1. A nurse is providing teaching about the gastrostomy tube feedings to the
parents of a school age child. Which of the following instructions should the
nurse take?
A. Administer the feeding over 30 minutes
B. Place the child in a supine position after the feeding.
C. Change the feeding bag and tubing every 3 days
D. Warm the formula in the microwave prior to administration.: A. Administer
the feeding over 30 min.
2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which
of the following findings should the nurse report to the provider?
A. Potassium level 4.2 mEq/L
B. Apical pulse 58/minute
C. Digoxin level 1ng/mL
D. Constipation for 2 days: C. Digoxin level 1 ng/ml.
3. A nurse is caring for a client who is comatose and has advance directives
that indicate the client does not want life-sustaining measures. The client's
family want the client to have life-sustaining measures. Which of the following
action should the nurse take?
A. Arrange for an ethics committee meeting to address the family's concerns.
B. Support the family's decision and initiate life-sustaining measures.
C. Complete and incident report
D. Encourage the family to contact an attorny.: A. Arrange for an ethics
committee meeting to address the family's concerns.
4. A nurse is caring for a client who wears glasses. Which of the following
actions should the nurse take?
A. Store the glasses in a labeled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.: A. Store the glasses in a labeled case.
5. A nurse is teaching a group of newly licensed nurses about measures to
take when caring for a client who is on contact precautions. Which of the
following should the nurse include in the teaching? A. Place the client in a
room with negative pressure
,B. Wear gloves when providing care to the client.
C. Wear a mask when changing the linens in the client's room.: B. Wear gloves
when providing care to the client.
6. A nurse is planning on care for a client who is recovering from an acute
myocardial infarction that occurred 3 days ago. Which of the following
instructions should the nurse include?
A. Perform an ECG every 12 hr.
B. Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. Obtain a cardiac rehabilitation consultation.: D. Obtain a cardiac
rehabilitation consultation.
7. The nurse is reviewing the medical record of a client who is requesting
combination oral contraceptives. Which of the following conditions in the
client's history is a contradiction to the use of oral contraceptives? A.
Hyperthyroidism.
B. Thrombophlebitis.
C. Diverticulosis.
D. Hypocalcemia.: B. Thrombophlebitis.
8. A nurse is caring for a client who request the creation of a living will. Which
of the following actions should the nurse take?
A. Schedule a meeting between the hospital ethics committee and the client.
B. Evaluate the client's understanding of life-sustaining measures.
C. Determine the client's preferences about post mortem care.
D. Request a conference with the client's family.: B. Evaluate the client's
understanding of life-sustaining measures.
9. A nurse is caring for an adolescent who has sickle-cell anemia. Which of
the following manifestations indicates acute chest syndrome and should
be immediately reported to the provider A. Substernal retractions.
B. Hematuria.
C. Temperature 37.9 C (100.2 F).
D. Sneezing.: A. Substernal retractions.
, 10. A nurse is preforming a gastric lavage for a client who has upper
gastrointestinal bleeding. Which of the .following action should the nurse
take? A. Instill 500 ml of solution through the NG tube.
B. Insert a large-bore NG tube.
C. Use a cold irrigation solution.
D. Instruct the client to lie on his right side.: B. Insert a large-bore NG tube. 11.
A nurse is providing care for a client who is in the advance stage of
amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the
nurse's priority? A. Psychologist.
B. Social worker.
C. Occupational therapist.
D. Speech-language pathologist.: D. Speech-language pathologist.
12. A nurse is reviewing the laboratory results of a client who has
rheumatoid arthritis. Which of the following findings should the nurse report
to the provider?
A. WBC count 8,000/mm3.
B. Platelets 150,000/mm3.
C. Aspartate aminotransferase 10 units/L.
D. Erythrocyte sedimentation rate 75 mm/hr: D. Erythrocyte sedimentation rate
75 mm/hr
13. A nurse is caring for a client who has generalized petechiae and
ecchymoses. The nurse should expect a prescription for which of the
following laboratory tests? A. Platelet count.
B. Potassium level.
C. Creatine clearance.
D. Prealbumin.: A. Platelet count
14. A nurse is caring for a client following application of a cast. Which of
the following actions should the nurse take first? A. Place an ice pack over
the cast.
B. Palpate the pulse distal to the cast.
C. Teach the client to keep the cast clean and dry.
D. Position the casted extremity on a pillow.: B. Palpate the pulse distal to the
cast.
parents of a school age child. Which of the following instructions should the
nurse take?
A. Administer the feeding over 30 minutes
B. Place the child in a supine position after the feeding.
C. Change the feeding bag and tubing every 3 days
D. Warm the formula in the microwave prior to administration.: A. Administer
the feeding over 30 min.
2. A nurse is administering digoxin 0.125 mg Po to an adult client. For which
of the following findings should the nurse report to the provider?
A. Potassium level 4.2 mEq/L
B. Apical pulse 58/minute
C. Digoxin level 1ng/mL
D. Constipation for 2 days: C. Digoxin level 1 ng/ml.
3. A nurse is caring for a client who is comatose and has advance directives
that indicate the client does not want life-sustaining measures. The client's
family want the client to have life-sustaining measures. Which of the following
action should the nurse take?
A. Arrange for an ethics committee meeting to address the family's concerns.
B. Support the family's decision and initiate life-sustaining measures.
C. Complete and incident report
D. Encourage the family to contact an attorny.: A. Arrange for an ethics
committee meeting to address the family's concerns.
4. A nurse is caring for a client who wears glasses. Which of the following
actions should the nurse take?
A. Store the glasses in a labeled case.
B. Clean the glasses with hot water.
C. Clean the glasses with a paper towel.
D. Store the glasses on the bedside table.: A. Store the glasses in a labeled case.
5. A nurse is teaching a group of newly licensed nurses about measures to
take when caring for a client who is on contact precautions. Which of the
following should the nurse include in the teaching? A. Place the client in a
room with negative pressure
,B. Wear gloves when providing care to the client.
C. Wear a mask when changing the linens in the client's room.: B. Wear gloves
when providing care to the client.
6. A nurse is planning on care for a client who is recovering from an acute
myocardial infarction that occurred 3 days ago. Which of the following
instructions should the nurse include?
A. Perform an ECG every 12 hr.
B. Place the client in a supine position while resting.
C. Draw a troponin level every 4hr.
D. Obtain a cardiac rehabilitation consultation.: D. Obtain a cardiac
rehabilitation consultation.
7. The nurse is reviewing the medical record of a client who is requesting
combination oral contraceptives. Which of the following conditions in the
client's history is a contradiction to the use of oral contraceptives? A.
Hyperthyroidism.
B. Thrombophlebitis.
C. Diverticulosis.
D. Hypocalcemia.: B. Thrombophlebitis.
8. A nurse is caring for a client who request the creation of a living will. Which
of the following actions should the nurse take?
A. Schedule a meeting between the hospital ethics committee and the client.
B. Evaluate the client's understanding of life-sustaining measures.
C. Determine the client's preferences about post mortem care.
D. Request a conference with the client's family.: B. Evaluate the client's
understanding of life-sustaining measures.
9. A nurse is caring for an adolescent who has sickle-cell anemia. Which of
the following manifestations indicates acute chest syndrome and should
be immediately reported to the provider A. Substernal retractions.
B. Hematuria.
C. Temperature 37.9 C (100.2 F).
D. Sneezing.: A. Substernal retractions.
, 10. A nurse is preforming a gastric lavage for a client who has upper
gastrointestinal bleeding. Which of the .following action should the nurse
take? A. Instill 500 ml of solution through the NG tube.
B. Insert a large-bore NG tube.
C. Use a cold irrigation solution.
D. Instruct the client to lie on his right side.: B. Insert a large-bore NG tube. 11.
A nurse is providing care for a client who is in the advance stage of
amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the
nurse's priority? A. Psychologist.
B. Social worker.
C. Occupational therapist.
D. Speech-language pathologist.: D. Speech-language pathologist.
12. A nurse is reviewing the laboratory results of a client who has
rheumatoid arthritis. Which of the following findings should the nurse report
to the provider?
A. WBC count 8,000/mm3.
B. Platelets 150,000/mm3.
C. Aspartate aminotransferase 10 units/L.
D. Erythrocyte sedimentation rate 75 mm/hr: D. Erythrocyte sedimentation rate
75 mm/hr
13. A nurse is caring for a client who has generalized petechiae and
ecchymoses. The nurse should expect a prescription for which of the
following laboratory tests? A. Platelet count.
B. Potassium level.
C. Creatine clearance.
D. Prealbumin.: A. Platelet count
14. A nurse is caring for a client following application of a cast. Which of
the following actions should the nurse take first? A. Place an ice pack over
the cast.
B. Palpate the pulse distal to the cast.
C. Teach the client to keep the cast clean and dry.
D. Position the casted extremity on a pillow.: B. Palpate the pulse distal to the
cast.
