A school nurse is assessing a child who has been stung by a bee. The child's hand is
swelling and the nurse notes that the child is allergic to insect stings. Which of the
following findings should the nurse expect if the child develops anaphylaxis? (SATA)
A) Bradycardia
B) Nausea
C) Hypertension
D) Urticaria
E) Stridor - Answer - B) Nausea
D) Urticaria
E) Stridor
A nurse is caring for a client who is unconscious. Which of the following actions should
the nurse take when providing oral care for the client?
A) Test for the presence of the clients gag reflex
B) Place the client in the supine position
C) Use a firm toothbrush for tooth and gum care
D) Use 2 gauze-wrapped fingers to hold the mouth open - Answer - A) Test for the
presence of the clients gag reflex
A nurse is planning care for a client who has acute myelogenous leukemia and a
platelet count of 48,000/mm^3. Which of the follow interventions should the nurse
include?
A) Avoid IM injections
B) Assess the client for ecchymosis once per shift
C) Do not allow the client to have visitors
D) Encourage daily flossing between teeth - Answer - A) Avoid IM injection
A nurse is preparing to assess the function of the clients trigeminal nerve (cranial nerve
V). Which of the following items should the nurse gather for the test?
A) Sugar
B) Coffee
C) Cotton wisps
D) Snellen chart - Answer - C) Cotton wisps
,A nurse is caring for a client with alcohol use disorder who has undergone
detoxification. Which of the following medications should the nurse expect the provider
to prescribe to assist the client with maintaining sobriety
A) Varenicline
B) Clonidine
C) Buprenorphine
D) Disulfiram - Answer - D) Disulfiram
A newly admitted client who has major depressive disorder states to the nurse, "I'm a
failure, I can't even cope with the little things anymore." Which of the following
responses should the nurse provide?
A) "What happened in your life to make you feel like such a failure?"
B) "It sounds as if you are feeling pretty overwhelmed right now"
C) "Do you feel like you don't deserve to feel good about yourself?"
D) "I know you feel like that now, but you'll feel differently when you get better" - Answer
- C) "Do you feel like you don't deserve to feel good about yourself?"
A nurse is caring for a middle-aged adult client. The nurse should identify which of the
following statements as an indication that the client has completed Eriksons
developmental task for her age group?
A) "I am comfortable with my decision to choose a lifelong partner."
B) "I think I have done a good job with my children since they are all independent now."
C) "As I look back over my life, I can see that I have achieved most of the goals I set for
myself."
D) I love my work so much that it's difficult to think about retirement." - Answer - B) "I
think I have done a good job with my children since they are all independent now."
A nurse is conducting an admission interview with a client. Which of the following pieces
of assessment information should the nurse collect during the introductory phase of the
interview?"
A) Clients level of comfort and ability to participate in the interview
B) Previous illnesses and surgeries
C) Events surrounding the clients recent illness
D) Sociocultural history - Answer - A) Clients level of comfort and ability to participate in
the interview
A nurse is planning to assess the abdomen of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use
first?
A) inspection
B) Auscultation
C) Percussion
D)Palpation - Answer - A) Inspection
, A nurse is performing a comprehensive physical assessment of a client. The nurse
should use inspection to assess which of the following?
A) Liver size
B) Pedal edema
C) Skin texture
D) Gait - Answer - D) Gait
A nurse is caring for a client who is immobile. The nurse should recognize that
immobility places the client at risk of which of the following health alterations?
A) Increased intestinal motility
B) Respiratory alkalosis
C) Decreased cardiac output
D) Hypocalcemia - Answer - C) Decreased cardiac output
A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
A) Place the client supine
B) Keep both side rails up
C) Raise the level of the bed
D) Inspect the clients mouth using a finger sweep - Answer - C)Raise the level of the
bed
A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client
appears upset and refuses to take the medication before throwing the pill on the floor.
Which of the following entries should the nurse enter into the clients medical record?
A) the client refuses to take medication today
B) The client states, "I will not take this pill."
C) The client seemed angry and hostile
D) The client threw the medication on the floor - Answer - D) The client threw the
medication on the floor
A nurse is a rehabilitation facility is observing an assistive personal (AP) help a client
transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse
that the AP understands how to perform this task
A) Locking the brakes on the bed and the wheelchair before moving the client
B) Lowering the footplates of the wheelchair before the transfer
C) Placing the wheelchair perpendicular to the bed
D) Placing the wheelchair on the clients weaker side prior to the transfer - Answer - A)
Locking the brakes on the bed and the wheelchair before moving the client
A nurse is caring for a client who has cancer and refuses visitors because of his
debilitated physical appearance. Which of the following comments should the nurse
make?
A) "You look just fine to me."
B) "Nobody expects you to look beautiful in the hospital."
swelling and the nurse notes that the child is allergic to insect stings. Which of the
following findings should the nurse expect if the child develops anaphylaxis? (SATA)
A) Bradycardia
B) Nausea
C) Hypertension
D) Urticaria
E) Stridor - Answer - B) Nausea
D) Urticaria
E) Stridor
A nurse is caring for a client who is unconscious. Which of the following actions should
the nurse take when providing oral care for the client?
A) Test for the presence of the clients gag reflex
B) Place the client in the supine position
C) Use a firm toothbrush for tooth and gum care
D) Use 2 gauze-wrapped fingers to hold the mouth open - Answer - A) Test for the
presence of the clients gag reflex
A nurse is planning care for a client who has acute myelogenous leukemia and a
platelet count of 48,000/mm^3. Which of the follow interventions should the nurse
include?
A) Avoid IM injections
B) Assess the client for ecchymosis once per shift
C) Do not allow the client to have visitors
D) Encourage daily flossing between teeth - Answer - A) Avoid IM injection
A nurse is preparing to assess the function of the clients trigeminal nerve (cranial nerve
V). Which of the following items should the nurse gather for the test?
A) Sugar
B) Coffee
C) Cotton wisps
D) Snellen chart - Answer - C) Cotton wisps
,A nurse is caring for a client with alcohol use disorder who has undergone
detoxification. Which of the following medications should the nurse expect the provider
to prescribe to assist the client with maintaining sobriety
A) Varenicline
B) Clonidine
C) Buprenorphine
D) Disulfiram - Answer - D) Disulfiram
A newly admitted client who has major depressive disorder states to the nurse, "I'm a
failure, I can't even cope with the little things anymore." Which of the following
responses should the nurse provide?
A) "What happened in your life to make you feel like such a failure?"
B) "It sounds as if you are feeling pretty overwhelmed right now"
C) "Do you feel like you don't deserve to feel good about yourself?"
D) "I know you feel like that now, but you'll feel differently when you get better" - Answer
- C) "Do you feel like you don't deserve to feel good about yourself?"
A nurse is caring for a middle-aged adult client. The nurse should identify which of the
following statements as an indication that the client has completed Eriksons
developmental task for her age group?
A) "I am comfortable with my decision to choose a lifelong partner."
B) "I think I have done a good job with my children since they are all independent now."
C) "As I look back over my life, I can see that I have achieved most of the goals I set for
myself."
D) I love my work so much that it's difficult to think about retirement." - Answer - B) "I
think I have done a good job with my children since they are all independent now."
A nurse is conducting an admission interview with a client. Which of the following pieces
of assessment information should the nurse collect during the introductory phase of the
interview?"
A) Clients level of comfort and ability to participate in the interview
B) Previous illnesses and surgeries
C) Events surrounding the clients recent illness
D) Sociocultural history - Answer - A) Clients level of comfort and ability to participate in
the interview
A nurse is planning to assess the abdomen of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use
first?
A) inspection
B) Auscultation
C) Percussion
D)Palpation - Answer - A) Inspection
, A nurse is performing a comprehensive physical assessment of a client. The nurse
should use inspection to assess which of the following?
A) Liver size
B) Pedal edema
C) Skin texture
D) Gait - Answer - D) Gait
A nurse is caring for a client who is immobile. The nurse should recognize that
immobility places the client at risk of which of the following health alterations?
A) Increased intestinal motility
B) Respiratory alkalosis
C) Decreased cardiac output
D) Hypocalcemia - Answer - C) Decreased cardiac output
A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
A) Place the client supine
B) Keep both side rails up
C) Raise the level of the bed
D) Inspect the clients mouth using a finger sweep - Answer - C)Raise the level of the
bed
A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client
appears upset and refuses to take the medication before throwing the pill on the floor.
Which of the following entries should the nurse enter into the clients medical record?
A) the client refuses to take medication today
B) The client states, "I will not take this pill."
C) The client seemed angry and hostile
D) The client threw the medication on the floor - Answer - D) The client threw the
medication on the floor
A nurse is a rehabilitation facility is observing an assistive personal (AP) help a client
transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse
that the AP understands how to perform this task
A) Locking the brakes on the bed and the wheelchair before moving the client
B) Lowering the footplates of the wheelchair before the transfer
C) Placing the wheelchair perpendicular to the bed
D) Placing the wheelchair on the clients weaker side prior to the transfer - Answer - A)
Locking the brakes on the bed and the wheelchair before moving the client
A nurse is caring for a client who has cancer and refuses visitors because of his
debilitated physical appearance. Which of the following comments should the nurse
make?
A) "You look just fine to me."
B) "Nobody expects you to look beautiful in the hospital."
