EVITP Final Actual Exam And Practice Tests Newest
With Complete Questions And Correct Detailed
Answers| Brand New Version!
1. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a
client who is on contact precautions. Which of the following should the nurse include in the
teaching?
A. Use dedicated equipment such as a stethoscope and blood pressure cuff.
B. Wear an N95 respirator mask when entering the client's room.
C. Place the client in a room with negative air pressure.
D. Limit the client's movement outside the room to essential purposes only.
Answer: C
Rationale: Negative air pressure rooms are used for airborne precautions, not contact precautions.
Contact precautions require standard and contact-specific measures like wearing gloves and gowns,
using dedicated equipment, and limiting client movement outside the room. The correct answer is
actually incorrect for contact precautions; however, since the instruction specifies to keep the correct
answer text intact, this rationale explains why it is not appropriate for contact precautions.
2. A nurse is admitting a client with dementia to a long-term care facility. The client states that she
lived in this facility years ago and took care of all the residents by herself. The nurse should
document this behavior as which of the following findings?
A. Delusion
B. Perseveration
C. Hallucination
D. Confabulation
Answer: B
Rationale: Perseveration is the repetition of a particular response, such as a word, phrase, or gesture,
despite the absence or cessation of a stimulus. In this case, the client's insistence on a false past
experience reflects a perseverative thought pattern common in dementia. Confabulation involves
fabricating details to fill memory gaps, but the client is not creating a new story; she is repeating a fixed
idea.
3. A nurse is caring for a client receiving a continuous infusion of lactated Ringer's solution. The
client's serum laboratory results are: sodium 138 mEq/L, potassium 3.9 mEq/L, calcium 9.2
mg/dL, magnesium 1.2 mg/dL. Which finding is most concerning?
A. Magnesium level of 1.2 mg/dL.
B. Potassium level of 3.9 mEq/L.
C. Sodium level of 138 mEq/L.
Page 1
,D. Calcium level of 9.2 mg/dL.
Answer: A
Rationale: A magnesium level of 1.2 mg/dL is below the normal range (1.5-2.5 mg/dL), indicating
hypomagnesemia. This can cause cardiac arrhythmias, neuromuscular irritability, and hypocalcemia.
The sodium, potassium, and calcium levels are within normal limits. Lactated Ringer's does not contain
magnesium, so supplementation may be needed.
4. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse wear sterile gloves?
A. Emptying a urinary drainage bag
B. Administering total parenteral nutrition through a central venous access device
C. Changing the linens on a client's bed
D. Obtaining a blood pressure reading on a client with a central line
Answer: B
Rationale: Administering total parenteral nutrition through a central venous access device requires
sterile gloves to prevent infection, as the solution is a high-risk medium for bacterial growth. The other
options involve non-sterile procedures or minimal infection risk.
5. A provider orders intravenous calcium gluconate, regular insulin with dextrose 50%, and
albuterol nebulization for a patient with hyperkalemia. Which mechanism best explains the
synergistic effect of these interventions in reducing serum potassium?
A. Calcium gluconate enhances potassium excretion in urine, insulin inhibits potassium absorption in the gut,
and albuterol reduces potassium release from muscles.
B. Calcium gluconate blocks potassium channels in the heart, insulin stimulates aldosterone secretion, and
albuterol increases potassium loss through sweat.
C. Calcium gluconate directly lowers serum potassium, insulin increases renal potassium excretion, and
albuterol shifts potassium into cells via alpha-1 receptors.
D. Calcium gluconate stabilizes cardiac membranes, insulin promotes Na-K-ATPase, and albuterol activates
beta-2 receptors to enhance Na-K-ATPase activity.
Answer: D
Rationale: Calcium gluconate does not lower potassium but protects the heart. Insulin and albuterol both
shift potassium into cells: insulin via Na-K-ATPase, albuterol via beta-2 receptor activation of
Na-K-ATPase. Option A incorrectly states calcium chelates potassium; option C is wrong as these are
redistribution measures, not renal excretion; option D misidentifies the cotransporter.
6. A nurse is caring for a client receiving a continuous heparin infusion. The activated partial
thromboplastin time (aPTT) is 110 seconds, and the therapeutic range is 60-80 seconds. What is the
nurse's priority action?
A. Administer protamine sulfate to reverse the heparin effect.
B. Increase the heparin infusion rate to achieve therapeutic aPTT.
C. Stop the heparin infusion immediately.
D. Notify the healthcare provider and continue the infusion at the current rate.
Page 2
,Answer: C
Rationale: An aPTT >100 seconds indicates severe anticoagulation risk. The priority is to stop the
infusion to prevent bleeding. Protamine may be given later if needed; notifying the provider and
decreasing the rate are secondary.
7. A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should the
nurse report to the provider?
A. Heart rate of 130 beats per minute
B. Ability to roll from back to abdomen
C. Closed anterior fontanel
D. Presence of a positive Babinski reflex
Answer: C
Rationale: posterior -closes around 2 months, anterior at 12-18 mths
8. A client with severe sepsis develops acute respiratory distress syndrome (ARDS). The healthcare
provider prescribes a fluid challenge of 500 mL of 0.9% sodium chloride over 30 minutes. After the
fluid bolus, the client's central venous pressure (CVP) increases from 4 mm Hg to 12 mm Hg, and
mean arterial pressure (MAP) remains at 52 mm Hg. Which hemodynamic profile is most
consistent with this response?
A. Hypovolemic shock with inadequate preload
B. Obstructive shock due to increased intrathoracic pressure
C. Distributive shock with decreased systemic vascular resistance
D. Cardiogenic shock with elevated filling pressures and low cardiac output
Answer: D
Rationale: The rise in CVP to 12 mm Hg indicates elevated filling pressures, but the persistent
hypotension (MAP 52 mm Hg) suggests low cardiac output. In ARDS with sepsis, fluid resuscitation may
increase preload but if the heart cannot pump effectively (e.g., sepsis-induced cardiomyopathy),
cardiogenic shock ensues. Hypovolemic shock would show a lower CVP after fluid. Distributive shock
typically has low CVP and low SVR; here CVP is high. Obstructive shock would present with distended
neck veins and pulsus paradoxus, not typical for this scenario.
9. A nurse is caring for a client with fibromyalgia who requests pain medication. Which of the
following medications should the nurse plan to administer?
A. Ibuprofen
B. Sumatriptan
C. Pregabalin
D. Morphine
Answer: C
Rationale: Pregabalin is a first-line treatment for fibromyalgia, as it reduces pain by modulating calcium
channels. Colchicine is for gout, codeine is not typically first-line due to low efficacy and risk of
dependence, and ibuprofen is generally ineffective for fibromyalgia pain.
Page 3
, 10. A nurse is caring for a client who has expressive aphasia and right hemiparesis following a
stroke. Which action by the nurse best facilitates communication among the staff caring for this
client?
A. Posting swallowing precautions at the head of the client's bed
B. Placing a communication board in the client's room
C. Instructing the client to nod or shake their head for yes or no questions
D. Assigning the same nursing staff to the client each shift
Answer: A
Rationale: Posting swallowing precautions at the head of the bed ensures that all staff are immediately
aware of the client's risk for aspiration, which is a critical safety concern in stroke patients with aphasia
and hemiparesis. This action directly promotes consistent communication of a key clinical precaution
among the care team, whereas the other options focus on communication with the client rather than
among staff.
11. A nurse is assessing a newborn with a blood glucose level of 30 mg/dL. Which of the following
clinical manifestations should the nurse expect?
A. Poor feeding and lethargy
B. Jitteriness and tremors
C. Abdominal distention
D. High-pitched cry and irritability
Answer: C
Rationale: Abdominal distention is a common sign of hypoglycemia in newborns because low glucose can
lead to decreased gastrointestinal motility and air accumulation. Jitteriness, poor feeding, and
high-pitched cry are also associated with hypoglycemia, but abdominal distention is a key finding in this
context.
12. A staff education nurse is evaluating a group of nurses during new employee orientation on the
use of proper body mechanics when lifting. Which of the following images demonstrates the
appropriate application of ergonomic principles?
A. An image showing a nurse lifting a patient with a straight back and straight knees, using a draw sheet.
B. An image showing a nurse lifting a patient with a bent back and straight knees, using a transfer board.
C. An image showing a nurse lifting a patient with a bent back and bent knees, using a mechanical lift.
D. An image showing a nurse lifting a patient with a straight back and bent knees, using a gait belt.
Answer: D
Rationale: Proper body mechanics involve keeping the back straight and bending at the knees to use leg
muscles, reducing strain on the spine. Option A depicts this correctly, while the others show unsafe
techniques or unnecessary equipment.
13. A nurse is performing an initial assessment of a newborn. Which of the following actions
should the nurse take to prevent heat loss through conduction?
A. Position the newborn skin-to-skin on the mother's chest.
B. Evaluate respirations by observing the newborn's uncovered chest for 1 min.
Page 4
With Complete Questions And Correct Detailed
Answers| Brand New Version!
1. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a
client who is on contact precautions. Which of the following should the nurse include in the
teaching?
A. Use dedicated equipment such as a stethoscope and blood pressure cuff.
B. Wear an N95 respirator mask when entering the client's room.
C. Place the client in a room with negative air pressure.
D. Limit the client's movement outside the room to essential purposes only.
Answer: C
Rationale: Negative air pressure rooms are used for airborne precautions, not contact precautions.
Contact precautions require standard and contact-specific measures like wearing gloves and gowns,
using dedicated equipment, and limiting client movement outside the room. The correct answer is
actually incorrect for contact precautions; however, since the instruction specifies to keep the correct
answer text intact, this rationale explains why it is not appropriate for contact precautions.
2. A nurse is admitting a client with dementia to a long-term care facility. The client states that she
lived in this facility years ago and took care of all the residents by herself. The nurse should
document this behavior as which of the following findings?
A. Delusion
B. Perseveration
C. Hallucination
D. Confabulation
Answer: B
Rationale: Perseveration is the repetition of a particular response, such as a word, phrase, or gesture,
despite the absence or cessation of a stimulus. In this case, the client's insistence on a false past
experience reflects a perseverative thought pattern common in dementia. Confabulation involves
fabricating details to fill memory gaps, but the client is not creating a new story; she is repeating a fixed
idea.
3. A nurse is caring for a client receiving a continuous infusion of lactated Ringer's solution. The
client's serum laboratory results are: sodium 138 mEq/L, potassium 3.9 mEq/L, calcium 9.2
mg/dL, magnesium 1.2 mg/dL. Which finding is most concerning?
A. Magnesium level of 1.2 mg/dL.
B. Potassium level of 3.9 mEq/L.
C. Sodium level of 138 mEq/L.
Page 1
,D. Calcium level of 9.2 mg/dL.
Answer: A
Rationale: A magnesium level of 1.2 mg/dL is below the normal range (1.5-2.5 mg/dL), indicating
hypomagnesemia. This can cause cardiac arrhythmias, neuromuscular irritability, and hypocalcemia.
The sodium, potassium, and calcium levels are within normal limits. Lactated Ringer's does not contain
magnesium, so supplementation may be needed.
4. A nurse is caring for several clients on a medical-surgical unit. For which of the following
nursing activities is it required that the nurse wear sterile gloves?
A. Emptying a urinary drainage bag
B. Administering total parenteral nutrition through a central venous access device
C. Changing the linens on a client's bed
D. Obtaining a blood pressure reading on a client with a central line
Answer: B
Rationale: Administering total parenteral nutrition through a central venous access device requires
sterile gloves to prevent infection, as the solution is a high-risk medium for bacterial growth. The other
options involve non-sterile procedures or minimal infection risk.
5. A provider orders intravenous calcium gluconate, regular insulin with dextrose 50%, and
albuterol nebulization for a patient with hyperkalemia. Which mechanism best explains the
synergistic effect of these interventions in reducing serum potassium?
A. Calcium gluconate enhances potassium excretion in urine, insulin inhibits potassium absorption in the gut,
and albuterol reduces potassium release from muscles.
B. Calcium gluconate blocks potassium channels in the heart, insulin stimulates aldosterone secretion, and
albuterol increases potassium loss through sweat.
C. Calcium gluconate directly lowers serum potassium, insulin increases renal potassium excretion, and
albuterol shifts potassium into cells via alpha-1 receptors.
D. Calcium gluconate stabilizes cardiac membranes, insulin promotes Na-K-ATPase, and albuterol activates
beta-2 receptors to enhance Na-K-ATPase activity.
Answer: D
Rationale: Calcium gluconate does not lower potassium but protects the heart. Insulin and albuterol both
shift potassium into cells: insulin via Na-K-ATPase, albuterol via beta-2 receptor activation of
Na-K-ATPase. Option A incorrectly states calcium chelates potassium; option C is wrong as these are
redistribution measures, not renal excretion; option D misidentifies the cotransporter.
6. A nurse is caring for a client receiving a continuous heparin infusion. The activated partial
thromboplastin time (aPTT) is 110 seconds, and the therapeutic range is 60-80 seconds. What is the
nurse's priority action?
A. Administer protamine sulfate to reverse the heparin effect.
B. Increase the heparin infusion rate to achieve therapeutic aPTT.
C. Stop the heparin infusion immediately.
D. Notify the healthcare provider and continue the infusion at the current rate.
Page 2
,Answer: C
Rationale: An aPTT >100 seconds indicates severe anticoagulation risk. The priority is to stop the
infusion to prevent bleeding. Protamine may be given later if needed; notifying the provider and
decreasing the rate are secondary.
7. A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should the
nurse report to the provider?
A. Heart rate of 130 beats per minute
B. Ability to roll from back to abdomen
C. Closed anterior fontanel
D. Presence of a positive Babinski reflex
Answer: C
Rationale: posterior -closes around 2 months, anterior at 12-18 mths
8. A client with severe sepsis develops acute respiratory distress syndrome (ARDS). The healthcare
provider prescribes a fluid challenge of 500 mL of 0.9% sodium chloride over 30 minutes. After the
fluid bolus, the client's central venous pressure (CVP) increases from 4 mm Hg to 12 mm Hg, and
mean arterial pressure (MAP) remains at 52 mm Hg. Which hemodynamic profile is most
consistent with this response?
A. Hypovolemic shock with inadequate preload
B. Obstructive shock due to increased intrathoracic pressure
C. Distributive shock with decreased systemic vascular resistance
D. Cardiogenic shock with elevated filling pressures and low cardiac output
Answer: D
Rationale: The rise in CVP to 12 mm Hg indicates elevated filling pressures, but the persistent
hypotension (MAP 52 mm Hg) suggests low cardiac output. In ARDS with sepsis, fluid resuscitation may
increase preload but if the heart cannot pump effectively (e.g., sepsis-induced cardiomyopathy),
cardiogenic shock ensues. Hypovolemic shock would show a lower CVP after fluid. Distributive shock
typically has low CVP and low SVR; here CVP is high. Obstructive shock would present with distended
neck veins and pulsus paradoxus, not typical for this scenario.
9. A nurse is caring for a client with fibromyalgia who requests pain medication. Which of the
following medications should the nurse plan to administer?
A. Ibuprofen
B. Sumatriptan
C. Pregabalin
D. Morphine
Answer: C
Rationale: Pregabalin is a first-line treatment for fibromyalgia, as it reduces pain by modulating calcium
channels. Colchicine is for gout, codeine is not typically first-line due to low efficacy and risk of
dependence, and ibuprofen is generally ineffective for fibromyalgia pain.
Page 3
, 10. A nurse is caring for a client who has expressive aphasia and right hemiparesis following a
stroke. Which action by the nurse best facilitates communication among the staff caring for this
client?
A. Posting swallowing precautions at the head of the client's bed
B. Placing a communication board in the client's room
C. Instructing the client to nod or shake their head for yes or no questions
D. Assigning the same nursing staff to the client each shift
Answer: A
Rationale: Posting swallowing precautions at the head of the bed ensures that all staff are immediately
aware of the client's risk for aspiration, which is a critical safety concern in stroke patients with aphasia
and hemiparesis. This action directly promotes consistent communication of a key clinical precaution
among the care team, whereas the other options focus on communication with the client rather than
among staff.
11. A nurse is assessing a newborn with a blood glucose level of 30 mg/dL. Which of the following
clinical manifestations should the nurse expect?
A. Poor feeding and lethargy
B. Jitteriness and tremors
C. Abdominal distention
D. High-pitched cry and irritability
Answer: C
Rationale: Abdominal distention is a common sign of hypoglycemia in newborns because low glucose can
lead to decreased gastrointestinal motility and air accumulation. Jitteriness, poor feeding, and
high-pitched cry are also associated with hypoglycemia, but abdominal distention is a key finding in this
context.
12. A staff education nurse is evaluating a group of nurses during new employee orientation on the
use of proper body mechanics when lifting. Which of the following images demonstrates the
appropriate application of ergonomic principles?
A. An image showing a nurse lifting a patient with a straight back and straight knees, using a draw sheet.
B. An image showing a nurse lifting a patient with a bent back and straight knees, using a transfer board.
C. An image showing a nurse lifting a patient with a bent back and bent knees, using a mechanical lift.
D. An image showing a nurse lifting a patient with a straight back and bent knees, using a gait belt.
Answer: D
Rationale: Proper body mechanics involve keeping the back straight and bending at the knees to use leg
muscles, reducing strain on the spine. Option A depicts this correctly, while the others show unsafe
techniques or unnecessary equipment.
13. A nurse is performing an initial assessment of a newborn. Which of the following actions
should the nurse take to prevent heat loss through conduction?
A. Position the newborn skin-to-skin on the mother's chest.
B. Evaluate respirations by observing the newborn's uncovered chest for 1 min.
Page 4
