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At First Attempt
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks
the nurse "What is our major concern now, and what will we have to deal with in the
future?" Which of the following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to a support group that
the family can attend." -Correct Answer C) "Thin, tenacious secretions from the lungs
are a constant struggle in cystic fibrosis."
A 20 year-old client has an infected leg wound from a motorcycle accident, and the
client has returned home from the hospital. The client is to keep the affected leg
elevated and is on contact precautions. The client wants to know if visitors can come.
The appropriate response from the home health nurse is that:
A) Visitors must wear a mask and a gown
B) There are no special requirements for visitors of clients on contact precautions
C) Visitors should wash their hands before and after touching the client
D) Visitors -Correct Answer C) Visitors should wash their hands before and after
touching the client
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the
nurse that the prescribed dosage is too high for this client? The client experiences:
A. Bradycardia and constipation
B. Lethargy and lack of appetite
C. Muscle cramping and dry, flushed skin
D. Palpitations and shortness of breath -Correct Answer D. Palpitations and shortness
of breath
A 30 month-old child is admitted to the hospital unit. Which of the following toys would
be appropriate for the nurse to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball -Correct Answer B) Large wooden puzzle
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
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D) Recommend relaxation exercises for pain control -Correct Answer C) Administer the
prescribed analgesia
A 38 year-old female client is admitted to the hospital with an acute exacerbation of
asthma. This is her third admission for asthma in 7 months. She describes how she
doesn't really like having to use her medications all the time. Which explanation by the
nurse best describes the long-term consequence of uncontrolled airway inflammation?
A) Degeneration of the alveoli
B) Chronic broncho constriction of the large airways
C) Lung remodeling and permanent changes in lung function
D) Frequent pneumonia -Correct Answer C) Lung remodeling and permanent changes
in lung function
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is
awake and alert, but has not been able to void since he returned from surgery 6 hours
ago.He received 1000 mL of IV fluid. Which action would be most likely to help him
void?
A) Have him drink several glasses of water
B) Crede' the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again -Correct Answer C) Assist him to stand
by the side of the bed to void
A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-
to-10 scale. The client refuses all pain medication other than Motrin, which does not
relieve his pain. The next action for the nurse to take is to
A) Ask the client about the refusal of certain pain medications
B) Talk with the client's family about the situation
C) Report the situation to the health care provider
D) Document the situation in the notes -Correct Answer A) Ask the client about the
refusal of certain pain medications
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal
meningitis. Which admission orders should the nurse do first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h -Correct Answer C) Place in
respiratory/secretion precautions
A client asks the nurse to call the police and states: "I need to report that I am being
abused by a nurse." The nurse should first
A) Focus on reality orientation to place and person
B) Assist with the report of the client's complaint to the police
C) Obtain more details of the client's claim of abuse
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D) Document the statement on the client's chart with a report to the manager -Correct
Answer C) Obtain more details of the client's claim of abuse
A client develops volume overload from an IV that has infused too rapidly. What
assessment would the nurse expect to find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation -Correct Answer A) S3 heart sound
A client frequently admitted to the locked psychiatric unit repeatedly compliments and
invites one of the nurses to go out on a date. The nurse's response should be to
A) Ask to not be assigned to this client or to work on another unit
B) Tell the client that such behavior is inappropriate
C) Inform the client that hospital policy prohibits staff to date clients
D) Discuss the boundaries of the therapeutic relationship with the client -Correct Answer
D) Discuss the boundaries of the therapeutic relationship with the client
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of
bipolar illness. When planning client teaching, what is most important to emphasize to
the client?
A) Maintain a low sodium diet
B) Take a diuretic with lithium
C) Come in for evaluation of serum lithium levels every 1-3 months
D) Have blood lithium levels drawn during the summer months -Correct Answer D)
Have blood lithium levels drawn during the summer months
A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She
suddenly experiences torticollis and involuntary spastic muscle movement. In addition to
administering the ordered anticholinergic drug, what other measure should the nurse
implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer PRN dose of IM antipsychotic medication -Correct Answer A) Have
respiratory support equipment available
A client has returned from a cardiac catheterization. Which one of the following
assessments would indicate the client is experiencing a complication from the
procedure?
A) Increased blood pressure
B) Increased heart rate
C) Loss of pulse in the extremity
D) Decreased urine output -Correct Answer C) Loss of pulse in the extremity
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At First Attempt
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks
the nurse "What is our major concern now, and what will we have to deal with in the
future?" Which of the following is the best response?
A) "There is a probability of life-long complications."
B) "Cystic fibrosis results in nutritional concerns that can be dealt with."
C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."
D) "You will work with a team of experts and also have access to a support group that
the family can attend." -Correct Answer C) "Thin, tenacious secretions from the lungs
are a constant struggle in cystic fibrosis."
A 20 year-old client has an infected leg wound from a motorcycle accident, and the
client has returned home from the hospital. The client is to keep the affected leg
elevated and is on contact precautions. The client wants to know if visitors can come.
The appropriate response from the home health nurse is that:
A) Visitors must wear a mask and a gown
B) There are no special requirements for visitors of clients on contact precautions
C) Visitors should wash their hands before and after touching the client
D) Visitors -Correct Answer C) Visitors should wash their hands before and after
touching the client
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter,
and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the
nurse that the prescribed dosage is too high for this client? The client experiences:
A. Bradycardia and constipation
B. Lethargy and lack of appetite
C. Muscle cramping and dry, flushed skin
D. Palpitations and shortness of breath -Correct Answer D. Palpitations and shortness
of breath
A 30 month-old child is admitted to the hospital unit. Which of the following toys would
be appropriate for the nurse to select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball -Correct Answer B) Large wooden puzzle
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
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D) Recommend relaxation exercises for pain control -Correct Answer C) Administer the
prescribed analgesia
A 38 year-old female client is admitted to the hospital with an acute exacerbation of
asthma. This is her third admission for asthma in 7 months. She describes how she
doesn't really like having to use her medications all the time. Which explanation by the
nurse best describes the long-term consequence of uncontrolled airway inflammation?
A) Degeneration of the alveoli
B) Chronic broncho constriction of the large airways
C) Lung remodeling and permanent changes in lung function
D) Frequent pneumonia -Correct Answer C) Lung remodeling and permanent changes
in lung function
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is
awake and alert, but has not been able to void since he returned from surgery 6 hours
ago.He received 1000 mL of IV fluid. Which action would be most likely to help him
void?
A) Have him drink several glasses of water
B) Crede' the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again -Correct Answer C) Assist him to stand
by the side of the bed to void
A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0-
to-10 scale. The client refuses all pain medication other than Motrin, which does not
relieve his pain. The next action for the nurse to take is to
A) Ask the client about the refusal of certain pain medications
B) Talk with the client's family about the situation
C) Report the situation to the health care provider
D) Document the situation in the notes -Correct Answer A) Ask the client about the
refusal of certain pain medications
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal
meningitis. Which admission orders should the nurse do first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h -Correct Answer C) Place in
respiratory/secretion precautions
A client asks the nurse to call the police and states: "I need to report that I am being
abused by a nurse." The nurse should first
A) Focus on reality orientation to place and person
B) Assist with the report of the client's complaint to the police
C) Obtain more details of the client's claim of abuse
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D) Document the statement on the client's chart with a report to the manager -Correct
Answer C) Obtain more details of the client's claim of abuse
A client develops volume overload from an IV that has infused too rapidly. What
assessment would the nurse expect to find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation -Correct Answer A) S3 heart sound
A client frequently admitted to the locked psychiatric unit repeatedly compliments and
invites one of the nurses to go out on a date. The nurse's response should be to
A) Ask to not be assigned to this client or to work on another unit
B) Tell the client that such behavior is inappropriate
C) Inform the client that hospital policy prohibits staff to date clients
D) Discuss the boundaries of the therapeutic relationship with the client -Correct Answer
D) Discuss the boundaries of the therapeutic relationship with the client
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of
bipolar illness. When planning client teaching, what is most important to emphasize to
the client?
A) Maintain a low sodium diet
B) Take a diuretic with lithium
C) Come in for evaluation of serum lithium levels every 1-3 months
D) Have blood lithium levels drawn during the summer months -Correct Answer D)
Have blood lithium levels drawn during the summer months
A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She
suddenly experiences torticollis and involuntary spastic muscle movement. In addition to
administering the ordered anticholinergic drug, what other measure should the nurse
implement?
A) Have respiratory support equipment available
B) Immediately place her in the seclusion room
C) Assess the client for anxiety and agitation
D) Administer PRN dose of IM antipsychotic medication -Correct Answer A) Have
respiratory support equipment available
A client has returned from a cardiac catheterization. Which one of the following
assessments would indicate the client is experiencing a complication from the
procedure?
A) Increased blood pressure
B) Increased heart rate
C) Loss of pulse in the extremity
D) Decreased urine output -Correct Answer C) Loss of pulse in the extremity
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