Question 1
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On
the basis of these findings, the nurse should implement which action?
A. Remove the IV
B. Apply a warm compress
C. Check for a blood return
D. Measure the area of infiltration
ANSWER
Answer: a
Determine if pt is experiencing infiltration. Next, consider the harmful effects of infiltra-
tion & determine which action to implement. Because infiltration can be damaging to the
surrounding tissue, the appropriate action is to remove the IV to prevent further damage.
Question 2
The nurse has received the client assignment for the day. Which client should the nurse as-
sess first?
A. The client who needs to receive subcutaneous insulin before breakfast
B. The client who has a nasogastric tube attached to intermittent suction
C. The client who is 2 days postop and is complaining of incisional pain
1
,D. The client who has a blood glucose level of 50mg/dl (2.8 mmol/L) and complains of
blurred vision
ANSWER
Answer: d
First establish priorities by comparing each client and deciding which is more urgent. The
client described in the correct option has a blood glucose level and symptoms reflective of
hypoglycemia. This client should be assessed first so that treatment can be implemented.
Question 3
The nurse is choosing age-appropriate toys for a toddler. Which toy is the BEST choice for
this age?
A. Puzzle
B. Toy soldiers
C. Large stacking blocks
D. A card game with large pictures
ANSWER
Answer: c
Toddlers like to master activities independently, such as stacking blocks. Because toddlers
do not have the developmental ability to determine what could be harmful, toys that are
safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in
the mouth and may be harmful for a toddler. A card game with large pictures may require
cooperative play, which is more appropriate for a school-aged child.
Question 4
2
,The nurse prepares to care for a client on contact precautions who has a hospital-acquired
infection caused by MRSA. The client has an abdominal wound that requires irrigation and
has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning.
The nurse should assemble which necessary protective items before entering the clients
room?
A. Gloves and gown
B. Gloves and face shield
C. Gloves, gown, face shield
D. Gloves, gown, and shoe protectors
ANSWER
Answer: c
By considering possible transmission of infection, based on clients condition due to
splashes of infective material that can occur during wound irrigation or suctioning trache-
ostomy.
Question 5
A patient with coronary artery disease has selected guided imagery to help cope with psy-
chological stress. Which client statement indicates an understanding of this stress reduction
measure?
A. "This will help only if I play music at the same time."
B. "This will work for me only if I am in a quiet area."
C. "I need to do this only when I lie down in case I fall asleep"
D. "The best thing about this is that I can use it anywhere, anytime."
ANSWER
Answer: d
3
, Guided imagery involves the client creating an image in the mind, concentrating on the im-
age, and gradually becoming less aware of the offending stimulus. It can be done anytime,
anywhere; some clients may use other relaxation techniques or play music with it.
Question 6
A client with Parkinson's disease develops akinesia while ambulating, increasing risk for falls.
Which suggestion should the nurse provide to the client to alleviate this problem?
A. Use a wheelchair to move around
B. Stand erect and use a cane to ambulate
C. Keep the feet close together while ambulating and use a walker
D. Consciously think about walking over imaginary lines on the floor
ANSWER
Answer: d
Clients with PD can develop bradykinesia or akinesia (freezing or no movement). Having
these clients imagine lines on the floor to walk over can keep them moving forward while
remaining safe.
Question 7
An MRI study is prescribed for a client with a suspected brain tumor. The nurse should im-
plement which action to prepare the client for this test?
A. Shave the groin for insertion of a femoral catheter
B. Remove all metal-containing objects from the client
C. Keep the client NPO for 6 hours before test
D. Instruct the client in inhalation techniques for the administration of the radioisotope
4
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On
the basis of these findings, the nurse should implement which action?
A. Remove the IV
B. Apply a warm compress
C. Check for a blood return
D. Measure the area of infiltration
ANSWER
Answer: a
Determine if pt is experiencing infiltration. Next, consider the harmful effects of infiltra-
tion & determine which action to implement. Because infiltration can be damaging to the
surrounding tissue, the appropriate action is to remove the IV to prevent further damage.
Question 2
The nurse has received the client assignment for the day. Which client should the nurse as-
sess first?
A. The client who needs to receive subcutaneous insulin before breakfast
B. The client who has a nasogastric tube attached to intermittent suction
C. The client who is 2 days postop and is complaining of incisional pain
1
,D. The client who has a blood glucose level of 50mg/dl (2.8 mmol/L) and complains of
blurred vision
ANSWER
Answer: d
First establish priorities by comparing each client and deciding which is more urgent. The
client described in the correct option has a blood glucose level and symptoms reflective of
hypoglycemia. This client should be assessed first so that treatment can be implemented.
Question 3
The nurse is choosing age-appropriate toys for a toddler. Which toy is the BEST choice for
this age?
A. Puzzle
B. Toy soldiers
C. Large stacking blocks
D. A card game with large pictures
ANSWER
Answer: c
Toddlers like to master activities independently, such as stacking blocks. Because toddlers
do not have the developmental ability to determine what could be harmful, toys that are
safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in
the mouth and may be harmful for a toddler. A card game with large pictures may require
cooperative play, which is more appropriate for a school-aged child.
Question 4
2
,The nurse prepares to care for a client on contact precautions who has a hospital-acquired
infection caused by MRSA. The client has an abdominal wound that requires irrigation and
has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning.
The nurse should assemble which necessary protective items before entering the clients
room?
A. Gloves and gown
B. Gloves and face shield
C. Gloves, gown, face shield
D. Gloves, gown, and shoe protectors
ANSWER
Answer: c
By considering possible transmission of infection, based on clients condition due to
splashes of infective material that can occur during wound irrigation or suctioning trache-
ostomy.
Question 5
A patient with coronary artery disease has selected guided imagery to help cope with psy-
chological stress. Which client statement indicates an understanding of this stress reduction
measure?
A. "This will help only if I play music at the same time."
B. "This will work for me only if I am in a quiet area."
C. "I need to do this only when I lie down in case I fall asleep"
D. "The best thing about this is that I can use it anywhere, anytime."
ANSWER
Answer: d
3
, Guided imagery involves the client creating an image in the mind, concentrating on the im-
age, and gradually becoming less aware of the offending stimulus. It can be done anytime,
anywhere; some clients may use other relaxation techniques or play music with it.
Question 6
A client with Parkinson's disease develops akinesia while ambulating, increasing risk for falls.
Which suggestion should the nurse provide to the client to alleviate this problem?
A. Use a wheelchair to move around
B. Stand erect and use a cane to ambulate
C. Keep the feet close together while ambulating and use a walker
D. Consciously think about walking over imaginary lines on the floor
ANSWER
Answer: d
Clients with PD can develop bradykinesia or akinesia (freezing or no movement). Having
these clients imagine lines on the floor to walk over can keep them moving forward while
remaining safe.
Question 7
An MRI study is prescribed for a client with a suspected brain tumor. The nurse should im-
plement which action to prepare the client for this test?
A. Shave the groin for insertion of a femoral catheter
B. Remove all metal-containing objects from the client
C. Keep the client NPO for 6 hours before test
D. Instruct the client in inhalation techniques for the administration of the radioisotope
4
