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1. A nurse is planning care for a child who has increased intracranial pressure with a
decrease in level of consciousness. Which of the following interventions should the
nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs - ANSWER-Maintain the head at a
midline position
2. A nurse notices smoke coming from a client's room and discovers a fire in the
wastebasket. After moving the client to safety, which of the followings is the priority
action?
A. Notify the facility operator
B. Close the fire doors on the unit
C. Turn off oxygen sources
D. Put out the fire with the appropriate extinguisher - ANSWER-Close the fire doors
on the unit
3. A nurse is talking with an adult child of a client who was involuntarily admitted to an
inpatient mental health facility. Which of the following statements should the nurse
make?
A. The provider will notify your patient's employer about admission to the facility
B. Your parent will have to take the medication that the doctor prescribes
C. Your parent might have electroconvulsive therapy without providing consent
D. The provider can prescribe restraints if your parent tries to harm others -
ANSWER-The provider can prescribe restraints if your parent tries to harm others
,4. A nurse is assessing a client who has delirium due to a febrile illness. Which of the
following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia - ANSWER-Hallucinations
5. A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The
nurse should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses - ANSWER-Bounding pulses
6. A nurse is caring for a client following an open colectomy. Which of the following
findings places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pai - ANSWER-Hyperemesis
7. A nurse is assessing a client who has a complete heart block and is receiving
transcutaneous pacing. Which of the following findings indicates to the nurse that the
treatment is effective?
A. Heart rate greater than 60/min
B. Pedal pulses 2+
C. Pacer spikes after the QRS complex
D. Distended jugular vein - ANSWER-Heart rate greater than 60/min
8. A nurse is caring for a client who is taking levothyroxine. Which of the following findings
should indicate to the nurse that the medication is effective?
A. Decreased blood pressure
, B. Weight loss
C. Decreased inflammation
D. Absence of seizures - ANSWER-Weight loss
9. A nurse at the family planning clinic triages several client over the phone. Which of the
following clients should the nurse instruct to come to the clinic?
A. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6
months dieting
B. A client who had an intrauterine device inserted yesterday and has cramping and
bleeding
C. A client who has started taking oral contraceptives and is experiencing bright red
vaginal breakthrough bleeding
D. A client who has sharp pain in her shoulder following a laparoscopic tubal
ligation yesterday - ANSWER-A client who has sharp pain in her shoulder
following a laparoscopic tubal ligation yesterday
10. A home health nurse is reviewing treatment goals with a client who has diabetes
mellitus. The nurse should evaluate which of the following laboratory tests to determine
effective long-term management of blood glucose levels?
A. 3-hr oral glucose tolerance test
B. HbA1c
C. Fasting blood glucose test
D. Urinalysis for ketone - ANSWER-HbA1c
11. A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client?
A. Wear an N95 respirator
B. Insert an indwelling urinary catheter to monitor urinary output
C. Monitor the client's vital signs every 8 hr
D. Use a dedicated stethoscope - ANSWER-Use a dedicated stethoscope
12. A nurse is planning care for a client who has a gambling disorder. Which of the following
instructions should the nurse provide to the client?
A. Participate in a 12-step program
, B. Plan to take clozapine for the next 6 months
C. Use systematic desensitization to decrease gambling behaviors
D. Learn to use projection to adapt to stressful experiences - ANSWER-Participate in
a 12-step program
13. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the
following actions should the nurse take?
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
B. Tell the client to avoid drinking fluids 1 hr before bedtime
C. Schedule routine care tasks during hours when the client is awake
D. Advise the client to leave the television in the room on when trying to fall asleep
- ANSWER-Tell the client to avoid drinking fluids 1 hr before bedtime
14. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive
phototherapy. Which of the following interventions should the nurse include?
A. Clothe the newborn in light cotton
B. Check the newborn's temperature every 8 hrs.
C. Administer 120 mL of water between feedings
D. Place the newborn 45 cm from the light source - ANSWER-Place the newborn 45
cm from the light source
15. A client who has a diagnosis of complete placenta previa is admitted to the labor and
delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in
duration. Which of the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam - ANSWER-Prepare the client for a cesarean section
16. A nurse enters a client's room and finds the client lying on the floor in a puddle of water.
Which of the following statements should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed down
B. Client's roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries