1. A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the
nurse expect?
A: Weight gain
B: Enlarged liver
C: Distended abdomen
D: Cool extremities
2. A Nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following Manifestations Should
the nurse expect?
A: Protruding tongue
B: Facial flushing
C: Nasal flaring
D: Tympany with chest percussion
3. A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma
exacerbation. Which of the following actions should the nurse take first?
A: Encourage the child to take frequent sips of cool fluids.
B: Apply humidified oxygen with a simple mask.
C: Start a peripheral access IV.
D: Administer an albuterol nebulizer treatment
4. A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client
statements indicates an understanding of the teaching?
A: "I'll wash my feet every day with soap and lukewarm water."
B: "I'll apply lotion to my feet daily, especially in between my toes."
C: "It's okay for me to go barefoot in the house, but not outside."
D: "I'll soak my feet every evening before bedtime."
5. A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings
should the nurse identify as a risk factor for the development of pyelonephritis?
A: Diabetes mellitus
B: Radical prostatectomy 2 years ago
C: Cholelithiasis
D: Taking permethrin to treat pediculosis capitis
,6. A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect?
(Select all that apply.)
A: Fever
B: Dyspepsia
C: Pain radiating to the left shoulder
D: Blood-tinged stools
E: Eructation
7. A nurse is an emergency department is caring for a client who has appendicitis. Which of the following actions should
the nurse take?
A: Restrict oral intake to clear fluids.
B: Place a heating pad on the client's abdomen.
C: Place the client in semi-Fowler's position.
D: Administer an enema.
8. A nurse is planning care for a client following collection of admission data. Which of the following findings should the
nurse identify as the priority client need?
A: The client requests to see a priest for spiritual guidance.
B: The client reports coughing and a change of voice whenever he eats.
C: The client reports pain immediately following physical therapy.
D: The client is worried about financially supporting his family because of his illness.
9. A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions
should the nurse take first?
A: Place the client on mechanical ventilation.
B: Apply oxygen using a rebreather oxygen mask.
C: Ensure a patent airway using a chin-lift maneuver.
D: Administer a reversal agent to the client.
10. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for
developing respiratory acidosis?
A: A client who has a fever
B: A client who has abdominal ascites
C: A client who is anxious
D: A client who is receiving nasogastric suctioning
, 11. A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following
statements should the nurse make?
A: "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby."
B: "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light."
C: "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet."
D: "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."
12. A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle
changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has
achieved a therapeutic response?
A: LDL 168 mg/dL
B: HDL 50 mg/dL
C: Total cholesterol 268 mg/dL
D: Triglycerides 250 mg/dL
13. A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription
for an epinephrine auto-injector. Which of the following instructions should the nurse include?
A: "Administer the medication into your child's abdomen."
B: "Expect your child to sleep for several hours after receiving the medication."
C: "Place your child's unused extra syringes in the refrigerator for storage."
D: "Give a second injection if the first fails to reverse your child's symptoms."
14. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A: Distract the client by having him complete a puzzle.
B: Encourage the client to take a deep breath every 2 seconds.
C: Administer methylphenidate to the client.
D: Stay with the client until manifestations subside.
15. A nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes
mellitus. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the
order of performance. Use all Steps.)
A: Withdraw the prescribed volume of insulin aspart into the syringe.
B: Inject air into the vial equal to the amount of NPH insulin prescribed.
C: Withdraw the prescribed volume of NPH insulin into the syringe.
D: Inject air into the vial equal to the amount of insulin aspart prescribed
16. A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to
consume 3 mL of oral rehydration solution every 5 minutes but still has emesis and diarrhea. Which if the following
nurse expect?
A: Weight gain
B: Enlarged liver
C: Distended abdomen
D: Cool extremities
2. A Nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following Manifestations Should
the nurse expect?
A: Protruding tongue
B: Facial flushing
C: Nasal flaring
D: Tympany with chest percussion
3. A nurse is caring for a school-age child who was admitted to the emergency department for acute asthma
exacerbation. Which of the following actions should the nurse take first?
A: Encourage the child to take frequent sips of cool fluids.
B: Apply humidified oxygen with a simple mask.
C: Start a peripheral access IV.
D: Administer an albuterol nebulizer treatment
4. A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client
statements indicates an understanding of the teaching?
A: "I'll wash my feet every day with soap and lukewarm water."
B: "I'll apply lotion to my feet daily, especially in between my toes."
C: "It's okay for me to go barefoot in the house, but not outside."
D: "I'll soak my feet every evening before bedtime."
5. A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings
should the nurse identify as a risk factor for the development of pyelonephritis?
A: Diabetes mellitus
B: Radical prostatectomy 2 years ago
C: Cholelithiasis
D: Taking permethrin to treat pediculosis capitis
,6. A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect?
(Select all that apply.)
A: Fever
B: Dyspepsia
C: Pain radiating to the left shoulder
D: Blood-tinged stools
E: Eructation
7. A nurse is an emergency department is caring for a client who has appendicitis. Which of the following actions should
the nurse take?
A: Restrict oral intake to clear fluids.
B: Place a heating pad on the client's abdomen.
C: Place the client in semi-Fowler's position.
D: Administer an enema.
8. A nurse is planning care for a client following collection of admission data. Which of the following findings should the
nurse identify as the priority client need?
A: The client requests to see a priest for spiritual guidance.
B: The client reports coughing and a change of voice whenever he eats.
C: The client reports pain immediately following physical therapy.
D: The client is worried about financially supporting his family because of his illness.
9. A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions
should the nurse take first?
A: Place the client on mechanical ventilation.
B: Apply oxygen using a rebreather oxygen mask.
C: Ensure a patent airway using a chin-lift maneuver.
D: Administer a reversal agent to the client.
10. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for
developing respiratory acidosis?
A: A client who has a fever
B: A client who has abdominal ascites
C: A client who is anxious
D: A client who is receiving nasogastric suctioning
, 11. A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following
statements should the nurse make?
A: "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby."
B: "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light."
C: "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet."
D: "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."
12. A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle
changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has
achieved a therapeutic response?
A: LDL 168 mg/dL
B: HDL 50 mg/dL
C: Total cholesterol 268 mg/dL
D: Triglycerides 250 mg/dL
13. A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription
for an epinephrine auto-injector. Which of the following instructions should the nurse include?
A: "Administer the medication into your child's abdomen."
B: "Expect your child to sleep for several hours after receiving the medication."
C: "Place your child's unused extra syringes in the refrigerator for storage."
D: "Give a second injection if the first fails to reverse your child's symptoms."
14. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A: Distract the client by having him complete a puzzle.
B: Encourage the client to take a deep breath every 2 seconds.
C: Administer methylphenidate to the client.
D: Stay with the client until manifestations subside.
15. A nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes
mellitus. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the
order of performance. Use all Steps.)
A: Withdraw the prescribed volume of insulin aspart into the syringe.
B: Inject air into the vial equal to the amount of NPH insulin prescribed.
C: Withdraw the prescribed volume of NPH insulin into the syringe.
D: Inject air into the vial equal to the amount of insulin aspart prescribed
16. A nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to
consume 3 mL of oral rehydration solution every 5 minutes but still has emesis and diarrhea. Which if the following
