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1. A nurse is assessing a client who has a diagnosis on colon cancer which
of the following should the nurse expect?
a) Statorrhea
b) Elevated hemoglobin
c) Hematochezia
d) Weight gain: Hematochezia
2. A nurse is assessing a client admitted with peripheral vascular disease,.
Which of the following findings indicates a venous vascular disorder?
a) An ulcer at the tip of a toe
b) Hair loss distal to the clients calves
c) Leg pain at rest
d) Edema of the ankle: Edema of the ankle
3. A nurse is assessing a client who has pericarditis. In which of the following
areas of the client's chest should the nurse place the stethoscope to best hear
a pericardial friction rub?
A) right 4th intercostal
B) left 4th intercostal
C) right nipple line
D) left lower sternal boarder: D) apical pulse
4. A nurse is caring for a client who has a chest tube. The client asks why
the fluid in the water-seal chamber rises and falls. Which of the following
statements should the nurse make?
a) " this means your lung is fully expanded "
b) " this indicates a possible leak"
c) " suction pressure that is too high causes this"
d) " Your breathing pattern causes this": d) " Your breathing pattern causes this"
5. A community health nurse is reviewing home care instructions with an older
adult client who has a new diagnosis of heart failure. Which of the following
is the priority topic for the nurse to review with the client?
a) Daily sodium restriction
b) Daily exercise routine
c) Changes in weight
d) Fluid intake record: C) changes in weight
6. A nurse is teaching a client about the use of transcutaneous electrical nerve
stimulation (TENS) unit. Which of the following statements should the nurse
include?
a) "Apply lotion to the site prior to attaching the electrodes"
b) " this device requires access to a 220 volt outlet"
c) ' this device delivers heat via electrodes that are attached to the effected
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area"
d) "adjust the dial until you feel a 'pins and needles' sensation": d) "adjust the
dial until you feel a 'pins and needles' sensation"
7. A nurse is providing teaching to a client who is postoperative following
a total hip arthroplasty. Which of the following statements should the nurse
make?
a) " use raised toilet seat to maintain your hips above the knees"
b) " twist at the waist when standing from a seated position"
c) "move your stronger leg first when using a walker"
d) " apply a heating pad to the operative hip to decrease pain": a) " use raised
toilet seat to maintain your hips above the knees"
8. A nurse finds a client in bed, unresponsive and breathing. Which of the
following action should the nurse take first?
a) Establish IV access
b) Apply blood pressure cuff
c) Palpate for the client's carotid pulse
d) Initiate cardiac monitoring for the client: c) Palpate for the client's carotid pulse
9. A nurse is caring for a patient who is experiencing a hypertensive crisis.
Which of the following actions should the nurse take?
a) Initiate IV dopamine infusion
b) Perform neurological assessments
c) Place the client supine
d) Begin an IV bolus of lacted ringer's: b) Perform neurological assessments
10. A nurse is providing discharge teaching about blood sugar monitoring for
a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should
instruct the client to obtain which of the following supplies?
a) Sterile lancets
b) Compression stockings
c) Hand mirror
d) toenail clippers: c) hand mirror
11. A nurse is completing discharge teaching to a patient who has a peripher-
ally inserted central catheter ( PICC) line in the left arm. Which of the following
instructions should the nurse include in the teaching?
a) Do not elevate the arm above the level of the heart
b) Change the catheter dressing daily
c) Use 10- mL syringe to flush line
d) Clean the insertion site using 20- mL of hydrogen peroxide: c) Use 10- mL
syringe to flush line
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12. A nurse is preparing naloxone 10 mcg/kg via IV bolus to a client who
weights 220 lbs. the amount available is 0.4 mg/mL . how many mL should
the nurse administer? ( round to the nearest tenth): 2.5ml
13. A nurse is caring for a client who has a sealed radiation implant. Which of
the following actions should the nurse take?
a) Remove soiled linens from the room after each change
b) Give the dosimeter badge to the oncoming nurse at the end of the shift
c) Apply a second pair of gloves before touching the client's implant if it
dislodges
d) Limit family member visits to 30 min per day: d) Limit family member visits to
30 min per day
14. A nurse is providing teaching to a client and his partner about performing
peritoneal dialysis at home. When discussing peritonitis, which of the follow-
ing manifestations should the nurse identify as the earliest indication of this
complication?
a) Generalized abdominal pain
b) Cloudy effluent
c) Increased heart rate
d) Fever: b) cloudy effluent
15. A nurse is caring for a client who is receiving a blood transfusion. The
nurse observes that the client has bounding peripheral pulses, hypertension,
and distended jugular veins. The nurse should anticipate administering which
of the following prescribed medications?
a) Pantoprazole
b) Acetaminophen
c) Furosemide
d) Diphenhydramine: c) Furosemide
Pantoprazole -PPI, decreases acid production
Acetaminophen -analgesic, pain control
Diphenhydramine -antihistamine
16. A nurse is planning care for a client who has upper gastrointestinal bleed-
ing due to a peptic ulcer. Which of the following actions should the nurse plan
to take?
a) Provide ketorolac for abdominal pain
b) Administer nitroprusside IV based on the client's weight
c) Insert a large bore nasogastric tube
d) Ensure that the client has a 22- gauge iv line in place: c) Insert a large bore
nasogastric tube