1. A 43-year-old African American male is admitted with sickle cell anemia.

The
nurse plans to assess circulation in the lower extremities every 2 hours. Which of
the following outcome criteria would the nurse use?
A. Body temperature of 99°F or less
B. Toes moved in active range of motion
C. Sensation reported when soles of feet are touched
D. Capillary refill of < 3 seconds
2. A 30-year-old male from Haiti is brought to the emergency department in sickle
cell crisis. What is the best position for this client?
A. Side-lying with knees flexed
B. Knee-chest
C. High Fowler's with knees flexed
D. Semi-Fowler's with legs extended on the bed
3. A 25-year-old male is admitted in sickle cell crisis. Which of the following
interventions would be of highest priority for this client?
A. Taking hourly blood pressures with mechanical cuff
B. Encouraging fluid intake of at least 200mL per hour
C. Position in high Fowler's with knee gatch raised
D. Administering Tylenol as ordered
4. Which of the following foods would the nurse encourage the client in sickle cell
crisis to eat?
A. Peaches
B. Cottage cheese
C. Popsicle
D. Lima beans
5. A newly admitted client has sickle cell crisis. The nurse is planning care based on
assessment of the client. The client is complaining of severe pain in his feet and
hands. The pulse oximetry is 92. Which of the following interventions would be
implemented first? Assume that there are orders for each intervention.
A. Adjust the room temperature
B. Give a bolus of IV fluids
C. Start O2
D. Administer meperidine (Demerol) 75mg IV push
6. The nurse is instructing a client with iron-deficiency anemia. Which of the
following meal plans would the nurse expect the client to select?
A. Roast beef, gelatin salad, green beans, and peach pie
B. Chicken salad sandwich, coleslaw, French fries, ice cream
C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
D. Pork chop, creamed potatoes, corn, and coconut cake
7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia
and hypoxemia. Which of the following activities would the nurse recommend?
A. A family vacation in the Rocky Mountains
B. Chaperoning the local boys club on a snow-skiing trip
C. Traveling by airplane for business trips
D. A bus trip to the Museum of Natural History
8. The nurse is conducting an admission assessment of a client with vitamin B12
deficiency. Which of the following would the nurse include in the physical
assessment?
A. Palpate the spleen
B. Take the blood pressure
C. Examine the feet for petechiae
D. Examine the tongue
9. An African American female comes to the outpatient clinic. The physician
suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical
manifestation of this type of anemia, what body part would be the best indicator?
A. Conjunctiva of the eye
B. Soles of the feet
C. Roof of the mouth
D. Shins
10. The nurse is conducting a physical assessment on a client with anemia. Which of
the following clinical manifestations would be most indicative of the anemia?
A. BP 146/88
B. Respirations 28 shallow
C. Weight gain of 10 pounds in 6 months
D. Pink complexion
11. The nurse is teaching the client with polycythemia vera about prevention of
complications of the disease. Which of the following statements by the client
indicates a need for further teaching?
A. "I will drink 500mL of fluid or less each day."
B. "I will wear support hose when I am up."
C. "I will use an electric razor for shaving."
D. "I will eat foods low in iron."
12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the
following would the nurse inquire about as a part of the assessment?
A. The client collects stamps as a hobby.
B. The client recently lost his job as a postal worker.
C. The client had radiation for treatment of Hodgkin's disease as a teenager.
D. The client's brother had leukemia as a child.
13. An African American client is admitted with acute leukemia. The nurse is
assessing for signs and symptoms of bleeding. Where is the best site for
examining for the presence of petechiae?
A. The abdomen
B. The thorax
C. The earlobes
D. The soles of the feet
14. A client with acute leukemia is admitted to the oncology unit. Which of the
following would be most important for the nurse to inquire?
A. "Have you noticed a change in sleeping habits recently?"
B. "Have you had a respiratory infection in the last 6 months?"
C. "Have you lost weight recently?"
D. "Have you noticed changes in your alertness?"
15. Which of the following would be the priority nursing diagnosis for the adult client
with acute leukemia?
A. Oral mucous membrane, altered related to chemotherapy
B. Risk for injury related to thrombocytopenia
C. Fatigue related to the disease process
D. Interrupted family processes related to life-threatening illness of a family
member
16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university.
He is engaged to be married and is to begin a new job upon graduation. Which of
the following diagnoses would be a priority for this client?
A. Sexual dysfunction related to radiation therapy
B. Anticipatory grieving related to terminal illness
C. Tissue integrity related to prolonged bed rest
D. Fatigue related to chemotherapy
17. A client has autoimmune thrombocytopenic purpura. To determine the client's
response to treatment, the nurse would monitor:
A. Platelet count
B. White blood cell count
C. Potassium levels
D. Partial prothrombin time (PTT)
18. The home health nurse is visiting a client with autoimmune thrombocytopenic
purpura (ATP). The client's platelet count currently is 80, It will be most
important to teach the client and family about:
A. Bleeding precautions
B. Prevention of falls
C. Oxygen therapy
D. Conservation of energy
19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which
of the following interventions would be appropriate for this client?
A. Place the client in Trendelenburg position for postural drainage
B. Encourage coughing and deep breathing every 2 hours
C. Elevate the head of the bed 30°
D. Encourage the Valsalva maneuver for bowel movements
20. The client with a history of diabetes insipidus is admitted with polyuria,
polydipsia, and mental confusion. The priority intervention for this client is:
A. Measure the urinary output
B. Check the vital signs
C. Encourage increased fluid intake
D. Weigh the client
21. A client with hemophilia has a nosebleed. Which nursing action is most
appropriate to control the bleeding?
A. Place the client in a sitting position with the head hyperextended
B. Pack the nares tightly with gauze to apply pressure to the source of
bleeding
C. Pinch the soft lower part of the nose for a minimum of 5 minutes
D. Apply ice packs to the forehead and back of the neck
22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent
complications, the most important measurement in the immediate post-operative
period for the nurse to take is:
A. Blood pressure
B. Temperature
C. Output
D. Specific gravity
23. A client with Addison's disease has been admitted with a history of nausea and
vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-
Medrol). Which of the following interventions would the nurse implement?
A. Glucometer readings as ordered
B. Intake/output measurements
C. Sodium and potassium levels monitored
D. Daily weights
24. A client had a total thyroidectomy yesterday. The client is complaining of tingling
around the mouth and in the fingers and toes. What would the nurses' next action
be?
A. Obtain a crash cart
B. Check the calcium level
C. Assess the dressing for drainage
D. Assess the blood pressure for hypertension
25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a
weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The
client is diagnosed with hypothyroidism. Which of the following nursing
diagnoses is of highest priority?
A. Impaired physical mobility related to decreased endurance
B. Hypothermia r/t decreased metabolic rate
C. Disturbed thought processes r/t interstitial edema
D. Decreased cardiac output r/t bradycardia
26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is
placed on rosuvastatin (Crestor). Which instruction should be given to the client?
A. Report muscle weakness to the physician.
B. Allow six months for the drug to take effect.
C. Take the medication with fruit juice.
D. Ask the doctor to perform a complete blood count before starting the
medication.
27. The client is admitted to the hospital with hypertensive crises. Diazoxide
(Hyperstat) is ordered. During administration, the nurse should:
A. Utilize an infusion pump
B. Check the blood glucose level
C. Place the client in Trendelenburg position
D. Cover the solution with foil
28. The 6-month-old client with a ventral septal defect is receiving Digitalis for
regulation of his heart rate. Which finding should be reported to the doctor?
A. Blood pressure of 126/80
B. Blood glucose of 110mg/dL
 C. Heart rate of 60bpm
D. Respiratory rate of 30 per minute
29. The client admitted with angina is given a prescription for nitroglycerine. The
client should be instructed to:
A. Replenish his supply every 3 months
B. Take one every 15 minutes if pain occurs
C. Leave the medication in the brown bottle
D. Crush the medication and take with water
30. The client is instructed regarding foods that are low in fat and cholesterol. Which
diet selection is lowest in saturated fats?
A. Macaroni and cheese
B. Shrimp with rice
C. Turkey breast
D. Spaghetti
31. The client is admitted with left-sided congestive heart failure. In assessing the
client for edema, the nurse should check the:
A. Feet
B. Neck
C. Hands
D. Sacrum
32. The nurse is checking the client's central venous pressure. The nurse should place
the zero of the manometer at the:
A. Phlebostatic axis
B. PMI
C. Erb's point
D. Tail of Spence
33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered
concomitantly to the client with hypertension. The nurse should:
A. Question the order
B. Administer the medications
C. Administer separately
D. Contact the pharmacy
34. The best method of evaluating the amount of peripheral edema is:
A. Weighing the client daily
B. Measuring the extremity
C. Measuring the intake and output
D. Checking for pitting
35. A client with vaginal cancer is being treated with a radioactive vaginal implant.
The client's husband asks the nurse if he can spend the night with his wife. The
nurse should explain that:
A. Overnight stays by family members is against hospital policy.
B. There is no need for him to stay because staffing is adequate.
C. His wife will rest much better knowing that he is at home.
D. Visitation is limited to 30 minutes when the implant is in place.
36. The nurse is caring for a client hospitalized with a facial stroke. Which diet
selection would be suited to the client?
 A. Roast beef sandwich, potato chips, pickle spear, iced tea
B. Split pea soup, mashed potatoes, pudding, milk
C. Tomato soup, cheese toast, Jello, coffee
D. Hamburger, baked beans, fruit cup, iced tea
37. The physician has prescribed Novalog insulin for a client with diabetes mellitus.
Which statement indicates that the client knows when the peak action of the
insulin occurs?
A. "I will make sure I eat breakfast within 10 minutes of taking my insulin."
B. "I will need to carry candy or some form of sugar with me all the time."
C. "I will eat a snack around three o'clock each afternoon."
D. "I can save my dessert from supper for a bedtime snack."
38. The nurse is teaching basic infant care to a group of first-time parents. The nurse
should explain that a sponge bath is recommended for the first 2 weeks of life
because:
A. New parents need time to learn how to hold the baby.
B. The umbilical cord needs time to separate.
C. Newborn skin is easily traumatized by washing.
D. The chance of chilling the baby outweighs the benefits of bathing.
39. A client with leukemia is receiving Trimetrexate. After reviewing the client's
chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for
administering leucovorin calcium to a client receiving Trimetrexate is to:
A. Treat iron-deficiency anemia caused by chemotherapeutic agents
B. Create a synergistic effect that shortens treatment time
C. Increase the number of circulating neutrophils
D. Reverse drug toxicity and prevent tissue damage
40. A 4-month-old is brought to the well-baby clinic for immunization. In addition to
the DPT and polio vaccines, the baby should receive:
A. Hib titer
B. Mumps vaccine
C. Hepatitis B vaccine
D. MMR
41. The physician has prescribed Nexium (esomeprazole) for a client with erosive
gastritis. The nurse should administer the medication:
A. 30 minutes before meals
B. With each meal
C. In a single dose at bedtime
D. 30 minutes after meals
42. A client on the psychiatric unit is in an uncontrolled rage and is threatening other
clients and staff. What is the most appropriate action for the nurse to take?
A. Call security for assistance and prepare to sedate the client.
B. Tell the client to calm down and ask him if he would like to play cards.
C. Tell the client that if he continues his behavior he will be punished.
D. Leave the client alone until he calms down.
43. When the nurse checks the fundus of a client on the first postpartum day, she
notes that the fundus is firm, is at the level of the umbilicus, and is displaced to
the right. The next action the nurse should take is to:
 A. Check the client for bladder distention
B. Assess the blood pressure for hypotension
C. Determine whether an oxytocic drug was given
D. Check for the expulsion of small clots
44. A client is admitted to the hospital with a temperature of 99.8°F, complaints of
blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are
consistent with a diagnosis of:
A. Pneumonia
B. Reaction to antiviral medication
C. Tuberculosis
D. Superinfection due to low CD4 count
45. The client is seen in the clinic for treatment of migraine headaches. The drug
Imitrex (sumatriptan succinate) is prescribed for the client. Which of the
following in the client's history should be reported to the doctor?
A. Diabetes
B. Prinzmetal's angina
C. Cancer
D. Cluster headaches
46. The client with suspected meningitis is admitted to the unit. The doctor is
performing an assessment to determine meningeal irritation and spinal nerve root
inflammation. A positive Kernig's sign is charted if the nurse notes:
A. Pain on flexion of the hip and knee
B. Nuchal rigidity on flexion of the neck
C. Pain when the head is turned to the left side
D. Dizziness when changing positions
47. The client with Alzheimer's disease is being assisted with activities of daily living
when the nurse notes that the client uses her toothbrush to brush her hair. The
nurse is aware that the client is exhibiting:
A. Agnosia
B. Apraxia
C. Anomia
D. Aphasia
48. The client with dementia is experiencing confusion late in the afternoon and
before bedtime. The nurse is aware that the client is experiencing what is known
as:
A. Chronic fatigue syndrome
B. Normal aging
C. Sundowning
D. Delusions
49. The client with confusion says to the nurse, "I haven't had anything to eat all day
long. When are they going to bring breakfast?" The nurse saw the client in the day
room eating breakfast with other clients 30 minutes before this conversation.
Which response would be best for the nurse to make?
A. "You know you had breakfast 30 minutes ago."
B. "I am so sorry that they didn't get you breakfast. I'll report it to the charge
nurse."
 C. "I'll get you some juice and toast. Would you like something else?"
D. "You will have to wait a while; lunch will be here in a little while."
50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's
disease. Which side effect is most often associated with this drug?
A. Urinary incontinence
B. Headaches
C. Confusion
D. Nausea

51. An 18 year-old client is admitted to intensive care from the emergency room
following a diving accident. The injury is suspected to be at the level of the 2nd cervical
vertebrae. The nurse's priority assessment should be the client’s

A. response to stimuli
B. bladder control
C. respiratory function
D. muscle weakness
52. A client has been admitted to the coronary care unit with a myocardial infarction.
Which nursing diagnosis should have priority?
A. pain related to ischemia
B. risk for altered elimination: constipation
C. risk for complication: dysrhythmias
D. anxiety related to pain
53. The nurse is caring for a client with a distal tibia fracture. The client has had a closed
reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly
becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit.
The first assessment the nurse should perform is
A) orientation to time, place and person
B) pulse oximetry
C) circulation to casted extremity
D) blood pressure
54. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following
treatments is most effective to promote healing?
A) Covering the wound with a dry dressing
B) Using hydrogen peroxide soaks
C) Leaving the area open to dry
D) Applying a hydrocolloid or foam dressing
55. A client is recovering from a thyroidectomy. While monitoring the client's initial
post-operative condition, which of the following should the nurse report immediately?
A) Tetany and paresthesia
B) Mild stridor and hoarseness
C) Irritability and insomnia
D) Headache and nausea
56. A client is scheduled for an intravenous pyelogram (IVP). Which of the following
data from the client’s history indicate a potential hazard for this test?
A) Reflex incontinence
 B) Allergy to shellfish
C) Claustrophobia
D) Hypertension
57. A client enters the emergency department unconscious via ambulance. What
document should be given priority to guide the direction of care for this client?
A) The statement of client rights and the client self determination act
B) Orders written by the provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency
department
58. A client diagnosed with hepatitis C discusses his health history with the admitting
nurse. The nurse should recognize which statement by the client as the most important?
A) I got back from Central America a few weeks ago.
B) I had the best raw oysters last week.
C) I have many different sex partners.
D) I had a blood transfusion 15 years ago.
59. Which of these children at the site of a disaster at a child day care center would the
triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying
episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with a lower leg fracture on one side and an upper leg
fracture on the other
D) A school-age child with singed eyebrows and hair on the arms
60. A client has returned to the unit following a renal biopsy. Which of the following
nursing interventions is appropriate?
A) Ambulate the client 4 hours after procedure
B) Maintain client on NPO status for 24 hours
C) Monitor vital signs
D) Change dressing every 8 hours
61. The nurse is providing instructions for a client with asthma. Which of the following
should the client monitor on a daily basis?
A) Respiratory rate
B) Peak air flow volumes
C) Pulse oximetry
D) Skin color
62. A client with a documented pulmonary embolism has the following arterial blood
gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based
on these data, what is the first nursing action?
A) Review other lab data
B) Notify the health care provider
C) Administer oxygen
D) Calm the client
63. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow
meter. The nurse explains that this should be used to
A) determine oxygen saturation
 B) measure forced expiratory volume
C) monitor atmosphere for presence of allergens
D) provide metered doses for inhaled bronchodilator
64. The nurse is assessing a 55 year-old female client who is scheduled for abdominal
surgery. Which of the following information would indicate that the client is at risk for
thrombus formation in the post-operative period?
A) Estrogen replacement therapy
B) 10% less than ideal body weight
C) Hypersensitivity to heparin
D) History of hepatitis
65. During the check up of a 2 month-old infant at a well baby clinic, the mother
expresses concern to the nurse because a flat pink birthmark on the baby's forehead and
eyelid has not gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these at
this time."
66. A 3 year-old child diagnosed as having celiac disease attends a day care center.
Which of the following would be an appropriate snack?
A) Cheese crackers
B) Peanut butter sandwich
C) Potato chips
D) Vanilla cookies
67. A nurse assigned to a manipulative client for 5 days becomes aware of feelings of
reluctance to interact with the client. The next action by the nurse should be to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the manipulative
behavior
C) Confront the client about the negative effects of behaviors on other clients
and staff
D) Develop a behavior modification plan that will promote more functional
behavior
68. A client is being treated for paranoid schizophrenia. When the client became loud
and boisterous, the nurse immediately placed him in seclusion as a precautionary
measure. The client willingly complied. The nurse’s action
A) may result in charges of unlawful seclusion and restraint
B) leaves the nurse vulnerable for charges of assault and battery
C) was appropriate in view of a client history of violence
D) was necessary to maintain the therapeutic milieu of the unit.
69. The provisions of the law for the Americans with Disabilities Act require nurse
managers to
A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities
70. Upon completing the admission documents, the nurse learns that the 87 year-old
client does not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary.
71. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has
died. Which type of precautions is appropriate to use when performing postmortem care?
A) Airborne precautions
B) Droplet precautions
C) Contact precautions
D) Compromised host precautions
72. An 8 year-old client is admitted to the hospital for surgery. The child’s parent reports
the allergies listed below. Which of these allergies should all health care personnel be
aware of?
A) Shellfish
B) Molds
C) Balloons
D) Perfumed soap.
73. A nurse is stuck in the hand by an exposed used hypodermic needle. What immediate
action should the nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management
74. The nurse is having difficulty reading the health care provider's written order that
was left just before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up on
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
75. When admitting a client to an acute care facility, an identification bracelet is sent up
with the admission form. In the event these do not match, the nurse’s best action is to
A) change whichever item is incorrect to the correct information
B) use the bracelet and admission form until a replacement is supplied
C) notify the admissions office and wait to apply the bracelet
D) make a corrected identification bracelet for the client
76. The nurse is planning discharge for a 90 year-old client with musculo-skeletal
weakness. Which intervention should be included in the plan that would be most effective
for the prevention of falls?
A) Place nightlights in the bedroom
B) Wear eyeglasses at all times
C) Install grab bars in the bathroom
D) Teach muscle strengthening exercises
77. An 8 year-old child is hospitalized during the edema phase of minimal change
nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is
the best choice?
A) Bologna sandwich, pudding, milk
B) Frankfurter, baked potato, milk
C) Chicken strips, corn on the cob, milk
D) Grilled cheese sandwich, apple, milk
78. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the
prescribed diet. The nurse should teach the client to
A) maintain previous calorie intake
B) keep a candy bar available at all times
C) reduce carbohydrates intake to 25% of total calories
D) keep a regular schedule of meals and snacks
79. A depressed client in an assisted living facility tells the nurse that "life isn't worth
living anymore." What is the best response to this statement?
A) "Come on, it is not that bad."
B) "Have you thought about hurting yourself?"
C) "Did you tell that to your family?"
D) "Think of the many positive things in life."
80. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient
setting. Which behavior is consistent with this diagnosis?
A) Repeatedly checking that the door is locked
B) Verbalized suspicions about thefts
C) Preference for consistent caregivers
D) Repetitive, involuntary movements
81. A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If
this turns out to be cancer and I have to have my breast removed, my partner will never
come near me." The nurse's best response would be which of these statements?
A) "I hear you saying that you have a fear for the loss of love."
B) "You sound concerned that your partner will reject you."
C) "Are you wondering about the effects on your sexuality?"
D) "Are you worried that the surgery will lead to changes?"
82. A client is admitted for treatment of a right upper lobe infiltrate and to rule out
tuberculosis. Which of these would be the most appropriate self-protective action by the
nurse ?
A) Provide negative room ventilation
B) Wear a face mask with shield
C) Wear a particulate respirator mask
D) Institute airborne precautions.
83. The charge nurse has a health care team that consists of 1 practical nurse (PN), 1
unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment
should be questioned by the nurse manager?
A) An admission at the change of shifts with atrial fibrillation and heart
failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
 C) A child with burns who has packed cells and albumin IV running - charge
nurse
D) An elderly client who had a myocardial infarction a week ago - UAP
84. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The
nurse is concerned that the client is unable to coordinate the release of the medication
with the inhalation phase. What is the nurse's best recommendation to improve delivery
of the medication?
A) Nebulized treatments for home care
B) Adding a spacer device to the MDI canister
C) Asking a family member to assist the client with the MDI
D) Request a visiting nurse to follow the client at home
85. The nurse is teaching a client newly diagnosed with asthma how to use the metered-
dose inhaler (MDI). The client asks when they will know the canister is empty. The best
response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
C) Count the number of doses as the inhaler is used
D) Shake the canister to detect any fluid movement.
86. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers
that 800 ml has been infused after 4 hours. What is the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
87. A nurse observes a family member administer a rectal suppository by having the
client lie on the left side for the administration. The family member pushed the
suppository until the finger went up to the second knuckle. After 10 minutes the client
was told by the family member to turn to the right side and the client did this. What is the
appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
88. As the nurse observes the student nurse during the administration of a narcotic
analgesic IM injection, the nurse notes that the student begins to give the medication
without first aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
C) Loudly state: “You forgot to aspirate.”
D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
89. An adult client is found to be unresponsive on morning rounds. After checking for
responsiveness and calling for help, the next action that should be taken by the nurse is
to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
 D) ensure an open airway
90. A practical nurse (PN) is assigned to care for a newborn with a neural tube defect.
Which dressing, if applied by the PN, would need no further intervention by the charge
nurse?
A) Telfa dressing with antibiotic ointment
B) Moist sterile nonadherent dressing
C) Dry sterile dressing that is occlusive
D) Sterile occlusive pressure dressing
91. A parent brings her 3 month-old into the clinic, reporting that the child seems to be
spitting up all the time and has a lot of gas. The nurse expects to find which of the
following on the initial history and physical assessment?
A) increased temperature and lethargy
B) restlessness and increased mucus production
C) increased sleeping and listlessness
D) diarrhea and poor skin turgor
92. The nurse manager hears a provider loudly criticize one of the staff nurses within the
hearing range of others. The nurse manager's next action should be to
A) Walk up to the provider and quietly state: "Stop this unacceptable
behavior."
B) Allow the staff nurse to handle this situation without interference
C) Notify the of the other administrative persons of a breech of professional
conduct
D) Request an immediate private meeting with the provider and staff nurse
93. The charge nurse is planning assignments on a medical unit. The client should be
assigned to the unlicensed assistive personnel (UAP).
A) difficulty swallowing after a mild stroke
B) an order of enemas until clear prior to colonoscopy
C) an order for a post-op abdominal dressing change
D) transfer orders to a long term facility
94. The nurse manager has been using a block scheduling plan to staff the nursing unit.
However, staff have asked for many changes and exceptions to the schedule over the past
few months. The manager considers self-scheduling knowing that this method will
A) Improve the quality of care
B) Decrease staff turnover
C) Minimize the amount of overtime payouts
D) Improve team morale
95. A client is admitted to a voluntary hospital mental health unit due to suicidal
ideation. The client has been on the unit for 2 days and now states “I demand to be
released now!” The appropriate from the nurse is
A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Let’s discuss your decision to leave and then we can prepare you for
discharge.
D) You have a right to sign out as soon as we get the provider's discharge
order.
96. The nurse is caring for a client who is post-op following a thoracotomy. The client
has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals
bubbling in the water seal chamber when the client coughs. What is the most appropriate
nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Continue to monitor the client to see if the bubbling increases
D) Instruct the client to try to avoid coughing
97. A newly admitted elderly client is severely dehydrated. When planning care for this
client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
A) Converse with the client to determine if the mucous membranes are
impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours
98. Which statement best describes time management strategies applied to the role of a
nurse manager?
A) Schedule staff efficiently to cover the anticipated needs on the managed
unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce work load associated with direct care and
meetings
99. The charge nurse on the night shift at an urgent care center has to deal with admitting
clients of a higher acuity than usual because of a large fire in the area. Which style of
leadership and decision-making would be best in this circumstance?
A) Assume a decision-making role
B) Seek input from staff
C) Use a non-directive approach
D) Shared decision-making with others
100. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?
A) Take a history on a newly admitted client
B) Adjust the rate of a gastric tube feeding
C) Check the blood pressure of a 2 hours post operative client
D) Check on a client receiving chemotherapy