To prepare the community for the possible threat of anthrax, a nurse must teach that:
1. immunizations can prevent anthrax.
2. blood and body secretions can transmit anthrax.
3. physicians use isoniazid (INH), rifampin (Rifadin), and pyrazinamide to treat
anthrax.
4. anthrax can infect the integumentary, GI, and respiratory systems.
A client with moderate Alzheimer's-related dementia is being prepared for discharge. What
statement by the caregiver demonstrates that discharge teaching about client safety has
been effective?
1. "I should encourage him to be active and do as much as he can on his own."
2. "Showering by himself is fine as long as he remains seated and holds tightly to the
safety rails."
3. "I need to place signs in each room to help remind him where he is."
4. "Someone should supervise him at all times."
While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and
then falls to the floor. After attending to the client, a nurse completes an incident report.
Which action by the nurse should the charge nurse correct?
1. Documenting the incident factually in her nurses' notes
2. Submitting the incident report to the appropriate hospital administrator
3. Notifying the physician of the incident and the client's condition
4. Making a copy of the incident report for the client
A nurse is teaching a client with a long leg cast how to use crutches properly while
descending a staircase. The nurse should tell the client to transfer body weight to the
unaffected leg, and then:
1. advance both legs.
2. advance the unaffected leg.
3. advance the affected leg.
4. advance both crutches.
A client is in Buck's traction after fracturing his right hip. The nurse should include which
action in the care plan?
1. Removing the weights once every shift
, 2. Maintaining the bed in the knee-Gatch position
3. Keeping the client in semi-Fowler's position
4. Maintaining correct body alignment
The nurse-manager of a 20-bed coronary care unit is off duty when a staff nurse makes a
serious medication error. The client, who received an overdose of medication, nearly dies.
Which statement accurately reflects the nurse-manager's accountability?
1. The nursing supervisor will notify the nurse-manager at home.
2. The nurse-manager is off duty; therefore, she need not be notified.
3. The nurse-manager should be informed when she returns to duty.
4. The nursing supervisor decides to call the off-duty nurse-manager if time permits
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the
high-pressure alarm on the ventilator sounds, what should the nurse do?
1. Check for an apical pulse.
2. Suction the client's artificial airway.
3. Increase the oxygen percentage.
4. Ventilate the client with a handheld mechanical ventilator.
A nurse places a client in full leather restraints. How often must the nurse check the client's
circulation?
1. Once per hour
2. Once per shift
3. Every 10 to 15 minutes
4. Every 2 hours
A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have
ruptured. If the membranes have ruptured, the paper will turn which color?
1. Pink
2. Blue
3. Yellow
4. Green
A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To
help the client manage a manic episode, the nurse should suggest that she:
, 1. go shopping with a friend.
2. read a book in a quiet room.
3. reorganize a kitchen cabinet.
4. play a game with a few friends.
A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old
child. She gives the medication immediately, and assesses the child. The child isn't harmed
by the delay. Which action should the nurse take next?
1. No further action is necessary.
2. The nurse should notify the physician of the error.
3. The nurse should follow facility procedures for reporting an error.
4. The nurse should document a medication error in the client's chart.
A client who is disoriented and restless after sustaining a concussion during a car accident
is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's
care plan?
1. Disturbed sensory perception (visual)
2. Dressing or grooming self-care deficit
3. Impaired verbal communication
4. Risk for injury
A nurse prepares to measure a client's blood pressure. What is the correct procedure for
measuring blood pressure?
1. Wrapping the cuff around the limb, with the uninflated bladder covering about one-
fourth of the limb circumference
2. Measuring the arm about 2″ (5 cm) above the antecubital space
3. Wrapping the cuff around the limb, with the uninflated bladder covering
about three-quarters of the limb circumference
4. Using a bladder that is 6″ (15 cm) long.
An assessment of a client's orientation is best obtained by:
1. asking the client's name, where he lives, and what time it is.
2. asking the client to repeat a series of three digits spoken slowly.
3. pointing to common objects and asking the client to name them.
, 4. using the Glasgow Coma Scale and computing the score.
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing
diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the
rationale for choosing this nursing diagnosis?
1. Obstruction of the appendix may increase venous drainage and cause the appendix
to rupture.
2. Obstruction of the appendix reduces arterial flow, leading to ischemia,
inflammation, and rupture of the appendix.
3. The appendix may develop gangrene and rupture, especially in a middle-aged client.
4. Infection of the appendix diminishes necrotic arterial blood flow and increases
venous drainage.
When caring for a client with severe impetigo, the nurse should include which intervention
in the care plan?
1. Placing mitts on the client's hands
2. Administering systemic antibiotics as ordered
3. Applying topical antibiotics as ordered
4. Continuing to administer antibiotics for 21 days as ordered
A physician orders meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has
just had abdominal surgery. When administering this drug, the nurse should use a needle
of which size?
1. 18G
2. 20G
3. 23G
4. 27G
A nurse is to collect a sputum specimen from a client. The best time to collect this
specimen is:
1. early in the evening.
2. any time during the day.
3. in the morning, as soon as the client awakens.
4. before bedtime.
1. immunizations can prevent anthrax.
2. blood and body secretions can transmit anthrax.
3. physicians use isoniazid (INH), rifampin (Rifadin), and pyrazinamide to treat
anthrax.
4. anthrax can infect the integumentary, GI, and respiratory systems.
A client with moderate Alzheimer's-related dementia is being prepared for discharge. What
statement by the caregiver demonstrates that discharge teaching about client safety has
been effective?
1. "I should encourage him to be active and do as much as he can on his own."
2. "Showering by himself is fine as long as he remains seated and holds tightly to the
safety rails."
3. "I need to place signs in each room to help remind him where he is."
4. "Someone should supervise him at all times."
While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and
then falls to the floor. After attending to the client, a nurse completes an incident report.
Which action by the nurse should the charge nurse correct?
1. Documenting the incident factually in her nurses' notes
2. Submitting the incident report to the appropriate hospital administrator
3. Notifying the physician of the incident and the client's condition
4. Making a copy of the incident report for the client
A nurse is teaching a client with a long leg cast how to use crutches properly while
descending a staircase. The nurse should tell the client to transfer body weight to the
unaffected leg, and then:
1. advance both legs.
2. advance the unaffected leg.
3. advance the affected leg.
4. advance both crutches.
A client is in Buck's traction after fracturing his right hip. The nurse should include which
action in the care plan?
1. Removing the weights once every shift
, 2. Maintaining the bed in the knee-Gatch position
3. Keeping the client in semi-Fowler's position
4. Maintaining correct body alignment
The nurse-manager of a 20-bed coronary care unit is off duty when a staff nurse makes a
serious medication error. The client, who received an overdose of medication, nearly dies.
Which statement accurately reflects the nurse-manager's accountability?
1. The nursing supervisor will notify the nurse-manager at home.
2. The nurse-manager is off duty; therefore, she need not be notified.
3. The nurse-manager should be informed when she returns to duty.
4. The nursing supervisor decides to call the off-duty nurse-manager if time permits
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the
high-pressure alarm on the ventilator sounds, what should the nurse do?
1. Check for an apical pulse.
2. Suction the client's artificial airway.
3. Increase the oxygen percentage.
4. Ventilate the client with a handheld mechanical ventilator.
A nurse places a client in full leather restraints. How often must the nurse check the client's
circulation?
1. Once per hour
2. Once per shift
3. Every 10 to 15 minutes
4. Every 2 hours
A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have
ruptured. If the membranes have ruptured, the paper will turn which color?
1. Pink
2. Blue
3. Yellow
4. Green
A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To
help the client manage a manic episode, the nurse should suggest that she:
, 1. go shopping with a friend.
2. read a book in a quiet room.
3. reorganize a kitchen cabinet.
4. play a game with a few friends.
A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old
child. She gives the medication immediately, and assesses the child. The child isn't harmed
by the delay. Which action should the nurse take next?
1. No further action is necessary.
2. The nurse should notify the physician of the error.
3. The nurse should follow facility procedures for reporting an error.
4. The nurse should document a medication error in the client's chart.
A client who is disoriented and restless after sustaining a concussion during a car accident
is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's
care plan?
1. Disturbed sensory perception (visual)
2. Dressing or grooming self-care deficit
3. Impaired verbal communication
4. Risk for injury
A nurse prepares to measure a client's blood pressure. What is the correct procedure for
measuring blood pressure?
1. Wrapping the cuff around the limb, with the uninflated bladder covering about one-
fourth of the limb circumference
2. Measuring the arm about 2″ (5 cm) above the antecubital space
3. Wrapping the cuff around the limb, with the uninflated bladder covering
about three-quarters of the limb circumference
4. Using a bladder that is 6″ (15 cm) long.
An assessment of a client's orientation is best obtained by:
1. asking the client's name, where he lives, and what time it is.
2. asking the client to repeat a series of three digits spoken slowly.
3. pointing to common objects and asking the client to name them.
, 4. using the Glasgow Coma Scale and computing the score.
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing
diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the
rationale for choosing this nursing diagnosis?
1. Obstruction of the appendix may increase venous drainage and cause the appendix
to rupture.
2. Obstruction of the appendix reduces arterial flow, leading to ischemia,
inflammation, and rupture of the appendix.
3. The appendix may develop gangrene and rupture, especially in a middle-aged client.
4. Infection of the appendix diminishes necrotic arterial blood flow and increases
venous drainage.
When caring for a client with severe impetigo, the nurse should include which intervention
in the care plan?
1. Placing mitts on the client's hands
2. Administering systemic antibiotics as ordered
3. Applying topical antibiotics as ordered
4. Continuing to administer antibiotics for 21 days as ordered
A physician orders meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has
just had abdominal surgery. When administering this drug, the nurse should use a needle
of which size?
1. 18G
2. 20G
3. 23G
4. 27G
A nurse is to collect a sputum specimen from a client. The best time to collect this
specimen is:
1. early in the evening.
2. any time during the day.
3. in the morning, as soon as the client awakens.
4. before bedtime.
