Question 1
The nurse is completing the admission assessment of a 3-year old who is admitted with
bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the
child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
CORRECT ANSWER
B. Sluggish and unequal pupillary responses
Question 2
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an
elevated serum amylase. Which additional information is the client most likely to report to
the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
CORRECT ANSWER
A. Abdominal pain decreases when lying supine
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,Question 3
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents prior
to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
CORRECT ANSWER
A. Instructions about how much fluid the child should drink daily
Question 4
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select
the location on the image with a red dot).
CORRECT ANSWER
I placed the red dot on the base of the neck on the right side
Question 5
After receiving report on an inpatient acute care unit, which client should the nurse assess
first?
A. The client with an obstruction of the large intestine who is experiencing abdominal
distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent
bowel sounds
C. The client with a small bowel obstruction who has a nasogastric tube that is draining
greenish fluid
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,D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
CORRECT ANSWER
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
Question 6
A teenager presents to the emergency department with palpitations after vaping at a
party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client
developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
CORRECT ANSWER
D. Respiratory alkalosis
Question 7
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's
arrival, the nurse should ensure that the client's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
CORRECT ANSWER
Fowlers
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, Question 8
The nurse is taking the blood pressure measurement of a client with Parkinson's disease.
Which information in the client's admission assessment is relevant to the nurse's plan for
taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
CORRECT ANSWER
A. Frequent syncope
C. Flat affect
D. Blurred vision
Question 9
While caring for a client's postoperative dressing, the nurse observes purulent drainage at
the wound. Before reporting this finding to the healthcare provider, the nurse should
review which of the client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
CORRECT ANSWER
B. Culture for sensitive organisms
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The nurse is completing the admission assessment of a 3-year old who is admitted with
bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the
child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope
CORRECT ANSWER
B. Sluggish and unequal pupillary responses
Question 2
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an
elevated serum amylase. Which additional information is the client most likely to report to
the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
CORRECT ANSWER
A. Abdominal pain decreases when lying supine
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,Question 3
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents prior
to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family
CORRECT ANSWER
A. Instructions about how much fluid the child should drink daily
Question 4
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select
the location on the image with a red dot).
CORRECT ANSWER
I placed the red dot on the base of the neck on the right side
Question 5
After receiving report on an inpatient acute care unit, which client should the nurse assess
first?
A. The client with an obstruction of the large intestine who is experiencing abdominal
distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent
bowel sounds
C. The client with a small bowel obstruction who has a nasogastric tube that is draining
greenish fluid
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,D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
CORRECT ANSWER
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
Question 6
A teenager presents to the emergency department with palpitations after vaping at a
party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client
developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
CORRECT ANSWER
D. Respiratory alkalosis
Question 7
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's
arrival, the nurse should ensure that the client's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers
CORRECT ANSWER
Fowlers
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, Question 8
The nurse is taking the blood pressure measurement of a client with Parkinson's disease.
Which information in the client's admission assessment is relevant to the nurse's plan for
taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling
CORRECT ANSWER
A. Frequent syncope
C. Flat affect
D. Blurred vision
Question 9
While caring for a client's postoperative dressing, the nurse observes purulent drainage at
the wound. Before reporting this finding to the healthcare provider, the nurse should
review which of the client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
CORRECT ANSWER
B. Culture for sensitive organisms
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