Question 1
It is the start of the shift and the nurse has just finished listening to a report on four
clients. Which client should the nurse assess first?
A. A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of
88/58
B. A client with a diagnosis of a concussion and who doesn't remember the motor vehicle
accident
C. A client diagnosed with viral meningitis and has signs of meningeal irritation
D. A client diagnosed with generalized seizures who complains of a headache following an
observed seizure
CORRECT ANSWER
A
Hypotension adversely affects cerebral perfusion following a traumatic brain injury. Both
hypotension and hypoxia are the greatest threats to functional outcomes in brain injury and
must be corrected early, taking priority over other interventions for brain injury. Headache
after a seizure is expected, amnesia is common with a concussion, and meningeal irritation is
an expected finding with viral meningitis, making these clients a lower priority at this point.
Question 2
The nurse discovers that a chest tube has become disconnected from the main connection
site of a closed chest drainage unit (CDU). What immediate action should be taken by the
nurse?
A. Cover the insertion site with a sterile petroleum gauze pad
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,B. Submerge the distal end of the tube in 2 - 4 centimeters of sterile water
C. Reconnect the drainage tube to the chest tube
D. Clamp the chest tube nearest to the client with a rubber-tipped hemostat
CORRECT ANSWER
B
If the tube becomes disconnected from the main connection site of a CDU, the nurse should
place the end of the chest tube in a bottle of sterile water (or saline solution) while someone
else prepares a new CDU setup. The health care provider should be called (the nurse should
expect an order for a chest X-ray.) To prevent the chest tube from coming apart, it's
important to spiral-tape the main connection site and not to let loops of tubing hang down
the side of the bed. If there is an air leak from the chest, do not clamp the chest tube as this
will cause air to accumulate in the pleural cavity, potentially leading to a collapsed lung or
tension pneumothorax. Only if the chest tube becomes dislodged from the client does the
nurse need to cover the insertion site with a sterile gauze dressing.
Question 3
The client states to the nurse: "I am ready to stop all of these treatments. I just want to go
home and enjoy my family for the little bit of time I have left." Which action is most
appropriate?
A. Call in a referral to a social worker and explain that the request will need to be discussed
in more detail at a later time
B. Encourage the client to discuss this decision with the health care provider and family
C. Tell the family members that the client's preference is to go home to die
D. No action is needed at this time unless the client repeats the statement to another
caregiver
CORRECT ANSWER
B
The client has the right to stop treatment and should be supported in clearly communicating
this decision with the health care provider and family. The nurse needs to act as an advocate
for the client. It is factually incorrect to wait until the request is repeated; clients should not
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,need to express their wishes repeatedly before caregivers listen to them. The nurse should
not be the one to share sensitive information with the family; the client controls that
information. Social services may get involved but time is of the essence for those who are
terminally ill.
Question 4
A client who is newly diagnosed with hypertension is prescribed benazepril. What is the
most important point to make when teaching the client about this medication?
A. "Notify the health care provider if there is a change in your voice."
B. "Monitor your blood pressure and pulse regularly."
C. "Take medication as directed at the same time each day, even if you feel well."
D. "Call your health care provider if you develop a dry cough."
CORRECT ANSWER
A
Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't
know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of
the side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to
require discontinuation of the drug. But the most important point to make is that if the
client's voice changes or "sounds funny" or there is any swelling of the lips, tongue or throat,
the client should contact the health care provider because this could indicate angioedema, a
potentially fatal condition.
Question 5
A client's admission urinalysis shows the specific gravity value of 1.039. Which of these
findings would the nurse expect to find during the physical assessment of this client?
A. Above normal heart rate
B. Moist mucous membranes
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, C. Poor skin turgor
D. Increased blood pressure
CORRECT ANSWER
C
The specific gravity value is high, which would indicate dehydration. Specific gravity
measures urine density and an average urine specific gravity value is around 1.020. Poor skin
turgor, as seen with tenting of the skin, is consistent with this problem.
Question 6
A male client is preparing for discharge after an acute myocardial infarction. The client
asks the nurse about sexual activity once the client is home. What should be the nurse's
initial approach?
A. Answer the questions accurately in a private environment
B. Schedule a private, uninterrupted teaching session with both the client and the partner
C. Assess the client's knowledge about the current health problems
D. Give the client written material from the American Heart Association about sexual activity
with heart disease
CORRECT ANSWER
C
The nursing process is continuous and cyclical in nature. When a client expresses a specific
concern, the nurse should perform a focused assessment to gather additional data prior to
planning and implementing nursing interventions.
Question 7
A nurse is caring for a 2 year-old child who is being treated for lead poisoning by chelation
therapy. The nurse should be alert for which side effect of chelation therapy?
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It is the start of the shift and the nurse has just finished listening to a report on four
clients. Which client should the nurse assess first?
A. A client with a diagnosis of an acute traumatic brain injury who has a blood pressure of
88/58
B. A client with a diagnosis of a concussion and who doesn't remember the motor vehicle
accident
C. A client diagnosed with viral meningitis and has signs of meningeal irritation
D. A client diagnosed with generalized seizures who complains of a headache following an
observed seizure
CORRECT ANSWER
A
Hypotension adversely affects cerebral perfusion following a traumatic brain injury. Both
hypotension and hypoxia are the greatest threats to functional outcomes in brain injury and
must be corrected early, taking priority over other interventions for brain injury. Headache
after a seizure is expected, amnesia is common with a concussion, and meningeal irritation is
an expected finding with viral meningitis, making these clients a lower priority at this point.
Question 2
The nurse discovers that a chest tube has become disconnected from the main connection
site of a closed chest drainage unit (CDU). What immediate action should be taken by the
nurse?
A. Cover the insertion site with a sterile petroleum gauze pad
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@THE STUDY VAULT
,B. Submerge the distal end of the tube in 2 - 4 centimeters of sterile water
C. Reconnect the drainage tube to the chest tube
D. Clamp the chest tube nearest to the client with a rubber-tipped hemostat
CORRECT ANSWER
B
If the tube becomes disconnected from the main connection site of a CDU, the nurse should
place the end of the chest tube in a bottle of sterile water (or saline solution) while someone
else prepares a new CDU setup. The health care provider should be called (the nurse should
expect an order for a chest X-ray.) To prevent the chest tube from coming apart, it's
important to spiral-tape the main connection site and not to let loops of tubing hang down
the side of the bed. If there is an air leak from the chest, do not clamp the chest tube as this
will cause air to accumulate in the pleural cavity, potentially leading to a collapsed lung or
tension pneumothorax. Only if the chest tube becomes dislodged from the client does the
nurse need to cover the insertion site with a sterile gauze dressing.
Question 3
The client states to the nurse: "I am ready to stop all of these treatments. I just want to go
home and enjoy my family for the little bit of time I have left." Which action is most
appropriate?
A. Call in a referral to a social worker and explain that the request will need to be discussed
in more detail at a later time
B. Encourage the client to discuss this decision with the health care provider and family
C. Tell the family members that the client's preference is to go home to die
D. No action is needed at this time unless the client repeats the statement to another
caregiver
CORRECT ANSWER
B
The client has the right to stop treatment and should be supported in clearly communicating
this decision with the health care provider and family. The nurse needs to act as an advocate
for the client. It is factually incorrect to wait until the request is repeated; clients should not
2
@THE STUDY VAULT
,need to express their wishes repeatedly before caregivers listen to them. The nurse should
not be the one to share sensitive information with the family; the client controls that
information. Social services may get involved but time is of the essence for those who are
terminally ill.
Question 4
A client who is newly diagnosed with hypertension is prescribed benazepril. What is the
most important point to make when teaching the client about this medication?
A. "Notify the health care provider if there is a change in your voice."
B. "Monitor your blood pressure and pulse regularly."
C. "Take medication as directed at the same time each day, even if you feel well."
D. "Call your health care provider if you develop a dry cough."
CORRECT ANSWER
A
Benazepril (Lotensin) is an angiotensin converting enzyme (ACE) inhibitor. Even if you don't
know this drug, remember that the spelling of ACE inhibitors usually end with "pril." One of
the side effects of ACE inhibitors is a dry cough; sometimes the cough is severe enough to
require discontinuation of the drug. But the most important point to make is that if the
client's voice changes or "sounds funny" or there is any swelling of the lips, tongue or throat,
the client should contact the health care provider because this could indicate angioedema, a
potentially fatal condition.
Question 5
A client's admission urinalysis shows the specific gravity value of 1.039. Which of these
findings would the nurse expect to find during the physical assessment of this client?
A. Above normal heart rate
B. Moist mucous membranes
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@THE STUDY VAULT
, C. Poor skin turgor
D. Increased blood pressure
CORRECT ANSWER
C
The specific gravity value is high, which would indicate dehydration. Specific gravity
measures urine density and an average urine specific gravity value is around 1.020. Poor skin
turgor, as seen with tenting of the skin, is consistent with this problem.
Question 6
A male client is preparing for discharge after an acute myocardial infarction. The client
asks the nurse about sexual activity once the client is home. What should be the nurse's
initial approach?
A. Answer the questions accurately in a private environment
B. Schedule a private, uninterrupted teaching session with both the client and the partner
C. Assess the client's knowledge about the current health problems
D. Give the client written material from the American Heart Association about sexual activity
with heart disease
CORRECT ANSWER
C
The nursing process is continuous and cyclical in nature. When a client expresses a specific
concern, the nurse should perform a focused assessment to gather additional data prior to
planning and implementing nursing interventions.
Question 7
A nurse is caring for a 2 year-old child who is being treated for lead poisoning by chelation
therapy. The nurse should be alert for which side effect of chelation therapy?
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@THE STUDY VAULT
