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A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions correct answers D. Contractions
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. Stay in bed at least 1 hr if unable to fall asleep
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime correct answers D. Eat a light snack before bedtime
A nurse on a telemetry unit is caring for a client who becomes unconscious and whose
monitor displays ventricular tachycardia. Which of the following actions should the nurse
take first after determining the client does not have a palpable pulse?
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
D. Administer epinephrine correct answers B. Defibrillate
A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding.
The nurse does not speak the same language as the client. The client's partner and 10-year-old
child are accompanying her. Which of the following actions should the
nurse take to gather the client's admission data?
A. Have the client's child translate
B. Allow the client's partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the client to translate correct
answers C. Request a female interpreter through the facility
A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a
cooling blanket. Which of the following findings indicates the client is having an adverse
reaction to the cooling?
a. Flushing
b. Tachycardia
c. Restlessness
d. Shivering correct answers d. Shivering
A nurse is caring for a client who has deep-vein-thrombosis of the left lower extremity.
Which of the following actions should the nurse take? (Exhibit)
A. Position the client with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
C. Administer acetaminophen
D. Massage the affected extremity every 4 hr correct answers B. Withhold heparin IV
infusion PTT- 30-40 seconds; x2 if on heparin
,A nurse is reviewing assessment data from several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4) correct answers B. A client
who has a nonhealing leg ulcer
8. A nurse is providing discharge teaching to a client who has a chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
a. Eat 1 g/kg of protein per day
b. Take magnesium hydroxide for indigestion
c. Drink at least 3 L of fluid daily-
Consume foods high in potassium- restrict correct answers a. Eat 1 g/kg of protein per day
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of
the following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial? correct answers B. A history of gastroesophageal
reflux disease
?A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse
should tell the client that she will undergo which of the following screening tests at 16 weeks
of gestation?
A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
C. Nonstress test -28 weeks
D. Maternal serum alpha-fetoprotein- 16 to 18 weeks correct answers D. Maternal serum
alpha-fetoprotein- 16 to 18 weeks
A nurse is caring for a client who is on bed rest. The nurse should recognize that which of
the following findings is a complication of immobility?
A. Decreased serum calcium levels- increased serum calcium
B. Increased blood pressure- hypotension
C. Swollen area on calf
D. Urinary frequency- correct answers C. Swollen area on calf
12. A nurse in acute care mental health facility is participating in a medication-education
group. The leader of the group uses a laissez-faire leadership style. Which of the following
actions should the nurse expect from the leader during the session?
A .The leader encourages group members to remain silent until questions are called for
B. The leader lecture about medication adverse effects to the group members
c. The leader allows the group to discuss whatever they would like to regarding their
medications
d. The leader has group members vote on what they would like to learn about during the
session correct answers d. The leader has group members vote on what they would like to
learn about during the session
,A nurse is providing teaching about digoxin administration to the parents of a toddler who
has heart failure. Which of the following statements should the nurse include in the teaching?
A "You can add the medication to a half-cup of your child's favorite juice."
B "Repeat the dose if your child vomits within 1 hour after taking medication." X
C "Limit your child's potassium intake while she is taking this medication."
D "Have your child drink a small glass of water after swallowing the medication." correct
answers D "Have your child drink a small glass of water after swallowing the medication."
A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for phenelzine. Which of the following foods should the nurse instruct the
client to avoid?
A. Grapefruit
B. Spinach
C. Cottage cheese- cream cheese ok.
D. Smoked salmon correct answers D. Smoked salmon
A nurse is planning care for a client who has COPD and weighs 99 lb. The provider has
prescribed a diet of a 1.5 g protein/kg/day. How many grams of protein per day should the
nurse include in the client's dietary plan? (Round to the nearest whole number correct
answers a. 68
A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room
B. Withdraw the client's TV privileges if he does not attend group therapy X
C. Encourage the client to take frequent rest periods
D. Place the client in seclusion when he exhibits signs of anxiety X correct answers C.
Encourage the client to take frequent rest periods
A parish nurse is leading a support group for clients whose family members have committed
suicide. Which of the following strategies should the nurse plan to use during the group
session?
a Encourage clients to establish a timeline for their own grieving process
b. Initiate a discussion with clients about ways to cope with changes in family
dynamics
c Discourage clients from sharing negative aspects of their relationship with the
deceased persons
d Assist clients in identifying ways suicide could have been prevented correct answers b.
Initiate a discussion with clients about ways to cope with changes in family
A nurse manager observes two staff nurses reviewing the computer records of a client who is
not under their care. Which of the following actions should the nurse manager take first?
a Instruct the nurses to close the client's computer record
b Request the nurses present an in-service on client confidentiality
c. Advise the nurses to read the facility's confidentiality policyd.
d. Place documentation of the nurses' actions in the personnel file correct answers a Instruct
the nurses to close the client's computer record
, A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to
the administration of clozapine?
a. Heart rate 58/min
b. Fasting blood glucose 100 mg/dL
c. Hgb 14 g/dL
d. WBC count 2,900/mm3- also agranulocytosis same thing or soar throat. correct answers d.
WBC count 2,900/mm3- also agranulocytosis same thing or soar throat.
A nurse is caring for several clients on a medical-surgical unit. For which of the following
nurses activities is it required that the nurse use sterile gloves?
a. Inserting an NG tube
b. Administering total parenteral nutrition through a central venous access device
c. Initiating IV access
d. Performing tracheostomy care correct answers d. Performing tracheostomy care
A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse give?
a. Influenza
b. Measles, mumps and rubella
c. Human papilloma virus
d. Varicella correct answers a. Influenza
A nurse is inserting an indwelling catheter for a male client. Which of the following actions
should the nurse take?
a. Perform the cleansing procedure with a fresh swab two times
b. Lift the penis so that it is perpendicular to the client's body
c. Cleanse the tip of the penis in a side-to-side motion
d. Pick up the catheter 13 cm (5 cm) from its tip correct answers b. Lift the penis so that it is
perpendicular to the client's body
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the
teaching?
a Bleeding gums- low platelet
b Faintness upon rising
c Swelling of the face
d Urinary frequency correct answers c. Swelling of the face
A nurse has received change-of-shift report for a group of clients. Which of the following
actions should the nurse take to manage time effectively?
a. Document client care at the end of the shift
b. Make the client to-do list for the day
c. Skip breaks until the client tasks are completed
d. Focus on several client tasks at a time correct answers b. Make the client to-do list for the
day
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The
nurse should monitor the client for which of the following complications?
A. Vomiting
B. Hypertension
C. Epigastric pain
D. Contractions correct answers D. Contractions
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. Stay in bed at least 1 hr if unable to fall asleep
B. Take a 1 hr nap during the day
C. Perform exercises prior to bedtime
D. Eat a light snack before bedtime correct answers D. Eat a light snack before bedtime
A nurse on a telemetry unit is caring for a client who becomes unconscious and whose
monitor displays ventricular tachycardia. Which of the following actions should the nurse
take first after determining the client does not have a palpable pulse?
A. Assess heart sounds
B. Defibrillate
C. Establish IV access
D. Administer epinephrine correct answers B. Defibrillate
A nurse is admitting a client who 1 week postpartum and reports excessive vaginal bleeding.
The nurse does not speak the same language as the client. The client's partner and 10-year-old
child are accompanying her. Which of the following actions should the
nurse take to gather the client's admission data?
A. Have the client's child translate
B. Allow the client's partner to translate
C. Request a female interpreter through the facility
D. Ask a nursing student who speaks the same language as the client to translate correct
answers C. Request a female interpreter through the facility
A nurse is caring for a client who is febrile. To reduce the client's fever, the nurse applies a
cooling blanket. Which of the following findings indicates the client is having an adverse
reaction to the cooling?
a. Flushing
b. Tachycardia
c. Restlessness
d. Shivering correct answers d. Shivering
A nurse is caring for a client who has deep-vein-thrombosis of the left lower extremity.
Which of the following actions should the nurse take? (Exhibit)
A. Position the client with the affected extremity lower than the heart
B. Withhold heparin IV infusion PTT- 30-40 seconds; x2 if on heparin
C. Administer acetaminophen
D. Massage the affected extremity every 4 hr correct answers B. Withhold heparin IV
infusion PTT- 30-40 seconds; x2 if on heparin
,A nurse is reviewing assessment data from several clients. For which of the following clients
should the nurse recommend referral to a dietitian?
A. An older adult client who has a BMI of 24
B. A client who has a nonhealing leg ulcer
C. An older adult client who has presbyopia
D. A client who has an albumin level of 3.7 g/dL (normal 3.4-5.4) correct answers B. A client
who has a nonhealing leg ulcer
8. A nurse is providing discharge teaching to a client who has a chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
a. Eat 1 g/kg of protein per day
b. Take magnesium hydroxide for indigestion
c. Drink at least 3 L of fluid daily-
Consume foods high in potassium- restrict correct answers a. Eat 1 g/kg of protein per day
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of
the following places the client at risk for aspiration?
A. Sitting in a high-Fowler's position during the feeding
B. A history of gastroesophageal reflux disease
C. Receiving a high osmolarity formula
D. A residual of 65 mL 1 hr postprandial? correct answers B. A history of gastroesophageal
reflux disease
?A nurse is providing prenatal teaching to a client who is at 12 weeks of gestation. The nurse
should tell the client that she will undergo which of the following screening tests at 16 weeks
of gestation?
A. Chorionic villus sampling- as early as 8 weeks
B. Cervical cultures for chlamydia- 1st appointment.
C. Nonstress test -28 weeks
D. Maternal serum alpha-fetoprotein- 16 to 18 weeks correct answers D. Maternal serum
alpha-fetoprotein- 16 to 18 weeks
A nurse is caring for a client who is on bed rest. The nurse should recognize that which of
the following findings is a complication of immobility?
A. Decreased serum calcium levels- increased serum calcium
B. Increased blood pressure- hypotension
C. Swollen area on calf
D. Urinary frequency- correct answers C. Swollen area on calf
12. A nurse in acute care mental health facility is participating in a medication-education
group. The leader of the group uses a laissez-faire leadership style. Which of the following
actions should the nurse expect from the leader during the session?
A .The leader encourages group members to remain silent until questions are called for
B. The leader lecture about medication adverse effects to the group members
c. The leader allows the group to discuss whatever they would like to regarding their
medications
d. The leader has group members vote on what they would like to learn about during the
session correct answers d. The leader has group members vote on what they would like to
learn about during the session
,A nurse is providing teaching about digoxin administration to the parents of a toddler who
has heart failure. Which of the following statements should the nurse include in the teaching?
A "You can add the medication to a half-cup of your child's favorite juice."
B "Repeat the dose if your child vomits within 1 hour after taking medication." X
C "Limit your child's potassium intake while she is taking this medication."
D "Have your child drink a small glass of water after swallowing the medication." correct
answers D "Have your child drink a small glass of water after swallowing the medication."
A nurse is providing teaching to a client who has a depressive disorder and a new prescription
for phenelzine. Which of the following foods should the nurse instruct the
client to avoid?
A. Grapefruit
B. Spinach
C. Cottage cheese- cream cheese ok.
D. Smoked salmon correct answers D. Smoked salmon
A nurse is planning care for a client who has COPD and weighs 99 lb. The provider has
prescribed a diet of a 1.5 g protein/kg/day. How many grams of protein per day should the
nurse include in the client's dietary plan? (Round to the nearest whole number correct
answers a. 68
A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Encourage the client to spend time in the day room
B. Withdraw the client's TV privileges if he does not attend group therapy X
C. Encourage the client to take frequent rest periods
D. Place the client in seclusion when he exhibits signs of anxiety X correct answers C.
Encourage the client to take frequent rest periods
A parish nurse is leading a support group for clients whose family members have committed
suicide. Which of the following strategies should the nurse plan to use during the group
session?
a Encourage clients to establish a timeline for their own grieving process
b. Initiate a discussion with clients about ways to cope with changes in family
dynamics
c Discourage clients from sharing negative aspects of their relationship with the
deceased persons
d Assist clients in identifying ways suicide could have been prevented correct answers b.
Initiate a discussion with clients about ways to cope with changes in family
A nurse manager observes two staff nurses reviewing the computer records of a client who is
not under their care. Which of the following actions should the nurse manager take first?
a Instruct the nurses to close the client's computer record
b Request the nurses present an in-service on client confidentiality
c. Advise the nurses to read the facility's confidentiality policyd.
d. Place documentation of the nurses' actions in the personnel file correct answers a Instruct
the nurses to close the client's computer record
, A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to
the administration of clozapine?
a. Heart rate 58/min
b. Fasting blood glucose 100 mg/dL
c. Hgb 14 g/dL
d. WBC count 2,900/mm3- also agranulocytosis same thing or soar throat. correct answers d.
WBC count 2,900/mm3- also agranulocytosis same thing or soar throat.
A nurse is caring for several clients on a medical-surgical unit. For which of the following
nurses activities is it required that the nurse use sterile gloves?
a. Inserting an NG tube
b. Administering total parenteral nutrition through a central venous access device
c. Initiating IV access
d. Performing tracheostomy care correct answers d. Performing tracheostomy care
A nurse is caring for a client who is at 11 weeks of gestation. Which of the following
immunizations should the nurse give?
a. Influenza
b. Measles, mumps and rubella
c. Human papilloma virus
d. Varicella correct answers a. Influenza
A nurse is inserting an indwelling catheter for a male client. Which of the following actions
should the nurse take?
a. Perform the cleansing procedure with a fresh swab two times
b. Lift the penis so that it is perpendicular to the client's body
c. Cleanse the tip of the penis in a side-to-side motion
d. Pick up the catheter 13 cm (5 cm) from its tip correct answers b. Lift the penis so that it is
perpendicular to the client's body
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to
report to the provider. Which of the following findings should the nurse include in the
teaching?
a Bleeding gums- low platelet
b Faintness upon rising
c Swelling of the face
d Urinary frequency correct answers c. Swelling of the face
A nurse has received change-of-shift report for a group of clients. Which of the following
actions should the nurse take to manage time effectively?
a. Document client care at the end of the shift
b. Make the client to-do list for the day
c. Skip breaks until the client tasks are completed
d. Focus on several client tasks at a time correct answers b. Make the client to-do list for the
day
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin
during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the
following actions should the nurse include in the plan?
