,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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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
D. Decreased afterload - CORRECT ANSWERS-B. Reduced preload
Which intervention should the nurse include in the plan of care for a child with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light - CORRECT ANSWERS-B. Minimize
the amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is
admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely
cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch - CORRECT ANSWERS-C. Had a cold and ear infection for the
past two days
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of
impending death. After notifying the family of the client's status, what priority action
should the nurse implement?
A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
C. The client's need for pain medication should be determined
D. The nurse manager should be updated on the client's status - CORRECT
ANSWERS-C. The client's need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of care of
a client recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan - CORRECT ANSWERS-B. Blood glucose monitoring
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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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
D. Decreased afterload - CORRECT ANSWERS-B. Reduced preload
Which intervention should the nurse include in the plan of care for a child with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light - CORRECT ANSWERS-B. Minimize
the amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is
admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely
cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch - CORRECT ANSWERS-C. Had a cold and ear infection for the
past two days
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of
impending death. After notifying the family of the client's status, what priority action
should the nurse implement?
A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
C. The client's need for pain medication should be determined
D. The nurse manager should be updated on the client's status - CORRECT
ANSWERS-C. The client's need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of care of
a client recently diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan - CORRECT ANSWERS-B. Blood glucose monitoring
