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Question: 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?
Options:
A. (Unreadable option)
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.
Answer: B. Tell the child they will feel discomfort during the catheter insertion.
Rationale: Children should be prepared for procedures in an age-appropriate way,
including honest but simple explanations about what to expect. Using restraints or
excluding parents unnecessarily can increase anxiety.
Question: A nurse is caring for a client who has an arteriovenous fistula. Which of the
following findings should the nurse report?
Options:
A. Thrill upon palpation
B. Absence of a bruit
C. Distended blood vessels
D. Swishing sound upon auscultation
Answer: B. Absence of a bruit
Rationale: A bruit is a normal finding over a functioning arteriovenous fistula. Its absence
may indicate thrombosis or other complications and should be reported immediately.
Question: A nurse is providing discharge teaching for a client who has an implantable
cardioverter defibrillator (ICD). Which statement demonstrates understanding?
Options:
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”
Answer: B. “I will wear loose clothing around my ICD”
Rationale: Loose clothing prevents irritation of the ICD site. Clients can generally shower
but should avoid soaking until the incision is fully healed. Microwaves and cellphones are
safe if not held directly over the ICD.
Question: A nurse is caring for a client who is 14 weeks gestation and reports ambivalence
about being pregnant. Which response should the nurse make?
Options:
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?”
Answer: A. “Describe your feelings to me about being pregnant”
Rationale: Encouraging open discussion allows the client to verbalize feelings, supporting
emotional processing and building trust. Directing the client elsewhere or asking closed
questions limits therapeutic engagement.
Question: A nurse is planning care for a client with a bowel-training program following a
spinal cord injury. Which action should be included?
Options:
A. Encourage a maximum fluid intake of 1,500 ml per day
B. Increase refined grains in the diet
C. Provide a cold drink prior to defecation
D. Administer a rectal suppository 30 minutes before scheduled defecation
Answer: D. Administer a rectal suppository 30 minutes before scheduled defecation
Rationale: Timing the suppository before scheduled defecation helps establish a
predictable bowel routine. Adequate fluids and fiber are encouraged, and cold drinks are
generally not recommended to stimulate defecation in this population.
Question: A nurse is caring for a client in active labor who requests pain management.
Which action should the nurse take?
,Options:
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
Answer: B. Place the client in a warm shower
Rationale: Warm water can reduce labor pain and promote relaxation. Fundal pressure is
unsafe. Supine position can decrease placental perfusion. Ondansetron is an antiemetic,
not a pain management intervention.
Question: A nurse in the emergency department is performing triage after a disaster.
Which client should be assigned the highest priority?
Options:
A. Below-the-knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10 cm laceration to the forearm
Answer: C. 95% full-thickness body burn
Rationale: Life-threatening injuries with the highest risk of mortality receive the highest
triage priority. Severe burns compromise multiple systems and require immediate
intervention.
Question: A nurse manager is updating protocols for the use of belt restraints. Which
guideline should be included?
Options:
A. Remove the client’s restraint every 4 hours
B. Document the client’s condition every 15 minutes
C. Attach the restraint to the bed’s side rails
D. Request a PRN restraint prescription for aggressive clients
Answer: B. Document the client’s condition every 15 minutes
Rationale: Frequent monitoring ensures safety and allows timely removal if the client’s
condition changes. Restraints should never be tied to side rails due to injury risk, and
removal frequency depends on policy and client needs.
, Question: A nurse is teaching an in-service about effective nursing leadership. Which
statement describes an effective leader?
Options:
A. Acts as an advocate for the nursing unit
B. (Unreadable)
C. Prioritizes staff requests over client needs
D. Provides routine client care and documentation
Answer: A. Acts as an advocate for the nursing unit
Rationale: Effective nurse leaders advocate for staff and patient needs, support the team,
and facilitate quality care rather than focusing solely on routine tasks.
Question: A nurse is reviewing lab results for a client with diabetes mellitus. Which finding
indicates a need to revise the client’s plan of care?
Options:
A. Serum sodium 144 mEq/L
B. (Unreadable)
C. HbA1c 10%
D. Random serum glucose 190 mg/dL
Answer: C. HbA1c 10%
Rationale: HbA1c of 10% indicates poor long-term glucose control, signaling that the
current care plan is ineffective and requires adjustment.
Question: A nurse is reviewing lab results for clients in a provider’s office. Which STI is
nationally notifiable and must be reported to the state health department?
Options:
A. Chlamydia
B. Human papillomavirus
C. Candidiasis
D. Herpes simplex virus
Answer: A. Chlamydia
Rationale: Chlamydia is a nationally notifiable disease. HPV, candidiasis, and HSV are not
required to be reported in most states.