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PREBOARD 31 -A

1.) The nurse is caring for a client with acute diverticulitis. Which of the following clinical
findings would cause the nurse to suspect the client may be developing sepsis? Select all
that apply.
a. Elevated WBC count
b. Heart rate 118/min
c. Mean arterial blood pressure 80 mm Hg
d. Respirations 28/min
e. Temperature 101.2 F (38.4 C)

2.) The nurse cares for a client with bipolar disorder during an acute manic episode. A family
member states that the client has been skipping meals frequently. Which diet guidelines are
most important for this client? Select all that apply.
a. Frequent reminders to eat
b. Increased calorie intake
c. Increased fluid intake
d. Increased protein intake
e. Restricted sodium intake

3.) The nurse in the mental health unit is talking with a client. Which of the following
statements by the client should the nurse recognize as transference?
a. "I pretend to have feelings; how would you know the difference?"
b. "I really like you because you remind me of my sibling."
c. "My roommate always glares at me; do you think they dislike me?"
d. "I do not think the people who work here are genuine."

4.) The nurse on the intensive care unit is caring for a client with a traumatic brain injury who is
unconscious. What is the best technique for the nurse to elicit a motor response?
a. Briskly turn the client's head while holding the eyelids open
b. Firmly press on the client's proximal nail bed
c. Hold the client's arms in front of the body and check for drift
d. Squeeze and release both the client's hands

5.) The nurse is caring for a client with schizophrenia who has a scheduled dose of haloperidol.
Which client statement would cause the nurse to hold the medication and contact the
health care provider?
a. "I feel anxious and am having a hard time sitting still today."
b. "I noticed that I feel slightly drowsy after taking this medication."
c. "It has been 2 days since I had my last bowel movement."
d. "My mouth has been dry since I began taking this medication."
6.) The nurse is preparing to insert a nasogastric tube (NGT) for a client. Which of the following
statements by the nurse would indicate a correct understanding of the procedure?
a. "I will estimate the length of NGT insertion by measuring from the mouth to the earlobe
and to the top of the sternum."
b. "I will insert the NGT with the client in the semi-Fowler position with a pillow behind the
shoulders."
c. "If I meet resistance during insertion, I will first try to advance the NGT by gently rotating
it."
d. "If the client begins to choke or gag during insertion of the NGT, I will remove it and
begin again."
7.) The nurse obtains a client's health history and identifies which of the following as risk factors
for developing peptic ulcer disease? Select all that apply.
a. 1 pack-per-day cigarette smoking
b. Daily consumption of 2 or 3 beers
c. Diet consisting of plant proteins and vegetables
d. Frequent ibuprofen use for arthritic pain
e. High levels of occupational stress

8.) The home health nurse observes a parent administering ear drops into the right ear of a 6-
year-old child. Which of the following actions by the parent indicate a correct understanding
of otic drop administration? Select all that apply.
a. Ensures that the otic drops are warmed to room temperature
b. Holds the dropper 2 in (~1 cm) above the ear canal
c. Lays the child on the left side with the right ear facing up
d. Maintains the child in a side-lying position for 2-3 minutes after instillation
e. Pulls the auricle of the right ear up and back during administration

9.) The nurse is reviewing new prescriptions for a client taking carbidopa-levodopa for
Parkinson disease. Which prescription should the nurse clarify with the health care provider?
a. Acetaminophen
b. Doxycycline
c. Isocarboxazid
d. Metformin

10.) The nurse is caring for a 9-month-old client during a well- child visit. Which of the following
gross motor skills should the nurse expect at this age? Select all that apply.
a. Crawls on the hands and knees
b. Holds the head up steadily
c. Rolls from the back to the abdomen
d. Sits on the floor without support
e. Walks with one hand on furniture
11.) The nurse is caring for a client who is receiving IV vincristine and is reporting burning and
small vesicles at the peripheral venous access device (VAD) site. Which of the following
actions should the nurse take? Select all that apply.
a. Apply a pressure dressing and ice pack to the VAD site.
b. Aspirate the medication from the VAD site.
c. Prepare the client for potential antidote administration.
d. Mark the affected skin with a felt pen.
e. Stop the infusion and disconnect the IV tubing.

12.) The nurse has attended a staff education program about metformin. Which of the following
statements by the nurse would require follow-up?
a. "Clients often experience a decreased appetite while taking metformin."
b. "Metformin may be used in combination with other antidiabetic medications."
c. "Rapid shifts in blood glucose levels may occur if metformin is not taken with food."
d. "Metformin may prevent the onset of type 2 diabetes mellitus in clients with
prediabetes."

13.) The nurse is participating in staff education about caring for clients with liver cirrhosis.
Which of the following statements are appropriate to include in the teaching? Select all that
apply.
a. "A decrease in the serum ammonia level indicates worsening hepatic encephalopathy."
b. "Changes in the client's behavior may indicate hepatic encephalopathy."
c. "Encourage clients with liver cirrhosis to limit foods high in sodium."
d. "Perform routine measurements of abdominal girth to monitor progression of ascites."
e. "Production of clotting factors is impaired, which increases the risk for bleeding."

14.) The nurse is preparing to administer a dose of IM promethazine to a client who is


experiencing nausea and vomiting. The medication is available in a glass ampule. Place in
order the steps for withdrawing medication from a glass ampule. All options must be used.
a. Grasp the upper stem with an alcohol pad or gauze and snap the neck away from the
nurse's body
b. Place the ampule upright on a flat surface or inverted in the nurse's hand
c. Remove the filter needle and replace it with an appropriate-length injection needle
d. Tap the upper stem gently to remove medication from the neck of the ampule
e. Withdraw the medication from the ampule with a filter needle and syringe

15.) The nurse is caring for several clients on the coronary care unit. Which of the following tasks
are appropriate to delegate to the unlicensed assistive personnel? Select all that apply.
a. Measure intake and output for a client with chronic kidney disease
b. Obtain vital signs for a client who is receiving mechanical ventilation
c. Perform a site check for a client who underwent cardiac catheterization
d. Reinforce teaching on the proper use of an incentive spirometer
e. Remain with a client who is a fall risk while the client uses a bedside commode
16.) The charge nurse is observing the nurse perform wound irrigation on an infected ulcer.
Which of the following actions by the nurse are appropriate? Select all that apply.
a. Administers prescribed analgesic 30 minutes prior to irrigation
b. Holds the tip of the syringe on the wound bed while irrigating
c. Instills the irrigation solution using low continuous pressure
d. Prepares a sterile syringe with a large- bore angiocatheter
e. Tilts the client on the side and irrigates downward from the top of the wound

17.) Which 4 client findings are most concerning?


a. Blood glucose level
b. Diaphoresis
c. Epigastric pain
d. Oxygen saturation
e. Upper back pain

18.)
19.)
20.)
21.)
22.)

23.) The nurse is caring for a client whose adult child was killed in a boating collision 6 months
ago. Which statement by the client indicates grief resolution?
a. "I drive a longer route home so that I don't see the lake where the collision occurred."
b. "I have decided to establish a scholarship in my child's name at a local college."
c. "I often ask myself why I allowed my child to use the family boat that day."
d. "I take extra shifts at work to stay busy and prevent my mind from wandering."

24.) The nurse is caring for a client experiencing an acute manic episode. Which diet order is
most appropriate for this client?
a. Beef and vegetable soup, crackers, and a glass of milk
b. Chicken pasta salad, hardboiled egg, and a piece of cake
c. Meatloaf, mashed potatoes with gravy, and a cup of coffee
d. Peanut butter and jelly sandwich, sliced apples, and a juice box

25.) The nurse receives a prescription to remove an indwelling urinary catheter. Place the steps
the nurse should take to remove the catheter in the appropriate order. All options must be
used.
a. Measure and record the urine remaining in the drainage bag
b. Position the client on the back with the knees bent
c. Provide privacy and explain the procedure to the client
d. Remove the catheter with a smooth motion
e. Withdraw all fluid from the catheter balloon

26.) The nurse is caring for a client in the emergency department. Which of the following clinical
findings are consistent with early alcohol withdrawal? Select all that apply. Click on the
exhibit button for additional information.

a. Bilateral hand tremors


b. Blood pressure 152/93 mm Hg
c. Diaphoresis
d. Nonproductive cough
e. Pulse 110/min

27.) The nurse is talking with a client who is scheduled for an elective surgical procedure. The
client expresses concern for potential misuse of opioid analgesics prescribed for
postoperative pain. Which of the following responses would be most appropriate for the
nurse to make?
a. "Biofeedback and guided imagery are other alternatives that are helpful for pain relief."
b. "You should focus on achieving pain control and not worry about opioid misuse."
c. "Opioid misuse is rare when medications are taken temporarily for acute pain."
d. "You can choose not to fill the prescription and use acetaminophen instead."

28.) The nurse is teaching a client who received radioactive iodine therapy for hyperthyroidism.
Which of the following client statements indicate correct understanding of the teaching?
Select all that apply.
a. "I cannot breastfeed any children I have in the future."
b. "I need to sleep in a different bed than my spouse."
c. "I should wash my clothes separately from everyone else's."
d. "I will ask my spouse to prepare the food for our household."
e. "I will use a different bathroom than everyone else in the house."

29.) The nurse is caring for a client with hyperthyroidism who suddenly develops confusion,
nausea, and tremors. Which of the following actions should the nurse take? Select all that
apply. Click the exhibit button for additional client information.

a. Administer propranolol.
b. Apply a cooling blanket.
c. Administer methimazole.
d. Provide 4 oz of orange juice.
e. Ask about an allergy to iodine.

30.) The nurse obtains an admission history for an older adult client with newly diagnosed
chronic obstructive pulmonary disease (COPD). Which of the following client statements
does the nurse identify as contributing factors to the development of COPD? Select all that
apply.
a. "Both of my parents smoked at home when I was growing up."
b. "I did quit smoking cigarettes but smoked a pack a day for 50 years."
c. "I drink alcohol, but not as much as before I stopped smoking."
d. "I had frequent respiratory illnesses and was told I had childhood asthma."
e. "I worked steadily as a house painter for about 40 years."

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