1. A nurse is assessing a client who received 2 units of packed
RBCs 48 hours ago. Which finding indicates the therapy has
been effective?
Answer: Hemoglobin 14.9 g/dL. This level is within the expected
reference range, indicating the therapy successfully increased the
client's red blood cell count.
2. A nurse in an ED is triaging four clients. Which client should
the nurse recommend for treatment first?
Answer: A middle adult client who has unstable vital signs. A
client with unstable vital signs requires immediate treatment to
reduce the risk of further injury or death.
3. A nurse is caring for a client who has fluid volume
overload. Which task should the nurse delegate to the CNA?
Answer: Measure the client’s daily weight. This task is within the
CNA's scope of practice and does not require nursing judgment.
4. A nurse is preparing to administer mannitol 0.2g/kg IV
bolus over 5 min. The client weighs 198 lb. What amount in
grams should the nurse administer?
,Answer: 18 g. Convert pounds to kilograms (198 lbs / 2.2 = 90 kg)
and multiply by the dose (90 kg * 0.2 g/kg = 18 g).
5. An adolescent is being assessed for range of motion of the
legs. Which image indicates the adolescent is abducting the
hip joint?
Answer: The adolescent is moving the leg away from the midline
of the body. Abduction is the movement of a body part away
from the midline.
6. A nurse is caring for a client who has hyperthyroidism.
Which finding should the nurse expect?
Answer: Tremors. Tremors, along with tachycardia, diaphoresis,
and weight loss, are classic manifestations of hyperthyroidism.
7. A nurse is assessing a school-aged child who has bacterial
meningitis. Which finding should the nurse expect?
Answer: Nuchal rigidity. Nuchal rigidity (stiff neck) is a key sign of
meningitis.
8. A nurse is assessing a newborn’s heart rate. Which action
should the nurse take?
Answer: Auscultate the apical pulse for at least 1 minute.
Auscultating for a full minute ensures an accurate assessment of
the newborn's rapid heart rate and rhythm.
9. A nurse is preparing to assist with a thoracentesis. Which
action should the nurse plan to take?
Answer: Instruct the client to avoid coughing during the
procedure. Coughing during a thoracentesis increases the risk of
puncturing the pleura.
,10. A nurse in the ED is assessing a preschooler with a facial
laceration. Which finding is a potential indication of child
sexual abuse?
Answer: The child exhibits discomfort while walking. Discomfort
while walking can be a sign of sexual abuse in children.
11. A nurse is teaching about dietary management to a client
who has Crohn’s disease and an enteroenteric fistula. Which
nutrient should the client decrease?
Answer: Fiber. A low-fiber diet is recommended to reduce
diarrhea and inflammation.
12. A client has a prescription for a CPM machine following a
total knee arthroplasty. Which action should the nurse take?
Answer: Turn off the CPM machine during mealtime. This
promotes client comfort and allows for adequate dietary intake.
13. A nurse is preparing to initiate IV access for an older adult
client. Which site should the nurse select?
Answer: Radial vein of the inner arm. This site generally has
adequate subcutaneous tissue for IV access.
14. A nurse is developing a client education program about
osteoporosis. Which variable should the nurse include as a
risk factor?
Answer: Sedentary lifestyle. Other risk factors include a small, thin
body frame and estrogen deficiency.
15. A nurse in the ED is caring for a child with a fever and
fluid-filled vesicles on the trunk and extremities. Which
intervention is the priority?
Answer: Initiate transmission-based precautions. The presentation
, suggests a communicable disease (e.g., varicella), and preventing
spread is the priority.
16. A nurse is caring for a client who has a clogged
percutaneous gastrostomy (PEG) feeding tube. Which action
should the nurse take first?
Answer: Change the position of the client. Changing the client's
position can sometimes relieve the clog.
17. A home health nurse is developing a teaching plan for a
client with a new ileostomy. Which instruction should the
nurse include?
Answer: Empty the appliance when it is one-third to one-half full.
This prevents leakage and skin breakdown from the weight of the
effluent.
18. A nurse is reviewing the lab report of a client with ESKD
who received hemodialysis 24 hr ago. Which value should the
nurse report to the provider?
Answer: Sodium 148 mEq/L. This is an elevated sodium level
(hypernatremia) that requires reporting.
19. A nurse is caring for four clients. Which task should the
nurse delegate to an AP?
Answer: Arrange the lunch tray for a client who has a hip fracture.
This is a non-invasive, routine task appropriate for an AP.
20. A nurse is preparing a client for a paracentesis. Which
action should the nurse take?
Answer: Instruct the client to void. Emptying the bladder helps
prevent accidental puncture during the procedure.
RBCs 48 hours ago. Which finding indicates the therapy has
been effective?
Answer: Hemoglobin 14.9 g/dL. This level is within the expected
reference range, indicating the therapy successfully increased the
client's red blood cell count.
2. A nurse in an ED is triaging four clients. Which client should
the nurse recommend for treatment first?
Answer: A middle adult client who has unstable vital signs. A
client with unstable vital signs requires immediate treatment to
reduce the risk of further injury or death.
3. A nurse is caring for a client who has fluid volume
overload. Which task should the nurse delegate to the CNA?
Answer: Measure the client’s daily weight. This task is within the
CNA's scope of practice and does not require nursing judgment.
4. A nurse is preparing to administer mannitol 0.2g/kg IV
bolus over 5 min. The client weighs 198 lb. What amount in
grams should the nurse administer?
,Answer: 18 g. Convert pounds to kilograms (198 lbs / 2.2 = 90 kg)
and multiply by the dose (90 kg * 0.2 g/kg = 18 g).
5. An adolescent is being assessed for range of motion of the
legs. Which image indicates the adolescent is abducting the
hip joint?
Answer: The adolescent is moving the leg away from the midline
of the body. Abduction is the movement of a body part away
from the midline.
6. A nurse is caring for a client who has hyperthyroidism.
Which finding should the nurse expect?
Answer: Tremors. Tremors, along with tachycardia, diaphoresis,
and weight loss, are classic manifestations of hyperthyroidism.
7. A nurse is assessing a school-aged child who has bacterial
meningitis. Which finding should the nurse expect?
Answer: Nuchal rigidity. Nuchal rigidity (stiff neck) is a key sign of
meningitis.
8. A nurse is assessing a newborn’s heart rate. Which action
should the nurse take?
Answer: Auscultate the apical pulse for at least 1 minute.
Auscultating for a full minute ensures an accurate assessment of
the newborn's rapid heart rate and rhythm.
9. A nurse is preparing to assist with a thoracentesis. Which
action should the nurse plan to take?
Answer: Instruct the client to avoid coughing during the
procedure. Coughing during a thoracentesis increases the risk of
puncturing the pleura.
,10. A nurse in the ED is assessing a preschooler with a facial
laceration. Which finding is a potential indication of child
sexual abuse?
Answer: The child exhibits discomfort while walking. Discomfort
while walking can be a sign of sexual abuse in children.
11. A nurse is teaching about dietary management to a client
who has Crohn’s disease and an enteroenteric fistula. Which
nutrient should the client decrease?
Answer: Fiber. A low-fiber diet is recommended to reduce
diarrhea and inflammation.
12. A client has a prescription for a CPM machine following a
total knee arthroplasty. Which action should the nurse take?
Answer: Turn off the CPM machine during mealtime. This
promotes client comfort and allows for adequate dietary intake.
13. A nurse is preparing to initiate IV access for an older adult
client. Which site should the nurse select?
Answer: Radial vein of the inner arm. This site generally has
adequate subcutaneous tissue for IV access.
14. A nurse is developing a client education program about
osteoporosis. Which variable should the nurse include as a
risk factor?
Answer: Sedentary lifestyle. Other risk factors include a small, thin
body frame and estrogen deficiency.
15. A nurse in the ED is caring for a child with a fever and
fluid-filled vesicles on the trunk and extremities. Which
intervention is the priority?
Answer: Initiate transmission-based precautions. The presentation
, suggests a communicable disease (e.g., varicella), and preventing
spread is the priority.
16. A nurse is caring for a client who has a clogged
percutaneous gastrostomy (PEG) feeding tube. Which action
should the nurse take first?
Answer: Change the position of the client. Changing the client's
position can sometimes relieve the clog.
17. A home health nurse is developing a teaching plan for a
client with a new ileostomy. Which instruction should the
nurse include?
Answer: Empty the appliance when it is one-third to one-half full.
This prevents leakage and skin breakdown from the weight of the
effluent.
18. A nurse is reviewing the lab report of a client with ESKD
who received hemodialysis 24 hr ago. Which value should the
nurse report to the provider?
Answer: Sodium 148 mEq/L. This is an elevated sodium level
(hypernatremia) that requires reporting.
19. A nurse is caring for four clients. Which task should the
nurse delegate to an AP?
Answer: Arrange the lunch tray for a client who has a hip fracture.
This is a non-invasive, routine task appropriate for an AP.
20. A nurse is preparing a client for a paracentesis. Which
action should the nurse take?
Answer: Instruct the client to void. Emptying the bladder helps
prevent accidental puncture during the procedure.
