2023
1. A nurse in an emergency department is assessing a client who reports
ingesting thirty diazepam tablets (Unable to read) a respiratory rate of
10/min. After securing the client's airway and initiating an IV, which of the
following actions should the nurse do next.
A. Monitor the client's IV site for thrombophlebitis.
B. Administer flumazenil to the client.
C. Evaluate the client for further suicidal behavior.
D. Initiate seizure precautions for the client.
B. Administer flumazenil to the client.
2. A nurse in an emergency department is caring for a client who reports
cocaine use 1hr ago. Which of the following findings should the nurse
expect?
A. Hypotension
B. Memory loss
C. Slurred speech
D. Elevated temperature
D. Elevated temperature
3. A nurse is assessing a newborn who has a blood glucose level of 30
mg/dl. Which of the following manifestations should the nurse expect?
A. Loose stools
B. Jitteriness
C. Hypertonia
D. Abdominal distention
,Jitteriness
3. A nurse in a pediatric clinic is reviewing the laboratory test results of a
school age child. Which of the following findings should the nurse report to
the provider?
A. Hgb 12.5 g/dl
B. Platelets 250,000/mm3
C. Hct 40%
D. WBC 14,000/mm3
D. WBC 14,000/mm3
4. A charge nurse is teaching a newly licensed nurse about clients
designating a health care proxy in situations that require a durable power of
attorney for heal care (DPSHC). Which of the following information should the
charge nurse include?
A. "The proxy should make health care decisions for the client regardless
of the client's ability to do so."
B. "The proxy can make financial decisions if the need arises."
C. "The proxy can make treatment decisions if the client is under
anesthesia."
D. "The proxy should manage legal issues for the client."
C. "The proxy can make treatment decisions if the client is under anesthesia."
4. A nurse in the PACU is caring for a client who reports nausea. Which of
the following actions should the nurse take first?
A. Turn the client on their side.
B. Administer an analgesic
C. Administer antiemetic
D. Monitor the client's vital signs.
A. Turn the client on their side.
5. A nurse is caring for a client who has a history of depression and is
experiencing a situational crisis. Which of the following actions should the
nurse take first?
A. Confirm the client's perception of the event
B. Notify the client's support system
,C. Help the client identify personal strengths
D. Teach the client relaxation techniques
A. Confirm the client's perception of the event
6. A nurse is caring for a client who has bipolar disorder and is experiencing
acute mania. The nurse obtained a verbal prescription for restraints. Which
of the following actions should the nurse take?
A. Request a renewal of the prescription every 8 hr.
B. Check the client's peripheral pulse rate every 30 min
C. Obtain a prescription for restraint within 4 hr.
D. Document the client's condition every 15 minutes.
D. Document the client's condition every 15 minutes.
7. A charge nurse on a medical-surgical unit is planning assignments for a
licensed practical nurse (LPN) who has been sent from the (Unable to read)
unit due to a staffing shortage. Which of the following client should the nurse
delegate to the LPN?
A. A client who has an Hgb of 6.3 g/dl and a prescription for packed RBCs.
B. A client who sustained a concussion and has unequal pupils.
C. A client who is postoperative following a bowel resection with an NG
tube set to continuous suction.
D. A client who fractured his femur yesterday and is experiencing
shortness of breath.
C. A client who is postoperative following a bowel resection with an NG tube set
to continuous suction.
8. A nurse is working on a surgical unit is developing a care plan for a client who
has paraplegia. The client has an area of nonbankable erythema over his
ischium. Which of the following interventions should the nurse include in the
care plan?
A. Place the client upright on a donut-shaped cushion
B. Teach the client to shift his weight every 15 min while sitting
C. Turn and reposition the client every 3 hr while in bed
D. Assess pressure points every 24 hr
A. Place the client upright on a donut-shaped cushion
, 9A nurse is caring for a client who is dilated to 10 cm and pushing. Which
of the following pain-management is a safe option for the client?
A. Naloxone hydrochloride.
B. Spinal anesthesia.
C. Pudendal block.
D. Butorphanol tartrate.
C. Pudendal block.
10. A nurse is assessing a client who has major depressive disorder. Which of
the following findings should the nurse identify as the priority (Most
important?)
A. The client changes the subject when future plans are mentioned.
B. The client talks about being in pain constantly.
C. The client sleeping over 12 hr. each day.
D. The client reports giving away personal items.
D. The client reports giving away personal items.
12. A nurse is providing teaching about immunizations to a client who is
pregnant. The nurse should inform the client that she can receive which of
the following immunizations during pregnancy? (Select all that apply)
A. Varicella vaccine.
B. Inactivated polio vaccine.
C. Tetanus diphtheria and acellular pertussis vaccine
D. Rubella vaccine.
E. Inactivated influenza vaccine.
C,E
13. A nurse is caring for a client who has end-stage kidney disease. The client's
adult child asks the nurse about becoming a living kidney donor for her father.
Which of the following condition in the child's medical history should the nurse
identify as a contraindication to the procedure?
A. Amputation
B. Osteoarthritis
C. Hypertension
D. Primary glaucoma