NUR 283 Comp 3 Review – Galen College of Nursing | Complete Q&A Study Guide | Latest Fall 2026/2027.

NUR 283 Comp 3 Review – Galen College of Nursing | Complete Q&A Study Guide | Latest Fall 2026/2027. 1. A nurse in the post-anesthesia care unit (PACU) is receiving a client following abdominal surgery. Which priority action should the nurse perform first upon arrival? A. Verify the client's identity using two unique identifiers. B. Check the patency of IV access lines and surgical drains. C. Inspect the abdominal surgical dressing for drainage. D. Assess the client's vital signs and respiratory status. ### 2. A nurse is caring for a client experiencing status asthmaticus. During auscultation, the nurse notes a sudden decrease in wheezing with clear, silent lung fields. How should the nurse interpret this finding? A. The client is demonstrating significant clinical improvement. B. The client's asthma attack is converting into pulmonary edema. C. The bronchodilator therapy has successfully resolved the bronchospasm. D. The client is experiencing severe airway obstruction and lack of air movement. ### 3. A client with chronic obstructive pulmonary disease (COPD) is being educated on dietary modifications to prevent fatigue during meals. Which instruction should the nurse include? A. Drink large amounts of liquid during meals to aid swallowing. B. Engage in active conversation while eating to maintain alertness. C. Consume three large, calorie-dense meals daily. D. Eat small, frequent meals and cut food into small bite-sized pieces. ### 4. A client taking metformin oral antidiabetic therapy is scheduled for a cardiac catheterization requiring IV radiopaque contrast dye. Which nursing action is essential? A. Instruct the client to perform capillary blood glucose testing every 2 hours. B. Administer IV normal saline containing regular insulin prior to contrast injection. C. Withhold metformin 48 hours before and 48 hours after the procedure. D. Double the metformin dose on the morning of the procedure. ### 5. A client receiving a continuous IV heparin infusion for deep vein thrombosis requires titration monitoring. Which laboratory parameter must the nurse evaluate? A. International Normalized Ratio (INR) B. Bleeding time C. Activated partial thromboplastin time (aPTT) D. Prothrombin time (PT) ### 6. A nurse provides discharge teaching to a client initiated on oral warfarin therapy. Which client statement indicates a correct understanding of dietary management? A. 'I will maintain a consistent intake of vitamin K-rich foods without drastic changes.' B. 'I will completely avoid all vitamin C-rich fruits and fruit juices.' C. 'I will eat a large spinach salad every evening to boost my vitamin levels.' D. 'I will double my dose if I consume extra green leafy vegetables.' ### 7. A nurse is reviewing medication orders for a client admitted with gastrointestinal distress. For which underlying condition is loperamide contraindicated? A. Chronic duodenal ulcer disease B. Irritable bowel syndrome (IBS) C. Acute infectious gastroenteritis D. Diverticulosis without active inflammation ### 8. A laboring client on an IV oxytocin infusion exhibits a fetal heart rate (FHR) baseline of 175 bpm with persistent late decelerations. What is the nurse's priority action? A. Increase the IV oxytocin infusion rate. B. Prepare the client immediately for spinal anesthesia. C. Place the client in a high-Fowler's position. D. Turn the client onto her left side and discontinue oxytocin. ### 9. A pediatric nurse suspects potential physical abuse in a 4-year-old child presenting with multiple cutaneous ecchymoses and a spiral fracture. What action should the nurse take first? A. Obtain a detailed medical and behavioral history from the caregiver. B. Immediately submit a report to Child Protective Services (CPS). C. Confront the parents directly about the origin of the injuries. D. Place the child into immediate protective isolation. ### 10. A client presenting with sudden facial drooping and slurred speech arrives at the emergency department. Which diagnostic intervention must be completed immediately upon admission? A. Carotid artery Doppler ultrasound B. Non-contrast head CT scan C. Lumbar puncture for cerebrospinal fluid analysis D. Continuous 12-lead electrocardiography ### 11. A nurse is conducting a community health seminar on primary health promotion. Which activity represents a primary prevention strategy? A. Screening middle school students for adolescent scoliosis. B. Instructing clients on performing monthly breast and testicular self-examinations. C. Educating cyclists and motorcyclists on wearing approved safety helmets. D. Providing stroke rehabilitation physical therapy sessions. ### 12. At what age should school-aged children undergo mandatory screening for scoliosis? A. Between 15 and 18 years old B. Between 7 and 9 years old C. Between 4 and 6 years old D. Between 10 and 14 years old ### 13. A nurse is evaluating a client admitted with acute facial and upper torso burns. Which finding requires immediate nursing intervention for inhalation injury? A. Partial-thickness blistering on the chest B. Severe localized incisional pain C. Singed nasal hairs, hoarseness, and charcoal-tinted sputum D. Extensive lower extremity edema ### 14. A client with gastroesophageal reflux disease (GERD) requests advice on reducing night-time reflux symptoms. Which lifestyle modification should the nurse recommend? A. Drink 500 mL of water immediately before reclining. B. Elevate the head of the bed and avoid food intake within 2 to 3 hours of sleeping. C. Lie flat in the supine position immediately after dinner. D. Eat a high-fat meal right before going to bed. ### 15. A nurse is performing postmortem care for a client who is designated as a coroner's autopsy case. Which action by the nurse is correct? A. Elevate the head of the bed to 90 degrees. B. Rinse the body thoroughly with antiseptic solution prior to family viewing. C. Retain all body tubes, lines, and drains in place. D. Remove all indwelling IV lines, urinary catheters, and surgical drains. ### 16. A nurse is monitoring a client with polycystic kidney disease (PKD). Which clinical manifestation represents an acute complication that must be reported to the provider immediately? A. Clear straw-colored urine output B. Gross hematuria in morning urine C. Mild flank discomfort during ambulation D. Trace pedale edema at the end of the shift ### 17. A client diagnosed with pleurisy describes chest pain to the nurse. Which description is characteristic of pleuritic chest pain? A. A dull, aching precordial pressure radiating to the left jaw B. A sharp, knife-like pain aggravated by deep breathing or coughing C. A burning substernal sensation relieved by oral antacids D. A constant throbbing pain exacerbated by lying prone ### 18. A client admitted with major depressive disorder who has been severely withdrawn suddenly displays a bright, cheerful affect and gives away personal belongings. How should the nurse interpret this behavior? A. The client is responding effectively to antidepressant pharmacotherapy. B. The client has achieved stage 5 acceptance of grief. C. The client is at heightened risk for imminent suicide. D. The client is demonstrating successful resolution of depression. ### 19. A client with histrionic personality disorder is causing frequent disruptions in the dayroom by engaging in dramatic, attention-seeking outbursts. Which nursing intervention is most appropriate? A. Encourage the client to elaborate on their feelings in a group session. B. Place the client immediately into physical seclusion. C. Ignore the behavior completely in front of other clients. D. Pull the client aside private and establish clear, concrete behavioral guidelines. ### 20. A client's lipid panel reveals an LDL level of 165 mg/dL and HDL of 35 mg/dL despite strict compliance with a low-cholesterol diet. What outcome should the nurse anticipate? A. Immediate hospital admission for plasmapheresis B. Discontinuation of dietary restrictions C. Initiation of statin pharmacotherapy by the primary care provider D. Recommendation to consume vegetable and coconut oils ### 21. During a mass casualty building explosion triage, which client should the nurse assign a RED (emergent) triage tag? A. A client with walking superficial facial abrasions B. A client with severe respiratory distress and chest burns C. A client with open brain tissue and fixed, dilated pupils D. A client with a closed tibia fracture and capillary refill of 2 seconds ### 22. A nurse is reviewing client profiles to identify individuals at elevated risk for a latex allergy. Which client is at highest risk? A. A client with a history of penicillin allergy B. A client who has undergone multiple surgical procedures and has spina bifida C. A client with severe seasonal allergic rhinitis D. A client diagnosed with acute viral hepatitis ### 23. A client with acute severe pancreatitis is admitted to the medical unit. Which prescription should the nurse clarify first? A. Maintain strict NPO status. B. Administer IV isotonic crystalloid fluids. C. Administer parenteral opioid analgesics. D. Provide regular oral diet as tolerated. ### 24. A nurse is evaluating developmental milestones during a 9-month-old infant's well-child visit. Which finding represents a developmental delay requiring further evaluation? A. The infant sits unsupported. B. The infant demonstrates a pincer grasp. C. The infant's birth weight has doubled since birth. D. The infant is unable to stand while holding onto furniture. ### 25. A client with myasthenia gravis (MG) is admitted to the unit. Which nursing intervention takes priority to prevent a severe complication? A. Schedule large, solid meals late in the evening. B. Administer prescribed anticholinesterase medications strictly on time. C. Encourage high-intensity aerobic exercise before meals. D. Apply hot moist compresses to bilateral upper extremities. ### 26. An obstetrics nurse is floated to a med-surg unit due to staffing needs. Which client assignment is most appropriate for this float nurse? A. A client requiring continuous titration of IV vasopressors B. A newly admitted client requiring initial stroke assessment C. A client who underwent abdominal surgery 24 hours ago D. A complex client preparing for immediate discharge teaching ### 27. A nurse is supervising an unlicensed assistive personnel (UAP). Which task is appropriate to delegate to the UAP? A. Rechecking blood glucose on a client treated for hypoglycemia 25 minutes ago B. Reinforcing post-operative wound care teaching C. Evaluating a client's response to IV antihypertensive medication D. Performing initial physical assessment on a newly admitted client ### 28. A client admitted with acute bipolar mania is paced around the unit, skipping meals, and sleeping 1 hour per night. What is the priority nursing focus? A. Teaching long-term stress management techniques B. Encouraging participation in complex competitive group sports C. Ensuring physical safety and meeting basic nutritional and fluid needs D. Enforcing strict bed rest in total isolation ### 29. A nurse is caring for a client receiving internal sealed radiation therapy (brachytherapy). Which safety precaution should the nurse implement? A. Assign the same nurse to care for the client each day for continuity. B. Permit pregnant visitors for up to 1 hour daily. C. Wash off the skin location markings with warm soapy water after each shift. D. Wear a dosimeter badge during the entire shift and restrict visitors to 30 minutes. ### 30. A client admitted with shingles (herpes zoster) exhibits skin lesions scattered across multiple dermatomes. Which isolation precautions must be initiated? A. Standard precautions only B. Contact precautions only C. Airborne and Contact precautions in a negative pressure room D. Droplet precautions in a private room ### 31. A nurse is differentiating between gastric and duodenal ulcers. Which assessment finding is characteristic of a duodenal ulcer? A. Sharp pain occurring 30 minutes after meals B. Vomiting bright red blood immediately after eating C. Pain relief occurring after eating food or taking antacids D. Presence of coffee-ground emesis ### 32. A client with a ventriculoperitoneal (VP) shunt is assessed for increased intracranial pressure (ICP). Which finding represents a late sign of elevated ICP? A. Tachycardia and narrowed pulse pressure B. Constricted, hyper-reactive pupils bilaterally C. Widened pulse pressure, bradycardia, and positive Babinski reflex D. Hypotension and tachypnea ### 33. A client diagnosed with Graves' disease is monitored for thyroid storm. Which clinical change requires immediate reporting to the healthcare provider? A. Soft, smooth skin texture B. Mild hand tremors during movement C. A weight loss of 2 lbs over 1 month D. A body temperature increase of 1°F (0.6°C) ### 34. A nurse is preparing to administer a unit of packed red blood cells (PRBCs). Which IV solution is the only fluid compatible with blood products? A. 0.9% Normal Saline (0.9% NS) B. Lactated Ringer's (LR) solution C. Dextrose 5% in water (D5W) D. 0.45% Half-Normal Saline (0.45% NS) ### 35. Fifteen minutes after starting a blood transfusion, a client reports severe lower back pain and chills. What is the nurse's immediate priority action? A. Stop the transfusion immediately and disconnect the tubing at the hub. B. Administer prescribed IV diphenhydramine. C. Slow the blood infusion rate and notify the physician. D. Obtain an arterial blood gas sample. ### 36. A nurse is evaluating a client who sustained a right-hemispheric stroke. Which behavior should the nurse anticipate? A. Receptive aphasia and right-sided motor deficit B. Expressive aphasia and slow, cautious movements C. Impulsive behaviors, poor judgment, and left-sided spatial neglect D. Intact depth perception and awareness of deficits ### 37. A nurse is teaching tracheostomy care to a newly licensed nurse. Which observation requires immediate intervention by the preceptor? A. The nurse uses sterile technique during suctioning. B. The nurse maintains an extra tracheostomy tube at the bedside. C. The tracheostomy cannula moves visibly when the client coughs. D. The nurse secures tracheostomy ties allowing one finger space beneath. ### 38. A client on mechanical ventilation triggers a high-pressure alarm. What is the nurse's first action? A. Press the alarm silence button and recheck in 15 minutes. B. Immediately disconnect the client and bag manual ventilation. C. Deflate the endotracheal tube cuff. D. Assess the client for coughing, biting the tube, or secretions. ### 39. A nurse is reviewing home care instructions for a client with a newly implanted permanent cardiac pacemaker. Which statement by the client requires correction? A. 'I can safely undergo an MRI scan if my joint pain worsens.' B. 'I will avoid lifting my arm above my shoulder on the pacemaker side for several weeks.' C. 'I will carry my pacemaker identification card in my wallet at all times.' D. 'I will check my daily pulse rate and record it in a logbook.' ### 40. A male client asks the nurse about the correct technique for performing testicular self-examination (TSE). What instruction should the nurse provide? A. Perform the exam monthly immediately after taking a warm bath or shower. B. Perform the exam only if scrotal pain or discoloration occurs. C. Palpate both testicles simultaneously using firm downward pressure. D. Examine the testicles once every year prior to bedtime. ### 41. A client with congestive heart failure (CHF) presents with severe dyspnea, bilateral pulmonary crackles, and a 5 lb weight gain over 2 days. Which intervention is the priority? A. Administer oral potassium supplements immediately. B. Position the client supine with legs elevated above heart level. C. Place the client in a high-Fowler's position and administer high-flow oxygen. D. Encourage 3 L of oral fluid intake per day. ### 42. A nurse checks the Babinski reflex in a 45-year-old adult client. Stroke of the lateral sole results in dorsiflexion of the big toe and fanning of the other toes. How should the nurse interpret this result? A. Normal neurological finding for an adult B. Abnormal finding indicating central nervous system pathology C. Inconclusive response requiring repetition after rest D. Expected reflex demonstrating healthy spinal cord conduction ### 43. A nurse is preparing to administer a subcutaneous insulin injection. Which needle gauge and angle are appropriate? A. 21-gauge, 1-inch needle at a 15-degree angle B. 27-gauge, 1.5-inch needle at a 30-degree angle C. 18-gauge, 1.5-inch needle at a 90-degree angle D. 25-gauge, 3/8-inch needle at a 45- to 90-degree angle ### 44. A nurse is evaluating client immunization status. In which situation should a scheduled vaccination be postponed? A. The client has a low-grade temperature of 98.8°F. B. The client reports mild localized soreness from a prior vaccine. C. The client has an active high fever and significantly abnormal WBC count. D. The client has a family history of hypertension. ### 45. A client who underwent a kidney transplant 1 week ago presents for follow-up. Which finding requires immediate notification of the surgeon? A. Urine output of 150 mL/hour B. Serum creatinine of 0.9 mg/dL C. Slight incisional tenderness on exertion D. Weight gain of 3.5 lbs (1.6 kg) within 24 hours ### 46. A nurse reviews an EKG rhythm strip displaying tall, peaked T waves. Which electrolyte imbalance is the primary cause? A. Hypernatremia B. Hyperkalemia C. Hypokalemia D. Hypocalcemia ### 47. A client who had a subtotal gastrectomy 12 hours ago has a nasogastric (NG) tube attached to low wall suction. Which intervention should be included in the plan of care? A. Irrigate the NG tube with 50 mL of sterile water every hour. B. Keep the head of the bed completely flat. C. Reposition the NG tube every 4 hours to verify patency. D. Reposition the client every 2 hours and apply sequential compression devices. ### 48. Which pediatric client should the nurse assess first at the start of the shift? A. A 10-year-old child reading a book with a respiratory rate of 20 breaths/min B. A 4-year-old child sleeping quietly with a heart rate of 95 bpm C. A 7-year-old child sitting at a table eating lunch with an elevated heart rate of 140 bpm D. A 2-year-old child playing with blocks with a temperature of 98.6°F ### 49. A client undergoing external beam radiation therapy for lung cancer demonstrates understanding of skin care when making which statement? A. 'I will avoid direct exposure of the treated skin to sunlight.' B. 'I will scrub the skin markings thoroughly with a washcloth daily.' C. 'I will expose the treated area to ice packs every evening.' D. 'I will apply scented lotions to the radiation area twice daily.' ### 50. A newly hired nurse is observed administering an IV injection of streptomycin. Which adverse effect mandates close monitoring of BUN and creatinine levels? A. Cardiotoxicity B. Pulmonary fibrosis C. Nephrotoxicity D. Hepatotoxicity ### 51. A nurse preceptor observes a new hire nurse engaging in client care. Which action represents an example of nursing malpractice? A. Applying a moisture barrier ointment to an incontinent client's perineum B. Documenting subjective client statements inside quotation marks C. Administering a client's refused medication by secretly crushing it into food without consent D. Administering a prescribed oral pain medication 15 minutes after the scheduled time ### 52. What is the primary nursing action for a newborn immediately following delivery once a patent airway is established? A. Administer oral hepatitis B vaccine. B. Dry the newborn thoroughly to maintain warmth. C. Bathe the newborn in lukewarm water. D. Perform a complete gestational age assessment. ### 53. A nurse is preparing to administer a Mantoux tuberculin skin test. Which administration technique is correct? A. Inject 0.5 mL subcutaneously into the upper deltoid. B. Inject 0.1 mL intradermally at a 5 to 15-degree angle using a 27-gauge tuberculin syringe. C. Apply a topical patch to the posterior chest wall. D. Inject 1.0 mL intramuscularly into the gluteus medius. ### 54. A client with blood type A-positive inadvertently receives a unit of O-positive packed red blood cells. What is the nurse's immediate action? A. Administer IV protamine sulfate. B. Stop the transfusion immediately and send the bag to the lab. C. Continue to closely assess the client. D. Initiate emergency hemodialysis. ### 55. A client receiving oral pyridostigmine therapy for myasthenia gravis reports mild gastrointestinal distress. The nurse identifies which symptom as a known side effect? A. Dry mouth B. Severe constipation C. Nausea D. Urinary retention ### 56. A nurse on a crisis hotline receives a call from a client who states, 'I just swallowed a whole bottle of sleeping pills.' What is the nurse's best initial response? A. 'Hold on while I transfer you to the police.' B. 'Why would you do something so foolish?' C. 'Please put your family member on the phone.' D. 'I am glad you called.' ### 57. During urinary catheter insertion in a female client, which observation by the preceptor requires follow-up intervention? A. Maintaining sterile gloving throughout insertion B. Inflating the catheter balloon immediately upon first seeing urine in the tubing C. Cleansing the meatus from front to back D. Securing the catheter to the client's inner thigh ### 58. A nurse is constructing a plan of care for a client admitted with severe preeclampsia. Which environmental intervention should be included? A. Place the client in a quiet, darkened environment. B. Maintain a brightly lit room with continuous background music. C. Allow unrestricted visitors throughout the day. D. Keep the head of the bed flat at all times. ### 59. A nurse is evaluating 24-hour post-operative clients on a surgical floor. Which client represents the priority assessment? A. A client requesting assistance with ambulation to the bathroom B. A client experiencing an unexpected increase in pain despite receiving prescribed analgesics C. A client with serosanguineous wound drainage on the dressing D. A client complaining of mild incisional soreness during coughing ### 60. A client diagnosed with gastroesophageal reflux disease (GERD) is preparing for discharge. Which dietary recommendation is correct? A. Avoid eating meals directly before bed or lying down. B. Consume large meals high in animal fats. C. Lie flat for 1 hour after eating. D. Drink a full glass of milk directly before bedtime. ### 61. A client who suffered an ischemic stroke is being discharged home. Which statement indicates a need for further discharge education? A. 'I will eat my evening meal 2 to 3 hours before going to bed.' B. 'I will scan my environment to compensate for visual loss.' C. 'I will feed the client solid foods 15 minutes before bedtime.' D. 'I will perform chin tucks when swallowing my food.' ### 62. A nurse is communicating with a client diagnosed with histrionic personality disorder. Which communication approach is most effective? A. Use concrete and descriptive language. B. Use vague, abstract metaphors. C. Engage in detailed debates regarding personal boundaries. D. Encourage dramatic emotional expressions. ### 63. A client receiving IV furosemide daily is monitored by the nurse. Which laboratory parameter requires frequent evaluation? A. Serum potassium level B. Serum sodium level C. Serum calcium level D. Serum magnesium level ### 64. A nurse is caring for a client with Addison's disease who is at risk for an Addisonian crisis. Which daily parameter provides the best evaluation of fluid balance? A. Serum bilirubin levels B. Hourly capillary blood glucose C. Abdominal girth measurement D. Daily weight monitoring ### 65. A client presenting with burns to the face, chest, and hands arrives at the emergency department. What is the priority nursing intervention? A. Calculate total body surface area percentage. B. Apply topical burn ointments to facial wounds. C. Insert an indwelling urinary catheter. D. Assess for signs and symptoms of inhalation injury. ### 66. A client with a history of recurrent streptococcal pharyngitis presents with new periorbital edema. What is the nurse's priority action? A. Administer oral antihistamines. B. Obtain a throat swab culture. C. Assess the client for systemic edema and hypertension. D. Instruct the client to increase fluid intake. ### 67. Which isolation precautions are required for a client diagnosed with disseminated herpes zoster? A. Contact precautions only B. Airborne and Contact precautions C. Droplet precautions D. Standard precautions only ### 68. A client receiving total parenteral nutrition (TPN) via a central venous catheter is evaluated. Which finding requires immediate nursing follow-up? A. Urine specific gravity of 1.015 B. Elevated temperature greater than 100.8°F (38.2°C) C. Capillary blood glucose of 130 mg/dL D. Weight gain of 1 lb over 3 days ### 69. A nurse is caring for a 9-year-old hospitalized child. Which play activity is developmentally appropriate? A. Large plastic building blocks B. Rattles and soft plush toys C. Coloring books with thick crayons D. Reading books and playing board games ### 70. A client with pertussis is being transported to the radiology department. Which infection control measure is required? A. Place an N95 respirator on the transport staff member. B. Cover the transport wheelchair with a sterile drape. C. Place a surgical mask on the client during transport. D. Administer prophylactic IV antibiotics prior to transport. ### 71. A nurse in an outpatient clinic is triaging four pediatric clients. Which child should be placed into an examination room first? A. A child with a localized itchy rash on the forearm B. A child reporting severe headache, vomiting, photophobia, and fever C. A child with a mild runny nose and cough D. A child requesting routine immunization ### 72. A 6-month-old infant presents for a routine checkup. Which developmental observation requires follow-up? A. The infant holds a rattle when placed in hand. B. The infant rolls over from stomach to back. C. The infant is unable to roll over in either direction. D. The infant's birth weight has doubled. ### 73. A client diagnosed with terminal cancer requests to know their diagnosis, but the spouse asks the nurse to withhold it. Which action reflects the ethical principle of veracity? A. Contact the healthcare provider to discuss the diagnosis directly with the client. B. Advise the spouse to seek legal guardianship. C. Comply with the spouse's request and withhold the information. D. Transfer the client to another nursing unit. ### 74. A nurse reviews laboratory results for four clients. Which client represents the highest risk for acute bleeding requiring immediate priority care? A. A client with pneumonia with a WBC count of 11,000/mm³ B. A client with heart failure taking digoxin with a potassium of 4.0 mEq/L C. A client with hypertension taking aspirin with a platelet count of 250,000/mm³ D. A client with end-stage cirrhosis exhibiting new ecchymosis and a PTT of 79 seconds ### 75. Which pediatric client requires immediate nurse assessment? A. A crying infant with a heart rate of 150 bpm B. A sleeping infant with a heart rate of 175 bpm C. A toddler playing with a heart rate of 110 bpm D. A school-aged child resting with a heart rate of 85 bpm ### 76. For which client should the nurse initiate an interdisciplinary team conference? A. A young child newly diagnosed with cystic fibrosis who has had multiple hospital readmissions B. A 20-year-old client recovering 24 hours after an uncomplicated appendectomy C. A client receiving routine IV fluids for mild dehydration D. A client undergoing a simple dressing change prior to discharge ### 77. A nurse preceptor is evaluating a new hire nurse caring for a client in physical wrist restraints. Which action by the new hire requires immediate correction? A. Assessing skin integrity and peripheral pulses under restraints B. Obtaining a renewed healthcare provider order within required timeframes C. Removing the wrist restraints only once every 4 hours D. Securing restraints to the bed frame with a quick-release knot ### 78. For which clinical event must the nurse complete an official incident report? A. Administering a routine medication more than 1.5 hours late B. Administering a scheduled medication 15 minutes after the scheduled time C. Receiving a verbal laboratory report for normal blood glucose D. Documenting client refusal of a daily bath ### 79. Which immunization should the nurse recommend to a high school senior preparing to reside in a college dormitory? A. Haemophilus influenzae type b (Hib) vaccine B. Meningococcal polysaccharide vaccine C. Inactivated polio vaccine D. Rotavirus vaccine ### 80. An arterial blood gas (ABG) report reveals: pH 7.51, PaCO2 26 mmHg, HCO3 25 mEq/L. How should the nurse interpret this result? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis ### 81. A client in hypovolemic shock receiving rapid IV crystalloid fluids remains tachycardic with an O2 saturation of 90%. What is the nurse's next action? A. Apply oxygen at 2 L/min via nasal cannula. B. Stop the IV fluid infusion. C. Administer oral beta-blockers. D. Place the client in high-Fowler's position. ### 82. A client diagnosed with end-stage cirrhosis, severe ascites, and hepatorenal failure is prescribed a specialized diet. Which diet is appropriate? A. High-potassium, fluid-unrestricted diet B. Purine-restricted diet C. Low-sodium diet D. High-sodium, high-fat diet ### 83. A nurse is providing disease management education to a client with multiple sclerosis (MS). Which client statement reflects correct understanding? A. 'I will drink at least 2 liters of fluid daily.' B. 'I will take hot baths daily to relieve muscle spasms.' C. 'I will restrict my daily fluid intake to less than 1 liter.' D. 'I will avoid all daily physical exercise.' ### 84. A client with type 1 diabetes mellitus presents with a capillary blood glucose of 44 mg/dL and is difficult to arouse. What is the priority nursing action? A. Recheck blood glucose in 30 minutes. B. Encourage the client to drink regular soda. C. Administer IV dextrose or IM glucagon immediately. D. Administer 15 grams of oral carbohydrates. ### 85. Following a paracentesis, a client's urinary catheter bag reveals pink-tinged urine. What is the priority nursing action? A. Clamp the urinary catheter for 2 hours. B. Notify the healthcare provider immediately. C. Increase the IV infusion rate. D. Document the finding as expected. ### 86. A client who underwent a lumbar puncture reports a severe headache and the nurse notes clear fluid leakage on the dressing. Which position should the nurse place the client in? A. Flat supine position (lower the head of bed) B. High-Fowler's position C. Reverse Trendelenburg position D. Left lateral Trendelenburg position ### 87. An infant receiving phototherapy for hyperbilirubinemia displays sunken fontanels and dry mucous membranes. How should the nurse interpret these findings? A. Normal developmental variation in newborns B. Expected therapeutic response to bilirubin breakdown C. Adverse reaction indicating severe dehydration D. Sign of acute intracranial hypertension ### 88. A laboring client suddenly complains of dizziness and lightheadedness. Assessment reveals HR 120 bpm, BP 84/50 mmHg, and pale skin color. What action should the nurse take first? A. Prepare for immediate vaginal delivery. B. Administer an IV bolus of oxytocin. C. Turn the client onto her left side. D. Place the client in Trendelenburg position. ### 89. A client receiving chemotherapy denies experiencing nausea or vomiting. Which meal selection is most appropriate? A. Heavy cream pasta with garlic bread B. Raw oysters and unpasteurized milk C. Broiled chicken, green beans, and cottage cheese D. Spicy beef tacos with fried jalapenos ### 90. A client receiving new hearing aids demonstrates correct care teaching by making which statement? A. 'I will turn my hearing aids off before removing them from my ears.' B. 'I will spray hairspray directly around my ears while wearing the aids.' C. 'I will clean my hearing aids by soaking them in alcohol daily.' D. 'I will keep the hearing aid volume at maximum level constantly.' ### 91. A client with unstable angina experiences chest pain. Five minutes after taking 1 sublingual nitroglycerin tablet, the pain persists. What is the nurse's next immediate action? A. Administer a second sublingual nitroglycerin tablet. B. Instruct the client to perform a Valsalva maneuver. C. Administer oral aspirin 325 mg. D. Wait 15 minutes before taking any further action. ### 92. A nurse preceptor observes a new hire preparing an IV insertion site on the left arm of a client who underwent a left radical mastectomy. What action should the preceptor take? A. Intervene immediately and instruct the new hire to use the right arm. B. Apply a warm compress to the left arm prior to insertion. C. Assist the new hire with tourniquet placement on the left arm. D. Document the procedure in the medical record. ### 93. A client is receiving an IV magnesium sulfate infusion for preeclampsia. Which adverse effect should the nurse monitor for closely? A. Severe hypertension and hyperreflexia B. Hyperthermia and diarrhea C. Decrease in blood pressure and depressed deep tendon reflexes D. Tachycardia and tachypnea ### 94. A nurse is planning care for a client with obsessive-compulsive disorder (OCD) who performs repetitive handwashing rituals. What action should the nurse take first? A. Administer high-dose sedative medications immediately. B. Isolate the client in their room during ritual execution. C. Identify precipitating factors and triggers that increase anxiety. D. Forcibly stop the client from washing their hands. ### 95. A client with a new fiberglass cast on the lower leg demonstrates understanding of cast care when making which statement? A. 'I will insert a coat hanger into the cast to scratch itchy skin.' B. 'I should ignore any burning sensations under the cast.' C. 'I will submerge the cast completely in water during baths.' D. 'I can apply an ice pack over the cast site for the first 24 to 48 hours.' ### 96. A nurse is teaching parents of a child diagnosed with impetigo. Which instruction is essential to prevent contagion? A. 'Wash the child's towels and linens separately in hot water.' B. 'The child may share bath towels with siblings once lesions dry.' C. 'Pop the skin vesicles daily to promote healing.' D. 'Keep the child in strict home isolation for 3 weeks.' ### 97. A client presenting with eye complaints is evaluated for retinal detachment. Which clinical manifestations are characteristic? A. Severe eye pain and purulent conjunctival discharge B. Flashes of light, dark floating spots, and a curtain-like shadow over the visual field C. Loss of peripheral vision with intact central vision D. Halos around lights and elevated intraocular pressure ### 98. A nurse is preparing to remove surgical sutures from a client's healed abdominal incision. What is the correct technique? A. Cut the suture far from the skin and pull the exposed thread through the tissue. B. Pull the knot firmly upward and clip both sides of the knot simultaneously. C. Cut the suture with scissors as close as possible to the skin prior to removal. D. Soak the sutures in hydrogen peroxide for 30 minutes before pulling. ### 99. A client admitted with deep vein thrombosis (DVT) has a PTT of 100 seconds while receiving an IV heparin drip. What is the nurse's priority action? A. Encourage vigorous leg massage. B. Stop/turn off the heparin drip and notify the physician. C. Administer oral warfarin immediately. D. Increase the heparin infusion rate. ### 100. A client with Addison's disease is admitted in acute Addisonian crisis. Which medication should the nurse prepare to administer immediately? A. IV Furosemide B. Subcutaneous Regular Insulin C. Oral Metformin D. IV Hydrocortisone