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1. Complete the following sentence by using the list of The nurse understands
options. that the patient has likely
developed Lithium toxicity
and will
need to be monitored for
seizure activity
2. A nurses preparing to initiate intravenous fluids via check the expiration date
infusion pump to our client. Which of the following on safety inspection stick-
actions should the nurse take? er of the pump
Obtain a surge protector that can accommodate the
pump and several other
appliances
verify that the extension cord for the pump is un-
grounded
report the pump has a frayed cord and proceed with
the infusion
check the expiration date on safety inspection sticker
of the pump
3. A nurse is caring for a client who has an implanted A non coring needle
venous access port. Which of the following should the
nurse use to access the port?
A non coring needle
An angio catheter
A butterfly needle
A 25 gauge needle
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4. A nurse is conducting an initial assessment of a client compare the current infu-
and notices A discrepancy between the client's current sion with the prescription
IV infusion and the information received during the and the client's medica-
shift report. Which of the following actions should the tion
nurse take?
a. Contact the charge nurse to see if the prescription
was changed
b. complete an incident report and place it in the
client's medical record
c. submit a written warning for the nurse involved in
the incident
d. compare the current infusion with the prescription
and the client's medication
5. case study case study
6. case study, client diagnosed with schixophrenia indicated :
- ask the client about the
content of their hallucina-
tions
- instruct the client on ex-
pected hygiene practices
- access the client for sui-
cidal ideation
contraindicated :
- allow the client to watch
tv at a high volume
- place the client in a room
near the activity room
7.
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A nurse is caring for a client who is near the end of life Tell me what concerns you
and is on a complete bed rest. The client states that have about using a bed-
he needs to have a bowel movement. The nurse offers pan
a bed pan. The client states "I ve always used the
bathroom". Which of the following responses should
the nurse make?
a. Tell me what concerns you have about using a bed-
pan
b. make sure to use a nearby furniture to support
yourself when walking to the bathroom
c. I will have the physical therapist ambulate you to
the bathroom
d. you have to use the bedpan for your own safety
8. A nurse is caring for a client who is in labor. Select the Increase the flow rate of
five actions the nurse should take. the maintenance IV fluid
a. Increase the flow rate of the maintenance IV fluid Have the charge nurse no-
b. have the charge nurse notify the provider tify the provider
c. place the client in a trendelenburg position
d. exert upward pressure on the presenting part Place the client in a tren-
e. attempt to push the umbilical cord back into the delenburg position
cervix
Exert upward pressure on
f. administer oxygen at 10L/min via non rebreather
the presenting part
face mask
Administer oxygen at
10L/min via non re-
breather face mask
9. A nurse is providing an in service about client evacua- a client who is ambulatory
tion during a fire. Which of the following client should and receiving oxygen
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the nurse instruct the staff to evacuate first?
a. a client who is ambulatory and receiving oxygen
b. a client who has a fracture in is imbalance suspen-
sion traction
c. a client who is bedridden and wears a hearing aid
d.a client who uses a wheelchair and is confused
10. Case Study Mastitus :
- painful tender breast
client is 4 days postpartum following a cesarean birth - temperature
assessment findings - chills
Endometritus :
- foul smelling lochia
- temperature
- chills
11. A nurse is assessing a client who has a possible Reduced right sided
right pneumothorax. Which of the following findings breath sounds
should the nurse expect the?
a. Reduced right sided breath sounds
b. intercostal retractions
c. High pitched stridor
d. paradoxical chest movement
12. Which of the following interventions should the nurse increase oxygen flow rate
include in the plan of care? Select all that apply to 4L/min
a. increase oxygen flow rate to 4L/min assess the clients breath
b. assess the clients breath sounds sounds
c. perform chest percussions and vibration