1) During a shift assessment, the nurse is identifying the client’s point of maximum impulse
(PMI). Where should the nurse best palpate the PMI?- Left midclavicular line of the chest at the fifth intercostal space
2) A nurse is caring for a client who is being treated for leukemia in the hospital. The client
was able to maintain nutritional status for the first few weeks following the diagnosis but
is now exhibiting early signs and symptoms of malnutrition. In collaboration with the
dietitian, the nurse should implement what intervention?- Provide the client with several small, soft textured meals
each day
3) After receiving a diagnosis of acute lymphocytic leukemia, client is visibly distraught,
stating, “I have no idea where to go from here.” How should the nurse prepare to meet the
clients’ psychosocial needs?- Assess the client specific needs for education and support
4) An adult client’s abnormal complete blood count (CBC) and physical assessment have
prompted the health care provider to order a diagnostic workup for Hodgkin lymphoma.The presence of what
assessment finding is considered diagnostic of the disease?- Presence of Reed–Sternberg cells
5) A nurse is caring for four clients with leukemia. After handing off a report which client
should the nurse see first? -Client who had two bloody diarrhea stools this morning
6) The family of a neutropenic client reports that the client is confused and is not acting right.
What action by the nurse is the priority?- - assesses the client for a urinary tract infection
7) A nurse is caring for a client recently diagnosed with leukemia. Which of the following
signs and symptoms are consistent with this diagnosis? (SATA)
o Bleeding gums
o Bone pain
o Bruising
8) Which of the following is a possible treatment plan for a client diagnosed with leukemia?- Stem cell transplant
9) • Disseminated intravascular coagulation (DIC) – Treatment Treat underlying cause
10) During hourly rounding the nurse enters a room where the client is unresponsive. Upon
assessment, the client is not breathing and there is no pulse. The electrocardiogram (ECG)
monitor reveals ventricular fibrillation (VF). What should be the nurses’ next priority?- Defibrillation as soon as the
equipment arrive
11) A nurse is caring for a client diagnosed with atherosclerosis. Which of the following is
considered a risk factor for the development of this disorder?- Low HDL-C/High LDL-C
12) The American Association recommends which lifestyle change to manage the modifiable
risk factors associated with atherosclerosis? (SATA)
o b. Limit red meat
o c. Exercise 3-4 times per week for at least 40 minutes each session
o d. Adhere to prescribed medication therapy
o e. Consume 5 or more servings per day of fresh fruit and vegetables
13) A male client is presenting with radiating chest pain. Which of the following would the
nurse recognize as indicators that an acute myocardial infarction may be occurring?
(SATA)
o Positive troponin markers
o ST- elevation on EKG on two contiguous leads
o Diaphoresis
o Pain radiating in the jaw, back, shoulder, or abdomen
14) A nurse is caring for a client with shortness of breath, heart palpitations, and dizziness.
The nurse placed the client on the cardiac monitor and finds the client in atrial fibrillation
at a rate of 190 beats per minute and has a blood pressure of 120/75 mm Hg. Which action
should the nurse anticipate? - Administer a calcium channel blocker intravenously
, 15) Which diagnostic test determines ejection fraction and cardiovascular valvular changes.
Pericardial effusion, chamber enlargement, and ventricular hypertrophy, and is the best
tool when diagnosing heart failure?
o a. Radionuclide studies
o b. chest x-ray
o c. mutilated angiographic (MUGA) scan
d. Echocardiogram
16) Testicular Self-Exam for community nurse teaching patient – Patient Teaching – will check my testicles after a
warm shower each monthTSE.
17) Digital Rectal Exam (DRE) – A screening for prostate enlargement, cancer, and nodules
18) The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin
sodium. What instruction is a priority for the nurse to provide to this client? -Notify your healthcare provider if your
stools appear dark or tarry.
19) nurse is caring for a post-operative heart transplant client. Which nursing intervention is
the priority in the post-operative phase? -. monitor for cardiac dysrhythmias
20) A nurse is reviewing the health history of a client who has angina pectoris and a
prescription for propranolol hydrochloride po 40 mg twice daily. Which finding in the
client’s past history should the nurse report to the provider? - The client has a history of bronchial asthma
21) The nurse assesses a client and documents the following findings: edema 2+ bilateral
ankles, brown pigmentation of lower extremity skin. Aching pain of lower extremities
when standing that resolves with elevation and 2+ pedal pulses. What condition does the
client likely have? - Peripheral Venous insufficiency
22) Sickle Cell Crisis – Treatment – o Oxygen o IV fluids, Opioids
23) A nurse is caring for a client recently diagnosed with hypertension. Which statement by
the client indicates the need for further teaching?
o I will reduce my sodium intake to less than 1500 mg daily
o I will use relaxation techniques to reduce my stress
o I will reduce my smoking to half a pack a day
o I will implement a heart-healthy diet and reduce my weight
24) Metabolic syndrome-
Large weight circumference
o Triglycerides > 150
o Low HDL: < 40 in men, < 50 in women
o Hypertension
o Elevated fasting glucose > 100
25) The nurse is assessing a client with severe anemia. Which clinical manifestation is
associated with this condition?- Hypotension
26) A client suffering from a narcotic overdose is seen in the Emergency Department. The
client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted
are temperature 102.6 F, heart rate 128 beats/minute, respirations 24 breaths/minute, and
blood pressure 130/86 mm Hg. A blood gas analysis sample was drawn on room air, and
the results are as follows: Ph 7.33 PaCO2 53 mm Hg, PaO2 72 mm Hg. HCO3 24 mEq/L. this
client is at risk for which of the following?- Respiratory acidosis
27) The nurse is caring for a client with pericarditis. If left untreated, the client is at risk for
cardiac tamponade. Which clinical manifestation is associated with cardiac tamponade?- Muffled heart sounds
28) A nurse is providing education on the safe use of nitroglycerin topical administration.
Which statement by the client indicates an understanding of the teaching? - I will apply the patch to a clean, dry, and
hairless area on the skin
(PMI). Where should the nurse best palpate the PMI?- Left midclavicular line of the chest at the fifth intercostal space
2) A nurse is caring for a client who is being treated for leukemia in the hospital. The client
was able to maintain nutritional status for the first few weeks following the diagnosis but
is now exhibiting early signs and symptoms of malnutrition. In collaboration with the
dietitian, the nurse should implement what intervention?- Provide the client with several small, soft textured meals
each day
3) After receiving a diagnosis of acute lymphocytic leukemia, client is visibly distraught,
stating, “I have no idea where to go from here.” How should the nurse prepare to meet the
clients’ psychosocial needs?- Assess the client specific needs for education and support
4) An adult client’s abnormal complete blood count (CBC) and physical assessment have
prompted the health care provider to order a diagnostic workup for Hodgkin lymphoma.The presence of what
assessment finding is considered diagnostic of the disease?- Presence of Reed–Sternberg cells
5) A nurse is caring for four clients with leukemia. After handing off a report which client
should the nurse see first? -Client who had two bloody diarrhea stools this morning
6) The family of a neutropenic client reports that the client is confused and is not acting right.
What action by the nurse is the priority?- - assesses the client for a urinary tract infection
7) A nurse is caring for a client recently diagnosed with leukemia. Which of the following
signs and symptoms are consistent with this diagnosis? (SATA)
o Bleeding gums
o Bone pain
o Bruising
8) Which of the following is a possible treatment plan for a client diagnosed with leukemia?- Stem cell transplant
9) • Disseminated intravascular coagulation (DIC) – Treatment Treat underlying cause
10) During hourly rounding the nurse enters a room where the client is unresponsive. Upon
assessment, the client is not breathing and there is no pulse. The electrocardiogram (ECG)
monitor reveals ventricular fibrillation (VF). What should be the nurses’ next priority?- Defibrillation as soon as the
equipment arrive
11) A nurse is caring for a client diagnosed with atherosclerosis. Which of the following is
considered a risk factor for the development of this disorder?- Low HDL-C/High LDL-C
12) The American Association recommends which lifestyle change to manage the modifiable
risk factors associated with atherosclerosis? (SATA)
o b. Limit red meat
o c. Exercise 3-4 times per week for at least 40 minutes each session
o d. Adhere to prescribed medication therapy
o e. Consume 5 or more servings per day of fresh fruit and vegetables
13) A male client is presenting with radiating chest pain. Which of the following would the
nurse recognize as indicators that an acute myocardial infarction may be occurring?
(SATA)
o Positive troponin markers
o ST- elevation on EKG on two contiguous leads
o Diaphoresis
o Pain radiating in the jaw, back, shoulder, or abdomen
14) A nurse is caring for a client with shortness of breath, heart palpitations, and dizziness.
The nurse placed the client on the cardiac monitor and finds the client in atrial fibrillation
at a rate of 190 beats per minute and has a blood pressure of 120/75 mm Hg. Which action
should the nurse anticipate? - Administer a calcium channel blocker intravenously
, 15) Which diagnostic test determines ejection fraction and cardiovascular valvular changes.
Pericardial effusion, chamber enlargement, and ventricular hypertrophy, and is the best
tool when diagnosing heart failure?
o a. Radionuclide studies
o b. chest x-ray
o c. mutilated angiographic (MUGA) scan
d. Echocardiogram
16) Testicular Self-Exam for community nurse teaching patient – Patient Teaching – will check my testicles after a
warm shower each monthTSE.
17) Digital Rectal Exam (DRE) – A screening for prostate enlargement, cancer, and nodules
18) The nurse is discharging home a client at risk for venous thromboembolism on enoxaparin
sodium. What instruction is a priority for the nurse to provide to this client? -Notify your healthcare provider if your
stools appear dark or tarry.
19) nurse is caring for a post-operative heart transplant client. Which nursing intervention is
the priority in the post-operative phase? -. monitor for cardiac dysrhythmias
20) A nurse is reviewing the health history of a client who has angina pectoris and a
prescription for propranolol hydrochloride po 40 mg twice daily. Which finding in the
client’s past history should the nurse report to the provider? - The client has a history of bronchial asthma
21) The nurse assesses a client and documents the following findings: edema 2+ bilateral
ankles, brown pigmentation of lower extremity skin. Aching pain of lower extremities
when standing that resolves with elevation and 2+ pedal pulses. What condition does the
client likely have? - Peripheral Venous insufficiency
22) Sickle Cell Crisis – Treatment – o Oxygen o IV fluids, Opioids
23) A nurse is caring for a client recently diagnosed with hypertension. Which statement by
the client indicates the need for further teaching?
o I will reduce my sodium intake to less than 1500 mg daily
o I will use relaxation techniques to reduce my stress
o I will reduce my smoking to half a pack a day
o I will implement a heart-healthy diet and reduce my weight
24) Metabolic syndrome-
Large weight circumference
o Triglycerides > 150
o Low HDL: < 40 in men, < 50 in women
o Hypertension
o Elevated fasting glucose > 100
25) The nurse is assessing a client with severe anemia. Which clinical manifestation is
associated with this condition?- Hypotension
26) A client suffering from a narcotic overdose is seen in the Emergency Department. The
client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted
are temperature 102.6 F, heart rate 128 beats/minute, respirations 24 breaths/minute, and
blood pressure 130/86 mm Hg. A blood gas analysis sample was drawn on room air, and
the results are as follows: Ph 7.33 PaCO2 53 mm Hg, PaO2 72 mm Hg. HCO3 24 mEq/L. this
client is at risk for which of the following?- Respiratory acidosis
27) The nurse is caring for a client with pericarditis. If left untreated, the client is at risk for
cardiac tamponade. Which clinical manifestation is associated with cardiac tamponade?- Muffled heart sounds
28) A nurse is providing education on the safe use of nitroglycerin topical administration.
Which statement by the client indicates an understanding of the teaching? - I will apply the patch to a clean, dry, and
hairless area on the skin
