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A female client presents in the emer-
gency department and tells the nurse
that she was raped last night. Which
question is most important for the nurse
to ask?
A. Has she taken a bath since the rape
A. Has she taken a bath since the rape
occurred?
occurred?
B. Is the place where she lives a safe
place?
C. Does she know the person who raped
her?
D. Did she report the rape to the police
department?
The nurse is completing the admission
assessment of a 3-year old who is ad-
mitted with bacterial meningitis and hy-
drocephalus. Which assessment finding
is evidence that the child is experiencing
increased intracranial pressure (ICP)?
B. Sluggish and unequal pupillary re-
A. Tachycardia and tachypnea
sponses
B. Sluggish and unequal pupillary re-
sponses
C. Increased head circumference and
bulging fontanels
D. Blood pressure fluctuations and syn-
cope
A client with acute pancreatitis is admit-
ted with severe, piercing abdominal pain
and an elevated serum amylase. Which
additional information is the client most
likely to report to the nurse?
A. Abdominal pain decreases when lying
A. Abdominal pain decreases when lying
supine
supine
B. Pain lasts an hour and leaves the ab-
domen tender
C. Right upper quadrant pain refers to
right scapula
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D. Drinks alcohol until intoxicated at least
twice weekly.
A child newly diagnosed with sickle cell
anemia (SCA) is being discharged from
the hospital. Which information is most
important for the nurse to provide the
parents prior to discharge?
A. Instructions about how much fluid the
A. Instructions about how much fluid the
child should drink daily.
child should drink daily
B. Signs of addiction to opioid pain med-
ications
C. Information about non-pharmaceuti-
cal pain relief measures
D. Referral for social services for the child
and family
To auscultate for a carotid bruit, the
nurse places the stethoscope at what lo- I placed the red dot on the base of the
cation. (Select the location on the image neck on the right side
with a red dot).
After receiving report on an inpatient
acute care unit, which client should the
nurse assess first?
A. The client with an obstruction of the
large intestine who is experiencing ab-
dominal distention
B. The client who had surgery yesterday D. The client with a bowel obstruction
and is experiencing a paralytic ileus with due to a volvulus who is experiencing
absent bowel sounds abdominal rigidity
C. The client with a small bowel obstruc-
tion who has a nasogastric tube that is
draining greenish fluid
D. The client with a bowel obstruction
due to a volvulus who is experiencing
abdominal rigidity
A teenager presents to the emergency
department with palpitations after vaping
at a party. The client is anxious, fearful,
and hyperventilating. The nurse antici-
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pates the client developing which acid
base imbalance?
A. Respiratory acidosis
D. Respiratory alkalosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
A client with dyspnea is being admitted
to the medical unit. To best prepare for
the client's arrival, the nurse should en-
sure that the client's bed is in which po-
sition? Fowlers
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
The nurse is taking the blood pressure
measurement of a client with Parkinson's
disease. Which information in the client's
admission assessment is relevant to the
nurse's plan for taking the blood pres- A. Frequent syncope
sure reading? (Select all the apply) C. Flat affect
A. Frequent syncope D. Blurred vision
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
While caring for a client's postoperative
dressing, the nurse observes purulent
drainage at the wound. Before reporting
this finding to the healthcare provider,
the nurse should review which of the
B. Culture for sensitive organisms
client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
A preschool-aged boy is admitted to the
pediatric unit following successful resus-
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citation from a near-drowning incident.
While providing care to the child, the
nurse begins talking with his preadoles-
cent brother who rescued the child from
the swimming pool and initiated resusci-
tation. The nurse notices the older boy
becomes withdrawn when asked about
what happened. Which action should the
B. Ask the older brother how he felt dur-
nurse take?
ing the incident
A. Develop a water safety teaching plan
for the family
B. Ask the older brother how he felt dur-
ing the incident
C. Tell the older brother that he seems
depressed
D. Commend the older brother for his
heroic actions
A male client with cirrhosis has jaundice
and pruritus. He tells the nurse that he
has been soaking in hot baths at night
with no relief of his discomfort. Which
action should the nurse take?
A. Encourage the client to use cooler wa-
ter and apply calamine lotion after soak-
A. Encourage the client to use cooler wa-
ing
ter and apply calamine lotion after soak-
B. Obtain a PRN prescription for an anal-
ing
gesic that the client can use for symptom
relief
C. Suggest that the client take brief
showers and apply oil-based lotion after
showering
D. Explain that the symptoms are caused
by liver damage and cannot be relieved
An older client with a long histo-
ry of coronary artery disease (CAD),
hypertension (HTN), and heart fail-
ure (HF) arrives in the Emergency
Department (ED) in respiratory dis-