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1. A nurse is assessing a client who has received an antibiotic. The nurse should identify
which of thefollowing findings as an indication of a possible allergic reaction to the
medication?
A. Bradycardia
B. Headache
C. Joint pain
D. Hypotension
2. A nurse on a mental health unit is caring for a client who has schizophrenia and is
experiencingauditory hallucinations telling them to hurt others. The client is refusing to
take anti-psychoticmedication. Which of the following responses should the nurse
make?
A. “You should plan to take this medication for a few weeks.”
B. “You will regret it if you do not take this medication.”
C. “This medication will help you respond to the voices.
D. “This medication will help you stop the voices you are hearing.”
3. A nurse is providing care for a patient who has depression and is to have electroconvulsive
therapy.Which of the following conditions should the nurse identify as increasing the
client’s risk for complications?
A. Hyperthyroidism
B. Renal calculi
C. Diabetes mellitus
D. Cardiac dysrhythmias
4. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis.
Which of thefollowing findings should the nurse report to the provider?
A. WBC count 8,000/mm
B. Platelets 150,000/mm
C. Aspartate aminotransferase 10
units/LD. Erythrocyte sedimentation
75 mm/hr
5. A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an
endotracheal tube. Which of the following findings should the nurse identify as an
indication thatsuctioning has been effective?
A. Presence of a productive cough
B. Decreased peak inspiratory pressure
,C. Thinning of mucous secretions
D. Flattening of the artificial airway cuff
,6. A nurse is caring for a client who is in a seclusion room following violent behavior.
The client continues to display aggressive behavior. Which of the following actions
should the nurse take?
A. Stand within 30cm (1 ft) of the client when speaking with them.
B. Express sympathy for the client’s situation.
C. Confront the client about his
behavior.D. Speak assertively to the
client.
7. A nurse is caring for a client who is immediately postoperative following an adrenalectomy
to treatCushing’s disease. Which of the following actions is the nurse’s priority?
A. Reposition the client for comfort every 2 hours
B. Observe for any indications of infection
C. Document amount and color of the incisional
drainage.D. Monitor the client’s fluid and electrolyte
status.
8. A nurse is caring for a client who is scheduled for a surgical procedure and states, “I don’t
want tohave this surgery anymore.” Which of the following responses should the nurse
make?
A. “We can manage your care following the procedure without
complications.”B. “You have the right to refuse the procedure.”
C. “Your doctor thinks the surgery is necessary.”
D. “Let me review the procedure so you can understand what is going to happen.”
9. A nurse is evaluating a client who has borderline personality disorder. Which of the
followingbehaviors indicates an improvement in the client’s condition?
A. Impulsive behaviors
B. Decreased clinging behavior
C. Liability of mood
D. Dependent behavior
10. A nurse is teaching a group of school-age children about healthy snack options.
Which of thefollowing snacks should the nurse include?
A. Air-popped popcorn
B. Milkshake made with whole milk.
C. Baked potato chips
D. Cheesecake
11. A nurse is providing teaching to a client who has a new prescription for enoxaparin.
Which of thefollowing medications for pain relief should the nurse include in the
teaching that can be taken concurrently with enoxaparin?
A. Naproxen sodium
, B. Ibuprofen
C. Acetaminophen
D. Aspirin
12. A nurse is caring for a client who has fibromyalgia and requests pain medication.
Which of thefollowing medications should the nurse plan to administer?
A. Colchicine
B. Lorazepa
mC.
Pregabalin
D. Codeine
13. A nurse is caring for a client who has congestive heart failure and is receiving
furosemide and digoxin. Which of the following laboratory values indicates that the client
is at risk for developingdigoxin toxicity?
A. Glucose 150 mg/dL
B. Magnesium 1.3
mEq/LC. Potassium 3.1
mEq/L
D. Sodium 134 mEq/L
14. A nurse is caring for a client who had an embolic stroke and has a prescription for alteplase.
Which ofthe following in the client’s history should the nurse identify as a contraindication
for receiving alteplase?
A. Hip arthroplasty 1 week ago correct
B. Obstructive lungs disease
C. Retinal detachment
D. Acute kidney failure 6 months ago
15. A nurse is providing discharge teaching for a client who has a new implantable
cardioverter defibrillator (ICD). Which of the following client statements demonstrates
understanding of theteaching?
A. “I will soak in the tub rather than showering.”
B. “I can hold my cellphone on the same side of my body as the
ICD.”C. “I will wear loose clothing over my ICD.”
D. “I will avoid using my microwave oven at home because of my ICD.”
16. A nurse is assessing a client who is postoperative following abdominal surgery and has an
indwellingurinary catheter that is draining dark yellow urine at 25ml/hr. Which of the
following interventions should the nurse anticipate?