RN QUESTIONS WITH ANSWERS -MID
TERM
• an adult male who fell 20 feet from the roof of this home has multiple injuries, including a
right pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright
red blood is measured in the collection chamber. Which intervention should the nurse
implement?
• Add sterile water to the suction control chamber.
• Give blood from the collection chamber as autotransfusion
• Manipulate blood in tubing to drain into chamber.
• Increase wall suction to eliminate fluctuation in water seal.
• A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room
air of 89%. Which action should the nurse take first?
• Elevate the foot of the bed.
• Restrict the client’s
fluid. c. Begin
supplemental oxygen.
d. Prepare the client for hemodialysis.
• A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client’s admitting diagnosis, which findings require immediate action by the
nurse?
(Select all that apply)
• Headache and tremors
• Irregular heart rate
• Skin hyperpigmentation
• Postural hypotension
• Pallor and diaphoresis
• An older client is admitted with fluid volume deficit and dehydration. Which assessment
finding is the best indicator of hydration that the nurse should report to the healthcare
, provider?
• Urine specific gravity is 1.040
• Systolic blood pressure decreases 10 points when standing.
• The client denies being thirsty.
• Skin tenting occurs when the client’s forearm is pinched.
• After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed copies
of client information in a uniform pocket. Which action should the nurse take?
• File a detailed incident report with the specific hiring facility.
• Warn the colleague that their actions are unprofessional.
• Comment anonymously about the action of a staff discussion board.
• Communicate the colleague’s actions to the unit charge nurse.
• The nurse is evaluating a tertiary prevention program for clients with cardiovascular
disease implemented in a rural health clinic. Which outcome indicate the program is
effective?
• At-risk clients received an increased number of routine health screenings.
• Clients reported having new confidence in making healthy food choices.
• Clients who incurred disease complications promptly received rehabilitation.
• Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
• The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the
client is having increased shortness of breath with respirations at 23 breaths/minute.
Which action should the nurse implement first?
• Determine if the client is experiencing any anxiety.
• Auscultate the client’s bilateral lung sounds and oxygen saturation.
• Notify the healthcare provider about the client’s distress.
• Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
• Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
an immediate investigation by the nurse?
• “When I get out of bed quickly, I feel a little dizzy.”
• “The dressing over my incision feels like it is too tight.”
• “I’m most comfortable when the head of the bed is raised.”
• “This IV infusion makes me urinate more often than usual.”
,• An older adult male who is in his early 70’s is admitted to the emergency department because
of a COPD exacerbation. This client is struggling to breathe and the healthcare team is
preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the
client, asks the nurse to stop the procedure and provide the nurse a copy of the client’s living
will. Which action should the nurse take?
• Facilitate a family meeting with the palliative care
team. b. Notify the healthcare provider of the client’s
wishes.
• Place a certified copy of the living will in the client’s record.
• Alert the nursing staff of the client’s don’t resuscitate status.
• An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that
the client is so obese that the UAP feels unable to safely assist the client in transferring from
the bed to the bedside commode. How should the nurse respond?
• Determine the client’s level of mobility and need for assistance.
• Instruct the UAP that all clients deserve equal care.
• Advice the client to maintain bedrest so that safety can be ensured.
• Assign another UAP to care for the client.
• A nurse determines that more than 25% of the students at a middle school are overweight.
The nurse presents the information at the parent-teacher meeting. What action is most
important for the nurse to include in the meeting?
• Provide information on ways to increase activity for the family.
• Have several teachers talk about health risks associated with
obesity. c. Distribute a shopping list of suggested healthy snack
items.
d. Determine the parents’ degree of concern about their children’s weight.
• After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone.
Which education should the nurse provide the client with regard to taking prednisone?
• Take prednisone doses before meals on an empty stomach.
• Wear sunglasses when exposed to bright sunlight.
• If sequential doses are missed, notify the healthcare provider.
• Schedule a monthly laboratory visit for a complete blood count.
, • The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse’s immediate attention?
• A 16-year-old client diagnosed with major depression who refuses to participate in
group.
• A 14-year-old client with anorexia nervosa who is refusing to eat the evening
snack. c. An 18-year-old client with antisocial behavior who is being yelled at by
other clients
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
• The nurse caring for a child with mononucleosis can expect the child to exhibit which
symptoms?
• Positive Epstein-Barr, and
malaise. b. Ear pain and fever.
• Elevated WBC and sedimentation rate.
• Increased BUN and serum creatinine.
• A client arrives for an annual physical exam and complains of having calf pain. The client’s
health history reveals peripheral atrial disease. Which question should the nurse ask the client
about expected finding related to chronic arterial symptoms?
• Were your legs ever suddenly swollen, red, warm, and
painful? b. Does the calf pain occur when walking short
distances?
• Did you receive treatment for weeping ulcers on lower legs?
• Have you experienced ankle edema and varicose veins?
• The nurse is preparing to send a client to the cardiac catheterization lab for an
angioplasty. Which client report is most important for them to explore further prior to
the start of the procedure?
• Drank a glass of water in the past 2 hours.
• Reports left chest wall pain prior to admission.
• Verbalize a fear of being in a confined
space. d. Experience facial swelling after
eating crab.
• The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the
mother reports that the child frequently scratches the lesions on the skin to the point of
causing bleeding. Which guideline is indicated for care of this child?
• Keep the nails trimmed short.
• Apply baby lotion to the skin twice daily.
• Bathe the child daily with bath oil.
• Allow the child to wear only 100% cotton clothing.
TERM
• an adult male who fell 20 feet from the roof of this home has multiple injuries, including a
right pneumothorax. Chest tubes were inserted in the emergency department prior to his
transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is
bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright
red blood is measured in the collection chamber. Which intervention should the nurse
implement?
• Add sterile water to the suction control chamber.
• Give blood from the collection chamber as autotransfusion
• Manipulate blood in tubing to drain into chamber.
• Increase wall suction to eliminate fluctuation in water seal.
• A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100
mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is
manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room
air of 89%. Which action should the nurse take first?
• Elevate the foot of the bed.
• Restrict the client’s
fluid. c. Begin
supplemental oxygen.
d. Prepare the client for hemodialysis.
• A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation.
Based on the client’s admitting diagnosis, which findings require immediate action by the
nurse?
(Select all that apply)
• Headache and tremors
• Irregular heart rate
• Skin hyperpigmentation
• Postural hypotension
• Pallor and diaphoresis
• An older client is admitted with fluid volume deficit and dehydration. Which assessment
finding is the best indicator of hydration that the nurse should report to the healthcare
, provider?
• Urine specific gravity is 1.040
• Systolic blood pressure decreases 10 points when standing.
• The client denies being thirsty.
• Skin tenting occurs when the client’s forearm is pinched.
• After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed copies
of client information in a uniform pocket. Which action should the nurse take?
• File a detailed incident report with the specific hiring facility.
• Warn the colleague that their actions are unprofessional.
• Comment anonymously about the action of a staff discussion board.
• Communicate the colleague’s actions to the unit charge nurse.
• The nurse is evaluating a tertiary prevention program for clients with cardiovascular
disease implemented in a rural health clinic. Which outcome indicate the program is
effective?
• At-risk clients received an increased number of routine health screenings.
• Clients reported having new confidence in making healthy food choices.
• Clients who incurred disease complications promptly received rehabilitation.
• Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
• The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the
client is having increased shortness of breath with respirations at 23 breaths/minute.
Which action should the nurse implement first?
• Determine if the client is experiencing any anxiety.
• Auscultate the client’s bilateral lung sounds and oxygen saturation.
• Notify the healthcare provider about the client’s distress.
• Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
• Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
an immediate investigation by the nurse?
• “When I get out of bed quickly, I feel a little dizzy.”
• “The dressing over my incision feels like it is too tight.”
• “I’m most comfortable when the head of the bed is raised.”
• “This IV infusion makes me urinate more often than usual.”
,• An older adult male who is in his early 70’s is admitted to the emergency department because
of a COPD exacerbation. This client is struggling to breathe and the healthcare team is
preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the
client, asks the nurse to stop the procedure and provide the nurse a copy of the client’s living
will. Which action should the nurse take?
• Facilitate a family meeting with the palliative care
team. b. Notify the healthcare provider of the client’s
wishes.
• Place a certified copy of the living will in the client’s record.
• Alert the nursing staff of the client’s don’t resuscitate status.
• An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose
prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that
the client is so obese that the UAP feels unable to safely assist the client in transferring from
the bed to the bedside commode. How should the nurse respond?
• Determine the client’s level of mobility and need for assistance.
• Instruct the UAP that all clients deserve equal care.
• Advice the client to maintain bedrest so that safety can be ensured.
• Assign another UAP to care for the client.
• A nurse determines that more than 25% of the students at a middle school are overweight.
The nurse presents the information at the parent-teacher meeting. What action is most
important for the nurse to include in the meeting?
• Provide information on ways to increase activity for the family.
• Have several teachers talk about health risks associated with
obesity. c. Distribute a shopping list of suggested healthy snack
items.
d. Determine the parents’ degree of concern about their children’s weight.
• After several months of chronic fatigue, morning stiffness, and join pain, a young adult is
diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone.
Which education should the nurse provide the client with regard to taking prednisone?
• Take prednisone doses before meals on an empty stomach.
• Wear sunglasses when exposed to bright sunlight.
• If sequential doses are missed, notify the healthcare provider.
• Schedule a monthly laboratory visit for a complete blood count.
, • The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the
nurse’s immediate attention?
• A 16-year-old client diagnosed with major depression who refuses to participate in
group.
• A 14-year-old client with anorexia nervosa who is refusing to eat the evening
snack. c. An 18-year-old client with antisocial behavior who is being yelled at by
other clients
d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
• The nurse caring for a child with mononucleosis can expect the child to exhibit which
symptoms?
• Positive Epstein-Barr, and
malaise. b. Ear pain and fever.
• Elevated WBC and sedimentation rate.
• Increased BUN and serum creatinine.
• A client arrives for an annual physical exam and complains of having calf pain. The client’s
health history reveals peripheral atrial disease. Which question should the nurse ask the client
about expected finding related to chronic arterial symptoms?
• Were your legs ever suddenly swollen, red, warm, and
painful? b. Does the calf pain occur when walking short
distances?
• Did you receive treatment for weeping ulcers on lower legs?
• Have you experienced ankle edema and varicose veins?
• The nurse is preparing to send a client to the cardiac catheterization lab for an
angioplasty. Which client report is most important for them to explore further prior to
the start of the procedure?
• Drank a glass of water in the past 2 hours.
• Reports left chest wall pain prior to admission.
• Verbalize a fear of being in a confined
space. d. Experience facial swelling after
eating crab.
• The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the
mother reports that the child frequently scratches the lesions on the skin to the point of
causing bleeding. Which guideline is indicated for care of this child?
• Keep the nails trimmed short.
• Apply baby lotion to the skin twice daily.
• Bathe the child daily with bath oil.
• Allow the child to wear only 100% cotton clothing.
