Form A
1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-
old. Which of the following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure.
2. A nurse is caring for a client who has arteriovenous fistula Which of the
following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation.
3. A nurse is providing discharge teaching for a client who has an
implantable cardioverter defibrillator which of the following statements
demonstrates understanding of the teaching?
A. “I will soak in the tub rather and showering”
B. “I will wear loose clothing around my ICD”
C. “I will stop using my microwave oven at home because of my ICD”
D. “I can hold my cellphone on the same side of my body as the ICD”
4. A nurse is caring for a client who is at 14 weeks gestation and reports
feelings of ambivalence about being pregnant. Which of the following
responses should the nurse make?
A. “Describe your feelings to me about being pregnant”
B. “You should discuss your feelings about being pregnant with your
provider”
C. “Have you discussed these feelings with your partner?”
D. “When did you start having these feelings?”
5. A nurse is planning care for a client who has a prescription for a bowel-
training program following a spinal cord injury. Which of the following actions
should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per day.
B. Increase the amount of refined grains in the client’s diet.
C. Provide the client with a cold drink prior to defecation.
, D. Administer a rectal suppository 30 minutes prior to scheduled
defecation times.
6. A nurse is caring for a client who is in active labor and requests pain
management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position.
7. a nurse in an emergency department is performing triage for multiple
clients following a disaster in the community. To which of the following types
of injuries should the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm
8. a nurse manager is updating protocols for the use of belt restraints. Which
of the following guidelines should the nurse include?
A. Remove the client’s restraint every 4hr
B. Document the client’s condition every 15 min
C. Attach the restrain to the bed’s side rails
D. Request a PRN restrain prescription for clients who are aggressive
9. A nurse is teaching an in-service about nursing leadership. Which of the
following information should the nurse include about an effective leader?
A. Acts as an advocate for the nursing unit.
B. (Unable to read) for the unit
C. Priorities staff request over client needs.
D. Provides routine client care and documentation.
10. A nurse is reviewing the laboratory findings of a client who has diabetes
mellitus and reports that she has been following her (unable to read) care.
The nurse should identify which of the following findings indicates a need to
revise the client’s plan of care.
A. Serum sodium 144 mEq/
B. (Unable to read)
C. Hba1c 10 %
, D. Random serum glucose 190 mg/dl.
11. A nurse in a provider’s office is reviewing the laboratory results of a
group of clients. The nurse should identify that which of the following
sexually transmitted infections is a nationally notifiable infectious disease
that should be reported to the state health department?
A. Chlamydia
B. Human papillomavirus
C. Candidiasis
D. Herps simplex virus
12. A nurse is teaching a newly licensed nurse about therapeutic techniques
to use when leading a group on a mental health unit. Which of the following
group facilitation techniques should the nurse include in the teaching?
A. Share personal opinions to help influence the group’s values
B. Measure the accomplishments of the group against a previous group
C. Yield in situations of conflicts to maintain group harmony
D. Use modeling to help the clients improve their interpersonal skills
13. A fnurse fis fplanning ffor fa fclient fwho fpractices fOrthodox fJudaism.
fThe fclient ftells fthe fnurse fthat f(Unable fto fread) fPassover fholiday. fWhich
fof fthe ffollowing faction fshould fthe fnurse finclude fin fthe fplan fof fcare?
A. Provide fchicken fwith fcream fsauce.
B. Avoid fserving ffish fwith ffins fand fscales.
C. Provide f unleavened f bread.
D. Avoid fserving ffoods fcontaining flamb.
14. A fnurse fis fcaring ffor fa fclient fwho fhas fa fpulmonary fembolism. fThe
fnurse fshould fidentify fthe feffectiveness fof fthe ftreatment
A. A fchest fx-ray freveals fincreased fdensity fin fall ffields.
B. The fclient freports ffeeling fless fanxious. f
C. Diminished fbreath fsounds fare fauscultated fbilaterally
D. ABG fresults finclude fPh f7.48 fPaO2 f77 fmm fHg fand fPaCO2 f47 fmm fHg.
15. A fnurse fin fan femergency fdepartment fis fassessing fa fclient fwho
freports fingesting fthirty fdiazepam ftablets f(Unable fto fread) fa frespiratory
frate fof f10/min. fAfter fsecuring fthe fclient’s fairway fand finitiating fan fIV,
fwhich fof fthe ffollowing factions fshould fthe fnurse fdo fnext.
A. Monitor fthe fclient’s fIV fsite ffor fthrombophlebitis.
, B. Administer fflumazenil fto fthe fclient. f
C. Evaluate fthe fclient ffor ffurther fsuicidal fbehavior.
D. Initiate fseizure fprecautions ffor fthe fclient.
16. A fnurse fin fan femergency fdepartment fis fcaring ffor fa fclient fwho
freports fcocaine fuse f1hr fago. fWhich fof fthe ffollowing ffindings fshould
fthe fnurse fexpect?
A. Hypotension
B. Memory f loss
C. Slurred fspeech
D. Elevated f temperature
17. A fnurse fis fassessing fa fnewborn fwho fhas fa fblood fglucose flevel fof
f30 fmg/dl. fWhich fof fthe ffollowing fmanifestations fshould fthe fnurse
fexpect?
A. Loose f stools
B. Jitteriness f
C. Hypertonia
D. Abdominal f distention
18. A fnurse fin fa fpediatric fclinic fis freviewing fthe flaboratory ftest fresults
fof fa fschool fage fchild. fWhich fof fthe ffollowing ffindings fshould fthe fnurse
freport fto fthe fprovider?
A. Hgb f12.5 fg/dl
B. Platelets f 250,000/mm3
C. Hct f40%
D. WBC f14,000/mm3 f
19. A fcharge fnurse fis fteaching fa fnewly flicensed fnurse fabout fclients
fdesignating fa fhealth fcare fproxy fin fsituations fthat frequire fa fdurable fpower
fof fattorney ffor fheal fcare f(DPSHC). fWhich fof fthe ffollowing finformation fshould
fthe fcharge fnurse finclude?
A. “The fproxy fshould fmake fhealth fcare fdecisions ffor fthe fclient
fregardless fof fthe fclient’s fability fto fdo fso.”
B. “The fproxy fcan fmake ffinancial fdecisions fif fthe fneed farises.”
C. “The fproxy fcan fmake ftreatment fdecisions fif fthe fclient fis
funder f fanesthesia.”
D. “The fproxy fshould fmanage flegal fissues ffor fthe fclient.”
20. A fnurse fin fthe fPACU fis fcaring ffor fa fclient fwho freports fnausea. fWhich
fof fthe ffollowing factions fshould fthe fnurse ftake ffirst?