2024/2025
A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin
via continuous IV infusion - CORRECT ANSWER Amount of vaginal bleeding
A nurse is providing discharge teaching to a new parent about car seat safety -
CORRECT ANSWER Secure the retainer clip at the level of your baby's armpits
A nurse received a request from a client to review the information in his medical record -
CORRECT ANSWER There is a protocol for reviewing your medical record, and I can
initiate the process
A nurse is planning care for a client who is receiving heparin to treat a DVT - CORRECT
ANSWER Elevate the affected leg
A nurse is teaching a client who has a new prescription for estradiol - CORRECT
ANSWER Headaches
A nurse is caring for a school-age child who is taking valproic acid - CORRECT
ANSWER Serum liver enzyme levels
A nurse is teaching a client who has a new prescription for digoxin about manifestations
of toxicity - CORRECT ANSWER Nausea
A nurse is teaching home wound care to the family of a child who has a large wound -
CORRECT ANSWER Double-bag soiled dressings in plastic bags for disposal
A client who has high blood pressure is having difficulty following their treatment plan -
CORRECT ANSWER Absence of symptoms
A nurse is proving teaching to a client who is scheduled for ECT - CORRECT ANSWER
Short term memory loss
A nurse is assessing a newborn following a vaginal delivery - CORRECT ANSWER
Nasal flaring
A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of
6/min and a blood pressure of 90/44 mmHg - CORRECT ANSWER Flumazenil
A nurse is assessing a client whose partner recently dies - CORRECT ANSWER You
seem to be having a difficult time right now
, A night shift nurse is giving change-of-shift report to the day shift nurse who is ready for
discharge - CORRECT ANSWER The client needs assistance when transferring from
the bed to a wheelchair
A nurse is caring for a client who has immunosuppression and a continuous IV infusion
- CORRECT ANSWER Monitor the client's mouth every 8 hr
A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and
an NG tube in place - CORRECT ANSWER Use 0.9% sodium chloride for irrigation of
the NG tube
A RN is planning care for a group of clients and is working with a LPN and an AP.
Delegate - CORRECT ANSWER Insertion of a nasogastric tube
The nurse is planning care for the client. Select the % actions the nurse should plan to
take. - CORRECT ANSWER CIWA
Seizure precautions
Chlordiazepoxide
Quiet environment
Thiamine
An RN is observing a LPN and an AP move a client up in bed. For which of the following
situations should the nurse intervene? - CORRECT ANSWER The LPN and the AP
grasp the client under their arms to lift him up in bed
A nurse is creating a plan of care for a client who has left-sided weakness following a
stroke. - CORRECT ANSWER Support the client's left arm on a pillow while sitting
A nurse is planning care for a client who has rheumatoid arthritis and has moderate to
severe pain in multiple joints. - CORRECT ANSWER Allow for frequent rest periods
throughout the day
A nurse is caring for a client who has bipolar disorder. The nurse observes that the
client is becoming increasingly restless and is pacing the unit, speaking rapidly -
CORRECT ANSWER Move the client to a quiet place away from others
A nurse is caring for a client who has a terminal illness and requests no lifesaving
measures is cardiac arrest occurs - CORRECT ANSWER I will provide you with
information about medical treatment to include in your living will
A nurse is assessing a 2-month-old infant during a well-baby examination. - CORRECT
ANSWER Stroke the infant's cheek
A nurse is assessing a client following a colonoscopy - CORRECT ANSWER Rapid
decrease in blood pressure