1. The nurse is caring for assigned clients. Which of the following actions is
appropriate for the nurse to take?
● having a client with pertussis wear a surgical mask during transport
● wearing a respirator mask when caring for a client who has impetigo
● initiating airborne precautions for a client who is diagnosed with epiglottis
● placing a client who had a stem cell transplant in contact isolation
2. The nurse is caring for a client who is currently prescribed bedrest. Which of the
following actions should the nurse take to help prevent the development of a pulmonary
embolus?
● instruct the client to perform leg exercises
● determine if the client is using the incentive spirometer correctly
● encourage the client to cough and deep breath
● elevate the clients legs on a pillow
3. The nurse is planning care for a client who has end-stage cirrhosis of the liver with
encephalopathy. Which of the following interventions should the nurse be prepared
to implement to decrease the clients ammonia level?
● restrict the clients intake of fluid
● administer prescribed vitamin K
● administer prescribed diuretics
● reduce the clients intake of protein
4. The nurse is caring for a client who is suspected of having bacterial meningitis. Which
of the following actions is a priority for the nurse to take?
● initiate droplet precautions
● prepare the client for a lumbar puncture
● administer intravenous antibiotics
● obtain a set of blood cultures
5. The nurses talking with the parent of a three-year-old child who states, “I am
concerned that my child is in constant motion and is unable to sit long enough to
listen to a story. I am wondering if my child may be hyperactive?“ Which of the
following responses is most appropriate for the nurse to make?
● “at three years of age, it is hard to tell“
● “I am not seeing any signs of hyperactivity“
● “describe when and where this occurs“
● “It is normal for parents to worry about hyperactivity in their children”
6. The nurse has provided dietary teaching to a client who has a history of other
sclerosis and a recent laboratory test indicating an increased cholesterol level. Which of
the following statements by the client indicates a need for follow up?
● “I flavor my fish with lemon juice”
● “I take omega-3 supplements daily“
● “I cook my food with canola oil“
● “I eat two poached eggs for breakfast every morning“
7. The nurse working on a medical surgical unit is delegating tasks to unlicensed
assistive personnel. Which of the following tasks would require follow up by the charge
nurse?
, ● assisting a client who had a total hip arthroplasty to transfer from the bed to
the chair for the second time since surgery
● assisting a client who had a paracentesis two hours ago to get out of bed
for the first time
● providing catheter care to a client who has a catheter associated urinary tract
infection
● taking the vital signs of a client who returned from the post anesthesia
care unit four hours ago and is reporting pain rated eight on a scale of 0-
10
8. The nurse is caring for a client who has sustained severe burn injuries to the entire
right and left legs, and the entire rear torso. Based on the rule of nines, the nurse
calculates the estimated percentage of the burned body surface area as
● 27%
● 45%
● 54%
● 36%
9. The nurse is talking with a newly hired nurse about peritoneal dialysis and how to
recognize peritonitis. Which signs and symptoms should the nurse include in the
discussion?
1. Fever
2. Rebound abdominal tenderness
3. Amber colored urine
4. Nausea and vomiting
5. Cloudy or opaque outflow
6. Diarrhea
● 1,2,4,5
● 2,3,5,6
● 1,4,6
● 4,5,6
10. The nurse is observing the closed chest drainage system of a client who had
a thoracotomy 24 hours ago. The nurse notes a slow steady bubbling in the
suction control chamber. Which of the following actions should the nurse take?
● reinforce the dressing at the insertion site
● check the amount of suction on the control gauge
● continue to monitor respiratory status
● assess the tubing connections for any air leaks
11. The nurse is preparing to administer prescribed medications to the following
clients. The nurse should question the prescription for the client who is receiving the
● alpha blocker, terazosin, and is reporting a headache
● thiazide diuretic, hydrochlorothiazide, and is reporting light cramps
● calcium channel blocker, diltiazem, and has 1+ non pitting edema
● angiotensin receptor blocker, losartan, and has a blood pressure of 168/94
12. The primary healthcare provider has prescribed ampicillin 150 mg PO TID to a
toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5mL.
Which action should the nurse take?
● administer 3mL by mouth three times a day
appropriate for the nurse to take?
● having a client with pertussis wear a surgical mask during transport
● wearing a respirator mask when caring for a client who has impetigo
● initiating airborne precautions for a client who is diagnosed with epiglottis
● placing a client who had a stem cell transplant in contact isolation
2. The nurse is caring for a client who is currently prescribed bedrest. Which of the
following actions should the nurse take to help prevent the development of a pulmonary
embolus?
● instruct the client to perform leg exercises
● determine if the client is using the incentive spirometer correctly
● encourage the client to cough and deep breath
● elevate the clients legs on a pillow
3. The nurse is planning care for a client who has end-stage cirrhosis of the liver with
encephalopathy. Which of the following interventions should the nurse be prepared
to implement to decrease the clients ammonia level?
● restrict the clients intake of fluid
● administer prescribed vitamin K
● administer prescribed diuretics
● reduce the clients intake of protein
4. The nurse is caring for a client who is suspected of having bacterial meningitis. Which
of the following actions is a priority for the nurse to take?
● initiate droplet precautions
● prepare the client for a lumbar puncture
● administer intravenous antibiotics
● obtain a set of blood cultures
5. The nurses talking with the parent of a three-year-old child who states, “I am
concerned that my child is in constant motion and is unable to sit long enough to
listen to a story. I am wondering if my child may be hyperactive?“ Which of the
following responses is most appropriate for the nurse to make?
● “at three years of age, it is hard to tell“
● “I am not seeing any signs of hyperactivity“
● “describe when and where this occurs“
● “It is normal for parents to worry about hyperactivity in their children”
6. The nurse has provided dietary teaching to a client who has a history of other
sclerosis and a recent laboratory test indicating an increased cholesterol level. Which of
the following statements by the client indicates a need for follow up?
● “I flavor my fish with lemon juice”
● “I take omega-3 supplements daily“
● “I cook my food with canola oil“
● “I eat two poached eggs for breakfast every morning“
7. The nurse working on a medical surgical unit is delegating tasks to unlicensed
assistive personnel. Which of the following tasks would require follow up by the charge
nurse?
, ● assisting a client who had a total hip arthroplasty to transfer from the bed to
the chair for the second time since surgery
● assisting a client who had a paracentesis two hours ago to get out of bed
for the first time
● providing catheter care to a client who has a catheter associated urinary tract
infection
● taking the vital signs of a client who returned from the post anesthesia
care unit four hours ago and is reporting pain rated eight on a scale of 0-
10
8. The nurse is caring for a client who has sustained severe burn injuries to the entire
right and left legs, and the entire rear torso. Based on the rule of nines, the nurse
calculates the estimated percentage of the burned body surface area as
● 27%
● 45%
● 54%
● 36%
9. The nurse is talking with a newly hired nurse about peritoneal dialysis and how to
recognize peritonitis. Which signs and symptoms should the nurse include in the
discussion?
1. Fever
2. Rebound abdominal tenderness
3. Amber colored urine
4. Nausea and vomiting
5. Cloudy or opaque outflow
6. Diarrhea
● 1,2,4,5
● 2,3,5,6
● 1,4,6
● 4,5,6
10. The nurse is observing the closed chest drainage system of a client who had
a thoracotomy 24 hours ago. The nurse notes a slow steady bubbling in the
suction control chamber. Which of the following actions should the nurse take?
● reinforce the dressing at the insertion site
● check the amount of suction on the control gauge
● continue to monitor respiratory status
● assess the tubing connections for any air leaks
11. The nurse is preparing to administer prescribed medications to the following
clients. The nurse should question the prescription for the client who is receiving the
● alpha blocker, terazosin, and is reporting a headache
● thiazide diuretic, hydrochlorothiazide, and is reporting light cramps
● calcium channel blocker, diltiazem, and has 1+ non pitting edema
● angiotensin receptor blocker, losartan, and has a blood pressure of 168/94
12. The primary healthcare provider has prescribed ampicillin 150 mg PO TID to a
toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5mL.
Which action should the nurse take?
● administer 3mL by mouth three times a day
