Question 1
601. During the initial newborn assessment, the nurse finds that a newborn's heart rate is
irregular. Which intervention should the nurse implement?
A. Notify the pediatrician immediately.
B. Teach the parents about congenital heart defects.
C. Document the finding in the infant's record.
D. Apply oxygen per nasal cannula at 3 L/min.
CORRECT ANSWER
Document the finding in the infant's record.
Question 2
602. Which assessment finding indicates to the nurse a client's readiness for pulmonary
function tests?
a- Expresses an understanding of the procedure.
b- NPO for 6 hrs.
c- No known drug allergies
d- Intravenous access intact.
CORRECT ANSWER
Expresses an understanding of the procedure.
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,Question 3
603. A young adult male is admitted to the emergency department with diabetic
ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose
is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?
a- Infuse sodium chloride 0.9% (normal saline)
b- Prepare an emergency dose of glucagon
c- Determine the last time the client ate
d- Check urine for ketone bodies with a dipstick
CORRECT ANSWER
Infuse sodium chloride 0.9% (normal saline).
Question 4
604. The nurse is assessing the thorax and lungs of a client who is having respiratory
difficulty. Which finding is most indicative of respiratory distress?
a- Contractions of the sternocleidomastoid muscle.
b- Respiratory rate of 20 breath/mints
c- Downward movement of diaphragm with inspiration
d- A pulse oximetry reading of SpO2 95%
CORRECT ANSWER
Contractions of the sternocleidomastoid muscle.
Question 5
605. After receiving lactulose, a client with hepatic encephalopathy has several loose
stools. What action should the nurse implement?
a- Send stool specimen to the lab
b- Measure abdominal girth
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,c- Encourage increased fiber in diet.
d- Monitor mental status.
CORRECT ANSWER
Monitor mental status.
Question 6
606. A client present at the clinic with blepharitis. What instructions should the nurse
provide for home care?
a- Use bilateral eyes patches while sleeping to prevent injury to eyes.
b- Wear sunglasses when out of doors to prevent photophobia
c- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo
d- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo.
CORRECT ANSWER
Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo.
Question 7
608. The nurse is teaching a client with atrial fibrillation about a newly prescribed
medication, dronedarone. Which information should the nurse include in client
interactions? (Select all that apply)
a- Discontinue medication when palpitation subside.
b- Avoid eating grapefruit or drinking grapefruit juice.
c- Report changes in the use of daily supplements
d- Notify your health care provider if your skin looks yellow
e- If a dose is missed, the next dose should be double.
CORRECT ANSWER
Avoid eating grapefruit or drinking grapefruit juice.
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, Report changes in the use of daily supplements.
Notify you heal care provider if your skin looks yellow.
Question 8
609. A male client recently released from a correctional facility arrives at the clinic with a
cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What
action should the nurse implement? (Select all that apply)
a- Administer a PPD test
b- Schedule the client for the chest radiograph
c- Obtain sputum for acid fast bacillus (AFB) testing
d- Place a mask on the client until he is moved to isolation.
e- Send the client home with instructions for a prescribe antibiotic.
CORRECT ANSWER
Schedule the client for the chest radiograph.
Obtain sputum for acid fast bacillus (AFB) testing.
Place a mask on the client until he is moved to isolation.
Question 9
610. A 16-year-old male is admitted to the pediatric intensive care unit after being
involved in a house fire. He has full thickness burns to his lower torso and extremities.
Before a dressing change to his legs, which intervention is most important for the nurse to
implement?
a- Encourage the parents to stay at the bedside
b- Use distraction techniques to reduce pain.
c- Maintain strict aseptic technique
d- Place a drape over the pubic area.
CORRECT ANSWER
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601. During the initial newborn assessment, the nurse finds that a newborn's heart rate is
irregular. Which intervention should the nurse implement?
A. Notify the pediatrician immediately.
B. Teach the parents about congenital heart defects.
C. Document the finding in the infant's record.
D. Apply oxygen per nasal cannula at 3 L/min.
CORRECT ANSWER
Document the finding in the infant's record.
Question 2
602. Which assessment finding indicates to the nurse a client's readiness for pulmonary
function tests?
a- Expresses an understanding of the procedure.
b- NPO for 6 hrs.
c- No known drug allergies
d- Intravenous access intact.
CORRECT ANSWER
Expresses an understanding of the procedure.
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@THE STUDY VAULT
,Question 3
603. A young adult male is admitted to the emergency department with diabetic
ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose
is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?
a- Infuse sodium chloride 0.9% (normal saline)
b- Prepare an emergency dose of glucagon
c- Determine the last time the client ate
d- Check urine for ketone bodies with a dipstick
CORRECT ANSWER
Infuse sodium chloride 0.9% (normal saline).
Question 4
604. The nurse is assessing the thorax and lungs of a client who is having respiratory
difficulty. Which finding is most indicative of respiratory distress?
a- Contractions of the sternocleidomastoid muscle.
b- Respiratory rate of 20 breath/mints
c- Downward movement of diaphragm with inspiration
d- A pulse oximetry reading of SpO2 95%
CORRECT ANSWER
Contractions of the sternocleidomastoid muscle.
Question 5
605. After receiving lactulose, a client with hepatic encephalopathy has several loose
stools. What action should the nurse implement?
a- Send stool specimen to the lab
b- Measure abdominal girth
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,c- Encourage increased fiber in diet.
d- Monitor mental status.
CORRECT ANSWER
Monitor mental status.
Question 6
606. A client present at the clinic with blepharitis. What instructions should the nurse
provide for home care?
a- Use bilateral eyes patches while sleeping to prevent injury to eyes.
b- Wear sunglasses when out of doors to prevent photophobia
c- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo
d- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo.
CORRECT ANSWER
Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo.
Question 7
608. The nurse is teaching a client with atrial fibrillation about a newly prescribed
medication, dronedarone. Which information should the nurse include in client
interactions? (Select all that apply)
a- Discontinue medication when palpitation subside.
b- Avoid eating grapefruit or drinking grapefruit juice.
c- Report changes in the use of daily supplements
d- Notify your health care provider if your skin looks yellow
e- If a dose is missed, the next dose should be double.
CORRECT ANSWER
Avoid eating grapefruit or drinking grapefruit juice.
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@THE STUDY VAULT
, Report changes in the use of daily supplements.
Notify you heal care provider if your skin looks yellow.
Question 8
609. A male client recently released from a correctional facility arrives at the clinic with a
cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What
action should the nurse implement? (Select all that apply)
a- Administer a PPD test
b- Schedule the client for the chest radiograph
c- Obtain sputum for acid fast bacillus (AFB) testing
d- Place a mask on the client until he is moved to isolation.
e- Send the client home with instructions for a prescribe antibiotic.
CORRECT ANSWER
Schedule the client for the chest radiograph.
Obtain sputum for acid fast bacillus (AFB) testing.
Place a mask on the client until he is moved to isolation.
Question 9
610. A 16-year-old male is admitted to the pediatric intensive care unit after being
involved in a house fire. He has full thickness burns to his lower torso and extremities.
Before a dressing change to his legs, which intervention is most important for the nurse to
implement?
a- Encourage the parents to stay at the bedside
b- Use distraction techniques to reduce pain.
c- Maintain strict aseptic technique
d- Place a drape over the pubic area.
CORRECT ANSWER
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