease the risk of bradycardia during surgery. Correct
D. One acute and one infectious illness.
C. Induce relaxation before induction of anesthesia.
10. 10 14
D. Minimize the amount of analgesia needed postoperatively. Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her
5. 5 86 newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication
A. Initiate the lactation process.
should the nurse question that poses a potential development of urinary retention in this geriatric client?
B. Prevent neonatal hypoglycemia.
A. Insulin.
C. Stimulate contraction of the uterus. Correct
B. Antacids.
D. Facilitate maternal-infant bonding.
C. Tricyclic antidepressants. Correct
11. 11 04
Which intervention should the nurse include in the plan of care for a female client with severe 16. 16 06
postpartum depression who is admitted to the inpatient psychiatric unit? The nurse manager is assisting a nurse with improving organizational skills and time management.
A. Full rooming-in for the infant and mother. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily
assignment?
B. Restrict visitors who irritate the client.
A. Medication administration. Correct
C. Supervised and guided visits with infant. Correct
B. Client personal hygiene.
D. Daily visits with her significant other.
12. 12 35 C. Colostomy care instruction.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured D. Tracheostomy tube suctioning.
bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action 17. 17 20
should be implemented to obtain a valid informed consent? What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-
A. Instruct the client sign the consent before giving medications. hour period?

B. Obtain the permission of the custodial parent for the surgery. Correct A. Team nursing.

C. Obtain the signature of the client’s stepfather for the surgery. B. Primary nursing. Correct

D. Notify the non-custodial parent to also sign a consent form. C. Case management.
13. 13 58 D. Functional nursing.
During a client assessment, the client says, "I can't walk very well." Which action should the nurse 18. 18 80
implement first? Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break
A. Identify the problem. Correct first. What is the most important basic guideline that the nurse should follow in resolving the conflict?

B. Consider alternatives. A. Deal with issues and not personalities. Correct

C. Predict the likelihood of the outcome. B. Require the UAPs to reach a compromise.

D. Choose the most successful approach. C. Weigh the consequences of each possible solution.
14. 14 12 D. Encourage the two to view the humor of the conflict.
The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less 19. 19 31
than body requirements, related to mental impairment and decreased intake, as evidenced by The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the
increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short- client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should
term goal is best for this client? the nurse document that indicates a successful outcome?
A. Eat 50% of six small meals each day by the end of one week. Correct A. Demonstrates adequate fluid intake and output.
B. Meals prepared during hospitalization will be fed by the nurse. B. Voids at least 1000 mL between 7 am and 3 pm.
C. Verbalize understanding of plan and of intention to eat meals. C. Verbalizes abdominal comfort without pressure.
D. Demonstrate progressive weight gain toward the ideal weight. D. Drinks 240 mL of fluid five times during the shift. Correct
15. 15 69 20. 20 53
A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to The nurse plans a teaching session with a client but postpones the planned session based on which
take his chart with him and states the chart is "his" and he doesn' t want any more contact with the nursing problem?
hospital. How should the nurse respond? A. Activity intolerance related to postoperative pain. Correct
A. Because you are leaving against medical advice, you may not have your chart. B. Noncompliance with prescribed exercise plan.
B. The information in your chart is confidential and cannot leave this facility legally. C. Ineffective management of treatment regimen.
C. This hospital does not need to keep it if you are leaving and not returning here. D. Knowledge deficit regarding impending surgery.
D. The chart is the property of the hospital but I will see that a copy is made for you. Correct 21. 21 06
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering
for the nurse to implement? more of the iris than the right eyelid. Which description should the nurse use to document this finding?
A. Place an isolation cart in the hallway. A. Ptosis on the left eyelid. Correct
B. Fit the client with a respirator mask. B. A nystagmus on the left.
C. Don a clean gown for client care. C. Astigmatism on the right.
D. Assign the client to a negative air-flow room. Correct D. Exophthalmos on the right.
22. 22 85 27. 27 26
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse
the client's apical pulse is 65 beats per minute. What action should the nurse implement next? plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for
A. Notify the healthcare provider. the child's height. What action should the nurse take?

B. Measure the blood pressure. A. Recommend a daily intake of at least four glasses of whole milk.

C. Administer the medication. Correct B. Encourage giving two additional snacks each day to the child.

D. Reassess the apical pulse. C. Question the type and quantity of foods eaten in a typical day. Correct
23. 23 75 D. Assess for signs of poor nutrition, such as a pale appearance.
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with 28. 28 02
which interpretation? A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body
A. Thyroid cyst. weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour
should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only.
B. Thyroid cancer.
If rounding is required, round to the nearest whole number.)
C. Hypothyroidism.
A. 61 Correct
D. Hyperthyroidism. Correct
B. 58
24. 24 70
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis C. 73
and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the D. 24
child for additional manifestations of a basilar skull fracture. What assessment finding would be 29. 29 20
consistent with a basilar skull fracture? The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin).
A. Asymmetry of the face and eye movements. Which action should the nurse take?

B. Abnormal position and movement of the arm. A. Assess respiratory rate for one minute next.

C. Hematemesis and abdominal distention. B. Give the medication dosage as scheduled.

D. Rhinorrhoea or otorrhoea with Halo sign. Correct C. Wait 30 minutes and give half of the dosage of medication.
25. 25 55 D. Withhold the medication and contact the healthcare provider. Correct
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. For an infant withhold digoxin for less than 90-100 bpm. For a child withhold digoxin less than 70bpm. For an
The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a adult withhold less than 60bpm.
staring expression. These findings are consistent with which disorder? 30. 30 67
A. Grave's disease. Correct The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction
should the nurse include?
B. Cushing syndrome.
A. Remove the brace just before going to bed.
C. Multiple sclerosis.
B. Dress with the brace over regular clothing.
D. Addison's disease.
26. 26 46 C. Shower with the brace directly against the skin.
D. Wear the brace over a T-shirt 23 hours per day. Correct A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A
31. woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, provide?
"Why do you have to wear a gown and mask when you are in my room?" How should the nurse A. Low doses of tamoxifen prevent menopausal hot flashes.
respond? B. An used to reduce the risk of breast cancer for all women.
A. “There are many forms of bacteria and germs in the hospital.” C. This anti-estrogen drug inhibits malignancy growth. Correct
B. “To protect you because you can get an infection very easily.” Correct D. Part of a combination of chemotherapeutic agents used to treat tumors.
C. “After taking medication for 24 hours a gown and mask won't be needed.” 37.
D. "Your condition could be spread to staff and other clients in the hospital.” A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should
32. be assigned to care for this client?
The nurse is giving discharge instructions to the parents of a newborn with a prescription for home A. The nurse who is caring for another client receiving intracavitary radiation.
phototherapy. Which statement by a parent indicates understanding of the phototherapy? B. A nurse with Marfan's syndrome who is postmenopausal. Correct
A. “I need to change the baby’s position every four hours.” C. A nurse with oncology experience who may be pregnant.
B. “I should leave the baby under the light all of the time.” D. The nurse who is caring for another client who has Clostridium difficile.
C. “I will keep the baby’s eyes covered when the baby is under the light.” Correct 38.
D. “I should dress the baby in light clothing when the baby is under the light.” Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A
33. cervical cancer?
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, A. Notify the healthcare provider if heavy vaginal discharge occurs.
and complains of dry mouth. Which action should the nurse implement? B. Use condoms for sexual intercourse during the next week.
A. Put petroleum jelly on the lips and around the nasogastric tube. C. Flat subclinical mucosal lesions are a common harmLess side effect.
B. Allow the client to drink water and record on the I and O record. D. Use a sanitary napkin instead of a tampon. Correct
C. Offer the client ice chips and instruct client to spit out the water. 39.
D. Apply a water soluble lubricant to the lips, oral mucosa and nares. Correct Which nurse follows a client from admission through discharge or resolution of illness and coordinates
34. the client's care between healthcare providers?
The nurse is assessing the laboratory results for a client who is admitted with renal failure and A. Case manager. Correct
osteodystrophy. Which findings are consistent with this client's clinical picture? B. Nurse-manager.
A. Blood urea nitrogen 40 m and creatinine 1.0. C. Quality manager.
B. Cloudy, amber urine with sediment, specific gravity of 1.040. D. Discharge manager.
C. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. Correct 40.
D. Hemoglobin of 10 g and hypophosphatemia. The nurse is preparing a client for a scheduled surgical procedure. What client statement should the
35. nurse report to the healthcare provider?
Which information should the nurse give a client with chronic kidney disease (CKD)? A. Expresses fear about the surgical procedure.
A. Restrict calcium-rich foods. B. Recalls drinking a glass of juice after midnight. Correct
B. Obtain monthly B12 injections. C. Reports a history of hives after eating shellfish.
C. Avoid salt substitutes. Correct D. States has a history of post-operative nausea.
D. Increase daily intake of fiber. 41.
36.
The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean- B. Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds.
cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he
C. Jugular venous pressure palpable with the client in an upright position.
continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?
D. Point of maximal impulse at the third intercostal space in the right midclavicular line.
A. Adolescents who demonstrate labile behaviors are at risk for self-injury.
47. 47 38
B. Rebelliousness requires consequences to prevent socially deviant behavior. The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and
C. Early adolescence is a developmental stage of normal experimentation. Correct hitting his head. Which assessment finding is the earliest and most sensitive indication of altered
D. The parents should consider hospitalization to prevent self injury. cerebral function?
42. A. Unequal pupils.
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse B. Loss of central reflexes.
answers most of the questions for the client. Which action is best for the nurse to implement?
C. Inability to open the eyes.
A. Direct the questions to the spouse whenever possible.
D. Change in level of consciousness. Correct
B. Repeat each question and tell the client to speak up. 48. 48 74
C. Ask another nurse to complete the interview. When documenting assessment data, which statement should the nurse record in the narrative nursing
D. Ask the spouse to step out for a few minutes. Correct notes?
43. A. Hair is within normal limits.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. B. Most all permanent teeth are present.
Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than
C. S1 murmur auscultated in supine position. Correct
body requirements?"
D. Slight tenderness in the left upper quadrant.
A. Morbidly obese.
49. 49 72
B. Markedly obese. A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my
C. Inadequate lifestyle changes in diet and exercise. Correct husband." What type of thoughts is the client having?
D. Increased morbidity and mortality risks. A. Obsessive. Correct
44. B. Phobic.
The nurse is assessing a client and identifies the presence of petechiae. Which documentation best
C. Delusional.
describes this finding?
D. Paranoid.
A. Purplish-red pinpoint lesions of the skin. Correct
50. 50 65
B. Purple to bluish discoloration of the skin. The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal
C. Small circumscribed elevations containing purulent fluid. reaction to psychotropic medications. When the receptionist for the answering service offers to take a
D. Generalized reddish discoloration of an area of skin. message, which nursing action is best for the nurse to take?
45. A. Ask when the healthcare provider plans to return to the office and the usual office hours.
The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? B. Tell the receptionist to have the healthcare provider return the phone call. Correct
A. A Hispanic client may have inward-turned eyelashes. C. Provide the receptionist with the client's name, age, and type of reaction.
B. An Asian client may have a horizontal palpebrale fissure. D. Ask the receptionist to notify the client's family if the healthcare provider cannot be
C. An African-American client may have slightly yellow sclerae. Correct contacted.
D. A Caucasian client may have a slightly protruding eyeball. 51. 51 32
46. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the
During the physical assessment, which finding should the nurse recognize as a normal finding? perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse
place the client?
A. Regular pulsation at the epigastric area when the client is supine. Correct
A. Left supine with thighs flexed on her abdomen. A work group is to be formed to determine a care map for a new surgical intervention that is being
conducted at the hospital. Which group is likely to be most effective in developing the new care map?
B. Right lateral side with both legs flexed.
A. Nurse-manager group.
C. Semi-Fowler's with head of bed elevated 30 degrees.
B. Multidisciplinary group. Correct
D. Supine with the foot of the bed elevated. Correct
52. 52 50 C. Single-discipline group.
The nurse is developing a series of childbirth preparation classes for primigravida women and their D. Surgical staff group.
significant others. What is the priority expected outcome for these classes? 57. 57 57
A. Educate significant others about providing support for their partner during labor. The scope of professional nursing practice is determined by rules promulgated by which organization?

B. Participants can identify at least three coping strategies to use during labor. Correct A. State's Board of Nursing. Correct

C. Teach and practice breathing techniques to help cope with contractions during labor. B. State Nursing Associations.

D. Introduce comfort measures that are effective techniques to use during labor and C. American Nurses Association (ANA).
delivery. D. National Labor Relations Board (NLRB).
53. 53 32 58. 58 02
A female client makes routine visits to a neighborhood community health center. The nurse notes that An older client who has been bedridden for a month is admitted with a pressure ulcer on the left
this client often presents with facial bruising, particularly around the eyes. The nurse discusses trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which
prevention of domestic violence with the client even though the client does not admit to being battered. stage should the nurse document this finding?
What level of prevention has the nurse applied in this situation? A. Stage 1.
A. Primary prevention. B. Stage 2.
B. Secondary prevention. Correct C. Stage 3. Correct
C. Tertiary prevention. D. Stage 4.
D. Health promotion. 59. 59 51
54. 54 82 After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse
Clinical portfolios are being introduced into the performance appraisal process for staff nurses assess first?
employed at a hospital. What should the nurse-manager request that each staff nurse include in the A. The client who has a new onset of difficult breathing. Correct
portfolio?
B. An anxious client who is 3 days post myocardial infarction.
A. Evaluations by past nursing faculty and employers to document ongoing competence.
C. The client with type 2 diabetes mellitus who has a call light on.
B. Copies of any articles the nurse has read that relate to client care on the nursing unit.
D. A client whose blood transfusion is near completion.
C. Letters of support from family members and friends who are healthcare professionals. 60. 60 12
D. A self-evaluation that identifies how the nurse has met professional objectives and When meeting with the client and the family, which nursing intervention demonstrates the nurse's role
goals. Correct as collaborator of care?
55. 55 63 A. Coordinating and educating about multidisciplinary services. Correct
When engaging in planned change on the unit, what should the nurse-manager establish first?
B. Providing information on financial assistance programs.
A. Goals for achieving the change are established.
C. Referring and consulting with other healthcare specialities.
B. Options for accomplishing the change are explored.
D. Informing about the findings that determine clinical diagnosis.
C. Resources needed for the change are available. 61. 61 78
D. Staff members are aware of the need for change. Correct Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains
56. 56 60 50 mg/mL. How much solution should the nurse administer?
A. 0.5 mL.
B. 1 mL. A. Increase the oxygen flow to 6 liters/minute.
C. 1.5 mL. Correct B. Encourage the use of an incentive spirometer. Correct
D. 2 mL. C. Notify the healthcare provider of the crisis blood gas values.
62. 62 18 D. Encourage the client to breathe slower.
A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? 67. 67 54
A. Dried prunes. Correct A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression.
B. Cottage cheese. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing
intervention is most important to include in the client's plan of care?
C. Mashed potatoes.
A. Gather more data about social support.
D. Mustard greens.
63. 63 71 B. Teach that anger will subside after two weeks on antidepressants.
A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission C. Ask client to describe triggers of anger. Correct
assessment, the nurse expects this client to exhibit which clinical manifestations? D. Collaborate with the treatment team about revising the goal.
A. Thin, fragile skin, ecchymoses, and complaints of weakness. 68. 68 28
B. Headache, diaphoresis, and palpitations. The nurse is conducting a drug education class for junior high school students. Which statement,
provided by one of the student participants, best describes the primary characteristic of addiction?
C. Hypotension, rapid weak pulse, and rapid respiratory rate. Correct
A. Addicts who use illegal drugs are trying to escape reality.
D. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium.
64. 64 00 B. Addiction causes people to steal and lie.
The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of C. Those who are unhappy with themselves are more likely to become addicts.
the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the D. Wanting the drug is all that matters to an addict. Correct
lungs. What safety factors should the nurse consider when suctioning this client? 69. 69 08
A. Suction for only 5 seconds since the client has only one lung and cannot hold his breath The nurse is caring for critically ill clients. Which client should be monitored for the development of
for very long. neurogenic shock? A client with
B. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. Correct A. congestive heart failure.
C. Have another person available to hold the client's hands to prevent inadvertent removal B. gastrointestinal hemorrhage.
of the suction tube. C. spinal cord injury. Correct
D. Suction deeply and vigorously to ensure that all secretions are removed in order to D. diabetes insipidus.
prevent atelectasis. 70. 70 96
65. 65 37 Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?
A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him.
A. I will be your primary resource person, and will gather the information you need to get
What oxygen delivery system is best for this client?
through this situation.
A. Rebreather mask.
B. Based on past coping, I believe you will be able to deal with future problems
B. Venturi mask. successfully.
C. Nasal cannula. Correct C. I have a plan of action that I think will help you. Would you like to see if it will work for
D. Hand-held nebulizer. you?
66. 66 81 D. You seem to be more tense these days. Would you like to talk about the problem and
Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg how you are dealing with it? Correct
and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to 71. 71 88
move in bed or deep breathe. Based on this information, what action should the nurse implement at
this time?
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which D. Encourage fluid intake of non-caffeinated beverages.
information is most important for the nurse to include in the teaching plan? 76. 76 88
A. Apply warm compresses to reduce swelling. The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The
B. Wear sunglasses to protect eyes from sunlight. 10 mL vial is labeled "Mucomyst 20% solution (20 grams/100 mL)." What volume of medication in
milliliters should the nurse administer? (Enter numeric value only.)
C. Take acetaminophen (Tylenol) for any eye discomfort.
D. Avoid sharing towels and washcloths with siblings. Correct
72. 72 40 Correct Responses
The school nurse is reviewing health risks associated with extracurricular activities of grade-school 1. 3
children. Regular participation in which activity places the child at highest risk for developing external 77. 77 08
otitis? A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low
fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him
A. Batting practice at a batting cage.
part of their meals. What intervention should the nurse implement?
B. Soccer practice at an outdoor field.
. Remove the client from the table and have him sit alone.
C. Swimming lessons in an indoor pool. Correct
A. Send the client back to his room and do not allow him to eat.
D. Roller skating at an indoor rink.
B. Report the behavior to the on-call psychologist immediately.
73. 73 06
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health C. Confront the client about the consequences of the behavior. Correct
clinic. Which individual has the greatest nutritional and energy demands? 78. 78 24
In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to
A. A pregnant woman. Correct
caution the parents to be alert for which condition?
B. A teenager beginning puberty.
. Increased thirst. Correct
C. A 3-month-old infant.
A. Soft anterior fontanel.
D. A school-aged child.
B. Cool, diaphoretic skin.
74. 74 80
The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential C. Swelling around the eyes and face.
hypertension. Which comment should the nurse include in the inservice presentation about the care of 79. 79 44
clients with hypertension? A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing
with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing.
A. Clients with an elevated blood pressure often exhibit a stiff neck and are diaphoretic.
Which intervention should the charge nurse implement?
B. As long as clients receive daily antihypertensive medications, no further interventions are
. Perform the wound care and have the PN provide the client's morning care.
needed.
A. Advise the PN to review the procedure in the procedure manual and then complete the
C. Caregivers should only conduct blood pressure checks under a registered nurse's direct
wound care.
supervision.
B. Note the PN's learning need to perform a wound packing and contact nursing education
D. Frequent blood pressure checks, including readings taken by automated machines, are
to schedule a time for instruction.
recommended. Correct
75. 75 26 C. Demonstrate the wound care procedure to the PN while the PN assists. Correct
A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention 80. 80 73
during the first 48 hours following admission? A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse
can lessen the symptoms of this "TET spell?"
A. Administer thiamine (B1) to prevent Korsakoff's syndrome.
. Remove child's constrictive clothing.
B. Monitor for increased blood pressure and pulse. Correct
A. Place child in knee-chest position. Correct
C. Administer a PRN benzodiazepine as needed for anxiety.
B. Have child stop all current activity.
C. Administer a dose of digoxin stat. B. Ask the legal department if the code should be continued.
81. 81 73 C. Assess the family's support for the durable power of attorney.
During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that 86. 86 98
she has not taken her medication for three years, her mother will not let her return home, and she does A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse
not have transportation or a job. Which client goal is most important for this client? explains a durable power of attorney for health care, which description is accurate?
. Taking medication, with community follow-up. Correct . It allows you to document your wishes regarding life-sustaining treatment if you can't
A. Obtain housing, with possibility of returning home. speak for yourself.
B. Become familiar with public transportation. A. It will identify someone that can make decisions for your health care if you are in a coma
C. Begin vocational rehabilitation. or vegetative state. Correct
82. 82 77 B. It is not legally binding, but helps the healthcare provider know exactly what medical
The nurse is preparing to administer a high volume saline enema to a client. Which information is most treatments you want.
important for the nurse to obtain prior to administering the enema? C. It is a form that all people must sign before admission to the hospital so that
. History of inflammatory bowel disorders. Correct individualized treatment plans can be developed.
A. Reason for administering the enema. 87. 87 98
Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness
B. Feelings about having an enema.
after administration? The client
C. Allergies to medications.
. smiling while visiting with family members.
83. 83 68
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her A. reports decrease in pain. Correct
daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set B. complained of pain; PRN pain medication given.
the table for her deceased husband. What nursing problem best describes this problem? C. was talking on the phone 30 minutes after pain medication was given.
. Confusion related to recent death of loved one. 88. 88 66
A. Delayed grief reaction related to death of husband. After eye drops are instilled, which instruction should the nurse provide to the client?

B. Denial related to the loss of a loved one. Correct . Tilt your head back.

C. Unresolved anger related to death of husband. A. Look to each side.


84. 84 78 B. Close your eyelids. Correct
A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager C. Blink quickly 3 times.
take? 89. 89 92
. Talk to the colleague about what was seen. The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which
A. Report the incident to the immediate supervisor. Correct feature is most important for the nurse to select?

B. Carefully observe the nurse to verify the behavior. . Micro drop factor.

C. Determine if other staff have observed similar behavior. A. Drop factor of 15 gtt/mL.
85. 85 49 B. An intact inline filter.
A client is brought into the emergency department following a sudden cardiac arrest. A full code is C. A Buretrol attachment. Correct
started. Five minutes later the family arrives with a durable power of attorney signed by the client 90. 90 86
requesting that no extraordinary measures be taken, including intubation, to save the client's life. What Prior to transferring a client to a chair using a mechanical lift, what is the most important client
action should the nurse take? characteristic the nurse should assess?
. Stop the code immediately. Correct . Ability to grasp objects.
A. Continue the code according to protocol. A. Ability to bear weight.
B. Upper body muscle strength. C. Conducts research studies that enhance health safety.
C. Tolerance of exertion. Correct 96. 96 36
91. 91 24 The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a
Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 man who is reading the names on the hall doors, he identifies himself as a reporter for the local
mg. Before breaking the tablet, what action should the nurse take? newspaper and requests information about the client's status. Which standard of nursing practice
should the nurse use to respond?
. Apply non-sterile gloves.
. Caring.
A. Perform hand hygiene. Correct
A. Veracity.
B. Consult with the pharmacist.
B. Advocacy.
C. Chart "half tablet administered."
92. 92 75 C. Confidentiality. Correct
Which assessment finding should make the nurse suspect that a 21-year-old male client is taking 97. 97 20
anabolic steroids? A client is being admitted to the medical unit from the emergency department after having a chest tube
inserted. What equipment should be brought to this client's room?
. Complains of increased facial hair growth.
. Crash cart.
A. Acne increased on face and back.
A. Endotracheal tube.
B. Describes working hard to develop muscles. Correct
B. Rubber-tipped clamps. Correct
C. Weight gain of 10 pounds in past month.
93. 93 52 C. Partial rebreather oxygen mask.
Which instruction should the nurse include in the discharge teaching for a client who is taking an 98. 98 16
antipsychotic medication? A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled
for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the
. Increase daily intake of raw fruits and vegetables. Correct
nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for
A. Follow a low carbohydrate diet.
the nurse to provide?
B. Take a multivitamin daily.
. You should have minimal withdrawal symptoms.
C. Report increased urine output to the healthcare provider immediately.
A. Headache and hyperirritability are common. Correct
94. 94 92
B. A common withdrawal response is hypertension.
Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to
screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse C. Expect to have a loss of appetite and tachycardia.
implement to ensure the validity of the test? 99. 99 38
The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one
. Collect the blood prior to the next 4-hour feeding to obtain a fasting specimen.
day post abdominal surgery. Which action should the nurse take next?
A. Instruct the mother to bring the newborn back in one week to have this test completed.
. Mark the drainage on the dressing and take vital signs. Correct
B. Assess the newborn's feeding patterns of formula or breast milk which has "come
A. Notify the healthcare provider of a potential for hemorrhage.
in." Correct
B. Remove the dressing and assess the surgical incision site.
C. Obtain venipuncture specimens to prevent hemolysis when expressed from capillaries.
95. 95 94 C. Reassess dressing in one hour for increased drainage.
Which nursing intervention is an example of a competent performance criterion for an occupational and 100. 100 48
environmental health nurse? The nurse is planning care for a client who is having abdominal surgery. To achieve desired
postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such
. Serves as a consultant to businesses and management.
as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse
A. Implements health programs for construction workers. Correct
include?
B. Designs quality improvement methods that measure health outcomes.
. Explain the rationale for each postoperative exercise and intervention.
A. Praise client when actively participating in postoperative exercises. C. Immobilization of the left knee to prevent dislocation.
B. Administer analgesics prior to encouraging progressive activities and ambulation. Correct 106. 106 56
A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not
C. Advise client about complications related to inactivity in the postoperative period.
responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is
101. 101 08
necessary. Which is the best response for the nurse to provide?
To assess a client's pupillary response to accommodation, a nurse should perform which activity?
. The dead bone needs to be removed to provide a blood supply for new bone growth.
. Cover one eye for one minute and note the pupil reaction when the cover is removed.
A. The infection is caused by a mutated bacteria that is resistant to most antibiotics.
A. Shine a light into the client’s eye and watch the pupil response in the opposite eye.
B. If the infected dead bone is not removed, it will make a path to the skin and drain pus.
B. Touch the cornea with a piece of sterile cotton and observe for a change in pupil size.
C. The infection has walled off into an area of infected bone creating a barrier to
C. Ask the client to look at a distant object and then at an object held 10 cm from the
antibiotics. Correct
nose. Correct
107. 107 64
102. 102 22
After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid
A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest
arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a
radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which
therapeutic response?
intervention for this nurse?
. Fasting serum glucose.
. Repeat the skin test and chest radiograph in three weeks.
A. Serum liver function test.
A. Administer isoniazid (INH) daily for 6 to 9 months. Correct
B. Serum electrolyte levels.
B. Give combination therapy of antitubercular drugs for 6 months.
C. Erythrocyte sedimentation rate. Correct
C. Recommend the bacille Calmette-Guérin (BCG) vaccine.
108. 108 79
103. 103 54
A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he
Prior to a cardiac catheterization, which activity should the nurse have the client practice?
may have been exposed. Which response should the nurse provide?
. Flexing hips and knees bilaterally.
. Cover the ticks with oil to suffocate and kill them to prevent transmission.
A. Valsalva's maneuver and coughing. Correct
A. Look for early signs of a lesion that increases in size with a red border, clear
B. Talking while walking on a treadmill.
center. Correct
C. Remain motionless for 5 minutes.
B. See a healthcare provider if nausea, vomiting, and joint pain occur after a tick bite.
104. 104 00
C. Obtain early treatment with antiviral agents to prevent cardiac manifestations.
A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain
109. 109 27
in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses
What information best supports the nurse's explanation for promoting the use of alternative or
are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take?
complementary therapies?
. Elevate the legs and medicate for pain.
. Focuses on the pathogenesis of the disease of an individual.
A. Apply firm pressure to the femoral artery.
A. Replaces the conventional Western modality treatments.
B. Keep the client in bed in the supine position. Correct
B. Recognizes the value of a client's input into their own health care. Correct
C. Encourage the client to exercise the leg.
C. Continues to be used by a limited number of Americans.
105. 105 00
110. 110 33
The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA).
The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients.
Which intervention should the nurse include in the plan of care?
Which factor is most influential for the acceptance of the healthcare practices?
. Progressive leg exercises to obtain 90-degree flexion. Correct
. Income grouping.
A. Ambulation with full weight-bearing on first postop day.
A. Ethic background.
B. Bed rest for three days with the left knee extended.
B. Individual beliefs. Correct C. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration
C. Educational level. on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is
111. 111 29 abusive. Correct
The nurse is planning a wellness program aimed at primary prevention in the community. Which action 115. 115 65
should the nurse implement? During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal
infection and says she is afraid she has another sexually transmitted infection. The client discloses her
. Immunizations that decrease occurrences of many contagious diseases. Correct
history of previous STI. Which condition should the nurse identify as the most prevalent STI in the
A. Blood pressure screenings to identify persons with high blood pressure.
United States among women?
B. Breast self-examination (BSE) for young women instead of a mammogram.
. Gonorrhea.
C. Home care monitoring for clients who are high-risk due to pregnancy.
A. Chlamydia. Correct
112. 112 14
B. Candidiasis.
A female client tells the nurse that she does not know which day of the month is best to do breast self-
exams (BSE). Which instruction should the nurse provide? C. Trichomoniasis.
116. 116 84
. Midway between menstrual cycles.
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections.
A. One week before your period.
Which instructions should the nurse provide?
B. The first day of your period.
. Use a douche preparation no more than once a month.
C. Five to seven days after menses cease. Correct
A. Increase daily intake of fiber and leafy green vegetables.
113. 113 10
B. Select nylon underwear that is loose-fitting, white, and comfortable.
A nurse takes a female client to the examination room and asks her to remove her clothes and put on
an examination gown with the front open. The woman states, "I have special undergarments that I do C. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. Correct
not remove for religious reasons." How should the nurse respond? 117. 117 18
A female client tells the nurse that her home pregnancy test is positive and her last menstrual period
. "I will ask the healthcare provider to modify the examination."
(LMP) was February 14. The client wants to know the expected date of birth (EDB). How should the
A. "All clothing must be removed before the examination to provide full access to the area
nurse respond?
to be assessed."
. September 17.
B. "What type of undergarments are you wearing?"
A. November 21. Correct
C. "Tell me about your undergarments so we can discuss how you can have your
B. December 17.
examination comfortably." Correct
114. 114 82 C. October 21.
A young adult female arrives at the emergency center with a black right eye and is bleeding from the left 118. 118 16
side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the
history and physical examination. How should the nurse document these findings? umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?

. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of the . Massage the uterine fundus.
face. A. Palpate above the symphysis for the bladder. Correct
A. Client reports her boyfriend hit her in the eye and on the head. Bruises and lacerations B. Perform bi-manual massage.
present on face. C. Inspect the perineum for excessive bleeding.
B. Client presents with a right black eye and a cut on the left side of her head that is 119. 119 12
bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe place to The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is
stay. in the first trimester of pregnancy. Which action should the nurse prepare the client for?
. Repeating the triple marker test.
A. Preparing for other diagnostic testing. Correct
B. Counseling about possible fetal defects. B. Has the client taken any over-the-counter agents for these symptoms?
C. Securing permission for pregnancy termination. C. When did the symptoms begin after the last dose of opiate analgesic? Correct
120. 120 76
Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family
history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious
reasons. Which concept should the nurse consider when responding to this couple? Questions
. Counseling about advantages and disadvantages of termination should be helpful. 1. 1 19
A. There is limited value in diagnostic testing if termination of pregnancy is not an option. A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become
addicted to paint fumes?" What is the best response for the nurse to provide?
B. Diagnostic testing may indicate a fetal problem that could be treated prior to
delivery. Correct A. Only hard drugs like cocaine and heroin can cause problems with addiction.
C. Many states legally require prenatal testing as a means of protecting the fetus. B. Tell me what you think may have caused him to start inhaling paint fumes.
121. 121 92 C. Abuse of any of the inhalants can eventually lead to addiction. Correct
Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy D. Any time you use an illegal substance, you are abusing drugs.
related to hyperbilirubinemia? 2. 2 41
. Mental retardation. A young adult female is brought to the emergency room by family members who report that she
A. Rigid extension of all extremities. ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to
be implemented?
B. Lethargy or irritability. Correct
A. IV administration of Narcan.
C. Increased or unstable temperature.
122. 122 87 B. Syrup of ipecac per nasogastric tube.
Which approach should the nurse use when preparing a toddler for a procedure? C. Acetylcysteine (Mucomyst) 140 mg/kg. Correct
. Demonstrate the procedure using a doll. Correct D. Gastric lavage with normal saline.
A. Avoid asking the child to make choices. C. Used reduce the extent of liver injury after Tylenol overdose
A. IV Narcan is for opioid overdose
B. Plan a teaching session to last about 20 minutes.
B. Syrup of ipecac is used to induce vomiting and used when poison is ingested
C. Show equipment but prevent child from handling it.
D. Gastric lavage also called stomach pumping is used to clean out contents of stomach after the ingestion
123. 123 44
of poison
Which action should the nurse implement when administering a prescription drug that should be given
on an empty stomach?
3. 3 095
. Administer after an eight-hour fast. An 8-year-old male client with nephrotic syndrome is in remission following treatment with prednisone
A. Give one hour before or two hours after a meal. Correct (Deltasone). The nurse should teach the child to check his urine for which finding?
B. Provide the dose after the client has missed a meal. A. White blood cells.
C. Take with liquids, but no solid foods. B. Glucose.
124. 124 46 C. Ketones.
A male client with a history of chronic back pain that was managed with opiate analgesics calls the
D. Protein. Correct
nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping
4. 4 93
the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which
When making a home visit to a family with a teething 4-month-old, what information is most important
assessment information should the nurse obtain next?
for the nurse to provide the parents?
. Did the client receive a prescription for methadone or clonidine?
A. Though child development is characterized by individual differences, first teeth usually erupt
A. Is the client using a fentanyl patch after stopping the opiate analgesic? during the seventh month.
B. Providing cooled teething toys can help decrease the discomfort associated with tooth A. Ask the parents to participate in encouraging the child's fluid intake.
eruption. B. Tell the child he can go outside after he drinks a full glass of water.
C. No action is required for the common symptoms associated with teething, which include C. Offer the child a popsicle and allow him to pick the flavor he prefers. Correct
drooling, irritability, and poor sleeping.
D. Make a game of seeing who can finish a glass of water first--the nurse or the child.
D. A slight fever is often associated with teething, but a fever lasting more than three days 10. 10 38
requires medical attention. Correct An overweight adolescent girl has been to the school nurse three times in the last two months
5. 5 21 complaining of vaginal and urinary tract infections. What action should the nurse take first?
To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing
A. Counsel the girl regarding hygiene.
in a long-term care facility. Which action is most important for the nurse to take prior to administering
B. Ask if she is going to the bathroom frequently. Correct
the first dose of this medication?
C. Teach the girl the importance of practicing safe sex.
A. Review the client's fasting blood glucose levels for a hyperglycemic trend.
D. Encourage the girl to see the school counselor.
B. Determine if the client has ever had a hypersensitivity reaction to penicillins. Correct
11. 11 58
C. Restrict the use of dairy products in the client's diet for the next 3 weeks.
About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness,
D. Take the client's vital signs prior to the first dose and once daily for 14 days. and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level
6. 6 42 of 57 mg/dl (approx. 3.2 mmol/L). Based on these assessment findings, which food is best for the
A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several nurse to encourage the child to eat?
medication errors in the past, but is currently working with the education department to improve this
A. Peanut butter crackers. Correct
skill. What action is best for the charge nurse to take?
B. A chocolate bar.
A. Dismiss the staff nurse's report about the float nurse because it may be just gossip.
C. A soft drink.
B. Call the nursing supervisor and request a different employee be sent to the unit.
D. A piece of buble gum.
C. Assign the float nurse to function as a UAP for the day.
12. 12 47
D. Arrange for someone to be available to assess and assist the float nurse. Correct When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the
7. 7 67 wound edges are close together, there is no sign of redness, and there is a slight amount of bright red
The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently blood oozing from the incision. What action should the nurse take?
different from those obtained by other staff members. What action should the charge nurse take first?
A. Record these findings in the client's record. Correct
A. Counsel the UAP about the inaccurate blood pressure readings.
B. Observe closely for possible dehiscence.
B. Observe the UAP performing blood pressure measurements. Correct
C. Notify the healthcare provider that the client's wound is producing a sanguineous drainage.
C. Make staff members aware of the possible errors in blood pressure readings.
D. Increase the IV fluid rate and encourage the client to eat more ice chips.
D. Ask the education department to provide additional training for the UAP. 13. 13 25
8. 8 12 When culturing a wound, the nurse should obtain the sample from which part of the wound?
A client at 13-weeks' gestation is scheduled for an amniocentesis in one week. The nurse knows that
A. The outer edges of the wound.
the primary reason for conducting this procedure is to obtain what information?
B. All necrotic sections of the wound.
A. Level of fetal lung maturity.
C. Areas containing purulent or pooled exudates. Correct
B. Presence of genetic disorders. Correct
D. Any particularly painful area of the wound.
C. Quantification of alpha-fetoprotein levels.
14. 14 69
D. Determination of gestational age. The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive
9. 9 44 client. What is the intended effect of this treatment? To increase
A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best
A. blood pressure to 140/80.
for the nurse to implement?
B. urine output to 55 mL/hr. Correct A. Deep tendon reflexes 1+.
C. pulse to 132 beats/min. B. Blood pressure of 140/90.
D. respirations to 24 breaths/min. C. Respirations of 10. Correct (remember that magnesium and calcium act like SEDATIVES)
15. 15 27 D. Urinary output of 130 mL in 4 hours.
Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be 20. 20 57
released from her case because they are going to get married on her birthday. Which statement made A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being discharged
by the client today indicates that the client is less delusional? postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for
A. I really wish that my birthday wasn't so soon. treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps
B. I don't talk about things like that anymore. Correct his nitroglycerin bottle in his pants pocket at all times, that he eats and drinks a snack before going to
bed, and that he checks his blood glucose before eating in the morning. This client requires further
C. The doctor won't talk with me about this.
teaching on which subject?
D. I think I should talk about this in group.
A. Storing nitroglycerin. Correct
16. 16 03
A newborn is brought to the admissions nursery by the nurse and the father of the baby. The baby B. Fluid intake.
weighs 9 pounds 3 ounces and measures 21 inches head to toe. Which description is a correct C. Blood glucose monitoring.
assessment of this infant? D. Diabetic diet.
A. Above average in weight but average in length. Correct 21. 21 30
B. Above average in weight and length. A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical
abdominal wound. Which room is best for the nurse to assign this client?
C. Above average in weight but below average in length.
A. A negative pressure room.
D. Macrosomia with an average length.
17. 17 72 B. A semi-private room on a surgical unit.
A client has a precipitous (dangerously fast) delivery attended only by the nurse. What nursing C. A postpartum room in the birthing center.
intervention has the highest priority? D. A private room on a medical unit. Correct
A. Ensure an adequate airway in the newborn. Correct 22. 22 38
B. Massage the uterine fundus until it is firm. A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview,
which assessment has the highest priority?
C. Clamp and cut the umbilical cord.
A. History of alcohol intake.
D. Assess for signs of placental detachment.
18. 18 45 B. Time of last meal.
A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which C. Frequency of vomiting.
explanation is correct? D. Intensity of pain. Correct
A. An antibiotic ointment is placed in each newborn's eyes to prevent infection. Correct 23. 23 16
B. Conjunctivitis neonatorum is common in newborns. Which outcome is best for the nurse to include in the plan of care for a client with impaired social
interaction and obsessive-compulsive disorder?
C. This type of question should be discussed with your pediatrician.
A. Describes success in dismissing persistent thoughts that used be bothersome.
D. Most infants have drainage from their eyes which usually resolves within 2 to 3 days of life.
19. 19 03 B. Reports that the obsessions and compulsions experienced are silly.
A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses C. Avoids obsessive verbalizations while interacting with family and staff.
the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and D. Participates in one social or recreational activity each morning and afternoon. Correct
urinary output 130 mL in 4 hours. The nurse will discontinue the magnesium infusion based on which 24. 24 36
assessment finding?
While conducting a routine health assessment of a woman who recently immigrated to the U.S. from C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness.
China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare
D. Provide the student with the latest research data describing the long-term effects of tobacco
personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take?
use.
A. Continue the interview process and record the findings. Correct 29. 29 43
B. Refer the client to a psychiatric outpatient clinic. Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion
C. Determine if there is a family history of emotional disorders. of packed red blood cells?

D. Encourage the woman to attend citizenship classes. A. Skin turgor.


25. 25 01 B. Weight.
After the sudden death of a severely injured client while in transport by helicopter, the flight nurse C. Oxygen saturation.
discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport.
D. Vital signs. Correct
What action should the flight nurse take?
30. 30 087
A. Replace the empty tank without reporting the situation to any members of the agency. A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the
B. Complete an adverse occurrence report and submit it to the nurse-manager. Correct prescription is written, the nurse notes that the provider has prescribed another medication that sounds
C. Send an anonymous letter explaining the situation to the family of the client. similar to the medication that the provider and nurse originally discussed. What action should the nurse
implement?
D. Advise the flight crew of the situation, then suggest that no further discussion be held.
26. 26 28 A. Write the correct prescription as a verbal order received from the healthcare provider.
A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse B. Correct the misspelled medication in the written prescription and initial the change.
and children tell the nurse privately that they want the client resuscitated, if the need arises. How should C. Consult with the pharmacist to determine the best medication for the client.
the nurse respond?
D. Contact the healthcare provider to clarify the prescription intended for the client. Correct
A. Nurses use their best judgment based on the client's condition. 31. 31 94
B. The healthcare team must honor the written wishes of the client. Correct Which action should the nurse take first when performing tracheostomy care?
C. Notify the healthcare provider of the family's wishes, so a decision can be made. A. Cleanse around the stoma.
D. Every effort must be made to honor the family's wishes about their loved one. B. Suction the tracheostomy.
27. 27 15 C. Oxygenate with 100% oxygen. Correct
The charge nurse observes that a demographic screen has been left open on a hallway computer by a
D. Secure the new neck strap.
nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a
32. 32 58
personal phone call. Which action should the charge nurse take first?
Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure
A. Page the unit manager to address the situation. 135/90, temperature 97.6° F, pulse rate of 98 beats/minute, and respiratory rate 22 breaths/minute.
B. Close the demographic screen on the computer. Correct The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching.
C. Instruct the UAP to end the phone call immediately. What action should the nurse take?

D. Send a UAP into the client's room to relieve the nurse. A. Notify the healthcare provider of the client's status. Correct
28. 28 66 B. Assess vital signs q15 minutes until stable.
A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes C. Place the client in a vest-type restraining jacket.
daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried
D. Encourage the client to take a warm bath to help relax.
unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement?
33. 33 80
A. Encourage the student to associate with non-smokers only while attempting to stop When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests
smoking. Correct the catheter balloon for patency. What action should the nurse implement next?
B. Tell the student that he is still young and should continue to try various smoking cessation A. Place a sterile drape under the client's buttocks.
methods.
B. Instruct the client to inhale and then exhale slowly. C. Arrange the exam sequence to minimizes position changes. Correct
C. Discard the gloves and apply new sterile gloves. D. Speak loudly and slowly when telling the client how to assist.
D. Apply a sterile lubricant to the end of the catheter. Correct 39. 39 89
34. 34 14 What is the most effective way to implement a teaching plan?
Which biological practices are federally regulated for healthcare workers? (Select all that apply.) A. Teach the information that the client wants to learn first. Correct
A. Standard precautions. Correct B. StreamLine the teaching plan to include only essential information.
B. N-95 tuberculosis standard. Correct C. Present to the client all the information necessary to meet the objectives.
C. Blood-borne pathogen standard. Correct D. Provide the client with written material to review before teaching sessions.
D. Biological product exposure limit (BPEL). 40. 40 64
Which assessment is most important for the nurse to implement when performing a comprehensive
E. Resource Conservation and Recovery Act (RCRA). Correct
assessment for an older adult?
F. As Low as Reasonably Allowable standard (ALARA).
A. Chronic illnesses.
35. 35 63
Which contextual factors are considered external environmental influences in the framework for B. Functional abilities. Correct
occupational health programs and services? (Select all that apply.) C. Immunologic function.
A. Economics. Correct D. Physical signs of aging.
B. Workforce. 41. 41 83
The nurse is assessing an older adult client's living arrangements and care. Which situation should the
C. Technology. Correct
nurse identify as contributing the most to the client's vulnerability for elder abuse?
D. Interventions.
A. The caregiver's stress level is overwhelming. Correct
E. Socio-economic status.
B. Programs for older adults are not being utilized.
F. Legislation/regulation. Correct
C. Several generations in the family are providing care.
36. 36 62
Which client requires the most immediate intervention by the nurse? D. The client does not appreciate the care provided by the family.
42. 42 20
A. A client with low back pain who is experiencing tolerance to the effects of an analgesic.
A male client who is two days postoperative for a bowel resection moves as little as possible and does
B. An adolescent with a history of drug addiction who is requesting a sedative.
not use the incentive spirometer unless specifically reminded. The client reports his pain level at an 8 on
C. A client with a chronic renal disease who is demonstrating a therapeutic response to a diuretic. a 10-point scale, but refuses a PRN dose of an opioid analgesic and tells the nurse that he can "tough it
D. A young adult who is reporting an anaphylactic response to an antibiotic. Correct out." What response is best for the nurse to provide?
37. 37 92 A. Side effects are not a concern because they usually decrease over time.
A nurse is caring for a male client with paranoid schizophrenia who believes that his antipsychotic B. Very few clients become addicted to opioids when using them for pain control.
medications are poison. Which intervention is best for the nurse to implement?
C. There are multiple options of medications that can be offered if one drug does not relieve the
A. Describe the need for consistently taking medications.
pain.
B. Offer the medication in a concentrated form.
D. Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from
C. Discard the medication and document the client's refusal. surgery. Correct
D. Approach the client with the medication 30 minutes later. Correct 43. 43 22
38. 38 42 A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU).
Which action should the nurse implement when implementing a physical assessment of an older client? What is the priority nursing action?
A. Avoid unnecessary touching while interacting with the client. A. Determine the client’s pain.
B. Apply additional pressure to palpate the hepatic edge. B. Take the client’s vital signs. Correct
C. Calculate the IV infusion rate. 49. 49 26
Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain
D. Check the postop prescriptions.
of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse
44. 44 32
implement?
A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse
question? A. Avoid any intramuscular medications to prevent localized bleeding. Correct

A. Morphine sulfate 5 mg IV on call to operating room. B. Have vitamin K available in the event the client begins to bleed.

B. Atropine sulfate 0.4 mg IM on call to operating room. Correct C. Notify the healthcare provider if the partial thromboplastin time is greater than 50 seconds.

C. Betaxolol (Betoptic) one drop in each eye the morning of surgery. D. Start instruction for self-administered SC heparin injections for long-term home therapy.
50. 50 52
D. Benzodiazepine (Valium) 5 mg by mouth the morning of surgery.
A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the
45. 45 99
right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What
An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should
nursing action should the nurse implement first?
the nurse provide to assist the client in adapting to the new hearing aids?
A. Flush the catheter to maintain patency of the CVC access.
A. Begin wearing the aids in quiet environments to experiment with adjustments. Correct
B. Describe the placement and rationale for care of the catheter. Correct
B. Wear the hearing aids for an hour a day at first, gradually increasing the time.
C. Reassure the client that the TPN administration is temporary.
C. Keep the volume on low until the conditions with noises are audible.
D. Provide passive range of motion to the right arm and neck.
D. Use one hearing aid until comfortable, then add the second aid.
51. 51 85
46. 46 73
The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is
skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding
breathing spontaneously. Which action should the nurse follow?
perianal care is effective?
A. Check the pilot balloon to ensure that it is firm.
A. Soaks in a sitz bath for 40 minutes after each diarrhea stool.
B. Verify the healthcare provider's prescription for the required cuff pressure.
B. Takes prescribed antidiarrheal medication after each diarrhea stool.
C. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
C. Applies witch hazel compresses to provide relief from anal irritation.
D. Inject air until no air is auscultated over the larynx during a deep breath. Correct
D. Cleans perianal area with mild soap and water after each diarrhea stool. Correct
47. 47 24
52. 52 56
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a
A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after
10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the
an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 mL. This
nurse implement?
finding supports which pathophysiological cause of the client's urinary tract obstruction?
A. Refer for further diagnostic evaluation. Correct
A. Obstruction at the urinary bladder neck. Correct
B. Determine exposure of others to the tuberculosis.
B. Ureteral calculi obstruction.
C. Begin anti-tubercular drug therapy.
C. Ureteropelvic junction stricture.
D. Quarantine or isolate to control communicability.
D. Partial post-renal obstruction due to ureteral stricture.
48. 48 08
53. 53 36
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a
A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies are
disturbance in electrical conduction in the ventricles?
living. One was born at 39-weeks' gestation, twins at 34-weeks' gestation, and another singleton at 35-
A. T wave of 0.16 second.
weeks' gestation. How should the nurse record her gravity and parity using the GTPAL system?
B. PR interval of 0.18 second.
A. 3-0-3-0-3.
C. QT interval of 0.34 second.
B. 3-1-1-1-3.
D. QRS interval of 0.14 second. Correct
C. 4-1-2-0-4. Correct
D. 4-2-1-0-3. The nurse asks an older female client with cognitive impairment who has been hospitalized for three
54. 54 06 days how her previous evening was. The client replies, "I had the best time. My husband took me out to
A client at 26-weeks' gestation comes to the labor and delivery unit and complains, "Something is not dinner and then to a concert. The music was wonderful." Which term should the nurse document to
right." Which finding should the nurse assess further? best describe the client's response?

A. Estriol is absent from the maternal saliva. A. Delusions.

B. The cervix is effacing and dilated to 2 cm. Correct B. Confabulation. Correct

C. Fetal fibronectin is absent in vaginal secretions. C. Concretization.

D. Irregular mild uterine contractions occurring daily. D. Circumstantiality.


55. 55 13 60. 60 08
A client who delivered a 9 pound 2 ounce infant 3 hours ago is experiencing uterine atony. Which action A young adult female comes to the health clinic to confirm a positive home pregnancy test. After
should the nurse implement first? determining the client's last menstrual period (LMP) as February 14, what expected date of birth (EDB)
should the nurse calculate?
A. Massage the fundus. Correct
A. January 7.
B. Catheterize the bladder.
B. October 17.
C. Establish venous access.
C. November 21. Correct
D. Prep for surgical intervention.
56. 56 71 D. December 11.
The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the 61. 61 82
mother's lap, chewing on a toy. Which action should the nurse implement first? A multigravida at 41-weeks' gestation is receiving an oxytocin (Pitocin) infusion for induction of labor.
The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the
A. Elicit reflexes.
peak of a contraction and then returns to the baseline before the end of the contraction. What action
B. Auscultate heart and lungs. Correct
should the nurse implement at this time?
C. Examine eyes, ears, and mouth.
A. Discontinue the oxytocin (Pitocin) infusion.
D. Take an axillary temperature.
B. Notify the healthcare provider.
57. 57 17
C. Administer 10 L of oxygen via face mask.
Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family
only briefly, and wants snacks "all the time." What recommendation should the nurse provide? D. Place the client on her left side. Correct
62. 62 31
A. Give the toddler nutritious snacks. Correct
The new parents express concern that they did not have the opportunity to hold and bond with their
B. Offer rewards for eating at mealtimes.
infant immediately after birth because the mother received anesthesia during an emergency cesarean
C. Avoid snacks so the child is hungry at mealtimes. delivery. What information should the nurse provide?
D. Explain to the child in a firm manner what is expected. A. The baby is healthy and they should not worry about the delay between birth and their first
58. 58 35 visit.
A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic
B. Early contact is essential for optimum parent-infant relationships.
relationship most effectively with which client?
C. The time immediately after birth is the critical period for human attachment.
A. A terminally ill and depressed client with cancer. Correct
D. Bonding is a process that occurs over time and begins with the first parent-newborn
B. A client who is planning to have an elective abortion.
contact. Correct
C. A suicidal client who has made a highly-lethal attempt. 63. 63 40
D. A client who refuses a blood transfusion due to religious beliefs. The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate
59. 59 74 primary defenses as evidenced by surgical incision and IV access." What nursing intervention should
the nurse implement?
A. Limit visitors to immediate family to decrease exposure to infection. 69. 69 84
Which type of delivery of nursing care is organized around tasks?
B. Maintain “clean” technique in the change of wound dressing and IV site.
A. Team nursing.
C. Assess and document skin condition around the incision and IV site at each shift. Correct
B. Primary nursing.
D. Require the use of a face mask by staff when providing care requiring close contact.
64. 64 37 C. Case management.
A male client is on contact precautions due to an infected draining wound and is being discharged D. Functional nursing. Correct
home. The client lives at home with his wife and their adolescent daughter. What discharge instruction 70. 70 093
should the nurse include for the client? A healthcare provider (HCP) asks the nurse to give a medication to a client, and the nurse tells the HCP
A. Use disposable plates and utensils. that the client is allergic to the medication. T he HCP says, "Give the medication or I will report this to
your supervisor." What response should the nurse provide?
B. Stay in a room with the door closed.
A. Walk away and ignore the threatening statement.
C. Dispose of soiled dressings in plastic bags that are securely closed. Correct
B. Give the prescribed medication and document the situation.
D. Others who are in the same room with the client should wear a mask.
65. 65 49 C. Tell the HCP that both of you should talk to the supervisor now. Correct
The nurse is preparing to perform oral care for an unconscious client. What is the first action the nurse D. Respond that this client is not assigned to the nurse.
should take before beginning oral care on this client? 71. 71 39
A. Place an emesis basin under the client's chin. A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part
of preoperative teaching, what information should the nurse provide?
B. Position the client in a flat side-lying position.
A. The transverse loop ostomy is permanent.
C. Raise bed to a comfortable working height. Correct
B. Easily removable appliances allow independence in self-care.
D. Lower the side rail between the nurse and the client.
66. 66 76 C. Daily irrigation is started after the J pouch heals.
Which responsibility best describes the role of a nurse as manager? D. Stool is eventually expelled through the rectum. Correct
A. Development of long range career goals. 72. 72 091
A client is responding to auditory hallucinations and shakes a fist at a nurse and says, "Back off, witch!"
B. Maintenance of harmony within the agency.
The nurse follows the client into the day room. What action should the nurse implement?
C. Assignment of nursing personnel and resources.
A. Sit down in a chair near the client.
D. Delivery of client care while meeting agency goals. Correct
B. Position self within an arm’s length of the client.
67. 67 23
The nurse is assigned a client with numerous treatments and decides it is not possible to complete all C. Ensure that there is physical space between the nurse and client. Correct
the needed treatments in the time scheduled for this shift. Which process should the nurse use? D. Move to a position that allows the client to be closest to the room's door.
A. Delegate tasks to competent team members. 73. 73 88
A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid replacement at 20
B. Prioritize tasks with the most crucial needs first. Correct
mL/kg. How many mL should the nurse administer? (Enter numeric value only.)
C. Report the incomplete treatments to next shift nurse.
D. Start with the easiest treatment first.
Correct Responses
68. 68 04
1. 400
Which type of management style is a case management model for nursing care delivery?
74. 74 53
A. Patient focused and primary nursing. Correct The nurse calculates the mean arterial pressure (MAP) for a client whose blood pressure is 152/90.
B. Clinically oriented and business oriented. What is the MAP in mm Hg? (Enter numeric value only. If rounding is required, round to the nearest
C. Centralized and decentralized systems models. whole number.)

D. Clinical pathways and patient classifications.


Correct Responses A mother calls the emergency department because her 9-year-old son has just fallen on his face and
0. 111 one of his front teeth has fallen out. Which instructions should the nurse provide to preserve the tooth's
75. 75 98 viability?
A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse . Clean the tooth with toothpaste.
insert the needle? (Enter numeric value only.)
A. Place the tooth in milk or water. Correct
B. Put the tooth back in the child’s mouth.
Correct Responses
C. Gently place the tooth in a plastic bag.
0. 90
81. 81 01
76. 76 11
Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)?
A client with chronic kidney disease (CKD) and severe anemia refuses blood transfusions. The
healthcare provider prescribes epoetin alfa. Which action should the nurse explain to the client about . An older client with intestinal obstruction and septic shock. Correct
the medication's therapeutic response? A. A near-drowning victim with a history of respiratory arrest.
. Accelerates neutrophil production, maturation, and activation. B. An adolescent with an autoimmune disease.
A. Activates the immune system with development of T and B cells and natural killer cells. C. An adult male with a myocardial infarction and pericarditis.
B. Stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes. Correct 82. 82 61
The nurse is assessing a client with multiple trauma from a motorcycle crash who is being ventilated
C. Increases production and maturation of granulocytes and macrophages.
due to multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse
77. 77 085
monitor as an indicator of MODS progression?
An adult male with a history of heart failure tells the nurse that his lower extremities and feet swell when
he sits at his computer all day. Which response is best for the nurse to provide? . Cardiac function.

. Limit the amount of table salt that you add to your meals. A. Renal function. Correct

A. Take a daily vitamin with minerals to correct imbalances. B. Hepatic function.

B. Get up and walk around frequently during the day. Correct C. Coagulation system.
83. 83 75
C. Elevate your feet every night to reduce swelling.
What is the underlying pathophysiologic process between free radicals and destruction of a cell
78. 78 14
membrane?
A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in
the myocardial cells as a result of the increased cardiac workload? . Inadequate mitochondrial ATP.

. Increase in size. Correct A. Enzyme release from lysosomes. Correct

A. Decrease in length. B. Defective chromosomes for protein.

B. Increase in number. C. Defective integral membrane proteins.


84. 84 02
C. Decrease in excitability.
Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis?
79. 79 91
A 6-year-old boy says he does not like the food at the hospital. A review of the child's intake reveals . Jaundice.
that he has eaten very little for the past 2 days. The nurse formulates a nursing problem of, "Imbalanced A. Vomiting.
nutrition, less than body requirements." What action should the nurse implement? B. Peripheral edema. Correct
. Select nutritious foods on the menu for the child. C. Left upper quadrant pain.
A. Provide the child with any snack foods between meals. 85. 85 72
B. Encourage family members to bring foods from home. Correct A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's
first action?
C. Arrange the child’s meal tray with generous portions of food.
80. 80 48 . Hyperextend the client's neck.
A. Call for emergency assistance. Correct A. Flaccid paralysis below the level of the injury.
B. Document the finding as a normal expectation. B. Systolic blood pressure 80 mm Hg after 2 fluid boluses.
C. Reassure the client that the voice change is temporary. C. SpO2 is 88% with shallow, slow respirations. Correct
86. 86 60 91. 91 70
What assessment findings should the nurse identify before referring a client for further evaluation to rule Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)?
out skin cancer? (Select all that apply.) . Type 1 DM and a serum hemoglobin-A1c of 3.5%.
. White patches. A. Type 1 DM and retinopathy and mild vision loss. Correct
A. Cherry angiomas. B. Type 2 DM and hypertension controlled by metoprolol.
B. Border irregularity. Correct C. Type 2 DM and a history of morbid obesity for 5 years.
C. Lesion with asymmetry. Correct 92. 92 22
D. Lesion with color variations. Correct During the initial home visit, the nurse performs a family assessment. Which component is most
important for the nurse to consider?
E. Lesion of 3 to 5 mm diameter.
87. 87 089 . The legal definition of family in the United States.
A client is receiving a continuous bladder irrigation at 1000 mL/hour after a prostatectomy. The nurse A. Members of the group that are direct descendents or bonded by marriage.
determines the client's urine output for the past hour is 200 mL. What action should the nurse B. An exploration of the group relationships, structure, functions, and roles. Correct
implement first?
C. Cultural differences among members of the extended family.
. Notify the healthcare provider. 93. 93 86
A. Stop the irrigation flow. Correct During an admission assessment interview, a client states, "I do not use many drugs." How should the
B. Document the finding and continue to observe. nurse respond?

C. Irrigate the catheter with a large piston syringe. . "Tell me about the drugs you use now.” Correct
88. 88 51 A. "Explain what you mean by many drugs.”
A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing B. “Do you mean legal drugs or illegal ones?”
shortness of breath and associated anxiety. Which prescription should the nurse implement first?
C. "What kind of drugs are you talking about?”
. Prednisone (Deltasone) 10 mg PO. 94. 94 26
A. Albuterol (Proventil) 0.5% solution per nebulizer. When assessing a client's interior eye structures with an ophthalmoscope, which action should the
B. Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. Correct nurse use?

C. Oxygen 2 to 6 liters per minute using a nasal cannula. . Use a red-free filter.
89. 89 07 A. Adjust the diopters. Correct
The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia B. Direct a wide-beam light.
(VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement?
C. Dilate the client’s pupils.
. Prepare for intubation. 95. 95 16
A. Defibrillate at 200 joules. Correct What instrument should the nurse use to determine the presence of deep tendon reflexes?
B. Insert intravenous catheter. . Goniometer.
C. Obtain arterial blood gases. A. Wood’s lamp.
90. 90 50 B. Reflex hammer. Correct
The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most
C. Transilluminator.
important for the nurse to report to the healthcare provider?
96. 96 54
. Sinus bradycardia at 50 beats per minute.
Which action should the nurse implement when using the confrontation technique during a vision C. A teenager with a femoral fracture who is in traction.
exam? 101. 101 59
. Use an ophthalmoscope to watch the client’s pupil constrict when a strong light is shown A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I
on it. am never going to get well." What is the most therapeutic response?
A. Stand behind the client and direct the client to tell the nurse when an object enters the . You need to stop thinking negative thoughts. They get in the way of your recovery.
peripheral field of vision. A. You are no bother to me or to the staff. We want you to get well and not feel sad anymore.
B. Show the client a series of four cards with printing of varying sizes and ask which card the B. I have known many clients with depression who have felt better after several weeks of
client sees most clearly. treatment. Correct
C. Sit facing the client and while look directly at the client's face, move an object inward from the C. You are feeling very pessimistic, but that is part of your illness. It should go away as you
periphery. Correct recover.
97. 97 24 102. 102 46
A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families
collaborate with the case manager regarding which aspect of this client's care? who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of
. Determination of the compatibility of the intravenous fluids and prescribed antibiotics. cancer?
A. Provision of nursing staff education about safe administration of IV antibiotics. . An older man who is always happy and chooses to view only the good in every situation.
B. Maintenance of data related to the number of IV infiltration occurrences in the hospital. A. A single mother who seeks the support of her two teenage daughters during difficult times.
C. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. Correct B. A successful businessman who is accustomed to handling highly-stressful situations.
98. 98 099 C. A teacher who seeks information about her disease and wants to continue teaching. Correct
When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid 103. 103 28
continues to flow when pressure is applied above the catheter tip. What action should the nurse A client who has been taking a diuretic and ACE inhibitor for hypertension has a blood pressure of
implement? 160/90. Today a new drug, carvedilol (Coreg), is prescribed, and the client expresses concern about
. Lower the extremity below the level of the client's heart. receiving so many different medications. What action should the nurse implement?
A. Gather the supplies needed to discontinue the IV fluid. Correct . Explain the rationale for the administration of all three medications to the client. Correct
B. Obtain an intravenous infusion pump to regulate the rate of infusion. A. Withhold the newly prescribed medication until contacting the healthcare provider.
C. Convert the IV to a saline lock until the healthcare provider is notified. B. Administer the newly prescribed medication and withhold the other two medications.
99. 99 96 C. Document the client's BP and refusal to take the newly prescribed medication.
The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for 104. 104 33
emergency admissions. Which client is stable enough to be discharged from the unit? The nurse is informed that a client is returning to the unit from the post-anesthesia care unit following
. An elderly client with end-stage cirrhosis who had a liver biopsy 8 hours ago. abdominal surgery. Which task is best to delegate to the unlicensed assistive personnel (UAP)?
A. A client scheduled for a femoro-popliteal bypass surgery tomorrow. Correct . Assess breathing pattern after transport is completed.
B. A middle-aged client with acute diverticulitis and lower left quadrant pain. A. Notify the family that the client is returning from surgery.
C. A female client with angina and ectopy noted on the telemetry monitor. B. Report to the charge nurse the appearance of the dressing.
100. 100 34 C. Assist the transport team with transferring the client to the bed. Correct
Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a 105. 105 65
medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best T he nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically
for the charge nurse to assign to the OB nurse? 120/60 in the same arm. What action should the nurse implement first?
. An adult who had a colon resection yesterday and has an IV. Correct . Use an electronic sphygmomanometer to take the BP every 30 minutes.
A. An older adult who has a fever of unknown origin. A. Retake the blood pressure in the same arm, deflating the cuff slowly. Correct
B. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.
B. Ask another nurse to recheck the blood pressure to compare results. . Collect blood for hemoglobin and hematocrit.
C. Obtain another blood pressure cuff and retake the blood pressure. A. Start the first transfusion of blood. Correct
106. 106 05 B. Insert an indwelling urinary catheter.
A graduate nurse (GN) tells the RN preceptor, "I need to insert a nasogastric tube, and though I was
C. Encourage alternate rest periods with activity.
checked off on this procedure in my nursing school's simulation lab, I have never inserted one on a real
111. 111 95
person." How should the preceptor respond?
The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been
. I must see documentation of successful check-off by your school's instructor. stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first?
A. Performing the procedure on a simulator is different from performing it on a real person. . Document the change in pulse rate on the graphics sheet.
B. Let's review the procedure, then I will supervise you while you perform the procedure. Correct A. Review the client's medical history for cardiac problems.
C. I will help you, but we need to inform the client that you are new at doing this. B. Reassess the rate and characteristics of the client's pulse. Correct
107. 107 18
C. Ask the UAP to recheck the client's pulse in thirty minutes.
The nurse is preparing a teaching plan for the parents of a 3-year-old who is newly diagnosed with
112. 112 10
Duchenne muscular dystrophy (DMD). Which implementation should the nurse include in the initial
The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV
teaching plan?
pump, but realizes that this client has no prescription for Cardizem. What is the nursing priority?
. Refer to a nutritionist for dietary management.
. Review medications client is taking.
A. Encourage the parents to join a grief support group.
A. Measure the client's vital signs. Correct
B. Teach the parents to suction the child's oropharynx.
B. Complete an incident report.
C. Develop an active range of motion exercise schedule. Correct
C. Notify the healthcare provider.
108. 108 97
113. 113 12
A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased
The nurse is planning to withdraw 10 mL of urine from the port on the tubing of a client's indwelling
lochia flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of
catheter to obtain a urine specimen. Which is the first step for the nurse to take when obtaining a urine
102.2°F, chills, pelvic pain, and uterine tenderness. What action should the nurse take?
specimen?
. Review the complete blood count. Correct
. Clamp the drainage tubing. Correct
A. Tell client to discard pumped milk.
A. Place in a biohazard bag.
B. Initiate a 24-hour urine collection.
B. Document the procedure.
C. Arrange for the baby to room-in.
C. Label the urine specimen.
109. 109 34
114. 114 097
The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot
The charge nurse, along with another RN, and a practical nurse (PN) are caring for clients on a
who has a prescription for partial weight-bearing. Which intervention should the nurse to implement
medical/surgical unit. Which nursing action should be assigned to the PN?
before the client is discharged?
. Assist a client to look at the colostomy stoma for the first time.
. Review the client's most recent serum calcium level.
A. Access a central venous catheter via an implanted port.
A. Verify that the crutches fit snugly under the axilla.
B. Develop a teaching plan for a client with rheumatoid arthritis.
B. Observe the client while demonstrating crutch walking. Correct
C. Administer a bolus tube feeding through a gastrostomy tube. Correct
C. Determine if the client lives alone or with others.
115. 115 10
110. 110 20
During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3
After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood
grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention
transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen
should the nurse implement?
saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per
. Prepare a written schedule to remind the client when to take each dose of aspirin.
minute. What intervention should the nurse implement next?
A. Observe the client place each dose in the correct boxes of her pill container. A. A client with a history of falls needs assistance to the bathroom.
B. Contact the client's healthcare provider to report the assessment findings. Correct B. A client's indwelling urinary catheter requires manual irrigation.
C. Ask a family member to ensure that the client takes the medication as prescribed. C. A client with an epidural infusion reports lower extremity parasthesia. Correct
116. 116 87 121. 121 18
Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of
respirations are six breaths per minute. What action should the nurse take first? the procedure, which subject is most important for the nurse to include in the teaching plan?
. Assess the client's current oxygen saturation level. . Hand washing prior to preparation of the injection.
A. Auscultate the client's breath sounds bilaterally. A. Method used to aspirate medication from a vial. Correct
B. Prepare to administer a dose of naloxone (Narcan) IV. B. Selection and rotation of injection sites.
C. Attempt to arouse the client to stimulate respirations. Correct C. Proper disposal of injection equipment.
117. 117 50 122. 122 78
While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, Which outcome statement or goal should the nurse include in the plan of care of an adolescent
snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on diagnosed with anorexia nervosa?
these assessment findings, which action should the nurse take? . Improve the client's body perception.
. Notify respiratory therapy immediately for a PRN bronchodilator treatment. A. Consume at least 50% of all meals. Correct
A. Obtain a prescription to increase the tidal volume setting on the ventilator. B. Exercise no more than one hour daily.
B. Stop mechanical ventilation and re-assess the client's lung sounds bilaterally. C. 5% decrease in serum potassium levels.
C. Suction the client's endotracheal tube and auscultate following suctioning. Correct 123. 123 29
118. 118 05 Designated funds are received to address the healthcare needs of a community's vulnerable
An elderly client is admitted with suspected bacterial pneumonia and lethargy. Ten minutes after the populations. Which group qualifies for this funding?
nurse initiates low-flow oxygenper nasal cannula and a peripheral IV with a secondary infusion of . African-American women who are 30 to 35 years of age.
ticarcillin (Ticar), the client becomes disoriented, restless, and tachypneic. Which nursing action has the
A. Survivors of violence that occurred at least 5 years ago. Correct
highest priority?
B. Active armed forces reserve unit returning from Europe.
. Call for the emergency resuscitation team and retrieve the unit's crash cart.
C. Full-time students who are attending public colleges.
A. Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute. Correct
124. 124 68
B. Observe the client's trunk and back for any hives and ask about the onset of urticaria. Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a
C. Notify the healthcare provider and prepare to administer IV diphenhydramine (Benadryl). preschool setting?
119. 119 30 . Promote hygiene by ensuring that children's faces and hair are kept clean.
While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair.
A. Ensure that all enrolled children have been immunized for Hepatitis A. Correct
Which information should the nurse obtain first?
B. Put a strip bandage on bleeding injuries to prevent contamination of others.
. Unexplained weight gain.
C. Teach children the correct handwashing technique to use after toileting.
A. Current hair care practices. Correct

B. Family history of alopecia.
Questions
C. Absence of axillary hair.
120. 120 09 1. 1 60
The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. The nurse-manager is developing a plan to increase the local population's utilization of a new
Which situation requires intervention by the RN? community-based public clinic. Which approach should the nurse utilize to obtain the most impact on
. A client receiving Lactated Ringer's solution requests pain medication. developing a collaborative partnership with the community?
A. Provide free services for those whose income is defined within the poverty range. A. Genital warts are not contagious during treatment.
B. Distribute flyers about recommended health screenings in the community. B. Use your fingers to spread the drug on the affected areas.
C. Create an “Ask a Nurse” telephone service for health related questions. C. Take this drug with meals to prevent gastrointestinal upset.
D. Conduct a focus group in community to gather data on culturally significant needs. Correct D. Redness, peeling, and itching may occur at the site of application. Correct
2. 2 4 7. 7 2
The nurse is conducting a retrospective chart audit to investigate whether outcomes recorded in each The nurse is reviewing the laboratory results of a n older client who is admitted to a medical unit. Which
nursing care plan are client-centered and written in behavioral terms. The Continuous Quality serum chemistry values should the nurse recognize as most commonly affected by the aging process?
Improvement (CQI) Committeepar e xpected benchmark is 98% compliance. The sample size is 200 (Select all that apply.)
charts, and the r esults show 180 charts met the benchmark. Which evaluation outcome should the A. Calcium. Correct
nurse conclude?
B. Chloride.
A. No action plan is necessary because the benchmark was met.
C. Phosphorus.
B. The benchmark was not met and an action plan should be developed. Correct
D. Potassium. Correct
C. An immediate re-audit is necessary because the benchmark was not met.
E. Sodium. Correct
D. The rate of compliance was close to the benchmark, so an action plan is unnecessary.
F. Magnesium.
3. 3 00
8. 8 94
The nurse instills an atropine ophthalmic solution into both eyes for a client who is having a routine eye
A 38-year-old female client is admitted to the mental health unit after a recent manic episode of
examination. Which side effects should the nurse tell the client to anticipate?
spending large amounts of money on new furniture, making excessive long- distance phone calls, and
A. Blurred vision. Correct not sleeping for three days. During the admission process, the client is wearing a green bathing suit.
B. Halos around objects. What intervention should the nurse implement?
C. Inability to see at night. A. Conduct a suicide assessment.
D. Itching of the conjunctiva. B. Assess the client's needs for food, liquids, and rest. Correct
4. 4 80 C. Set strict limits on the client's dress and actions.
A client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis
D. Obtain a psychosocial assessment.
media. Which therapeutic response should the nurse tell the client to expect?
9. 9 14
A. Decreases inflammation and pain. Correct During admission to the mental health unit, a female client with bipolar disorder, manic phase, is loud,
B. Reduces the existing colony count. hyperverbal, hyperactive, and is garishly dressed. Which intervention should the nurse include when
C. Slows the rate of organism growth. planning care for this client?

D. Prevents hearing loss as a possible complication. A. Encourage others to use peer pressure to modify the client's behaviors.
5. 5 78 B. Plan group activities that focus on the client as the center of attention.
The nurse is providing tracheostomy care for a client who has encrusted secretions inside the inner C. Maintain an environment that reduces stimulation of the client. Correct
cannula. Which solution should the nurse use to remove the debris?
D. Include activities that require attention to detail to limit inappropriate behavior.
A. Iodine. 10. 10 08
B. Azelaic acid. A 50-year-old male client with amyotropic lateral sclerosis (ALS) is becoming increasingly debilitated
C. Isopropyl alcohol. and tells the nurse, "Since I haven' t been able to go to church, I feel out of touch with God. I pray, but I
wonder whether my prayers are heard." Which nursing diagnosis should the nurse include in the client's
D. Hydrogen peroxide. Correct
plan of care?
6. 6 02
The nurse is instructing a client about the use of podofilox (Condylox) for the treatment of genital warts. A. Death anxiety.
Which information should the nurse provide? B. Powerlessness.
C. Spiritual distress. Correct A. Letter writing.
D. Disturbed thought processes. B. Dance and movement therapy. Correct
11. 11 74 C. Personality inventory testing.
A mother brings her 4-year-old boy to the clinic because he spends his day in constant motion, talks
D. Cooking and meal planning classes.
excessively, and is easily distracted from playing with his toys. His preschool teacher is unable to keep
16. 16 22
him focused in the classroom and suggested he undergo a mental health evaluation. Which nursing
Which therapeutic response should the nurse identify that best evaluates the use of reminiscence
diagnosis should the nurse formulate?
strategies with an older adult?
A. Risk for Injury.
A. Improve mood towards a more positive affect.
B. Compromised Family Coping.
B. Reduce the client’s anxiety.
C. Impaired Social Interaction. Correct
C. Stimulate memory chains through associations. Correct
D. Deficient Knowledge.
D. Broaden the client’s judgment and general knowledge.
12. 12
17. 17 78
A male client calls the crisis center and tells the nurse that he wants to die and is planning to commit
During a group therapy session, a client with hypomania threatens to strike another client. What
suicide. What means of suicide should the nurse determine is most lethal if in the client's possession?
intervention is best for the nurse to implement?
A. A loaded gun. Correct
A. Summon assistance of several other staff.
B. A garden hose.
B. Send the other clients out of the group setting.
C. Two bottles of Prozac.
C. Tell the client to leave the group to gain control of the behavior.
D. A bottle of an alcoholic beverage.
D. Firmly inform the client that acting out anger is not acceptable. Correct
13. 13 74
18. 18 24
An 11-year-old boy with oppositional defiant disorder becomes angry and defiant over the rules of the
An adolescent female who lost fifty pounds during the past three months is hospitalized. During the
day treatment mental health program. Which response by the nurse is the most effective way to defuse
admission assessment, the client complains of dry skin, poor skin turgor, hair breakage, brittle nails,
the situation?
and a history of menstrual cycle problems. Which finding is most important for the nurse to obtain
A. Approach and secure the child in a basket hold. additional assessment information?
B. Administer a PRN anxiolytic medication. A. Amenorrhea. Correct
C. Call additional staff to restrain and seclude the child. B. Dysmenorrhea.
D. Tell the child to go to the gym to play basketball. Correct C. Heavy menstrual flow.
14. 14 68
D. Premenstrual syndrome.
A male client with degenerative arthritis of the knees and hips takes an over-the-counter (OTC)
19. 19 28
nonsteroidal antiinflammatory drug (NSAID) for pain. During a routine clinic visit, the client tells the
Upon admission, the nurse determines a male client with alcohol withdrawal syndrome is experiencing
nurse, "For the past month I' ve been having a lot of trouble sleeping. I can' t seem to fall asleep, and
visual and auditory hallucinations, confusion, dehydration, a swollen tongue, and bruising. Which action
when I finally do get to sleep, I find that I wake up a number of times during the night." Which
should the nurse include in this client's plan of care to ensure physiological stability?
information should the nurse obtain first?
A. Keep the room dark.
A. Does the client snore or experience sleep apnea?
B. Monitor vital signs. Correct
B. How intense does the client rate his pain on a scale of 1 to 10? Correct
C. Encourage oral fluids.
C. What type of medications does the client take before bedtime?
D. Apply ice to his tongue.
D. Are there any white noise or lights on during the night?
20. 20 72
15. 15 46
When conducting an assessment interview with a new client, which question should the nurse use to
A female client who is diagnosed with an eating disorder has difficulty translating her pain into words.
elicit the most information?
Which approach should the nurse implement to allow this client greater self-disclosure?
A. Where is your family? A. Dependence on healthcare providers.
B. Do you have a family? B. Denial of traditional medical treatment.
C. Tell me about your family. Correct C. Lack of motivation to participate in self-care.
D. Would you like to talk about your family? D. Reliance on family members to assist with care. Correct
21. 21 38 26. 26 10
Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? Which intervention demonstrates the nurse's accountability in a specific decision-making process?
(Select all that apply). A. Selecting the best medication administration schedule for a client.
A. Adhere to strict time limits for activities. B. Evaluating a client’s outcomes after implementation of care. Correct
B. Give all instructions at the start of the activity. C. Promoting participation of all staff members in unit meetings.
C. Encourage verbal and nonverbal communication. Correct D. Implementing discharge teaching plans that meet individual needs.
D. Speak to the client in a loud and clear voice. 27. 27 70
E. Maintain a calm demeanor during all interactions. Correct A male client gives a copy of his living will to the nurse upon admission to the hospital. What action
22. 22 02 should the nurse implement if the client is unable to express his desire about life-prolonging measures?
A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts A. Ask the spouse to make decisions regarding life-saving measures.
should the nurse include in teaching the client ways to increase glycogen store in muscles? B. Allow the client to die with dignity and without life-prolonging techniques. Correct
A. Moderate exercise and low fat intake. C. Administer medications to ensure a painless death and end the client's suffering.
B. Rest and increased carbohydrate intake. Correct D. Implement all measures of technical assistance and equipment to prolong life.
C. Intense exercise and decreased carbohydrate intake. 28. 28 58
D. Intense exercise and high intake of complex carbohydrates. Which individual may legally sign an informed consent?
23. 23 92 A. A 42-year-old client who is sedated.
A client with chronic kidney disease (CKD) receives peritoneal dialysis at home and is upset because of B. A 16-year-old mother for her newborn. Correct
the expenses of therapy. What information response should the home health nurse provide as the client
C. The friend of an 84-year-old married client.
's advocate?
D. A 56-year-old who questions a proposed treatment plan.
A. An alternative to consider is renal transplant.
29. 29 88
B. Peritoneal dialysis is less expensive than hemodialysis. Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus
C. Self pity and angry is common with chronic disease that requires life sustaining treatment. of control?
D. Explore options with the regional dialysis center about reducing the cost of home A. Hopelessness.
dialysis. Correct B. Powerlessness. Correct
24. 24 98
C. Social isolation.
What is the largest contributing factor for the increase in the need for home care?
D. Personal identity disturbance.
A. Government funding of the home care setting has increased greatly.
30. 30 64
B. Clients are more acutely ill when discharged from acute care facilities. Correct The nurse is assessing an adult who displays stagnation, boredom, and interpersonal impoverishment.
C. Home care agencies can provide seven-day services for older adults. Based on Erikson's developmental model, which stage should the nurse develop interventions for this
D. Fixed single-incomes of older adults has increased the need for home care. client?
25. 25 06 A. Identity versus role confusion.
An older Chinese client refuses to perform the range-of-motion and breathing exercises after a surgical B. Intimacy versus isolation.
procedure and is hesitant to complete hygienic care and grooming. What cultural factor should the
C. Generativity versus stagnation. Correct
nurse consider that is related to this client's behavior?
D. Integrity versus despair.
31. 31 92 B. Offer high-protein foods. Correct
At what phase of the therapeutic relationship should the nurse ask a male client about his reasons for
C. Provide a high-residue diet.
seeking medical care and hospitalization?
D. Give prompt mouth care.
A. Working phase.
37. 37 38
B. Termination phase. Which information is most accurate for the nurse to use when calculating safe drug dosage s for a
C. Orientation phase. Correct child?
D. Prior to discharge. A. Age.
32. 32 0 B. Height.
An adolescent client is admitted to the mental health unit for impulsivity and acting-out behavior at
C. Weight.
school. What intervention should the nurse implement that is most beneficial for this client?
D. Body surface area. Correct
A. Administer an antianxiety agent PRN.
38. 38 74
B. Implement close observation precautions. After attending an inservice for bioterrorism preparedness and staff education, the nurse should identify
C. Separate the adolescent from adult clients on the unit. which findings consistent with a possible anthrax exposure?
D. Explain the consequences for breaking the unit rules. Correct A. Fever, cough, chest pain, and hemoptysis.
33. 33 70 B. Vesicular skin lesions on the face and extremities.
Which entry in the client's medical record provides the best documentation of client care?
C. Flu-like symptoms, gastrointestinal distress, and papular lesions. Correct
A. 1230 - Client’s vital signs taken.
D. Abdominal cramping, diarrhea, drooping eyelids, and jaw clench.
B. 0700 - Client drank adequate amount of fluids. 39. 39 76
C. 0900 - Meperidine (Demerol) given for lower abdominal pain. What assessment finding should the nurse identify in a client with fluid volume excess?
D. 0830 - IV fluid rate increased to 100 mL/hour according to protocol. Correct A. Flushed skin.
34. 34 84 B. Elevated blood pressure. Correct
An older client who is admitted with terminal cancer of the liver begins to talk with the nurse about
C. Weak, thready pulse.
spiritual life after death. Which response by the nurse best assesses the client's spiritual needs?
D. Dry mucous membranes.
A. “What do you believe happens to your spirit when you die?"
40. 40 32
B. “Has your terminal condition made you lose your faith or beliefs?” Which assessment finding should the nurse identify in an adult client with sleep deprivation?
C. "Members of your church are allowed to visit you whenever you desire.” A. Mood swings and irritability. Correct
D. “I notice you have a Bible. Is that a source of spiritual strength for you?” Correct B. Persistent elevated blood pressure.
35. 35 96
C. Decreased temperature.
Which action should the hospice nurse implement to assist a client maintain self-worth during the end-
D. Inappropriate and acting out behaviors.
of-life process?
41. 41 94
A. Arrange for a grief counselor to visit with the client.
Which change in sleep patterns is most likely to occur in an older adult?
B. Plan regular visits with the client throughout the day. Correct
A. Becomes more difficult to arouse from sleep.
C. Allow the client time alone to finalize personal affairs.
B. Takes less time to fall asleep.
D. Ensure the client’s spiritual advisor provides support.
C. Has a decline in stage 4 sleep. Correct
36. 36 86
D. Requires more sleep than a younger adult.
The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea
42. 42 16
and vomiting. Which action is best for the nurse to take to promote the client's comfort?
A. Increase fluid intake.
The nurse is developing the plan of care for an older client who is immobile and at risk for pressure D. Biot's breathing.
ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin 47. 47 56
integrity?" The nurse is teaching a client who is newly diagnosed with Type 1 diabetes mellitus about diet and
A. Poor nutrition. insulin. The client should be instructed to perform glucose self-monitoring when which symptom occurs
B. Tissue ischemia. Correct after exercising?

C. Prolonged illness or disease. A. Shakiness. Correct

D. Nitrogen buildup in the underlying tissues. B. Unusual thirst.


43. 43 94 C. Sudden anorexia.
A male client tells the nurse that he is frequently constipated. Which finding should the nurse identify as D. Excessive urination.
a common dietary cause of constipation? 48. 48 54
A. Megacolon or Hirschsprung’s disease. Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive
B. Inadequate intake of dietary fiber and fluids. Correct client?

C. Chronic intake of excessive amounts of caffeine. A. Check residual volume every four hours. Correct

D. Inadequate intake of fruit and vegetable juices. B. Stimulate the gag reflex every eight hours.
44. 44 78 C. Administer small amounts of the formula.
The nurse is obtaining a client's consent for a paracentesis. Which information should the nurse provide D. Give the feeding while the client is supine.
to ensure the client understands the purpose of the procedure? 49. 49 72
A. A needle is inserted to remove excessive fluid from the abdominal peritoneal cavity. Correct The healthcare provider prescribes digital evacuation of a fecal impaction for an older client who is
B. A biopsy is taken from the stomach wall to determine the presence of Helicobacter pylori. admitted with a closed head injury after falling out of bed. As a part of the procedure policy, the nurse
applies a topical anesthetic gel to the rectum. Which rationale best supports the use of the anesthetic
C. Dye is injected into the biliary tract using an esophagogastroduodenoscopy (EGD).
gel?
D. Fluid removal from the pleural space uses an x-ray guided insertion of a needle.
A. Decrease risk for bradycardia. Correct
45. 45 90
The nurse is teaching a client with Addison's disease about this new diagnosis. What B. Prevent rectal mucosal tearing.
pathophysiological explanation should the nurse share with the client? C. Minimize hemorrhoidal trauma.
A. End stage renal disease causes hypertension due to decreased renal perfusion that results in D. Dislodge the fecal mass.
an increased secretion of renin. 50. 50 42
B. Hyperthyroidism is an autoimmune disease that causes an increased secretion of thyroxine What nursing intervention should the nurse include in the plan of care for a client following a bone
resulting in an increased basal metabolic rate. marrow aspiration?

C. Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells A. Use of a compression dressing for firm pressure to the site. Correct
damaging the adrenal cortex. Correct B. Proper positioning of the client in a prone position.
D. Pituitary dysfunction, such as diabetes insipidus, can occur after a head injury or primary C. Follow-up hematological laboratory studies.
tumor that causes increased intracranial pressure. D. Application of warm, moist compresses to the puncture site.
46. 46 36 51. 51 50
The nurse is caring for a client with diabetic ketoacidosis (DKA) who is manifesting rapid and deep A client is admitted with myasthenia gravis (MG). During the admission assessment, the nurse identifies
respirations. Which respiratory pattern should the nurse document? that the client's upper eyelid s are drooping. Which term should the nurse document to describe this
A. Kussmaul respirations. Correct assessment finding?
B. Hyperventilation. A. Ptosis. Correct
C. Apneustic respirations. B. Myopia.
C. Keratitis. C. Failure of the liver to convert ammonia absorbed from the bowel to urea. Correct
D. Astigmatism. D. An increased reabsorption of urobilinogen from the bowel into the blood.
52. 52 30 57. 57 04
The nurse identifies the nursing diagnosis of, "Visual sensory/ perceptual alterations related to increased A client with gastroesophageal reflux disease (GERD) is unconscious and unresponsive to stimuli. The
intraocular pressure (IOP)" for a client with glaucoma. Which nursing intervention should the nurse nurse places the client in a side-lying position. The nurse should monitor the client for the risk of which
include in the plan of care? complication?
A. Encourage compliance with drug therapy to prevent loss of vision. Correct A. Stress ulcers.
B. Develop pain management strategies associated with ocular nerve atrophy. B. Aspiration pneumonia. Correct
C. Identify coping mechanisms related to the eventual loss of peripheral vision. C. Esophageal hemorrhage.
D. Recognize that damage to the eye can be reversed until late stages of the disease. D. Thromboembolic problems.
53. 53 66 58. 58 68
A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food A client returns to the unit after abdominal Nissen fundoplication for treatment of gastroesophageal
allergies is scheduled for surgery. Which action should the nurse implement? reflux disease. After 4 hours, the nurse determines the client has no drainage from the nasogastric tube
A. Document a possible Type I latex allergy. Correct (NGT) and has absent bowel sounds. What action should the nurse implement?

B. Determine if the client carries an epinephrine kit for Type IV allergic reaction. A. Notify the healthcare provider.

C. Advise the client to use oil-based hand creams when wearing latex gloves. B. Continue to monitor the client.

D. Encourage the client to use vinyl gloves at work. C. Reposition the nasogastric tube.
54. 54 54 D. Irrigate the NGT with normal saline. Correct
In reviewing the medical record, the nurse notes that a client's last eye examination revealed an 59. 59 36
intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client? A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal
A. Length of time the client has been wearing prescription lenses. pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the
nurse report to the healthcare provider?
B. Recent experience of seeing light flashes or floaters.
A. Rapid, deep respirations.
C. Complaints of any blind spots in the client's field of vision.
B. A rigid, boardlike abdomen. Correct
D. Use of prescribed eye drops since last exam by ophthalmologist. Correct
55. 55 82 C. Vomiting of undigested food.
Which action should the nurse implement to assess for jugular vein distention (JVD) in a client with heart D. Bowel sounds increased in frequency and pitch.
failure (HF)? 60. 60 32
A. Ask the client to perform the Valsalva maneuver while lying in a supine position. A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a
perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled
B. Palpate the jugular veins, comparing the volume and pressure of one with those of the other.
analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and
C. Measure in centimeters the distance that the jugular veins are distended outward from the
antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical
neck.
unit. The nurse determines the client has no bowel sounds, and 200 mL of bright red nasogastric
D. Observe the vertical distention of the veins as the client is gradually elevated to an upright drainage is in the suction canister in the past hour. What is the priority action the nurse should
position. Correct implement?
56. 56 10
A. Notify the healthcare provider. Correct
The nurse reviews a client's laboratory results and identifies an elevated serum ammonia level. Which
B. Irrigate the nasogastric tube per prescription.
pathophysiological process contributes to this finding?
C. Assess the client’s use of the PCA device.
A. A decreased bile flow into the small intestine due to a bile duct obstruction.
D. Splint the abdomen to relieve pressure on the incision.
B. Bowel flora act on bowel protein to deaminate amino acids and form ammonia.
61. 61 80
A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid D. Elevate the extremity with ice at the wound site.
colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal 66. 66 24
incision is partially closed with two drains attached to Jackson-Pratt suction bulbs. During the early On the second day after admission, a client with a fractured pelvis develops chest pain, tachypnea, and
postoperative period, the nurse should give the highest priority to which nursing action? tachycardia. Which additional finding should the nurse identify that is most likely related to a fat
A. Provide a low-residue diet. embolism?
B. Monitor drainage from the colostomy stoma. A. Hypotension.
C. Maintain dry perineal dressings. Correct B. Restlessness and confusion.
D. Encourage looking at the colostomy site. C. Warm, reddened areas in the legs.
62. 62 44 D. Petechiae of the anterior chest wall. Correct
What information in a client's history indicates the highest risk factor for hepatitis C? 67. 67 92
A. Monogamous sexual activity. A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes
B. Intravenous drug abuse. Correct with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which
intervention should the nurse prepare to implement to maintain the client's airway?
C. Eating contaminated shellfish.
A. Tracheostomy tube insertion.
D. Recent travel to an underdeveloped country.
63. 63 44 B. An endotracheal tube.
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ C. A nasopharyngeal tube. Correct
pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. D. An oral airway.
Which intervention is most important for the nurse to include in the client's plan of care? 68. 68 68
A. Turn the client every 4 hours. The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate (FHR)
B. Restrict dietary protein intake. decelerations. The nurse recognizes that this change in the FHR pattern is due to which
pathophysiological incident?
C. Perform passive range of motion 4 times per day.
A. Fetal hypoxemia.
D. Apply a pressure-relieving mattress under the client. Correct
64. 64 20 B. Umbilical cord compression. Correct
A female client arrives at the clinic because her boyfriend received the results of a Gram stain smear C. Uteroplacental insufficiency.
that revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she has not had any D. Altered fetal cerebral blood flow.
symptoms and almost did not come to the clinic. What information should the nurse provide the client? 69. 69 84
A. Subclinical cases of gonorrhea occur in women but do not cause damage. Which fetal heart rate (FHR) finding should the nurse report to the healthcare provider immediately?
B. Women serve as carriers of gonorrheal infections that are manifested in men. A. Late decelerations. Correct
C. Gonorrhea is often asymptomatic in women because the infection is not visible. Correct B. Early decelerations.
D. Infertility in women is the result of ovarian dysfunction due to gonorrheal infections. C. Accelerations with fetal movement.
65. 65 76 D. Average FHR of 126 beats per minute.
A client with an open reduction and application of an external fixator for open, comminuted fractures of 70. 70 62
the tibia and fibula begins to complain of severe pain in the affected leg, which is not relieved by A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not
analgesics. The client says the toes are numb and tingling, although they appear pink. What action smiling. Which information should the nurse provide?
should the nurse implement?
A. Social smiling begins at approximately 2 months of age. Correct
A. Notify the healthcare provider. Correct
B. Smiling during feeding should occur around 1 month of age.
B. Check the client's temperature.
C. An infant should smile and coo when a parent enters the room at approximately 3 months of
C. Loosen the screws on the external fixator pins. age.
D. Baby babbling begins at approximately 4 months of age in response to a parent talking to the B. Arrest of active phase. Correct
infant. C. Prolonged latent phase.
71. 71 72
D. Protracted active phase.
The nurse is explaining dietary management to a client with pregestational diabetes during a prenatal
76. 76 96
visit. Which client statement indicates that the teaching has been effective?
Which information is most important for the nurse to provide parents about long-term care for their child
A. "Diet and insulin needs will change significantly throughout my pregnancy." Correct with hydrocephalus and a ventriculoperitoneal (VP) shunt?
B. "Dietary selections should be based on my urine glucose testing results." A. Physical contact sports may be restricted during childhood.
C. "I should eat an additional 600 calories/day throughout my pregnancy." B. Shunt malfunction or infection requires immediate treatment. Correct
D. “I can continue the same well-balanced diet as I did before pregnancy." C. Normal intellectual ability is expected with surgical diversion.
72. 72 28
D. The use of a protective helmet is recommended during childhood.
The nurse is assessing a postpartum client who delivered in the car. Which finding should the nurse
77. 77 18
identify as the earliest manifestation of a puerperal infection?
The nurse is instructing a mother about the care of her child who has pediculosis capitis. Which
A. Dysuria and pyuria with each voiding. information should the nurse provide?
B. White blood cells (WBC) greater than 12,000/mm3. A. Wash all nits out of hair with a regular shampoo.
C. Increased vaginal bleeding with ambulation. B. Cut hair shorter if infestation and nits are severe.
D. Temperature of 100.8° F 24 hours after delivery. Correct C. Use a fine-toothed comb or tweezers to remove nits. Correct
73. 73 42
D. Remove viable and moving parasites from hair shafts.
Which infant is at risk for Rh incompatibility?
78. 78 98
A. Infant who is Rh-negative and mother who is Rh-negative. The nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. Which
B. Infant who is Rh-positive and mother who is Rh-positive. interventions should the nurse include in the teaching plan?
C. Infant of an Rh-negative mother and a father who is Rh-positive and homozygous for the Rh A. Plan a low-calorie, low-protein diet.
factor. Correct B. Use nutritious foods as a method of reward.
D. Infant of an Rh-negative mother and a father who is Rh-positive and heterozygous for the Rh C. Encourage diversional activities during mealtimes.
factor.
D. Incorporate favorite foods into the adolescent's diet. Correct
74. 74 16
79. 79 50
An infant who is delivered at 32-weeks' gestation arrives in the nursery intubated. After the infant is
The mother of an 8-year-old child with a chronic illness and tracheotomy is rooming-in during this
placed under a radiant warmer with prescribed ventilator settings, the nurse applies a cardiorespiratory
hospitalization. The mother insists on providing all of the child's care and tells the nurse how to care for
monitor and pulse oximeter, which indicates an oxygen saturation of 80%. What action should the
the child. The nurse should recognize that the mother plays which function when planning this child's
nurse implement first?
care?
A. Inform the parents about the infant's status.
A. The nurse's role.
B. Notify the healthcare provider.
B. Source of the child's safety.
C. Continue with the admission assessment.
C. An expert in care of the child. Correct
D. Ensure patency of the endotracheal tube. Correct
D. Supervisor of nurses providing care.
75. 75 26
80. 80 22
A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the
The parents of a 5-year-old are concerned because their child showed more outward grief when a pet
cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal
died than when a sibling died from sudden infant death syndrome (SIDS). What response should the
examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the
nurse provide?
nurse document to describe the client's progress?
A. The child should be old enough to have the concept of death as final and irreversible.
A. Protracted descent.
B. The child's behavior suggests maladaptive coping and referral for counseling is needed. C. Weight gain. Correct
C. The child focuses on another connection because the sibling's death is D. Photosensitivity.
misunderstood. Correct 86. 86 40
D. The child is not old enough to have formed a significant attachment to the infant sibling. A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological
81. 81 6 consequence should the nurse identify if the client receives the medication at regular intervals?
The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory A. Metabolic acidosis.
infections and chronic constipation. Which intervention should the nurse include in the plan of care? B. Metabolic alkalosis.
A. Provide a high caloric diet that meets the child's mental age. C. Respiratory acidosis. Correct
B. Delay solid food introduction until the child's tongue thrust subsides. D. Respiratory alkalosis.
C. Maintain regular meal times to minimize frequency of constipation. 87. 87 82
D. Use a bedside cool-mist vaporizer during naps and night time. Correct A client who is taking nitroglycerin for angina is concerned about having headaches after taking more
82. 82 14 than one tablet. What information should the nurse provide?
The parents of a 4-month-old infant who is hospitalized tell the nurse that they have to work and cannot A. This means that the levels of the nitroglycerin are toxic.
stay with the baby except on weekends. Which actions should the nurse-manager implement to B. The bottle of tablets has passed the expiration date.
address the infant's emotional needs?
C. Headaches after taking nitroglycerin are indicative that a stroke is imminent.
A. Place the child in a room away from other children.
D. This is a common side effect due to the vasodilatory effects of the medication. Correct
B. Tell the parents that frequent visiting is unnecessary. 88. 88 06
C. Assign the same nurse to care for the child each day. Correct A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal
D. Allow several nurses to care for the child each shift. hematologic parameters. Which vitamin should the nurse explain to the client is indicated to take for his
83. 83 88 lifetime?
The nurse is catheterizing a 7-year-old boy who has been admitted to the pediatric unit. After cleansing A. Vitamin A.
the glans penis, what should the nurse do first to minimize discomfort? B. Vitamin C.
A. Insert 5 mL of 2% lidocaine lubricant into the urethra. Correct C. Vitamin E.
B. Compress the glans to retain the lidocaine lubricant. D. Vitamin B12. Correct
C. Apply sterile lubricant to catheter tip prior to insertion. 89. 89 34
D. Wait 2 to 5 minutes before insertion of the catheter. A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare the dose?
84. 84 86 A. Insulin glulisine (Apidra).
The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel B. Insulin regular (Humulin R). Correct
mucus. Which action should the nurse implement to provide effective pulmonary toileting?
C. Insulin detemir (Levemir).
A. Encourage child to cough to raise the secretions before suctioning.
D. Insulin glargine (Lantus).
B. Allow child to rest after every five times the suction catheter is passed. 90. 90 98
C. Each pass of the suction catheter should take no longer than five seconds. Correct Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding
D. Select a catheter 3/4 the size of the diameter of the tracheostomy tube. should the nurse report to the healthcare provider?
85. 85 80 A. Has a family history of diabetes mellitus, type I.
The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the B. Receives carvedilol (Coreg) for heart failure (HF). Correct
client for which common side effect that is most likely to occur during therapy?
C. Works outdoors as a construction site supervisor.
A. Dystonia.
D. Drinks alcoholic beverages twice a week.
B. Akathisia. 91. 91 90
The neonatologist requests a mother to provide breast milk for her 32-week gestational premature
newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk.
Which additional information should the nurse include to ensure the mother understands the request?
A. To promote maternal production with neonatal demand, pump only the volume the newborn
takes.
B. Providing breast milk ensures the premature newborn can easily digest and absorb the
nutrients. Correct
C. Pump every 2 to 3 hours, including during the night, to increase breast milk volume.
D. A glass of wine prior to pumping reduces anxiety and increases breast milk production.
92. 92 40
Three days after a colon resection, the nurse is assessing a client with a nasogastric tube (NGT) to
intermittent suction. What assessment should the nurse implement to determine proper placement of
the NGT?
A. Auscultate bowel sounds in all quadrants.
B. Percuss abdomen for stomach distention.
C. Aspirate the tube contents to test the pH. Correct
D. Review the X-ray report from 3 days prior.
93. 93 48
When administering an intramuscular (IM) injection to an adult client using the ventro gluteal site, which
landmarks should the nurse identify to locate the area for injection?
A. The greater trochanter and the knee.
B. The acromion process and the dorsal surface of the upper arm.
C. The greater trochanter and the posterior iliac spine.
D. The anterosuperior iliac spine and the greater trochanter. Correct
94. 94 26
The nurse identifies a break in sterile technique as a client is draped for an operative procedure. What
action should the nurse implement?
A. Inform the surgeon before an incision is made.
B. Tell the circulating nurse at the end of the surgery.
C. Say nothing because someone else is likely to report it.
D. Point out the observation immediately to the surgical team. Correct
95. 95 84
The nurse is supervising an unlicensed assistive personnel (UAP) who is feeding an older client with
dysphagia. Which action by the UAP requires the nurse's intervention?
A. Thickens the broth and juice on the client's tray.
B. Assists the client from the bed to a chair for the meal.
C. Divides solid food items into one inch cube pieces. Correct
D. Keeps the client upright for 60 minutes after eating.

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