1. A nurse is reviewing the laboratory results of a client who has rheumatoid
arthritis. Which of the following findings should the nurse report to the
provider?
A. WBC count 8,000/mm3.
B. Platelets 150,000/mm3.
C. Aspartate aminotransferase 10 units/L.
D. Erythrocyte sedimentation rate 75 mm/hr
2. A nurse is caring for a client who has generalized petechiae and ecchymoses. The
nurse should expect a prescription for which of the following laboratory tests?
A. Platelet count.
B. Potassium level.
C. Creatine clearance.
D. Prealbumin.
3. A nurse is caring for a client following application of a cast. Which of the following
actions should the nurse take first?
A. Place an ice pack over the cast.
B. P alpate the pulse distal to the cast.
C. Teach the client to keep the cast clean and dry.
D. Position the casted extremity on a pillow.
4. A nurse is caring for a client who has vision loss. Which of the following actions
should the nurse take? (Select all that apply)
A. Keep objects in the client’s room in
the same place.
B. Ensure there is high-wattage lighting
in the client’s room.
C . Approach the client from the side.
D. Allow extra time for the client to
perform tasks.
E . Touch the client gently to
announce presence.
5. A nurse is caring for a client who is newly diagnosed with pancreatic cancer
,and has questions about the disease. To research the nurse should identify that which
of the following electronic database has the most comprehensive collection of nursing
(Unable to read) articles?
A. MEDLINE
B. CINAHL.
C. ProQuest.
D. Health Source.
6. A nurse in an emergency department is assessing newly admitted client who is
experiencing drooling and hoarseness following a burn injury. Which of the following
should actions should the nurse take first?
A. Obtain a baseline ECG.
B. Obtain a blood specimen for ABG analysis.
C. Insert an 18-gauge IV catheter.
D. Administer 100% humidified oxygen.
7. A nurse is planning care for a client who has unilateral paralysis and
dysphagia following a right hemispheric stroke. Which of the following
interventions should the nurse include in the plan?
A. Place food on the left side of the client’s mouth when he is ready to eat.
B. Provide total care in performing the client’s ADLs.
C. Maintain the client on bed rest.
D. P lace the client’s left arm on a pillow while he is sitting.
8. A nurse is caring for a client who is in a seclusion room following violent
behavior. The client continues to display aggressive behavior. Which of the following
actions should the nurse take?
A. Confront the client about this behavior.
B. Express sympathy for the client’s situation.
C. Speak assertively to the client.
D. Stand within 30 cm (1 ft) of the client when speaking with them.
9. A nurse is caring for a client who is receiving brachytherapy for treatment of
prostate cancer. Which of the following actions should the nurse take?
A. Cleanse equipment before removal from the client’s room.
,B. L imit the client’s visitors to 30 min per day.
C. Discard the client’s linens
in a double bag.
D. Discard the radioactive
source in a biohazard bag
10. A nurse is caring for a client who has severe preeclampsia and is receiving
magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate
after the client displaces toxicity. Which of the following actions should the nurse
take?
a. Position the client supine
b. Prepare an IV bolus of dextrose 5% in water
c. Administer methylergonovine IM
d. Administer calcium gluconate IV
11. A charge nurse is teaching new staff members about factors that increase a client’s risk
to become violent. Which of the following risk factors should the nurse include as the
best predictor of future violence?
a. Experiencing delusions
b. Male gender
c. Previous violent behavior
d. A history of being in prison
12. A nurse is preparing to perform a sterile dressing change. Which of the
following actions should the nurse take when setting up the sterile field?
a. Place the cap from the solution sterile side up on clean surface
b. Open the outermost flap of the sterile kit toward the body→ flap AWAY
from the body's first
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile
field → 2.5 cm (1-inch) border around any sterile drape or wrap that is
considered contaminated.
d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW
waist level; should be ABOVE waist level
13. A nurse is providing teaching to an older adult client about methods to promote
nighttime sleep. Which of the following instructions should the nurse include?
a. Eat a light snack before bedtime
b. Stay in bed at least 1 hr if unable to fall asleep
c. Take a 1 hr nap during the day
d. Perform exercises prior to bedtime
14. A home health nurse is preparing for an initial visit with an older adult client
who lives alone. Which of the following actions should the nurse take first?
a. Educate the client about current medical diagnosis
b. Refer the client to a meal delivery program
c. Identify environmental hazards in the home
, d. Arrange for client transportation to follow-
up appointments Rationale Priority: Assess first.
15. A nurse is assessing the remote memory of an older adult client who
has mild dementia. Which of the following questions should the nurse
ask the client?
a. “Can you tell me who visited you today?”
b. “What high school did you graduate from
c. “Can you list your current medications?”
d. “What did you have for breakfast yesterday?”
16. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus.
Which of the following goals should the nurse include in the teaching
a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. >
b. Blood glucose level greater than 200 mg/dL at bedtime
c. Blood glucose level less than 60 mg/dL before breakfast- < 70 =
HYPOGLYCEMIC
d. HbA1c level less than 7%
17. A nurse is caring for a client who is receiving phenytoin for management of
grand mal seizures and has a new prescription for isoniazid and rifampin. Which of
the following should the nurse conclude if the client develops ataxia and
incoordination?
a. The client is experiencing an adverse reaction to rifampin
b. The client’s seizure disorder is no longer under control
c. The client is showing evidence of phenytoin toxicity
d. The client is having adverse effects due to combination antimicrobial therapy
18. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty.
Which of the following manifestations requires immediate action by the nurse?
a. Increase in frequency of swallowing→ may indicate bleeding
b. Moderate sanguineous drainage on the drip pad
c. Bruising to the face→ side effect
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour
postoperative) Rationale “Requires immediate action” choose the worst
possibility that could lead to. ABC
19. A nurse is planning care for a preschool-age child who is in the acute phase
Kawasaki disease. Which of the following interventions should the nurse include
in the plan of care?
a. Give scheduled doses of
acetaminophen every 6 hr
b. Monitor the child’s cardiac status
c. Administer antibiotics via intermittent IV bolus for 24 hr
d. Provide stimulation with children of the same age in the playroom
20. A nurse is planning an educational program for high school students about
cigarette smoking. Which of the following potential consequences of smoking is most
likely to discourage adolescents from using tobacco?
a. Use of tobacco might lead to alcohol and drug abuse