1. A nurse is caring for a client who is at 33 weeks of gestation following an
amniocentesis. The nurse should monitor the client for which of the following
complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions: D. Contractions
2. A nurse is providing teaching to an older adult client about methods to
promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1 hr if unable to fall asleep
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime: D. Eat a light snack before bedtime
3. A nurse on a telemetry unit is caring for a client who becomes unconscious
and whose monitor displays ventricular tachycardia. Which of the following
actions should the nurse take first after determining the client does not have
a palpable pulse?
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
D. Administer epinephrine: B. Defibrillate
,4. A nurse is admitting a client who 1 week postpartum and reports excessive
vaginal bleeding. The nurse does not speak the same language as the client.
The client's partner and 10-year-old child are accompanying her. Which of the
following actions should the
nurse take to gather the client's admission data?
A. Have the client's child translate
B. Allow the client's partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the client to
translate: C. Request a female interpreter through the facility
5. A nurse is caring for a client who is febrile. To reduce the client's fever, the
nurse applies a cooling blanket. Which of the following findings indicates the
client is having an adverse reaction to the cooling?
a. Flushing
b. Tachycardia
, c. Restlessness
d. Shivering: d. Shivering
6. A nurse is caring for a client who has deep-vein-thrombosis of the left lower
extremity. Which of the following actions should the nurse take? (Exhibit)
A. Position the client with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
C. Administer acetaminophen
D. Massage the affected extremity every 4 hr: B. Withhold heparin IV infusion
PTT- 30-40 seconds; x2 if on heparin
7. A nurse is reviewing assessment data from several clients. For which of the
following clients should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4): B. A client who
has a nonhealing leg ulcer
8. 8. A nurse is providing discharge teaching to a client who has a chronic kid-
ney disease and is receiving hemodialysis. Which of the following instructions
should the nurse include in the teaching?
a. Eat 1 g/kg of protein per day
b. Take magnesium hydroxide for indigestion
c. Drink at least 3 L of fluid daily-
Consume foods high in potassium- restrict: a. Eat 1 g/kg of protein per day
9. A nurse is caring for a client who is receiving intermittent enteral tube
feedings. Which of
the following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial?: B. A history of gastroesophageal reflux
disease
10. ?A nurse is providing prenatal teaching to a client who is at 12 weeks of
gestation. The nurse should tell the client that she will undergo which of the
following screening tests at 16 weeks of gestation?
A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
C. Nonstress test -28 weeks
, D. Maternal serum alpha-fetoprotein- 16 to 18 weeks: D. Maternal serum al-
pha-fetoprotein- 16 to 18 weeks
11. A nurse is caring for a client who is on bed rest. The nurse should recognize
that which of
the following findings is a complication of immobility?
A. Decreased serum calcium levels- increased serum calcium
B. Increased blood pressure- hypotension
C. Swollen area on calf
D. Urinary frequency-: C. Swollen area on calf
12. 12. A nurse in acute care mental health facility is participating in a medica-
tion-education group. The leader of the group uses a laissez-faire leadership
style. Which of the following actions should the nurse expect from the leader
during the session?
A .The leader encourages group members to remain silent until questions are
called for
B. The leader lecture about medication adverse effects to the group members
c. The leader allows the group to discuss whatever they would like to regarding
their
medications
d. The leader has group members vote on what they would like to learn about
during the session: d. The leader has group members vote on what they would like
to learn about during the session
13. A nurse is providing teaching about digoxin administration to the parents
of a toddler who has heart failure. Which of the following statements should
the nurse include in the teaching?
A "You can add the medication to a half-cup of your child's favorite juice."
B "Repeat the dose if your child vomits within 1 hour after taking medication."
X
C "Limit your child's potassium intake while she is taking this medication."
D "Have your child drink a small glass of water after swallowing the med-
ication.": D "Have your child drink a small glass of water after swallowing the
medication."
14. A nurse is providing teaching to a client who has a depressive disorder
and a new prescription for phenelzine. Which of the following foods should
the nurse instruct the
client to avoid?
A. Grapefruit
amniocentesis. The nurse should monitor the client for which of the following
complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions: D. Contractions
2. A nurse is providing teaching to an older adult client about methods to
promote nighttime
sleep. Which of the following instructions should the nurse include?
A. Stay in bed at least 1 hr if unable to fall asleep
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime: D. Eat a light snack before bedtime
3. A nurse on a telemetry unit is caring for a client who becomes unconscious
and whose monitor displays ventricular tachycardia. Which of the following
actions should the nurse take first after determining the client does not have
a palpable pulse?
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
D. Administer epinephrine: B. Defibrillate
,4. A nurse is admitting a client who 1 week postpartum and reports excessive
vaginal bleeding. The nurse does not speak the same language as the client.
The client's partner and 10-year-old child are accompanying her. Which of the
following actions should the
nurse take to gather the client's admission data?
A. Have the client's child translate
B. Allow the client's partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the client to
translate: C. Request a female interpreter through the facility
5. A nurse is caring for a client who is febrile. To reduce the client's fever, the
nurse applies a cooling blanket. Which of the following findings indicates the
client is having an adverse reaction to the cooling?
a. Flushing
b. Tachycardia
, c. Restlessness
d. Shivering: d. Shivering
6. A nurse is caring for a client who has deep-vein-thrombosis of the left lower
extremity. Which of the following actions should the nurse take? (Exhibit)
A. Position the client with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
C. Administer acetaminophen
D. Massage the affected extremity every 4 hr: B. Withhold heparin IV infusion
PTT- 30-40 seconds; x2 if on heparin
7. A nurse is reviewing assessment data from several clients. For which of the
following clients should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4): B. A client who
has a nonhealing leg ulcer
8. 8. A nurse is providing discharge teaching to a client who has a chronic kid-
ney disease and is receiving hemodialysis. Which of the following instructions
should the nurse include in the teaching?
a. Eat 1 g/kg of protein per day
b. Take magnesium hydroxide for indigestion
c. Drink at least 3 L of fluid daily-
Consume foods high in potassium- restrict: a. Eat 1 g/kg of protein per day
9. A nurse is caring for a client who is receiving intermittent enteral tube
feedings. Which of
the following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial?: B. A history of gastroesophageal reflux
disease
10. ?A nurse is providing prenatal teaching to a client who is at 12 weeks of
gestation. The nurse should tell the client that she will undergo which of the
following screening tests at 16 weeks of gestation?
A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
C. Nonstress test -28 weeks
, D. Maternal serum alpha-fetoprotein- 16 to 18 weeks: D. Maternal serum al-
pha-fetoprotein- 16 to 18 weeks
11. A nurse is caring for a client who is on bed rest. The nurse should recognize
that which of
the following findings is a complication of immobility?
A. Decreased serum calcium levels- increased serum calcium
B. Increased blood pressure- hypotension
C. Swollen area on calf
D. Urinary frequency-: C. Swollen area on calf
12. 12. A nurse in acute care mental health facility is participating in a medica-
tion-education group. The leader of the group uses a laissez-faire leadership
style. Which of the following actions should the nurse expect from the leader
during the session?
A .The leader encourages group members to remain silent until questions are
called for
B. The leader lecture about medication adverse effects to the group members
c. The leader allows the group to discuss whatever they would like to regarding
their
medications
d. The leader has group members vote on what they would like to learn about
during the session: d. The leader has group members vote on what they would like
to learn about during the session
13. A nurse is providing teaching about digoxin administration to the parents
of a toddler who has heart failure. Which of the following statements should
the nurse include in the teaching?
A "You can add the medication to a half-cup of your child's favorite juice."
B "Repeat the dose if your child vomits within 1 hour after taking medication."
X
C "Limit your child's potassium intake while she is taking this medication."
D "Have your child drink a small glass of water after swallowing the med-
ication.": D "Have your child drink a small glass of water after swallowing the
medication."
14. A nurse is providing teaching to a client who has a depressive disorder
and a new prescription for phenelzine. Which of the following foods should
the nurse instruct the
client to avoid?
A. Grapefruit
