2025/2026
A newly licensed nurse has just completed orientation on a medical-surgical
unit. The nursing supervisor asks the nurse to float to the labor and delivery
unit. Which of the following actions should the newly licensed nurse take? (
Correct answers ) Request to float to an adult medical-surgical unit
instead.
Rationale::The nurse should recognize that this assignment is unsafe due
to a lack of experience and orientation to the labor and delivery unit. The
nurse should confer with the supervisor for an alternative assignment.
A client is admitted to the surgical unit after sustaining a compound fracture
of the left femur. The client is alert and oriented with the following vital
signs: T 99.4 F, P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of
bright red blood on the pressure dressing on the left lower extremity. The
client is receiving intravenous fluids of normal saline at 150 ml/hr. One hour
after being admitted to the unit, the nurse finds the client confused and
combative. Which of the following is the most likely cause of the change in
the client's condition? ( Correct answers ) Hypoxia related to fat embolism
from the fractured bone.
The nurse is planning care for a client who is prescribed antiembolic
stocking following abdominal surgery. Which of the following interventions
should the nurse include? ( Correct answers ) Remove stockings one to
three times per day for skin care and inspection
A nurse is caring for a client with Addison's disease. Which of the following
diets should
the nurse teach the client to follow? ( Correct answers ) High Sodium, low
potassium
and increased
fluids
,A nurse is caring for a client who is experiencing a sodium level of 119
mEq/L. Which nursing action would be most appropriate at this time? (
Correct answers ) Administer 0.9% Normal Saline.
A nurse is reviewing a client's lab results. Which finding would lead the nurse
to suspect
the client is experiencing dehydration? ( Correct answers )
Hematocrit 55%
A client is admitted to the medical unit from the convalescent center for
treatment of urosepsis. The client's adult daughter reports to the nurse, "I
don't know what to do. I love my mom and would like to have her live in my
home, but I just can't be with her every minute, and that's what she needs
now." Which of the following would be the best approach to improve
integration of the elderly mother into the family structure? ( Correct
answers ) Determine if the daughter would consider having the client visit
in her home
one day a
week.
specific gravity ( Correct answers ) 1.010-1.030
A nurse is caring for a client recovering from an abdominal aortic
aneurysm (AAA)
repair. Which of the following findings would have the highest
priority? ( Correct
answers ) Blood pressure 136/90
mmHg
A nurse is caring of a client recently diagnosed with diabetes mellitus
(DM). Which of
the following is the physiologic basis for the polyuria manifested by
individuals with
untreated DM? ( Correct answers ) Hyperosmolarity of the
extracellular fluids
,secondary to
hyperglycemia
A client diagnosed with atrial fibrillation has a pacemaker set at a
ventricular rate of 70 beats per minute. Which of the following findings
should the nurse immediately report to the provider? ( Correct answers )
60 beats /minute and regular
A client presents to the emergency department with an abdominal stab
wound. The nurse visualizes intestines protruding through the wound.
Which of the following is an appropriate action for the nurse? ( Correct
answers ) Cover the wound with warm saline-soaked gauze
A nurse is caring for a client who has just undergone a bone marrow
transplant.
Neutropenic precautions are implemented to prevent infection.
Which is not a
precautionary neutropenic measure? ( Correct answers )
Monitor platelets
A client who has been experiencing prolonged vomiting has the following
ABG results:
pH 7.48; pCO2 40 mm Hg; HCO3 34 mEq/L; pO2 85 mm Hg. The nurse
determines
that the client is experiencing which of the following imbalance? ( Correct
answers )
Metabolic
Alkalosis
A client is admitted to the hospital with a diagnosis of Grave's disease.
Which of the following findings should be reported to the provider
immediately? ( Correct answers ) Increase in temperature from 99.5 F to
100.5 F
A nurse is caring for a client with severe peripheral arterial disease of the
right lower
, extremity. Which intervention is appropriate? ( Correct answers ) Keep
the affected
extremity below the level of the
heart.
A nurse is providing care for a client with a Jackson-Pratt drain. Which of
the following nursing interventions has the highest priority? ( Correct
answers ) Keeping the drainage bulb depressed to manual suction.
A client diagnosed with diabetes mellitus consumed less than 50% of the
lunch tray and reports feeling shaky. Which of the following is the first
action the nurse should take? ( Correct answers ) Observe for signs of
hypoglycemia
A nurse is reinforcing discharge instructions with a client following cataract
surgery. Which of the following statements by the client indicates the need
for further teaching reinforcement? ( Correct answers ) "I will wear my bi-
focal glasses when sitting outside on the deck."
A client in the early postpartum period is talkative and enjoys recounting the
details of her labor and birth. The nurse recognizes that the behaviors must
likely indicate which of the following? ( Correct answers ) · The taking-in
phase of maternal postpartum adjustment
A nurse is caring for a neonate who exhibits abstinence syndrome and
demonstrates clinical manifestations of the condition. Which assessment
finding is associate with this condition? ( Correct answers ) · Hypothermia
A nurse is performing a fundal assessment on the client's second
postpartum day. Which of the following should the nurse expect if the client
is experiencing normal involution? ( Correct answers ) The fundus will be
one centimeter below the umbilicus
A nurse is teaching a client the correct use a diaphragm as a method of
contraception.
Which of the following statements is correct? ( Correct answers ) Leave
diaphragm in