NUR 202 RN VATI
90. A nurse is caring for a client who has a chest tube and notes continuous bubbling in the water-
seal chamber. Which of the following actions should the nurse take?
a. turn down the wall suction
b. observe the system for an air leak
c. obtain a prescription to discontinue the chest tube
d. empty the drainage from the collection chamber
91. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis.
Which of the following instructions is appropriate for the nurse to include in the plan of care?
a. assist the client to a supine position
b. recommend prophylactic acyclovir
c. initiate droplet precautions for the client
d. perform a Glasgow coma scale every 24 hr
92. a nurse is caring for a child who has infectious mononucleosis. Which of the following findings
are associated with this diagnosis?
a. koplik spots
b. splenomegaly
c. malaise
d. sore throat
e. vertigo
93. a nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which
of the following is an appropriate nursing action?
a. administer chlorpromazine with a loop diuretic
b. check orthostatic blood pressure 1 hr after administration
c. administer once daily 30 min before breakfast
d. check weekly calcium levels
94.94.
95. a nurse is planning care for a child who is unresponsive and has increased intracranial
pressure. Which of the following actions should the nurse take?
a. schedule routine oral suctioning
b. pad the side rails of the bed
, c. obtain isolation supplies
d. place the child in Trendelenburg position
96. a nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of
the following foods should the nurse recommend?
a. beef liver
b. egg whites
c. steamed clams
d. broiled lobster
97. a nurse is caring for a client who has meningitis. Which of the following assessments should
the nurse perform?
a. homans’ sign
b. trousseau’s sign
c. brudzinski’s sign
d. chvostek’s sign
98. a nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via
continuous IV infusion. Which of the following findings should the nurse report to the provider?
a. respiratory rate 14/min
b. blood pressure 150/98 mm Hg
c. magnesium 9 mEq/L
d. 2+ deep tendon reflexes
99. a nurse is teaching a client who has a new prescription for digoxin. Which of the following
statement should the nurse include in the teaching?
a. “notify your provider if you experience muscle weakness”
b. “report a weight gain of one- half pound per day”
c. “expect this medication to increase your blood pressure”
d. “you will need to take a diuretic while taking this medication”
100. an infection control nurse is reviewing the medical records of several clients. Which of the
following infections should the nurse report to the Centers for Disease Control and Prevention?
a. candidiasis
b. pelvic inflammatory disease
, c. MRSA
d. syphilis
101. a nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of
the following actions should the nurse take?
a. maintain the child in a sitting position for 3 min following administration
b. administer the drops directly to the center of the eyeball
c. apply pressure to the lacrimal punctum for 1 min following administration
d. wipe excess medication from the outer canthus toward the nose.
102. a nurse is caring for a client who has schizophrenia. The client states, “run cats spine the rain
throwing procedure mechanical paper lake.” The nurse should document that the client is
demonstrating which of the following speech alterations?
a. echolalia
b. word salad
c. neolgisms
d. clang association
103. a nurse is discussing a living will with a client. Which of the following statements by the
client indicates an understanding of this document?
a. “it expressed my wishes about distribution of my belongings after death.”
b. “it designates a family member to make my health care decisions.”
c. “it is required for anyone undergoing surgery.”
d. “it commuanicated my wishes for end-of-life care.”
104. a nurse is assessing a client who was brought to the ED by hid adult child. The client has
visable contusions on all four extremities. Which of the following actions should the nurse take?
a. report the incident to Adult Protective Services
b. Interview the client with his adult child present
c. tell the client he must answer every assessment question
d. advise the client to consult a social worker
105. a nurse is planning care for a client who has new diagnosis of dysphagia. Which of the
following foods should the nurse recommend?
a. apple juice
b. oatmeal
90. A nurse is caring for a client who has a chest tube and notes continuous bubbling in the water-
seal chamber. Which of the following actions should the nurse take?
a. turn down the wall suction
b. observe the system for an air leak
c. obtain a prescription to discontinue the chest tube
d. empty the drainage from the collection chamber
91. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis.
Which of the following instructions is appropriate for the nurse to include in the plan of care?
a. assist the client to a supine position
b. recommend prophylactic acyclovir
c. initiate droplet precautions for the client
d. perform a Glasgow coma scale every 24 hr
92. a nurse is caring for a child who has infectious mononucleosis. Which of the following findings
are associated with this diagnosis?
a. koplik spots
b. splenomegaly
c. malaise
d. sore throat
e. vertigo
93. a nurse is caring for a client who has a new prescription for chlorpromazine by IM injection. Which
of the following is an appropriate nursing action?
a. administer chlorpromazine with a loop diuretic
b. check orthostatic blood pressure 1 hr after administration
c. administer once daily 30 min before breakfast
d. check weekly calcium levels
94.94.
95. a nurse is planning care for a child who is unresponsive and has increased intracranial
pressure. Which of the following actions should the nurse take?
a. schedule routine oral suctioning
b. pad the side rails of the bed
, c. obtain isolation supplies
d. place the child in Trendelenburg position
96. a nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of
the following foods should the nurse recommend?
a. beef liver
b. egg whites
c. steamed clams
d. broiled lobster
97. a nurse is caring for a client who has meningitis. Which of the following assessments should
the nurse perform?
a. homans’ sign
b. trousseau’s sign
c. brudzinski’s sign
d. chvostek’s sign
98. a nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via
continuous IV infusion. Which of the following findings should the nurse report to the provider?
a. respiratory rate 14/min
b. blood pressure 150/98 mm Hg
c. magnesium 9 mEq/L
d. 2+ deep tendon reflexes
99. a nurse is teaching a client who has a new prescription for digoxin. Which of the following
statement should the nurse include in the teaching?
a. “notify your provider if you experience muscle weakness”
b. “report a weight gain of one- half pound per day”
c. “expect this medication to increase your blood pressure”
d. “you will need to take a diuretic while taking this medication”
100. an infection control nurse is reviewing the medical records of several clients. Which of the
following infections should the nurse report to the Centers for Disease Control and Prevention?
a. candidiasis
b. pelvic inflammatory disease
, c. MRSA
d. syphilis
101. a nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which of
the following actions should the nurse take?
a. maintain the child in a sitting position for 3 min following administration
b. administer the drops directly to the center of the eyeball
c. apply pressure to the lacrimal punctum for 1 min following administration
d. wipe excess medication from the outer canthus toward the nose.
102. a nurse is caring for a client who has schizophrenia. The client states, “run cats spine the rain
throwing procedure mechanical paper lake.” The nurse should document that the client is
demonstrating which of the following speech alterations?
a. echolalia
b. word salad
c. neolgisms
d. clang association
103. a nurse is discussing a living will with a client. Which of the following statements by the
client indicates an understanding of this document?
a. “it expressed my wishes about distribution of my belongings after death.”
b. “it designates a family member to make my health care decisions.”
c. “it is required for anyone undergoing surgery.”
d. “it commuanicated my wishes for end-of-life care.”
104. a nurse is assessing a client who was brought to the ED by hid adult child. The client has
visable contusions on all four extremities. Which of the following actions should the nurse take?
a. report the incident to Adult Protective Services
b. Interview the client with his adult child present
c. tell the client he must answer every assessment question
d. advise the client to consult a social worker
105. a nurse is planning care for a client who has new diagnosis of dysphagia. Which of the
following foods should the nurse recommend?
a. apple juice
b. oatmeal
