Form A2 (180 QUESTIONS)
1. **A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old child. Which
of the following actions should the nurse take?**
- A. (Unable to read)
- B. Inform the child that they will experience some discomfort during the catheter insertion.
- C. Use a mummy restraint to hold the child in place during the catheter insertion.
- D. Ask the parents to leave the room during the procedure.
2. **A nurse is caring for a client with an arteriovenous fistula. Which of the following findings
should the nurse report?**
- A. Presence of a thrill upon palpation.
- B. Absence of a bruit.
- C. Distended blood vessels.
- D. Swishing sound upon auscultation.
3. **A nurse is providing discharge teaching for a client with an implantable cardioverter
defibrillator (ICD). Which statement indicates the client understands the teaching?**
- A. “I will take a bath instead of showering.”
- B. “I will wear loose clothing around my ICD.”
- C. “I will stop using my microwave oven because of my ICD.”
- D. “I can hold my cellphone on the same side of my body as the ICD.”
4. **A nurse is caring for a client who is 14 weeks pregnant and reports feeling ambivalent about
the pregnancy. Which response should the nurse give?**
- A. “Tell me more about your feelings regarding the pregnancy.”
- B. “You should discuss your feelings about the pregnancy with your provider.”
- C. “Have you talked about these feelings with your partner?”
- D. “When did you start feeling this way?”
5. **A nurse is planning care for a client who has a prescription for a bowel training program
following a spinal cord injury. Which action should the nurse include in the plan?**
- A. Encourage a maximum fluid intake of 1,500 ml per day.
- B. Increase the amount of refined grains in the client’s diet.
- C. Provide the client with a cold drink before defecation.
- D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
,6. **A nurse is caring for a client in active labor who requests pain management. Which action
should the nurse take?**
- A. Administer ondansetron.
- B. Place the client in a warm shower.
- C. Apply fundal pressure during contractions.
- D. Assist the client into a supine position.
7. **A nurse in an emergency department is triaging multiple clients following a community
disaster. Which injury should the nurse prioritize?**
- A. Below-the-knee amputation.
- B. Fractured tibia.
- C. 95% full-thickness body burn.
- D. 10 cm (4 in) laceration to the forearm.
8. **A nurse manager is updating protocols for the use of belt restraints. Which guideline should
be included?**
- A. Remove the client’s restraint every 4 hours.
- B. Document the client’s condition every 15 minutes.
- C. Attach the restraint to the bed’s side rails.
- D. Request a PRN restraint prescription for aggressive clients.
9. **A nurse is teaching an in-service about nursing leadership. Which information should be
included about effective leadership?**
- A. Acts as an advocate for the nursing unit.
- B. (Unable to read) for the unit.
- C. Prioritizes staff requests over client needs.
- D. Provides routine client care and documentation.
10. **A nurse is reviewing laboratory findings for a client with diabetes mellitus who reports
following their care plan. Which finding indicates a need to revise the client’s care plan?**
- A. Serum sodium 144 mEq/L.
- B. (Unable to read)
- C. HbA1c 10%.
- D. Random serum glucose 190 mg/dL.
11. **A nurse in a provider’s office is reviewing laboratory results. Which sexually transmitted
infection is nationally notifiable and should be reported to the state health department?**
- A. Chlamydia.
- B. Human papillomavirus.
- C. Candidiasis.
, - D. Herpes simplex virus.
12. **A nurse is teaching a newly licensed nurse about therapeutic techniques for leading a
group on a mental health unit. Which technique should be included?**
- A. Share personal opinions to influence the group’s values.
- B. Measure the group’s accomplishments against a previous group.
- C. Yield to conflict situations to maintain group harmony.
- D. Use modeling to help clients improve interpersonal skills.
13. **A nurse is planning care for a client who practices Orthodox Judaism and mentions they
are observing Passover. Which action should be included in the care plan?**
- A. Provide chicken with cream sauce.
- B. Avoid serving fish with fins and scales.
- C. Provide unleavened bread.
- D. Avoid serving foods containing lamb.
14. **A nurse is caring for a client with a pulmonary embolism. Which finding indicates the
treatment is effective?**
- A. A chest x-ray reveals increased density in all fields.
- B. The client reports feeling less anxious.
- C. Diminished breath sounds are auscultated bilaterally.
- D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.
15. **A nurse in an emergency department is assessing a client who ingested thirty diazepam
tablets and has a respiratory rate of 10/min. After securing the airway and initiating an IV, what
should be the next action?**
- A. Monitor the client’s IV site for thrombophlebitis.
- B. Administer flumazenil.
- C. Evaluate the client for further suicidal behavior.
- D. Initiate seizure precautions.
16. **A nurse in an emergency department is assessing a client who used cocaine 1 hour ago.
Which finding should the nurse expect?**
- A. Hypotension.
- B. Memory loss.
- C. Slurred speech.
- D. Elevated temperature.
17. **A nurse is assessing a newborn with a blood glucose level of 30 mg/dL. Which
manifestation should the nurse expect?**
, - A. Loose stools.
- B. Jitteriness.
- C. Hypertonia.
- D. Abdominal distention.
18. **A nurse in a pediatric clinic is reviewing a school-age child’s lab results. Which finding
should be reported to the provider?**
- A. Hemoglobin 12.5 g/dL.
- B. Platelets 250,000/mm³.
- C. Hematocrit 40%.
- D. WBC 14,000/mm³.
19. **A charge nurse is teaching about designating a health care proxy for durable power of
attorney for health care (DPSHC). Which information should be included?**
- A. “The proxy should make health care decisions for the client, even if the client is capable
of making them.”
- B. “The proxy can make financial decisions if needed.”
- C. “The proxy can make treatment decisions if the client is under anesthesia.”
- D. “The proxy should manage legal issues for the client.”
20. **A nurse in the PACU is caring for a client who reports nausea. Which action should the
nurse take first?**
- A. Turn the client onto their side.
- B. Administer an analgesic.
- C. Administer an antiemetic.
- D. Monitor the client’s vital signs.
21. **A nurse is caring for a client with a history of depression who is experiencing a situational
crisis. Which action should the nurse take first?**
- A. Confirm the client’s perception of the event.
- B. Notify the client’s support system.
- C. Help the client identify personal strengths.
- D. Teach the client relaxation techniques.
22. **A nurse is caring for a client with bipolar disorder who is experiencing acute mania and
has a verbal prescription for restraints. Which action should the nurse take?**
- A. Request a renewal of the prescription every 8 hours.
- B. Check the client’s peripheral pulse rate every 30 minutes.
- C. Obtain a prescription for restraint within 4 hours.
- D. Document the client’s condition every 15 minutes.