1
,Question 1
A nurse is completing a health screening activity to identify at which point in the
menstrual cycle a client’s problem occurs. Place the pathophysiologic steps of the
menstrual cycle listed below in the correct sequential order. All options must be used.
Correct response:
The top layer of the endometrium breaks down and sloughs.
The endometrium begins thickening.
The level of estrogen in the blood peaks.
A follicle matures and ovulation occurs.
Peak endometrial thickening occurs.
Increased estrogen and progesterone levels inhibit luteinizing hormone.
Question 2
The nurse is caring for a client during the postsurgical period after having a right
femoral–popliteal bypass graft. The nurse enters the room to conduct a nursing
assessment and care. Order the nurse’s actions according to priority. All options must
be used.
Correct response:
Assess peripheral pulses.
Assess incision site.
Assess lung fields.
Assess pain/obtain medication.
Instruct on client positioning.
Offer clear fluids.
Question 3
All of the children were admitted yesterday. In which order from first to last would the
nurse assess these children? All options must be used.
Correct response:
a 12-year-old child with a fractured femur and lacerated liver
a 6-year-old child with a concussion and little change in vital signs
a 3-year-old child with acute pyelonephritis and a temperature of 104.5° F (40.3°
C)
a 10-month-old infant with pneumonia and respiratory rate of 50 breaths/minute
a 3-month-old infant with respiratory syncytial virus and stable vital signs
2
,Question 4
A 4-year-old postoperative child is found unresponsive. Place the following actions in the
correct sequence to perform CPR after the child has been assessed for responsiveness
and help has been called. All options must be used.
Correct response:
Feel for the carotid pulse.
Perform 30 compressions.
Open the airway.
Check for breathing.
Provide 2 rescue breaths.
Question 5
A client on a stretcher in the emergency department begins to thrash around, slap the
sheets, and yell, “Get these bugs off of me.” The client is disoriented and has a blood
pressure of 189/75 mm Hg and a pulse of 96 bpm. The friend who is with the client says,
“My friend was drinking a lot 3 days ago and asked me for money to get more vodka, but
I didn’t have any.” What should the nurse do in order of priority from first to last? All
options must be used.
Correct response:
Remind the client that they are in the hospital and the nurse is with them.
Implement constant observation.
Administer haloperidol and lorazepam IM as prescribe.
Monitor vital signs every 15 minutes.
Obtain a prescription to place the client in restraints, if needed.
Chart the client’s response to the interventions.
Question 6
A nurse is caring for a client with a spinal cord injury who has a urinary catheter. The
nurse finds the client in a recumbent position and notices that the client’s blood
pressure is rapidly increasing. The client reports having a pounding headache and is
damp from sweating. Place the nursing actions in the order in which the nurse should
perform them to properly respond to this client’s situation. All options must be used.
Correct response:
Notify the health care provider.
Sit the client up.
Loosen the client’s clothing.
Check the urinary catheter for kinks.
3
, Question 7
The nurse received an order for a sputum sample to be obtained in the morning. Prior to
the client’s breakfast, the nurse explains the procedure to the client, obtains all
equipment, washes hands, and dons clean gloves. Place the next nursing actions in
proper sequence. All options must be used.
Correct response:
Place the client in a Fowler position.
Instruct the client to cough.
Obtain the sample.
Perform oral hygiene.
Remove gloves/hand hygiene.
Label the container/take for analysis.
Question 8
A nurse assesses a client who has manifestations of peripheral intravenous
extravasation. List the actions to take in order of priority. All options must be used.
Correct response:
Discontinue the intravenous tubing as close to the hub as possible.
Notify the healthcare provider.
Elevate the affected arm on pillows.
Apply ice in short intervals to the affected site.
Photograph the site with the client’s written permission.
Question 9
At 0500, the nurse on the antepartum reviews all remaining tasks to complete before
giving the change of shift handoff at 0700. In what order from first to last should the
nurse should complete the tasks? All options must be used.
Correct response:
fetal monitor strip for one-half hour every shift
magnesium sulfate draw at 0600
documentation check, final check of each client
point-of-care blood glucose and sliding scale insulin due at 0700, 1100, 1600, and
bedtime
Question 10
A parent brings her 3-month-old child into the emergency department. The child is
listless with dry mucous membranes, tenting of the skin on the forehead, a depressed
fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from
first to last should the nurse implement the primary care provider’s prescriptions? All
options must be used.
Correct response:
4
,Question 1
A nurse is completing a health screening activity to identify at which point in the
menstrual cycle a client’s problem occurs. Place the pathophysiologic steps of the
menstrual cycle listed below in the correct sequential order. All options must be used.
Correct response:
The top layer of the endometrium breaks down and sloughs.
The endometrium begins thickening.
The level of estrogen in the blood peaks.
A follicle matures and ovulation occurs.
Peak endometrial thickening occurs.
Increased estrogen and progesterone levels inhibit luteinizing hormone.
Question 2
The nurse is caring for a client during the postsurgical period after having a right
femoral–popliteal bypass graft. The nurse enters the room to conduct a nursing
assessment and care. Order the nurse’s actions according to priority. All options must
be used.
Correct response:
Assess peripheral pulses.
Assess incision site.
Assess lung fields.
Assess pain/obtain medication.
Instruct on client positioning.
Offer clear fluids.
Question 3
All of the children were admitted yesterday. In which order from first to last would the
nurse assess these children? All options must be used.
Correct response:
a 12-year-old child with a fractured femur and lacerated liver
a 6-year-old child with a concussion and little change in vital signs
a 3-year-old child with acute pyelonephritis and a temperature of 104.5° F (40.3°
C)
a 10-month-old infant with pneumonia and respiratory rate of 50 breaths/minute
a 3-month-old infant with respiratory syncytial virus and stable vital signs
2
,Question 4
A 4-year-old postoperative child is found unresponsive. Place the following actions in the
correct sequence to perform CPR after the child has been assessed for responsiveness
and help has been called. All options must be used.
Correct response:
Feel for the carotid pulse.
Perform 30 compressions.
Open the airway.
Check for breathing.
Provide 2 rescue breaths.
Question 5
A client on a stretcher in the emergency department begins to thrash around, slap the
sheets, and yell, “Get these bugs off of me.” The client is disoriented and has a blood
pressure of 189/75 mm Hg and a pulse of 96 bpm. The friend who is with the client says,
“My friend was drinking a lot 3 days ago and asked me for money to get more vodka, but
I didn’t have any.” What should the nurse do in order of priority from first to last? All
options must be used.
Correct response:
Remind the client that they are in the hospital and the nurse is with them.
Implement constant observation.
Administer haloperidol and lorazepam IM as prescribe.
Monitor vital signs every 15 minutes.
Obtain a prescription to place the client in restraints, if needed.
Chart the client’s response to the interventions.
Question 6
A nurse is caring for a client with a spinal cord injury who has a urinary catheter. The
nurse finds the client in a recumbent position and notices that the client’s blood
pressure is rapidly increasing. The client reports having a pounding headache and is
damp from sweating. Place the nursing actions in the order in which the nurse should
perform them to properly respond to this client’s situation. All options must be used.
Correct response:
Notify the health care provider.
Sit the client up.
Loosen the client’s clothing.
Check the urinary catheter for kinks.
3
, Question 7
The nurse received an order for a sputum sample to be obtained in the morning. Prior to
the client’s breakfast, the nurse explains the procedure to the client, obtains all
equipment, washes hands, and dons clean gloves. Place the next nursing actions in
proper sequence. All options must be used.
Correct response:
Place the client in a Fowler position.
Instruct the client to cough.
Obtain the sample.
Perform oral hygiene.
Remove gloves/hand hygiene.
Label the container/take for analysis.
Question 8
A nurse assesses a client who has manifestations of peripheral intravenous
extravasation. List the actions to take in order of priority. All options must be used.
Correct response:
Discontinue the intravenous tubing as close to the hub as possible.
Notify the healthcare provider.
Elevate the affected arm on pillows.
Apply ice in short intervals to the affected site.
Photograph the site with the client’s written permission.
Question 9
At 0500, the nurse on the antepartum reviews all remaining tasks to complete before
giving the change of shift handoff at 0700. In what order from first to last should the
nurse should complete the tasks? All options must be used.
Correct response:
fetal monitor strip for one-half hour every shift
magnesium sulfate draw at 0600
documentation check, final check of each client
point-of-care blood glucose and sliding scale insulin due at 0700, 1100, 1600, and
bedtime
Question 10
A parent brings her 3-month-old child into the emergency department. The child is
listless with dry mucous membranes, tenting of the skin on the forehead, a depressed
fontanel, and a history of vomiting and diarrhea for the last 36 hours. In what order from
first to last should the nurse implement the primary care provider’s prescriptions? All
options must be used.
Correct response:
4
