A female client presents in the emergency department and tells the nurse that she was raped last night.
m m m m m m m m m m m m m m m m m
Which question is most important for the nurse to ask?
m m m m m m m m m m
A. Has she taken a bath since the rape occurred?
m m m m m m m m m m
B. Is the place where she lives a safe place?
m m m m m m m m m m
C. Does she know the person who raped her?
m m m m m m m m
D. Did she report the rape to the police department? - Correct ansA. Has she taken a bath since the rape
m m m m m m m m m m m m m m m m m m m m
occurred?
m
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial
m m m m m m m m m m m m m m m
meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing
m m m m m m m m m m m m m
increased intracranial pressure (ICP)?
m m m m
A. Tachycardia and tachypnea
m m m
B. Sluggish and unequal pupillary responses
m m m m m
C. Increased head circumference and bulging fontanels
m m m m m m
D. Blood pressure fluctuations and syncope - Correct ansB. Sluggish and unequal pupillary responses
m m m m m m m m m m m m m
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum
m m m m m m m m m m m m m m m
amylase. Which additional information is the client most likely to report to the nurse?
m m m m m m m m m m m m m m
A. Abdominal pain decreases when lying supine
m m m m m m
B. Pain lasts an hour and leaves the abdomen tender
m m m m m m m m m
C. Right upper quadrant pain refers to right scapula
m m m m m m m m
D. Drinks alcohol until intoxicated at least twice weekly. - Correct ansA. Abdominal pain decreases when
m m m m m m m m m m m m m m m
lying supine
m m
,A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which
m m m m m m m m m m m m m m m
information is most important for the nurse to provide the parents prior to discharge?
m m m m m m m m m m m m m m
A. Instructions about how much fluid the child should drink daily.
m m m m m m m m m m
B. Signs of addiction to opioid pain medications
m m m m m m m
C. Information about non-pharmaceutical pain relief measures
m m m m m m
D. Referral for social services for the child and family - Correct ansA. Instructions about how much fluid
m m m m m m m m m m m m m m m m m
the child should drink daily
m m m m m
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location
m m m m m m m m m m m m m m m m
on the image with a red dot). - Correct ansI placed the red dot on the base of the neck on the right side
m m m m m m m m m m m m m m m m m m m m m m m m
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
m m m m m m m m m m m m m m m
A. The client with an obstruction of the large intestine who is experiencing abdominal distention
m m m m m m m m m m m m m m
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
m m m m m m m m m m m m m m m m
C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
m m m m m m m m m m m m m m m m m
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity - Correct
m m m m m m m m m m m m m m m m m
ansD. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
m m m m m m m m m m m m m m m m
A teenager presents to the emergency department with palpitations after vaping at a party. The client is
m m m m m m m m m m m m m m m m
anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base
m m m m m m m m m m m m m
imbalance?
m
A. Respiratory acidosis
m m
B. Metabolic alkalosis
m m
C. Metabolic acidosis
m m
D. Respiratory alkalosis - Correct ansD. Respiratory alkalosis
m m m m m m m
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the
m m m m m m m m m m m m m m m m m m
nurse should ensure that the client's bed is in which position?
m m m m m m m m m m m
A. Supine
m
B. supine; feet elevated higher than head
m m m m m m
C. supine; head elevated higher than feet
m m m m m m
,D. Fowlers - Correct ansFowlers
m m m m
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
m m m m m m m m m m m m m m
information in the client's admission assessment is relevant to the nurse's plan for taking the blood
m m m m m m m m m m m m m m m m
pressure reading? (Select all the apply)
m m m m m m
A. Frequent syncope
m m
B. Occasional nocturia
m m
C. Flat affect
m m
D. Blurred vision
m m
E. Frequent drooling - Correct ansA. Frequent syncope
m m m m m m m
C. Flat affect
m m
D. Blurred vision
m m
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound.
m m m m m m m m m m m m m m
Before reporting this finding to the healthcare provider, the nurse should review which of the client's
m m m m m m m m m m m m m m m m
laboratory values?
m m
A. Serum albumin
m m
B. Culture for sensitive organisms
m m m m
C. Serum blood glucose level
m m m m
D. Creatinine level - Correct ansB. Culture for sensitive organisms
m m m m m m m m m
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-
m m m m m m m m m m m m m m
drowning incident. While providing care to the child, the nurse begins talking with his preadolescent
m m m m m m m m m m m m m m
brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices
m m m m m m m m m m m m m m m
the older boy becomes withdrawn when asked about what happened. Which action should the nurse
m m m m m m m m m m m m m m m
take?
m
A. Develop a water safety teaching plan for the family
m m m m m m m m m
B. Ask the older brother how he felt during the incident
m m m m m m m m m m
C. Tell the older brother that he seems depressed
m m m m m m m m
D. Commend the older brother for his heroic actions - Correct ansB. Ask the older brother how he felt
m m m m m m m m m m m m m m m m m m
during the incident
m m m
, A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot
m m m m m m m m m m m m m m m m m m m
baths at night with no relief of his discomfort. Which action should the nurse take?
m m m m m m m m m m m m m m m
A. Encourage the client to use cooler water and apply calamine lotion after soaking
m m m m m m m m m m m m m
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
m m m m m m m m m m m m m m m
C. Suggest that the client take brief showers and apply oil-based lotion after showering
m m m m m m m m m m m m m
D. Explain that the symptoms are caused by liver damage and cannot be relieved - Correct ansA.
m m m m m m m m m m m m m m m m
Encourage the client to use cooler water and apply calamine lotion after soaking
m m m m m m m m m m m m m
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart
m m m m m m m m m m m m m m m
failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider
m m m m m m m m m m m m m m
prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the
m m m m m m m m m m m m m m
client with acute HF?
m m m m
A. Increased cardiac contractility
m m m
B. Reduced preload
m m
C. Relaxed vascular tone
m m m
D. Decreased afterload - Correct ansB. Reduced preload
m m m m m m m
Which intervention should the nurse include in the plan of care for a child with tetanus?
m m m m m m m m m m m m m m m
A. Encourage coughing and deep breathing
m m m m m
B. Minimize the amount of stimuli in the room
m m m m m m m m
C. Reposition from side to side every hour
m m m m m m m
D. Open window shades to provide natural light - Correct ansB. Minimize the amount of stimuli in the
m m m m m m m m m m m m m m m m m
room
m
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the
m m m m m m m m m m m m m m m m m m
hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
m m m m m m m m m m m m m m
A. Ate an extra peanut butter sandwich before gym class
m m m m m m m m m
B. incorrectly administered too much insulin
m m m m m m
C. Had a cold and ear infection for the past two days
m m m m m m m m m m m m
D. Skipped eating lunch - Correct ansC. Had a cold and ear infection for the past two days
m m m m m m m m m m m m m m m m m
m m m m m m m m m m m m m m m m m
Which question is most important for the nurse to ask?
m m m m m m m m m m
A. Has she taken a bath since the rape occurred?
m m m m m m m m m m
B. Is the place where she lives a safe place?
m m m m m m m m m m
C. Does she know the person who raped her?
m m m m m m m m
D. Did she report the rape to the police department? - Correct ansA. Has she taken a bath since the rape
m m m m m m m m m m m m m m m m m m m m
occurred?
m
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial
m m m m m m m m m m m m m m m
meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing
m m m m m m m m m m m m m
increased intracranial pressure (ICP)?
m m m m
A. Tachycardia and tachypnea
m m m
B. Sluggish and unequal pupillary responses
m m m m m
C. Increased head circumference and bulging fontanels
m m m m m m
D. Blood pressure fluctuations and syncope - Correct ansB. Sluggish and unequal pupillary responses
m m m m m m m m m m m m m
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum
m m m m m m m m m m m m m m m
amylase. Which additional information is the client most likely to report to the nurse?
m m m m m m m m m m m m m m
A. Abdominal pain decreases when lying supine
m m m m m m
B. Pain lasts an hour and leaves the abdomen tender
m m m m m m m m m
C. Right upper quadrant pain refers to right scapula
m m m m m m m m
D. Drinks alcohol until intoxicated at least twice weekly. - Correct ansA. Abdominal pain decreases when
m m m m m m m m m m m m m m m
lying supine
m m
,A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which
m m m m m m m m m m m m m m m
information is most important for the nurse to provide the parents prior to discharge?
m m m m m m m m m m m m m m
A. Instructions about how much fluid the child should drink daily.
m m m m m m m m m m
B. Signs of addiction to opioid pain medications
m m m m m m m
C. Information about non-pharmaceutical pain relief measures
m m m m m m
D. Referral for social services for the child and family - Correct ansA. Instructions about how much fluid
m m m m m m m m m m m m m m m m m
the child should drink daily
m m m m m
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location
m m m m m m m m m m m m m m m m
on the image with a red dot). - Correct ansI placed the red dot on the base of the neck on the right side
m m m m m m m m m m m m m m m m m m m m m m m m
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
m m m m m m m m m m m m m m m
A. The client with an obstruction of the large intestine who is experiencing abdominal distention
m m m m m m m m m m m m m m
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
m m m m m m m m m m m m m m m m
C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
m m m m m m m m m m m m m m m m m
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity - Correct
m m m m m m m m m m m m m m m m m
ansD. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
m m m m m m m m m m m m m m m m
A teenager presents to the emergency department with palpitations after vaping at a party. The client is
m m m m m m m m m m m m m m m m
anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base
m m m m m m m m m m m m m
imbalance?
m
A. Respiratory acidosis
m m
B. Metabolic alkalosis
m m
C. Metabolic acidosis
m m
D. Respiratory alkalosis - Correct ansD. Respiratory alkalosis
m m m m m m m
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the
m m m m m m m m m m m m m m m m m m
nurse should ensure that the client's bed is in which position?
m m m m m m m m m m m
A. Supine
m
B. supine; feet elevated higher than head
m m m m m m
C. supine; head elevated higher than feet
m m m m m m
,D. Fowlers - Correct ansFowlers
m m m m
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
m m m m m m m m m m m m m m
information in the client's admission assessment is relevant to the nurse's plan for taking the blood
m m m m m m m m m m m m m m m m
pressure reading? (Select all the apply)
m m m m m m
A. Frequent syncope
m m
B. Occasional nocturia
m m
C. Flat affect
m m
D. Blurred vision
m m
E. Frequent drooling - Correct ansA. Frequent syncope
m m m m m m m
C. Flat affect
m m
D. Blurred vision
m m
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound.
m m m m m m m m m m m m m m
Before reporting this finding to the healthcare provider, the nurse should review which of the client's
m m m m m m m m m m m m m m m m
laboratory values?
m m
A. Serum albumin
m m
B. Culture for sensitive organisms
m m m m
C. Serum blood glucose level
m m m m
D. Creatinine level - Correct ansB. Culture for sensitive organisms
m m m m m m m m m
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-
m m m m m m m m m m m m m m
drowning incident. While providing care to the child, the nurse begins talking with his preadolescent
m m m m m m m m m m m m m m
brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices
m m m m m m m m m m m m m m m
the older boy becomes withdrawn when asked about what happened. Which action should the nurse
m m m m m m m m m m m m m m m
take?
m
A. Develop a water safety teaching plan for the family
m m m m m m m m m
B. Ask the older brother how he felt during the incident
m m m m m m m m m m
C. Tell the older brother that he seems depressed
m m m m m m m m
D. Commend the older brother for his heroic actions - Correct ansB. Ask the older brother how he felt
m m m m m m m m m m m m m m m m m m
during the incident
m m m
, A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot
m m m m m m m m m m m m m m m m m m m
baths at night with no relief of his discomfort. Which action should the nurse take?
m m m m m m m m m m m m m m m
A. Encourage the client to use cooler water and apply calamine lotion after soaking
m m m m m m m m m m m m m
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
m m m m m m m m m m m m m m m
C. Suggest that the client take brief showers and apply oil-based lotion after showering
m m m m m m m m m m m m m
D. Explain that the symptoms are caused by liver damage and cannot be relieved - Correct ansA.
m m m m m m m m m m m m m m m m
Encourage the client to use cooler water and apply calamine lotion after soaking
m m m m m m m m m m m m m
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart
m m m m m m m m m m m m m m m
failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider
m m m m m m m m m m m m m m
prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the
m m m m m m m m m m m m m m
client with acute HF?
m m m m
A. Increased cardiac contractility
m m m
B. Reduced preload
m m
C. Relaxed vascular tone
m m m
D. Decreased afterload - Correct ansB. Reduced preload
m m m m m m m
Which intervention should the nurse include in the plan of care for a child with tetanus?
m m m m m m m m m m m m m m m
A. Encourage coughing and deep breathing
m m m m m
B. Minimize the amount of stimuli in the room
m m m m m m m m
C. Reposition from side to side every hour
m m m m m m m
D. Open window shades to provide natural light - Correct ansB. Minimize the amount of stimuli in the
m m m m m m m m m m m m m m m m m
room
m
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the
m m m m m m m m m m m m m m m m m m
hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
m m m m m m m m m m m m m m
A. Ate an extra peanut butter sandwich before gym class
m m m m m m m m m
B. incorrectly administered too much insulin
m m m m m m
C. Had a cold and ear infection for the past two days
m m m m m m m m m m m m
D. Skipped eating lunch - Correct ansC. Had a cold and ear infection for the past two days
m m m m m m m m m m m m m m m m m
