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1. A nurse has delegated care to an assistive person- Tell the AP to contact the
nel. At the end of the shift, the Ap asks the nurse to IT department for charting
enter data for her because the AP has forgotten her assistance.
password and needs to leave. Which of the following
actions should the nurse take?
2. A nurse is reinforcing teaching about car seat safety to Rear-facing position in the
the parents of a newborn. The nurse should instruct back seat.
the parents to place the car seat in a....
3. A nurse is preparing a client for surgery. The client contact security personnel
tells the nurse that he is concerned about the safety to place the money in the
of a large sum of money in his wallet. Which of the facility safe.
following actions is appropriate for the nurse to take?
4. A nurse is caring for a toddler who is admitted to the Frequent Swallowing
pediatric unit and is 2 hr postoperative following a
tonsillectomy. Which of the following findings is a sign
on hemorrhage?
5. A nurse is reinforcing discharge teaching with an older Instruct the client to bear
adult client's family about safety precautions when down during rectal tube
administering a tap water enema to the client. Which insertion.
of the following should the nurse include?
6. A nurse is caring for a client. Which of the following "My heartburn pain is go-
client statements should the nurse attend first? ing into my jaw now"
7. A nurse is caring for a client who is 3 days postoper- Leave the drain insertion
ative following abdominal surgery and has a Penrose site open to air
drain. Which of the following actions should the nurse
take?
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8. A nurse is reinforcing with a client who is about to "You will have to drink a
undergo an upper gastrointestinal series with fluo- contrast medium before
roscopy. Which of the following information should the test."
the nurse provide?
9. A nurse is reviewing the medical record of a client who Hypernatremia
has sustained a full-thickness burn and is in the emer-
gent phase of burn. Which of the following findings
should the nurse expect?
10. A nurse is planing to administer an ophthalmic med- Wait 5 mins after instil-
ication to a client. Which of the following actions lation before instilling the
would minimize systemic absorption of the medica- drops in the other eye
tion?
11. A nurse is preparing morning medication for a client Furosemide
who has potassium level of 3.2 mEq/L. For which of
the following medications should the nurse withhold
administration and notify the provider?
12. A nurse is collecting data from a client who has Facial flushing
preeclampsia and is receiving magnesium sulfate via
a continuous IV infusion. Which of the following find-
ings should the nurse report to the provider?
13. A nurse in a provider'a office is collecting data from The client takes ibupro-
a client who was discharged from the hospital 7 days fen to treat musculosketal
ago following treatment from deep-vein thrombosis. pain.
Which of the following findings is the nurse's priority?
14. A nurse in an urgent care clinic is collecting data from Muscle weakness
a client who reports having diarrhea for the past 3
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days. Which of the following findings indicates hy-
pokalemia?
15. A nurse is participating in a performance improve- Client data indicates a de-
ment process to decrease the rate of health care-asso- creased rate of infection
ciated infections within the facility. The nurse should
recognize that which of the following is an appropriate
performance improvement outcome indicator?
16. A nurse is establishing a baseline postoperative as- The client's foot feels cool-
sessment for a client who is recovering from a right er than the previous as-
femoropopliteal bypass graft. Which of the following sessment
findings in the assessment of the clients's right leg
should be of the most concern to the nurse?
17. A nurse is preparing a client regimen. Which of the Aspart
following insulins can be mixed? Regular
Detemir
Lispro
Glargine cannot be mixed
with any insulin
18. A nurse is caring for a school-age child whose family Vitamin D
adheres to a vegan diet in the home. The nurse should
recognize the child is at risk for deficiency of which of
the following?
19. A nurse is reinforcing teaching with a postpartum Reducing the risk of new-
client. Which of the following should the nurse explain born abduction
as the most important reason for staff to wear identi-
fication?
20.
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A nurse is reinforcing teaching with a group of ex- I can place a rolled towel
pectant parents regarding the proper use of a car on each side of my new-
seat. Which of the following statements by the parent born's head until he can
indicates an understanding of the teaching? hold his head up.
21. A nurse on a mental health unit is discussing client A nurse must withdraw
rights with a group of coworkers. Which of the follow- consent for treatment in
ing statements should the nurse include? writing if he is competent
to do so.
22. A nurse from a medical-surgical unit is floating to a A client who had a cesare-
postpartum unit. Which of the following clients is an an delivery 24hr ago
appropriate assignment for the nurse to accept?
23. A nurse is caring for a client who is in mechanical Document in the client's
restraints after becoming violent with a staff member. medical record every 15
Which of the following actions should the nurse take? mins
24. A nurse is reinforcing teaching with the family of Administer schedule dos-
a client who is receiving palliative care for terminal es of medication from
cancer. Which of the following guidelines should the a patient-controlled anal-
nurse emphasize about appropriate pain control mea- gesia (PCA) pump.
sures?
25. A nurse is assisting with a group therapy session in schedule one-on-one dis-
which a client begins to monopolize the group's time. cussion time with the
Which of the following interventions is appropriate? client
26. A nurse is preparing to administer required immu- "You should avoid admin-
nization to a toddler during a well-child visit. The par- istering aspirin to your
ent ask the nurse how many baby aspirin he should child"
administer if the toddler develops a fever. Which of the
following responses should the nurse make?