FINAL COACHING EXTENDED

PREBOARDS EXAMINATION NP4

Prepared by: Prof. Faisal Jackarain RN, MPH
Take One Nursing

NURSING PRACTICE IV

1. The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection
after discharge from the hospital. The nurse determines that the client needs further reinforcement of
information if the client makes which statement?
A. "I should use disposable plates, forks, and knives."
B. "I should cough into tissues and throw them away carefully."
C. "It's important to cover my mouth if I laugh, sneeze, or cough."
D. "It's very important to wash my hands after I touch my mask, tissues, or body fluids."

2. A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the
possibility of infecting family members and others. How should the nurse respond to provide reassurance?
A. The family does not need therapy, and the client will not be contagious after 1 month of medication
therapy.
B. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of
medication therapy.
C. The family will be treated prophylactically, and the client will not be contagious after 1 continuous week of
medication therapy.
D. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive
weeks of medication therapy.

3. A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed
medication therapy. The nurse assesses that this client may ultimately need which intervention as a last
resort?
A. Directly observed therapy
B. More medication instructions
C. Involvement of the family in teaching
D. Reinforcement by the primary health care provider

4. Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin
would indicate a need for further instruction regarding the management of the disease process?
A. Wearing protective garb when visiting the infant
B. Washing the hands before leaving the infant's room
C. Telling a family member who has asthma that he should not visit the infant
D. Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant

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5. A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home
care instructions to the client regarding measures that will promote sinus drainage and comfort. Which
statement by the client indicates a need for further instruction?
A. "I should drink large amounts of fluids."
B. "I should use a hot mist vaporizer to liquefy secretions."
C. "I should try to sleep with the head of the bed elevated."
D. "I should apply heat, such as a wet pack, over the sinuses."

6. A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is
voiding through the vagina. The nurse interprets that the client may be experiencing which condition?
A. Rupture of the bladder
B. The development of a vesicovaginal fistula
C. Extreme stress caused by the diagnosis of cancer
D. Altered perineal sensation as a side effect of radiation therapy

7. The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma.
What assessment findings should the nurse expect to note? Select all that apply.
A. Pathological fracture
B. Urinalysis positive for Bence Jones protein
C. Hemoglobin level of 15.5 g/dL (155 mmol/L)
D. Calcium level of 8.6 mg/dL (2.15 mmol/L)
E. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

8. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines
that further teaching is necessary related to colorectal cancer if the client identifies which item as an
associated risk factor?
A. Age younger than 50 years
B. History of colorectal polyps
C. Family history of colorectal cancer
D. Chronic inflammatory bowel disease

9. The nurse is assessing the perineal wound in a client who has returned from the operating room following
an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing
intervention is most appropriate?
A. Clamp the surgical drain.
B. Change the dressing as prescribed.
C. Notify the surgeon.
D. Remove and replace the perineal packing.

10. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note
documentation of which most common sign or symptom of this type of cancer?
A. Dysuria
B. Hematuria
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C. Urgency on urination
D. Frequency of urination

11. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the
procedure?
A. Lying in bed on the affected side
B. Lying in bed on the unaffected side
C. Sims' position with the head of the bed flat
D. Prone with the head turned to the side and supported by a pillow

12. The nurse is preparing to care for a client who has returned to the nursing unit after cardiac
catheterization performed through the femoral vessel. The nurse checks the primary health care provider's
(PHCP's) prescription and plans to allow which client position or activity after the procedure?
A. Bed rest in high-Fowler's position
B. Bed rest with bathroom privileges only
C. Bed rest with head elevation at 60 degrees
D. Bed rest with head elevation no greater than 30 degrees

13. A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which
item as part of the client's care plan?
A. Monitoring the temperature
B. Monitoring complaints of heartburn
C. Giving warm gargles for a sore throat
D. Assessing for the return of the gag reflex

14. The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography
(ERCP) procedure. The nurse determines that the client needs further information if the client makes which
statement?
A. "I know I must sign the consent form."
B. "I hope the throat spray keeps me from gagging."
C. "I'm glad I don't have to lie still for this procedure."
D. "I'm glad some intravenous medication will be given to relax me."

15. A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will
be used during the procedure?
A. Side-lying with a pillow under the hip
B. Prone with a pillow under the abdomen
C. Prone in slight Trendelenburg's position
D. Side-lying with the legs pulled up and the head bent down onto the chest

16. The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?
A. Dependent edema
B. Diminished distal pulse

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C. Presence of a "hot spot" on the cast
D. Coolness and pallor of the extremity

17. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is
complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic,
with little relief. Which problem may be causing this pain?
A. Infection under the cast
B. The anxiety of the client
C. Impaired tissue perfusion
D. The recent occurrence of the fracture

18. The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg
fracture and had a plaster cast applied. Which position would be best for the casted leg?
A. Elevated for 3 hours, then flat for 1 hour
B. Flat for 3 hours, then elevated for 1 hour
C. Flat for 12 hours, then elevated for 12 hours
D. Elevated on pillows continuously for 24 to 48 hours

19. A client is being discharged to home after application of a plaster leg cast. Which statement indicates that
the client understands proper care of the cast?
A. "I need to avoid getting the cast wet."
B. "I need to cover the casted leg with warm blankets."
C. "I need to use my fingertips to lift and move my leg."
D. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

20. A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm
for extra support. The nurse responds knowing that which would most likely result from this improper crutch
measurement?
A. A fall and further injury
B. Injury to the brachial plexus nerves
C. Skin breakdown in the area of the axilla
D. Impaired range of motion while the client ambulates

21. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin
time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?
A. Adding a dose of heparin sodium
B. Holding the next dose of warfarin
C. Increasing the next dose of warfarin
D. Administering the next dose of warfarin

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22. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that
the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which
value?
A. 3 mg/dL (1.08 mmol/L)
B. 15 mg/dL (5.4 mmol/L)
C. 29 mg/dL (10.44 mmol/L)
D. 35 mg/dL (12.6 mmol/L)

23. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis.
The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action
is needed?
A. Discontinuing the heparin infusion
B. Increasing the rate of the heparin infusion
C. Decreasing the rate of the heparin infusion
D. Leaving the rate of the heparin infusion as is

24. A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium
level, if noted in the client's laboratory report, should be reported before administering the dose of
furosemide?
A. 3.2 mEq/L (3.2 mmol/L)
B. 3.8 mEq/L (3.8 mmol/L)
C. 4.2 mEq/L (4.2 mmol/L)
D. 4.8 mEq/L (4.8 mmol/L)

25. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which
laboratory test results should the nurse report? Select all that apply.
A. Platelets 35,000 mm3 (35 × 109/L)
B. Sodium 150 mEq/L (150 mmol/L)
C. Potassium 5.0 mEq/L (5.0 mmol/L)
D. Segmented neutrophils 40% (0.40)
E. Serum creatinine, 1 mg/dL (88.3 mcmol/L)
F. White blood cells, 3000 mm3 (3.0 × 109/L)

26. The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which
observation indicates that spinal shock persists?
A. Hyperreflexia
B. Positive reflexes
C. Flaccid paralysis
D. Reflex emptying of the bladder

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27. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions
should the nurse take? Select all that apply.
A. Loosening restrictive clothing.
B. Restraining the client's limbs.
C. Removing the pillow and raising padded side rails.
D. Positioning the client to the side, if possible, with the head flexed forward.
E. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter
to assist.

28. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain
attack). Which characteristics are associated with this condition? Select all that apply.
A. The client is aphasic.
B. The client has weakness on the right side of the body.
C. The client has complete bilateral paralysis of the arms and legs.
D. The client has weakness on the right side of the face and tongue.
E. The client has lost the ability to move the right arm but is able to walk independently.
F. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself
without assistance.

29. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous
hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the
family understands the measures to use when caring for the client?
A. "We need to discourage him from wearing eyeglasses."
B. "We need to place objects in his impaired field of vision."
C. "We need to approach him from the impaired field of vision."
D. "We need to remind him to turn his head to scan the lost visual field."

30. The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain
attack). Which observation indicates to the nurse that the client is adapting most successfully?
A. Gets angry with family if they interrupt a task
B. Experiences bouts of depression and irritability
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self

31. The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30
mm Hg (30 mmol/L), and HCO3– of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which
condition?
A. Metabolic acidosis, compensated
B. Respiratory alkalosis, compensated
C. Metabolic alkalosis, uncompensated
D. Respiratory acidosis, uncompensated

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32. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors
the client for manifestations of which disorder that the client is at risk for?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

33. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is
hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor
displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse
reviews the results, expecting to note which finding?
A. A decreased pH and an increased Paco2
B. An increased pH and a decreased Paco2
C. A decreased pH and a decreased HCO3–
D. An increased pH and an increased HCO3–

34. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial
blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which
conclusion about the client should the nurse make?
A. The client has acidotic blood.
B. The client is probably overreacting.
C. The client is fluid volume overloaded.
D. The client is probably hyperventilating.

35. The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing
Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.
A. Respirations that are shallow
B. Respirations that are increased in rate
C. Respirations that are abnormally slow
D. Respirations that are abnormally deep
E. Respirations that cease for several seconds

36. The nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic
shock syndrome (TSS). Which assessment question would assist in eliciting the most specific data regarding
the cause of this syndrome?
A. "Did you start your menses at an early age?"
B. "Have your menstrual periods been irregular?"
C. "Do you use tampons during your menstrual period?"
D. "Have you been consuming a high intake of green leafy vegetables?"

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37. The clinic nurse has provided instructions regarding home care measures to a female client diagnosed
with pelvic inflammatory disease (PID). Which statement, if made by the client, indicates an understanding of
these measures?
A. "I need to avoid tight-fitting clothing."
B. "I need to douche once in the morning and once in the evening."
C. "I need to see a primary health care provider to get an intrauterine device for birth control."
D. "I need to wear tampons instead of sanitary pads when I have my menstrual period."

38. A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which
assessment question would elicit data associated with this infection?
A. "Have you had any vaginal discharge?"
B. "Do you have any blood in your urine?"
C. "Have you had any flank pain or headaches?"
D. "Have you noticed any swelling in your feet?"

39. The nurse employed in a fertility clinic is providing information to a couple considering in vitro
fertilization. The nurse's explanation should most appropriately include which information? Select all that
apply.
A. Embryo transfer occurs through an abdominal incision.
B. A fertilized ovum is transferred into the woman's uterus.
C. Mild spotting or cramping may occur following egg removal.
D. A medication protocol for follicle development will be prescribed.
E. Ova and sperm are collected and immediately transferred into the woman's uterus.

40. The nurse is performing an assessment on a client who asks how she might recognize when she is
ovulating. The nurse should explain that which occurs at ovulation? Select all that apply.
A. Breast tenderness
B. Decreased sex drive
C. Small amount of vaginal spotting
D. Slight decrease in basal body temperature
E. Lower abdominal pain known as Mittelschmerz
F. Presence of spinnbarkeit–thin and clear mucous discharge

41. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is
dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to
note in this client if excess fluid volume is present?
A. Weight loss and dry skin
B. Flat neck and hand veins and decreased urinary output
C. An increase in blood pressure and increased respirations
D. Weakness and decreased central venous pressure (CVP)

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42. The nurse reviews a client's record and determines that the client is at risk for developing a potassium
deficit if which situation is documented?
A. Sustained tissue damage
B. Requires nasogastric suction
C. Has a history of Addison's disease
D. Uric acid level of 9.4 mg/dL (557 mcmol/L)

43. The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5
mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the
laboratory value? Select all that apply.
A. U waves
B. Absent P waves
C. Inverted T waves
D. Depressed ST segment
E. Widened QRS complex

44. The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of
hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
A. Twitching
B. Hypoactive bowel sounds
C. Negative Trousseau's sign
D. Hypoactive deep tendon reflexes

45. The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which
patterns would the nurse watch for on the electrocardiogram? Select all that apply.
A. U waves
B. Widened T wave
C. Prominent U wave
D. Prolonged QT interval
E. Prolonged ST segment

46. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy?
Select all that apply.
A. Use nonlatex gloves.
B. Use medications from glass ampules.
C. Place the client in a private room only.
D. Keep a latex-safe supply cart available in the client's area.
E. Avoid the use of medication vials that have rubber stoppers.
F. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

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47. A client presents at the primary health care provider's office with complaints of a ring-like rash on his
upper leg. Which question should the nurse ask first?
A. "Do you have any cats in your home?"
B. "Have you been camping in the last month?"
C. "Have you or close contacts had any flu-like symptoms within the last few weeks?"
D. "Have you been in physical contact with anyone who has the same type of rash?"

48. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed?
A. Maintain bed rest as much as possible.
B. Administer corticosteroids as prescribed for inflammation.
C. Advise the client to remain supine for 1 to 2 hours after meals.
D. Keep the room temperature warm during the day and cool at night.

49. A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like
to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the
toilet. Which actions are most appropriate? Select all that apply.
A. Tell the client that testing is not necessary unless arthralgia develops.
B. Tell the client to avoid any woody, grassy areas that may contain ticks.
C. Instruct the client to immediately start to take the antibiotics that are prescribed.
D. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.
E. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an
antiseptic.

50. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma.
Based on this diagnosis, the nurse understands that this has been confirmed by which finding?
A. Swelling in the genital area
B. Swelling in the lower extremities
C. Positive punch biopsy of the cutaneous lesions
D. Appearance of reddish-blue lesions noted on the skin

51. Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level
of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client’s temperature before
hanging the blood transfu¬sion and records 100.6° F (38.1° C) orally. Which action should the nurse take?
A. Begin the transfusion as prescribed.
B. Administer an antihistamine and begin the transfusion.
C. Administer 2 tablets of acetaminophen and begin the transfusion.
D. Delay hanging the blood and notify the primary health care provider (PHCP).

52. The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before
explaining the procedure to the client, the nurse should ask which initial question?
A. "Have you ever had a transfusion before?"
B. "Why do you think that you need the transfusion?"
C. "Have you ever gone into shock for any reason in the past?"
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D. "Do you know the complications and risks of a transfusion?"

53. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood
pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8º F (38.2º C)
orally from a baseline of 99.2º F (37.3º C) orally. The nurse determines that the client may be experiencing
which complication of a blood transfusion?
A. Septicemia
B. Hyperkalemia
C. Circulatory overload
D. Delayed transfusion reaction

54. The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion,
which action should be taken next?
A. Remove the intravenous (IV) line.
B. Run a solution of 5% dextrose in water.
C. Run normal saline at a keep-vein-open rate.
D. Obtain a culture of the tip of the catheter device removed from the client.

55. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from
this therapy if the client exhibits which finding?
A. Increased hematocrit level
B. Increased hemoglobin level
C. Decline of elevated temperature to normal
D. Decreased oozing of blood from puncture sites and gums

56. The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with
another nurse. Just before beginning the transfusion, the nurse should assess which priority item?
A. Vital signs
B. Skin color
C. Urine output
D. Latest hematocrit level

57. The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned
client. What action should the nurse take next?
A. Check a set of vital signs.
B. Order the blood from the blood bank.
C. Obtain Y-site blood administration tubing.
D. Check to be sure that consent for the transfusion has been signed.

58. Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia,
bounding pulses, crackles, and wheezes. Which action should the nurse implement first?
A. Maintain bed rest with legs elevated.
B. Place the client in high-Fowler's position.
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C. Increase the rate of infusion of intravenous fluids.
D. Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy.

59. The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes
the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to
assess the effectiveness of the transfusion?
A. Hematocrit level
B. Erythrocyte count
C. Hemoglobin level
D. White blood cell count

60. A client is brought to the emergency department having experienced blood loss related to an arterial
laceration. Which blood component should the nurse expect the primary health care provider to prescribe?
A. Platelets
B. Granulocytes
C. Fresh-frozen plasma
D. Packed red blood cells

61. A nursing graduate is attending an agency orientation regarding the nursing model of practice
implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach.
The nurse determines that which scenario is characteristic of the team-based model of nursing practice?
A. Each staff member is assigned a specific task for a group of clients.
B. A staff member is assigned to determine the client's needs at home and begin discharge planning.
C. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an
assistive personnel (AP).
D. An RN leads 2 pharmacists and 3 APs in providing care to a group of 12 clients.

62. The registered nurse is planning the client assignments for the day. Which is the most appropriate
assignment for an assistive personnel (AP)?
A. A client requiring a colostomy irrigation
B. A client receiving continuous tube feedings
C. A client who requires urine specimen collections
D. A client with difficulty swallowing food and fluids

63. The senior nurse employed in a long-term care facility is planning assignments for the clients on a nursing
unit. The senior nurse needs to assign four clients and has a junior RN and 3 assistive personnel (APs) on a
nursing team. Which client would the senior nurse most appropriately assign to the junior RN?
A. A client who requires a bed bath
B. An older client requiring frequent ambulation
C. A client who requires hourly vital sign measurements
D. A client requiring abdominal wound irrigations and dressing changes every 3 hours

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64. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful
of when planning the assignment? Select all that apply.
A. The acuity level of the clients
B. Specific requests from the staff
C. The clustering of the rooms on the unit
D. The number of anticipated client discharges
E. Client needs and workers' needs and abilities

65. The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints
(safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained
hands?
A. Every 2 hours
B. Every 3 hours
C. Every 4 hours
D. Every 30 minutes

66. The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted
central catheter (PICC). The nurse determines that the client needs further instructions if the client made
which statement?
A. "I need to wear a MedicAlert tag or bracelet."
B. "I need to restrict my activity while this catheter is in place."
C. "I need to keep the insertion site protected when in the shower or bath."
D. "I need to check the markings on the catheter each time the dressing is changed."

67. A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The
nurse should be sure to check which results before initiating the flow rate of the client's intravenous (IV)
solution at 100 mL/hour?
A. Serum osmolality
B. Serum electrolyte levels
C. Intake and output record
D. Chest radiology results

68. Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal
jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon
entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which
additional signs of a complication should the nurse assess based on the previously known data?
A. Excessive bleeding
B. Crackles in the lungs
C. Incompatibility of the infusion
D. Chest pain radiating to the left arm

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69. Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should
prepare to administer this medication by which route?
A. Orally
B. By inhalation
C. By intravenous infusion
D. Through a Sengstaken-Blakemore tube

70. Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is
preparing to administer the medication to the client. Which essential item is needed during the administration
of this medication?
A. An airway
B. A suction setup
C. A cardiac monitor
D. A tracheotomy set

71. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the
client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary
health care provider, and completes an occurrence report. Which statement should the nurse document on
the occurrence report?
A. The client fell out of bed.
B. The client climbed over the side rails.
C. The client was found lying on the floor.
D. The client became restless and tried to get out of bed.

72. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a
car. The name of the client is unknown, and the client has sustained a severe head injury and multiple
fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the
surgical procedure, which is the best action?
A. Obtain a court order for the surgical procedure.
B. Ask the EMS team to sign the informed consent.
C. Transport the victim to the operating room for surgery.
D. Call the police to identify the client and locate the family.

73. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because
the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the
ICU. The nurse should take which best action?
A. Refuse to float to the ICU based on lack of unit orientation.
B. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.
C. Ask the nursing supervisor to review the hospital policy on floating.
D. Submit a written protest to nursing administration, and then call the hospital lawyer.

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74. The nurse who works on the night shift enters the medication room and finds a coworker with a
tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe
containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?
A. Call security.
B. Call the police.
C. Call the nursing supervisor.
D. Lock the coworker in the medication room until help is obtained.

75. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer
will be bringing the document to the hospital today for witness signatures. The client asks the nurse for
assistance in obtaining a witness to the will. Which is the most appropriate response to the client?
A. "I will sign as a witness to your signature."
B. "You will need to find a witness on your own."
C. "Whoever is available at the time will sign as a witness for you."
D. "I will call the nursing supervisor to seek assistance regarding your request."

76. The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines
that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply.
A. A client with extensive burns
B. A client with cancer who is septic
C. A client who has had an open cholecystectomy
D. A client with severe exacerbation of Crohn's disease
E. A client with persistent nausea and vomiting from chemotherapy

77. The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an
assigned client. The nurse should obtain which most essential piece of equipment before hanging the
solution?
A. Urine test strips
B. Blood glucose meter
C. Electronic infusion pump
D. Noninvasive blood pressure monitor

78. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN)
bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed
and delivered to the nursing unit?
A. 5% dextrose in water
B. 10% dextrose in water
C. 5% dextrose in Ringer's lactate
D. 5% dextrose in 0.9% sodium chloride

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79. The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1
hour behind. Which action should the nurse take?
A. Adjust the infusion rate to catch up over the next hour.
B. Increase the infusion rate to catch up over the next 2 hours.
C. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
D. Adjust the infusion rate to run wide open until the solution is back on time.

80. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The
nurse should next assess the client for the presence of which condition?
A. Thirst
B. Polyuria
C. Decreased blood pressure
D. Crackles on auscultation of the lungs

81. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse
assess first?
A. A postoperative client preparing for discharge with a new medication
B. A client requiring daily dressing changes of a recent surgical incision
C. A client scheduled for a chest x-ray after insertion of a nasogastric tube
D. A client with asthma who requested a breathing treatment during the previous shift

82. The nurse employed in an emergency department is assigned to triage clients coming to the emergency
department for treatment on the evening shift. The nurse should assign priority to which client?
A. A client complaining of muscle aches, a headache, and history of seizures
B. A client who twisted her ankle when rollerblading and is requesting medication for pain
C. A client with a minor laceration on the index finger sustained while cutting an eggplant
D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

83. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the
assigned clients, which client should the nurse plan to care for first?
A. A client who is ambulatory demonstrating steady gait
B. A postoperative client who has just received an opioid pain medication
C. A client scheduled for physical therapy for the first crutch-walking session
D. A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

84. The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's
room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most
appropriate nursing action?
A. Finish the bed bath and then administer the pain medication to the other client.
B. Ask the AP to find out when the last pain medication was given to the client.
C. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is
complete.

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D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain
medication to the other client.

85. The nurse is conducting a session about the principles of first aid and is discussing the interventions for a
snakebite to an extremity. The nurse should inform those attending the session that the first-priority
intervention in the event of this occurrence is which action?
A. Immobilize the affected extremity.
B. Remove jewelry and constricting clothing from the victim.
C. Place the extremity in a position so that it is below the level of the heart.
D. Move the victim to a safe area away from the snake and encourage the victim to rest.

86. An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary
resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which
action?
A. The ratio of compressions to ventilations is 30:2.
B. The carotid pulse is palpable with each compression.
C. Respirations are given at a rate of 10 breaths per minute.
D. The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5 cm).

87. The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An
automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to
assess the client's cardiac rhythm?
A. Hold the defibrillator paddles firmly against the chest.
B. Apply adhesive patch electrodes to the chest and move away from the client.
C. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device.
D. Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm.

88. The nurse is teaching adult cardiopulmonary resuscitation (CPR) guidelines to a group of laypeople. The
nurse observes the group correctly demonstrate 2-rescuer CPR when which ratio of compressions to
ventilations is performed on the mannequin?
A.10:1
B. 15:2
C. 20:1
D. 30:2

89. The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community members. The nurse
tells the group that when chest compressions are performed on infants, the sternum should be depressed
how far?
A. At least 2 inches (5 cm)
B. About 1½ inches (4 cm)
C. At least one half the depth of the chest
D. Deep enough to make a finger impression

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90. The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor
asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than
1 year of age. Which response would indicate that the student understands the appropriate assessment
procedure?
A. Radial artery
B. Carotid artery
C. Brachial artery
D. Popliteal artery

91. The nurse manager has involved all staff members in the development of goals and decision making.
Which leadership style has the unit manager exercised?
A. Autocratic
B. Democratic
C. Situational
D. Laissez-faire

92. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which
instructions should the nurse manager include in the discussion? Select all that apply.
A. Open doors to client rooms.
B. Move beds away from windows.
C. Close window shades and curtains.
D. Place blankets over clients who are confined to bed.
E. Relocate ambulatory clients from the hallways back into their rooms.

93. The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership
style should the nurse select to achieve this goal?
A. Autocratic
B. Situational
C. Democratic
D. Laissez-faire

94. The nurse educator presents an in-service training session on case management to nurses on the clinical
unit. During the presentation the nurse educator clarifies that what is a characteristic of case management?
A. Requires that 1 nurse take care of 1 client
B. Promotes appropriate use of hospital personnel
C. Requires a case manager who plans the care for all clients
D. Uses a team approach, but 1 nurse supervises all other employees

95. The staff members working at the trauma center have characterized their nurse manager as task oriented
and directive. Which leadership style does the nurse manager exhibit?
A. Autocratic
B. Situational
C. Democratic
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D. Laissez-faire

96. The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that
bleeding is excessive. Which should be the initial nursing action?
A. Record the findings.
B. Massage the fundus.
C. Notify the obstetrician (OB).
D. Place the client in Trendelenburg's position.

97. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission
of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what
is the nurse's highest priority?
A. Turn on the apnea and cardiorespiratory monitors.
B. Connect the resuscitation bag to the oxygen outlet.
C. Set up the intravenous line with 5% dextrose in water.
D. Set the radiant warmer control temperature at 36.5° C (97.6° F).

98. A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes
that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from
the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action?
A. Place the child in a supine position.
B. Place the child in Trendelenburg's position.
C. Increase the flow rate of the intravenous fluids.
D. Notify the primary health care provider (PHCP).

99. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction
temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse
is absent on the right foot. Which action should the nurse take?
A. Administer an analgesic.
B. Release the skin traction.
C. Apply ice to the extremity.
D. Notify the primary health care provider (PHCP).

100. The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the
infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness
and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and
should take which actions? Select all that apply.
A. Stop the infusion.
B. Prepare to apply ice or heat to the site.
C. Restart the IV at a distal part of the same vein.
D. Notify the primary health care provider (PHCP).
E. Prepare to administer a prescribed antidote into the site.
F. Increase the flow rate of the solution to flush the skin and subcutaneous tissue.
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