A nurse is assessing an infant who has water intoxication. Which of the following findings should
the nurse expect? - ANSbounding pulse
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose
of the technique - ANSa. This technique decreases the risk of subcutaneous infiltration
1. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan? - ANSa. Monitor the client for 1 hr
after meals
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket.
After moving the client to safety, which of the followings is the priority action? - ANSa. Close the
fire door on the unit
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following
findings should the nurse expect? - ANSa. Hallucinations
1. A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing? - ANShyperemesis
1. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The
nurse should evaluate which of the following laboratory tests to determine effective long-term
management of blood glucose levels? - ANSA1C
1. A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client? - ANSa. Use a dedicated
stethoscope
1. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the
following actions should the nurse take? - ANSTell the client to avoid drinking fluids 1 hr before
bedtime
1. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive
phototherapy. Which of the following interventions should the nurse include? - ANSa. Place the
newborn 45 cm from the light source
1. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing
their feelings. Which of the following referrals should the nurse make? - ANSsocial worker
,1. A nurse is caring for a client who has heart failure and has started taking a loop diuretic.
Which of the following findings indicates the client is experiencing an adverse effect of the
medication - ANSdecreased reflexes
1. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a
list of client reports. Which of the following client reports should the nurse assess first? -
ANSindigestion
1. A nurse is caring for a client who has just returned to the unit following a bronchoscopy.
Which of the following actions by the assistive personnel requires the nurse to intervene? -
ANSoffer oral fluids to the client
1. A nurse on a medical unit has just received change-of-shift report. Which of the following
clients should the nurse assess first? - ANSa. A 68 year old client who had a myocardial
infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10
1. A nurse is assessing a client prior to performing a blood draw. The nurse should identify that
an allergy to which of the following food can indicate that the client has an allergy to latex? -
ANSavocados
1. A nurse is preparing to witness a client's signature on an informed consent for a total knee
arthroplasty. Which of the following client statements indicates the nurse should contact the
surgeon? - ANSa. I am thankful there are no serious complications from this type of surgery
1. A nurse is admitting a client who has antisocial personality disorder. Which of the following
client behaviors should the nurse identify as consistent with this disorder? - ANSa. Uses others
for personal gain
1. A nurse is teaching the parent of a school-age child who has scabies about the application of
permethrin 5% cream. The nurse should include which of the following as a potential adverse
effect of the medication? - ANSburning
1. A nurse is teaching a client who has a new prescription for digoxin. Which of the following
statements should the nurse include in the teaching? - ANSmuscle weakness
1. A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of
urinary tract infections. Which of the following information should the nurse plan to include in the
teaching about UTI prevention? - ANSa. Empty the bladder before and after intercourse
1. A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed.
Which of the following should the nurse recommend the client increase in their diet during
lactation? - ANSa. Calcium
, 1. A nurse is providing teaching about preventing mastitis to a client who is postpartum and
breastfeeding her newborn. Which of the following instructions should the nurse include? -
ANSa. Try to have your baby empty your breasts with each feeding."
1. A nurse is caring for a client who reports chest pain. Which of the following findings indicates
myocardial damage? - ANSa. Troponin I 1.8 ng/mL
1. A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of
the following statements by the parent indicates an understanding of the teaching? - ANSa. "I
should place my baby's car seat rear-facing until 6 months of age."
1. A nurse is performing high-frequency chest compressions using a mechanical chest
compression device for a child who has cystic fibrosis. Which of the following findings indicates
the treatment has been effective? - ANSa. The child has increased sputum production
1. A nurse is caring for a client following a possible exposure to anthrax. Which of the following
actions should the nurse take? - ANSantitoxin
1. A nurse is caring for a client who has a newly implanted sealed internal radiation device to
treat cervical cancer. Which of the following is an appropriate action for the nurse to take? -
ANSa. Keep a 3 foot distance from the radiation implant
A nurse is admitting a client to the medical-surgical unit. Which of the following actions should
the nurse take first? - ANSa. Observe the client's level of mobility
1. A nurse at a public health clinic is caring for a group of clients. Which of the following should
the nurse identify as a reportable diagnosis to the CDC? - ANShep A
1. A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of
the following actions should the charge nurse identify as an effective time management skill? -
ANSa. Completes activities for one client before moving to the next client
1. A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal.
Which of the following findings should the nurse expect? - ANSa. Hyperreflexia
1. A nurse is planning to perform wound irrigation for a client who has an open secondary
wound. When creating a sterile field, which of the following actions should the nurse take? -
ANSa. Hold the bottle of sterile solution with the palm over the label while pouring
1. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the
hospital for 1 week. Which of the following should the nurse include in the plan of care? - ANSa.
Wear a dosimeter film badge while in the client's room