A charge nurse is reviewing guidelines for initiating airborne precautions.

Which of the following clients

requiring airborne precautions?

A client who has scabies

A client who has perutsis

A client who has streptococcal pharyngitis

A client who has measles

2.

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse
take?( Select all that apply)

Keep the client's room dark at night

Teach the client to use the call light

Keep the client's bed in the lowest postion

Place a fall risk identification band on the clients wrist

Assess the client every 4 hrs

A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the
values?

Answer

Potassium levels are increased in clients who have polyuria.

Specific gravity is decreased in clients who have hypovolemia.

BUN is decreased in clients who have dehydration.

Creatinine levels are increased in clients who have kidney injury.

A nurse is preparing to administer 0.45% sodium chloride (NaCI) 1000 mL IV to infuse over 8 hr. The
nurse should set the IV pump to deliver how many mu/hr? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero) JUST TYPE IN THE NUMBER)

Answer
125

A nurse is preparing to administer antibiotic X over 20 min. Available is antibiotic X in 50 mL of 0.9%

Answer

50

A nurse is preparing to administer ceftriaxone 1 g via intermittent IV bolus over 30 min. Available is 1 g
ceftriaxone sodium in 100 mL dextrose 5% in water. The nurse should set the pump to deliver how many
mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a
trailing zero.) JUST TYPE IN THE NUMBER)

answer

200

A nurse is preparing to administer dextromethorphan 30 mg PO. The amount available is

Answer 20

A nurse is preparing to administer valproic acid 400 mg PO bid for migraine headaches. Available is
valproic acid 250 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to
the nearest whole number Use a leading zero if it applies. Do not use a trailing zero.) (JUST TYPE IN THE
NUMBER)

Answer 8

9
A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of
the following conditions can increase the risk for renal calculi?

Protein in the urine

Dehydration

Iron deficiency

Obesity

10

A client is to have hemodialysis. What must the nurse do before this treatment?

Obtain a urine specimen

Weigh the client

Administer medications

Explain that the peritoneum removes waste

11

A nurse is caring for a client receiving hemodialysis for kidney disease. The nurse should monitor the
client for which complication?

Answer

Peritonitis

Hepatitis B

Renal calculi

Bladder infection

12

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following
manifestations should the nurse identify as a finding specifically associated with this client?

Urinary retention

Low back pain

Incontinence

Confusion

13
The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an
elevated serum purine. How should the nurse interpret these findings about the stone's composition?

It contains cystine

It contains uric acid

It contains calcium oxalate

It contains magnesium ammonium phosphate

14

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection
in a postoperative client?

Pouring warm water over the perineum

Ensuring the patency of the catheter

Removing the catheter within 24 hours

Cleaning the catheter insertion site

15

The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest
compressions, the nurse should depress the sternum by how many inch (es)?

Answer

A. 2 inches

B. 1 inch

13

C. ¾ inch

D. 3 inches

16

The nurse performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how
many seconds to the child?

Answer

A. 6-8
B. 8-10

C. 10-12

D. 12-14

17

Nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne
precautions and is receiving multidrug therapy. Which of the following precautions should the nurse
take to transport the client safely to the radiology department for a chest x-ray?

A. Ask the x-ray technician to come to the client's room to obtain a portable x-ray

B. Have the client wear a mask

C. Notify the x-ray department that the client requires airborne precautions,

D. Wear a filtration mask and gloves during transport

18

A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer
do first after determining that the person is not responding and the emergency medical system has been
activated?

Identify absence of pulse

Give two rescue breaths with CPR mask

Perform the head tilt chin lift maneuver

Perform chest compression at a rate of 100/min

19

A nurse arrives at the scene of an accident and finds a 5-month-old infant unconscious. After performing
the initial steps of

cardiopulmonary resuscitation (CPR), the nurse plans to locate the infant's pulse. Which pulse site in the
accompanying figure should

be palpated? Brachial

20
Immediately after a storm has passed, the nurse is working with a rescue team that is searching for
injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not
breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first
intervention.

Treat the victim for shock

Start rescue breathina immediately

Apply surface pressure to the foot wound

Safely remove the victim from the immediate vicinity

21

The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest
compressions, the nurse compresses at least how many times?

Answer

A. 60 times per minute

B. 80 times per minute

C. 100 times per minute

D. 160 times per minute

22

The nurse performing rescue breathing on a 30 year old male. The nurse delivers one breath per how
many seconds to the child?

Answer

A. 6-8

B. 8-10

C. 10-12

D. 12-14

23

A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should
the nurse assess each specimen of urine?

Clarity
Viscosity

Glucose level

Specific gravity

24

client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity
report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare
provider, which action should the nurse take to decrease the risk of transmission to others?

Insert a urinary catheter

Initiate droplet precautions

Move the client to a private room

Use a high-efficacy particulate air (HEPA) respirator during care

25

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are
noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which
action should the nurse take first?

Raise the client to a high fowler position

Obtain the apical pulse and blood pressure

Call the primary healthcare provider immediately

Monitor the pulse oximeter to ascertain the oxygen level

26

A client reports severe pain 2 days after surgery. After assessing the characteristics of the pain, which
initial action should the nurse take next?

Answer

Encourage Rest

Obtain vital signs

Administer the prescribed analgesic

Document the clients pain response

During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1
mg/dL (260 mcmol/L). What should the nurse do first in response to this laboratory result?

Notify the primary healthcare provider

Obtain current blood test results

Assess for decreased urine output

Check the intravenous (IV) infusion

28

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. Which
factors does the nurse determine were the most likely cause of the hyponatremia? Select all that apply.

Diabetes insipidus

Profuse diaphoresis

Excess Sodium intake

Removal of parathyroid glands

Rapid intravenous (IV) infusion of 5% dextrose in water

29

A client's serum potassium level is below the normal range. Which clinical indicators should the nurse
determine are consistent with hypokalemia? Select all that apply.

Abdominal cramping

Tall, peaked T wave

Irregular heart rate

Muscular weakness

Decreased bowel sounds

Hyperactive deep tendon reflexes

30
A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and
electrolyte imbalance associated with this surgery?

Constipation

Muscle spasms

Hypoactive reflexes

Increased specific gravity

31

A nurse anticipates that dialysis will be necessary for a patient with chronic kidney disease when the
patient begins to exhibit which symptom?

Answer

Hypotension

Hypokalemia

Hypervolemia

Hypercalcemia

32

After the nurse provides education about hydrochlorothiazide, the client will agree to notify the
healthcare provider regarding the development of which symptom?

Insomnia

Nasal Congestion

Increased thirst

Generalized weakness

33

A client with the diagnosis of Cushing syndrome has the following laboratory results: Na * (sodium) 149
mEq/L (149 mmol/L):K + (potassium) 3.2 mEg/L (3.2 mmol/L): Hb (hemoglobin) 17 g/dL (170 mmol/L);
and glucose 90 mg/dL (5 mmol/L). What should the nurse teach the client? Select all that apply.

Avoid foods high in salt

Restrict your fluid intake

Limit your carbohydrate intake

Continue your regular diet as before

34

The nurse is assessing the respiratory status of the client at 2-hour intervals as a nursing safety priority.
Which condition is affecting the client?

Answer

Hypokalemia

Hyperkalemia

Hyponatremia

Hypernatremia

35

Which client should a nurse consider the greatest risk for developing hypernatremia?

A 52-year-old who is receiving 0.45% NaCl intravenously

A 76-year-old who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as
a result of head trauma

A 63-year-old who has had watery diarrhea since traveling abroad

A 48-year-old who is admitted with a diagnosis of Addison's disease

36

The healthcare team is conducting a physical assessment of a client. What are the priorities to assess
during the breathing component? Select all that apply.

Observe for chest trauma

Establish a patent airway by positioning

Evaluate the client's level of consciousness

Assess breath sounds and respiratory effort

Remove all clothing for a complete assessment

A client with a head injury underwent a physical examination. The nurse observes that the client's
temperature assessments do not correspond with the client's condition. An injury to which part of the
brain may be the reason for this condition?

Pons

Medulla

Thalamus

Hypothalamus

38

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority
nursing action during the health history portion of the assessment?

Determining drug allergies

Noting the general appearance

Examining the neck for stiffness

Auscultating for heart and lung sounds

39

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach
pain. When determining the order of the assessment, the nurse recognizes that it is important to assess
the symptomatic quadrant when?

Answer

First

Second

Third

Last

40

A disturbed client is brought to the emergency department by the police. What should be included in
the nurse's initial mental assessment?
Recollection of past events

Previous methods of coping with stress

Current behavior, cognitive function, and orientation

Cultural background, developmental level, and verbal skills

41

A client is brought to the emergency department after an automobile collision. The client's blood
pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early
clinical indicator of decreased arterial pressure should the nurse assess the client?

Warm, flushed skin

Increased pulse pressure

Lethargy with confusion

Reduced peripheral pulses

42

Which component of delegation is retained while the delegator is delegating the client's care task to the
nursing aide?

Authority

Supervision

Responsibility

Accountability

43

A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous
ambulatory peritoneal dialysis (CAP). Which statement by the student nurse indicates to the primary
nurse that the student nurse understands the purpose of this therapy?

Answer

It provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration

It exchanges and cleanses blood by correction of electrolytes and excretion of creatinine

It decreases the need for immobility, because it clears toxins in short and intermittent periods
It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion

44

a client on peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of
the dialysate solution, what should the nurse do?

Increase the rate of infusion

Auscultate the lungs for breath sounds

Place the client in a low-fowler position

Drain the fluid from the peritoneal cavity

45

client is to have hemodialysis. What must the nurse do before this treatment?

Obtain a urine specimen to evaluate kidney function

Weigh the client to establish a baseline for later comparison

Administer medications that are scheduled to be given within the next hour

Explain that the peritoneum serves as a semipermeable membrane to remove wastes

46

When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from
the peritoneal cavity has ceased before the required volume has returned. What should the nurse
instruct the client to do?

Drink a glass of water

Turn from side to side

Deep breathe and cough

Rotate the catheter periodically

47
A nurse is performing peritoneal dialysis for a client. Which action should the nurse take?

the client in a side-lying position

Warm the dialysate solution slightly before installation

Infuse the dialysate solution quickly over 5 to 10 minutes

Withhold the routine medications until after the procedure

48

What criteria should the nurse consider when determining if an infection should be categorized as a
health care-associated infection?

Originated primarily from an exogenous source

Is associated with drug resistant microorganism

Occurred in conjunction with treatment for an illness

Still has the infection despite completing the prescribed therapy

49

Which action performed by the nursing student during the chest examination of a client needs
correction?

Placing the stethoscope over bony prominences

Palpating two ribs inferiorly in the midaxillary line

Dividing the anterior and posterior lungs into thirds

Listening to at least one cycle of inspiration and expiration

50

During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the
lungs. Which sound should the nurse document in the medical record?

Answer

Dull

Flat

Tympany

RESONANCE