QUESTIONS AND CORRECT ANSWERS
Question 1
A nurse is assessing a client who has a long arm cast. For which of the following findings should
the nurse monitor when assessing for acute compartment syndrome
A. Edema
B. Shortness of breath
C. Petechiae
D. Change in mental status
Correct Answer
A. Edema
Question 2
A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient
mental health facility. Which of the following statements should the nurse make?
A. The provider will notify your patient's employer about admission to the facility
B. Your parent will have to take the medication that the doctor prescribes
C. Your parent might have electroconvulsive therapy without providing consent
D. The provider can prescribe restraints if your parent tries to harm others
Correct Answer
The provider can prescribe restraints if your parent tries to harm others
Question 3
a nurse is caring for a client who has a new prescription for chlorpromazine by IM injection.
Which of the following is an appropriate nursing action?
a. administer chlorpromazine with a loop diuretic
b. check orthostatic blood pressure 1 hr after administration
c. administer once daily 30 min before breakfast
d. check weekly calcium levels
Correct Answer
b. check orthostatic blood pressure 1 hr after administration
,Question 4
A nurse is caring for an infant who is being treated for dehydration. Which of the following
findings indicates the treatment is effective?
A. Flat anterior fontanel
B. Oliguria
C. Oral intake of 4 oz every 3 hr
D. Capillary refill 4 seconds
Correct Answer
A. Flat anterior fontanel
Question 5
A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea.
Which of the following actions should the nurse take?
A. Discard opened cans of formula after 24 hrs
B. Replace the extension tubing every 48 hrs
C. Irrigate the tubing every 12 hr with 50 mL of warm water
D. Increase the infusion rate
Correct Answer
A. Discard opened cans of formula after 24 hrs
Question 6
A charge nurse is discussing the use of applying ice to a client's injured knee with a newly
licensed nurse. Which of the following should the nurse identify as a benefit?
a.Systemic analgesic effect
b.Increase in your metabolism
c.Decreased capillary permeability
d.Vasodilation
Correct Answer
c. Decreased capillary permeability
,Question 7
A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood
pressure. The nurse should identify that these findings are potential manifestations of which of
the following?
A. Cannabis withdrawal
B. Opioid intoxication
C. Amphetamine intoxication
D. Alcohol withdrawal
Correct Answer
B. Opioid intoxication
Question 8
A nurse is planning to delegate client assignments to the assistive personnel. Which of the
following task is appropriate for the nurse to delegate?
a.Just the flow rate of the client oxygen tank
b.Collecting urine sample
c.Measuring the clients pain level
d.Monitoring blood glucose levels
Correct Answer
b. Collecting urine sample
Question 9
A nurse is caring for a client following an open colectomy. Which of the following findings places
the client at risk for delayed wound healing?
A. INR 1.1 (0.8-1.1)
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
Correct Answer
B. Hyperemesis
, Question 10
A nurse in a postpartum unit is caring for several clients. After receiving a change of shift report,
which of the following clients should the nurse assess first?
A. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus
B. A client who is 1 day postpartum and has not voided in 8 hr
C. A client who is 3 days postpartum and has not had a bowel movement since prior to
admission
D. A client who is 4 days postpartum and has lochia serosa
Correct Answer
C. A client who is 3 days postpartum and has not had a bowel movement since prior to
admission
Question 11
A nurse is assessing a client who has non-Hodgkin's lymphoma. Which of the following findings
should indicate to the nurse that the client might be experiencing syndrome of inappropriate
antidiuretic hormone
Correct Answer
diminished deep tendon reflexes
Question 12
A nurse is assessing a full-term newborn who is 24 hr old. Which of the following findings
should the nurse report to the provider?
a. the newborns neck is short and surrounded by skin folds
b. the newborns glucose level is 50 mg/dl
c. the newborns sclera have a yellowish tint
d. the newborn has experienced a weight loss of 3% since birth
Correct Answer
c. the newborns sclera have a yellowish tint
Question 13