1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy
products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?
• Review with the client the need to avoid foods that are rich in milk and cream
2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the
clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking
the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the
nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
• Stroke secondary to hemorrhage
3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a
seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the
nurse implement?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days.
Which assessment finding requires immediate follow-up?
• Describes life without purpose
5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and
is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information
should the nurse include in the client’s teaching plan?
• Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is
most important for the nurse to include in the discharge plan?
• Teach tracheal suctioning techniques
7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute.
What action should the nurse implement?
• Document the assessment data
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which alarm investigate first?
• Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action is taken first?
• Check the client for lacerations or fractures
10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that
she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action is taken first?
• Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an
S3 heart sound is present, what action should the nurse take first?
• Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment.
Which agency should the client be referred to by the employee health nurse for health insurance needs?
• Medicare
,13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the
nurse instruct the client to take with the tetracycline?
• Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the
client is experiencing a complication?
• “I have a headache that gets worse when I sit up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which
action should the nurse implement?
• Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the
child’s dietary restrictions. Which foods are contraindicated for this child?
• Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a
3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse
provide?
• Direct the nurse to continue the surgical hand scrub for a 5 minute duration
18. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary
management of osteoporosis?
• Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should receive the most
care hours by a registered nurse (RN)?
• An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft
wrist restrains applied
20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon
inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action
should the nurse implement first?
• Cleanse the foot with soap and water and apply an antibiotic ointment
21. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple
antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide?
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine
sodium (Synthroid) is prescribed. Which symptoms indicate the prescribed dosage is too high for this client?
• Palpitations and shortness of breath
23. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and
palpitations. Which finding is most important for the nurse to assess to the client?
• Obtain a list of medications taken for cardiac history
24. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select apply)
,Fluid shifts from intravascular to interstitial area due to decreased serum protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
Increased circulating aldosterone levels that increase sodium and water retention
28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What
assessment is most important for the nurse to complete?
• Auscultate the client's bowel sounds
29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of
breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the
nurse to document this in her medical record. What action should the nurse implement?
• Ask the client to discuss “do not resuscitate” with her healthcare provider
30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The
client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?
• Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows
have disappeared, and that her eyes are all puffy. Which follow-up question should nurse to ask?
• Have you noticed any changes in your fingernails?
32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition.
The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding
warrants immediate intervention by the nurse?
• Capillary refill of 8 seconds
33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a
witness. What are legal implications of the nurse’s signature on the client’s surgical consent form? (sata)
• The client voluntarily grants permission for the procedure to be done
• The client is competent to sign the consent without impairment of judgment
• The client understands the risks and benefits associated with the procedure
34. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be
assigned to his care and is belligerent when another nurse is assigned. Charge nurse implement what?
• Advise the client that assignments are not based on clients requests
35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While
providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
• Place the implant in a lead container using long-handled forceps
36. The client with which type of wound is most likely to need immediate intervention by the nurse?
• Laceration
37. The nurse is planning care for client admitted with a diagnosis of pheochromocytoma. Intervention?
• Monitor blood pressure frequently
38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of
the bed 30 degrees. What is the reason for this intervention?
• To reduce abdominal pressure on the diaphragm
, 39. When assessing a mildly obese 35-year-old female, the nurse is unable to locate the gallbladder when
palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely
explanation for failure to locate the gallbladder by palpation?
• The gallbladder is normal
40. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since
the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety
medications, but thinks she may need to start taking them again because of her increased anxiety. What response is
best for the nurse to provide this woman?
• Inform her that some antianxiety medications are safe to take while breastfeeding
41. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the
clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he
took his last dose of insulin or ate last. What action should the nurse implement first?
• Start an intravenous (IV) infusion of normal saline
42. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood
pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive
medication?
• The additive effect of multiple medications has caused the blood pressure to drop too low
43. Which client is at the greatest risk for developing delirium?
• An adult client who cannot sleep due to constant pain.
44. Which intervention should the nurse include in a long-term plan of care for a client with COPD?
• Reduce risks factors for infection
45. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?
• A business and professional women’s group
46. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After
stopping the medication abruptly, the client reports feeling “very tired”. Most important intervention to implement?
• Measure Vital signs
47. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is
important for the nurse to review before contacting the health care provider?
• Serum calcium
48. What explanation is best for the nurse to provide a client who asks the purpose of using the logrolling
technique for turning?
• The technique is intended to maintain straight spinal alignment.
49. A client receiving chemotherapy has severe neutropenia. Which snack is best to recommend to the client?
• Baked apples topped with dried raisins
50. Which action should the school nurse take first when conducting a screening for scoliosis?
• Inspect for symmetrical shoulder height.
51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a
client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse apply?
• Assign a practical nurse (LPN) to determine if an apical radial deficit is present
products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?
• Review with the client the need to avoid foods that are rich in milk and cream
2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the
clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking
the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the
nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
• Stroke secondary to hemorrhage
3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a
seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the
nurse implement?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days.
Which assessment finding requires immediate follow-up?
• Describes life without purpose
5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and
is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information
should the nurse include in the client’s teaching plan?
• Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is
most important for the nurse to include in the discharge plan?
• Teach tracheal suctioning techniques
7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen
reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute.
What action should the nurse implement?
• Document the assessment data
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which alarm investigate first?
• Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action is taken first?
• Check the client for lacerations or fractures
10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that
she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action is taken first?
• Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an
S3 heart sound is present, what action should the nurse take first?
• Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment.
Which agency should the client be referred to by the employee health nurse for health insurance needs?
• Medicare
,13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the
nurse instruct the client to take with the tetracycline?
• Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the
client is experiencing a complication?
• “I have a headache that gets worse when I sit up”
15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which
action should the nurse implement?
• Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the
child’s dietary restrictions. Which foods are contraindicated for this child?
• Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a
3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse
provide?
• Direct the nurse to continue the surgical hand scrub for a 5 minute duration
18. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary
management of osteoporosis?
• Bagel with jelly and skim milk
19. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal
number of registered nurses will be working that shift. In planning assignments, which client should receive the most
care hours by a registered nurse (RN)?
• An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft
wrist restrains applied
20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon
inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action
should the nurse implement first?
• Cleanse the foot with soap and water and apply an antibiotic ointment
21. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple
antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide?
Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine
sodium (Synthroid) is prescribed. Which symptoms indicate the prescribed dosage is too high for this client?
• Palpitations and shortness of breath
23. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and
palpitations. Which finding is most important for the nurse to assess to the client?
• Obtain a list of medications taken for cardiac history
24. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select apply)
,Fluid shifts from intravascular to interstitial area due to decreased serum protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
Increased circulating aldosterone levels that increase sodium and water retention
28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What
assessment is most important for the nurse to complete?
• Auscultate the client's bowel sounds
29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of
breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the
nurse to document this in her medical record. What action should the nurse implement?
• Ask the client to discuss “do not resuscitate” with her healthcare provider
30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The
client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?
• Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows
have disappeared, and that her eyes are all puffy. Which follow-up question should nurse to ask?
• Have you noticed any changes in your fingernails?
32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition.
The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding
warrants immediate intervention by the nurse?
• Capillary refill of 8 seconds
33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a
witness. What are legal implications of the nurse’s signature on the client’s surgical consent form? (sata)
• The client voluntarily grants permission for the procedure to be done
• The client is competent to sign the consent without impairment of judgment
• The client understands the risks and benefits associated with the procedure
34. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be
assigned to his care and is belligerent when another nurse is assigned. Charge nurse implement what?
• Advise the client that assignments are not based on clients requests
35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While
providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
• Place the implant in a lead container using long-handled forceps
36. The client with which type of wound is most likely to need immediate intervention by the nurse?
• Laceration
37. The nurse is planning care for client admitted with a diagnosis of pheochromocytoma. Intervention?
• Monitor blood pressure frequently
38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of
the bed 30 degrees. What is the reason for this intervention?
• To reduce abdominal pressure on the diaphragm
, 39. When assessing a mildly obese 35-year-old female, the nurse is unable to locate the gallbladder when
palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely
explanation for failure to locate the gallbladder by palpation?
• The gallbladder is normal
40. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since
the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety
medications, but thinks she may need to start taking them again because of her increased anxiety. What response is
best for the nurse to provide this woman?
• Inform her that some antianxiety medications are safe to take while breastfeeding
41. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the
clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he
took his last dose of insulin or ate last. What action should the nurse implement first?
• Start an intravenous (IV) infusion of normal saline
42. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood
pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive
medication?
• The additive effect of multiple medications has caused the blood pressure to drop too low
43. Which client is at the greatest risk for developing delirium?
• An adult client who cannot sleep due to constant pain.
44. Which intervention should the nurse include in a long-term plan of care for a client with COPD?
• Reduce risks factors for infection
45. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?
• A business and professional women’s group
46. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After
stopping the medication abruptly, the client reports feeling “very tired”. Most important intervention to implement?
• Measure Vital signs
47. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is
important for the nurse to review before contacting the health care provider?
• Serum calcium
48. What explanation is best for the nurse to provide a client who asks the purpose of using the logrolling
technique for turning?
• The technique is intended to maintain straight spinal alignment.
49. A client receiving chemotherapy has severe neutropenia. Which snack is best to recommend to the client?
• Baked apples topped with dried raisins
50. Which action should the school nurse take first when conducting a screening for scoliosis?
• Inspect for symmetrical shoulder height.
51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a
client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse apply?
• Assign a practical nurse (LPN) to determine if an apical radial deficit is present
