lOMoARcPSD|55550609
1. client with a history of lung cancer reluctantly comes to the clinic because of persistent
hoarseness and a chronic cough. The client’s respirations are labored when speaking and the
capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?
a. Clubbed fingernails.
b. Unexplained fatigue.
c. Coarse breath sounds.
d. Rust colored sputum.
, lOMoARcPSD|55550609
2. The nurse is assisting the healthcare provider with a wound debridement at the bedside of a
client who is mildly confused. The client is draped, and a sterile field is created. Which
nursing intervention should the nurse implement for client safety? a. Instruct the client to
keep hands under the sterile field.
b. Verify that the client has given informed consent.
c. Pour cleansing solution onto the sterile field.
d. Assess for discomfort when procedure is completed.
3. A client with end stage Alzheimer’s disease is brought to the clinic by the caregiver for an
appointment with the healthcare provider. The caregiver speaks privately to the nurse about
not sleeping well at night and experiencing frequent periods of crying. Which intervention
should the nurse implement?
a. Advise to have a case management evaluation of the client’s home
environment.
b. Proposed the extended family could return to the area to help provide
assistance.
c. Tell the caregiver to consider hiring a private duty nurse for time to be away.
, lOMoARcPSD|55550609
d. Suggest social services be contacted to find a respite care facility for the client.
4. The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes.
The client reports having sex with multiple partners. Which response should the nurse provide?
a. Remain non-judgmental and assure the client of confidentiality.
b. Inform the client that complications will not result from reinfection.
c. Provide counseling that most contraceptives protect against infection.
d. Clarify that all STIs are transmitted through sexual intercourse.
5. A client with a chlamydia infection receives a prescription for a single dose azithromycin
1 gram by mouth. The bottle is labeled “Azithromycin for Oral Suspension, USP 200 mg per
5 mL”. How many mL should the nurse administer? (Enter numerical value only).
25m2
6. The nurse is providing care to a client having surgery to repair a retinal detachment to the left
eye. Which intervention should the nurse implement during the postoperative period? a. Provide
an eye shield to be worn while sleeping.
b. Obtain vital signs every 2 hours during hospitalization.
c. Teach a family member to administer eye drops.
d. Encourage deep breathing and coughing exercises.
7. The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The
client wants to resume social activities with family. How should the nurse respond? a. Reinforce
the need to avoid social contact for several weeks.
b. Recommend the use of a face mask during family events.
c. Encourage family gatherings to reduce feelings of isolation.
d. Explain the need to avoid persons with respiratory infections.
8. A mother brings her 3-week-old son to the clinic because he is vomiting “all the time”. In
performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost
, lOMoARcPSD|55550609
20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which
intervention should the nurse implement first? a. Insert a nasogastric tube for feeding.
b. Initiate a prescribed IV for parental fluid.
c. Feed the infant 3 ounces of Isomil.
d. Give the infant 5% dextrose in water orally.
9. An older client with a history of heart failure and admitted to the medical unit after falling at
home and has become increasingly confused. The client’s spouse is designated as the client’s
power of attorney. When reporting to the healthcare provider using SBAR (Situation,
Background, Assessment, Recommendation) communication, which information should the
nurse provide first? A. Increasing confusion of the client. B. Fall at home as reason for
admission.
C. Client’s healthcare power of attorney.
D. Currently prescribed medication.
10. An adult client is admitted for severe pain in his side and back and is sent for an
intravenous pyelogram. Which report from the client is the earliest indication to the nurse that
the client is experiencing an adverse reaction to this procedure? a. Tingling on tongue or lips.
b. Salty taste in the mouth.
c. Episodes of shivering.
d. Difficulty breathing.
11. A client tells the nurse about jogging every day with the hope of losing weight and sleeping
better. The client states that it takes hours to fall asleep at night and is experiencing fatigue and
sleepiness throughout the day. Which action should the nurse implement? a. Ask the client for a
description of the exercise schedule that is being followed.
b. Encourage the client to exercise very day to eliminate bedtime wakefulness.
c. Determine the amount of weight the client has lost since increasing activity.
d. Advise the client that lifestyle changes often takes several weeks to be effective.
1. client with a history of lung cancer reluctantly comes to the clinic because of persistent
hoarseness and a chronic cough. The client’s respirations are labored when speaking and the
capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?
a. Clubbed fingernails.
b. Unexplained fatigue.
c. Coarse breath sounds.
d. Rust colored sputum.
, lOMoARcPSD|55550609
2. The nurse is assisting the healthcare provider with a wound debridement at the bedside of a
client who is mildly confused. The client is draped, and a sterile field is created. Which
nursing intervention should the nurse implement for client safety? a. Instruct the client to
keep hands under the sterile field.
b. Verify that the client has given informed consent.
c. Pour cleansing solution onto the sterile field.
d. Assess for discomfort when procedure is completed.
3. A client with end stage Alzheimer’s disease is brought to the clinic by the caregiver for an
appointment with the healthcare provider. The caregiver speaks privately to the nurse about
not sleeping well at night and experiencing frequent periods of crying. Which intervention
should the nurse implement?
a. Advise to have a case management evaluation of the client’s home
environment.
b. Proposed the extended family could return to the area to help provide
assistance.
c. Tell the caregiver to consider hiring a private duty nurse for time to be away.
, lOMoARcPSD|55550609
d. Suggest social services be contacted to find a respite care facility for the client.
4. The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes.
The client reports having sex with multiple partners. Which response should the nurse provide?
a. Remain non-judgmental and assure the client of confidentiality.
b. Inform the client that complications will not result from reinfection.
c. Provide counseling that most contraceptives protect against infection.
d. Clarify that all STIs are transmitted through sexual intercourse.
5. A client with a chlamydia infection receives a prescription for a single dose azithromycin
1 gram by mouth. The bottle is labeled “Azithromycin for Oral Suspension, USP 200 mg per
5 mL”. How many mL should the nurse administer? (Enter numerical value only).
25m2
6. The nurse is providing care to a client having surgery to repair a retinal detachment to the left
eye. Which intervention should the nurse implement during the postoperative period? a. Provide
an eye shield to be worn while sleeping.
b. Obtain vital signs every 2 hours during hospitalization.
c. Teach a family member to administer eye drops.
d. Encourage deep breathing and coughing exercises.
7. The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The
client wants to resume social activities with family. How should the nurse respond? a. Reinforce
the need to avoid social contact for several weeks.
b. Recommend the use of a face mask during family events.
c. Encourage family gatherings to reduce feelings of isolation.
d. Explain the need to avoid persons with respiratory infections.
8. A mother brings her 3-week-old son to the clinic because he is vomiting “all the time”. In
performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost
, lOMoARcPSD|55550609
20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which
intervention should the nurse implement first? a. Insert a nasogastric tube for feeding.
b. Initiate a prescribed IV for parental fluid.
c. Feed the infant 3 ounces of Isomil.
d. Give the infant 5% dextrose in water orally.
9. An older client with a history of heart failure and admitted to the medical unit after falling at
home and has become increasingly confused. The client’s spouse is designated as the client’s
power of attorney. When reporting to the healthcare provider using SBAR (Situation,
Background, Assessment, Recommendation) communication, which information should the
nurse provide first? A. Increasing confusion of the client. B. Fall at home as reason for
admission.
C. Client’s healthcare power of attorney.
D. Currently prescribed medication.
10. An adult client is admitted for severe pain in his side and back and is sent for an
intravenous pyelogram. Which report from the client is the earliest indication to the nurse that
the client is experiencing an adverse reaction to this procedure? a. Tingling on tongue or lips.
b. Salty taste in the mouth.
c. Episodes of shivering.
d. Difficulty breathing.
11. A client tells the nurse about jogging every day with the hope of losing weight and sleeping
better. The client states that it takes hours to fall asleep at night and is experiencing fatigue and
sleepiness throughout the day. Which action should the nurse implement? a. Ask the client for a
description of the exercise schedule that is being followed.
b. Encourage the client to exercise very day to eliminate bedtime wakefulness.
c. Determine the amount of weight the client has lost since increasing activity.
d. Advise the client that lifestyle changes often takes several weeks to be effective.
