Kaplan Qbank SATA
Kaplan Qbank SATA
Kaplan Qbank SATA
The nurse prepares a teaching plan for a client who experienced anaphylaxis after receiving a dose of
penicillin. Which steps will the nurse inform the client to take if anaphylaxis occurs in the future? (Please
arrange in order. All options must be used.)
Have 2 epinephrine auto injectors available at all times
Administer one injection of epinephrine
Leave the epinephrine injector in place for 10 seconds
Call 911 for transport to the emergency department
Bring the used auto injector to the emergency department
Two nurses, who work together on an orthopedic unit, are involved in a disagreement. The
disagreement has caused tension among all staff members resulting in decreased morale on the unit.
Which initial action by the unit manager is appropriate when handling this situation? (Select all that
apply.)
Speak with both nurses individually.
Serve as a mediator in a meeting with both nurses.
The nurse teaches a client about the use of a walker following hip replacement surgery. Which
statement, if made by the client, requires follow-up by the nurse? (Select all that apply.)
“I will lean over the handles of the walker while moving my feet forward.
“I will wear shoes with leather soles.”
A client is terminally ill and days away from death. The hospice nurse wants to help the client cope by
discussing end-of-life needs. Which topic is appropriate to discuss at the end of life? (Select all that
apply.)
The effects of dehydration.
The possibility of hallucinations.
Fears of the unknown.
A client who is reporting persistent lower back pain requests a pain medication. After reviewing the
client’s medication administration record, the nurse informs the client that the next dose of pain
medication is not due for several hours. Which non-pharmacological intervention is appropriate for the
nurse to offer? (Select all that apply.)
A heating pad to place on the painful area.
Repositioning in bed to relieve pressure from the painful area.
Aromatherapy to provide a distraction from the pain.
A nurse provides care for a client who was admitted to the mental health unit following a suicide
attempt. When talking to the sibling of the client, which question is appropriate for assessing the family
dynamics? (Select all that apply.)
“Who would you describe as the leader of the family?”
“What would you describe as a strength of the family?”
“What is something you think should change in your family?”
The nurse provides care for a client who has undergone an abdominal hysterectomy. Which
interventions will the nurse include in the client’s plan of care? (Select all that apply.)
Changing the client’s position at least every 2 hours.
Monitoring the client’s urine output.
Assessing the client’s perineal pads for bleeding.
Encouraging the client to perform leg exercises.
The nurse receives a phone call from a caller who states a bomb is in the hospital. Which action does the
nurse take when handling this situation? (Select all that apply.)
Ask the caller about the location of the device.
Inquire about what will make it explode.
The nurse provides care to a client diagnosed with Paget disease. Which findings are anticipated by the
nurse as characteristic of this disorder? (Select all that apply.)
An elevated serum alkaline phosphatase.
A pathologic fracture.
An abnormal remodeling and resorption of bone.
The nurse prepares to administer newly prescribed clonazepam and meloxicam to the client. Upon
assessment, the client reports hives and difficulty breathing after taking midazolam and oxycodone
years ago. Which actions will the nurse implement? (Select all that apply.)
Holds the clonazepam.
Notifies the health care provider.
A client diagnosed with a fracture of the left ulna undergoes an open reduction procedure.
Postoperatively, a plaster cast is placed on the client’s left arm. Which client statement requires an
intervention by the nurse? (Select all that apply.)
“The cast will be fully dried in the next few hours.”
“The cast should be covered to promote drying and prevent cracking.”
“It is best if I elevate my arm and cast on a plastic-covered pillow.”
The nurse in the pediatric clinic assesses a young school-age client. The parent reports the client has
been tired and cranky for over a week and "just picks at food." Which questions does the nurse ask?
(Select all that apply.)
"Has your child had any fever?"
"Have you noticed any bruises on your child's body?"
"Will you take off your child's shoes so I can weigh your child?"
"Has your child ever had blood drawn before?"
The nurse provides care to an intrapartum client on the labor-and-delivery unit. Which observation
requires follow up? (Select all that apply.)
The partner answers questions that are directed toward the the client.
The partner refuses to leave the client's side when asked to do so.
Each contraction lasts longer than 90 seconds.
The nurse provides care for a toddler during a well-child visit. Which statement by the parent indicates
additional teaching is needed? (Select all that apply.)
“I just bought my toddler a pretend cash register that uses real coins.”
“We moved the safety gate from the bottom of the stairs to the top of the stairs.”
“Household cleaners are stored in the cabinet under the sink in the kitchen.”
The nurse provides care to a client with the following assessment data: nonproductive cough, fever, lung
crackles, headache, and myalgia. Which nursing concerns are appropriate? (Select all that apply.)
Acute discomfort.
Inefficient gas exchange.
Ineffective breathing pattern.
The nurse provides care for the client diagnosed with pneumonia. During a routine assessment, the
nurse notes an SpO 2 reading of 89%, pulse of 100 beats/min, and respiratory rate of 30 breaths/min. In
what order will the nurse respond when providing care to this client? (Please arrange in order. All
options must be used.)
Adjust client’s position to high-fowler’s
Administer Oxygen at 2 L by nasal cannula
Auscultate lungs for adventitious sounds
Reassess oxygen saturation by pulse oximetry
Notify the health care provider
Which task does the nurse properly delegate to the unlicensed assistive personnel (UAP)? (Select all that
apply.)
Measure the diameter of the client’s calf.
Obtain a midstream urine specimen.
Cleanse a superficial wound with an antiseptic solution.
Measure a client’s rectal temperature.
The nurse coordinates care on the medical-surgical unit. Which client indicators, if assigned by the nurse
to the LPN/LVN, suggest professional negligence? (Select all that apply.)
Client with hemoglobin 6 g/dL (60 g/L).
Client with blood urea nitrogen 80 mg/dL (28.56 mmol/L).
Client with platelet count 22,000/mm 3 (22 ×10 9 /L.)
Upon reviewing a client’s electronic medical record, the nurse notes that the serum sodium level is 128
mEq/L (128 mmol/L). Which assessment finding does the nurse anticipate? (Select all that apply.)
Headache.
The nurse manager reviews the unit’s emergency response plan for a fire with the staff. Which
statement by a staff member indicates a need for further education? (Select all that apply.)
“Keep the doors to the unit open at all times so staff, clients, and visitors can evacuate more easily.”
“The nurse should extinguish the fire and then activate the fire alarms.”
“The nurse should aim the fire extinguisher at the top of the fire.”
A client recovering from surgical removal of an abdominal tumor frequently asks for intravenous
morphine that has been prescribed every 4 hours. During a change of shift, the night nurse verbalizes a
plan to administer normal saline the next time because “the client is going to overdose if I give any more
morphine.” Which action by the day nurse is appropriate? (Select all that apply.)
Explain to the nurse that this is not ethical.
Encourage the nurse to discuss the plan with the charge nurse.
A client at 30 weeks gestation is diagnosed with preeclampsia and is being treated with magnesium
sulfate infusion. Which assessment does the nurse prioritize? (Select all that apply.)
Observing for facial edema.
Measuring blood pressure.
Eliciting deep tendon reflexes.
Counting the respiratory rate.
The nurse reviews the medical record under the prescription tab. Which prescription documented in the
medical record should the nurse address with the health care provider regarding appropriate
abbreviations and standard terminology when documenting care? (Select all that apply.)
“Aspirin 81 mg q.d.”
“MS 4 mg PRN”
The nurse provides care for a postoperative client and changes the dressing with dry gauze and tape.
Shortly after the dressing change, the client reports intense itching at the surgical incision site. Which
action by the nurse is appropriate? (Select all that apply.)
Remove the dressing and notify the health care provider.
Review the client’s allergies.
The nurse champions a nurse-driven performance improvement project for a critical care unit. The goal
is to reduce the number of catheter-associated urinary tract infections (CAUTIs). Which action should
the nurse promote among staff members to reduce CAUTI rates? (Select all that apply.)
Use a securement device on the leg.
Verify the necessity for indwelling urinary catheters on a daily basis
Clean the periurethral area daily with soap and water.
Empty collection bags frequently. The nurse assesses a group of clients to determine the risk for
developing a health care acquired infection.
In which order, from greatest to least risk, should the nurse identify the risk? (Please arrange in order.
All options must be used.)
86-year-old client diagnosed with cancer and a white blood cell count of 2,000/mm
90-year-old client with difficulty eating and is severely underweight
52-year-old client who has urinary retention and an indwelling urinary catheter
62-year-old client with obesity and altered sensation of the feet and lower legs
The nurse provides care for an older adult client who is receiving 24-hour total parenteral nutrition
(TPN) via a central line. Which assessment finding requires the nurse to collaborate with the health care
provider? (Select all that apply.)
Urine output of 100 mL/hr.
Muscle cramps and spasms.
Presence of clay-colored stools.
The nurse supervises a novice nurse providing care to a client with new symptoms of a cerebrovascular
accident (CVA). Which actions by the novice nurse cause the seasoned nurse to intervene? (Select all
that apply.)
Administers to the client aspirin 325 mg by mouth.
Assigns the client a 0 score on the National Institute of Health stroke scale screen.
Reassures the client that all symptoms will resolve.
While working on an inpatient hospital unit, the nurse observes a visitor approach the nurses’ station.
The visitor stands close to the nurse and makes aggressive verbal threats. Which action by the nurse is
appropriate? (Select all that apply.)
Remain calm and acknowledge that the visitor is upset and frustrated.
Call for security staff to assist with the individual.
The perioperative nurse is evaluating a group of clients for risk factors that may lead to postoperative
complications. Which clients are at high risk for developing respiratory complications following surgery?
(Select all that apply.)
A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago.
A 34-year-old smoker who underwent a left ankle repair 2 days ago.
A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago.
A 42-year-old nonsmoker who had a chest tube removed 2 hours ago.
The nurse provides care for an adolescent client diagnosed with sickle cell disease who is in severe pain
and reports feeling sad. Which statement should the nurse use to evaluate the client’s spiritual and
religious needs? (Select all that apply.)
“What things are helpful to your well-being that we may be able to incorporate into your care?”
“What are the major concerns you think your disease has caused you?”
The nurse provides discharge instructions to an adult client diagnosed with infectious diarrhea. In which
situation does the nurse advise the client to call a health care provider immediately? (Select all that
apply.)
Development of dry skin.
Pulse rate exceeding 100 beats per minute.
Cold extremities.
Increased thirst.
The nurse cares for a young adult client with cystic fibrosis receiving gentamicin for a Pseudomonas
aeruginosa pulmonary infection. The nurse is concerned if the client makes which statement? (Select all
that apply.)
“I woke up with a buzzing noise in my ear.”
“I forgot to tell my provider I am 2 months pregnant.”
A client diagnosed with pelvic inflammatory disease (PID) has a prescription for intravenous
tetracycline. Which intervention should the nurse include in the client’s plan of care? (Select all that
apply.)
Ask the dates of the client’s last menstrual period.
Assess the IV catheter site frequently.
Instruct the client to use barrier contraceptives.
Instruct the client to use sunscreen.
A client recovering from a hemorrhagic stroke is prescribed a bedside swallow evaluation prior to oral
intake. In which order does the nurse perform the actions? (Please arrange in order. All options must be
used.)
Verifies the client can follow commands
Explains the procedure to the client Positions the client in high fowler position
Performs oral care on the client Gives the client 30 ml of water from a medicine cup
Monitors for coughing choking or drooling
The nurse educator prepares an educational session on medication error prevention. Which teaching
point does the nurse include in the session? (Select all that apply.)
Two nurses must verify dose adjustments on high-risk medications such as IV heparin or insulin.
Two client identifiers must be used every time medications are administered.
Complete all steps prompted by the electronic medical record at the time of medication administration.
The nurse instructs a client prescribed hydralazine as treatment for hypertension. Which client
statements indicate to the nurse that the teaching is effective? (Select all that apply.)
“I will take my hydralazine with my breakfast.”
“I will call my health care provider before taking ibuprofen.”
“I will sit on the edge of my bed for 2 minutes before I get out of bed.”
Prior to administering medications to clients on a cardiopulmonary unit, the nurse assesses each client
to evaluate the effect of the prescribed medication. Which client is experiencing an expected outcome?
(Select all that apply.)
A client prescribed losartin for hypertension who has a BP of 118/76 mm Hg.
A client prescribed spironolactone for right-sided heart failure who has less pedal edema.
A client prescribed warfarin for a pulmonary embolism with an international normalized ratio (INR) of 2.
The nurse instructs the unlicensed assistive personnel (UAP) on the emptying of a drainage evacuator. In
which order will the nurse teach the UAP to perform the required actions? (Please arrange in order. All
options must be used.)
Identify the client
Elevate the bed to a workable height
Don gloves
Pour drainage into measuring cup
Compress the evacuator and replace the plug
The nurse is working with an unlicensed assistive personnel (UAP) to care for clients in a birthing center.
Which task does the nurse safely delegate to the UAP? (Select all that apply.)
Assist a client in active labor with breathing and relaxation.
Empty the urine from a client’s catheter bag and record the amount.
Ambulate a client who is post-cesarean to the bathroom.
A client admitted with community-acquired pneumonia requires infusions of IV antibiotics. The nurse
knows to stop the infusion immediately if which assessment is made? (Select all that apply.)
An intense, high-pitched sound is heard from the upper airways.
The client’s BP changes from 126/82 mm Hg to 92/59 mm Hg.
The client reports a sense of impending doom.
The health care provider prescribed 40 mg of furosemide IV for a client. The electronic medication
dispensary has 40 mg vials of furosemide available and the screen reads, “Take 2 vials.” The nurse
realizes that the 40 mg vials are in the designated 20 mg vial cubicle. Which action does the nurse take?
(Select all that apply.)
Report the error to the pharmacy and wait to remove medication from the cubicle.
The nurse and an experienced unlicensed assistive personnel (UAP) are assigned to care for a client who
had an ischemic stroke 5 days ago and is experiencing residual left-sided weakness. Which task does the
nurse delegate to the UAP? (Select all that apply.)
Reapply the pneumatic compression boots.
Set up the client’s meal tray and assist as needed.
Assist the client to reposition every 2 hours.
The nurse teaches colostomy care to a client prior to discharge. Which client statements indicate to the
nurse that the teaching is effective? (Select all that apply.)
"Some mild swelling of my stoma may be seen for 2 –3 weeks."
"Eating yogurt will decrease odor from the colostomy."
"The opening in the pouch for the stoma may need to be adjusted over time."
The nurse assesses a newborn and notes that the neonate is hypothermic. Which interventions are
appropriate for the nurse to include in the newborn ’s plan of care? (Select all that apply.)
Warm the newborn slowly to avoid potential apnea episodes.
Wrap the newborn in a warm blanket.
Place a hat on the newborn ’s head.
Provide the newborn with skin-to-skin contact with the mother.
A client who types as part of their job is worried about developing carpal tunnel syndrome. Which action
does the nurse take? (Select all that apply.)
Ask the client to demonstrate their position when typing.
Determine how often the client takes breaks from typing.
Which clients are appropriate for the charge nurse to assign to the LPN/LVN on a medical unit? (Select
all that apply.)
The client with a colostomy whose appliance is leaking.
The client with a seizure history who is receiving gabapentin.
The client who needs elastic compression stockings applied.
The client with diabetes mellitus who is due a dose of insulin.
The nurse in the post-anesthesia care unit (PACU) provides care for an adult client who had repair of an
abdominal aortic aneurysm. Which assessment finding may indicate unexpected bleeding? (Select all
that apply.)
Arterial blood pressure 84/56 mm Hg.
Bilateral pedal pulses +1.
Capillary refill 4 seconds.
The nurse provides care for a client diagnosed with postural hypotension. The nurse includes which
intervention in the client ’s plan of care? (Select all that apply.)
Teach the client energy conservation techniques.
Encourage the client to increase fluid intake.
Instruct the client to rise slowly.
The nurse provides care for a client who is homeless and reports drinking alcohol daily. Upon assessing
the client, the nurse notes twitching at the corner of the client’s mouth when stimulating the facial
nerve and carpopedal spasm to the hand when measuring the client’s blood pressure. Which electrolyte
imbalance does the nurse anticipate the client is experiencing? (Select all that apply.)
Hypomagnesemia.
Hypocalcemia.
The nurse cares for a client who weighs 400 lb (181.8 kg) and is on bed rest. The nurse must assist the
client to move up to the head of the bed with the use of the draw sheet. Which technique, if performed
by the nurse, ensures proper lifting of the client? (Select all that apply.)
The nurse keeps own spine, neck, and back straight and aligned throughout the lift.
The nurse pivots feet in the direction of the move prior to moving the client.
The nurse places the bed in Trendelenburg position prior to moving the client.
The nurse prepares to administer an angiotensin II receptor blocker (ARB) to a client. Which laboratory
value requires the nurse to contact the health care provider prior to the administration of the prescribed
medication? (Select all that apply.)
A serum potassium level of 5.2 mEq/L (5.2 mmol/L).
When providing care to a group of postoperative clients, which interventions does the charge nurse
delegate to the LPN/LVN? (Select all that apply.)
Changing the gauze dressing for a client who had a hip pinning yesterday.
Titrating oxygen administration according to prescribed parameters.
The nurse provides care for the client who is a strict vegetarian. Which assessment data does the nurse
document to support the current diagnosis of vitamin B12 deficiency? (Select all that apply.)
Fatigue
Constipation
Sore tongue
Diarrhea.
A client is scheduled to receive a hemodialysis treatment this morning. Which medication does the
nurse hold for administration after the hemodialysis treatment is finished? (Select all that apply.)
Doxazosin 2 mg PO every day
Captopril 100 mg PO bid
Vancomycin 500 mg IV every 6 hours.
The nurse provides care to a client with a suspected latex allergy. Which clinical manifestations noted on
the nurse's assessment support this diagnosis? (Select all that apply.)
Runny nose
Angioedema
Bronchospasm
Shock.
A fire occurred at a community center during a town meeting. When the nurse assesses the victims at
the scene, which victim requires immediate transport to the hospital? (Select all that apply.)
A middle-age client without injuries who is coughing and has a respiratory rate of 24
An older adult client with partial-thickness burns to both lower extremities
A client who has been confined to bed for several weeks begins to show early signs of a pressure injury
on the heel. Which action does the nurse take? (Select all that apply.)
Place a rolled towel under the calf
Have the client wear socks when moving in bed
The nurse performs a moist-to-dry dressing. (Please arrange in order. All options must be used.)
Assess the client’s comfort level
Remove gauze dressings
Observe the appearance of the would
Clean the wound with saline solution
Apply moist gauze in a single layer to the wound
Record date and time dressing applied as per family policy
The nurse changes the dressing on a client’s double-lumen peripherally inserted central venous catheter
(PICC). Which technique should the nurse use? (Select all that apply.)
Cleanse around the catheter insertion site using a circular motion outward.
Apply an occlusive dressing over the insertion site.
Use sterile technique during the dressing change.
Change gloves between removal of the old dressing and application of the new dressing.
The nurse provides care for the client diagnosed with hemophilia. The nurse intervenes if the client
makes which statement? (Select all that apply.)
"I drink two beers every day after work."
"I receive intramuscular pain injections weekly."
"I take meloxicam daily for arthritis pain."
The nurse evaluates care provided to a client diagnosed with excessive body fluid. Which finding
indicates to the nurse that additional interventions are required? (Select all that apply.)
Third heart sound is present.
Weight gain of 3 lb (1.36 kg) overnight.
+2 pitting edema bilateral feet and ankles.
The nurse orients a novice nurse to the unit. The nurse recognizes that the novice nurse understands
principles of safe IV therapy when which action is observed? (Select all that apply.)
The novice nurse scrubs the hub of the access port for 45 seconds.
The novice nurse flushes the IV with normal saline before and after administering an incompatible
medication.
The novice nurse uses a syringe with a filter needle to draw up medication from a glass ampule.
The health care provider asks the nurse to use restraints on an older adult client diagnosed with
dementia. Which action does the nurse take before applying the restraints? (Select all that apply.)
Ensure the prescribed restraint is the least restrictive for the situation.
Ask the health care provider for the prescription in writing.
Ensure that the prescription includes when the restraint will be removed.
The parent of a toddler asks the nurse about toilet training. Which statement should the nurse include
when discussing this topic? (Select all that apply.)
“It is important to identify the signs that indicate your child is ready.”
“Your child will likely accomplish bowel control before bladder control.”
“Nighttime bladder control usually occurs several months after daytime bladder control is achieved.”
“It is better to provide a freestanding potty chair for your child than having your child sit on the toilet.”
“Sessions on the potty with your child should last 5 to 10 minutes.”
The nurse teaches a client with a right sprained ankle how to use crutches safely. Which client
statement indicates correct understanding? (Select all that apply.)
“I know it is important that I use only the crutches that were measured for me.”
“I know it is important for me to inspect my crutches regularly.”
“I should put weight on my crutches then place my left foot on the step when going up the stairs.”
The nurse prepares to administer amikacin to a client diagnosed with an enterococcal infection. Which
client findings cause the nurse to question administration of the medication? (Select all that apply.)
Reports nausea and diarrhea.
Receives warfarin for atrial fibrillation.
Receives hemodialysis three times weekly.
The nurse provides care for a client who has been admitted to the observation unit for chest tightness.
The health care provider has prescribed an exercise stress test. Which intervention does the nurse
initiate prior to this scheduled test? (Select all that apply.)
Educate the client on the procedure, including symptoms that could warrant discontinuation of the test.
Ensure that the client has been NPO 4 hours before the test.
The nurse prepares assignments related to nutrition for the evening shift. Which client can be assigned
to the unlicensed assistive personnel (UAP)? (Select all that apply.)
The weak client diagnosed with human immunodeficiency virus (HIV) and pneumonia.
The client diagnosed with rheumatoid arthritis (RA) and who is allergic to fish.
The client diagnosed with epilepsy and who is alert and oriented.
A nurse prepares to administer medications to clients at 0900. In which order does the nurse administer
the medications? (Please arrange in order of priority. All options must be used.)
The client receiving levetiraceram 1000mg twice daily by mouth for a seizure disorder
The client receiving metronidazole 500 mg every 8 hours intravenously for clostridium difficile
The client receiving hydrochlorathiazide 25 mg daily by mouth with a recent blood pressure of 140/84
mm hg
The client receiving digoxin 0.375 mg daily by mouth with a recent heart rate of 92 bpm
The nurse performs a physical assessment on a client to assess cranial nerve function. Which actions will
the nurse take to assess the client’s trigeminal nerve? (Select all that apply.)
Palpate the temporal and masseter muscles while the client clenches teeth.
Use a cotton swab on the client’s face to test light touch.
The nurse is notified that a client undergoing brachytherapy is being transferred from the radiation
department. Which action must the nurse take before the client arrives to the unit? (Select all that
apply.)
Determine the location of the radioactive implant.
Discuss the concepts of time, distance, and shielding with the assigned unlicensed assistive personnel
(UAP).
Review the agency’s protocol for dislodgement of the radioactive implant.
Ensure a private room is available.
A client is admitted to the hospital with a fever, cough, and a maculopapular rash that appeared 3 days
after symptoms first began. Rubeola (measles) is suspected. The nurse knows care is effective if which
action is observed? (Select all that apply.)
The unlicensed assistive personnel (UAP) washes hands before and after client care.
The nurse prepares a client diagnosed of end-stage liver disease for a paracentesis. Which response by
the nurse is appropriate when the client states refusal of the procedure? (Select all that apply.)
“I will let your health care provider know of your decision.”
“I will contact your health care provider so we can review your advance directives.”
“I will contact your health care provider to discuss medications to decrease the discomfort from excess
fluid in your abdomen.”
The nurse receives an assignment for 4 clients at the beginning of a shift. In which order does the nurse
assess the clients, beginning with the first client seen? (Please arrange in order. All options must be
used.)
The client experiencing chest pain, dyspnea, and hemoptysis
The client experiencing worsening dyspnea and chest pain with inspiration
The client experiencing a productive cough and an elevated temperature
The client with a chronic productive cough awaiting biopsy
The nurse provides nutrition education to a client who follows a vegan diet. Which nutrients does the
nurse include in the teaching session as those that may be deficient? (Select all that apply.)
Calcium
Vitamin B 12.
Iron.
Vitamin D.
A preschool-age client is admitted with measles (rubeola). The nurse knows that measles requires
airborne transmission-based precautions. How will the nurse manage care of this client? (Arrange the
steps in order. All options must be used.)
The nurse organizes and prepares all the equipment to be taken into the child’s room
The nurse steps into the anteroom and acknowledges the child through the window
The nurse puts on an N95 mask
The nurse enters the child’s room
The nurse provides care for several clients who have urinary issues.
Which client will the nurse refer to the health care provider for immediate follow-up? (Select all that
apply.)
A client 2 days post right kidney transplant with vital signs HR 88 beats/minute, BP 100/58 mm Hg, R 16
breaths/minute, T 103.1°F (39.5°C).
A multigravida client with a pessary in place who reports trouble passing urine.
The nurse works in the emergency department. A motor vehicle accident with multiple victims is called
in on the radio. Which client will require the highest priority intervention? (Select all that apply.)
A client in the same vehicle as a victim who was deceased at the scene.
A client with second-degree burns to chest and hoarseness reporting a painful throat.
The client taking sitagliptin asks the nurse for breakfast suggestions from the hospital menu. Which
foods will the nurse recommend? (Select all that apply.)
Scrambled egg with salsa, whole wheat toast, and fruit jelly.
Whole grain cereal with sliced banana and 1% milk.
Yogurt with blueberries and almonds, and hot tea with lemon.
A client must follow a high-protein, low-sodium, and low-potassium diet. Which menu selections by the
client require follow-up teaching by the nurse? (Select all that apply.)
Roast beef sandwich, coleslaw, and baked beans.
Broiled chicken breast, spinach salad, and green beans.
Poached salmon fillet, broiled cabbage, and lemonade.
Grilled chicken Caesar salad and whole grain roll with iced tea.
The nurse prepares to administer subcutaneous enoxaparin to a postoperative client when the client
states, “I don’t want that!” Which response by the nurse is appropriate? (Select all that apply.)
“You have the right to refuse, but I’d like to explain what the enoxaparin does.”
“The enoxaparin is prescribed to help prevent blood clots, since you are not up walking as much as
usual.”
A client is placed on NPO status because of an esophageal mass. A family member gives the client juice,
which is vomited immediately. Which are appropriate nursing actions? (Select all that apply.)
Suction the client ’s mouth with an oral suction.
Elevate the head of the bed to 45 degrees.
Notify the health care provider immediately.
Auscultate the client ’s breath sounds frequently.
The nurse is assigned four clients on a medical-surgical unit. During the medication pass at 2100, in
which order does the nurse give medications to these clients? (Please arrange in order. All options must
be used.)
The client prescribed metronidazole 500 mg IV for necrotizing pancreatitis
The client prescribed levetiracetam 750 mg PO for a seizure disorder
The client post-exploratory laporatomy who is prescribed famotidine 20 mg IVP
The client reporting mild anxiety who is prescribed hydroxyzine 25 mg po as needed
The nurse monitors a client in labor who is receiving a continuous IV infusion of oxytocin. Which
assessment finding prompts the nurse to stop the infusion? (Select all that apply.)
Contractions lasting 120 seconds.
Maternal nausea and vomiting.
Late fetal heart rate decelerations.
The nurse reviews laboratory values for a group of clients. Which results does the nurse report to the
health care provider? (Select all that apply.)
Positive nitrates in the urinalysis of a client receiving chemotherapy.
A blood glucose level of 140 mg/dL (7.77 mmol/L) in a client diagnosed with diabetes mellitus receiving
IV methylprednisolone.
A serum potassium level of 3.3 mEq/dL (3.3 mmol/L) in a client receiving IV antibiotics.
The nurse has completed an educational conference on the appropriate handling of infectious and
hazardous materials. Which action by the nurse indicates an understanding of the topic presented?
(Select all that apply.)
Place used syringes with needles directly into the sharps disposal box.
Use personal protective equipment when preparing IV chemotherapeutic agents. 5
The nurse plans care for a 7-year-old client who has undergone hematopoietic stem cell transplantation.
Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Playing a board game with the client while the parents go home for a break.
Measuring the client’s vital signs every 4 hours.
Stocking the room with personal protective equipment.
Reminding the client to wear a mask when being transported outside of the room.
The nurse assesses a newborn immediately after birth using the Apgar scoring system. Which data does
the nurse assess when using this scoring system? (Select all that apply.)
Heart rate.
Respiratory effort.
Muscle tone.
Reflex irritability.
A client who is confused and cannot speak for themself is due for a wound dressing change.
The surgical team enters the room to perform the procedure. Which action by the nurse represents
advocacy for this client? (Select all that apply.)
Requesting pain medication for the client prior to the dressing change.
Informing the client that the surgical team is getting ready to change the wound dressing.
The nurse teaches a new parent about childhood immunizations for a 2- month-old client. Which
immunizations does the nurse include in this teaching? (Select all that apply.)
Rotavirus.
Diphtheria, tetanus, pertussis.
Haemophilus influenzae type b.
Inactivated poliovirus.
The nurse provides care to a client diagnosed with chronic heart failure (HF) and an acute bacterial
infection. The client's medications include furosemide 40 mg PO daily and aspirin 81 mg PO daily. Which
new prescriptions cause the nurse to seek clarification from the health care provider? (Select all that
apply.
Vancomycin 3 g IV piggyback every 12 hours.
Digoxin 0.25 mg PO daily.
The parents of a young toddler admitted to the emergency department report excessive sweating and
refusal of fluids for the past 6 hours. The client’s serum sodium is 155 mEq/L (155 mmol/L). Which
action by the nurse is priority? (Select all that apply.)
Administer IV fluids.
Assess for changes in consciousness.
Weigh all diapers.
The nurse prepares to give a complete bed bath to a conscious adult client. (Arrange the steps in order.
All options must be used.)
Offer the bedpan or urinal, putting on clean gloves to assist the client as needed
Raise the bed to a comfortable working height
Place a bath blanket over the client
Wash the client’s face including the eyes
Wash the client’s upper extremities, hands trunk
Wash the clients back
The nurse prepares to change a client’s sterile dressing. Which action demonstrates appropriate
technique when setting up a sterile field? (Select all that apply.)
Unwraps sterile items and carefully drops the items onto the sterile field
Keeps sterile gloved hands at table level.
Touches 1 inch (2.5 centimeters) edge of the sterile field with clean gloves.
Closes the door before establishing the sterile field.
Explains the procedure to the client before setting up the sterile field.
The nurse provides care to a client with chronic pain due to knee osteoarthritis. The client asks about
ways to manage pain in addition to taking medication. Which non-pharmacologic pain relief measure is
appropriate for this client? (Select all that apply.)
Yoga.
Water aerobics.
Cushioning footwear.
Massage.
Adequate sleep.
Application of heat 2–3 times/day.
A client receives a prescription for clopidogrel. Which laboratory results are important for the nurse to
monitor based on this new prescription? (Select all that apply.)
Hemoglobin.
Hematocrit.
The nurse reviews information about gabapentin before providing the medication to a client. Which
information will the nurse include about this medication? (Select all that apply.)
Is used for neuropathic pain.
May cause drowsiness.
May be used as an anti-seizure medication.
Is prescribed for postherpetic neuralgia.
The nurse provides care for an older adult client admitted to the medical-surgical IV unit who is awaiting
surgical repair of the left hip. Surgery has been delayed to medically stabilize the client. Which situation
requires an intervention by the nurse? (Select all that apply.)
The LPN/LVN auscultates crackles at the base of the lungs bilaterally.
The client has a low Braden Scale score.
The nurse provides care for a pregnant client, weighing 155 lb (70.45 kg), with partial thickness burns on
bilateral lower extremities. Which assessment finding indicates adequate nutritional and fluid intake?
(Select all that apply.)
Daily caloric intake is 3000 calories.
Serum total protein = 7 g/dL (70 g/L), glucose = 102 mg/dL (5.66 mmol/L), albumin = 4 g/dL (40 g/L).
Body mass index (BMI) = 22.
The nurse provides care for a client who is undergoing an elective surgical procedure. Which statement,
if made by the client, requires an intervention by the nurse? (Select all that apply.)
“I am having second thoughts about this procedure. Are there risks involved?”
“That medication they gave me made me so drowsy I could barely write my own name on that consent
form.”
The nurse discusses breastfeeding with a new mother. Which client statements require the nurse to
intervene? (Select all that apply.)
“I wash my nipples with soap between feedings. ”
“I use breast pads with plastic lining. ”
The nurse provides care for a client following a permanent pacemaker insertion 4 hours ago. Which
assessment finding indicates the procedure was successful? (Select all that apply.)
Pulse is 78 beats per minute.
Blood pressure is 118/78 mm Hg.
Paced spikes noted on the cardiac monitor.
The nurse conducts an admission assessment for an older adult client who is at risk for developing deep
vein thrombosis (DVT). Which preventive measures does the nurse expect to be prescribed? (Select all
that apply.)
Low molecular weight heparin.
Compression stockings.
Sequential compression devices.
The nursing supervisor works to improve client and visitor safety by encouraging incident reporting in
the facility. Which statement by the nursing staff indicates an understanding about incident reporting?
(Select all that apply.)
“I completed an incident report after a medication was mislabeled and I almost administered the wrong
dose.”
“I completed an incident report after a client’s family member slipped on the wet floor and fell.”
The nurse provides care for a postoperative client reporting pain. The nurse removes an opioid
medication from the electronic medication dispensing system. Prior to administering the medication,
the nurse notices that another nurse medicated the client with the same medication 5 minutes earlier.
Which action is appropriate for the nurse to take? (Select all that apply.)
Return the medication to the electronic medication dispensing system.
The nurse provides education to a client who is newly diagnosed with systemic lupus erythematosus
(SLE). Which client statement indicates to the nurse a need for further instruction? (Select all that
apply.)
"I will wear SPF 15 sunscreen when I am outside."
"The rash on my face will go away in time."
"I may need to take a medication that will boost my immune system."
The nurse provides discharge teaching to a client diagnosed with chronic kidney disease. Which client
statements indicate the teaching is effective? (Select all that apply.)
“I will notify my health care provider if my legs start feeling numb or weak.”
“I’ll keep some hard candy with me for when my mouth gets dry.”
“If I quit smoking, I’ll have a better chance of getting a kidney transplant.”
Following a diagnosis of colon cancer, a middle-age client undergoes a colon resection procedure, which
results in an ascending colostomy. Which intervention by the nurse is appropriate when providing
postoperative care to the client? (Select all that apply.)
Assess the stoma every 4 hours.
Provide emotional support to the client.
The nurse teaches a client who is newly diagnosed with type 1 diabetes mellitus. Which information
does the nurse include in the client’s discharge teaching? (Select all that apply.)
Insulin administration.
Symptoms and treatment of hypoglycemia.
The use of a portable blood glucose monitor.
The nurse teaches a client on actions to reduce urinary tract infections (UTIs). Which beverage selections
demonstrate to the nurse that client teaching is effective? (Select all that apply.)
Cranberry juice.
Water.
The nurse provides care for a client receiving chemotherapy. The medication is an alkylating agent.
Which actions will the nurse implement to minimize adverse effects? (Select all that apply.)
Administer anti-emetics prophylactically and as needed.
Teach client to use saline mouth rinse before and after meals.
Encourage client to increase fluid intake for the next 3 days.
Educate client about the benefits of exercise to manage fatigue.
A young adult female client is prescribed atorvastatin to treat familial hypercholesterolemia. Which
teaching points will the nurse make to this client while conducting medication instruction? (Select all
that apply.)
“It is important to use contraception while taking statin medications.”
“Most people taking statin medications experience few adverse effects.”
“Plan to have blood work done at least yearly if you take atorvastatin.”
The nurse dropped a narcotic tablet on the floor in the client’s room prior to medication administration.
How will the nurse waste the narcotic tablet and get another one? (Arrange the steps in order. All
options must be used.)
The nurse must pick up the dropped narcotic in order to waste it properly in the presence of another
licensed professional.
The nurse informs the client about what is going on and why the nurse must go get another tablet.
Before going to the medication dispensary machine, the nurse must find a second nurse to be present
when wasting the narcotic tablet.
The second nurse must watch as the primary nurse wastes the narcotic tablet.
The second nurse must sign off on the narcotic waste log sheet after the primary nurse wastes the
narcotic tablet.
After the waste process is completed, the primary nurse can get another narcotic tablet.
The primary nurse should not get a new narcotic tablet prior to wasting the narcotic tablet that was
dropped.
The cardiac monitor of a client who is awake and alert and has a peripheral pulse shows ventricular
tachycardia with a rate of 160 beats/min. Which actions are appropriate for the nurse to implement?
(Select all that apply.)
Monitor blood pressure.
Alert the rapid response team.
Obtain a 12-lead electrocardiogram as prescribed.
The nurse supervises a team of LPN/LVNs. The nurse intervenes if one of the LPN/LVNs allows clients to
take licorice pills when which medications are administered? (Select all that apply.)
Potassium chloride.
Furosemide.
Prednisone.
The pediatric nurse provides one-on-one education regarding burn prevention and fire safety to the
parents of a toddler client. Which parental statement requires the nurse to provide further instruction?
(Select all that apply.)
“I will firmly discourage my child from touching outlets or cords.”
The nurse prepares to discharge a client who had a laryngectomy. Which information will the nurse
include in the discharge instructions regarding stoma and laryngectomy care? (Select all that apply.)
Avoid swimming.
Avoid direct exposure to cold air.
Get a medical identification bracelet.
A client's cardiac monitor shows a new onset of atrial fibrillation with a ventricular rate of 90 beats/min.
Which actions will the nurse implement when providing care for the client? (Select all that apply.)
Measure vital signs.
Assess for associated signs and symptoms.
Notify the health care provider.
While performing abdominal thrusts to remove a foreign body, the client becomes unconscious. Which
action is appropriate for the nurse to implement at this time? (Select all that apply.)
Begin chest compressions.
Look in the client’s mouth for a foreign body.
Open the client’s airway using a head-tilt, chin-lift maneuver.
Activate the emergency response system.
The nurse transports a client by stretcher for a STAT computed tomography (CT) scan. The client is being
continuously monitored with a transportable cardiac monitor. In route, the monitor loses battery life
and turns off. Which action does the nurse take? (Select all that apply.)
Notify the charge nurse to bring another transportable cardiac monitor to the radiology department.
Place a portable SpO2 sensor on the client’s finger to monitor heart rate.
The nurse learns that a client with an ileostomy has not had any output for 6 hours. Which action does
the nurse instruct the client to take to help promote elimination? (Select all that apply.)
Drink warm fluids.
Massage around the stoma.
Take a warm shower or bath.
The nurse performs a 6-minute walk test on a client diagnosed with chronic obstructive pulmonary
disease (COPD) to determine the need for long-term oxygen therapy. During ambulation, the client’s
oxygen saturation is measured at 88%. Oxygen of 2 liters via nasal cannula is placed on the client. The
SpO2 now measures 95%. Which action will the nurse perform? (Select all that apply.)
Document the walk test and oxygen saturations.
Advocate for a case management consultation to initiate long-term oxygen therapy.
A client in Buck traction for a fractured right femur experiences increased anxiety and pain. Which non-
pharmacological method of pain management is appropriate for the nurse to initiate? (Select all that
apply.)
Play music.
Turn the television on.
The nurse provides care for a client receiving lithium carbonate 300 mg orally three times per day.
Which clinical manifestation does the nurse identify as an early indication of toxicity? (Select all that
apply.)
Nausea.
Slurred speech.
Muscle weakness.
The nurse prepares to administer digoxin 0.25 mg PO to a client diagnosed with heart failure. The nurse
recognizes that which factor increases the risk for digoxin toxicity? (Select all that apply.)
Serum potassium level of 3 mEq/L (3 mmol/L).
Renal insufficiency.
Total serum calcium level of 11.5 mg/dL (2.88 mmol/L).
Diuretic therapy.
The nurse provides care for a toddler in the emergency department. The parents report that the child
started screaming 2 hours ago and refuses to eat. Which intervention should the nurse perform when
completing a focused assessment of the gastrointestinal (GI) tract? (Select all that apply.)
Ask if the child has had a stool with blood and mucus in it.
Determine if the child has vomited.
Inspect the abdomen for distention.
Palpate the abdomen for a mass.
The nurse provides care for a client diagnosed with Guillain-Barré syndrome. Which statement indicates
to the nurse that the client’s family member understands the diagnosis? (Select all that apply.)
“Intravenous immunoglobulins are often used for treatment.”
“The cause of the syndrome may be a virus.”
“My loved one’s ability to walk will be affected.”
“A feeding tube may be required for treatment.”
The nurse assesses a client who is diagnosed with hypoparathyroidism. Which data, if found in the
client's medical history, are associated with the diagnosis of hypoparathyroidism? (Select all that apply.)
Carpal spasms.
History of convulsions.
Muscle irritability.
The nurse is made aware of a client’s situation during hand-off of care via the Situation Background-
Assessment-Recommendation (SBAR) report. Which detail about the client should the nurse address
with the off-going nurse? (Select all that apply.)
The client has a troponin level of 1.5 ng/mL (1.5 mcg/L).
The client has a newly placed nasogastric tube in the right nare.
The client is on a 1.5-liter fluid restriction.
The nurse noticed blood in the client’s stool.
The client’s temperature reached a peak of 101.2°F (38.4°C) during the past 12 hours.
While ambulating a client, the client suddenly reports dizziness and weakness. Which action does the
nurse prioritize? (Select all that apply.)
Call for help.
Stand with feet apart to create a broad stance.
Grasp the gait belt.
Slide client down leg, lowering client to the floor.
The nurse prepares to administer hydrocodone in a client diagnosed with breast cancer. Which nursing
intervention is an essential part of the plan of care for this client? (Select all that apply.)
Include avocados and bananas in the client’s diet.
Instruct the client to cough every 2 hours.
Ask the client about herbal supplement use.
A client is prescribed enoxaparin prior to discharge from the acute-care facility. Which client statements
require the nurse to intervene? (Select all that apply.)
"I will need frequent blood tests with this medicine."
"I will inject the medicine deep into my thigh muscle."
"Normal side effects of this medicine include black or tarry stools.
An older adult client tells the nurse, “I do not want to be resuscitated if my heart stops.” The client’s
family interjects and tells the nurse to ignore the client’s request and do everything possible to keep the
client alive. The client is awake but drowsy and oriented. Which action by the nurse is appropriate when
responding to this situation? (Select all that apply.)
Prepare a do-not-resuscitate (DNR) form for the client and health care provider to sign.
Acknowledge the family, but inform them it is the right of the client to make this decision.
The nurse discovers twice the prescribed dose of medication has been administered to a client. Which
action is appropriate? (Select all that apply.)
Notify the client’s health care provider of the error.
Inform the charge nurse of the medication error.
Complete the medication variance report.
The nurse manager is informed that a client on the unit has developed a central line-associated
bloodstream infection (CLABSI). The nurse manager collaborates with the risk manager during an
investigation of the incident. Which actions are appropriate for the nurse to take in this situation?
(Select all that apply.)
Determine if lack of supplies was a contributing factor.
Review nursing documentation prior to the CLABSI.
Determine the method by which nurses access central lines.
The nurse in a pediatric clinic teaches a class on the care of infants and how to prevent diaper
dermatitis. Which statement by a parent indicates teaching is successful? (Select all that apply.)
“I should change my baby’s diaper as soon as it gets wet or soiled.”
“Some disposable wipes may cause diaper rash.”
The nurse assists a graduate nurse with the care of a client whose blood glucose is 525 mg/dL (29.14
mmol/L), pH is 7.1, and serum bicarbonate level is 14 mEq/L (14 mmol/L) and has ketonuria. The nurse
intervenes if the graduate nurse makes which statement? (Select all that apply.)
"I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL (5.55
mmol/L)."
"The client's potassium level will increase as the blood glucose decreases."
"The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS)."
"I should check the client's blood glucose every 2 hours."
A nurse assesses an older adult client who reports a 2-day history of vomiting and diarrhea. Which
findings will the nurse expect during the physical exam? (Select all that apply.)
Urine specific gravity 1.035.
Hematocrit 55% (0.55).
Weak, thready pulse.
The nurse provides care to a client who has just undergone cardiac catheterization. The nurse is
concerned by which assessment finding? (Select all that apply.)
The client has difficulty swallowing ice chips and water.
The area around the insertion site is swollen and tender.
The client reports feeling anxious and short of breath.
The nurse provides care for a client diagnosed with heart failure. Which client statements indicate to the
nurse that medication therapy is effective? (Select all that apply.)
"Since I've been taking captopril, my feet are not as puffy."
"Lisinopril seems to help me not be as short of breath."
"Before taking valsartan, I had to stop and rest while cooking."
"I seem to urinate more when I take digoxin."
The nurse prepares to insert an indwelling urinary catheter into a male client. Which actions will the
nurse implement? (Select all that apply.)
Select an 18 French size catheter.
Hold penis perpendicular to body.
Use sterile technique on insertion.
A client is diagnosed with heart failure (HF). Which information will the nurse include when teaching the
client about self-management at home? (Select all that apply.)
Take medications at the same time each day.
Limit the consumption of sodium to 3 to 4 grams per day.
Report increased shortness of breath to the health care provider.
Inform the health care provider about a weight gain greater than 3 lb/week.
The nurse provides care for a client with a colostomy. Which nursing intervention is an essential part of
the plan of care for this client? (Select all that apply.)
Empty the pouch six or more times daily.
Remove the pouch by pushing the skin away from the barrier.
The nurse at an assisted living memory care unit is reviewing a client’s medication prescriptions. The
client has a history of dementia. Which medications require an intervention by the nurse? (Select all that
apply.)
Divalproex sodium 250 mg PO twice a day.
Risperidone 1 mg PO at 0800 and 0.5 mg at 1600 daily.
Lorazepam 0.5 mg PO three times a day PRN anxiety.
The nurse provides care for a client diagnosed with mild preeclampsia. Which assessment data,
identified by the nurse, supports this diagnosis? (Select all that apply.)
Blood pressure of 150/96 mm Hg.
ALT level 30 U/L (0.50 µkat/L).
The nurse accidentally provides a client with carvedilol 300 mg by mouth instead of clopidogrel 300 mg
by mouth. In which order will the nurse complete actions because of this medication error? (Please
arrange in order. All options must be used.)
Instruct to stay in bed
Place on continuous monitoring
Report the error to the healthcare provider
Assess urine output
A young adult client who is diagnosed with depression is prescribed duloxetine. The client has not
showered or eaten in days. Which response by the nurse to the client is appropriate? (Select all that
apply.)
“When did you last take your prescribed medication?”
“Do you have thoughts of harming yourself?”
The nurse provides cares for a client receiving peritoneal dialysis. Which finding leads the nurse to
suspect the client is experiencing peritonitis? (Select all that apply.)
Abdominal pain.
Rebound tenderness.
Cloudy dialysate return.
A client who experienced a stroke with residual mobility deficits has entered a residential rehabilitation
program. Which action does the nurse take to promote personal hygiene? (Select all that apply.)
Teach the client about the use of handrails in the bathroom.
Show the client and family how to use the shower chair.
Provide the client with wet wipes for handwashing.
The nurse provides education about car and booster seat safety to parents. Which information does the
nurse include? (Select all that apply.)
Remove heavy coats before placing a toddler in the car seat.
A car seat should be secured in the back center seat.
The nurse provides care for a client under legal guardianship. The health care provider prescribed a
computed tomography (CT) scan to confirm a hemorrhagic stroke. The client is refusing this exam.
Which action does the nurse take? (Select all that apply.)
Phones the legal guardian to discuss the procedure and options.
While working in a skilled nursing facility, the nurse prepares to walk with a client using a four-point
walker. Which client statement indicates the need for additional teaching before using the walker
independently? (Select all that apply.)
“I should slide the walker in front of me before I take a step.”
“It is okay to use one hand when maneuvering the walker right or left.”
“I don’t need to try to balance myself when using the walker.”
The nurse provides care for a client newly diagnosed with community-acquired pneumonia (CAP). Which
action is important for the nurse to include in the client’s plan of care? (Select all that apply.)
Obtain a sputum culture prior to initiating IV antibiotics.
Assess pulse oximetry readings at least every 4 hours.
The nurse provides care for pediatric clients on an infectious disease unit. The nurse understands
appropriate transmission-based precautions are in place for which client? (Select all that apply.)
A preschooler with varicella who shares a room with another preschooler with varicella.
An infant with rotavirus whose nurse wears a gown and nonsterile gloves while providing care.
The nurse notices a client’s family gathering outside of the client’s room to take a group picture. The
client seems to be in agreement with the picture. Which action by the nurse is appropriate? (Select all
that apply.)
Politely instruct the family to take the picture inside the client’s room.
Escort the family to a common area of the hospital outside the unit to take the picture.
A client diagnosed with chronic kidney disease is informed that hemodialysis must be started
immediately. The client becomes extremely upset and begins to cry. Considering the client’s medical
diagnosis and emotional state, which statement does the nurse make? (Select all that apply.)
“I am just going to sit here with you for a while.”
“I am here if you want someone to talk to.”
The risk management nurse conducts an audit of a client’s medical record and determines a potential
for a medication error based on which transcribed prescription? (Select all that apply.)
“MS 4 mg IVP q 6 hours PRN.”
“Irrigate coccyx wound with Dakin solution HS.”
“Metformin 500 mg PO qd.”
An infant diagnosed with failure to thrive has been prescribed enteral feedings via a nasogastric (NG)
tube. Which intervention does the nurse include in the plan of care? (Select all that apply.)
Weigh the infant daily.
Flush the tube once per shift.
Allow the infant to suck a pacifier.
The nurse coordinates care for clients in the emergency department (ED). Which activity can the nurse
properly delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Transport a client to the radiology department for a diagnostic procedure.
Chaperone the health care provider during a client’s pelvic examination.
The nurse receives a phone call from a pediatric client's caregiver. The caregiver reports a pin is stuck in
the child's eye. Which statement by the caregiver concerns the nurse? (Select all that apply.)
"The tears will probably push out the pin."
"I washed the eye with my allergy eye drops."
"How do I sterilize tweezers to pull the pin out?"
The nurse provides dietary teaching to a client with advanced stage liver cirrhosis. Which client
statements require intervention by the nurse? (Select all that apply.)
“I will increase the amount of fat in my diet. ”
“I will increase the amount of sodium in my diet. ”
“I will increase the amount of fluids in my diet. ”
The nurse receives report on an acute care unit. Which information does the nurse report immediately
to the health care provider? (Select all that apply.)
A client admitted with an acute inferior myocardial infarction has a new murmur that is heard loudest at
the cardiac apex.
A client with a history of peptic ulcer disease reports sudden, severe upper abdominal pain.
A client reports “feeling like a curtain is being pulled” across the visual field of the left eye.
The nurse provides care to a client with suspected influenza. To promote infection control, the nurse
ensures implementation of which precautions? (Select all that apply.)
Standard precautions.
Droplet precautions.
The health care provider prescribes a bedside procedure for a client admitted with severe abdominal
distention. The client refuses to sign the consent for treatment and informs the nurse that
pharmacological treatment is preferred. Which response by the nurse is appropriate? (Select all that
apply.)
“May I ask why you don’t want to have the procedure?”
“I support your decision and will inform the health care provider.”
“I would like to educate you more about the procedure and other treatment options.”
The nurse in the post-anesthesia care unit (PACU) cares for a client following a bronchoscopy and
mediastinoscopy for lung biopsy. Which assessment is important for the nurse to perform before
offering the client oral fluids? (Select all that apply.)
Level of consciousness.
Presence of cough reflex.
The nurse provides care for a client with a family history of hypertension. The nurse prepares to teach
the client about primary prevention measures. Which information does the nurse include in the teaching
plan? (Select all that apply.)
Maintain a healthy weight.
Utilize stress reduction techniques.
Reduce salt intake.
The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse
implement to meet the client’s needs? (Select all that apply.)
Explain the sounds in the environment.
Stay in the client’s field of vision.
Identify self by name and staff position.
The nurse completes dietary teaching with a client diagnosed with chronic kidney failure. The nurse
determines further teaching is needed when the client makes which menu selection? (Select all that
apply.)
Grilled cheese sandwich, canned tomato soup, diet cola.
Toast with peanut butter, coffee, orange juice.
Macaroni with salt substitute, bread pudding with raisins.
A client’s serum potassium level is 3 mEq/L (3 mmol/L). The health care provider prescribes an IV
infusion of potassium chloride. The screen on the infusion pump is displaying a “maintenance required”
error message. Which action does the nurse take? (Select all that apply.)
Remove the infusion pump from service and obtain a different infusion pump.
The nurse observes a student nurse preparing to insert an indwelling urinary catheter.
Which action by the student indicates the nurse needs to provide additional teaching? (Select all that
apply.)
Applies sterile gloves prior to positioning client.
Transfers of catheter from dominant to non-dominant hand after cleansing the urethral meatus.
The nurse at a health fair screens clients for vitamin B12 deficiency. Which client will the nurse
determine as needing vitamin B12 supplementation? (Select all that apply.)
Recently diagnosed with pernicious anemia.
Follows a strict vegan diet.
Takes metformin for type 2 diabetes.
Had a gastrectomy 2 years ago.
The nurse learns that an older adult client refused a prescribed sleeping medication and was awake
most of the night. Which actions will the nurse take? (Select all that apply.)
Ask if pain or discomfort interrupts sleep.
Obtain information about sleep habits when at home.
Instruct nursing staff to minimize unnecessary noise and talking in the hallway.
The nurse provides care for a client in the emergency department (ED) who is shaking and crying after
witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which
interventions does the nurse include in the client's plan of care? (Select all that apply.)
Remain with the client.
Administer prescribed lorazepam 1 mg orally.
Provide privacy for the client.
Write down important information.
The nurse assumes care for a client from the post-anesthesia care unit (PACU). In which order does the
nurse provide care for this client? (Please arrange in order. All options must be used.)
Perform a focused assessment of the client, including vitals sign
Observe incision or dressing and drainage tubes
Review healthcare provider’s postoperative prescriptions
Develop a plan of care based on findings and the individuals risk factor
Develops and implement individualized client education
The nurse provides care for a client who requires neurological checks every 2 hours. The nurse identifies
which components as part of the Glasgow Coma Scale (GCS)? (Select all that apply.)
Best verbal response — confused.
Eye-opening response — none.
Best verbal response — incomprehensible sounds.
Best motor response — localizes pain.
The nurse prepares to transfer a client from a bed to a wheelchair. What action by the nurse will assist
in maintaining proper body mechanics? (Select all that apply.)
Ask for assistance.
Avoid twisting at the waist.
Remain close to the client.
Use a pivoting motion.
After receiving a report on the client, the nurse finds the client unconscious with extremities jerking.
Which action does the nurse take? (Select all that apply.)
Place the head of the bed flat.
Remain with the client.
Notify the health care provider.
Remove all items from the client ’s bed.
The nurse prepares a presentation for a group of parents about the importance of teaching personal
hygiene to children with diabetes mellitus. Which point does the nurse include in the presentation?
(Select all that apply.)
Feet should be protected with socks and well-fitting protective shoes.
Consult with a podiatrist regarding proper foot and nail care.
Regular candida infections may indicate poor glucose control.
Periodontitis may be prevented with regular dental care.
The nurse provides education to an adolescent client diagnosed with type 1 diabetes who is
transitioning to an insulin pump. Which client statement represents accurate teach-back on the safe use
of this equipment? (Select all that apply.)
“Troubleshooting issues with my device can help prevent DKA.”
“No matter where I go, I have my insulin pen with me.”
The nurse provides care for the client diagnosed with left-sided heart failure. Which data documented
by the nurse support the client's current diagnosis? (Select all that apply.)
The client leans over the bedside table and pauses often while speaking.
The client's lung sounds are positive for crackles bilaterally.
The client's heart rate as 128 beats/min. 6 . The client has distended neck veins.
The nurse provides care for a client diagnosed with acute pancreatitis. The nurse intervenes if the client
makes which statement? (Select all that apply.)
“After I get better, I need to eat a high-fat diet.”
“I’m glad I won’t get sick like this again.”
“I’m glad my blood sugar will not be affected.”
The nurse teaches a client whose oral hygiene has been inconsistent and poor. Which method does the
nurse use to evaluate the client’s understanding of oral hygiene and dental practices? (Select all that
apply.)
Ask the client to demonstrate brushing teeth.
Ask the client about the recommended frequency of dental checkups.
Ask the client to describe changes in the mouth that may require further assessment by a health care
provider.
Ask the client about access to regular dental care.
The nurse teaches a client who is prescribed prednisone for systemic lupus erythematosus (SLE). Which
information related to prednisone does the nurse include in the teaching plan? (Select all that apply.)
Report any symptoms of infection.
Do not discontinue medication abruptly.
Report unusual weight gain.
The nurse wants to assess the gait and lower limb mobility of an older adult client who had a knee
replacement 6 months ago. Which action does the nurse ask the client to perform? (Select all that
apply.) Walk across the room and back.
Walk heel to toe across the room.
Close eyes then stand with feet together with arms resting at side.
Close eyes and stand on one foot. .
Run the heel down the shin of the opposite leg toward the foot.
Some events observed by a nurse must be reported to the supervisor in an effort to improve quality and
performance. Which client situation is a serious reportable event (SRE)? (Select all that apply.)
A client attempts suicide and goes into hypovolemic shock.
An older adult client develops a stage 3 pressure injury.
A client has a stroke due to an air embolism in a central line.
A client diagnosed with cancer dies during surgery.
The nurse delegates tasks to an unlicensed assistive personnel (UAP) for the first time. Which action is
appropriate for the nurse to implement? (Select all that apply.)
State to the UAP how to report task completion.
Describe to the UAP which tasks will be delegated.
Describe to the UAP the expected task outcomes.
The nurse manager is presenting information at a staff meeting. When outlining the responsibilities of
the nurse manager, which statement should be included? (Select all that apply.)
“Monitoring professional nursing standards of practice on the unit.”
“Serving as an advocate for the nursing staff to the institution’s administration.”
“Conducting regular client rounds and helping to solve client or family concerns.”
The nurse performs a bedside swallow evaluation on a client diagnosed with an ischemic stroke. The
client drools, swallows the food, and then coughs during the evaluation. Which action does the nurse
take? (Select all that apply.)
Monitor breath sounds.
Request a speech therapy consultation.
Monitor for temperature measurement of 100.4°F (38°C) or greater.
The nurse assigns a client who is receiving a red blood cell transfusion to the unlicensed assistive
personnel (UAP). Which actions can be delegated to the UAP? (Select all that apply.)
Obtain vital signs prior to the transfusion.
Obtain blood products from the blood bank.
Perform hourly rounding during the transfusion.
Assist the client with toileting during the transfusion.
A client with a right femur fracture has permission to use the bedside commode with assistance and
crutches. The client states, “I don’t need any help from you!” The nurse recognizes that the client is at
high risk for falling. Which action by the nurse is appropriate in this situation? (Select all that apply.)
Utilize a bed alarm.
The nurse reviews lab results for a client receiving a heparin drip.The activated partial thromboplastin
time (aPTT) result is 116 seconds, and the heparin (25,000 units/250 mL) is currently infusing at 1200
units per hour. Based on the algorithm below, and a client weight of 75 kg (165.3 lb), which action does
the nurse take? (Select all that apply.)
A client has been given instructions about supplemental oxygen therapy in the home. Which client
statement indicates a need for further discussion with the nurse? (Select all that apply.)
“I will avoid using the microwave oven.”
“I can use petroleum-based lip balm.”
“I should choose clothing made of synthetic fabrics.”
The nurse provides discharge teaching to a client diagnosed with diabetes mellitus, obesity, and chronic
kidney disease (CKD). Which statement should be included in the teaching? (Select all that apply.)
“Take your enalapril as prescribed.”
A client diagnosed with an ischemic stroke has a percutaneous endoscopic gastrostomy (PEG) tube
placed for dysphagia. The health care provider prescribes strict NPO. Which medication from the
medical record should the nurse question? (Select all that apply.)
Aspirin 325 mg enteric-coated tablet daily via PEG tube.
Finasteride 5 mg tablet daily via PEG tube.
Levetiracetam 500 mg tablet BID via PEG tube.
Potassium chloride 20 mEq tablet daily via PEG tube.
Metoprolol 25 mg extended-release tablet daily via PEG tube.
The nurse provides teaching for a client diagnosed with herpes zoster. Which client statements indicate
to the nurse a correct understanding of the information presented? (Select all that apply.)
“I should expect only one side of my face to hurt.”
“This pain may linger for months.”
“I will try not to scratch the lesions.”
The nurse provides care for the client diagnosed with rheumatoid arthritis (RA). Which physical activities
does the nurse recommend to the client? (Select all that apply.)
Swimming.
Yoga.
A client is discharged from the hospital with prescriptions to continue taking several medications. The
nurse provides discharge teaching that includes the interaction of these medications with foods. Which
statement by the client indicates understanding? (Select all that apply.)
“I should avoid grapefruit juice while I am on atorvastatin, buspirone, and nifedipine.”
“I should limit my caffeine intake while I am on ciprofloxacin.”
“I should avoid alcohol while I am on buspirone.”
The nurse assesses the client diagnosed with type 1 diabetes mellitus (DM). Which clinical manifestation
indicates to the nurse the client needs glucose? (Select all that apply.)
Incoherence.
Diaphoresis.
Palpitations.
The nurse provides care for a client preparing for discharge from the facility. Which action should the
nurse take when the client states, “I haven’t told anyone else but I don’t have any place to go. I live
under the highway bridge”? (Select all that apply.)
Collaborate with the unit discharge planner.
Ask the client’s permission to share the information with the unit’s discharge planner.
The nurse receives hand-off communication on assigned clients with traumatic injuries. In which order
will the nurse prioritize the care of these client? (Please arrange in order. All options must be used.)
Client experiencing indigestion 4 hours after surgery
Client is prescribed to receive PRBC
Client reporting pain as 9/10 eight hours after surgery
Client prescribed preoperative medication when called to the surgical suite
A client who is experiencing palpitations but otherwise appears stable is admitted to the telemetry unit.
Once the 5-lead cardiac monitor is in place, the cardiac monitor technician informs the nurse that the
client’s rhythm appears to be supraventricular tachycardia (SVT). How will the nurse respond to this
information? (Arrange the steps in order. All options must be used.)
Verify lead placement and rhythm
MEasure the client’s blood pressure
Notify the healthcare provider
Obtain vials of adenosine
The nurse notices asystole on the cardiac monitor of a client with an advance directive of “do not
resuscitate.” The client’s spouse is at the bedside requesting that the nurse intervene immediately.
Which action is appropriate for the nurse to take? (Select all that apply.)
Do not perform CPR and remind the spouse that the client’s wish was for no resuscitation.
Inform the spouse that the client has legal documents that specify approved medical treatments.
The nurse provides care for a client diagnosed with diabetes mellitus who is unconscious and does not
have IV access. The client’s blood glucose is 27 mg/dL (1.5 mmol/L). Which action does the nurse take
immediately? (Select all that apply.)
Give glucagon 1 mg subcutaneously.
Notify the health care provider.
The nurse provides medication teaching to a client who is prescribed losartan. The client asks the nurse
why the medication is required since lower leg swelling only occurs when standing too long. Which
responses will the nurse make to this client? (Select all that apply.)
“It works by dilating blood vessels, which then reduces your blood pressure.”
“Do you have a bathroom scale at home?”
“You may feel dizzy at first when taking this medication. Get up slowly to avoid falls.”
The nurse provides care for a client diagnosed with bulimia nervosa. Which intervention does the nurse
initiate as part of the client’s plan of care? (Select all that apply.)
Monitor the client for an hour after meals.
Assist the client in identifying situations that produce anxiety.
Provide a quiet, non-stimulating environment for the client.
Weigh the client every morning on the same scale.
Establish a client contract.
An older adult client is admitted to the hospital. During the health history, the client reports that her
sleep patterns have changed with age. Which explanation does the nurse include when discussing sleep
changes that occur due to the aging process? (Select all that apply.)
Total sleep time is usually shorter in the older adult.
Stage IV sleep is substantially decreased.
Physical problems and medications can affect sleep.
Older adults have more difficulty falling asleep.
The nurse considers changing roles from staff nurse to performance improvement (PI) nurse. Which
direct impact on client care describes the purpose of the PI nurse? (Select all that apply.)
Evaluate unit processes in an attempt to streamline the workload of the nurse.
Evaluate the outcomes of newly implemented unit processes.
Collect and record data for review by accrediting agencies.
The nurse administers an immunization to an adult client. Which observations made after the injection
cause the nurse to immediately intervene? (Select all that apply.)
The client is clearing the throat and coughing.
The client is anxious and exhibits rapid breathing.
The client reports dizziness upon standing.
The client has a diffuse rash across the trunk.
The nurse prepares a client for a Holter monitor study (it is portable and used to continuously detect
arrythmias at home that are not detected in EKG). Which instructions will the nurse include when
teaching the client about this study? (Select all that apply.)
Trigger the event marker when pain or other symptoms occur.
Use a regular toothbrush instead of an electric toothbrush.
Keep a diary of activities, focusing on symptom occurrence.
Immediately report fast heart rate or difficulty breathing.
The nurse manager makes rounds on the nursing unit and overhears several staff conversations. Which
conversation violates the Health Insurance Portability and Accountability Act (HIPAA) laws necessitating
follow-up? (Select all that apply.)
The nurse informs an unassigned nurse that a client has acquired immunodeficiency syndrome (AIDS).
The nurse informs the client’s spouse that the client tested positive for chlamydia infection.
The nurse informs the assigned UAP that the client diagnosed with pneumonia had an elective abortion
13 years ago.
A client recently diagnosed with a myocardial infarction prepares for discharge from the hospital. The
health care provider (HCP) has prescribed isosorbide dinitrate 20 mg by mouth every 12 hours. Which
statement by the client indicates an understanding of the medication? (Select all that apply.)
“Acetaminophen should effectively treat headaches related to the medication.”
“I will contact my health care provider if I’m tired all the time.”
The nurse teaches a client about a new medication for hypertension. Which client statement indicates
that further teaching is needed? (Select all that apply.)
“I should not take acetaminophen with this medication.”
“I do not need to stop smoking now that I have this medication.”
The nurse answers the phone on a medical unit and is told by an unknown caller that there is a bomb in
the hospital. Which response by the nurse is appropriate? (Select all that apply.)
Try to determine the gender of the caller.
Listen for other sounds that can be heard on the call.
Ask the caller when and how the bomb will be detonated.
Ask the caller where the bomb is located in the hospital.
During mealtime, the nurse assists with feeding a client diagnosed with advanced dementia. The nurse
notices the client is pocketing food in the mouth. Which intervention does the nurse include in the
client’s plan of care? (Select all that apply.)
Continue oral feeding by hand with smaller portions.
Allow family members to bring the client’s favorite food items. 5
The nurse assesses a 10-year-old client during a well-child visit. Which statements will the nurse expect
the client to make? (Select all that apply.)
“I am allergic to strawberries. Whenever I eat one my lips get real big.”
“I have a kitten. I love having an animal.”
“A child in my class has hurt feelings when teased by others.”
The nurse provides care to a middle-age adult client who is hospitalized following a cerebrovascular
accident (CVA). Which information in the client's history does the nurse recognize as being a risk factor
for experiencing a CVA? (Select all that apply.)
Pheochromocytoma.
Routine use of ibuprofen.
Diabetes mellitus.
The nurse provides education about influenza treatment and prevention at a local health fair. Which
statement from a participant demonstrates correct understanding of oseltamivir? (Select all that apply.)
“I will begin taking the medication as soon as I experience flu symptoms.”
“If the medication upsets my stomach, I can take it with food.”
The nurse prepares to care for a client recently admitted with a diagnosis of borderline personality
disorder (BPD). The client’s admission documents indicate self-harming behaviors, impulsiveness,
intense rage, isolation, and depression. Which intervention does the nurse anticipate implementing?
(Select all that apply.)
Identify stimuli leading to maladaptive client behaviors.
Encourage verbalization of feelings, perceptions, and fears.
Explore past achievements, strengths, and successes with the client.
Consistently enforce clear and agreed-upon boundaries.
The nurse prepares to administer subcutaneous enoxaparin to a client diagnosed with deep venous
thrombosis. Which technique does the nurse implement when administering the medication? (Select all
that apply.)
Uses a tuberculin syringe for multi-dose vials.
Rotates injection sites with each dose.
While a nurse works in the emergency department at the triage desk, five clients arrive at the same
time. Based on assessments of these clients, the care of which one should be prioritized? (Select all that
apply.)
A young adult who dislocated a shoulder while playing tackle football.
A middle-age adult client with a dislocated right hip after falling at home.
An adult client who has rebound tenderness in the right lower quadrant of the abdomen.
A middle-age adult client who is diaphoretic and reporting crushing chest pain.
The health care provider prescribes a magnetic resonance imaging (MRI) exam of the brain to determine
if a client has an exophytic tectal glioma. The nurse must complete an MRI screening tool to ensure
client safety prior to the exam. (Arrange the steps in order. All options must be used.)
The nurse verifies the health care provider’s prescription for an MRI
The nurse determines whether the client agrees to the exam
The nurse completes the questionnaire
The nurse phones the MRI department
The nurse removes the client’s jewelry
The nurse escorts the client
The wound care nurse assesses a group of clients. The nurse determines that which client is receiving
appropriate care? (Select all that apply.)
The client with a stage 3 pressure injury whose hydrocolloid dressing is changed weekly.
The client with a spinal cord injury who has a non-blanching reddened area covered by a foam dressing.
The client whose poorly healing leg wound is being treated with a negative-pressure wound vacuum
system.
The nurse observes the unlicensed assistive personnel (UAP) providing care for a client diagnosed with
disseminated herpes zoster (shingles). Which UAP action requires the nurse to intervene? (Select all that
apply.)
Ambulating the client to the nurses’ station.
Refusing to enter the client’s room due to a personal positive titer.
Performing hand hygiene upon entering the client’s room.
Using the unit equipment to monitor the client’s vital signs.
The nurse teaches a community education course for clients at risk of developing chronic kidney disease.
Which characteristics are appropriate for the nurse to include as risk factors of chronic kidney disease?
(Select all that apply.)
Age greater than 60 years.
Older African Americans.
Hypertension.
Diabetes mellitus.
The nurse delivers a change-of-shift report. Which information is important for the nurse to include in
the report? (Select all that apply.)
Client ’s admitting diagnosis and relevant history.
Client ’s emotional response to condition.
Current intravenous (IV) solution and flow rate.
Use of and response to as needed medications.
The nurse provides care for a client following a tracheostomy. Which actions will the nurse take to
prevent dislodgement of the tube during this time? (Select all that apply.)
Wait at least 24 hours to change the tracheostomy ties.
Suction the tube when there is a moist cough or hypoxia.
A client seeks medical attention for cramping pelvic pain and saturating five sanitary napkins over a 2
hour period. Which questions are most important for the nurse to ask the client when conducting the
health history of the current issue? (Select all that apply.)
"Are you feeling dizzy?"
"When was the first day of your last period?"
"When did the bleeding start?"
An adult client was prescribed trazodone hydrochloride 100 mg PO daily by the health care provider 2
months ago. Which client statement indicates the medication is effective? (Select all that apply.)
“Overall, I’ve noticed my mood is much better since starting this medication.”
“I’m finding it easier to focus at work now that I am sleeping 7 to 8 hours every night.”
The nurse provides care for clients in the emergency department. Which client situation most benefits
from having a case manager assigned to the care plan team? (Select all that apply.)
A middle-age adult diagnosed with chronic obstructive pulmonary disease.
An adolescent diagnosed with type 1 diabetic ketoacidosis.
The nurse admits a client with severe, persistent headaches. Which question is appropriate to ask when
assessing the client’s orientation? (Select all that apply.)
“What is your health care provider’s name?”
“What is the name of this health care facility?”
“What year and month is it currently?”
The nurse works with a LPN/LVN and an unlicensed assistive personnel (UAP). Which task does the nurse
appropriately delegate? (Select all that apply.)
Assign the LPN/LVN to perform all dressing changes.
Instruct the LPN/LVN to reinforce client discharge teaching.
Assign the UAP to take vital signs and report findings to the nurse.
The nurse supervises a team of LPN/LVNs. Which actions by an LPN/LVN will cause the nurse to take
action? (Select all that apply.)
An LPN/LVN prepares to administer carvedilol to a client with a documented allergy to nadolol.
An LPN/LVN prepares to administer thioridazine to a client with a documented allergy to promethazine.
An LPN/LVN prepares to administer ceftriaxone to a client with a documented allergy to cefazolin.
The nurse has educated a client diagnosed with esophageal cancer who will be having an implanted port
for chemotherapy and possible total parenteral nutrition (TPN). Which statement made by the client
indicates that teaching is successful? (Select all that apply.)
“I will have less risk of infection this way.”
“My port will only be accessed when needed.”
“I will remind health care providers that I have a port.”
A client diagnosed with Addison disease suddenly reports weakness, fatigue, and decreased appetite.
Upon assessment, the nurse notes poor skin turgor and a blood pressure of 90/60 mm Hg. Which
nursing intervention is an essential part of the plan of care for this client? (Select all that apply.)
Infuse normal saline solution, as prescribed.
Provide a quiet environment for the client.
Administer IV hydrocortisone, as prescribed.
The nurse has been assigned to evaluate the occurrence of nursing errors on a telemetry unit. Which
action will be reported to the supervisor? (Select all that apply.)
When administering medications, the nurse asks clients their names and then administers the
medications.
The health care provider prescribes “5.0 mg metoprolol IV push now” for a client with new onset atrial
fibrillation.
The unit is short-staffed and nurses are regularly requested to work 16-hour shifts.
The nurse is unable to read a prescription due to poor handwriting and requests another nurse to verify
what is written.
The nurse completes a client’s initial fall risk assessment 36 hours after admission.
The nurse teaches a client diagnosed with multiple rib fractures on pulmonary hygiene. Which
statement by the client indicates that further teaching is necessary? (Select all that apply.)
“I should exhale deeply into the incentive spirometer 10 times an hour during the day.”
“I don’t want to ask the health care provider for pain medicine because they will think I am an addict.”
The nurse prepares a client for surgery. In which order does the nurse perform the preoperative
interventions to ensure safe care? (Place the answers in priority order. All options must be used.)
Verify that the operative permit is signed
Obtain and record the vital signs Ask the client to go the bathroom Instruct the client to remain in bed
Administer preoperative medication
The nurse assesses the newly-admitted client. Which data indicate the client is at risk for having a latex
allergy? (Select all that apply.)
The client has an allergy to avocado.
The client has undergone multiple surgeries.
The client is employed as a health care worker.
A client diagnosed with type 1 diabetes mellitus has a capillary blood glucose of 60 mg/dL (3.3 mmol/L)
and reports hunger, sweating, tachycardia, and tremulousness. Which food choices does the nurse
select that provide the client with 15 grams of an oral carbohydrate? (Select all that apply.)
Half cup of plain pasta.
Half cup of canned fruit.
125 mL of apple juice.
The nurse manager prepares to implement self-scheduling for the unit. In which order does the nurse
manager proceed with this task? (Please arrange in order. All options must be used.)
Assess staffing
Discuss unit Hold a Unit Meeting Post a blank
REview the sched
The nurse instructs parents on ways to decrease the incidence of sudden infant death syndrome (SIDS).
Which statements require the nurse to intervene? (Select all that apply.)
“My baby takes naps in the car seat. ”
“My baby sleeps covered with one blanket from chest to feet. ”
“My baby sleeps with one pillow under the head. ”
“My baby sleeps best on the sofa. ”
The nurse teaches an adult female client with a family history of hypertension. Which recommendation
does the nurse include in client education? (Select all that apply.)
Limit sodium intake to 2 grams or less daily.
Exercise at least twice weekly.
Avoid use of tobacco products.
Limit alcohol consumption to one serving per day. 5
Limit coffee consumption to two servings daily.
The nurse instructs a group of parents about age-appropriate toys for toddlers. Which toys will the
nurse recommend that toddlers use? (Select all that apply.)
Educational computer programs.
Pounding board.
Cloth picture books.
The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which
actions will the nurse implement when providing care to this client? (Select all that apply.)
Remove the newborn’s eye patches during feedings.
Cluster activities when caring for the newborn.
The nurse provides care to a client diagnosed with acute renal failure secondary to severe kidney
infection. During the oliguric phase, which assessment finding does the nurse expect to observe? (Select
all that apply. )
Azotemia.
Pruritus.
Nausea.
Serum potassium (K+) is 6 mEq/L (6 mmol/L).
The nurse teaches a client who experiences persistent tachycardia. Which instruction does the nurse
include in teaching the client about tachycardia? (Select all that apply.)
Avoid becoming overheated while outdoors.
Seek counseling as needed for anxiety management.
Use prescribed medications to control asthma.
The nurse supervises care provided by an unlicensed assistive personnel (UAP). Which action by the UAP
requires an intervention by the nurse? (Select all that apply.)
The UAP applies elastic compression stockings to a client after the client returns to bed after breakfast.
The UAP assists a 418.8 lb (190 kg) client diagnosed with lower extremity weakness to the bathroom.
The UAP wears a gown and gloves when assisting a client just admitted with meningitis to change into a
hospital gown.
A pediatric client presents with flushed skin, generalized itching, nausea, wheezes, and inspiratory
stridor after being stung by a bee. Which medication prescriptions will the nurse expect to implement
for this client? (Select all that apply.)
IM epinephrine.
IV diphenhydramine.
IV methylprednisolone.
Nebulized albuterol treatment.
The nurse assesses the client diagnosed with seizures, migraines, and type 1 diabetes mellitus (DM).
Which client statement requires follow up by the nurse? (Select all that apply.)
"I see fireflies around my head."
"I can't seem to wake up today."
"My hands won't stop shaking."
The nurse teaches a client with chronic pancreatitis about the dietary modifications needed to manage
the condition. Which foods will the nurse teach the client to limit in the diet? (Select all that apply.)
Fried foods.
Fatty foods.
Whole milk.
The nurse provides care for an older adult client who had a stroke. Assessment findings include right-
sided weakness, facial drooping, difficulty swallowing, and limited mobility. The nurse recognizes which
sites are appropriate for use when assessing the client's temperature? (Select all that apply.)
Axillary.
Tympanic membrane.
Temporal artery.
The nurse provides care for a client with an exacerbation of ulcerative colitis. The nurse determines
teaching is effective when the client makes which dietary choice? (Select all that apply.)
Canned green beans and applesauce.
Grilled cheese sandwich on white bread with creamed tomato soup.
Roast beef and mashed potatoes.
The nurse provides care for a client receiving enteral feedings via a gastrostomy tube. The nurse gives
the feedings by bolus. In which order does the nurse complete the activities associated with
administering the bolus feeding? (Please arrange in order. All options must be used.)
Ensure Formula
Check For Gastric Flush
Gastronomy
Assess Daily
Monitor
The nurse performs an assessment of a client diagnosed with Parkinson disease. The nurse expects to
assess which symptoms? (Select all that apply.)
Tremors. .
Bradykinesia.
Slurred speech.
Propulsive gait.
The nurse assesses several newborns after delivery. Which findings are anticipated by the nurse during
the physical examination? (Select all that apply.)
Head circumference 13 in (33 cm).
Irregular respiration.
The nurse provides care for a client diagnosed with type 1 diabetes mellitus. Which assessment findings
alert the nurse to a hypoglycemic reaction? (Select all that apply.)
Tremors.
Nervousness .
Irritability.
The nurse in the emergency department receives a client with burn injuries to more than 50% of the
body. Which nursing intervention is appropriate? (Select all that apply.)
Check the client’s capillary refill time.
Place an intubation set at client’s bedside.
The nurse instructs a client on how to use a standard walker for ambulation. Which steps will the nurse
use to educate the client on appropriate walker use? (Please arrange in order. All options must be used.)
Stand in the middle
Grasp the walker
Move the walker
Make Sure Step affected Step non affected
The nurse instructs a client about trimethoprim/sulfamethoxazole. The nurse needs to intervene if the
client makes which statements? (Select all that apply.)
"I should take the medication with food."
"This medication is safe during pregnancy."
A client, whose fists are clenched, loudly states, “I’m going to hurt someone if I don’t get my dinner
before 5 o’clock.” Which action should the nurse take? (Select all that apply.)
Request that other staff members stay close by.
Speak in a non-threatening, matter-of-fact tone.
The nurse prepares to apply sequential compression devices (SCDs) on a postoperative adult client.
Which aspect of care is included in the nursing care plan? (Select all that apply.)
Remove SCDs at least once every 8 hours.
Assess circulation of the client’s lower extremities.
After applying SCDs, monitor SCD functioning for one full cycle.
Maintain SCD use until the client is fully ambulatory.
Monitor skin integrity.
Instruct the client on the purpose and procedure of SCD use.
The nurse reviews the prenatal records of pregnant clients. Which maternal factor, associated with the
potential for fetal macrosomia, is appropriate for the nurse to identify? (Select all that apply.)
Gestational diabetes.
Maternal obesity.
A client diagnosed with acute kidney injury is scheduled to receive continuous renal replacement
therapy (CRRT). Which action will the nurse take when providing care to the client? (Select all that
apply.)
Frequently assess the client’s blood pressure.
Administer an anticoagulant, as prescribed.
Monitor the client’s electrolytes daily.
Obtain the client’s weight daily.
The home health nurse conducts a home visit with a client who is the first-time parent of a newborn.
Which client statements require further assessment by the nurse? (Select all that apply.)
"The baby's just so quiet and sleeps almost through the night!"
"I'm afraid of hurting my baby, and I can't keep my baby happy."
A client newly diagnosed with a terminal illness states, “I cannot believe this is happening. How am I
going to get through this?” Which response by the nurse will assess the presence of a support system for
this client? (Select all that apply.)
“Is there someone we can call to drive you home?”
“Do you attend a church or are you a member of any spiritual group?”
“Are you aware that you can contact a group for people who have the same diagnosis as yours?”
“Are there family members or friends you often talk to?”
“Do you live with anyone at home?”
A female older adult client, who appears confused and weak, is admitted to the hospital. The metabolic
panel reveals BUN is 29 mg/dL (10.35 mmol/L) and urine specific gravity is 1.15. The health care provider
prescribes 0.9% sodium chloride IV at 100 mL per hour. Which finding indicates to the nurse that the
prescribed treatment is effective? (Select all that apply.)
Six hours after initiating IV therapy, BUN is 19 mg/dL (6.78 mmol/L), and urine specific gravity is 1.02. 4 .
The client states, “How did I get to the hospital?”
Eight hours after initiating IV therapy, the client voids 300 mL of clear, yellow urine.
Hemoglobin is 13 g/dL (130 g/L) and hematocrit is 40% (0.4).
The nurse provides care for a client in isolation. Which item must be marked as biohazardous when
removing it from the room? (Select all that apply.)
Lab specimen.
Discarded syringes.
An older adult client with a diagnosis of urinary incontinence wears disposable undergarments and
changes them infrequently. The client reports new perineal skin irritation. Which suggestion does the
nurse make to address the irritation? (Select all that apply.)
Gently rinse the perineum area with warm water and pat dry several times a day.
Apply a zinc oxide-based barrier cream to the perineal area during each brief or incontinence pad
change.
The nurse prepares to obtain a wound culture from a client in long-term care. In which order will the
nurse perform the steps necessary to culture the wound? (Please arrange in order. All options must be
used.)
Assess
Perform
Clean
Insert
Ensure
The nurse assesses a client diagnosed with a descending colon tumor. Which characteristic symptoms of
this type of tumor does the nurse ask the client about during the physical examination? (Select all that
apply.)
Rectal bleeding.
Flat, ribbonlike stools.
Alternating diarrhea and constipation.
The nurse assists the health care provider performing a thoracentesis in the client's hospital room. The
nurse monitors for which symptom indicating a thoracentesis complication? (Select all that apply.)
Sudden dyspnea.
Asymmetric chest excursion.
Tachypnea.
Which action involving the client does the nurse determine to be violations of the EMTALA (Emergency
Medical Treatment and Active Labor Act)? (Select all that apply.)
Client who reports dental pain is denied a medical screening.
Client is transferred to another facility before attempts are made to stabilize client.
The nurse is assigned a process improvement project by the clinical nurse manager. Which quality
initiative process will increase the likelihood of hand hygiene among staff members? (Select all that
apply.)
Displaying posters with the “My Five Moments for Hand Hygiene” around the unit.
Educating staff during staff meetings about soap and water and alcohol-based hand disinfection.
Providing skill checkoffs regarding the expected hand-hygiene technique.
Performing routine observation and feedback to staff.
Educating clients about the importance of hand hygiene.
A client is prescribed intravenous fluid therapy with 0.9% sodium chloride 100 mL per hour into the left-
hand IV catheter. Which step will the nurse take while administering and changing the IV fluid solution?
(Select all that apply.)
Don clean gloves prior to assessing the IV catheter site.
Use aseptic technique to change out IV solution bags.
Perform hand hygiene before changing the IV solution.
Inspect the tissue around the IV entry site.
Use an alcohol swab to clean the cap on the short extension tubing.
Monitor the IV infusion at periodic intervals.
A client diagnosed with cirrhosis of the liver reports, “I cannot catch my breath.” Which finding does the
nurse report to the health care provider? (Select all that apply.)
Palpable swelling on bilateral ankles.
Blood pressure of 165/90 mm Hg.
Auscultation of crackles in the lung fields.
Bulging jugular vein.
A weight gain of 2 kg (4.4 lb) in 24 hours.
Blood urea nitrogen (BUN) level is 7 mg/dL (2.5 mmol/L).
The nurse teaches parents of children prescribed atomoxetine. Which information does the nurse
include in the teaching? (Select all that apply.)
“There is a low risk of dependence with this medication.”
“Your child may take atomoxetine with or without food.”
“Record your child’s weight weekly.”
“Offer your child fresh fruits and vegetables daily to prevent constipation.”
“Risk of suicidal thoughts may occur in children taking atomoxetine.”
After creating a genogram, the nurse identifies that a client is at risk for hypertension. Which secondary
preventive health interventions will the nurse include in the client’s plan of care? (Select all that apply.)
Monitor blood pressure frequently.
Monitor cholesterol level.
The nurse provides care to clients on a telemetry unit. The nurse will intervene if which action is
observed? (Select all that apply.)
A nurse obtains informed consent prior to a client being taken to the operating room.
The health care provider obtains informed consent in English from a client whose primary language is
Spanish.
The surgeon arrives to obtain informed consent from a client just after the anesthesiologist has
administered the preoperative benzodiazepine.
When obtaining informed consent for a left heart catheterization, the cardiologist states, “Risks of the
procedure included myocardial infarction, arrhythmias, cerebral vascular accident, and acute tubular
necrosis.”
The nurse provides care to a client who is prescribed long-term corticosteroid medication therapy for
the treatment of asthma. During the client assessment, the nurse recognizes which manifesations of
Cushing syndrome? (Select all that apply.)
Serum sodium (Na + ) 150 mEq/L (150 mmol/L).
Hyperglycemia.
Serum potassium (K + ) 3 mEq/L (3 mmol/L).