A 3-year-old boy was successfully toilet-trained before his admission to the hospital for injuries sustained
from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which
information should the nurse provide to the parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers
C. A potty chair should be brought from home so he can maintain his toileting skills
D. Children usually resume their toileting behaviors when they leave the hospital - ansD. Children usually
resume their toileting behaviors when they leave the hospital
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low
intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare
provider?
A. Shift intake of 640mL IV fluids plus 30mL PO ice chips
B. Serum pH of 7.45
C. Gastric output of 100 mL in the last 8 hours
D. Serum potassium of 3.0 mg/dL - ansD. Serum potassium of 3.0 mg/dL
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 to 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 - ansA. Instructions about how much fluid the child
should drink daily
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia
(BPH). Which information should the nurse provide?
,A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test - ansB. Increase physical activity
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum.
Which action is most important for the nurse to implement?
A. Obtain the client's 24-hour dietary recall
B. Document mucosal membrane status
C. Schedule a consult with a nutritionist
D. Initiate prescribed intravenous fluids - ansD. Initiate prescribed intravenous fluids
A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum
hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare
provider's attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose - ansB. Allopurinol
A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which
information should the nurse include in the client's health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip - ansD. The client fell sustaining a fracture to the left hip
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three
hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the
laboratory value for which medication?
A. Lorazepam
B. Fluoxetine
,C. Divalproex
D. Olanzapine - ansC. Divalproex
A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and that
her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two
weeks. What action should the nurse take?
A. Tell the client to begin nipple stimulation to prepare for breast feeding.
B. Reschedule the client's prenatal appointment for the following day
C. Explain that this normal secretion can be assessed at the next visit
D. Recommend that the client start wearing a supportive brassiere - ansC. Explain that this normal secretion
can be assessed at the next visit
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report
to the healthcare provider?
A. Volume of each voiding is more than 300mL
B. Serum potassium that is elevated
C. Relief of flank pain that radiated into the groin
D. Hematuria that is beginning to turn pink - ansD. Hematuria that is beginning to turn pink
A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in
the plan of care?
A. Risk for ineffective self-health management related to deficient knowledge
B. Ineffective coping related to personal vulnerability
C. Risk for injury related to vertigo
D. Anxiety related to disruption of lifestyle - ansC. Risk for injury related to vertigo.
A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for adverse effects of the
medication, which serum laboratory value is most important for the nurse to monitor?
A. Glucose
B. Calcium
C. Platelet count
D. White blood cell count - ansC. Platelet count
, A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and
heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the
client complains of pain at the right groin insertion site. What action should the nurse implement?
A. Check femoral site for hematoma formation
B. Stimulate the client to take deep breaths
C. Evaluate the integrity of the IV insertion site
D. Assess distal lower extremity capillary refill - ansB. Stimulate the client to take deep breaths
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary
embolism. Which information in the client's history requires follow-up by the nurse?
A. CT scan that was performed 6 months earlier
B. Metal hip prosthesis was placed 20 years ago
C. Report of client's sobriety for the last 5 years
D. Takes metformin for type 2 diabetes mellitus - ansD. Takes metformin for type 2 diabetes mellitus
A client presents to the emergency department with muscle aches, headache, fever, and describes a recent
loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most
important for the nurse to take?
A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag
B. Move the client to a private room, keep the door closed, and initiate droplet precautions.
C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus
D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. -
ansA. Place the nasal swab specimen for COVID-19 directly into a biohazard bag
A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal
discharge. Which action should the nurse take first?
A. Start an intravenous infusion
B. Administer oxygen via facemask
C. Perform a vaginal exam
D. Begin continuous fetal monitoring - ansD. Begin continuous fetal monitoring
from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which
information should the nurse provide to the parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers
C. A potty chair should be brought from home so he can maintain his toileting skills
D. Children usually resume their toileting behaviors when they leave the hospital - ansD. Children usually
resume their toileting behaviors when they leave the hospital
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low
intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare
provider?
A. Shift intake of 640mL IV fluids plus 30mL PO ice chips
B. Serum pH of 7.45
C. Gastric output of 100 mL in the last 8 hours
D. Serum potassium of 3.0 mg/dL - ansD. Serum potassium of 3.0 mg/dL
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 to 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 - ansA. Instructions about how much fluid the child
should drink daily
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia
(BPH). Which information should the nurse provide?
,A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test - ansB. Increase physical activity
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum.
Which action is most important for the nurse to implement?
A. Obtain the client's 24-hour dietary recall
B. Document mucosal membrane status
C. Schedule a consult with a nutritionist
D. Initiate prescribed intravenous fluids - ansD. Initiate prescribed intravenous fluids
A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum
hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare
provider's attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose - ansB. Allopurinol
A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which
information should the nurse include in the client's health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip - ansD. The client fell sustaining a fracture to the left hip
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three
hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the
laboratory value for which medication?
A. Lorazepam
B. Fluoxetine
,C. Divalproex
D. Olanzapine - ansC. Divalproex
A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and that
her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two
weeks. What action should the nurse take?
A. Tell the client to begin nipple stimulation to prepare for breast feeding.
B. Reschedule the client's prenatal appointment for the following day
C. Explain that this normal secretion can be assessed at the next visit
D. Recommend that the client start wearing a supportive brassiere - ansC. Explain that this normal secretion
can be assessed at the next visit
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report
to the healthcare provider?
A. Volume of each voiding is more than 300mL
B. Serum potassium that is elevated
C. Relief of flank pain that radiated into the groin
D. Hematuria that is beginning to turn pink - ansD. Hematuria that is beginning to turn pink
A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in
the plan of care?
A. Risk for ineffective self-health management related to deficient knowledge
B. Ineffective coping related to personal vulnerability
C. Risk for injury related to vertigo
D. Anxiety related to disruption of lifestyle - ansC. Risk for injury related to vertigo.
A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for adverse effects of the
medication, which serum laboratory value is most important for the nurse to monitor?
A. Glucose
B. Calcium
C. Platelet count
D. White blood cell count - ansC. Platelet count
, A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and
heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the
client complains of pain at the right groin insertion site. What action should the nurse implement?
A. Check femoral site for hematoma formation
B. Stimulate the client to take deep breaths
C. Evaluate the integrity of the IV insertion site
D. Assess distal lower extremity capillary refill - ansB. Stimulate the client to take deep breaths
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary
embolism. Which information in the client's history requires follow-up by the nurse?
A. CT scan that was performed 6 months earlier
B. Metal hip prosthesis was placed 20 years ago
C. Report of client's sobriety for the last 5 years
D. Takes metformin for type 2 diabetes mellitus - ansD. Takes metformin for type 2 diabetes mellitus
A client presents to the emergency department with muscle aches, headache, fever, and describes a recent
loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most
important for the nurse to take?
A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag
B. Move the client to a private room, keep the door closed, and initiate droplet precautions.
C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus
D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. -
ansA. Place the nasal swab specimen for COVID-19 directly into a biohazard bag
A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal
discharge. Which action should the nurse take first?
A. Start an intravenous infusion
B. Administer oxygen via facemask
C. Perform a vaginal exam
D. Begin continuous fetal monitoring - ansD. Begin continuous fetal monitoring
