A. Has she taken a bath since the rape occurred?
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?
B. Sluggish and unequal pupillary responses
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
A. Abdominal pain decreases when lying supine
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.
A. Instructions about how much fluid the child should drink daily
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
, I placed the red dot on the base of the neck on the right side
To auscultate for a carotid bruit, the nurse
places the stethoscope at what location.
(Select the location on the image with a red
dot).
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
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
D. Respiratory alkalosis
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
Fowlers
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
A. Frequent syncope
C. Flat affect
D. Blurred vision
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
B. Culture for sensitive organisms
While caring for a client's postoperative
dressing, the nurse observes purulent
drainage at the wound. Before reporting this
, B. Ask the older brother how he felt during the incident
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
A. Encourage the client to use cooler water and apply calamine lotion after soaking
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
B. Reduced preload
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
B. Minimize the amount of stimuli in the room
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
, C. Had a cold and ear infection for the past two days
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
C. The client's need for pain medication should be determined
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
B. Blood glucose monitoring
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
A. Apply ice to the breasts for comfort
A client who gave birth 48 hours ago has
decided to bottle feed the infant. During the
assessment, the nurse observes that both
breasts are swollen, warm, and tender on
palpation. Which instruction should the
nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to
prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the
breasts to relieve pressure
B. Use a residual limb shrinker
D. Inspect skin for redness
The nurse is preparing a client who had a E. Wash the stump with soap and water
below-the-knee (BKA) amputation for
discharge to home. Which recommendations
should the nurse provide this client? (Select
all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
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?
B. Sluggish and unequal pupillary responses
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
A. Abdominal pain decreases when lying supine
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.
A. Instructions about how much fluid the child should drink daily
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
, I placed the red dot on the base of the neck on the right side
To auscultate for a carotid bruit, the nurse
places the stethoscope at what location.
(Select the location on the image with a red
dot).
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
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
D. Respiratory alkalosis
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
Fowlers
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
A. Frequent syncope
C. Flat affect
D. Blurred vision
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
B. Culture for sensitive organisms
While caring for a client's postoperative
dressing, the nurse observes purulent
drainage at the wound. Before reporting this
, B. Ask the older brother how he felt during the incident
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
A. Encourage the client to use cooler water and apply calamine lotion after soaking
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
B. Reduced preload
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
B. Minimize the amount of stimuli in the room
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
, C. Had a cold and ear infection for the past two days
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
C. The client's need for pain medication should be determined
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
B. Blood glucose monitoring
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
A. Apply ice to the breasts for comfort
A client who gave birth 48 hours ago has
decided to bottle feed the infant. During the
assessment, the nurse observes that both
breasts are swollen, warm, and tender on
palpation. Which instruction should the
nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to
prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the
breasts to relieve pressure
B. Use a residual limb shrinker
D. Inspect skin for redness
The nurse is preparing a client who had a E. Wash the stump with soap and water
below-the-knee (BKA) amputation for
discharge to home. Which recommendations
should the nurse provide this client? (Select
all that apply)
A. Avoid range of motion exercises
B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
