Test A:
1. A nurse is caring for a client who is at 33 weeks of gestation following an
amniocentesis. The nurse should monitor the client for which of the following
complications?
D. Contractions
2. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instruction should the nurse include?
D. Eat a light stack before bedtime.
3. A nurse on a telemetry unit is caring for a client who becomes unconscious and
whose monitor displays ventricular tachycardia. Which of the following actions
should the nurse take first after determining the client does not have a palpable
pulse?
B. Defibrillate
4. A nurse is admitting a client who is 1 week postpartum and reports excessive
vaginal bleeding. The nurse does not speak the same language as the client. The
client’s partner and 10-year-old child are accompanying her. Which of the following
actions should the nurse take to gather the client’s admission data?
C. Request a female interpreter through the facility.
5. A nurse is caring for a client who is febrile. To reduce the client’s fever, the nurse
applies a cooling blanket. Which of the following findings indicates the client is
having an adverse reaction to the cooling.
D. Shivering
6. A nurse is caring for a client who has deep-vein thrombosis of the left lower
extremity which of the following actions should the nurse take? (Click on the
“Exhibit” button below for additional client information. There are three tabs that
contain separate categories of data.)
B. Withhold heparin IV infusion
[OR] C. Administer acetaminophen
7. A nurse is reviewing assessment data from several clients. For which of the
following clients should the nurse recommend referral to a dietitian.
B. A client who has a nonhealing leg ulcer
8. A nurse is providing discharge teaching to a client who has a chronic kidney
disease and is receiving hemodialysis. Which of the following instructions should the
nurse include in the teaching?
A. Eat 1 g/kg of protein per day
9. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
B. A history of gastroesophageal reflux disease
10. A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation.
The nurse should tell the client that she will undergo which of the following
screening tests at 16 weeks of gestation?
D. Maternal serum alpha-fetoprotein
11. A nurse is caring for a client who is on bed rest. The nurse should recognize that
which of the following findings is a complication of immobility?
C. Swollen area on calf
,12. A nurse in an acute care mental health facility is participating in a medical-
education group. The leader of the group uses a laissez-faire leadership style. Which
of the following actions should the nurse expect from the leader during the session?
C. The leader allows the group to discuss whatever they would like to
regarding their medications.
13. A nurse is providing teaching about digoxin administration to the parents of a
toddler who has heart failure. Which of the following statements should the nurse
include in the teaching?
D. “Have your child drink a small glass of water after swallowing the
medication.”
14. A nurse is providing teaching to a client who has a depressive disorder and a
new prescription for phenelzine. Which of the following foods should the nurse
instruct the client to avoid?
D. Smoked salmon
16. A nurse is planning care for a client who has bipolar disorder and is
experiencing mania. Which of the following interventions should the nurse include
in the plan?
C. Encourage the client to take frequent rest periods.
17. A parish nurse is leading a support group for clients whose family members have
committed suicide. Which of the following strategies should the nurse plan to use
during the group session?
A. Initiate a discussion with clients about ways to cope with changes in
family dynamics.
18. A nurse manager observes two staff nurses reviewing the computer records of a
client who is not under their care. Which of the following actions should the nurse
manager take first?
A. Instruct the nurses to close the client’s computer record.
19. A nurse is reviewing the medical record of a client who has schizophrenia and is
taking clozapine. Which of the following findings should the nurse identify as a
contraindication to the administration of clozapine?
D. WBC count 2,900/mm3
20. A nurse is caring for several clients on a medical-surgical unit. For which of the
following nursing activities is it required that the nurse use sterile gloves?
D. Performing tracheostomy care
21. A nurse is caring for a client who is at 11 weeks of gestation. Which of the
following immunizations should the nurse recommend?
A. Influenza
22. A nurse is inserting an indwelling urinary catheter for a male client. Which of the
following actions should the nurse take?
B. Lift the penis so that it is perpendicular to the client’s body.
23. A nurse is providing teaching to a client who is at 14 weeks of gestation about
findings to report to the provider. Which of the following findings should the nurse
include in the teaching?
C. Swelling of the face
,24. A nurse has received change-of-shift report for a group of clients. Which of the
following actions should the nurse take to manage time effectively?
A. Document client care at the end of shift.
B. Make a client to-do list for the day.
C. Skip breaks until client tasks are completed.
D. Focus on several client tasks at a time.
25. A nurse is developing a plan of care for a newborn whose mother tested positive
for heroin during pregnancy. The newborn is experiencing neonatal abstinence
syndrome. Which of the following actions should the nurse include in the plan?
A. Minimize the noise in the newborn’s environment.
B. Administer naloxone to the newborn.
C. Swaddle the newborn with his legs extended.
D. Maintain eye contact with the newborn during feedings.
26. A nurse is assessing the fontanels of an 8-month-old infant. Which of the
following findings should the nurse recognize as an expected finding?
A. The anterior fontanel is open
B. The posterior fontanel is open.
C. Both fontanels are the same size.
D. Both fontanels show molding.
27. A nurse is caring for a client who has acute diverticulitis. Which of the following
diets should the nurse recommend to the client?
A. High residue
B. Lactose-free
C. Gluten-free
D. Low-fiber
28. A nurse is caring for a client who is 48 hr postoperative following a total hip
arthroplasty. Which of the following actions should the nurse include in the plan of
care?
A. Administer low-dose heparin
B. Place the client on a full liquid diet.
C. Use an incentive spirometer ever 3 hr.
D. Maintain the client on bed rest.
29. A nurse is providing teaching to the parent of an infant who has a cleft lip palate.
Which of the following feeding techniques should the nurse include in the teaching?
A. Burp the infant frequently during feedings.
B. Position the nipple at the front of the infant’s mouth.
C. Hold the infant in a supine position.
D. Use feeding devices without nipples.
30. A nurse in an acute mental health care facility is prioritizing care for multiple
clients. Which of the following clients should the nurse see first?
, A. A client who has depressive disorder and requires assistance with ADL’s
B. A client who has obsessive-compulsive disorder and is upset about a
change in daily routine
C. A client who is taking clozapine to treat schizophrenia and reports a
sore throat
D. A client who has narcissistic personality disorder and is mocking others
during group therapy
31. A nurse is planning care for a group of clients and is working with one licensed
practical nurse (LPN) and one assistive personnel (AP). Which of the following
actions should the nurse take first to manage her time effectively?
A. Develop an hourly time frame for tasks.
B. Schedule daily activities.
C. Determine goals of the day.
D. Delegate tasks to the AP
32. A nurse is performing an admission assessment for a client who is in the manic
phase of bipolar disorder. Which of the following behaviors should the nurse expect?
A. Performance of ritualistic behaviors
B. Suspiciousness and distrust
C. Distractibility and poor judgment
D. Reports of physical discomfort
33. A nurse is caring for an infant who has coarctation of the aorta. Which of the
following should the nurse identify as an expected finding?
A. Weak femoral pulses
B. Frequent nosebleeds
C. Upper extremity hypotension
D. Increased intracranial pressure
34. A nurse is developing an in-service about personality disorders. Which of the
following information would the nurse include when discussing borderline
personality disorder?
A. “The client might act seductively.”
B. “The client is overly concerned about minor details.”
C. “The client exhibits impulsive behavior.”
D. “The client is exceptionally clingy to others.”
35. A nurse is assessing a client who has a chest tube with a water seal drainage
system. Upon assessment, the nurse notes tidaling in the water seal. Which of the
following is an explanation of tidaling?
A. There is a loop of tubing below the drainage system.
B. The system is working properly
C. The lung has re-expanded
D. The tubing is partially obstructed by clots
1. A nurse is caring for a client who is at 33 weeks of gestation following an
amniocentesis. The nurse should monitor the client for which of the following
complications?
D. Contractions
2. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instruction should the nurse include?
D. Eat a light stack before bedtime.
3. A nurse on a telemetry unit is caring for a client who becomes unconscious and
whose monitor displays ventricular tachycardia. Which of the following actions
should the nurse take first after determining the client does not have a palpable
pulse?
B. Defibrillate
4. A nurse is admitting a client who is 1 week postpartum and reports excessive
vaginal bleeding. The nurse does not speak the same language as the client. The
client’s partner and 10-year-old child are accompanying her. Which of the following
actions should the nurse take to gather the client’s admission data?
C. Request a female interpreter through the facility.
5. A nurse is caring for a client who is febrile. To reduce the client’s fever, the nurse
applies a cooling blanket. Which of the following findings indicates the client is
having an adverse reaction to the cooling.
D. Shivering
6. A nurse is caring for a client who has deep-vein thrombosis of the left lower
extremity which of the following actions should the nurse take? (Click on the
“Exhibit” button below for additional client information. There are three tabs that
contain separate categories of data.)
B. Withhold heparin IV infusion
[OR] C. Administer acetaminophen
7. A nurse is reviewing assessment data from several clients. For which of the
following clients should the nurse recommend referral to a dietitian.
B. A client who has a nonhealing leg ulcer
8. A nurse is providing discharge teaching to a client who has a chronic kidney
disease and is receiving hemodialysis. Which of the following instructions should the
nurse include in the teaching?
A. Eat 1 g/kg of protein per day
9. A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following places the client at risk for aspiration?
B. A history of gastroesophageal reflux disease
10. A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation.
The nurse should tell the client that she will undergo which of the following
screening tests at 16 weeks of gestation?
D. Maternal serum alpha-fetoprotein
11. A nurse is caring for a client who is on bed rest. The nurse should recognize that
which of the following findings is a complication of immobility?
C. Swollen area on calf
,12. A nurse in an acute care mental health facility is participating in a medical-
education group. The leader of the group uses a laissez-faire leadership style. Which
of the following actions should the nurse expect from the leader during the session?
C. The leader allows the group to discuss whatever they would like to
regarding their medications.
13. A nurse is providing teaching about digoxin administration to the parents of a
toddler who has heart failure. Which of the following statements should the nurse
include in the teaching?
D. “Have your child drink a small glass of water after swallowing the
medication.”
14. A nurse is providing teaching to a client who has a depressive disorder and a
new prescription for phenelzine. Which of the following foods should the nurse
instruct the client to avoid?
D. Smoked salmon
16. A nurse is planning care for a client who has bipolar disorder and is
experiencing mania. Which of the following interventions should the nurse include
in the plan?
C. Encourage the client to take frequent rest periods.
17. A parish nurse is leading a support group for clients whose family members have
committed suicide. Which of the following strategies should the nurse plan to use
during the group session?
A. Initiate a discussion with clients about ways to cope with changes in
family dynamics.
18. A nurse manager observes two staff nurses reviewing the computer records of a
client who is not under their care. Which of the following actions should the nurse
manager take first?
A. Instruct the nurses to close the client’s computer record.
19. A nurse is reviewing the medical record of a client who has schizophrenia and is
taking clozapine. Which of the following findings should the nurse identify as a
contraindication to the administration of clozapine?
D. WBC count 2,900/mm3
20. A nurse is caring for several clients on a medical-surgical unit. For which of the
following nursing activities is it required that the nurse use sterile gloves?
D. Performing tracheostomy care
21. A nurse is caring for a client who is at 11 weeks of gestation. Which of the
following immunizations should the nurse recommend?
A. Influenza
22. A nurse is inserting an indwelling urinary catheter for a male client. Which of the
following actions should the nurse take?
B. Lift the penis so that it is perpendicular to the client’s body.
23. A nurse is providing teaching to a client who is at 14 weeks of gestation about
findings to report to the provider. Which of the following findings should the nurse
include in the teaching?
C. Swelling of the face
,24. A nurse has received change-of-shift report for a group of clients. Which of the
following actions should the nurse take to manage time effectively?
A. Document client care at the end of shift.
B. Make a client to-do list for the day.
C. Skip breaks until client tasks are completed.
D. Focus on several client tasks at a time.
25. A nurse is developing a plan of care for a newborn whose mother tested positive
for heroin during pregnancy. The newborn is experiencing neonatal abstinence
syndrome. Which of the following actions should the nurse include in the plan?
A. Minimize the noise in the newborn’s environment.
B. Administer naloxone to the newborn.
C. Swaddle the newborn with his legs extended.
D. Maintain eye contact with the newborn during feedings.
26. A nurse is assessing the fontanels of an 8-month-old infant. Which of the
following findings should the nurse recognize as an expected finding?
A. The anterior fontanel is open
B. The posterior fontanel is open.
C. Both fontanels are the same size.
D. Both fontanels show molding.
27. A nurse is caring for a client who has acute diverticulitis. Which of the following
diets should the nurse recommend to the client?
A. High residue
B. Lactose-free
C. Gluten-free
D. Low-fiber
28. A nurse is caring for a client who is 48 hr postoperative following a total hip
arthroplasty. Which of the following actions should the nurse include in the plan of
care?
A. Administer low-dose heparin
B. Place the client on a full liquid diet.
C. Use an incentive spirometer ever 3 hr.
D. Maintain the client on bed rest.
29. A nurse is providing teaching to the parent of an infant who has a cleft lip palate.
Which of the following feeding techniques should the nurse include in the teaching?
A. Burp the infant frequently during feedings.
B. Position the nipple at the front of the infant’s mouth.
C. Hold the infant in a supine position.
D. Use feeding devices without nipples.
30. A nurse in an acute mental health care facility is prioritizing care for multiple
clients. Which of the following clients should the nurse see first?
, A. A client who has depressive disorder and requires assistance with ADL’s
B. A client who has obsessive-compulsive disorder and is upset about a
change in daily routine
C. A client who is taking clozapine to treat schizophrenia and reports a
sore throat
D. A client who has narcissistic personality disorder and is mocking others
during group therapy
31. A nurse is planning care for a group of clients and is working with one licensed
practical nurse (LPN) and one assistive personnel (AP). Which of the following
actions should the nurse take first to manage her time effectively?
A. Develop an hourly time frame for tasks.
B. Schedule daily activities.
C. Determine goals of the day.
D. Delegate tasks to the AP
32. A nurse is performing an admission assessment for a client who is in the manic
phase of bipolar disorder. Which of the following behaviors should the nurse expect?
A. Performance of ritualistic behaviors
B. Suspiciousness and distrust
C. Distractibility and poor judgment
D. Reports of physical discomfort
33. A nurse is caring for an infant who has coarctation of the aorta. Which of the
following should the nurse identify as an expected finding?
A. Weak femoral pulses
B. Frequent nosebleeds
C. Upper extremity hypotension
D. Increased intracranial pressure
34. A nurse is developing an in-service about personality disorders. Which of the
following information would the nurse include when discussing borderline
personality disorder?
A. “The client might act seductively.”
B. “The client is overly concerned about minor details.”
C. “The client exhibits impulsive behavior.”
D. “The client is exceptionally clingy to others.”
35. A nurse is assessing a client who has a chest tube with a water seal drainage
system. Upon assessment, the nurse notes tidaling in the water seal. Which of the
following is an explanation of tidaling?
A. There is a loop of tubing below the drainage system.
B. The system is working properly
C. The lung has re-expanded
D. The tubing is partially obstructed by clots
