1. A nurse is reviewing the laboratory results for 5. A nurse is caring for an older adult client who
a client who is at 32 gestation. For which of the has pneumonia. When reinforcing teaching about
following results should the nurse notify the the diagnosis age- related changes with the client’s
provider? family, which of the following alterations should
a. Hgb 12 g/dL the nurse include?
b. Platelet count 90,000/mm2 a. Increased inflation of the basilar lungs
c. Hematocrit 37% b. Increased elasticity of the thoracic cage
d. Creatinine 0.7 mg/dL c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex
2. After receiving change-of-shift report, which of
the following clients should the nurse collect data 6. A client is participating in an anger
from first? management session explain that his recent
a. A client who has a history of pancreatitis behavior are related to his job loss. Which of the
and reports severe abdominal pain following mechanism is the client using?
b. A client who has heart failure and reports a. Projection
severe dyspnea b. Rationalism
c. A client who is scheduled for abdominal c. Repression
surgery in 1 hrs d. Sublimation
d. A postoperative client who has diabetes
mellitus and a blood glucose of 280 mg/dK 7. A nurse is reinforcing teaching with the client
who is about to undergo a thoracentesis. Which if
3. A nurse is preparing a client for surgery. The the following statements by the client indicates an
client tells the nurse that he is concerned about the understanding of the information?
safety of a large sum of money in his wallet. a. “I will have general anesthesia during the
Which of the following actions is appropriate for procedure.”
the nurse to take? b. “I will lie flat for 6 hours before the
a. Place the money in an envelope and lock it procedure.”
in the client’s medication drawer c. “I will have the chest x-ray following the
b. Contact security personnel to place the procedure.”
money in the facility safe d. “I will breathe deeply through my nose
c. Hold the money for the client until he during the procedure.”
returns from surgery
d. Label the money and leave it with the unit 8. A nurse is reviewing the medical record of a
secretary. client who is requesting an oral contraceptive.
Which of the following findings should the nurse
4. A nurse is preparing to instill an otic suspension identify as a contraindication to the use of oral
into an adult client’ ear. Which of the following contraceptive?
methods should the nurse plan to use? a. History of renal calculi
a. Pull the auricle upward and outward. b. Migraines with aura
b. Pull the auricle downward and backward. c. BMI of 26
c. Pull the auricle upward and backward. d. History of cholecystectomy
d. Pull the auricle downward an outward.
,9. A nurse is reinforcing discharge teaching about 13. A nurse is reinforcing teaching about
transmission precautions with a client who has colostomy care with a client. Which of the
Hepatitis C. Which of the following information following client statements indicate an
should the nurse include? understanding of how to care for the colostomy?
a. Avoid sharing razors with other family a. I will cleanse the stoma site gently with an
members. antiseptic solution.
b. Clean toilet surfaces with bleach after each b. I will contact my doctor right away if my
use stoma is red
c. Advice family members to receive a c. I will cut the water opening 1 inch bigger
hepatitis c immunization than my stoma.
d. Do not prepare food for other family d. I will empty the colostomy bag when is I
member s while infectious. one half full.
10. A nurse is preparing to administer an IM 14. A nurse is reinforcing teaching with a client
injection to a client. To reduce the risk of a needle who has a permanent pacemaker in place. Which
stick injury, the nurse should take which of the of the following statements by the client indicates
following actions? an understanding of the teaching?
a. Place a cap hold securely on the used needle a. “I should have my doctor replace the battery
a before disposal. in the pacemaker in a year.”
b. Recap the needle using a one-handed scoop b. “I need to record my pulse rate daily.”
approach before proper disposal. c. “I should avoid taking tub baths.”
c. Dispose of the used needle immediately in d. “I will remove my microwave oven from my
a puncture proof sharps container. house.”
d. Detach and dispose of the use needle
promptly following injection. 15. A nurse is collecting data from a parent of a
preschooler at a well-child visit. Which of the
11. A nurse is reinforcing teaching with a client following findings is a contraindication to a
who has new prescription for levothyroxine. measles, mumps and rubella (MMR)
Which of the following statements indicates immunization?
understanding of the instructions? a. Family history of allergies to penicillin
a. “I should take this medication with meals.” b. Erythema at injection site with previous
b. This medication will take 2 weeks to reach immunization.
full effectiveness.” c. Long-term use of immunosuppressants
c. “I need to take this medication for the d. Current use of antimicrobial therapy.
rest of my life.”
d. “If I forget to take the medication, I can 16. A nurse is reinforcing teaching with a client
double the next dose.” who has a vitamin C deficiency. Which of the
following foods should the nurse include as having
12. A nurse is caring for a client who is receiving the highest vitamin C content?
prazosin. The client’s blood pressure is 100/60 mm a. 1 cup yogurt
Hg. which of the following actions should the nurse b. 1 cup raw broccoli
take? c. 1 large baked potato
a. Administer a reversal agent d. 1 cup boiled carrots
b. Initiate cardiac monitoring
c. Instruct the client to stand up slowly
d. Inform the client to report urinary retention
, 17. A nurse is checking the home environment of 22. A nurse is collecting data from a client who has
a client for safety hazards. Which of the following diabetes mellitus. Which of the following indicates
items require intervention by the nurse? the client might be experiencing diabetic
a. The television set is turned to a loud volume ketoacidosis?
b. The dining room table has low chairs with a. Negative urine ketones
no armrests b. Kussmaul respirations
c. The bedroom extension cord is placed under c. Hypoglycemia
a heavy nightstand d. Anuria
d. The living room contains wall to wall
carpeting. 23. A nurse receives a verbal order for a client to
receive a stat dose of meperidine 100 mg PO. She
18. A nurse is caring for a 17-yr. old client who is administers the medication, charts the
admitted for an emergency appendectomy. Which administration and then realizes she has
of the following is an appropriate action by the administered phenytoin 100 mg. which of the
nurse in obtaining informed consent? following actions should the nurse take first?
a. Have the client’s older sibling give a. Check client’s vital signs.
consent if parent is not available. b. Complete an incident report.
b. Delay the procedure if the provider cannot c. Notify the provider
contact the parents. d. Administer the meperidine.
c. Witness the signature of the client’s parents
when he arrives. 24. A nurse is caring for a client and begins to
d. Obtain verbal consent from the client while suspect he is experiencing transference. Which of
waiting for the parents to arrive. the following client statements should the nurse
identify as an indicator of transference?
19. A nurse is reinforcing teaching with a parent a. I’m going to inform my provider that I’m
about appropriate snacks for a toddler. Which of going to quit taking my medication
the following food should the nurse include? b. I don’t want to talk to you about how I’m
a. Marshmallows feeling right now
b. Graham crackers c. I feel really close to you because you
c. Almonds remind me of my ex-boyfriend.
d. Carrot sticks d. I feel happy about the progress I have been
making in my life.
20. A nurse is preparing to catheterize a client’s
bladder to check for residual urine. The nurse 25. A nurse is reinforcing teaching about self-
should schedule this procedure at which of the administration of nasal drops with a client. Which
following times? of the following position should the nurse
a. Right after the client void recommend for installation of the drops?
b. When the client feels an urge to void a. Sims’
c. While voiding on a bedpan b. Prone
d. Before obtaining a bladder scan. c. Supine
d. Orthopneic
21. A nurse is caring for a client who has viral
pneumonia. Which of the following actions should
the nurse take?
a. Place the client in a private room
b. Administer azithromycin
c. Recommend a pneumococcal immunization.
d. Limit fluid intake to 1L per day.
a client who is at 32 gestation. For which of the has pneumonia. When reinforcing teaching about
following results should the nurse notify the the diagnosis age- related changes with the client’s
provider? family, which of the following alterations should
a. Hgb 12 g/dL the nurse include?
b. Platelet count 90,000/mm2 a. Increased inflation of the basilar lungs
c. Hematocrit 37% b. Increased elasticity of the thoracic cage
d. Creatinine 0.7 mg/dL c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex
2. After receiving change-of-shift report, which of
the following clients should the nurse collect data 6. A client is participating in an anger
from first? management session explain that his recent
a. A client who has a history of pancreatitis behavior are related to his job loss. Which of the
and reports severe abdominal pain following mechanism is the client using?
b. A client who has heart failure and reports a. Projection
severe dyspnea b. Rationalism
c. A client who is scheduled for abdominal c. Repression
surgery in 1 hrs d. Sublimation
d. A postoperative client who has diabetes
mellitus and a blood glucose of 280 mg/dK 7. A nurse is reinforcing teaching with the client
who is about to undergo a thoracentesis. Which if
3. A nurse is preparing a client for surgery. The the following statements by the client indicates an
client tells the nurse that he is concerned about the understanding of the information?
safety of a large sum of money in his wallet. a. “I will have general anesthesia during the
Which of the following actions is appropriate for procedure.”
the nurse to take? b. “I will lie flat for 6 hours before the
a. Place the money in an envelope and lock it procedure.”
in the client’s medication drawer c. “I will have the chest x-ray following the
b. Contact security personnel to place the procedure.”
money in the facility safe d. “I will breathe deeply through my nose
c. Hold the money for the client until he during the procedure.”
returns from surgery
d. Label the money and leave it with the unit 8. A nurse is reviewing the medical record of a
secretary. client who is requesting an oral contraceptive.
Which of the following findings should the nurse
4. A nurse is preparing to instill an otic suspension identify as a contraindication to the use of oral
into an adult client’ ear. Which of the following contraceptive?
methods should the nurse plan to use? a. History of renal calculi
a. Pull the auricle upward and outward. b. Migraines with aura
b. Pull the auricle downward and backward. c. BMI of 26
c. Pull the auricle upward and backward. d. History of cholecystectomy
d. Pull the auricle downward an outward.
,9. A nurse is reinforcing discharge teaching about 13. A nurse is reinforcing teaching about
transmission precautions with a client who has colostomy care with a client. Which of the
Hepatitis C. Which of the following information following client statements indicate an
should the nurse include? understanding of how to care for the colostomy?
a. Avoid sharing razors with other family a. I will cleanse the stoma site gently with an
members. antiseptic solution.
b. Clean toilet surfaces with bleach after each b. I will contact my doctor right away if my
use stoma is red
c. Advice family members to receive a c. I will cut the water opening 1 inch bigger
hepatitis c immunization than my stoma.
d. Do not prepare food for other family d. I will empty the colostomy bag when is I
member s while infectious. one half full.
10. A nurse is preparing to administer an IM 14. A nurse is reinforcing teaching with a client
injection to a client. To reduce the risk of a needle who has a permanent pacemaker in place. Which
stick injury, the nurse should take which of the of the following statements by the client indicates
following actions? an understanding of the teaching?
a. Place a cap hold securely on the used needle a. “I should have my doctor replace the battery
a before disposal. in the pacemaker in a year.”
b. Recap the needle using a one-handed scoop b. “I need to record my pulse rate daily.”
approach before proper disposal. c. “I should avoid taking tub baths.”
c. Dispose of the used needle immediately in d. “I will remove my microwave oven from my
a puncture proof sharps container. house.”
d. Detach and dispose of the use needle
promptly following injection. 15. A nurse is collecting data from a parent of a
preschooler at a well-child visit. Which of the
11. A nurse is reinforcing teaching with a client following findings is a contraindication to a
who has new prescription for levothyroxine. measles, mumps and rubella (MMR)
Which of the following statements indicates immunization?
understanding of the instructions? a. Family history of allergies to penicillin
a. “I should take this medication with meals.” b. Erythema at injection site with previous
b. This medication will take 2 weeks to reach immunization.
full effectiveness.” c. Long-term use of immunosuppressants
c. “I need to take this medication for the d. Current use of antimicrobial therapy.
rest of my life.”
d. “If I forget to take the medication, I can 16. A nurse is reinforcing teaching with a client
double the next dose.” who has a vitamin C deficiency. Which of the
following foods should the nurse include as having
12. A nurse is caring for a client who is receiving the highest vitamin C content?
prazosin. The client’s blood pressure is 100/60 mm a. 1 cup yogurt
Hg. which of the following actions should the nurse b. 1 cup raw broccoli
take? c. 1 large baked potato
a. Administer a reversal agent d. 1 cup boiled carrots
b. Initiate cardiac monitoring
c. Instruct the client to stand up slowly
d. Inform the client to report urinary retention
, 17. A nurse is checking the home environment of 22. A nurse is collecting data from a client who has
a client for safety hazards. Which of the following diabetes mellitus. Which of the following indicates
items require intervention by the nurse? the client might be experiencing diabetic
a. The television set is turned to a loud volume ketoacidosis?
b. The dining room table has low chairs with a. Negative urine ketones
no armrests b. Kussmaul respirations
c. The bedroom extension cord is placed under c. Hypoglycemia
a heavy nightstand d. Anuria
d. The living room contains wall to wall
carpeting. 23. A nurse receives a verbal order for a client to
receive a stat dose of meperidine 100 mg PO. She
18. A nurse is caring for a 17-yr. old client who is administers the medication, charts the
admitted for an emergency appendectomy. Which administration and then realizes she has
of the following is an appropriate action by the administered phenytoin 100 mg. which of the
nurse in obtaining informed consent? following actions should the nurse take first?
a. Have the client’s older sibling give a. Check client’s vital signs.
consent if parent is not available. b. Complete an incident report.
b. Delay the procedure if the provider cannot c. Notify the provider
contact the parents. d. Administer the meperidine.
c. Witness the signature of the client’s parents
when he arrives. 24. A nurse is caring for a client and begins to
d. Obtain verbal consent from the client while suspect he is experiencing transference. Which of
waiting for the parents to arrive. the following client statements should the nurse
identify as an indicator of transference?
19. A nurse is reinforcing teaching with a parent a. I’m going to inform my provider that I’m
about appropriate snacks for a toddler. Which of going to quit taking my medication
the following food should the nurse include? b. I don’t want to talk to you about how I’m
a. Marshmallows feeling right now
b. Graham crackers c. I feel really close to you because you
c. Almonds remind me of my ex-boyfriend.
d. Carrot sticks d. I feel happy about the progress I have been
making in my life.
20. A nurse is preparing to catheterize a client’s
bladder to check for residual urine. The nurse 25. A nurse is reinforcing teaching about self-
should schedule this procedure at which of the administration of nasal drops with a client. Which
following times? of the following position should the nurse
a. Right after the client void recommend for installation of the drops?
b. When the client feels an urge to void a. Sims’
c. While voiding on a bedpan b. Prone
d. Before obtaining a bladder scan. c. Supine
d. Orthopneic
21. A nurse is caring for a client who has viral
pneumonia. Which of the following actions should
the nurse take?
a. Place the client in a private room
b. Administer azithromycin
c. Recommend a pneumococcal immunization.
d. Limit fluid intake to 1L per day.
