A nurse is admitting a client who has antisocial personality disorder. Which of the following
client behaviors should the nurse identify as consistent with this disorder?
A. Compulsive attention to details
B. Avoids interacting with others
C. Uses others for personal gain
D. Socially awkward in group situations - ANSWER C. Uses others for personal gain
A nurse is interpreting the cardiac rhythm strip of a client who was admitted with syncope.
Which of the following images indicates that the client has atrial fibrillation? -
ANSWER No P waves or P waves erratic; PR interval indiscernible
A client who has a diagnosis of complete placenta previa is admitted to the labor and
delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in
duration. Which of the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam - ANSWER C. Prepare the client for a cesarean section
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical
unit. Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
1
,B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect
tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a
Harrington rod - ANSWER A. A 10-year-old client who has pneumonia and is receiving
respiratory treatments
• The 10-year-old with pneumonia is a stable pediatric patient who requires routine
respiratory treatments, which a medical unit nurse would be familiar with.
• The other clients have more complex, high-risk needs
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket.
After moving the client to safety, which of the following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher. - ANSWER A. Notify the facility
operator.
This follows the R.A.C.E. acronym:
• R: Rescue (move the client to safety)
• A: Alarm (notify appropriate personnel)
• C: Confine (close fire doors)
• E: Extinguish (use the fire extinguisher if possible)
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
2
,D. Increased hematocrit - ANSWER A. Generalized edema
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the
purpose of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug - ANSWER This technique
decreases the risk of subcutaneous infiltration
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes - ANSWER C. Monitor the client for 1 hr after
meals
A nurse is planning care for a child who has increased intracranial pressure with a decrease
in level of consciousness. Which of the following interventions should the nurse include in
the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs - ANSWER B. Maintain the head at a
midline position
10. A nurse is assessing a client who has delirium due to a febrile illness. Which of the
following findings should the nurse expect?
3
, A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia - ANSWER A. Hallucinations
A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The
nurse should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses - ANSWER D. Bounding pulses
A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain - ANSWER B. Hyperemesis
A home health nurse is reviewing treatment goals with a client who has diabetes mellitus.
The nurse should evaluate which of the following laboratory tests to determine effective
long-term management of blood glucose levels?
A. 3-hr oral glucose tolerance test
B. HbA1c
C. Fasting blood glucose test
D. Urinalysis for ketones - ANSWER B. HbA1c
A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client?
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client behaviors should the nurse identify as consistent with this disorder?
A. Compulsive attention to details
B. Avoids interacting with others
C. Uses others for personal gain
D. Socially awkward in group situations - ANSWER C. Uses others for personal gain
A nurse is interpreting the cardiac rhythm strip of a client who was admitted with syncope.
Which of the following images indicates that the client has atrial fibrillation? -
ANSWER No P waves or P waves erratic; PR interval indiscernible
A client who has a diagnosis of complete placenta previa is admitted to the labor and
delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in
duration. Which of the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam - ANSWER C. Prepare the client for a cesarean section
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical
unit. Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
1
,B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect
tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a
Harrington rod - ANSWER A. A 10-year-old client who has pneumonia and is receiving
respiratory treatments
• The 10-year-old with pneumonia is a stable pediatric patient who requires routine
respiratory treatments, which a medical unit nurse would be familiar with.
• The other clients have more complex, high-risk needs
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket.
After moving the client to safety, which of the following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher. - ANSWER A. Notify the facility
operator.
This follows the R.A.C.E. acronym:
• R: Rescue (move the client to safety)
• A: Alarm (notify appropriate personnel)
• C: Confine (close fire doors)
• E: Extinguish (use the fire extinguisher if possible)
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
2
,D. Increased hematocrit - ANSWER A. Generalized edema
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the
purpose of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug - ANSWER This technique
decreases the risk of subcutaneous infiltration
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes - ANSWER C. Monitor the client for 1 hr after
meals
A nurse is planning care for a child who has increased intracranial pressure with a decrease
in level of consciousness. Which of the following interventions should the nurse include in
the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs - ANSWER B. Maintain the head at a
midline position
10. A nurse is assessing a client who has delirium due to a febrile illness. Which of the
following findings should the nurse expect?
3
, A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia - ANSWER A. Hallucinations
A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The
nurse should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses - ANSWER D. Bounding pulses
A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain - ANSWER B. Hyperemesis
A home health nurse is reviewing treatment goals with a client who has diabetes mellitus.
The nurse should evaluate which of the following laboratory tests to determine effective
long-term management of blood glucose levels?
A. 3-hr oral glucose tolerance test
B. HbA1c
C. Fasting blood glucose test
D. Urinalysis for ketones - ANSWER B. HbA1c
A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client?
4
