SOLUTIONS
A- female- client- presents- in- the- emergency- department- and- tells- the- nurse- that- she-
was- raped- last- night.- Which- question- is- most- important- for- the- nurse- to- ask?
A.- Has- she- taken- a- bath- since- the- rape- occurred?-
B.- Is- the- place- where- she- lives- a- safe- place?-
C.- Does- she- know- the- person- who- raped- her?
D.- Did- she- report- the- rape- to- the- police- department?- -- Correct- answer~- A.- Has-
she- taken- a- bath- since- the- rape- occurred?
The- nurse- is- completing- the- admission- assessment- of- a- 3-year- old- who- is- admitted-
with- bacterial- meningitis- and- hydrocephalus.- Which- assessment- finding- is- evidence-
that- the- child- is- experiencing- increased- intracranial- pressure- (ICP)?
A.- Tachycardia- and- tachypnea
B.- Sluggish- and- unequal- pupillary- responses
C.- Increased- head- circumference- and- bulging- fontanels
D.- Blood- pressure- fluctuations- and- syncope- -- Correct- answer~- B.- Sluggish- and-
unequal- pupillary- responses
A- client- with- acute- pancreatitis- is- admitted- with- severe,- piercing- abdominal- pain-
and- an- elevated- serum- amylase.- Which- additional- information- is- the- client- most-
likely- to- report- to- the- nurse?
A.- Abdominal- pain- decreases- when- lying- supine
B.- Pain- lasts- an- hour- and- leaves- the- abdomen- tender
C.- Right- upper- quadrant- pain- refers- to- right- scapula
,D.- Drinks- alcohol- until- intoxicated- at- least- twice- weekly.- -- Correct- answer~- A.-
Abdominal- pain- decreases- when- lying- supine
A- child- newly- diagnosed- with- sickle- cell- anemia- (SCA)- is- being- discharged- from- the-
hospital.- Which- information- is- most- important- for- the- nurse- to- provide- the- parents-
prior- to- discharge?
A.- Instructions- about- how- much- fluid- the- child- should- drink- daily.
B.- Signs- of- addiction- to- opioid- pain- medications
C.- Information- about- non-pharmaceutical- pain- relief- measures
D.- Referral- for- social- services- for- the- child- and- family- -- Correct- answer~- A.-
Instructions- about- how- much- fluid- the- child- should- drink- daily
To- auscultate- for- a- carotid- bruit,- the- nurse- places- the- stethoscope- at- what-
location.- (Select- the- location- on- the- image- with- a- red- dot).- -- Correct- answer~- I-
placed- the- red- dot- on- the- base- of- the- neck- on- the- right- side
After- receiving- report- on- an- inpatient- acute- care- unit,- which- client- should- the-
nurse- assess- first?
A.- The- client- with- an- obstruction- of- the- large- intestine- who- is- experiencing-
abdominal- distention
B.- The- client- who- had- surgery- yesterday- and- is- experiencing- a- paralytic- ileus- with-
absent- bowel- sounds
C.- The- client- with- a- small- bowel- obstruction- who- has- a- nasogastric- tube- that- is-
draining- greenish- fluid
D.- The- client- with- a- bowel- obstruction- due- to- a- volvulus- who- is- experiencing-
abdominal- rigidity- -- Correct- answer~- D.- The- client- with- a- bowel- obstruction- due- to-
a- volvulus- who- is- experiencing- abdominal- rigidity
A- teenager- presents- to- the- emergency- department- with- palpitations- after- vaping- at-
a- party.- The- client- is- anxious,- fearful,- and- hyperventilating.- The- nurse- anticipates-
the- client- developing- which- acid- base- imbalance?
A.- Respiratory- acidosis
,B.- Metabolic- alkalosis
C.- Metabolic- acidosis
D.- Respiratory- alkalosis- -- Correct- answer~- D.- Respiratory- alkalosis
A- client- with- dyspnea- is- being- admitted- to- the- medical- unit.- To- best- prepare- for-
the- client's- arrival,- the- nurse- should- ensure- that- the- client's- bed- is- in- which-
position?
A.- Supine
B.- supine;- feet- elevated- higher- than- head
C.- supine;- head- elevated- higher- than- feet
D.- Fowlers- -- Correct- answer~- Fowlers
The- nurse- is- taking- the- blood- pressure- measurement- of- a- client- with- Parkinson's-
disease.- Which- information- in- the- client's- admission- assessment- is- relevant- to- the-
nurse's- plan- for- taking- the- blood- pressure- reading?- (Select- all- the- apply)
A.- Frequent- syncope
B.- Occasional- nocturia
C.- Flat- affect
D.- Blurred- vision
E.- Frequent- drooling- -- Correct- answer~- A.- Frequent- syncope
C.- Flat- affect
D.- Blurred- vision
While- caring- for- a- client's- postoperative- dressing,- the- nurse- observes- purulent-
drainage- at- the- wound.- Before- reporting- this- finding- to- the- healthcare- provider,- the-
nurse- should- review- which- of- the- client's- laboratory- values?
A.- Serum- albumin
B.- Culture- for- sensitive- organisms
C.- Serum- blood- glucose- level
D.- Creatinine- level- -- Correct- answer~- B.- Culture- for- sensitive- organisms
, A- preschool-aged- boy- is- admitted- to- the- pediatric- unit- following- successful-
resuscitation- from- a- near-drowning- incident.- While- providing- care- to- the- child,- the-
nurse- begins- talking- with- his- preadolescent- brother- who- rescued- the- child- from-
the- swimming- pool- and- initiated- resuscitation.- The- nurse- notices- the- older- boy-
becomes- withdrawn- when- asked- about- what- happened.- Which- action- should- the-
nurse- take?
A.- Develop- a- water- safety- teaching- plan- for- the- family
B.- Ask- the- older- brother- how- he- felt- during- the- incident
C.- Tell- the- older- brother- that- he- seems- depressed
D.- Commend- the- older- brother- for- his- heroic- actions- -- Correct- answer~- B.- Ask- the-
older- brother- how- he- felt- during- the- incident
A- male- client- with- cirrhosis- has- jaundice- and- pruritus.- He- tells- the- nurse- that- he-
has- been- soaking- in- hot- baths- at- night- with- no- relief- of- his- discomfort.- Which-
action- should- the- nurse- take?
A.- Encourage- the- client- to- use- cooler- water- and- apply- calamine- lotion- after- soaking
B.- Obtain- a- PRN- prescription- for- an- analgesic- that- the- client- can- use- for- symptom-
relief
C.- Suggest- that- the- client- take- brief- showers- and- apply- oil-based- lotion- after-
showering
D.- Explain- that- the- symptoms- are- caused- by- liver- damage- and- cannot- be- relieved- --
Correct- answer~- A.- Encourage- the- client- to- use- cooler- water- and- apply- calamine-
lotion- after- soaking
An- older- client- with- a- long- history- of- coronary- artery- disease- (CAD),- hypertension-
(HTN),- and- heart- failure- (HF)- arrives- in- the- Emergency- Department- (ED)- in-
respiratory- distress.- The- healthcare- provider- prescribes- furosemide- IV.- Which-
therapeutic- response- to- furosemide- should- the- nurse- expected- in- the- client- with-
acute- HF?
A.- Increased- cardiac- contractility
B.- Reduced- preload
C.- Relaxed- vascular- tone