SET 1
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1. A nurse is assessing a client who is receiving a peripheral IV infusion
and notes infiltration of fluid into the tissues surrounding the insertion site.
Which of the following actions should the nurse take?
A. Apply pressure to the IV site.
B. Elevate the extremity.
C. Flush the IV catheter.
D. Slow the infusion rate.
Correct Answer: B. Elevate the extremity
Rationale: Elevating the extremity helps reduce swelling and promotes fluid
reabsorption. It also reduces further leakage of the infiltrated fluid and
alleviates discomfort.
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2. A nurse is caring for a client who takes warfarin and reports beginning
several herbal supplements. The nurse should identify that which of the
following supplements is contraindicated for use with warfarin?
A. Probiotics
B. Coenzyme Q10
C. Valerian
,D. Ginkgo biloba
Correct Answer: D. Ginkgo biloba
Rationale: Ginkgo biloba has antiplatelet properties, which can increase the
risk of bleeding when taken with warfarin.
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3. CASE STUDY (NGN-Style):
• Three days ago: Client reported intermittent spotting between menstrual
cycles. Pelvic exam and swabs for STIs obtained. Current medication
includes a combined oral contraceptive.
• Today: Client returns to the office for lab results and receives new
prescriptions.
A nurse is providing teaching to this client regarding a new prescription of
doxycycline. Which two of the following statements should the nurse
include?
A. “You should avoid the sun while taking this medication.”
B. “You should use an alternate form of birth control while taking this
medication.”
C. “It is common to experience headache or blurred vision while taking this
medication.”
D. “This medication may cause constipation.”
E. “You should take this medication with dairy products.”
,Correct Answers:
A. “You should avoid the sun while taking this medication.”
B. “You should use an alternate form of birth control while taking this
medication.”
Rationale:
• Doxycycline increases photosensitivity, so advising the client to avoid
excessive sun exposure or use sunscreen is essential.
• Antibiotics (including doxycycline) can reduce the effectiveness of oral
contraceptives, warranting a back-up birth control method.
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4. A nurse is preparing to mix short-acting (regular) insulin with NPH insulin
from two vials. Which of the following actions should the nurse take?
A. Administer the insulin within 20 minutes of preparing it.
B. Ensure the NPH insulin is drawn into the syringe first.
C. Inject air into the vial to withdraw the short-acting insulin first.
D. Use two separate syringes to mix the insulin.
Correct Answer: C. Inject air into the vial to withdraw the short-acting insulin
first.
Rationale: Injecting air and then withdrawing the clear (short-acting) insulin
before the cloudy (NPH) insulin prevents contamination of the short-acting
vial.
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5. A nurse is caring for a client who is receiving an IV infusion via pump at a
rate of 3 mL/min. The infusion started 2 hours ago with a 500 mL bag. How
many milliliters have infused?
A. 180 mL
B. 157 mL
C. 360 mL
D. 334 mL
Correct Answer: C. 360 mL
Rationale: Calculation = 3 mL/min × 60 min/hr = 180 mL/hr; over 2 hours =
360 mL.
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6. CASE STUDY (NGN-Style):
• Last week: Vitals → T 37°C (98.6°F), HR 64/min, RR 12/min, BP 118/72
mmHg
• Today: Vitals → T 37.2°C (98.9°F), HR 82/min, RR 16/min, BP 110/68
mmHg
A nurse is teaching a client diagnosed with stomatitis. Which of the
following client statements indicates effective teaching? Select all that
apply.
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1. A nurse is assessing a client who is receiving a peripheral IV infusion
and notes infiltration of fluid into the tissues surrounding the insertion site.
Which of the following actions should the nurse take?
A. Apply pressure to the IV site.
B. Elevate the extremity.
C. Flush the IV catheter.
D. Slow the infusion rate.
Correct Answer: B. Elevate the extremity
Rationale: Elevating the extremity helps reduce swelling and promotes fluid
reabsorption. It also reduces further leakage of the infiltrated fluid and
alleviates discomfort.
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─────────
2. A nurse is caring for a client who takes warfarin and reports beginning
several herbal supplements. The nurse should identify that which of the
following supplements is contraindicated for use with warfarin?
A. Probiotics
B. Coenzyme Q10
C. Valerian
,D. Ginkgo biloba
Correct Answer: D. Ginkgo biloba
Rationale: Ginkgo biloba has antiplatelet properties, which can increase the
risk of bleeding when taken with warfarin.
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─────────
3. CASE STUDY (NGN-Style):
• Three days ago: Client reported intermittent spotting between menstrual
cycles. Pelvic exam and swabs for STIs obtained. Current medication
includes a combined oral contraceptive.
• Today: Client returns to the office for lab results and receives new
prescriptions.
A nurse is providing teaching to this client regarding a new prescription of
doxycycline. Which two of the following statements should the nurse
include?
A. “You should avoid the sun while taking this medication.”
B. “You should use an alternate form of birth control while taking this
medication.”
C. “It is common to experience headache or blurred vision while taking this
medication.”
D. “This medication may cause constipation.”
E. “You should take this medication with dairy products.”
,Correct Answers:
A. “You should avoid the sun while taking this medication.”
B. “You should use an alternate form of birth control while taking this
medication.”
Rationale:
• Doxycycline increases photosensitivity, so advising the client to avoid
excessive sun exposure or use sunscreen is essential.
• Antibiotics (including doxycycline) can reduce the effectiveness of oral
contraceptives, warranting a back-up birth control method.
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4. A nurse is preparing to mix short-acting (regular) insulin with NPH insulin
from two vials. Which of the following actions should the nurse take?
A. Administer the insulin within 20 minutes of preparing it.
B. Ensure the NPH insulin is drawn into the syringe first.
C. Inject air into the vial to withdraw the short-acting insulin first.
D. Use two separate syringes to mix the insulin.
Correct Answer: C. Inject air into the vial to withdraw the short-acting insulin
first.
Rationale: Injecting air and then withdrawing the clear (short-acting) insulin
before the cloudy (NPH) insulin prevents contamination of the short-acting
vial.
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─────────
5. A nurse is caring for a client who is receiving an IV infusion via pump at a
rate of 3 mL/min. The infusion started 2 hours ago with a 500 mL bag. How
many milliliters have infused?
A. 180 mL
B. 157 mL
C. 360 mL
D. 334 mL
Correct Answer: C. 360 mL
Rationale: Calculation = 3 mL/min × 60 min/hr = 180 mL/hr; over 2 hours =
360 mL.
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6. CASE STUDY (NGN-Style):
• Last week: Vitals → T 37°C (98.6°F), HR 64/min, RR 12/min, BP 118/72
mmHg
• Today: Vitals → T 37.2°C (98.9°F), HR 82/min, RR 16/min, BP 110/68
mmHg
A nurse is teaching a client diagnosed with stomatitis. Which of the
following client statements indicates effective teaching? Select all that
apply.
