2 The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high
protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was
effective?
a. A peanut butter sandwich with soda and
cookies. b. A tuna fish sandwich with chips and ice
cream.
c. Vegetable soup, crackers, and milk.
d. A salad with three kinds of lettuce and fruit.
3 The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center.
Which outcome indicates that the program was effective?
A. Average client scores improved on specific risk factor knowledge test.
B. More than half of at-risk client were diagnosed early in their process.
C. New screening protocols were developed, validated, and implemented.
D. Clients who incurred disease complications promptly received rehabilitation.
4 A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the
dashboard. Admission assessments include blood pressure 85/45 mm Hg, oral temperature 98.6° F (37° C), pulse 124
beats/minute, and respirations 22 breaths/minute. Based on these data, the nurse formulates the first portion of a nursing
problem as "Risk for injury". What term best expresses the "related to" portion of the nursing problem?
a. head injury.
b. infection.
c. increased intracranial pressure.
d. shock.
5 A nurse working on an endocrine unit should see which client first.
a. An adolescent male with diabetes who is arguing about his insulin dose.
b. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).
c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last
hour. d. A client taking corticosteroids who has become disoriented in the last two hours.
6 Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to
administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends
a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention
should the nurse implement?
a. Transfuse Type A negative blood until Type AB negative is available.
b. Recheck the clienfs hemoglobin, blood type, and Rh factor.
c. Obtain additional consent for administration of Type A negative blood.
d. Administer normal saline solution until Type AB negative is available.
7 An older client who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left
hip. With no immediate family in the area, the client is concerned about the pets at home. Which interventions should the
nurse implement? (Select au that apply.)
A- Evaluate pain using a standard pain scale
B- Alert social worker of client's concerns.
C- Support left leg with two pillows.
D- Palpate and mark pedal pulses.
E- Assess ability to bear weight when standing
1
,8 Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare provider? (Click on the
correct location on the chart. To change, click on a new location.)
▪ Serum Sodio 142 mEq/L (142 mmol/L)
▪ Postassium 3.9 mEq/L (3.9 mmol'/L)
▪ Serum glucose 62 mg/dl (3.4 mmdl/L)
▪ Blood urea nitrogen 18 mg/dl (6.4 mmol/L)
9 An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds,
2
, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the
nurse to implement?
a. Observe neck for jugular vein distention
b. Notify healthcare provider to prepare for pericardiocentesis
c. Asses for paradoxical blood pressure
d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry
10 The parent of a child born with a cleft lip asks the nurse to explain why this happened. The parent is concerned that they
did something wrong that caused this to occur. Which response is most helpful?
a. "You didn't do anything wrong."
b. "This must be a very difficult time for you."
c. "With surgery, your baby should have a full recovery.
d. "Is there any particular reason why you think this is your fault?
11 After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the
mother, which statement by the child's mother indicates that she understands home care treatment to promote
pulmonary functions?
a. Chest physiotherapy should be performed twice a day before a meal.
b. Administer a cough suppressant every 8 hours."
c. Energy should be conserved by scheduling minimally strenuous activities."
d. Maintain supplemental oxygen at 4 to 6 Uminute."
12 A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry,
black diarrhea and reports abdominal pain. Which actions should the nurse implement? (Select all that apply.)
a. Auscultate bowel sounds in all quadrants.
b. Review last partial thromboplastin time
results. c. Assess characteristics of pain.
d. Prepare to administer warfarin.
e. Monitor stools for presence of blood.
13 The nurse is developing a teaching program for the community. What population characteristic is most influential when
choosing strategies for implementing a teaching plan?
a. Literacy level.
b. Median age.
c. Prevalent learning style.
d. Percent with Internet access.
14 The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the
healthcare provider immediately?
a. Gradual onset of continuous eye pain and blurred vision.
b. Recent change in the ability to read and drive after dark.
c. Gray-white circle around the iris of both eyes.
d. Cloudy opacity of the crystalline lens.
15 While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which
action should the nurse take?
a. Inform the client that falls occur more often in the hospital than at
home. b. Continue to obtain client data needed to complete the fall risk
survey.
c. Record a minimal risk for falls, documenting the client's statement.
d. Place the client on a high fall risk protocol because of advanced age.
3
, 16 A client with gestational diabetes is being induced for labor. Which assessment is most important for the nurse to perform
prior to increasing the oxytocin
rate? a. Contraction pattern.
b. Blood pressure.
c. Fingerstick glucose.
d. Vaginal exam.
4
protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was
effective?
a. A peanut butter sandwich with soda and
cookies. b. A tuna fish sandwich with chips and ice
cream.
c. Vegetable soup, crackers, and milk.
d. A salad with three kinds of lettuce and fruit.
3 The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center.
Which outcome indicates that the program was effective?
A. Average client scores improved on specific risk factor knowledge test.
B. More than half of at-risk client were diagnosed early in their process.
C. New screening protocols were developed, validated, and implemented.
D. Clients who incurred disease complications promptly received rehabilitation.
4 A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the
dashboard. Admission assessments include blood pressure 85/45 mm Hg, oral temperature 98.6° F (37° C), pulse 124
beats/minute, and respirations 22 breaths/minute. Based on these data, the nurse formulates the first portion of a nursing
problem as "Risk for injury". What term best expresses the "related to" portion of the nursing problem?
a. head injury.
b. infection.
c. increased intracranial pressure.
d. shock.
5 A nurse working on an endocrine unit should see which client first.
a. An adolescent male with diabetes who is arguing about his insulin dose.
b. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).
c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last
hour. d. A client taking corticosteroids who has become disoriented in the last two hours.
6 Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to
administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends
a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention
should the nurse implement?
a. Transfuse Type A negative blood until Type AB negative is available.
b. Recheck the clienfs hemoglobin, blood type, and Rh factor.
c. Obtain additional consent for administration of Type A negative blood.
d. Administer normal saline solution until Type AB negative is available.
7 An older client who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left
hip. With no immediate family in the area, the client is concerned about the pets at home. Which interventions should the
nurse implement? (Select au that apply.)
A- Evaluate pain using a standard pain scale
B- Alert social worker of client's concerns.
C- Support left leg with two pillows.
D- Palpate and mark pedal pulses.
E- Assess ability to bear weight when standing
1
,8 Which laboratory finding for an adult client is most critical for the nurse to report to the healthcare provider? (Click on the
correct location on the chart. To change, click on a new location.)
▪ Serum Sodio 142 mEq/L (142 mmol/L)
▪ Postassium 3.9 mEq/L (3.9 mmol'/L)
▪ Serum glucose 62 mg/dl (3.4 mmdl/L)
▪ Blood urea nitrogen 18 mg/dl (6.4 mmol/L)
9 An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds,
2
, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the
nurse to implement?
a. Observe neck for jugular vein distention
b. Notify healthcare provider to prepare for pericardiocentesis
c. Asses for paradoxical blood pressure
d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry
10 The parent of a child born with a cleft lip asks the nurse to explain why this happened. The parent is concerned that they
did something wrong that caused this to occur. Which response is most helpful?
a. "You didn't do anything wrong."
b. "This must be a very difficult time for you."
c. "With surgery, your baby should have a full recovery.
d. "Is there any particular reason why you think this is your fault?
11 After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the
mother, which statement by the child's mother indicates that she understands home care treatment to promote
pulmonary functions?
a. Chest physiotherapy should be performed twice a day before a meal.
b. Administer a cough suppressant every 8 hours."
c. Energy should be conserved by scheduling minimally strenuous activities."
d. Maintain supplemental oxygen at 4 to 6 Uminute."
12 A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry,
black diarrhea and reports abdominal pain. Which actions should the nurse implement? (Select all that apply.)
a. Auscultate bowel sounds in all quadrants.
b. Review last partial thromboplastin time
results. c. Assess characteristics of pain.
d. Prepare to administer warfarin.
e. Monitor stools for presence of blood.
13 The nurse is developing a teaching program for the community. What population characteristic is most influential when
choosing strategies for implementing a teaching plan?
a. Literacy level.
b. Median age.
c. Prevalent learning style.
d. Percent with Internet access.
14 The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the
healthcare provider immediately?
a. Gradual onset of continuous eye pain and blurred vision.
b. Recent change in the ability to read and drive after dark.
c. Gray-white circle around the iris of both eyes.
d. Cloudy opacity of the crystalline lens.
15 While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which
action should the nurse take?
a. Inform the client that falls occur more often in the hospital than at
home. b. Continue to obtain client data needed to complete the fall risk
survey.
c. Record a minimal risk for falls, documenting the client's statement.
d. Place the client on a high fall risk protocol because of advanced age.
3
, 16 A client with gestational diabetes is being induced for labor. Which assessment is most important for the nurse to perform
prior to increasing the oxytocin
rate? a. Contraction pattern.
b. Blood pressure.
c. Fingerstick glucose.
d. Vaginal exam.
4
