V1. Theelectroconvulsive
nurse working in a mental health unit is caring for a client who is scheduled to have
therapy (ECT) treatment the next day. The client asks, “Can I refuse the ECT
treatment tomorrow?” Which of the following responses should the nurse make?
a. “You should consider discussing this decision with your family first.”
b. “Having this treatment can be scary, but it is going to help you feel better.”
c. “Let’s talk with your doctor before you make a final decision.”
d. “You have a right to refuse even though you have signed the consent.”
v2. The nurse has attended a conference on informed consent. It indicates a correct understanding of the
teaching if the nurse states that informed consent
a. is an agreement to receive medical treatment that can't be revoked once signed.
b. forms must be signed when a client is competent to make an informed decision.
c. is signed by the nurse to indicate that the client understands the procedure.
d. is the nurse's responsibility to explain the risks, benefits, and alternative treatments.
V3. The nurse is prioritizing client care after receiving the change-of-shift report. The nurse should first
plan to see the client who
a. had laparoscopic surgery 12 hours ago and is reporting right shoulder pain.
b. had a cardiac catheterization one hour ago and has been drowsy since returning from the
procedure.
c. is scheduled for an echocardiogram in one hour and is eating food brought in by a visitor.
d. had an endoscopic retrograde cholangiopancreatography (ERCP) 1 hour ago and is reporting
difficulty swallowing.
⑰ 4. The nurse working in the labor and delivery (L&D) unit has become aware of the following clients who are
in the-
second stage of labor and are being monitored with external fetal monitors. The nurse identifies
which client as a priority for follow-up?
a. The client whose cervix has dilated to 10 cm with moderately intense contractions of 40 to 50
seconds.
b. The client whose fetal heart rate (FHR) remains consistent at 132 beats per minute.
c. The client whose bloody show is dark red with active pushing.
d. The client whose contractions are lasting 60 seconds with a 3-minute interval.
,⑰5. The registered nurse (RN) is planning care for clients and is assigning tasks to a licensed
practical/vocational nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which of the
following tasks is best for the RN to assign to the LPN/VN?
-
-
a. Collection of past medical history for a client who is admitted for cellulitis.
b. Recording the output for a client who just urinated in the collection container of the toilet.
c. Assisting with the delivery of the breakfast trays to the clients. UAP
-RN
d. Development of a plan of care for a client who is postoperative from a cholecystitis.
My
6. The nurse working in the emergency department (ED) has been made aware of the following client
situations. Which client information requires reporting by the nurse to an outside agency?
a. 18-year-old female who has abdominal pain and is 4 months pregnant.
b. 27-year-old who has a history of gonorrhea and chlamydia infection from 1 year ago.
c. 45-year-old who was involved in a local factory fire and has 50% total body surface area
(TBSA) burns.
d. 72-year-old who lives with their daughter and has several pressure ulcers (stage 3).
neglect abuse
X7. The nurse working on the pediatric unit has been made aware of the following information. Which of the
following children should the nurse assess first?
a. 15-year-old who has acute post-streptococcal glomerulonephritis (PSGN) and has- crackles in the
lungs with neck vein distention.
-
-
b. 13-year-old who has hemophilia and requires prolonged pressure held to a venipuncture site after
the collection of laboratory blood work.
c. 10-year-old who has sickle cell disease (SCD), is reporting a pain level of 7 on a scale of 0 (no
pain) to 10 (severe pain) and is scheduled to receive a dose of prescribed pain medication. exp.
d. 7-year-old who has celiac disease and has had 3 episodes of diarrhea in the past 8 hours. exp.
8. The nurse is caring for a client who had a kidney transplant 1 week ago. It is a priority for the nurse to
notify the primary health care provider (PHCP) if the client has
a. a urine output that continues to be slightly pink in color since surgery.
expe
b. an increase in weight from 199 to 201 lb in the past 72 hours. as
c. a change in the blood urea nitrogen (BUN) level from 10 to 16 mg/dL over the past 48 hours.
&>
d. a change in blood pressure (BP) from 122/78 to 92/58 mm Hg over the past 4 hours.
9. The nurse is preparing to develop a plan of care after assessing a newly admitted client who is
diagnosed with pericarditis. Which of the following actions should the nurse take first?
a. Prioritize the client’s reported concerns.
b. Determine any referrals that need to be initiated.
, c. Formulate short-term and long-term client goals.
d. Review client data to identify the areas of concern.
10. The charge nurse is reviewing clients' electronic medical records (EMRs). Which of the following
indicates correct documentation by a staff nurse?
a. “Intravenous (IV) catheter site in antecubital space is red and warm. IV catheter removed. New
IV started.”
b. “Found client sitting on floor. All 4 side-rails were in upright position. Client reports no pain. No
abrasions or bleeding noted. Primary health care provider (PHCP) notified. Incident report
completed.”
c. “Returned from radiology department following a diagnostic procedure. Vital signs (VS)
obtained with slight increase in blood pressure (BP) from before procedure.”
d. “Ambulated from bed to doorway without assistance. No shortness of breath or diaphoresis
noted. Vital signs (VS) remain within baseline after ambulating.”
3-
11. The nurse working in a medical-surgical unit is aware of the following situations. Which situation
requires the nurse to complete an incident report?
a. A client has developed phlebitis from an intravenous (IV) catheter and is now receiving
antibiotics.
b. A staff member called a code for a client who developed respiratory distress.
c. The client who reports having an advance directive does not have a copy on their chart.
d. The nurse finds a PRN prescription for restraints on a client’s medical record.
12. The nurse working on a medical-surgical unit is caring for the following assigned clients when the
facility's emergency response plan is activated. Which client should the nurse recommend for
discharge?
a. The client who has suspected appendicitis, intense pain at McBurney’s point, and now reports
cessation of the pain
b. The client who has pneumonia, a history of asthma, and has received intravenous (IV)
antibiotics for the last 24 hours.
c. The client who is positive for human immunodeficiency virus (HIV), has a nonproductive
cough, and a 24-hour Mantoux test reading of 6 mm induration.
d. The client who has ulcerative colitis, is receiving prednisone, and is having 3 to 4 diarrheal
stools with streaks of blood.
⑧
13. The nurse is observing a newly hired unlicensed assistive personnel (UAP) care for assigned clients.
It indicates correct client care if the newly hired UAP is observed
a. donning sterile gloves to empty a urinary drainage device.
b. removing protective eyewear before removing gloves.
, c. wearing a gown, mask, and gloves when entering the room of a client who has influenza.
d. placing dedicated equipment in the room of a client who has cellulitis of the left leg.
8
14. The nurse working in an ambulatory health center has assessed the following clients who are waiting to
see the primary health care provider (PHCP). The nurse should immediately remove from the waiting
room and place in an examining room the client who has
a. reports of burning and pruritus with a linear rash of vesicles extending around the right lower rib
cage.
shingles
-
b. a 1 mm area that is flat and red at the site of a Mantoux test which was administered 48 hours ago.
c. congestive heart failure -(CHF) and reports gaining 3 lb in the past 3 days.
d. a fever of 99.6° F, and is reporting generalized pain and malaise, and has a history of
borderline personality disorder.
-
15. The nurse is reviewing newly written prescriptions for assigned clients. It requires follow-up by the nurse
if the primary health care provider (PHCP) prescribes
a. filgrastim for a 46-year-old client who has a white blood cell (WBC) of 2,500 mm³.
b. preoperative atropine for a 60-year-old client who has glaucoma.
c. a fluid bolus of 500 mL over 1 hour for a 12-year-old client who has sickle cell crisis.
d. a low-potassium diet for a 5-year-old client who has acute glomerulonephritis.
⑦ 16. The nurse working in the medical-surgical unit is admitting a client who has arrived from the
postanesthesia care unit (PACU). The client is postoperative from a -I colon resection, responds to
commands, and reports a moderate pain level. Which of the following actions should the nurse take
first?
a. Confirm the client’s identity.
b. Assess the client’s surgical bandage.
c. Auscultate the client’s abdomen.
d. Evaluate the client’s vital signs.
17. The nurse is caring for a newborn who has hyperbilirubinemia and is currently undergoing
phototherapy. Which of the following interventions should the nurse include in the plan of care?
a. Cover newborn with a light blanket.
b. Maintain newborn on their back.
c. Remove eye shields each shift or during feedings.
d. Provide a quiet, stimulate-free environment.
8
18. The nurse is screening adult clients at a health fair. It is a priority for the nurse to recommend follow- up
with a primary health care provider (PHCP) for the client who is
nurse working in a mental health unit is caring for a client who is scheduled to have
therapy (ECT) treatment the next day. The client asks, “Can I refuse the ECT
treatment tomorrow?” Which of the following responses should the nurse make?
a. “You should consider discussing this decision with your family first.”
b. “Having this treatment can be scary, but it is going to help you feel better.”
c. “Let’s talk with your doctor before you make a final decision.”
d. “You have a right to refuse even though you have signed the consent.”
v2. The nurse has attended a conference on informed consent. It indicates a correct understanding of the
teaching if the nurse states that informed consent
a. is an agreement to receive medical treatment that can't be revoked once signed.
b. forms must be signed when a client is competent to make an informed decision.
c. is signed by the nurse to indicate that the client understands the procedure.
d. is the nurse's responsibility to explain the risks, benefits, and alternative treatments.
V3. The nurse is prioritizing client care after receiving the change-of-shift report. The nurse should first
plan to see the client who
a. had laparoscopic surgery 12 hours ago and is reporting right shoulder pain.
b. had a cardiac catheterization one hour ago and has been drowsy since returning from the
procedure.
c. is scheduled for an echocardiogram in one hour and is eating food brought in by a visitor.
d. had an endoscopic retrograde cholangiopancreatography (ERCP) 1 hour ago and is reporting
difficulty swallowing.
⑰ 4. The nurse working in the labor and delivery (L&D) unit has become aware of the following clients who are
in the-
second stage of labor and are being monitored with external fetal monitors. The nurse identifies
which client as a priority for follow-up?
a. The client whose cervix has dilated to 10 cm with moderately intense contractions of 40 to 50
seconds.
b. The client whose fetal heart rate (FHR) remains consistent at 132 beats per minute.
c. The client whose bloody show is dark red with active pushing.
d. The client whose contractions are lasting 60 seconds with a 3-minute interval.
,⑰5. The registered nurse (RN) is planning care for clients and is assigning tasks to a licensed
practical/vocational nurse (LPN/VN) and an unlicensed assistive personnel (UAP). Which of the
following tasks is best for the RN to assign to the LPN/VN?
-
-
a. Collection of past medical history for a client who is admitted for cellulitis.
b. Recording the output for a client who just urinated in the collection container of the toilet.
c. Assisting with the delivery of the breakfast trays to the clients. UAP
-RN
d. Development of a plan of care for a client who is postoperative from a cholecystitis.
My
6. The nurse working in the emergency department (ED) has been made aware of the following client
situations. Which client information requires reporting by the nurse to an outside agency?
a. 18-year-old female who has abdominal pain and is 4 months pregnant.
b. 27-year-old who has a history of gonorrhea and chlamydia infection from 1 year ago.
c. 45-year-old who was involved in a local factory fire and has 50% total body surface area
(TBSA) burns.
d. 72-year-old who lives with their daughter and has several pressure ulcers (stage 3).
neglect abuse
X7. The nurse working on the pediatric unit has been made aware of the following information. Which of the
following children should the nurse assess first?
a. 15-year-old who has acute post-streptococcal glomerulonephritis (PSGN) and has- crackles in the
lungs with neck vein distention.
-
-
b. 13-year-old who has hemophilia and requires prolonged pressure held to a venipuncture site after
the collection of laboratory blood work.
c. 10-year-old who has sickle cell disease (SCD), is reporting a pain level of 7 on a scale of 0 (no
pain) to 10 (severe pain) and is scheduled to receive a dose of prescribed pain medication. exp.
d. 7-year-old who has celiac disease and has had 3 episodes of diarrhea in the past 8 hours. exp.
8. The nurse is caring for a client who had a kidney transplant 1 week ago. It is a priority for the nurse to
notify the primary health care provider (PHCP) if the client has
a. a urine output that continues to be slightly pink in color since surgery.
expe
b. an increase in weight from 199 to 201 lb in the past 72 hours. as
c. a change in the blood urea nitrogen (BUN) level from 10 to 16 mg/dL over the past 48 hours.
&>
d. a change in blood pressure (BP) from 122/78 to 92/58 mm Hg over the past 4 hours.
9. The nurse is preparing to develop a plan of care after assessing a newly admitted client who is
diagnosed with pericarditis. Which of the following actions should the nurse take first?
a. Prioritize the client’s reported concerns.
b. Determine any referrals that need to be initiated.
, c. Formulate short-term and long-term client goals.
d. Review client data to identify the areas of concern.
10. The charge nurse is reviewing clients' electronic medical records (EMRs). Which of the following
indicates correct documentation by a staff nurse?
a. “Intravenous (IV) catheter site in antecubital space is red and warm. IV catheter removed. New
IV started.”
b. “Found client sitting on floor. All 4 side-rails were in upright position. Client reports no pain. No
abrasions or bleeding noted. Primary health care provider (PHCP) notified. Incident report
completed.”
c. “Returned from radiology department following a diagnostic procedure. Vital signs (VS)
obtained with slight increase in blood pressure (BP) from before procedure.”
d. “Ambulated from bed to doorway without assistance. No shortness of breath or diaphoresis
noted. Vital signs (VS) remain within baseline after ambulating.”
3-
11. The nurse working in a medical-surgical unit is aware of the following situations. Which situation
requires the nurse to complete an incident report?
a. A client has developed phlebitis from an intravenous (IV) catheter and is now receiving
antibiotics.
b. A staff member called a code for a client who developed respiratory distress.
c. The client who reports having an advance directive does not have a copy on their chart.
d. The nurse finds a PRN prescription for restraints on a client’s medical record.
12. The nurse working on a medical-surgical unit is caring for the following assigned clients when the
facility's emergency response plan is activated. Which client should the nurse recommend for
discharge?
a. The client who has suspected appendicitis, intense pain at McBurney’s point, and now reports
cessation of the pain
b. The client who has pneumonia, a history of asthma, and has received intravenous (IV)
antibiotics for the last 24 hours.
c. The client who is positive for human immunodeficiency virus (HIV), has a nonproductive
cough, and a 24-hour Mantoux test reading of 6 mm induration.
d. The client who has ulcerative colitis, is receiving prednisone, and is having 3 to 4 diarrheal
stools with streaks of blood.
⑧
13. The nurse is observing a newly hired unlicensed assistive personnel (UAP) care for assigned clients.
It indicates correct client care if the newly hired UAP is observed
a. donning sterile gloves to empty a urinary drainage device.
b. removing protective eyewear before removing gloves.
, c. wearing a gown, mask, and gloves when entering the room of a client who has influenza.
d. placing dedicated equipment in the room of a client who has cellulitis of the left leg.
8
14. The nurse working in an ambulatory health center has assessed the following clients who are waiting to
see the primary health care provider (PHCP). The nurse should immediately remove from the waiting
room and place in an examining room the client who has
a. reports of burning and pruritus with a linear rash of vesicles extending around the right lower rib
cage.
shingles
-
b. a 1 mm area that is flat and red at the site of a Mantoux test which was administered 48 hours ago.
c. congestive heart failure -(CHF) and reports gaining 3 lb in the past 3 days.
d. a fever of 99.6° F, and is reporting generalized pain and malaise, and has a history of
borderline personality disorder.
-
15. The nurse is reviewing newly written prescriptions for assigned clients. It requires follow-up by the nurse
if the primary health care provider (PHCP) prescribes
a. filgrastim for a 46-year-old client who has a white blood cell (WBC) of 2,500 mm³.
b. preoperative atropine for a 60-year-old client who has glaucoma.
c. a fluid bolus of 500 mL over 1 hour for a 12-year-old client who has sickle cell crisis.
d. a low-potassium diet for a 5-year-old client who has acute glomerulonephritis.
⑦ 16. The nurse working in the medical-surgical unit is admitting a client who has arrived from the
postanesthesia care unit (PACU). The client is postoperative from a -I colon resection, responds to
commands, and reports a moderate pain level. Which of the following actions should the nurse take
first?
a. Confirm the client’s identity.
b. Assess the client’s surgical bandage.
c. Auscultate the client’s abdomen.
d. Evaluate the client’s vital signs.
17. The nurse is caring for a newborn who has hyperbilirubinemia and is currently undergoing
phototherapy. Which of the following interventions should the nurse include in the plan of care?
a. Cover newborn with a light blanket.
b. Maintain newborn on their back.
c. Remove eye shields each shift or during feedings.
d. Provide a quiet, stimulate-free environment.
8
18. The nurse is screening adult clients at a health fair. It is a priority for the nurse to recommend follow- up
with a primary health care provider (PHCP) for the client who is
