1. A nurse in a pediatric unit is preparing to insert an IV
catheter for 7-year-
old. Which of the following actions should the nurse
take?
A. (Unable to read)
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.
✓ Correct Answer: B. Tell the child they will feel discomfort
during the catheter insertion.
2. A nurse is caring for a client who has arteriovenous
fistula Which of the
following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation.
✓ Correct Answer: B. Absence of a bruit.
3. A nurse is providing discharge teaching for a client who
has an
implantable cardioverter defibrillator which of the
following statements
,demonstrates understanding of the teaching?
A. "I will soak in the tub rather and 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"
✓ Correct Answer: B. "I will wear loose clothing around my ICD"
4. A nurse is caring for a client who is at 14 weeks
gestation and reports
feelings of ambivalence about being pregnant. Which of
the following
responses should the nurse make?
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?"
✓ Correct Answer: A. "Describe your feelings to me about being
pregnant"
5. A nurse is planning care for a client who has a
prescription for a bowel-
training program following a spinal cord injury. Which of
,the following actions
should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per
day.
B. Increase the amount of refined grains in the client's
diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to
scheduled
defecation times.
D. Administer a rectal suppository 30 minutes prior to
scheduled
defecation times.
6. A nurse is caring for a client who is in active labor and
requests pain
management. Which of the following actions should the
nurse take?
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.
✓ Correct Answer: B. Place the client in a warm shower.
7. a nurse in an emergency department is performing
triage for multiple
clients following a disaster in the community. To which of
the following types
, of injuries should the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm
✓ Correct Answer: A. Below-the knee amputation
8. a nurse manager is updating protocols for the use of
belt restraints. Which
of the following guidelines should the nurse include?
A. Remove the client's restraint every 4hr
B. Document the client's condition every 15 min
C. Attach the restrain to the bed's side rails
D. Request a PRN restrain prescription for clients who are
aggressive
✓ Correct Answer: B. Document the client's condition every 15
min
9. A nurse is teaching an in-service about nursing
leadership. Which of the
following information should the nurse include about an
effective leader?
A. Acts as an advocate for the nursing unit.
B. (Unable to read) for the unit
C. Priorities staff request over client needs.
D. Provides routine client care and documentation.
✓ Correct Answer: A. Acts as an advocate for the nursing unit.
catheter for 7-year-
old. Which of the following actions should the nurse
take?
A. (Unable to read)
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.
✓ Correct Answer: B. Tell the child they will feel discomfort
during the catheter insertion.
2. A nurse is caring for a client who has arteriovenous
fistula Which of the
following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation.
✓ Correct Answer: B. Absence of a bruit.
3. A nurse is providing discharge teaching for a client who
has an
implantable cardioverter defibrillator which of the
following statements
,demonstrates understanding of the teaching?
A. "I will soak in the tub rather and 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"
✓ Correct Answer: B. "I will wear loose clothing around my ICD"
4. A nurse is caring for a client who is at 14 weeks
gestation and reports
feelings of ambivalence about being pregnant. Which of
the following
responses should the nurse make?
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?"
✓ Correct Answer: A. "Describe your feelings to me about being
pregnant"
5. A nurse is planning care for a client who has a
prescription for a bowel-
training program following a spinal cord injury. Which of
,the following actions
should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per
day.
B. Increase the amount of refined grains in the client's
diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to
scheduled
defecation times.
D. Administer a rectal suppository 30 minutes prior to
scheduled
defecation times.
6. A nurse is caring for a client who is in active labor and
requests pain
management. Which of the following actions should the
nurse take?
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.
✓ Correct Answer: B. Place the client in a warm shower.
7. a nurse in an emergency department is performing
triage for multiple
clients following a disaster in the community. To which of
the following types
, of injuries should the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm
✓ Correct Answer: A. Below-the knee amputation
8. a nurse manager is updating protocols for the use of
belt restraints. Which
of the following guidelines should the nurse include?
A. Remove the client's restraint every 4hr
B. Document the client's condition every 15 min
C. Attach the restrain to the bed's side rails
D. Request a PRN restrain prescription for clients who are
aggressive
✓ Correct Answer: B. Document the client's condition every 15
min
9. A nurse is teaching an in-service about nursing
leadership. Which of the
following information should the nurse include about an
effective leader?
A. Acts as an advocate for the nursing unit.
B. (Unable to read) for the unit
C. Priorities staff request over client needs.
D. Provides routine client care and documentation.
✓ Correct Answer: A. Acts as an advocate for the nursing unit.
