1. A nurse in a pediatric unit is preparing to insert an IV catheterfor 7-year-old.
Which of the following actions should the nurse take?
1. Tell the child they will feel discomfort during the catheter insertion.
2. A nurse is caring for a client who has arteriovenous fistulaWhich of
the following findings should the nurse report?
Absence of a bruit.
3. A nurse is providing discharge teaching for a client who has animplantable
cardioverter defibrillator which of the following statements demonstrates
understanding of the teaching?
1. “I will wear loose clothing around my ICD”
4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings
of ambivalence about being pregnant. Which of thefollowing responses should
the nurse make?
1. “Describe your feelings to me about being pregnant”
5. A nurse is planning care for a client who has a prescription fora bowel-
training program following a spinal cord injury. Whichof the following
actions should the nurse include in the plan of care?
1. Administer a rectal suppository 30 minutes prior to scheduled
defecation times.
6. A nurse is caring for a client who is in active labor and requests pain
management. Which of the following actions should the nursetake?
1. Place the client in a warm shower.
,7. a nurse in an emergency department is performing triage for multiple clients
following a disaster in the community. To which ofthe following types of
injuries should the nurse assign the highest priority?
1. Below-the knee amputation
8. a nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurseinclude?
1. Document the client’s condition every 15 min
9. A nurse is teaching an in-service about nursing leadership. Whichof the
following information should the nurse include about an effective leader?
1. Acts as an advocate for the nursing unit.
10. A nurse is reviewing the laboratory findings of a client who has diabetes
mellitus and reports that she has been following her (unable to read) care. The
nurse should identify which of the following findings indicates a need to revise the
client’s plan of care.
1. Hba1c 10 %
11. A nurse in a provider’s office is reviewing the laboratory resultsof a group of
clients. The nurse should identify that which of the following sexually
transmitted infections is a nationally notifiable infectious disease that should be
reported to the state health department?
1. Chlamydia
12. A nurse is teaching a newly licensed nurse about therapeutic techniques to use
when leading a group on a mental health unit. Which of the following group
facilitation techniques should the nurse include in the teaching?
, 1. Use modeling to help the clients improve their interpersonal skills
13. A nurse is planning for a client who practices Orthodox Judaism.The client tells
the nurse that (Unable to read) Passover holiday. Which of the following action
should the nurse include in the plan ofcare?
1. Provide unleavened bread.
14. A nurse is caring for a client who has a pulmonary embolism.The nurse
should identify the effectiveness of the treatment
1. The client reports feeling less anxious.
15. A nurse in an emergency department is assessing a client who reports
ingesting thirty diazepam tablets (Unable to read) a respiratory rate of 10/min.
After securing the client’s airway and initiating an IV, which of the following
actions should the nurse donext.
1. Administer flumazenil to the client.
16. A nurse in an emergency department is caring for a client whoreports
cocaine use 1hr ago. Which of the following findings should the nurse expect?
1. Elevated temperature
17. A nurse is assessing a newborn who has a blood glucose levelof 30
mg/dl. Which of the following manifestations should the nurse expect?
A. Jitteriness
18. A nurse in a pediatric clinic is reviewing the laboratory testresults of a
school age child. Which of the following findings should the nurse report
to the provider?
, 1. WBC 14,000/mm3
19. A charge nurse is teaching a newly licensed nurse about clients designating a
health care proxy in situations that require a durablepower of attorney for heal
care (DPSHC). Which of the following information should the charge nurse
include?
1. “The proxy can make treatment decisions if the client is under
anesthesia.”
20. A nurse in the PACU is caring for a client who reports nausea.Which of the
following actions should the nurse take first?
1. Turn the client on their side.
21. A nurse is caring for a client who has a history of depression andis
experiencing a situational crisis. Which of the following actions should the nurse
take first?
1. Confirm the client’s perception of the event
22. A nurse is caring for a client who has bipolar disorder and isexperiencing
acute mania. The nurse obtained a verbal prescription for restraints. Which
of the following should the actions should the nurse take?
1. Document the client’s condition every 15 minutes.
23. A nurse is working on a surgical unit is developing a care planfor a
client who has paraplegia. The client has an area of nonblanchable
erythema over his ischium. Which of the following interventions should
the nurse include in the care plan?
1. Place the client upright on a donut-shaped cushion