@ INITIAL EVALUATIVE TEST
L M0091. Four clients are seen by the emergency
department nurse. Which client is a priority for treatment
and definitive care?
4, 7-day-old fussy infant wit a rectal temperature of
100.6 F (38.1 C) and 6 wet diapers today
2. Client receiving radiation therapy who has 6-in (15.2-
cm) arm laceration that is not actively bleeding
3. Client with purulent drainage and crusting of the eyelid
with vision unaffected
4, New parent who is crying and overwhelmed, and
denies suicidal ideation
BCC0092, A postoperative client with obesity and diabetes
mellitus has an abdominal wound and is at risk for poor
wound healing. Which interventions would the nurse
include in the plan of care to prevent wound dehiscence?
Select all that apply.
Administer docusate orally, daily
‘Administer ondansetron IV PRN for nausea
Apply an abdominal binder
Implement caloric restriction to promote
weight loss
5. Monitor blood sugar to maintain tight glucose
control
M0001. All nursing staff on the medical unit are
responsible for implementing a new interdisciplinary fall
prevention protocol. Which tasks are appropriate for the
registered nurse (RN) to delegate to the UAP to promote
client safety? Select all that apply.
1 Orient the client to the bedside unit and explain the
call bell system on admission
2. Place the bedside commode as clase to the bed as
possible
3. Remind the client to change position slowly
4, Report observations of changes in client's condition
immediately
5. Report whether clients using correct gait and balance
while ambulating with walker
MHO141. When the community health nurse visits a client
at home, the client states, “I haven't slept at all the last
couple of nights.” Which response by the nurse illustrates
a therapeutic communication response to this client?
"Ise."
"Really?"
"You're having difficulty sleeping?”
"Sometimes, | have trouble sleeping too.”
LMO014. The nurse caring for a terminally il client asks if
the client has an advance directive. The client states, "|
already have a power of attorney.” What is the best,
response by the nurse?
1. "Apower of attorney (POA) is good to have in place.
It sounds like you are on the right track.”
2. “Great. Your POA can start to make decisions for you
when you are no longer able to do so.”
3. "Many people find a lawyer at this stage of life, A
lawyer can help you get your affairs in order.”
4. "There are many types of POAs. Let's clarify if your
POA can make health care decisions for you."
BCC0027. A client's opioid therapy is being tapered off,
and the nurse is watchful for signs of withdrawal. What is
one of the first signs of withdrawal?
Fever
Nausea
Diaphoresis
Abdominal eramps1
2
3
SPOT:
@ INITIAL EVALUATIVE TEST
LM0022. An emergency department nurse is assigned to
triage. Which client should the nurse assess first?
Five-year-old with a superficial leg laceration
Lethargic 3-month-old with diarthea for the past 12
hours
Seven-year-old with a elevated temperature of 104 F
(38.3 C) and hematuria
Seventeen-year-old with severe, acute abdominal pain
25. A blood transfusion is prescribed for a client with
sickle cell exacerbation and a hemoglobin level of 6 g/dL.
(60 gIL), Which are appropriate actions by the registered
nurse? Select all that apply.
Loo:
4, Administer O negative (0-) blood to the AB positive
(AB+) client
2, Delegate the fourth set of vital signs to the unlicensed
assistive personnel
3, Prime line with normal saline prior to hanging the
blood
4, Time the blood infusion to occur over a 6-hour period
5. Validate the client's name and room number with a
licensed practical nurse
136. The health care provider gives the preoperative
nurse a signed consent form and walks away rapidly. The
client
turns to the nurse and states, "I don't know what is,
going on. Why do I need surgery?" What is the most
appropriate action?
1
Call the nursing supervisor
Call the operating room scheduler and cancel the
surgery
Page the health care provider and request clarification
on behalf of the client
Report the incident to hospital administration
BCC0008. The nurse plans discharge teaching for a client
with active herpes lesions who has a new prescription for
oral acyclovir and topical lidocaine, What information will
the nurse include in the teaching plan?
1. Adhesive bandaging should remain on the lesions to
prevent virus shedding
2. Blood tests will be drawn to ensure the virus is
eradioated
3. Condoms should be used during intercourse until the
lesions are healed
4, Gloves should be used to apply the medication to the
lesions
LM0060. A Native American client is hospitalized for
depression and attempted suicide. Family members have
requested that they be allowed to bring in a medicine
healer to perform a ritual on the client, Which of the
following is the best action by the nurse?
1. Explain that the client's depression is being treated
with medications
2. Explain that the client's depression will not be relieved
by aritual
3. Plan a meeting with the health care provider (HCP),
family, nurse, and medicine healer to make
arrangements for the ceremony
4. Tel the family that such practices are not alowed in
the hospital
BCC0003. The hospice nurse is assisting a client's family
in managing anorexia during end-of-life care. Which
interventions would be most supportive? Select al that
apply.
Administer nausea medication prior to meals
Involve the cient in daily meal planning
Offer food items the client desires
Plan for loved ones to share meal time withthe
client
5. Prepare 3 highly nutrtious meals a day on a schedule@ INITIAL EVALUATIVE TEST
LM0098. The unlicensed assistive personnel on the
cardiac floor reports to the registered nurse that during
the first vital sign measurement on the shift, a client's
blood pressure measured 198/102 mm Hg on the
automated blood pressure machine, What action should
the nurse take first?
1, Have the unlicensed assistive personnel recheck the
client's blood pressure
2. Immediately notify the health care provider
3. Obtain the client's PRN labetalal from the medication
dispensing machine
4, Recheck the client's blood pressure with a manual cuff
SAF0027. A client is scheduled for an elective
laparoscopic prostatectomy in the morning. The nurse
should notify the health care provider (HCP) about which
assessment data as soon as possible before surgery?
Hemoglobin 45 g/dL. (150 giL), hematocrit 45% (0.45)
International Normalized Ratio (INR) 1.3
Platelet count 296,000/mms3 (295 109/L)
Temperature 100.4 F (38 C) with cough
SAFO031. Which equipment warnings indicate a clinical
issue with a client and not an issue with the programming
of the equipment or a mechanical failure? Select all that
apply.
1 The glucometer displays "HI" from a blood specimen
of a client with diabetic ketoacidosis,
2. The intravenous infusion pump display lights up and
sounds an alarm for a few seconds when turned on
3. The patient-contralled analgesia (PCA) pump
indicates its unable to read the barcode on the
medication vial
4, The pulse oximeter does not register a heart rate
pulsation or reading in a client with peripheral vascular
disease
5. The ventilator high pressure alarm sounds for a client
intubated for acute respiratory distress syndrome
‘SAF0033. The school nurse is speaking with the parent of
a fourth grade student about a bed bug that was found on
the child's sweater. The parent confirms that their home
is infested but that the issue is being resolved. WI
the best action by the nurse?
1, Instruct the parent to launder the child's clothing and
store itin tightly sealed plastic bags
2. Instruct the teacher of the child's classroom to use an
insecticide spray
3. Send letters home to all of the children's parents
informing them about the finding
4, Send the child home and prohibit school attendance
until the infestation has been resolved
BCC0030, For a cognitively impaired client who cannot
accurately report pain, what is the first action that you
should take?
1. Closely assess for nonverbal signs such as grimacing
or rocking.
2. Obtain baseline behavioral indicators from family
members.
3. Look at the MAR and chart to note the time of the last
dose of analgesic and the client's response.
4. Give the maximum PRN dose within the minimum time
frame for relief
‘SAF0034. Which prescriptions for these clients does the
nurse question? Select all that apply.
1 Client with Clostridium difficile colitis, prescribed
vancomycin 125 mg PO
2. — Client with diabetes and elevated mealtime glucose,
prescribed lispro insulin scale 6 units subcutaneously
3. Client with gastrointestinal bleed and nasogastric tube,
prescribed pantoprazole 40 mg intravenous
4, Client with hypertension and blood pressure (BP)
94/40 mm Hg, prescribed metoprolol succinate SR 50
mg PO
5. Client wth otitis media and penicilin allergy,
prescribed ampicilin 500 mg PO@ INITIAL EVALUATIVE TEST
SAF0042. The nurse is conducting intake interviews at the
clinic, Which client situations would require the nurse to
intervene? Select all that apply.
4. Client with ron deficiency anemia takes iron
supplements with milk
2. Client takes levothyroxine early in the morning on an
empty stomach
3. Client taking phenazopyridine for urine infection states
that the urine has turned orange
4, Client taking metronidazole mentions going to a wine-
tasting party tonight
5. Client with closed-angle glaucoma takes over-the-
counter diphenhydramine for a cold
LM0103. The nurse is working on a busy medical-surgical
unit and is responding to the client cal lights. Which
statement would be the priority to assess first?
1. 65-year-old female client recently started on
celecoxib says, "| am having some nausea and my
upper back and shoulder are hurting quite abit" [51%]
2. Aclients child says, "My parent has been here for 2
days without anything to eat or drink."
3. Aparaplegic clent with mute stage 4 pressure
ulcers says, "| have had a bowel movement and need
to be cleaned up.”
4. A postoperative client says, "| am very nauseous and
just threw up. This pain medicine is making me really
siok."
‘SAFO067. The nurse is reinforcing teaching to the parent
of a child diagnosed with ringworm. Which statement by
the parent indicates a need for further teaching?
4, "Antifungal cream must be applied to all affected
areas to eradicate ringworm from the body.”
2, "Hand washing is very important as ringworm can be
spread among humans and pets."
3, "My child has been infected by a worn and must be
treated to ridit from the body.”
4. "My child will be uncomfortable due to itching, but this
is not a dangerous condition.”
LM0042. After receiving the shift report, the nurse should
assess which infant first?
1. An infant bom 6 hours ago after 38 weeks gestation
who has a respiratory rate of 52/min
2. Aninfant born 12 hours ago who is jittery and has a
blood glucose level of 40 mg/dl. (2.2 mmol/L)
3. An infant with bilateral crackles who was delivered
vaginally 30 minutes ago
4. An infant wrapped in a warm blanket 15 minutes ago
due to a temperature of 97.7 F (36.5 C)
P0199. The clinic nurse prepares to perform a focused
assessment on a client who is complaining of symptoms
of a cold, a cough, and lung congestion. Which should the
nurse include for this type of assessment? Select all that
apply.
1. Auscuttating lung sounds
2. Obtaining the client's temperature
3. _ Assessing the strength of peripheral pulses
4. Obtaining information about the client's respirations
5. Performing a musculoskeletal and neurological
examination
6. Asking the client about a family history of any illness
or disease
00003. Which statements made by a group of
community clients communicate to the nurse a potential
warning sign of cancer? Select all that apply.
1, “Forthe past 2 years, | have had a chronic productive
cough for 3 months out ofthe year.”
2, “I.seem to have heartburn an hour ater | eat eggs and
‘sausage and drink whole milk.”@ INITIAL EVALUATIVE TEST
3. "Last month when | was doing my self-breast
examination, | noticed a lump the size of a marble.”
4, "My moles itchy and the borders have become
uneven with a blackish to bluish color.”
5. "Recently | have noticed that my bowel movements
appear black.”
IMMU0011. A 12-month-old with Kawasaki disease
received IV immunoglobulin (IVIG) 2 months ago. The
child is in the clinic for follow-up and scheduled
immunizations. Which vaccine should be delayed?
Select all that apply.
Haemophilus influenzae type b (Hib)
Hepatitis B (Hep 8)
Measles, mumps, rubella (MMR)
Pneumococcal conjugate (PCV)
Varicella
iMMU0016. Several 12-month-old infants are brought to
the clinic for routine immunizations. Which situation
would be most important for the nurse to clarify with the
provider before administering the vaccination?
1. Haemophilus influenzae type b vaccine for client
allergic to penicilin
2. Hepatitis A vaccine fora client with a “cold” and
temperature of 99.0 F (37.2 C)
3. Pneumococcal vaccine for client with local swelling
after last immunization
4, Varicella-zoster vaccine for client recently diagnosed
with leukemia
(GD0024, The registered nurse has completed a well-baby
assessment of an 18-month-old. Which assessment
findings prompted the nurse to make a referral for a
formal developmental screening test?
4. Cannot climb steps by self, pulls a toy, tums the pages
of a book
2. Is botlle fed, can hold a spoon, creeps down stairs
3. Throws a ball, is able to point to 2 or 3 body parts,
cannot draw a picture
4, Uses 2 words, cannot hold a cup, can seat self in a
small chair
LM0012. The charge nurse on the telemetry unit is making
client assignments, Which client is appropriate to assign
to the licensed practical nurse (LPN)?
1. Client 2 days after aortic valve surgery who needs a
urinary catheter reinserted due to inability to void
2. Client being discharged after deep vein thrombosis
who needs teaching on how to setf-administer
‘enoxaparin injections
3. Client who has just been admitted tothe telemetry unit
from the emergency department with a rule-out
myocardial infarction
4, Client with a nitroglycerin infusion with prescription to
titrate to keep systolic blood pressure <150 mm Hg;
currently is 110/62 mm Hg
GD0042. The nurse assesses 4 infants. Which
assessment finding would require follow-up by the health
care provider?
1. 3-week-old whose anterior fontanelle bulges with
crying
2, 4-week-old whose posterior fontanelle is soft
3. 6-month-old with birth weight of 7 Ib 3 oz (3.3 kg) who
now weighs 12 Ib (5.4 kg)
4, 12-month-old with birth weight of 6 lb 4 oz (2.8 kg)
who now weighs 20 lb (9.1 kg)@ INITIAL EVALUATIVE TEST
MHO070. The nurse is conducting a follow-up interview
with a client who is being treated for depression and
Suicidal ideation. Which factor best indicates the client is
not currently at risk for suicide?
1. Client claims to have more energy and vigor since
starting therapy
2. Client has clear future plans involving personal goals
and family milestones
3. Client has signed a contract promising not to commit
suicide
4. Client reports losing amitiptyiine and requests a refill
‘SAFO061. A client is being admitted to the health care
facility with a new diagnosis of Clostridium difficile colitis
Which elements of infectious disease precautions are
necessary when providing routine care for this client?
Select all that apply.
1. Alcohol-based sanitizers for hand cleaning
2, Client in single-room (private) isolation
3. Nurse using N96 respirator
4, Nurse using sterile gloves,
5, Nurse using surgical mask
6, Nurse wearing disposable gown
MHOO71. The mental health nurse engaged in dialogue
with a client would recognize transference when the client
makes which statement?
1. "Ican pretend to have feelings; how would you know
the difference?”
2. "My roommate doesn't seem to like me very much.”
3. "Sharing my thoughts with you will be difficult; you
remind me of my sister.”
4, "The people who work here do not seem genuine.”
LM0025. The nurse completes the following drug
administrations. Which would require an incident report?
1
2.
CV0157. The nurse is prey
Client with chronic stable angina and blood pressure
‘of 84/52 mm Hg; isosorbide mononitrate held
Client with depression stopped phenelzine yesterday;
escitalopram given today
Client with diabetes and morning glucose of 90 mg/dL
(5.0 mmol/L); the daily NPH insulin 20 units given at
8:00 AM
Ciient with pulmonary embolism and Intemational
Normalized Ratio (INR) of 2.5; warfarin given
ing to administer 40 mg of IV
furosemide. Prior to administering the medication, the
nurse should assess which parameters? Select all that
apply.
Blood pressure
Blood urea nitrogen
Liver enzymes
Potassium
White blood cell count
MHO078. A client with schizophrenia that is resistant to
other antipsychotic medications is about to start on a
course of clozapine. Which of these periodic
measurements has the highest priority in this client?
1
2
‘Complete blood count (CBC) and absolute neutrophil
count (ANC)
Electrocardiogram
Fasting blood sugar and fasting lipids
Height, weight, and waist circumference
€C0008, To obtain accurate continuous blood pressure
readings via a radial arterial catheter, the nurse places the
airJilled interface of the stopcock at the phlebostatic axis.
Where is it located?
1
‘Angle of Louis at 2nd intercostal space (ICS) to left
of stemal border@ INITIAL EVALUATIVE TEST
2. Aortic area at 2nd ICS to right of sternal border
3, Level of atria at 4th ICS, % anterior-posterior (AP)
diameter
4. 5th ICS at mid clavicular ine (MCL)
MH0098. The home health aide reports to the nurse care
manager that the client has been trying to give away
possessions. When the nurse asks the client about this
behavior, the client says, "With my spouse dead, there's
no reason for me to go on.” What is the best priority
response by the nurse?
4. "Do you have any frends in the building?*
2, "Have you had any thoughts of hurting yourself?”
3. "Tell me more about how you'e feeling"
4, "You'te not thinking of killing yourself, are you?"
MHO160, The nurse determines that the wife of an
alcoholic client is benefiting from attending an Al-Anon
group if the nurse hears the wife make which statement?
41, “Ino longer feel that I deserve the beatings my
husband inflicts on me."
2. “My attendance at the meetings has helped me to see
that | provoke my husband's violence."
3. “Tenjoy attending the meetings because they get me
cut ofthe house and away from my husband.”
4. ‘Ican tolerate my husband's destructive behaviors
now that | know they are common with alcoholics."
‘SP0053. A student nurse has prepared instructions for the
caregiver of an 8-month-old who weighs 16.5 lb. The
health care provider (HCP) has prescribed oral amoxicillin
25 mg/kgiday in 2 divided doses for 5 days as treatment
for acute otitis media. Amoxicillin for oral suspension
comes packaged as 125 mgJ5 mL. Which instruction by
the student nurse needs an intervention by the RN?
4. "Give the medicine right before feeding your baby.”
2. "Give your baby 7.5 mL of the medicine at 8 AM and 8
PM."
3. “Give your baby the medicine for the full days even if
the baby seems better before then.”
4, “Stroke your baby's cheek gently before administering
the medicine.”
P0134. The health care provider prescribes a continuous
IV insulin infusion for a client. The insulin drip is initiated
with 50 units of regular insulin in 100 mL of normal saline
solution at §units/hr. At what rate in mililiters per hour
does the nurse set the IV pump? Record your answer
using a whole number.
Answer:
(muh)
CV0130. A client with heart failure is started on
furosemide, The laboratory results are shown in the
exhibit. The nurse is most concerned about which
condition?
Na= 139 meq
K =5.1 meqil
Ca=8 megl
Mg = 0.8 meqi
Altial fibrilation
Atrial flutter
Mobitz II
Torsades de pointes
CV0147. A client is admitted to the cardiac care unit with
atrial fibrillation. Vital signs are shown in the exhibit.
Which prescription should the nurse perform first? Click
on the exhibit button for additional information.
1. Administer diltiazem 20 mg IVP
2. Administer rivaroxaban 20 mg PO
3. Draw blood for a thyroid function test@ INITIAL EVALUATIVE TEST
4, Send the client for echocardiogram
MHOO74, The nurse on the mental health unit receives
report about a client diagnosed with schizophrenia who is
experiencing a delusion of reference. Which client
statement supports this symptom?
1. "Ineed for you to get rid of these bugs that are
crawling under my skin.”
2, "Hear that? She told me to kill my father.
3. "That song is a message sent to me in secret code.”
4, "Those Martians are trying to poison me with the tap
water."
CV0162. A nurse is caring for a 6-year-old who had a
cardiac catheterization. During assessment of the groin
;, the nurse notices that the dressing is saturated with
blood and a small trickle leaks down the child's leg. What
should the nurse's first action be?
1. Apply a new pressure dressing to the catheterization
site
2. Call the health care provider (HCP)
3. Check the peripheral pulse distal to the catheterization
site
4, Remove the dressing and apply direct pressure above
the puncture site
M0097. An unaccompanied 16-year-old girl comes to the
‘emergency department with severe abdominal pain and
vomiting. The client has a temperature of 102.2 F (39 C)
and a pulse of 120/min and is lethargic. The client's
parents are out of town, and no guardians can be reached.
How should this client's care be handled?
1. Administer care unt the parents or guardians can be
reached
2. ‘Admit the client but without giving care until the
parents or guardians can be reached
3. Perform a pregnancy test to see if the client qualifies
as an emancipated minor
4. Provide health care and follow-up advice but do not,
give any direct care
CV0196. A client is started on lisinopril therapy. Which
assessment finding requires immediate action?
1. Blood pressure 129/80 mm Hg
2. Heart rate 100/min
3. Serum creatinine 2.5 mg/dL (221 umolL)
4, Serum potassium 3,5 mEqiL (3.5 mmol/L)
C0010. A client with acute respiratory distress syndrome
is receiving positive pressure mechanical ventilation with
15cm H20 (11 mm Hg) positive end-expiratory pressure
(PEEP). The nurse should assess for which complication
associated with PEEP?
Barotrauma
Decreased oxygen saturation
Hypertension
Oxygen toxicity
G10053. The nurse is caring for a client with a balloon
tamponade tube in place due to bleeding esophageal
varices. The client suddenly develops respiratory
distress, and the nurse finds that the tube has been
partially pulled out. Which intervention should be the
nurse's priority?
Contact the health care provider
Cut the tube with scissors
Increase gastric suction evel
Place the client in high Fowler position1
2
END0042. The nurse evaluates the effectiveness of
@ INITIAL EVALUATIVE TEST
C0057. Which client incident would be classified as an
adverse event that requires an incidentleventiirregular
‘occurrencelvariance report? Select all that apply.
Client admitted with white blood cell count of 28,000
mmm (28.0 x 109/L) and dies from sepsis
Client receives 1 mg morphine instead of prescribed
0.5 mg morphine
Client refuses pneumonia vaccination and contracts
pneumonia
Nurse did not report client's new hemoglobin result of
6 g/dL (60 gIL) to oncoming nurse
Provider was not notified of client's positive blood
culture results
desmopressin use for diabetes insipidus in a client with a
pituitary tumor, Which client assessment finding
indicates that the medication is having the desired effect?
Appetite has improved
Blood glucose is 110 mg/dl. (6.1 mmol/L)
Urine output has decreased
Urine specific gravity is lower
CV0167. A clientis admitted with palpitations. The ECG
shows supraventricular tachycardia (SVT) with a rate of
20!mi
. The nurse has received an order to adr
ter
adenosine 6 mg IV. Which action should the nurse take?
1
2
‘Adenosine is contraindicated for SVT. Verity the order
with the health care provider
‘Administer medication only through a central venous
access
Administer medication rapidly over 1-2 seconds
followed by a saline flush
Mix medication in 50 mL normal saline and administer
over 10 minutes
ENDO155. The community health nurse visits a client at
home, Prednisone, 10 mg orally daily, has been
prescribed for the client and the nurse teaches the client
about the medication. Which statement, if made by the
client, indicates that further teaching is necessary?
1, “can take aspirin or my antihistamine if | need it.”
2, *Ineed to take the medication every day at the same
time.”
3. “Ineed to avoid coffee, tea, cola, and chocolate in my
diet”
4, “If {gain more than 5 pounds a week, I will call my
health care provider (HCP).”
10432. You are caring for a client with peptic ulcer
disease, Which assessment finding is the most serious?
Projectile vomiting
Burning sensation 2 hours after eating
Coffee-ground emesis
Boardlke abdomen with shoulder pain
ENDO156. A client with hyperthyroidism has been given
methimazole (Tapazole). Which nursing considerations
are associated with this medication? Select all that apply.
Administer methimazole with food,
Place the client on a low-calorie, low-protein diet.
Assess the client for unexplained bruising or bleeding.
Instruct the client to report side/adverse effects such
as sore throat, fever, or headaches.
5. Use special radioactive precautions when handling the
client’ urine forthe first 24 hours following inital
administration.
‘AP0031, The nurse is counseling a pregnant client who
is HIV positive. Which information is appropriate to
discuss?@ INITIAL EVALUATIVE TEST
1. Infant should be exclusively breastfed for 6 months to
receive maternal antibodies
2. Infant wil not require treatment for HIV after birth
3. Prescribed antiretroviral therapy should be continued
during pregnancy
4, Tetanus-diphthera-pertussis vaccine should be
avoided until after birth
C0204. A client is diagnosed with lower-extremity deep
venous thrombosis (DVT) after a cross-country road trip.
Which clinical manifestations most characteristic of a
DVT does the nurse expect to assess? Select all that
apply.
Blue, cyanotic toes
Calf pain
Dry, shiny, hairless skin
Edema
Warmth and erythema
‘SP0094. The orthopedic health care provider instructs
a client with a fractured right femur, who has been non-
weight bearing for the past 5 weeks, to progress to full
weight bearing on the right leg. Which advanced
crutch gait that most closely resembles normal walking
should the office nurse teach the client?
4. 2-point gait
2. 3-point gait
3, 4-point gait
4. S-point gait
RES0085, The nurse is teaching a 9-year-old child with
asthma how to use a metered-dose inhaler (MDI).
Place the instructions in the appropriate order. All
options must be used.
4. Exhale completely
2. Deliver one puff of medication into spacer
3. Place lips ightly around the mouth piece
4, Rinse mouth with water
5, Shake MDI and attach it to spacer
6. Take a slow deep breath and hold for 10 seconds
MH0003. The nurse is caring for a client admitted with
serotonin syndrome after taking citalopram and tramadol
Which assessment findings does the nurse expect to
find? Select all that apply.
Absent deep tendon reflexes
Cold, clammy skin
Muscle rigidity
Restlessness and agitation
Sinus tachycardia
10080, The school nurse is teaching a class of 10-year-
old children about prevention of dental caries. Which
recommendations would be part of the nurse's teaching
plan? Select all that apply.
4. Chewing sugar-free gum
2, Including milk, yogurt, and cheese in the diet
3. Minimizing intake of sweet, sticky foods
4, Rinsing the mouth with water after meals when
brushing is not possible
5, Substituting fut juices and drinks for sugary,
carbonated beverages
€C0048. Upon arrival in the post-anesthesia care unit, the
nurse performs the initial assessment of a client who had.
surgery under general anesthesia. Which assessment
finding prompts the nurse to notify the health care
provider immediately?
1. Difficult to arouse
2, Muscle stiness
3. Pinpoint pupils,
4. Temperature 94 F (34.4 C)@ INITIAL EVALUATIVE TEST
\VA0046. The nurse is reviewing the laboratory results for 610042. The nurse teaches a client diagnosed with iron-
a child scheduled for tonsillectomy. The nurse determines deficiency anemia about iron-rich foods. Which meal
that which laboratory value is most significant to review? does the client choose to indicate that teaching has
been effective?
4. Creatinine level
2. Prothrombin ime 1. Chicken salad with lettuce on French bread,
3. Sedimentation rate chocolate pudding, and milk
4, Blood urea nitrogen level 2. Fatfree yogurt, carrot sticks, apple slices, and diet
soda
3. Ham, steamed carrots, green beans, gelatin dessert,
10129. A client is receiving an infusion of total
parenteral nutrition (TPN) with 20% dextrose through a
and iced tea
Kale salad with boiled eggs and dried fruit, a
brownie, and orange juice
central ine at 75 mL/hr. The nurse responds to the
client's IV pump alarm, which indicates that the bag is
empty. The new bag is not expected to arrive from the
pharmacy for an hour, What is the most appropriate
nursing action? €C0029. Two days after surgical debridement for a
pressure ulcer, the client develops new-onset
confusion, a temperature of 101 F (38.3 C), blood
pressure 74/48 mm Hg, pulse 110/min, respirations
26imin, and oxygen saturation 88% on room air. Place
the prescribed interventions in the order the nurse
would perform them. All options must be used.
1, Hang 0.9% normal saline until new bag arrives, then
increase TPN to 150 mLihr for 1 hour
2, Hang 10% dextrose in water until the new bag
arrives, then resume TPN at 75 mL/hr
3, Hang dextran in saline until the new bag arrives,
then resume TPN at 75 mUhr
4, Hang lactated Ringer's unti the new bag arrives,
then resume TPN at 75 mL/hr
‘Administer acetaminophen every 6 hours as needed
Administer oxygen using a non-rebreathing mask
‘Assess lung sounds
Increase 0.9% IV normal saline rate from 75 mL/hr to
200 mLihr
Reassess a ful set of vital signs
INT0059. A client is brought to the emergency
department with partial thickness burns to his faci
neck, arms, and chest after trying to put out a car fire.
The nurse should implement which nursing actions for
this client? Select all that apply.
‘SAF0144. A hospitalized 88-year-old client who has been
receiving antibiotics for 10 days tells you that he is.
having frequent watery stools. Which action will you
take first?
Restrict fluids
Assess for airway patency.
Administer oxygen as prescribed.
Place a cooling blanket on the client
Elevate extremities if no fractures are present.
Prepare to give oral pain medication as prescribed,
1 Notify the physician about the loose stools
2, Obtain stool specimens for culture.
3, Instruct the client about correct hand washing
4, Place the client on contact precautions.@ INITIAL EVALUATIVE TEST
(C0056. The nurse is caring for an 11-month-old child in
the pediatric hospital. Which of these child's findings
would be a common criterion to activate the rapid
response team? Select all that apply.
New-onset right-sided paralysis of extremities
Pulse rate sustained at 120/min
Respirations continued at 38/min
Sudden inabilty to be aroused to an awake state
Temperature of 101.3 F (38.5 C)
Gl0101. The nurse is caring for a client with cirrhosis of
the liver. Which blood test values would the nurse
typically anticipate to be elevated when reviewing the
client's morning laboratory results? Select all that
apply.
Albumin
‘Ammonia
Bilirubin
Prothrombin time
Sodium
€C0064. The nurse in the intensive care unit is caring for
a client who is postoperative from a cardiac surgery.
The client has a mediastinal chest tube. During
assessment, the nurse notes bubbling in the suction
control chamber. Which nursing action is appropriate?
1. Assess the insertion site for presence of
subcutaneous emphysema
2. Notify he surgeon of a large airleak
3, Take no action as the chest tube is functioning
appropriately
4, Tum down the wall suction unti the bubbling
disappears
NEU0037. The nurse taught the caregiver of a child
a ventriculoperitoneal (VP) shunt about when to contact
the health care provider (HCP). The caregiver shows
understanding of the instructions by contacting the HCP
about which symptom?
1. A temperature of 99 F (37 C) that occurs during the
evening
2. The child cannot recall tems eaten for lunch the
previous day
3. The child vomits after awakening from a nap and 1
hour later
4, The VP shunt s palpated along the posterior-ateral
portion of the skull
SAF0037, A home health nurse is supervising a home
health aide who is changing the dressing for a client with
a chronic heel wound, Which actions by the aide indicate
adherence to appropriate infection control procedures?
Select all that apply,
1. Open asterile container of 4 x 4's using the outermost,
corner to peel back the cover
2. Pull glove off over the soiled dressing to encase it
before disposal
3. Save unused sterile 4 x 4's by taping original package
shut for the next dressing change
4, Wash hands prior to putting on gloves and after
removing them
5. Wrap soiled dressing in paper towels before disposing
of it in the trash can
NEU0043. The nurse is caring for a client after a lumbar
puncture (spinal tap). Which client assessment is most
concerning and requires a nursing response?
Consumes 600 mL liquid over 4 hours
Insertion site dressing saturated with clear fluid
Observed lying inthe right sided Sims position
Reports a headache rated 6/10@ INITIAL EVALUATIVE TEST
LM0008. There has been a community disaster with
multiple victims, Stable clients must be released to make
room for the victims. Which clients would the nurse
recommend as stable for discharge? Select all that apply.
1. Acute head injury with Glasgow Coma Scale of 12
2. Admitted with cihosis of iver with oozing esophageal
varices
3. Asthma exacerbation with peak flow at 85% of
personal best
4, Deep venous thrombosis on IV heparin with platelets
40,000/mm3 (40 x 109/L)
5. Myasthenia gravis with ptosis in the evening
CC0012. The nurse provides triage to victims of a mass
casualty event on arrival in the emergency department.
Which victim would need to be seen first?
Client with a broken neck and agonal breaths
Client with a head injury and fixed pupils,
Client with an open right femur fracture
Client with shallow lacerations over legs and arms