(Questions 1-180)
1. A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old.
Which of the following actions should the nurse take?
◦ A. (Unable to read)
◦ B. Tell the child they will feel discomfort during the catheter insertion.
◦ C. Use a mummy restraint to hold the child during the catheter insertion.
◦ D. Require the parents to leave the room during the procedure.
◦ Correct Answer: B
◦ Rationale: Informing the child about expected discomfort prepares them,
reducing anxiety and aligning with age-appropriate communication. Mummy
restraints (C) are overly restrictive, and excluding parents (D) may increase
distress (Page 1).
2. A nurse is caring for a client who has an arteriovenous stula. Which of the
following ndings should the nurse report?
◦ A. Thrill upon palpation.
◦ B. Absence of a bruit.
◦ C. Distended blood vessels.
◦ D. Swishing sound upon auscultation.
◦ Correct Answer: B
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, ◦ Rationale: Absence of a bruit indicates potential stula occlusion, requiring
immediate reporting. Thrill (A), distended vessels (C), and swishing sound (D)
are normal ndings (Page 1).
3. A nurse is providing discharge teaching for a client who has an implantable
cardioverter de brillator. Which of the following statements demonstrates
understanding of the teaching?
◦ A. "I will soak in the tub rather than showering."
◦ B. "I will wear loose clothing around my ICD."
◦ C. "I will stop using my microwave oven at home because of my ICD."
◦ D. "I can hold my cellphone on the same side of my body as the ICD."
◦ Correct Answer: B
◦ Rationale: Loose clothing prevents irritation over the ICD site. Soaking in tubs
(A), avoiding microwaves (C), or holding phones on the same side (D) are
incorrect or unnecessary (Page 1).
4. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of
ambivalence about being pregnant. Which of the following responses should the
nurse make?
◦ A. "Describe your feelings to me about being pregnant."
◦ B. "You should discuss your feelings about being pregnant with your provider."
◦ C. "Have you discussed these feelings with your partner?"
◦ D. "When did you start having these feelings?"
◦ Correct Answer: A
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, ◦ Rationale: Asking the client to describe feelings encourages open communication
and exploration of ambivalence, supporting emotional health (Page 1).
5. A nurse is planning care for a client who has a prescription for a bowel-training
program following a spinal cord injury. Which of the following actions should the
nurse include in the plan of care?
◦ A. Encourage a maximum uid intake of 1,500 ml per day.
◦ B. Increase the amount of re ned grains in the client’s diet.
◦ C. Provide the client with a cold drink prior to defecation.
◦ D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
◦ Correct Answer: D
◦ Rationale: A rectal suppository stimulates bowel movement at scheduled times,
supporting the bowel-training program. Fluid intake should exceed 1,500 ml (A),
and re ned grains (B) may worsen constipation (Page 1).
6. A nurse is caring for a client who is in active labor and requests pain management.
Which of the following actions should the nurse take?
◦ A. Administer ondansetron.
◦ B. Place the client in a warm shower.
◦ C. Apply fundal pressure during contractions.
◦ D. Assist the client to a supine position.
◦ Correct Answer: B
◦ Rationale: A warm shower provides non-pharmacological pain relief during
labor. Ondansetron (A) is for nausea, fundal pressure (C) is unsafe, and supine
position (D) may reduce blood ow (Page 2).
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, 7. A nurse in an emergency department is performing triage for multiple clients
following a disaster in the community. To which of the following types of injuries
should the nurse assign the highest priority?
◦ A. Below-the-knee amputation.
◦ B. Fractured tibia.
◦ C. 95% full-thickness body burn.
◦ D. 10 cm (4 in) laceration to the forearm.
◦ Correct Answer: C
◦ Rationale: A 95% full-thickness burn is life-threatening due to extensive tissue
damage and risk of shock, requiring immediate attention (Page 2).
8. A nurse manager is updating protocols for the use of belt restraints. Which of the
following guidelines should the nurse include?
◦ A. Remove the client’s restraint every 4 hr.
◦ B. Document the client’s condition every 15 min.
◦ C. Attach the restraint to the bed’s side rails.
◦ D. Request a PRN restraint prescription for clients who are aggressive.
◦ Correct Answer: B
◦ Rationale: Documenting the client’s condition every 15 minutes ensures safety
and compliance with restraint protocols. Attaching to side rails (C) is unsafe, and
PRN prescriptions (D) are not allowed (Page 2).
9. A nurse is teaching an in-service about nursing leadership. Which of the following
information should the nurse include about an effective leader?