1. An older patient complains of having no energy and feeling increasingly weak. The patient has
had a 12lb weight loss over the past year. Which action should the nurse take initially?
- Ask the patient about daily dietary intake
- Describe normal changes associated with aging to the patient
- Discuss long term care placement with the patient
- Schedule regular range of motion exercise
2. A client arrives in the emergency department unconscious and exhibiting decerebrate
posturing. When assessing the client, what does the nurse expect to observe?
- Hyperextension of both the upper and lower extremities
- Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities
- Hyperflexion of the upper extremities and hyperextension of the lower extremities
- Spastic paralysis of both the upper and lower extremities
3. The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the
client to experience the most pain and limited movement of the joints?
- During the evening hours
- After assistive exercise
- In the morning on awakening
- When the room is cool
4. The son of a dying patient tells the nurse, mother doesn’t really respond any more when I visit. I
don’t think she knows that I am here. Which response by the nurse is appropriate/
- Most dying patients don’t know what is going on around them
- It is important to stimulate your mother so she can’t retreat from you
- Withdrawal can be normal response in the process of dying
- Cut back your visits for now to avoid overtiring your mother
5. The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could
help reduce the patients risk of lung cancer?
- Plan to monitor the patient carcinoembryonic antigen (CEA) level
- Teach the patient about annual chest x-rays for lung cancer screening
- Discuss risks associated with cigarette smoking and smoking cessation approaches
- Teach the patent about the seven warning signs of cancer
6. A patient who is HIV infected has a CD4+ cell count of 400/nl. Which factor is most important
for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
- HIV genotype and phenotype
- Patients tolerance for potential medication side effects
- CD4+ cell count trajectory
- Patients ability to follow a complex medication regimen
7. The nurse is assessing four clients in a healthcare setting who have respiratory disorders.
Which client’s findings indicate possible metabolic acidosis?
a. Client 1 – tachypnea
b. Client 2 – pursed lip- breathing
c. Client 3 - Kussmaul respirations
d. Client 4 – abdominal paradox
8. A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow
respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has
been made. What is the primary nursing concern?
- Electrolyte imbalance
- Chronic pain
- Inadequate gas exchange
- Risk of injury
,9. Which assessment finding should the nurse caring for a patient with thrombocytopenia
communicate immediately to the health care provider?
- The platelet count of 52,00/nl
- There are large bruises on the patient’s back
- There are purpura on the oral mucosa
- The patient is difficult to arouse
10. A patient is to receive an infusion of 250ml of platelets over 2 hours through tubing that is
labeled: 1ml equals 20 drops. How many drops per minute will the nurse infuse?
- 42 gtt/min
11. A patient who has been receiving IV heparin infusion and oral warfarin (coumadin) for a deep
vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the
platelet level drops to 110,00nl. Which action will the nurse include in the plan of ca re?
- Use low molecular weight heparin (LMWH)
- Discontinue the heparin infusion
- Prepare for platelet transfusion
- Administer prescribed warfarin (Coumadin).
12. Family members are in the patient’s room when the patient has a cardiac arrest and the staff
start resuscitation measures. Which action should the nurse take next?
- Keep the family in the room and assign a staff member to explain the care given and answer
questions
- Ask the family to wait outside the patients room with a designated staff member to provide
emotional support
- Ask the family members whether they would prefer to remain in the patient’s room
or wait outside the room
- Tell the family members that patients are comforted by having family members present
during resuscitation efforts
13. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin. Which
patient statement indicates that the teaching has been effective?
- I can expect nausea as a side effect of nitroglycerin
- Nitroglycerin helps prevents a clot from forming and blocking blood flow to my heart
- I will call an ambulance if I still have pain after taking one nitroglycerin tablet
- I should take 3 at a time for chest pain
14. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which
intervention included in the plan of care is appropriate for the RN to delegate to an experienced
licensed practical/vocational nurse (LPN/LVN)?
- Education of the patient about the pathophysiology of heart disease
- Reinforcement of teaching about the purpose of prescribed medications
- Evaluation of the patient’s response to walking in the hallway
- Completion of the referral form for a home health nurse follow-up
15. A patient who has chest pain is admitted to the emergency department (ED) and all of the
following are ordered. Which one should the nurse arrange to be completed first?
- Insertion of a peripheral IV
- Chest x-ray
- Electrocardiogram
- Troponin level
16. After receiving change of shift report about the following four patients on the cardiac care unit.
which patient should the nurse assess first?
- A 59 y/o patient with unstable angina who has just returned after a percutaneous
coronary interventions (PCI)
, - A 65 y/o patient who had a myocardial infarction (MI) 4 days ago and is anxious about
todays planned discharge
- A 56 y/o patient with variant angina who is scheduled to receive nifedipine (Procardia)
- A 39 y/o patient with pericarditis who is complaining of sharp, stabbing chest pain
17. During a visit to a 78 y/o patient with chronic heart failure, the home care nurse finds that the
patient has ankle edema, a 2kg weight gain over the past 2 days, and complains of feeling too
tired to get out of bed. Based on these data a correct nursing diagnosis for the patient is
- Disturbed body image related to weight gain
- Activity intolerance related to fatigue
- Impaired gas exchange related to dyspnea on exertion
- Impaired skin integrity related to edema
18. After receiving change of shift report on a heart failure unit, which patient should the nurse
assess first? Patient who is taking
- Isosorbide dinitrate/hydralazine (BiDil) and has a headache
- Captopril and has a frequent non-productive cough
- Digoxin and has a potassium level of 3.1 meq/L
- Carvedilol (Coreg) and has a heart rate of 58
19. Which nursing intervention for a patient who had an open repair of a abdominal aortic
aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive
personnel (UAP)
- Help the patient to use a pillow to splint while coughing
- Teach the patient the signs of possible wound infection
- Monitor the quality and presence of the pedal pulses
- Check the lower extremities for strength and movement
20. A patient is admitted with active TB the nurse should question a health care providers order to
discontinue airborne precautions unless which assessment finding is documented?
- Chest x-ray shows no upper lobe infiltrates
- Sputum smear for acid-fast bacilli are negative
- TB medications have been taken for 6 months
- Mantoux testing shows an induration of 10 mm
21. Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will
be most useful in evaluating the effectiveness of treatment?
- Even, unlabored respirations
- Pulse oximetry reading of 92%
- Respiratory rate of 18 breaths/min
- Absence of wheezes or crackles
22. When a patient with acute kidney injury (AKI) has an arterial blood ph of 7.30. the nurse will
expect n assessment finding of
- Rapid, deep respirations
- Bounding peripheral pulses
- Persistent skin tenting
- Hot, flushed face and neck
23. A female patient with chronic kidney disease is receiving peritoneal dialysis with 2-l inflows,
which information should the nurse report promptly to the health care provider?
- The patient’s abdomen appears bloated after the inflow
- The patient has abdominal pain during the inflow rate
- The patient has an outflow volume of 1800ml
- The patients peritoneal output appears cloudy
, 24. A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse
expect during the assessment?
- Purplish streaks on the abdomen
- Chronically low blood pressure
- Decreased axillary and pubic hair
- Bronzed appearance of the skin
25. Which finding indicates to the nurse that the current therapies are effective for a patient with
acute adrenal insufficiency?
- Increasing serum sodium levels
- Decreasing serum chloride levels
- Decreasing blood glucose levels
- Increasing serum potassium levels
26. The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement
supports the need to plan additional teaching?
- I always double my dose of hydrocortisone on the days that I go for a long run
- I take twice as much hydrocortisone in the morning dose as I do in the afternoon
- I had the flu earlier this week, so I couldn’t take the hydrocortisone
- I frequently eat at restaurants, and my food has a lot of added salt
27. A 29 y/o woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose
prednisone therapy. Which information about the prednisone is most important for the nurse
to include?
- The prednisone dose should be decreased gradually
- Call the health care provider if you have mood changes with the prednisone
- Weigh yourself daily to monitor for weight gain
- A weight-bearing exercise program will help minimize risk for osteoporosis
28. Which result for a patient with systemic lupus erythematous (SLE) is most important for the
nurse to communicate to the care provider
- Elevated blood urea nitrogen (BUN)
- Decreased C-reactive protein (CRP)
- Positive antinuclear antibodies (ANA)
- Positive lupus erythematosus cell prep
29. Which nursing action has the highest priority for a patient who was admitted 16 hours earlier
with CS spinal cord injury
- Assessment of respiratory rate and effort
- Administration of low-molecular-weight heparin
- Application of pneumatic compression devices to legs
- Cardiac monitoring for bradycardia
30. A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the
nurse. I have a pounding headache and I feel sick to my stomach, which action should the nurse
take first?
- Notify the health care provider
- Give the prescribed antiemetic
- Assess the blood pressure (BP)
- Check for a fecal impaction
31. Which action should the nurse take to evaluate treatment effectiveness for a patient who has
hepatic encephalopathy?
- The patient is alert and oriented x4
- Ask the patient to perform the Valsalva maneuver
- Request that the patient stand on one foot
- Request that the patient walk with eyes closed
had a 12lb weight loss over the past year. Which action should the nurse take initially?
- Ask the patient about daily dietary intake
- Describe normal changes associated with aging to the patient
- Discuss long term care placement with the patient
- Schedule regular range of motion exercise
2. A client arrives in the emergency department unconscious and exhibiting decerebrate
posturing. When assessing the client, what does the nurse expect to observe?
- Hyperextension of both the upper and lower extremities
- Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities
- Hyperflexion of the upper extremities and hyperextension of the lower extremities
- Spastic paralysis of both the upper and lower extremities
3. The nurse is caring for a client with rheumatoid arthritis. When should the nurse expect the
client to experience the most pain and limited movement of the joints?
- During the evening hours
- After assistive exercise
- In the morning on awakening
- When the room is cool
4. The son of a dying patient tells the nurse, mother doesn’t really respond any more when I visit. I
don’t think she knows that I am here. Which response by the nurse is appropriate/
- Most dying patients don’t know what is going on around them
- It is important to stimulate your mother so she can’t retreat from you
- Withdrawal can be normal response in the process of dying
- Cut back your visits for now to avoid overtiring your mother
5. The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could
help reduce the patients risk of lung cancer?
- Plan to monitor the patient carcinoembryonic antigen (CEA) level
- Teach the patient about annual chest x-rays for lung cancer screening
- Discuss risks associated with cigarette smoking and smoking cessation approaches
- Teach the patent about the seven warning signs of cancer
6. A patient who is HIV infected has a CD4+ cell count of 400/nl. Which factor is most important
for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
- HIV genotype and phenotype
- Patients tolerance for potential medication side effects
- CD4+ cell count trajectory
- Patients ability to follow a complex medication regimen
7. The nurse is assessing four clients in a healthcare setting who have respiratory disorders.
Which client’s findings indicate possible metabolic acidosis?
a. Client 1 – tachypnea
b. Client 2 – pursed lip- breathing
c. Client 3 - Kussmaul respirations
d. Client 4 – abdominal paradox
8. A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow
respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has
been made. What is the primary nursing concern?
- Electrolyte imbalance
- Chronic pain
- Inadequate gas exchange
- Risk of injury
,9. Which assessment finding should the nurse caring for a patient with thrombocytopenia
communicate immediately to the health care provider?
- The platelet count of 52,00/nl
- There are large bruises on the patient’s back
- There are purpura on the oral mucosa
- The patient is difficult to arouse
10. A patient is to receive an infusion of 250ml of platelets over 2 hours through tubing that is
labeled: 1ml equals 20 drops. How many drops per minute will the nurse infuse?
- 42 gtt/min
11. A patient who has been receiving IV heparin infusion and oral warfarin (coumadin) for a deep
vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the
platelet level drops to 110,00nl. Which action will the nurse include in the plan of ca re?
- Use low molecular weight heparin (LMWH)
- Discontinue the heparin infusion
- Prepare for platelet transfusion
- Administer prescribed warfarin (Coumadin).
12. Family members are in the patient’s room when the patient has a cardiac arrest and the staff
start resuscitation measures. Which action should the nurse take next?
- Keep the family in the room and assign a staff member to explain the care given and answer
questions
- Ask the family to wait outside the patients room with a designated staff member to provide
emotional support
- Ask the family members whether they would prefer to remain in the patient’s room
or wait outside the room
- Tell the family members that patients are comforted by having family members present
during resuscitation efforts
13. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin. Which
patient statement indicates that the teaching has been effective?
- I can expect nausea as a side effect of nitroglycerin
- Nitroglycerin helps prevents a clot from forming and blocking blood flow to my heart
- I will call an ambulance if I still have pain after taking one nitroglycerin tablet
- I should take 3 at a time for chest pain
14. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which
intervention included in the plan of care is appropriate for the RN to delegate to an experienced
licensed practical/vocational nurse (LPN/LVN)?
- Education of the patient about the pathophysiology of heart disease
- Reinforcement of teaching about the purpose of prescribed medications
- Evaluation of the patient’s response to walking in the hallway
- Completion of the referral form for a home health nurse follow-up
15. A patient who has chest pain is admitted to the emergency department (ED) and all of the
following are ordered. Which one should the nurse arrange to be completed first?
- Insertion of a peripheral IV
- Chest x-ray
- Electrocardiogram
- Troponin level
16. After receiving change of shift report about the following four patients on the cardiac care unit.
which patient should the nurse assess first?
- A 59 y/o patient with unstable angina who has just returned after a percutaneous
coronary interventions (PCI)
, - A 65 y/o patient who had a myocardial infarction (MI) 4 days ago and is anxious about
todays planned discharge
- A 56 y/o patient with variant angina who is scheduled to receive nifedipine (Procardia)
- A 39 y/o patient with pericarditis who is complaining of sharp, stabbing chest pain
17. During a visit to a 78 y/o patient with chronic heart failure, the home care nurse finds that the
patient has ankle edema, a 2kg weight gain over the past 2 days, and complains of feeling too
tired to get out of bed. Based on these data a correct nursing diagnosis for the patient is
- Disturbed body image related to weight gain
- Activity intolerance related to fatigue
- Impaired gas exchange related to dyspnea on exertion
- Impaired skin integrity related to edema
18. After receiving change of shift report on a heart failure unit, which patient should the nurse
assess first? Patient who is taking
- Isosorbide dinitrate/hydralazine (BiDil) and has a headache
- Captopril and has a frequent non-productive cough
- Digoxin and has a potassium level of 3.1 meq/L
- Carvedilol (Coreg) and has a heart rate of 58
19. Which nursing intervention for a patient who had an open repair of a abdominal aortic
aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive
personnel (UAP)
- Help the patient to use a pillow to splint while coughing
- Teach the patient the signs of possible wound infection
- Monitor the quality and presence of the pedal pulses
- Check the lower extremities for strength and movement
20. A patient is admitted with active TB the nurse should question a health care providers order to
discontinue airborne precautions unless which assessment finding is documented?
- Chest x-ray shows no upper lobe infiltrates
- Sputum smear for acid-fast bacilli are negative
- TB medications have been taken for 6 months
- Mantoux testing shows an induration of 10 mm
21. Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will
be most useful in evaluating the effectiveness of treatment?
- Even, unlabored respirations
- Pulse oximetry reading of 92%
- Respiratory rate of 18 breaths/min
- Absence of wheezes or crackles
22. When a patient with acute kidney injury (AKI) has an arterial blood ph of 7.30. the nurse will
expect n assessment finding of
- Rapid, deep respirations
- Bounding peripheral pulses
- Persistent skin tenting
- Hot, flushed face and neck
23. A female patient with chronic kidney disease is receiving peritoneal dialysis with 2-l inflows,
which information should the nurse report promptly to the health care provider?
- The patient’s abdomen appears bloated after the inflow
- The patient has abdominal pain during the inflow rate
- The patient has an outflow volume of 1800ml
- The patients peritoneal output appears cloudy
, 24. A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse
expect during the assessment?
- Purplish streaks on the abdomen
- Chronically low blood pressure
- Decreased axillary and pubic hair
- Bronzed appearance of the skin
25. Which finding indicates to the nurse that the current therapies are effective for a patient with
acute adrenal insufficiency?
- Increasing serum sodium levels
- Decreasing serum chloride levels
- Decreasing blood glucose levels
- Increasing serum potassium levels
26. The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement
supports the need to plan additional teaching?
- I always double my dose of hydrocortisone on the days that I go for a long run
- I take twice as much hydrocortisone in the morning dose as I do in the afternoon
- I had the flu earlier this week, so I couldn’t take the hydrocortisone
- I frequently eat at restaurants, and my food has a lot of added salt
27. A 29 y/o woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose
prednisone therapy. Which information about the prednisone is most important for the nurse
to include?
- The prednisone dose should be decreased gradually
- Call the health care provider if you have mood changes with the prednisone
- Weigh yourself daily to monitor for weight gain
- A weight-bearing exercise program will help minimize risk for osteoporosis
28. Which result for a patient with systemic lupus erythematous (SLE) is most important for the
nurse to communicate to the care provider
- Elevated blood urea nitrogen (BUN)
- Decreased C-reactive protein (CRP)
- Positive antinuclear antibodies (ANA)
- Positive lupus erythematosus cell prep
29. Which nursing action has the highest priority for a patient who was admitted 16 hours earlier
with CS spinal cord injury
- Assessment of respiratory rate and effort
- Administration of low-molecular-weight heparin
- Application of pneumatic compression devices to legs
- Cardiac monitoring for bradycardia
30. A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the
nurse. I have a pounding headache and I feel sick to my stomach, which action should the nurse
take first?
- Notify the health care provider
- Give the prescribed antiemetic
- Assess the blood pressure (BP)
- Check for a fecal impaction
31. Which action should the nurse take to evaluate treatment effectiveness for a patient who has
hepatic encephalopathy?
- The patient is alert and oriented x4
- Ask the patient to perform the Valsalva maneuver
- Request that the patient stand on one foot
- Request that the patient walk with eyes closed
