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Question 1
A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old child. Which of the
following actions should the nurse take?
A. Tell the child the procedure will not hurt
B. Apply a topical anesthetic cream before insertion
C. Ask the parents to leave the room
D. Use only verbal explanation without demonstration
Correct Answer: B. Apply a topical anesthetic cream before insertion
Examiner’s Note:
School-age children benefit from pain-reduction strategies and honest preparation. Topical anesthetics
(e.g., EMLA) reduce procedural pain and anxiety. Never give false reassurance (“won’t hurt”). Parental
presence is usually beneficial.
Question 2
A nurse is caring for a client who has an arteriovenous (AV) fistula. Which of the following findings
should the nurse report immediately?
A. Palpable thrill
B. Audible bruit
C. Absence of bruit
D. Distended veins near the site
Correct Answer: C. Absence of bruit
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Examiner’s Note:
A functioning AV fistula should have both a thrill and bruit. Absence indicates possible clotting or
occlusion and requires urgent intervention to prevent loss of access.
Question 3
A nurse is providing discharge teaching for a client who has an implantable cardioverter-defibrillator
(ICD). Which of the following statements by the client indicates understanding?
A. “I will keep my cell phone at least 6 inches from the device.”
B. “I can place magnets directly over the ICD.”
C. “I will avoid all physical activity.”
D. “I should expect the device to shock me daily.”
Correct Answer: A. “I will keep my cell phone at least 6 inches from the device.”
Examiner’s Note:
Clients with ICDs should avoid strong electromagnetic interference. Cell phones should be kept at least 6
inches (15 cm) away. Magnets can deactivate the device. Regular activity is usually encouraged.
Question 4
A nurse is caring for a client who is at 14 weeks of gestation and reports feelings of ambivalence about
being pregnant. Which response should the nurse make?
A. “You should be excited about your pregnancy.”
B. “These feelings are common during pregnancy.”
C. “You need counseling immediately.”
D. “Try not to think negatively.”
Correct Answer: B. “These feelings are common during pregnancy.”
Examiner’s Note:
Ambivalence is normal in early pregnancy. The therapeutic response is to normalize feelings and
encourage expression, not to judge or minimize.
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Question 5
A nurse is planning care for a client who has a prescription for a bowel-training program following a
spinal cord injury. Which action should the nurse include?
A. Schedule bowel care at the same time each day
B. Perform digital stimulation randomly
C. Encourage a low-fiber diet
D. Limit fluid intake
Correct Answer: A. Schedule bowel care at the same time each day
Examiner’s Note:
Consistency is the cornerstone of bowel training. High fiber and adequate fluids are encouraged.
Random stimulation disrupts reflex training.
Question 6
A nurse is caring for a client in active labor who requests pain management. Which action should the
nurse take first?
A. Administer IV opioid immediately
B. Assess fetal heart rate and contraction pattern
C. Prepare for emergency cesarean birth
D. Encourage the client to delay medication
Correct Answer: B. Assess fetal heart rate and contraction pattern
Examiner’s Note:
Assessment precedes intervention in labor. The nurse must determine labor status and fetal well-being
before administering analgesia or anesthesia.
Question 7
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A nurse is caring for a client with heart failure who has gained 2 kg (4.4 lb) in 48 hours. Which action
should the nurse take first?
A. Notify the provider
B. Assess lung sounds
C. Restrict fluids
D. Administer a diuretic
Correct Answer: B. Assess lung sounds
Examiner’s Note:
Rapid weight gain suggests fluid overload. First step = further assessment to determine severity before
implementing or requesting interventions.
Question 8 (Select All That Apply)
A nurse is teaching a client about warfarin therapy. Which statements indicate understanding?
A. “I will use a soft-bristle toothbrush.”
B. “I should increase my intake of leafy greens suddenly.”
C. “I will have my INR checked regularly.”
D. “I will report unusual bruising.”
E. “I can take aspirin for headaches.”
Correct Answers: A, C, D
Examiner’s Note:
Soft toothbrush → prevents bleeding
Regular INR monitoring → essential
Report bruising → bleeding risk
Avoid sudden vitamin K increases and avoid aspirin unless prescribed.
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