lOMoARcPSD|22830792
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1. A nurse is assessing a client who has left-sided heart failure. Which of the following will
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the nurse identify as the highest priority?
la
A. Jugular distention
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B. Frothy pink septum
sh
C. Hepatomegaly
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D. Weight gain
2.
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A nurse in the emergency department is assisting with the suturing of a laceration to the
la
client. Which of the following actions should the nurse take?
A. Pour the sterile cleansing solution holding on the bottle10 cm(4 in) above the sterile
sh
Sp
field
ne
B. Pull the top flap of the suture tray towards the body when opening
C. Place the bottle of local anesthetics 5 cm (2 in) inside the sterile field border.
la
D. Drop the suture package on the sterile field from a distance of 30 cm (12 in)
tz
sh
Sp
3. A nurse is assessing a client 1 hr following delivery and notes that her uterus is boggy and
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located near the umbilicus. Which of the following actions should the nurse take fisrt?
A. Massage the fundus
la
B. Assess lochia
sh
C. Take vital signs
Sp
D. Give oxytocin (Pitocin) IV bolus
ne
la
4. A nurse in the emergency department is assisting with the suturing of a laceration to the
tz
client. Which of the following actions should the nurse take?
sh
A. Pour the sterile cleansing solution holding on the bottle10 cm(4 in) above the sterile
Sp
field
ne
B. Pull the top flap of the suture tray towards the body when opening
la
C. Place the bottle of local anesthetics 5 cm (2 in) inside the sterile field border.
D. Drop the suture package on the sterile field from a distance of 30 cm (12 in)
sh
Sp
ne
5. A nurse is caring for a client who is 1 day postoperative following a hypophysectomy for
removal of a pituitary tumor. Which of the following findings requires further assessment by the
la
nurse?
tz
A. Urinary output greater than fluid intake sh
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B. Report of dry mouth
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C. Glasgow coma scale score of 15
D. Bloody drainage on the nasal dressings measuring 3 cm
la
sh
6. A nurse in an emergency department is caring for a client who has multiple wounds due to
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a motor-vehicle crash. Which of the following interventions are appropriate? (Select all that
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apply)
A. Apply direct pressure to bleeding wounds
a
tz
B. Clean lacerations and abrasions with hydrogen peroxide
l
sh
C. Administer 650 mg aspirin PO as needed for pain
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D. Cover the wound with sterile dressing
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E. Determine date of last tetanus toxoid vaccination
la
sh
Sp
la
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, lOMoARcPSD|22830792
ne
sh
7. A nurse is planning care for four clients. Which of the following clients is the highest
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priority? la
A. A client who has frequent incontinence
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B. A client who has dry, black eschar on the heel
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C. A client who has a reddened skin area with blanching around the coccyx
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D. A client who is wearing an arm cast and reports numb fingers
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la
8. A nurse is assisting with mass casualty triage following an explosion at a local factory.
Which of the following clients should the nurse identify as the priority?
sh
Sp
A. A client who has massive head trauma
ne
B. A client who has an open fracture of the lower extremity
C. A client who has full-thickness burns to the face and trunk
la
D. A client who has indications of hypovolemic shock
tz
sh
Sp
9. A nurse is planning care for a newly admitted adolescent who has bacterial meningitis.
ne
Which of the following instructions is appropriate for the nurse to include in the plan of care?
A. Assist the client to a supine position
la
B. Recommend prophylactic acyclovir (Zovirax) for the client9s family
sh
C. Initiate droplet precautions for the client
Sp
D. Perform a Glasgow Coma Scale every 24 hrs
ne
la
10. A nurse Is caring for a client who is unconscious and has an advanced directive indicating
no extraordinary measures. The client9s son wants everything possible done for his father. Which
tz
sh
of the following is an appropriate statement by the nurse?
Sp
A. <I will notify the health care provider of your wishes=
ne
B. <Have you talked about this with your family?=
la
C. <We have to honor your father9s wishes.=
D. <Have you discussed this with your minister?=
sh
Sp
11. A nurse is assessing a client brought to the hospital9s psychiatric emergency services by a
ne
law enforcement officer. The client has disorganized, incoherent speech with loose associations
la
and religious content. The nurse recognizes these signs and symptoms as being consistent with
tz
which of the following? sh
Alzheimer9s disease
Sp
A.
ne
B. Depression
C. Substance intoxication
la
D. Schizophrenia
sh
Sp
12. A nurse is caring for a patient who has a stool culture that is positive for Clostridium
ne
difficile ( C. difficile) . Which of the following infection control precautions is appropriate?
A. Place the client in a negative pressure room.
a
tz
B. Place the client in a private room.
l
sh
C. Wear a face shield prior to entering the room.
Sp
D. Use an alcohol-based hand rub following client care.
ne
la
sh
Sp
la
Downloaded by charity nimo ()
Sp
, lOMoARcPSD|22830792
ne
sh
13. A nurse is caring for a client who sprained his left ankle 12 hrs ago. Which of the orders
ne
given by the provider should the nurse clarify?
la
A. Elevate the affected extremity using two pillows.
tz
B. Apply heat to the affected extremity for 45 min on and then 45 min off.
sh
C. Assess the affected extremity for sensation movement, and pulse every 4 hr.
Sp
D. Wrap the affected extremity with a compression dressing.
ne
la
14. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following
actions should the nurse plan to take?
sh
Remove the disposable gown after leaving the toddler9s room
Sp
A.
ne
B. Place the toddler in a room with negative air pressure
C. Use a designated stethoscope when caring for the toddler
la
D. Wear an N95 respiratory mask while caring for the toddler
tz
sh
Sp
15. A nurse is developing a discharge care plan for a client who has osteoporosis. To prevent
ne
injury, the nurse should instruct the client to
A. Avoid sitting in one position for prolonged periods
la
B. Avoid crossing the legs beyond the midline
sh
C. Splint the affected area
Sp
D. Perform weight bearing exercises
ne
la
16. A nurse receives a change-of-shift report on four clients. Based on the shift report
tz
information, which of the following clients should the nurse plan to assess first?
sh
A. A client who had a barium enema 2 days ago and reports constipation
Sp
B. A client who has anorexia and peripheral edema
ne
C. A client who has Addison9s disease with a blood glucose level of 75 mg/Dl
la
D. A client who had a hip arthroplasty reports pain and erythema in his calf
sh
Sp
17. A nurse working in a long-term care facility is caring for an older adult client who has
ne
dementia. The client is often agitated and frequently wanders the halls. Which of the following
interventions should the nurse include in the plan?
la
A. Maintain nutritional requirements by offering finger foods
tz
B. Confront the client regarding unacceptable behavior sh
Sp
C. Stimulate the client by leaving the television on throughout the day
ne
D. Give the client several choices when scheduling activities
la
18. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the
sh
following foods should be included when initiating feeding?
Sp
A. Toast
ne
B. Oatmeal
C. Beef broth
a
tz
D. Apple juice
l
sh
Sp
19. A nurse is performing a skin assessment on a client with risk factors for development of skin
ne
cancer. The nurse should understand that a suspicious lesion is
la
A. Asymmetric, with variegated coloring
sh
Sp
la
Downloaded by charity nimo ()
Sp
ne
sh
1. A nurse is assessing a client who has left-sided heart failure. Which of the following will
ne
the nurse identify as the highest priority?
la
A. Jugular distention
tz
B. Frothy pink septum
sh
C. Hepatomegaly
Sp
D. Weight gain
2.
ne
A nurse in the emergency department is assisting with the suturing of a laceration to the
la
client. Which of the following actions should the nurse take?
A. Pour the sterile cleansing solution holding on the bottle10 cm(4 in) above the sterile
sh
Sp
field
ne
B. Pull the top flap of the suture tray towards the body when opening
C. Place the bottle of local anesthetics 5 cm (2 in) inside the sterile field border.
la
D. Drop the suture package on the sterile field from a distance of 30 cm (12 in)
tz
sh
Sp
3. A nurse is assessing a client 1 hr following delivery and notes that her uterus is boggy and
ne
located near the umbilicus. Which of the following actions should the nurse take fisrt?
A. Massage the fundus
la
B. Assess lochia
sh
C. Take vital signs
Sp
D. Give oxytocin (Pitocin) IV bolus
ne
la
4. A nurse in the emergency department is assisting with the suturing of a laceration to the
tz
client. Which of the following actions should the nurse take?
sh
A. Pour the sterile cleansing solution holding on the bottle10 cm(4 in) above the sterile
Sp
field
ne
B. Pull the top flap of the suture tray towards the body when opening
la
C. Place the bottle of local anesthetics 5 cm (2 in) inside the sterile field border.
D. Drop the suture package on the sterile field from a distance of 30 cm (12 in)
sh
Sp
ne
5. A nurse is caring for a client who is 1 day postoperative following a hypophysectomy for
removal of a pituitary tumor. Which of the following findings requires further assessment by the
la
nurse?
tz
A. Urinary output greater than fluid intake sh
Sp
B. Report of dry mouth
ne
C. Glasgow coma scale score of 15
D. Bloody drainage on the nasal dressings measuring 3 cm
la
sh
6. A nurse in an emergency department is caring for a client who has multiple wounds due to
Sp
a motor-vehicle crash. Which of the following interventions are appropriate? (Select all that
ne
apply)
A. Apply direct pressure to bleeding wounds
a
tz
B. Clean lacerations and abrasions with hydrogen peroxide
l
sh
C. Administer 650 mg aspirin PO as needed for pain
Sp
D. Cover the wound with sterile dressing
ne
E. Determine date of last tetanus toxoid vaccination
la
sh
Sp
la
Downloaded by charity nimo ()
Sp
, lOMoARcPSD|22830792
ne
sh
7. A nurse is planning care for four clients. Which of the following clients is the highest
ne
priority? la
A. A client who has frequent incontinence
tz
B. A client who has dry, black eschar on the heel
sh
C. A client who has a reddened skin area with blanching around the coccyx
Sp
D. A client who is wearing an arm cast and reports numb fingers
ne
la
8. A nurse is assisting with mass casualty triage following an explosion at a local factory.
Which of the following clients should the nurse identify as the priority?
sh
Sp
A. A client who has massive head trauma
ne
B. A client who has an open fracture of the lower extremity
C. A client who has full-thickness burns to the face and trunk
la
D. A client who has indications of hypovolemic shock
tz
sh
Sp
9. A nurse is planning care for a newly admitted adolescent who has bacterial meningitis.
ne
Which of the following instructions is appropriate for the nurse to include in the plan of care?
A. Assist the client to a supine position
la
B. Recommend prophylactic acyclovir (Zovirax) for the client9s family
sh
C. Initiate droplet precautions for the client
Sp
D. Perform a Glasgow Coma Scale every 24 hrs
ne
la
10. A nurse Is caring for a client who is unconscious and has an advanced directive indicating
no extraordinary measures. The client9s son wants everything possible done for his father. Which
tz
sh
of the following is an appropriate statement by the nurse?
Sp
A. <I will notify the health care provider of your wishes=
ne
B. <Have you talked about this with your family?=
la
C. <We have to honor your father9s wishes.=
D. <Have you discussed this with your minister?=
sh
Sp
11. A nurse is assessing a client brought to the hospital9s psychiatric emergency services by a
ne
law enforcement officer. The client has disorganized, incoherent speech with loose associations
la
and religious content. The nurse recognizes these signs and symptoms as being consistent with
tz
which of the following? sh
Alzheimer9s disease
Sp
A.
ne
B. Depression
C. Substance intoxication
la
D. Schizophrenia
sh
Sp
12. A nurse is caring for a patient who has a stool culture that is positive for Clostridium
ne
difficile ( C. difficile) . Which of the following infection control precautions is appropriate?
A. Place the client in a negative pressure room.
a
tz
B. Place the client in a private room.
l
sh
C. Wear a face shield prior to entering the room.
Sp
D. Use an alcohol-based hand rub following client care.
ne
la
sh
Sp
la
Downloaded by charity nimo ()
Sp
, lOMoARcPSD|22830792
ne
sh
13. A nurse is caring for a client who sprained his left ankle 12 hrs ago. Which of the orders
ne
given by the provider should the nurse clarify?
la
A. Elevate the affected extremity using two pillows.
tz
B. Apply heat to the affected extremity for 45 min on and then 45 min off.
sh
C. Assess the affected extremity for sensation movement, and pulse every 4 hr.
Sp
D. Wrap the affected extremity with a compression dressing.
ne
la
14. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following
actions should the nurse plan to take?
sh
Remove the disposable gown after leaving the toddler9s room
Sp
A.
ne
B. Place the toddler in a room with negative air pressure
C. Use a designated stethoscope when caring for the toddler
la
D. Wear an N95 respiratory mask while caring for the toddler
tz
sh
Sp
15. A nurse is developing a discharge care plan for a client who has osteoporosis. To prevent
ne
injury, the nurse should instruct the client to
A. Avoid sitting in one position for prolonged periods
la
B. Avoid crossing the legs beyond the midline
sh
C. Splint the affected area
Sp
D. Perform weight bearing exercises
ne
la
16. A nurse receives a change-of-shift report on four clients. Based on the shift report
tz
information, which of the following clients should the nurse plan to assess first?
sh
A. A client who had a barium enema 2 days ago and reports constipation
Sp
B. A client who has anorexia and peripheral edema
ne
C. A client who has Addison9s disease with a blood glucose level of 75 mg/Dl
la
D. A client who had a hip arthroplasty reports pain and erythema in his calf
sh
Sp
17. A nurse working in a long-term care facility is caring for an older adult client who has
ne
dementia. The client is often agitated and frequently wanders the halls. Which of the following
interventions should the nurse include in the plan?
la
A. Maintain nutritional requirements by offering finger foods
tz
B. Confront the client regarding unacceptable behavior sh
Sp
C. Stimulate the client by leaving the television on throughout the day
ne
D. Give the client several choices when scheduling activities
la
18. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the
sh
following foods should be included when initiating feeding?
Sp
A. Toast
ne
B. Oatmeal
C. Beef broth
a
tz
D. Apple juice
l
sh
Sp
19. A nurse is performing a skin assessment on a client with risk factors for development of skin
ne
cancer. The nurse should understand that a suspicious lesion is
la
A. Asymmetric, with variegated coloring
sh
Sp
la
Downloaded by charity nimo ()
Sp
