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Question 1
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
Correct Answer: A
Rationale: Enalapril is an ACE inhibitor. Priority is to check blood pressure due to risk of
first-dose hypotension.
Question 2
A client is scheduled to undergo an upper gastrointestinal (GI) series. Which statement by the
client indicates a need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on
the morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink
for the test can be constipating."
Correct Answer: C
Rationale: Upper GI series requires only NPO status. Laxative/enema prep is for lower GI
series. Barium can cause constipation, so laxative is given after the test.
Question 3
A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's answering
service and is told that the physician is off for the night and will be available in the morning. The
nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
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D. Administer the medication but consult the physician when he becomes available
Correct Answer: B
Rationale: The nurse has identified a potential medication error. According to the chain of
command and safety standards, any questionable or unsafe order must be clarified before
administration. The most appropriate action is to have the on-call physician contacted
immediately for clarification or a new order. Withholding until morning may delay needed
treatment, and administering an incorrect dose violates patient safety.
Question 4
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial
infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the
sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's
carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action
by the nurse is:
A. Document the findings
B. Ask the ED physician to check the client
C. Continue to monitor the client’s cardiac status
D. Inform the client that PVCs are expected after an MI
Correct Answer: B
Non-perfusing PVCs in the context of suspected myocardial infarction require immediate
medical evaluation. The physician needs to assess the client and determine if
antiarrhythmic treatment or other intervention is needed.
Question 5
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the
client's record and notes that the client routinely takes an oral antihypertensive medication each
morning. The nurse should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration the day after ECT
Correct Answer: A
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Rationale: Most oral medications, including antihypertensives, can be given with a small
sip of water before ECT unless specifically contraindicated. Withholding blood pressure
medication could cause rebound hypertension.
Question 6
A client who recently underwent coronary artery bypass graft surgery comes to the physician's
office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed.
Which response by the nurse is therapeutic?
A. “Tell me more about what you’re feeling.”
B. “That’s a normal response after this type of surgery.”
C. “It will take time, but, I promise you, you will get over this depression.”
D. “Every client who has this surgery feels the same way for about a month.”
Correct Answer: A
Rationale: This is an open-ended therapeutic communication technique that encourages the
client to express feelings and shows empathy.
Question 7
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse
notes that the fluid is yellow and has a strong odor. Which of the following actions should be the
nurse's priorit:
A. Contacting the physician
B. Documenting the findings
C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR
Correct Answer: A
Rationale: Yellow fluid with a foul odor suggests possible chorioamnionitis (intrauterine
infection). Immediate notification of the physician is required.
Question 8
A nurse has assisted a physician in inserting a central venous access device into a client with a
diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion
of the catheter, the nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
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Question 1
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
Correct Answer: A
Rationale: Enalapril is an ACE inhibitor. Priority is to check blood pressure due to risk of
first-dose hypotension.
Question 2
A client is scheduled to undergo an upper gastrointestinal (GI) series. Which statement by the
client indicates a need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on
the morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink
for the test can be constipating."
Correct Answer: C
Rationale: Upper GI series requires only NPO status. Laxative/enema prep is for lower GI
series. Barium can cause constipation, so laxative is given after the test.
Question 3
A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a
prescribed medication is higher than the normal dose. The nurse calls the physician's answering
service and is told that the physician is off for the night and will be available in the morning. The
nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
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D. Administer the medication but consult the physician when he becomes available
Correct Answer: B
Rationale: The nurse has identified a potential medication error. According to the chain of
command and safety standards, any questionable or unsafe order must be clarified before
administration. The most appropriate action is to have the on-call physician contacted
immediately for clarification or a new order. Withholding until morning may delay needed
treatment, and administering an incorrect dose violates patient safety.
Question 4
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial
infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the
sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's
carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action
by the nurse is:
A. Document the findings
B. Ask the ED physician to check the client
C. Continue to monitor the client’s cardiac status
D. Inform the client that PVCs are expected after an MI
Correct Answer: B
Non-perfusing PVCs in the context of suspected myocardial infarction require immediate
medical evaluation. The physician needs to assess the client and determine if
antiarrhythmic treatment or other intervention is needed.
Question 5
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo
electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the
client's record and notes that the client routinely takes an oral antihypertensive medication each
morning. The nurse should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration the day after ECT
Correct Answer: A
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Rationale: Most oral medications, including antihypertensives, can be given with a small
sip of water before ECT unless specifically contraindicated. Withholding blood pressure
medication could cause rebound hypertension.
Question 6
A client who recently underwent coronary artery bypass graft surgery comes to the physician's
office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed.
Which response by the nurse is therapeutic?
A. “Tell me more about what you’re feeling.”
B. “That’s a normal response after this type of surgery.”
C. “It will take time, but, I promise you, you will get over this depression.”
D. “Every client who has this surgery feels the same way for about a month.”
Correct Answer: A
Rationale: This is an open-ended therapeutic communication technique that encourages the
client to express feelings and shows empathy.
Question 7
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately
counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse
notes that the fluid is yellow and has a strong odor. Which of the following actions should be the
nurse's priorit:
A. Contacting the physician
B. Documenting the findings
C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR
Correct Answer: A
Rationale: Yellow fluid with a foul odor suggests possible chorioamnionitis (intrauterine
infection). Immediate notification of the physician is required.
Question 8
A nurse has assisted a physician in inserting a central venous access device into a client with a
diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion
of the catheter, the nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
