NCLEX EXAM PREVIEW ANSWER

1. The charge nurse has received a change-of-shift report on the following clients in labor.
The charge nurse should ask a staff member to first see the client in the

1. first stage of labor who has an oral temperature of 99.7° F (37.6° C)

2. first stage of labor whose contractions are occurring every 30 seconds
3. second stage of labor who has respirations of 26
4. second stage of labor whose contractions are lasting for 60 seconds

ANSWER:
2. first stage of labor whose contractions are occurring every 30 seconds
Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs)
90 secs is the duration, 2 mins is the frequency.

Rationale:
1. Elevated temp is normal during labor
3. Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern
4. Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal
Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain

2. The nurse is observing a staff member caring for a client who has chickenpox.
Which of the following actions by the staff member would require the nurse to intervene?

1. placing the client in a private room with monitored negative air pressure
2. placing a box of disposable face shields outside the client’s room
3. placing an alcohol-based hand rub in the client’s room for hand hygiene
4. placing a surgical mask on the client during transport out of the client’s room

ANSWER:
2. placing a box of disposable face shields outside the client's room
disposable face masks are not suitable for airborne precautions

Rationale:
Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal
precautions (hand sanitizer in room) and placing surgical mask on client during transport are all
correct interventions for Varicilla.

3. The nurse is caring for a client who reports feeling faint and is experiencing the cardiac
rhythm shown in the

1. Administer the client’s prescribed beta blocker.

2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina.
,,
2. transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare
but can happen). Assessment of angina is appropriate

Rationale:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus
Tachy)
4. Chest compressions are for cardiac arrest

4. The nurse is planning care for a client with moderate Alzheimer’s disease (AD).
Which of the following interventions should the nurse include in the client’s plan of care?

1. Encourage the client to reminisce about happy memories.

2. Confront the client when inappropriate or agitated behaviors occur.
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
4. Provide the client with information about activity choices in the morning so the client can
make plans for the day.

ANSWER:
1. Encourage the client to reminisce about happy memories.
Its possible for AD patients to retain long-term memories

Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and
planning daily activities. Asking them to plan can frustrate them and cause distress.
STRUCTURED pleasant activities that consider the persons likes and interests are the best.

5. The nurse is teaching a client how to ambulate using crutches. Which of the following
information should the nurse include?

1. “Use your hands and arms to support your body weight.”

2. “Wear slippers when ambulating with the crutches in your home.”
3. “Maintain the crutches 12 in (30 cm) in front of your feet while standing.”
4. “Adjust the hand grips of the crutches so that your elbows are fully extended.”

ANSWER:
1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands

Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle

6. The nurse has taught a client with multiple sclerosis (MS). Which of the following
statements by the client would indicate a correct understanding of the teaching?

1. “I will complete all of my household chores in the morning when I am well rested.”
2. “I have learned how to massage my bladder to help empty my bladder completely.”
3. “I will take a hot bath in the evening to help me relax if I have had a stressful day at work.”
4. “I should expect the blurred vision to resolve after I have received medications for several
weeks.”
ANSWER:
4. "I should expect the blurred vision to resolve after I have received medications for several
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases
it resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it
quicker

Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities and allow
time for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with
it but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked
up and extra heat can stress your body into overdrive

7. The nurse has attended a staff education program about caring for clients who are
receiving positive pressure mechanical ventilation. Which of the following statements by
the nurse would indicate a correct understanding of the teaching?

1. “Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation.”
2. “Clients may develop stress ulcers and gastrointestinal bleeding.”
3. “Clients will be chemically paralyzed to improve oxygenation.”
4. “Clients will experience diuresis and polyuria.”

ANSWER:
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
Rationale: Positive Pressure Ventilation may cause stress ulcers and GI bleeding because

8. The charge nurse must transfer a female client from the medical-surgical unit to the
maternity unit to make a bed available. It would be most appropriate for the nurse to
transfer the client who is

1. 28 years old, had a right mastectomy and has a closed-wound drainage system
2. 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
4. 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours
ago

ANSWER:
3. 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
 9. The nurse has been made aware of the following client situations. The nurse should first
assess the client with

1. heart failure who has a productive cough and is anxious

2. regional enteritis (Crohn’s disease) who is reporting cramping abdominal pain and diarrhea
3. idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting
heavy menses
4. chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using
accessory muscles to breathe

ANSWER:
1. heart failure who has a productive cough and is anxious
Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be caused by
decreased perfusion

10. The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients.
Which of the following tasks would be appropriate for the nurse to assign to UAP?

1. assisting a client with atrial fibrillation to shower

2. checking the ability of a client to swallow water after a transesophageal echocardiogram
(TEE)
3. observing while a client with dysphagia begins a thickened liquid diet
4. transporting a client with respiratory distress to the radiology department for a chest
radiograph

ANSWER:
1. assisting a client with atrial fibrillation to shower
UAP can perform hygiene

Rationale: Only nurses can assess. Transporting a client in respiratory arrest is not safe to
delegate to a UAP

11. The nurse has taken a nutritional history from parents of clients. It would be a priority
for the nurse to follow up with the

1. 5-month-old client whose only source of nutrition is 5 formula feedings daily

2. 7-month-old client who eats several crackers as finger food
3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple
juice, and 3 servings of infant cereal
4. 1-year-old client whose typical food intake includes 4 breast-feedings and 3 servings of
cooked vegetables, pears, or sliced cheese
ANSWER:
3. 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice,
and 3 servings of infant cereal

Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the necessary
nutrients and baby can develop iron deficiency

12. The nurse is planning a staff education program about client privacy. Which of the
following scenarios should the nurse include as an example of a violation of client
privacy?

1. discussing with an unlicensed assistive personnel (UAP) that the UAP’s assigned client will
require a smaller condom catheter
2. sharing the client’s blood alcohol level (BAL) test result with the police officer who brought
the client to the emergency department (ED)
3. responding to the call light of the client who is assigned to another nurse and needs
assistance in the bathroom
4. allowing a nursing student who has been assigned to the client to review the client’s medical
record

ANSWER:
2. sharing the client's blood alcohol level (BAL) test result with the police officer who brought
the client to the emergency department (ED)

Rationale: PHI is permitted to be disclosed to police when PHI is needed to apprehend the
perpetrator of a violent crime, suspect, or fugitive.

13. The nurse has become aware of the following client situations. The nurse should first
assess the client

1. who had a right pneumonectomy 24 hours ago and is in the high-Fowler’s position while lying
on the right side
2. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and
reporting hemoptysis
3. who had a wedge resection of the left lung 24 hours ago and is sitting in the high-Fowler’s
position
4. with heart failure who has a productive cough and is restless

ANSWER:
4. with heart failure who has a productive cough and is restless
Productive cough (pink frothy sputum) is indicative of pulmonary edema which is life-
threatening. T(x) would be to improve cardiac output by placing client in high fowlers, O2,
mechanical ventilation, meds

14. The nurse is caring for a 3-year-old client with a cerebral concussion who is being
observed overnight in the pediatric unit. Which of the following observations would be
most significant for the nurse to report to the oncoming shift?

1. The client has a blood pressure of 94/58 mm Hg and an apical pulse of 90.
2. The client is sleeping but is easily aroused.
3. The client’s pupils are equal and reactive to light.
4. The client has an axillary temperature of 99.0° F (37.2° C) and respirations of 24.

ANSWER:
2. The client is sleeping but is easily aroused.
Important to keep checking for decline in M/S with concussions, even when sleeping.

15. The nurse in the same-day surgical center has received a change-of-shift report on the
following clients. The nurse should first see the client who had

1. closed reduction of a fractured tibia with cast application 1 hour ago and is reporting that the
casted leg feels hot
2. extraction of a cataract lens 2 hours ago and is reporting nausea
3. an arthroscopy of the right knee 3 hours ago and is reporting knee pain rated as 4 on a scale
of 0 (no pain) to 10 (severe pain)
4. a laparoscopic cholecystectomy 4 hours ago and is reporting right shoulder pain

ANSWER:
1. closed reduction of a fractured tibia with cast application 1 hour ago and is reporting that the
casted leg feels hot
Pain, tightness, hot feeling can indicate that the cast is on too tight

Rationale:
2. Normal to feel nauseous after coming off of anesthesia
3. Knee pain is expected after knee surgery
4. Right shoulder pain is common in laparoscopic cholecystectomy due to gas left in abdomen
after the procedure. Will resolve on its own

16. The nurse is planning care for a client with multiple sclerosis (MS) who has ataxia.
Which of the following interventions should the nurse include in the client’s plan of care?

1. Add thickener to thin liquids for the client.

2. Obtain a referral to a physical therapist for the client.
3. Face the client directly when speaking with the client.
4. Provide a board with pictures to help the client communicate needs.

ANSWER:
2. Obtain a referral to a physical therapist for the client.
Ataxia is lack of muscle control in arms and legs leading to lack of balance, coordination, and
walking. PT is the area of referral for this type of issue.
Rationale:
1. thick liquids for dysphagia
3. Always indicated
4. Can be a tool for patients with expressive aphasia

17. The home-health nurse is assigned to visit the following clients who live within 3 miles
(4.8 km) of one another. The nurse should first visit the client with

1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage from the
closed-wound drainage system in the past 12 hours
2. lung cancer who received a dose of chemotherapy 2 weeks ago and has a temperature of
101.1° F (38.4° C)
3. chronic obstructive pulmonary disease (COPD) who is reporting expectorating large amounts
of thick, yellow mucus
4. diabetes mellitus (type 1) who had a right below-the-knee amputation (BKA) and is reporting
having right toe pain

ANSWER:
1. breast cancer who had a mastectomy 2 days ago and has had 25 mL of drainage from the
closed-wound drainage system in the past 12 hours
This is really little blood in 12 hours for a surgery that was only 2 days ago. Nurse should assess
for obstruction of the drainage system which could be life-threatening if not resolved.
 18. The nurse has become aware of the following client situations. The nurse should first
assess the client

1. who had a total abdominal hysterectomy (TAH) 1 day ago and is unable to void 7 hours after
the indwelling urethral catheter was removed
2. who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the
chest
3. with bacterial pneumonia who has bronchial breath sounds auscultated between the
scapulae and a temperature of 103.3° F (39.6° C)
4. with hepatic cirrhosis who has an elevated aspartate aminotransferase (AST) level and
respirations of 24

ANSWER:
2. who had a total knee replacement 24 hours ago, is restless, and has a petechial rash on the
chest

petechial rash — sign of DIC or fat embolus

19. The nurse is planning care for a pediatric client being admitted with pertussis.
Which of the following interventions should the nurse include in the client’s plan of care?

1. Keep the client NPO.

2. Place a dehumidifier in the client’s room.
3. Encourage the client to ambulate frequently.
4. Implement droplet precautions.

ANSWER:
4. Implement droplet precautions.

20. The nurse has attended a staff education program about infection control precautions.
It would indicate a correct understanding of the teaching if the nurse is observed

1. wearing a particulate respirator mask (N95) when entering the room of a client with
Haemophilus influenzae pneumonia
2. placing a client with streptococcal pneumonia in a room with a client who has respiratory
syncytial virus (RSV)
3. wearing a protective gown when entering the room of a client with Escherichia coli O157.H7
who is incontinent
4. placing a client with pediculosis capitis (head lice) in a room with a client who has scabies
ANSWER:
3. wearing a protective gown when entering the room of a client with Escherichia coli who is
incontinent
E. Coli is contact precautions; wear gown whenever coming in contact with bodily fluids which is
highly likely with an incontinent patient

Rationale:
1. H. flu is droplet precautions
2. Strep is droplet and RSV is contact
4. They will infect each other, they need private rooms

21. The nurse is assessing an older adult client who is scheduled for discharge and is at risk
for falls. Which of the following are extrinsic risk factors for falling? Select all that apply.

1. uneven stairs
2. throw rugs
3. hemiparesis
4. dim lighting
5. confusion

ANSWER:
uneven stairs, throw rugs, dim lighting

Hemiparesis and confusion are intrinsic risk factors

22. The nurse is caring for a 3-year-old client with impetigo. Which of the following infection
control precautions should the nurse implement? Select all that apply.

1. Wear a surgical mask when bathing the client.

2. Wear a protective gown when changing the client’s bed linens.
3. Keep the door to the client’s room closed.
4. Place a box of clean gloves outside the client’s door.
5. Place a surgical mask on the client during transport to other departments.

ANSWER:
2. Wear a protective gown when changing the client's bed linens.
4. Place a box of clean gloves outside the client's door.
Rationale: Impetigo is a highly infectious skin disease spread by direct contact. Contact
precautions include gown and gloves. Private closed door and surgical masks are appropriate
for airborne and not necessary for contact

23. The nurse is evaluating a staff member’s care of a client with active pulmonary
tuberculosis (TB). Which of the following actions by the staff member would indicate to
the nurse an understanding of the principles of infection control for tuberculosis
isolation?

1. instructing visitors to wash their hands before entering the client’s room
2. putting on a mask, gown, and gloves before entering the client’s room
3. placing tissues and a trash receptacle within the client’s reach
4. asking the client to put on a clean mask each time someone enters the room

ANSWER:
3. placing tissues and a trash receptacle within the client's reach
Important to not leave tissues laying around and to put them in a leak proof bag in the trash.

24. The nurse in the pediatric unit is preparing to admit a client with rubeola (measles).
The nurse should assign the client to a

1. private room at the end of the hallway

2. private room with monitored negative air pressure
3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema)

ANSWER:
2. private room with monitored negative air pressure

Measles is airborne (MTV) and requires a private room with negative air pressure

25. The charge nurse is observing the following client situations. It would require
intervention if a

1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis
wearing a protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client’s room
open
ANSWER:
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to intervene if
the patient is eating and possibly sharing food with another person.

26. The nurse is reviewing the orders of a client who has acute kidney injury.
Which of the following orders should the nurse clarify?

1. computed tomography (CT) scan of the abdomen with intravenous contrast media
2. urine specimen for urinalysis
3. blood specimen for arterial blood gas (ABG)
4. referral to registered dietitian for parenteral nutrition evaluation

ANSWER:
1. computed tomography (CT) scan of the abdomen with intravenous contrast media
CTs use iodinated contrast which is harmful to the kidneys and therefore contraindicated in a
client with AKI

27. The nurse is planning a staff education program about caring for clients with restraints.
Which of the following information should the nurse include?

1. “Restraints should be removed once during a shift to perform passive range-of-motion (ROM)
exercises for the client.”
2. “Restraints should be secured to the side rails of the client’s bed for quick release.”
3. “Restraints require an order from the primary health care provider.”
4. “Restraints may be used p.r.n. for clients who are confused.”

ANSWER:
3. "Restraints require an order from the primary health care provider."

Rationale:
1. Restraints are removed every 2 HOURS for ROM exercises, toileting, and fluids. Assess every
15 mins for the first hour and then every 30 minutes
2. Restraints should be secured to the bed, not side rails
4. Restraints are never PRN

28. The nurse is caring for a client with active pulmonary tuberculosis (TB).
Which of the following should the nurse include in the client’s plan of care?
1. placing the client in a private room with the door open
2. putting a surgical mask on the client during transport to the radiology department
3. instructing the primary caregivers to wear surgical masks when caring for the client
4. instituting the standards for droplet precautions while caring for the client

ANSWER:
2. putting a surgical mask on the client during transport to the radiology department
X-Ray to confirm active TB d(x)

Rationale:
1. Door should be closed
3.
4. Airborne precautions

29. The home-health nurse is teaching the parents of a 4-year-old client with impetigo.
Which of the following information should the nurse include?

1. “Put a surgical mask on your child when around siblings.”

2. “Cleanse the lesions with a povidone-iodine solution daily.”
3. “Apply petroleum jelly to the lesions daily.”
4. “Instruct your child not to use the same towels as siblings.”

ANSWER:
4. "Instruct your child not to use the same towels as siblings."
Impetigo is highly contagious through contact. Towels can easily spread the infection

Rationale:
1. It is contact precautions; surgical mask would be for airborne

30. The nurse has attended a staff education program about bioterrorism.
Which of the following statements by the nurse would require follow-up?

1. “Botulism is transmitted by ingestion of contaminated canned foods.”

2. “Hemorrhagic fever is spread by direct contact with blood or body fluids.”
3. “Anthrax is spread through direct contact with the bacteria and its spores.”
4. “Bubonic plague is transmitted from person to person via airborne droplets.”

ANSWER:
4. "Bubonic plague is transmitted from person to person via airborne droplets."
It is spread through flea bites and contact with infected skin
Rationale:
1. Botulism is transmitted by foods. ex: babies getting Botulism from honey
2. Infectious diseases that affect clotting and is spread by blood or body fluids
3. Anthrax: Contact

31. The nurse observes a coworker who is assessing a client’s thoracic expansion.
Which of the following would indicate that the coworker is using the correct assessment
technique?

1. percussion from the apex of the scapula downward on each side

2. placement of the hands flat on the back with the thumbs at the level of the tenth ribs
pointing to the spine, then asking the client to inhale
3. measurement of the anteroposterior diameter of the chest
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid
process, then asking the client to inhale

ANSWER:
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid
process, then asking the client to inhale
This is how to measure anterior thoracic expansion.

2. Posterior thoracic expansion

32. The nurse at a health fair is talking with a client who is in perimenopause and is
experiencing hot flashes. Which of the following lifestyle modifications would be
appropriate for the nurse to recommend?

1. increasing fluid intake

2. exercising daily
3. decreasing sodium intake
4. wearing clothing in layers
ANSWER:
4. wearing clothing in layers
Wear light layers so you can remove layers when you get a hot flash

33. The nurse in a community-based setting is teaching clients over 65 years of age about
health promotion activities.

Which of the following information should the nurse include?

1. “Purchase all of your prescribed medications at the same pharmacy.”
2. “Schedule an appointment for a vision screening every 3 years.”
3. “Participate in daily aerobic exercises for 60 minutes.”
4. “Increase your intake of fat-soluble vitamins.”

ANSWER:
3. "Participate in daily aerobic exercises for 60 minutes.
34. The nurse is screening clients for those at increased risk for developing cancer.
At highest risk for developing leukemia is the client who

1. received more than 3 blood transfusions

2. has a magnetic resonance imaging (MRI) scan annually
3. has polycythemia vera and requires phlebotomy treatments
4. had colon cancer and received chemotherapy treatments

ANSWER:
4. had colon cancer and received chemotherapy treatments
Chemotherapy is known to cause Leukemia, and Chemo has a greater risk than radiation to
cause Leukemia.

35. The nurse is caring for an older adult client in the postoperative period.
The nurse should know that this client, compared with younger clients in the postoperative
period, will have an increased need for

1. oral hygiene
2. analgesics
3. high-calorie foods
4. early mobilization

ANSWER:
4. early mobilization
 36. The nurse is planning a staff education program about the prevention of urinary tract
infections (UTls) in children. Which of the following information should the nurse
include? Select all that apply.

1. “Teach the child to perform Kegel exercises.”

2. “Encourage the child to empty the bladder completely.”
3. “Encourage the child to maintain an adequate fluid intake.”
4. “Teach the child how to properly cleanse the perineal area.”
5. “Offer the child noncarbonated, decaffeinated beverage choices.”

ANSWER:
2, 3, 4

37. The nurse is teaching the family member of a client with moderate Alzheimer’s disease
(AD). Which of the following interventions should the nurse include in the teaching?
Select all that apply.

1. Use distraction when the client becomes agitated.

2. Place calendars within clear view of the client.
3. Use short, simple sentences and provide step-by-step instructions for the client.
4. Avoid reminiscing with the client about past experiences in order to avoid feelings of loss and
loneliness.
5. Encourage the client to participate in a daytime exercise program to promote restful sleep at
night.

ANSWER:
1, 2, 3, 5

38. The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client.
Which of the following actions should the nurse take?

1. Assess the client’s recent urine output.

2. Prime a Y-tubing blood administration set with lactated Ringer’s solution.
3. Ensure that the client has a peripheral venous access device (VAD) that is 24-gauge or larger.
4. Verify with another nurse that the client’s room number is on both the blood product label
and the client’s identification band.

ANSWER:
4. Verify with another nurse that the client's room number is on both the blood product label
and the client's identification band.
Always verify blood products with another nurse
Rationale: Blood should only be given with normal saline and infused with an 18 or 20 gauge
needle.

39. The nurse is assessing the coping strategies of a client who had a myocardial infarction (MI)
3 days ago. Which of the following statements by the client would indicate ineffective coping?

1. “I know that stopping smoking will be difficult.”

2. “I plan to attend a cardiac rehabilitation support group.”
3. “I have trouble believing this has really happened to me.”
4. “I have let down my family because I will not be able to financially support them any longer.”

ANSWER:
4. "I have let down my family because I will not be able to financially support them any longer."
40. The hospice nurse has taught an in-home caregiver about comfort care for a client at
the end of life. Which of the following statements by the caregiver would require follow-
up?

1. “I have been applying petroleum jelly to keep the client’s lips moist.”
2. “I have been offering healthy foods frequently to keep up the client’s strength.”
3. “A blowing fan seems to be less anxiety-producing for the client than an oxygen mask.”
4. “Sitting upright seems to reduce the client’s noisy breathing more than lying down in the
bed.”

ANSWER:
4. "Sitting upright seems to reduce the client's noisy breathing more than lying down in the
bed."
It is common for hospice patients to have "death rattle," which are loud wet respirations. The
correct intervention is to reposition them laterally, not upright. And never suction!
Hospice is characterized as making the patient as comfortable as possible so if they have less
anxiety with a fan, let them continue using it. Offering food is okay but don't force them to eat.

41. The nurse is witnessing the client’s signature on a consent form.

Which of the following conditions should the nurse recognize must be met to ensure the
consent is valid? Select all that apply.

1. The client gave consent voluntarily.

2. The client received adequate disclosure.
3. The consent form is witnessed by 2 health care professionals.
4. The client understands the scheduled procedure or treatment.
5. The consent form is signed within 24 hours of the scheduled procedure or treatment.
ANSWER:
1, 2, 4

3, PCP explains procedure and nurse witnesses consent. Only 1 RN needed to witness.

42. The nurse is talking with a client who has been sexually assaulted. The client states, “I
never should have walked home late at night. I am to blame for what has happened to
me.” Which of the following would be an appropriate response for the nurse to make?
Select all that apply.

1. “The police officers who brought you into the hospital will be with you during this interview.”
2. “You should take a warm, calming shower in order to feel more relaxed.”
3. “You did the best you could in very difficult circumstances.”
4. “Sometimes the victim’s behavior causes the violence.”
5. “You are safe here.”

ANSWER:
3, 5

2. Don't shower yet because the nurse needs to collect physical evidence

43. The nurse is planning care for a client with moderate Alzheimer’s disease (AD). Which of
the following interventions should the nurse include in the client’s plan of care? Select
all that apply.

1. Establish a daily routine for the client.

2. Assist the client to void every 2 hours.
3. Introduce self upon interacting with the client.
4. Display a clock and calendar in the client’s room.
5. Keep the client’s television on during the day to distract the client.

ANSWER:
1, 2, 3, 4

44. A parent is discussing with the nurse about the behaviors of a 4-year-old child following the
death of a grandparent. The nurse should understand that the child may be experiencing
dysfunctional grieving if the parent reports that the child

1. conducts mock funerals with stuffed animals

2. refuses to go to sleep at night
3. continues to talk about the grandparent coming to visit
4. asks to play with the grandparent while at the cemetery

ANSWER:
2. refuses to go to sleep at night

45. The nurse has taught a client who has been ordered a low-sodium diet about appropriate
food choices. Which of the following statements by the client would indicate a correct
understanding of the teaching?

1. “I will eat steamed, fresh broccoli with herbs and spices for an evening meal.”
2. “I will add cottage cheese and other dairy products to my daily diet.”
3. “I am glad I can still enjoy eating cereals, such as bran flakes with raisins.”
4. “I am glad I can eat lean meats daily because I eat ham sandwiches for an afternoon meal.”

ANSWER:
1. "I will eat steamed, fresh broccoli with herbs and spices for an evening meal."
Veggies are low sodium and herbs and spices are great substitutes for salt.

46. The nurse is caring for a client who had a left modified radical mastectomy. The client
received discharge instructions for performing range-of-motion (ROM) exercises on her left
arm. Which of the following, if reported by the client on her return visit to the clinic, would
indicate to the nurse that the instructions have been followed correctly?

1. regular squeezing of a tennis ball in her left hand

2. placing her left palm against a wall and “climbing” the wall with the left fingers
3. carrying light hand weights while walking 1 mile every other day
4. performing isometric exercises with both arms extended

ANSWER:
2. placing her left palm against a wall and "climbing" the wall with the left fingers

47. The nurse is planning care for a client who has expressive aphasia after a left-sided stroke.
Which of the following statements by the client’s spouse would indicate a correct
understanding of the client’s communication abilities and interaction needs? Select all that
apply.

1. “My spouse’s response of ‘fine’ when asked how the day has been may or may not be what
my spouse meant to communicate.”
2. “I can anticipate what my spouse wants to say, so I complete my spouse’s sentences to make
communication quicker.”
3. “I will purchase a picture board to help my spouse express common needs, thoughts, and
feelings that are difficult to communicate.”
4. “My spouse’s angry response when we have a conversation makes me hesitant to try further
communication.”
5. “I have arranged for my spouse to meet with a speech therapist twice each week to improve
communication skills.”

ANSWER:
1, 3, 5

48. The nurse is caring for a client who is in Buck traction. Which of the following would require
immediate intervention?

1. A pillow is placed under the knee.

2. The foot is 2 in (5 cm) away from the foot plate.
3. The weights attached to the pulley are 6 in (15 cm) from the floor.
4. A pillow is placed under the lower leg with the heel off the bed.

ANSWER:
2. The foot is 2 in (5 cm) away from the foot plate.
Should be touching the foot plate

49. The nurse has taught the adult child caregiver of a client with moderate Alzheimer’s disease
(AD) about home care. Which of the following statements by the adult child would indicate a
correct understanding of the teaching?

1. “I will only allow my parent to smoke while my parent is outdoors.”

2. “I will place a picture on the bathroom door to indicate which room in our home is the
bathroom.”
3. “I will encourage family members to visit in large groups to keep my parent interested in the
conversation.”
4. “I will encourage my parent to take walks in the park when the weather permits to get the
exercise needed.”

ANSWER:
2. "I will place a picture on the bathroom door to indicate which room in our home is the
bathroom."
4. dangerous, they can get lost

50. The nurse is teaching a client newly diagnosed with diverticulosis. Which of the following
information should the nurse include?

1. “Limit your daily fluid intake to 2 L to avoid bloating.”

2. “You may be prescribed a bulk-forming laxative.”
3. “Limit your intake of dairy products such as milk and yogurt.”
4. “You should avoid consuming cooked vegetables.”

ANSWER:
2. "You may be prescribed a bulk-forming laxative."

No need to restrict fluids and no need to restrict diet. Diet does not cause diverticulitis
exacerbations!

51. The nurse is preparing to administer lorazepam 2 mg, IV, now to a client who is scheduled
for surgery in 30 minutes. The nurse is unfamiliar with the dosage for the medication. Which of
the following actions should the nurse take next?

1. Check the medication dosage in a medication reference source.

2. Ask another nurse whether the prescribed dose is a safe dose.
3. Clarify that the dose is correct with the primary health care provider.
4. Contact the pharmacist to verify the safe dosage range for the medication.

ANSWER:
1. Check the medication dosage in a medication reference source.

52. The nurse is caring for a client who is receiving a high dose of a phenothiazine. When
evaluating the client for a life-threatening syndrome related to the medication, it would be a
priority for the nurse to report

1. dry mouth
2. orthostatic hypotension
3. fever
4. photophobia

ANSWER:
3. fever
Rationale: Phenothazine side effects include ABCDEFG -- Anticholinergic (dry mouth), blurry
vision, constipation, drowsiness, EPS, Photosensitivity, and agranulocytosis. Fever would be a
complication of agranulocytosis and requires the nurse to report.

The nurse is caring for a client who is receiving a blood transfusion and states, “I feel chilled and
am having back pain.” Which of the following actions should the nurse take? Select all that
apply.
1. Stop the transfusion.
2. Check the client’s vital signs.
3. Notify the client’s primary health care provider.
4. Return the blood and infusion tubing to the blood bank.
5. Infuse 5% dextrose in water through the intravenous catheter.
6. Administer a dose of an antiemetic prescribed p.r.n. to the client.

ANSWER:
1, 2, 3, 4
Back pain and chills are symptoms of Hemolytic transfusion reaction (wrong blood type). Must
stop infusion, check vital signs, and notify the provider

5. NS to keep the line open, not dextrose in water

The nurse is preparing a staff education program about total parenteral nutrition (TPN).
Which of the following information should the nurse include? Select all that apply.
1. “The TPN intravenous tubing should be changed once a week.”
2. “TPN can be administered through a peripherally inserted central catheter (PICC).”
3. “Clients receiving TPN should be weighed daily.”
4. “An infusion pump is used to deliver TPN.”
5. “Serum glucose levels should be monitored in clients receiving TPN.”

ANSWER:
2, 3, 4, 5

1. TPN tubing is changed daily (every 24hr)!

The nurse has taught a client with bipolar I disorder who is experiencing a manic episode and is
receiving lithium. Which of the following statements by the client would indicate a correct
understanding of the teaching?
1. “I will increase my oral fluid intake to 2 to 3 L daily while taking the medication.”
2. “I will experience an improvement in my condition 5 weeks after starting the medication.”
3. “I should decrease my intake of dietary sodium after starting the medication.”
4. “I should limit time spent in a sauna to 1 hour weekly while taking the medication.”
ANSWER:
1. "I will increase my oral fluid intake to 2 to 3 L daily while taking the medication."
Getting dehydrated can increase risk for lithium toxicity.

Rationale:
2. about 1-3 weeks to work
3. Do NOT go on a low sodium diet bc it can decrease lithium elimination and cause lithium
toxicity
4. Sweating too much can cause you to lose too much sodium.

The nurse has administered haloperidol to a client with schizophrenia who is agitated.
Which of the following findings would require immediate follow-up?

1. continued lack of motivation

2. reports of muscle stiffness
3. inappropriate emotional expressions
4. difficulty focusing due to blurred vision

ANSWER:
3. inappropriate emotional expressions

Rationale: Haloperidol has ABCDEFG side effects. Muscle stiffness would be considered EPS and
needs follow-up for possible medication administration

The nurse is teaching a client who is receiving newly prescribed propylthiouracil.

Which of the following information should the nurse include?

1. “Carry emergency identification with you listing your condition and medication regimen.”
2. “The medication dose will need to be reduced if you develop agranulocytosis.”
3. “You will experience weight loss if the medication is effective.”
4. “Increase your daily intake of foods containing iodine.”

ANSWER:
1. "Carry emergency identification with you listing your condition and medication regimen."

Rationale:
2. PTU and Methimazole both cause neutropenia and agranulocytosis at therapeutic doses
3. You will experience weight gain (slowed metabolism)
The nurse is preparing to administer a beta blocker to a client. Which of the following would be
a contraindication to administer the medication?

1. heart block
2. myocardial infarction (MI)
3. heart failure
4. angina pectoris

ANSWER:
1. heart block
Beta blockers will further depress the cardiac rhythm

Rationale: Beta blockers are indicated in MI, HF, and angina pectoris

The nurse is planning a staff education program about informed consent. Which of the
following information should the nurse include? Select all that apply.

1. “The main value of informed consent is for protection against lawsuits.”

2. “Clients may withdraw consent after signing the informed consent form.”
3. “Clients must sign the informed consent form before receiving preprocedural medication.”
4. “Nurses witness the signing of the informed consent form to confirm that consent is
voluntary.”
5. “The signed consent form serves as evidence that the informed consent process has taken
place.”

ANSWER:
2, 3, 4, 5

The nurse has taught a client who is receiving alendronate. Which of the following statements
by the client would indicate a correct understanding of the teaching? Select all that apply.

1. “I will take alendronate a half hour before I eat breakfast.”

2. “I should avoid weight-bearing exercises while taking alendronate.”
3. “I should discontinue alendronate if I experience nausea or vomiting.”
4. “I will need to remain in an upright position for 30 minutes after I take alendronate.”
5. “I should notify my primary health care provider if I experience difficulty swallowing while
taking alendronate.”

ANSWER:
1, 4, 5
Take Alendronate (osteoporosis med) with water only just after waking up 30 minutes before
eating breakfast or taking any other meds. Stay upright for 30 mins after taking.
Side effects include nausea and vomiting. Pt should report dysphagia and bloody vomiting

The nurse is developing a plan of care for a client with a spinal cord injury at C5 who has an
indwelling urethral catheter. Which of the following would be a priority for the nurse to include
in the plan of care?

1. encouraging the client to drink 6 to 8 glasses of fluid per day

2. maintaining the urine collection bag in a dependent position
3. teaching the client about foods high in fiber
4. assessing the color of the urine output

ANSWER:
2. maintaining the urine collection bag in a dependent position
Drainage bag should always be below the level of the bladder to prevent back flow

The nurse has been made aware that the following 4 clients require assistance. The nurse
should first assist the client who had

1. an abdominal hysterectomy 5 hours ago and is reporting severe incisional pain

2. a transurethral resection of the prostate (TURP) yesterday and whose catheter has become
disconnected
3. a lumbar laminectomy 2 days ago and is reporting that the feet are still numb
4. a spinal cord injury at T2 two weeks ago and is currently diaphoretic and nauseated

ANSWER:

The nurse has taught a client who has a positive laboratory test result for human
immunodeficiency virus (HIV) infection. The client is scheduled for a viral load test. Which of
the following statements by the client would indicate a correct understanding of the teaching?

1. “The viral load test is used to determine my response to the treatment regimen I am
receiving for HIV.”
2. “The viral load test can rapidly detect HIV-specific antibodies in the blood.”
3. “I will be able to decrease the dosage of my prescribed medications if my viral load is low.”
4. “I am unlikely to develop acquired immune deficiency syndrome (AIDS) if my viral load is
high.”
ANSWER:

The nurse is teaching a client who is scheduled for a 24-hour urine collection. Which of the
following information should the nurse include? Select all that apply.

1. “You will be asked to urinate when starting the collection, and the initial urine will be
discarded.”
2. “A sign will be posted on the bathroom door as a reminder to save your urine.”
3. “You will be asked to void at the end of the designated time period to complete the urine
collection.”
4. “You should discard urine that is dark or pink in color.”
5. “The collected urine will be sent to the laboratory at the end of each shift.”

ANSWER:

The nurse has taught a client with diabetes mellitus (type 2) about foot care. Which of the
following statements by the client would indicate a correct understanding of the teaching?
Select all that apply.
1. “I will check my shoes for foreign objects prior to putting them on.”
2. “I should use a large, coarse file to remove dry skin from a bunion.”
3. “I will apply a petroleum-based ointment between my toes after bathing.”
4. “I should avoid crossing my legs to prevent decreased circulation to my feet.”
5. “I should wear new shoes for a few hours for several days until they fit well.”

The nurse is teaching a client who is scheduled for a total hip arthroplasty via a posterior
approach. Which of the following information should the nurse include? Select all that apply.
1. “The type of prosthesis used is based on the muscle strength and joint function of your upper
extremities.”
2. “Do not bend the affected hip more than 90 degrees after surgery.”
3. “Skin preparation and cleansing is mandatory before surgery.”
4. “Use an elevated toilet seat for at least 6 weeks after surgery.”
5. “You can resume sexual intercourse after surgery if your partner is in a dependent position.”

The nurse is caring for a client who is receiving an intravenous infusion via a peripheral venous
access device (VAD). The client reports sharp pain at the VAD site. The nurse notes the
intravenous fluid is infusing more slowly than prescribed. The nurse should recognize that the
client is most likely experiencing
1. venous spasm
2. nerve damage
3. septicemia
4. hematoma

The nurse has attended a staff education program about obtaining blood specimens from a
central venous access device (VAD). Which of the following statements by the nurse would
require follow-up?
1. “I will use a 3 mL syringe to flush the catheter port.”
2. “The injection cap should be cleansed with antiseptic and allowed to air-dry.”
3. “I will aspirate 5 mL of blood and discard the syringe in the biohazard container before
obtaining the specimen.”
4. “The infusion should be turned off for at least 1 minute before the specimen is aspirated.”

The nurse has taught about preventing osteoporosis to a 45-year-old client who has had a
hysterectomy and bilateral salpingo-oophorectomy. Which of the following statements by the
client would indicate correct understanding of the teaching?

1. “I will begin to take dancing lessons.”

2. “I will get more rest at night.”
3. “I will take a multivitamin supplement daily.”
4. “I will add more fiber to my diet.”

The nurse is preparing to insert a peripheral venous access device (VAD) for a client. Which of
the following actions should the nurse take?
1. Ask the client to open and close the fist multiple times.
2. Tap the client’s vein multiple times to promote dilation.
3. Apply the tourniquet 9 to 10 in (22.5 to 25 cm) above the venipuncture site.
4. Palpate for a vein after cleansing the selected site.

The nurse is assessing a newly admitted client who sustained partial-thickness (second-degree)
burns to the anterior thorax in a house fire. Which of the following findings would require
immediate follow-up?
1. dizziness and confusion
2. hypoactive bowel sounds and nausea
3. vesicular breath sounds throughout the lung fields
4. pain rated 5 on a scale of 0 (no pain) to 10 (severe pain)

The nurse has taught a client with a hiatal hernia about interventions for the condition.
Which of the following statements by the client would indicate a correct understanding of the
teaching?
1. “I will consume 3 regular-sized meals daily.”
2. “Wearing an abdominal binder can help relieve symptoms.”
3. “I should elevate the head of the bed on 6 in (15 cm) blocks.”
4. “Eating foods with a high fat content will increase gastric emptying.”
The nurse is assessing a client with suspected gout. Which of the following findings would
support a diagnosis of gout? Select all that apply.
1. elevated serum uric acid level
2. a swollen, red joint
3. reports of moderate fatigue
4. distal extremities cool to touch
5. pain associated with movement of the affected extremity
6. intolerance of dairy products

The nurse is assessing a client with suspected endometriosis. Which of the following findings
would support a diagnosis of endometriosis?
1. dyspareunia
2. hot flashes
3. weight gain
4. amenorrhea

The nurse is assessing a client with cirrhosis. Which of the following findings would be
consistent with a diagnosis of cirrhosis?
1. steatorrhea
2. deep vein thrombosis (DVT)
3. high fever
4. spontaneous bruising

The nurse is assessing a male client who has suspected syphilis. Which of the following findings
would support a diagnosis of syphilis?
1. urethritis
2. conjunctivitis
3. chancre lesions
4. penile discharge

The nurse has attended a staff education program about spinal shock following acute spinal
cord injury. Follow-up is required if the nurse states that manifestations of spinal shock include
1. bowel dysfunction
2. bladder dysfunction
3. spastic paralysis below the level of injury
4. loss of sensation below the level of injury
The nurse is planning care for a client who has an arteriovenous (AV) shunt in the left arm.
Which of the following interventions should the nurse include in the client’s plan of care?
1. Instruct the client to protect the AV shunt by tucking the left arm under the body while
sleeping.
2. Check for a bruit by palpating the AV shunt.
3. Administer prescribed intravenous fluids through the AV shunt.
4. Avoid obtaining blood pressure measurements in the arm with the AV shunt.

The nurse is caring for a client who has a chest tube attached to a closed-chest drainage system.
It would be a priority for the nurse to monitor the client for
1. tracheal deviation
2. pain at the insertion site
3. subcutaneous emphysema
4. redness or swelling at the insertion site

The nurse is caring for the following clients. The nurse should recommend a referral to an
occupational therapist for the client with
1. rheumatoid arthritis (RA) who has a 2-month-old infant
2. an intertrochanteric hip fracture who works as a surgeon
3. mononucleosis who is a college student
4. tendonitis who is a professional tennis player

The nurse is preparing to admit a client who has pleuritic chest pain and is reporting a cough
productive of yellow sputum for the past 1 week. The client has a pulse oximetry reading of
90% on room air. Which of the following infection control precautions should the nurse
implement?
1. Use a stethoscope that is designated for use with the client only.
2. Wear sterile gloves when inserting a peripheral venous access device (VAD).
3. Assign the client to a private room with monitored negative air pressure.
4. Place a box of surgical masks inside the client’s room.
The nurse is planning a staff education program about infection control guidelines.
Which of the following information about alcohol-based hand rub should the nurse include?
1. “Use before touching medical equipment that will come in direct contact with the client.”
2. “Avoid using when moving your hands from a contaminated body site to a clean body site
during client care.”
3. “Avoid using before caring for clients who have severe neutropenia.”
4. “Use after contact with body excretions that do not cause your hands to be visibly soiled.”
The nurse is assessing a client with suspected mononucleosis. Which of the following findings
would support a diagnosis of mononucleosis?
1. polyarthralgia
2. costovertebral pain
3. cervical lymphadenopathy
4. left lower quadrant (LLQ) tenderness

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. It would be
most appropriate for the nurse to assign UAP to
1. apply a continuous passive motion (CPM) device to the affected extremity of a client who had
a total knee replacement
2. change the bed linens for a client who was admitted 1 hour ago following a closed-head
injury and is comatose
3. reposition a client with hydrocephalus who has a headache and is vomiting
4. place in the prone position a client who had an above-the-knee amputation (AKA) 1 day ago

The nurse in the inpatient psychiatric unit is leading a support group for clients. It would be a
priority for the nurse to intervene if the client with
1. bipolar I disorder is experiencing a manic episode, is moving the legs, and is looking around
the room restlessly
2. borderline personality disorder is saying that another group member is too disturbed to be
attending the session
3. major depressive disorder is sitting quietly with the eyes downcast
4. schizophrenia is rocking in place and copying the gestures of another client in the group

The nurse has observed a staff member tell a client with bipolar disorder that there will be
consequences for making negative comments about conditions in the facility.
When the nurse meets privately with the staff member, which of the following statements
would be most appropriate for the nurse to make to the staff member?
1. “Threatening a client can result in the immediate dismissal of a staff member.”
2. “Staff members who have difficulty with control issues often seek power over clients.”
3. “Clients have a right to provide feedback about services without fear of punishment.”
4. “Staff should set limits with clients in a nonjudgmental manner.”

The nurse has been made aware of the following client situations. The nurse should first assess
the client
1. with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing after
ambulating in the hallway
2. with pericarditis who has a systolic blood pressure that is 20 mm Hg higher during expiration
than during inspiration
3. who had a total abdominal hysterectomy (TAH) 12 hours ago and has saturated 1 perineal
pad in the past 5 hours
4. who has Guillain-Barré syndrome and has had an increase in the vital capacity over the past 4
hours

The nurse in the psychiatric unit is administering medications when a client with a borderline
personality disorder approaches and asks to talk. The nurse suggests having a talk in 1 hour.
The client shouts, “I’ll wait, but you will be sorry!” and then picks up a pitcher of water and
throws it onto the floor.

1. Offer to listen to the client while continuing to administer the medications.

2. Suggest that the client take a p.r.n. prescribed medication for agitation.
3. Ask another nurse to finish administering the medications, and talk with the client.
4. Request assistance from several nearby staff members with controlling the client’s behavior.
Which of the following actions should the nurse take?

The nurse is talking with a client who has a positive laboratory test result for human
immunodeficiency virus (HIV) infection. Which of the following statements by the client would
require follow-up?
1. “I try to eat a well-balanced diet.”
2. “I avoid crowds when I go outside the house.”
3. “I am taking a vitamin C tablet daily to help prevent infections.”
4. “I take echinacea every day to help improve my immune system.”

The nurse is planning a staff education program about informed consent. Which of the
following information should the nurse include? Select all that apply.
1. “An individual designated by a power of attorney for health care can provide informed
consent despite the competency of the client.”
2. “The nurse has a duty to insist that the client repeat what has been said about a procedure
for which consent is necessary.”
3. “The primary health care provider must disclose the risks if the client declines a
recommended procedure.”
4. “The client should sign the consent form prior to receiving prescribed opioids.”
5. “Informed consent is not needed for emergency procedures that are in the client’s best
interest.”

The nurse is caring for a client who has a prescription for an intravenous infusion of 0.45%
sodium chloride (half- strength saline). The nurse notes the client is receiving 5% dextrose in
water. Which of the following actions should the nurse take first?
1. Change the intravenous fluid to the prescribed fluid.
2. Notify the primary health care provider.
3. Complete an incident report.
4. Assess the client.

The nurse is caring for a client in the first stage of labor and observes that a segment of the
umbilical cord is visible in the vaginal opening after rupture of the client’s amniotic membranes.
Which of the following actions should the nurse take?
1. Instruct the client to lie on her left side.
2. Attempt to place the umbilical cord back into the uterus.
3. Assist the client into a knee-chest position.
4. Administer an intravenous tocolytic agent.

The nurse is preparing to administer an aminoglycoside. Which of the following laboratory test
results should the nurse review before administering the medication?
1. serum electrolyte level and serum uric acid level
2. hemoglobin (Hgb) and white blood cell (WBC) count
3. serum ammonia level and serum glucose level
4. blood urea nitrogen (BUN) and serum creatinine

The nurse is talking with a client who is scheduled for endoscopic retrograde
cholangiopancreatography (ERCP) in 2 hours in the outpatient department. Which of the
following questions would be important for the nurse to ask? Select all that apply.
1. “How will you be getting home after the procedure?”
2. “Do you have access to a thermometer after you leave here?”
3. “What allergies do you have?”
4. “Are you wearing dentures?”
5. “Do you have external hemorrhoids?”

The nurse is assessing a client who had cardiac catheterization 2 hours ago. Which of the
following findings would require immediate follow-up?
1. blood pressure, 104/70 mm Hg
2. 1+ pedal pulse of the affected extremity
3. heart rate, 98
4. urine output of 100 mL for the past 2 hours

The nurse has taught the parent of a 9-year-old child who has been newly diagnosed with
bacterial conjunctivitis. Which of the following statements by the parent would indicate a
correct understanding of the teaching?
1. “The infection produces profuse watery discharge.”
2. “I should clean my child’s eyelids and eyelashes with soap and water prior to instilling the
medication.”
3. “My child’s eyes may be sensitive to light until the infection resolves.”
4. “The prescribed corticosteroid eyedrops should be used for 1 week.”

The nurse is talking with a client who has diabetes mellitus (type 1) and is receiving insulin via
an infusion pump. Which of the following statements by the client would require follow-up?
1. “I need a bolus dose of insulin prior to a meal.”
2. “I should refill the pump with short-duration insulin.”
3. “I can decrease serum glucose monitoring to twice daily.”
4. “I will change the infusion needle every 2 to 3 days.”

The nurse is caring for a client who is scheduled for a spinal fusion in 1 hour. Which of the
following situations would require follow-up? Select all that apply.
1. The nurse notes that the client signed the consent form 1 week ago.
2. The nurse determines that the last analgesia the client received was yesterday afternoon.
3. The client states, “I need to find out why the surgery is needed before I sign the consent
form.”
4. The nurse administers the prescribed preoperative sedation after the client signs the consent
form.
5. The client states, “I am afraid to sign the consent form because I know I am going to die
during the surgery.”
6. The client states, “The surgery may result in some paralysis, but the resolution of the pain is
worth the risk to me.”

The nurse in the emergency department (ED) is assessing a client with multiple injuries that
occurred as a result of a motor vehicle collision. Which of the following findings should receive
highest priority?
1. avulsion injury of the left index finger
2. deep laceration on the right forearm with blood oozing from the surface
3. hematoma on the left side of the neck
4. open fracture of the right tibia and fibula

The nurse has received information about assigned clients. The nurse should first assess the
client
1. with multiple sclerosis (MS) who had an indwelling urethral catheter removed 5 hours ago
and has not been able to urinate
2. with an abdominal aortic aneurysm who reports recent onset of low back pain
3. who had coronary artery bypass graft (CABG) surgery 2 days ago and reports sternal pain
when coughing
4. who has bacterial pneumonia and is requesting a cough suppressant

The nurse that cared for a client with chronic obstructive pulmonary disease (COPD) who lost
more than 10% of ideal body weight has been named in a lawsuit charging negligence. Which of
the following entries in the client’s medical record would help refute the charge of negligence?
1. The client has been instructed to eat 3 large meals daily.
2. The client has been encouraged to maintain a high-calorie, high-protein diet.
3. The client has been encouraged to drink fluids with meals to promote digestion.
4. The client has been instructed to exercise 30 minutes before eating to improve appetite.

The nurse is documenting care for a client who had a peripheral venous access device (VAD)
inserted 10 minutes ago. Which of the following would be the best example of correct
documentation for the nurse to include in the client’s medical record?
1. 22-gauge catheter inserted into the right hand.
2. Secured the site with paper tape to avoid skin tears.
3. Infusion started slowly due to reports of coolness at the site.
4. Labeled site, tubing, and intravenous fluid bag.

The nurse is caring for assigned clients. It would be most important for the nurse to monitor
1. serum lipase levels for the client with hypercholesterolemia
2. arterial blood gas (ABG) results for the client who has an acid-base imbalance
3. serum glucose levels for the client with diabetes insipidus (DI)
4. adrenocorticotropic hormone (ACTH) levels for the client who has a fluid imbalance

The nurse is planning a staff education program about collaborative conflict resolution
strategies. Which of the following would best describe implementation of a collaborative
conflict resolution strategy?
1. “A staff nurse is working with the nurse manager and offering suggestions about an
upcoming new procedure.”
2. “The clinical nurse leader is flattered by being asked to help create a clinical ladder for
nursing staff members.”
3. “The charge nurse is working with staff nurses and the nurse manager to develop shared
goals and a plan for the new staffing format.”
4. “A new nurse has offered to work on a holiday in exchange for having the following weekend
off.”
The nurse is caring for a client who lives with a spouse and 2 adolescent children. The client has
been admitted to a hospital for treatment of active pulmonary tuberculosis (TB). The local
health department has been notified about the client’s diagnosis. The nurse should recognize
that after this notification the local health department will
1. schedule periodic examinations of the client’s chest and sputum
2. contact the client’s family to arrange for family members to be examined
3. immunize those persons with whom the client has been in contact
4. isolate members of the client’s immediate family at home until diagnostic studies rule out TB

Nbmbbvc

The nurse is participating in a community-based disaster drill. The nurse should give priority for
treatment to a
1. 2-year-old client with a bleeding scalp laceration and briskly reactive pupils
2. 15-year-old client who is restless and has a distended, firm abdomen
3. 30-year-old client who has a leg wound exposing the femur, a blood pressure of 120/76 mm
Hg, and a pulse of 90
4. 60-year-old client with heart failure whose pulse oximetry reading is 92% on room air and
whose respirations are 26

The nurse in a community-based setting has received the following telephone messages.
The nurse should first return the telephone call to the parent of a
1. 3-year-old child who sustained a concussion and was irritable when awakened every 2 hours
during the night
2. 4-year-old child with impetigo contagiosa who has eruptions spreading around the mouth
and nose that are draining thin yellow fluid
3. 5-year-old child with Ewing sarcoma who is receiving external radiation and the irradiated
area appears reddened
4. 6-year-old child with a right long-leg cast whose toes on the affected extremity are swollen
and cool to the touch

The nurse is teaching a client who is receiving newly prescribed clopidogrel. Which of the
following information should the nurse include?
1. “Notify your primary health care provider if you experience unusual bruising.”
2. “Avoid taking over-the-counter (OTC) medications containing acetaminophen.”
3. “Avoid driving your car for a short time until your response to the medication is known.”
4. “Have a blood specimen obtained every 3 months to check your serum albumin level.”