PREBOARD 5 ASSESSMENT

May 29 & 30, 2021

1. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar
hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary
health care provider’s prescription?

1. Endotracheal intubation
2. 100 units of NPH insulin
3. Intravenous infusion of normal saline
4. Intravenous infusion of sodium bicarbonate

2. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and
ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should
be taken if which symptoms develop? Select all that apply.

1. Polyuria
2. Shakiness
3. Palpitations
4. Blurred vision
5. Lightheadedness
6. Fruity breath odor

3. A client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report recurrent
episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding
of the peak action of NPH insulin and exercise?

1. “I should not exercise since I am taking insulin.”

2. “The best time for me to exercise is after breakfast.”
3. “The best time for me to exercise is mid- to late afternoon.”
4. “NPH is a basal insulin, so I should exercise in the evening.”

4. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client’s nostril.
The nurse should take which initial action?

1. Lower the head of the bed.

2. Test the drainage for glucose.
3. Obtain a culture of the drainage.
4. Continue to observe the drainage.

5. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary
hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply.

1. Polyuria
2. Headache
3. Bone pain
4. Nervousness
5. Weight gain

6. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone
secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider
prescriptions should the nurse anticipate receiving? Select all that apply.

1. Initiate an infusion of 3% NaCl.

2. Administer intravenous furosemide.
3. Restrict fluids to 800 mL over 24 hours.
4. Elevate the head of the bed to high-Fowler’s.
5. Administer a vasopressin antagonist as prescribed
7. A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will
the interprofessional health care team focus on? Select all that apply.

1. Hypotension
2. Leukocytosis
3. Hyperkalemia
4. Hypercalcemia
5. Hypernatremia

8. The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal
hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the
presence of a possible postoperative complication? Select all that apply.

1. Anxiety
2. Leukocytosis
3. Chvostek’s sign
4. Urinary output of 800 mL/hr
5. Clear drainage on nasal dripper pad

9. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines
that the client understands discharge instructions if the client states that which signs and symptoms are
associated with this diagnosis? Select all that apply.

1. Tremors
2. Weight loss
3. Feeling cold
4. Loss of body hair
5. Persistent lethargy
6. Puffiness of the face

10. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute
pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.

1. Maintain NPO (nothing by mouth) status.

2. Encourage coughing and deep breathing.
3. Give small, frequent high-calorie feedings.
4. Maintain the client in a supine and flat position.
5. Give hydromorphone intravenously as prescribed for pain.
6. Maintain intravenous fluids at 10 mL/hr to keep the vein open.

11. The nurse is providing discharge teaching for a client with newly diagnosed Crohn’s disease about dietary
measures to implement during exacerbation episodes. Which statement made by the client indicates a need for
further instruction?

1. “I should increase the fiber in my diet.”

2. “I will need to avoid caffeinated beverages.”
3. “I’m going to learn some stress reduction techniques.”
4. “I can have exacerbations and remissions with Crohn’s disease.”

12. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is
documentation of the presence of asterixis. How should the nurse assess for its presence?

1. Dorsiflex the client’s foot.

2. Measure the abdominal girth.
3. Ask the client to extend the arms.
4. Instruct the client to lean forward.
13. The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS).
Which statement by the client indicates a need for further teaching?

1. “I need to limit my intake of dietary fiber.”

2. “I need to drink plenty, at least 8 to 10 cups daily.”
3. “I need to eat regular meals and chew my food well.”
4. “I will take the prescribed medications because they will regulate my bowel patterns.

14. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings
indicate this occurrence?

1. Sweating and pallor

2. Bradycardia and indigestion
3. Double vision and chest pain
4. Abdominal cramping and pain

15. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should
expect to note which finding?

1. Slow, deep respirations

2. Rapid, deep respirations
3. Paradoxical respirations
4. Pain, especially with inspiration

16. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive
sign of flail chest?

1. Cyanosis
2. Hypotension
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation

17. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for
tuberculosis. Which instructions should the nurse include on the list? Select all that apply.

1. Activities should be resumed gradually.

2. Avoid contact with other individuals, except family members, for at least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4. Respiratory isolation is not necessary, because family members already have been exposed.
5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can
return to former employment.

18. The community health nurse is conducting an educational session with community members regarding the
signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is
considered as a diagnosis if which signs and symptoms are present? Select 1608all that apply.

1. Dyspnea
2. Headache
3. Night sweats
4. A bloody, productive cough
5. A cough with the expectoration of mucoid sputum
19. Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and
tuberculosis. The nurse should monitor for which side and adverse effects of rifabutin? Select all that apply.

1. Signs of hepatitis
2. Flu-like syndrome
3. Low neutrophil count
4. Vitamin B6 deficiency
5. Ocular pain or blurred vision
6. Tingling and numbness of the fingers

20. The nurse has just administered the first dose of omalizumab to a client. Which statement by the client alerts
the nurse of a life-threatening effect?

1. “I have a severe headache.”

2. “My feet are quite swollen.”
3. “I am nauseated and may vomit.”
4. “My lips and tongue are swollen.”

21. The client has developed atrial fibrillation, with a ventricular rate of 150 beats per minute. The nurse should
assess the client for which associated signs and/or symptoms? Select all that apply.

1. Syncope
2. Dizziness
3. Palpitations
4. Hypertension
5. Flat neck veins

22. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary
health care provider and prepares to implement which priority interventions? Select all that apply.

1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low-Fowler’s side-lying position

23. The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client
has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client’s urine output
for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client’s blood urea nitrogen level
is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning.
Which nursing action is the priority?

1. Check the serum albumin level.

2. Check the urine specific gravity.
3. Continue monitoring urine output.
4. Call the primary health care provider (PHCP)

24. The nurse is monitoring a client with heart failure who is taking digoxin. Which findings are characteristic of
digoxin toxicity? Select all that apply.

1. Tremors
2. Diarrhea
3. Irritability
4. Blurred vision
5. Nausea and vomiting
25. A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely
anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which
interventions should the nurse anticipate? Select all that apply.

1. Stop the infusion.

2. Raise the head of the bed.
3. Administer protamine sulfate.
4. Administer diphenhydramine.
5. Call for the Rapid Response Team (RRT)

26. A client with valvular heart disease who has a clot in the right atrium is receiving a heparin sodium infusion
at 1000 units/hr and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows:
activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse
should take which action based on the client’s laboratory results?

1. Collaborate with the primary health care provider (PHCP) to discontinue the heparin infusion and administer
the warfarin sodium as prescribed.
2. Collaborate with the PHCP to obtain a prescription to increase the heparin infusion and continue the warfarin
sodium as prescribed.
3. Collaborate with the PHCP to withhold the warfarin sodium since the client is receiving a heparin infusion and
the aPTT is within the therapeutic range.
4. Collaborate with the PHCP to continue the heparin infusion at the same rate and to discuss use of dabigatran
etexilate in place of warfarin sodium

27. A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains
of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the
priority nursing actions? Select all that apply.

1. Administer oxygen to the client.

2. Continue dialysis at a slower rate after checking the lines for air.
3. Notify the primary health care provider (PHCP) and Rapid Response Team.
4. Stop dialysis, and turn the client on the left side with head lower than feet.
5. Bolus the client with 500 mL of normal saline to break up the air embolus.

28. The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the
inflow. Which actions should the nurse take? Select all that apply.

1. Check the level of the drainage bag.

2. Reposition the client to her or his side.
3. Place the client in good body alignment.
4. Check the peritoneal dialysis system for kinks.
5. Contact the primary health care provider (PHCP).
6. Increase the flow rate of the peritoneal dialysis solution.

29. A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse
anticipates which treatment will be done to relieve the obstruction? Select all that apply.

1. Peritoneal dialysis
2. Analysis of the urinary stone
3. Intravenous opioid analgesics
4. Insertion of a nephrostomy tube
5. Placement of a ureteral stent with ureteroscopy
30. Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports
a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client’s
complaints?

1. The client may have contracted the flu.

2. The client is experiencing anaphylaxis.
3. The client is experiencing expected effects of the medication.
4. The client is experiencing a pulmonary reaction requiring cessation of the medication

31. The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation.
Which home care measures should the nurse include in the plan? Select all that apply.

1. Avoid activities that require bending over.

2. Contact the surgeon if eye scratchiness occurs.
3. Take acetaminophen for minor eye discomfort.
4. Expect episodes of sudden severe pain in the eye.
5. Place an eye shield on the surgical eye at bedtime.
6. Contact the surgeon if a decrease in visual acuity occurs

32. The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate
procedure for this visual acuity test?

1. The right eye is tested, followed by the left eye, and then both eyes are tested.
2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye.
3. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on
the chart.
4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can
be read 200 feet (60 meters) away by an individual with unimpaired vision.

33. The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the
drops? Select all that apply.

1. Wash hands.
2. Put gloves on.
3. Place the drop in the conjunctival sac.
4. Pull the lower lid down against the cheekbone.
5. Instruct the client to squeeze the eyes shut after instilling the eye drop.
6. Instruct the client to tilt the head forward, open the eyes, and look down.

34. 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.

1. Loosening restrictive clothing.

2. Restraining the client’s limbs.
3. Removing the pillow and raising padded side rails.
4. Positioning the client to the side, if possible, with the head flexed forward.
5. Keeping the curtain around the client and the room door open so when help arrives, they can quickly enter
to assist.

35. The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic
crises. Which client activity suggests that teaching is most effective?

1. Taking medications as scheduled

2. Eating large, well-balanced meals
3. Doing muscle-strengthening exercises
4. Doing all chores early in the day while less fatigued
36. The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history
finding makes the client most at risk for this disease?

1. Meningitis or encephalitis during the last 5 years

2. Seizures or trauma to the brain within the last year
3. Back injury or trauma to the spinal cord during the last 2 years
4. Respiratory or gastrointestinal infection during the previous month

37. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include
which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

1. Keeping the linens wrinkle-free under the client

2. Preventing unnecessary pressure on the lower limbs
3. Limiting bladder catheterization to once every 12 hours
4. Turning and repositioning the client at least every 2 hours
5. Ensuring that the client has a bowel movement at least once a week

38. The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse
would note which trend in vital signs if the intracranial pressure is rising?

1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

39. 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.

1. The client is aphasic.

2. The client has weakness on the right side of the body.
3. The client has complete bilateral paralysis of the arms and legs.
4. The client has weakness on the right side of the face and tongue.
5. The client has lost the ability to move the right arm but is able to walk independently.
6. The client has lost the ability to ambulate independently but is able to feed and bathe herself or
himself without assistance.

40. Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse
monitor for? Select all that apply.

1. Diarrhea
2. Tremors
3. Drowsiness
4. Hypotension
5. Urinary frequency
6. Increased respiratory rate

41. Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the
right forearm? Select all that apply.

1. Keep the cast clean and dry.

2. Allow the cast 24 to 72 hours to dry.
3. Keep the cast and extremity elevated.
4. Expect tingling and numbness in the extremity.
5. Use a hair dryer set on a warm to hot setting to dry the cast.
6. Use a soft, padded object that will fit under the cast to scratch
42. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most
concerned with which finding?

1. Redness around the pin sites

2. Pain on palpation at the pin sites
3. Thick, yellow drainage from the pin sites
4. Clear, watery drainage from the pin sites

43. The nurse has given the client instructions about crutch safety. Which statements indicate that the client
understands the instructions? Select all that apply.

1. “I should not use someone else’s crutches.”

2. “I need to remove any scatter rugs at home.”
3. “I can use crutch tips even when they are wet.”
4. “I need to have spare crutches and tips available.”
5. “When I’m using the crutches, my arms need to be completely straight.”

44. The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was
wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse
take?

1. Apply ice to the site.

2. Call the primary health care provider (PHCP).
3. Rewrap the residual limb with an elastic compression bandage.
4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow

45. The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to
note in the client?

1. Calcium level of 9.0 mg/dL (2.25 mmol/L)

2. Uric acid level of 9.0 mg/dL (540 mcmol/L)
3. Potassium level of 4.1 mEq/L (4.1 mmol/L)
4. Phosphorus level of 3.1 mg/dL (1.0 mmol/L)

46. A client with a hip fracture asks the nurse about Buck’s (extension) traction that is being applied before
surgery and what is involved. The nurse should provide which information to the client?

1. Allows bony healing to begin before surgery and involves pins and screws
2. Provides rigid immobilization of the fracture site and involves pulleys and wheels
3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws
4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys
and wheels

47. In monitoring a client’s response to disease-modifying antirheumatic drugs (DMARDs), which assessment
findings would the nurse consider acceptable responses? Select all that apply.

1. Control of symptoms during periods of emotional stress

2. Normal white blood cell, platelet, and neutrophil counts
3. Radiological findings that show no progression of joint degeneration
4. An increased range of motion in the affected joints 3 months into therapy
5. Inflammation and irritation at the injection site 3 days after the injection is given
6. A low-grade temperature on rising in the morning that remains throughout the day
48. 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.

1. Tell the client that testing is not necessary unless arthralgia develops.
2. Tell the client to avoid any woody, grassy areas that may contain ticks.
3. Instruct the client to immediately start to take the antibiotics that are prescribed.
4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.
5. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an
antiseptic

49. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client
about methods to manage fatigue. Which statement by the client indicates a need for further instruction?

1. “I should take hot baths because they are relaxing.”

2. “I should sit whenever possible to conserve my energy.”
3. “I should avoid long periods of rest because it causes joint stiffness.”
4. “I should do some exercises, such as walking, when I am not fatigued.”

50. The nurse is caring for a client who has been taking a sulfonamide and should monitor for signs and
symptoms of which adverse effects of the medication? Select all that apply.

1. Ototoxicity
2. Palpitations
3. Nephrotoxicity
4. Bone marrow suppression
5. Gastrointestinal (GI) effects
6. Increased white blood cell (WBC) count

51. What is the most appropriate nursing action to help manage a manic client who is monopolizing a group
therapy session?

1. Ask the client to leave the group for this session only.
2. Refer the client to another group that includes other manic clients.
3. Tell the client to stop monopolizing in a firm but compassionate manner.
4. Thank the client for the input, but inform the client that others now need a chance to contribute

52. A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed
to be administered before discharge. The nurse provides which information to the client about the vaccine?
Select all that apply.

1. Breast-feeding needs to be stopped for 3 months.

2. Pregnancy needs to be avoided for 1 to 3 months.
3. The vaccine is administered by the subcutaneous route.
4. Exposure to immunosuppressed individuals needs to be avoided.
5. A hypersensitivity reaction can occur if the client has an allergy to eggs.
6. The area of the injection needs to be covered with a sterile gauze for 1 week.

53. The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the
client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select
all that apply.

1. Ballottement
2. Chadwick’s sign
3. Uterine enlargement
4. Positive pregnancy test
5. Fetal heart rate detected by a nonelectronic device
6. Outline of fetus via radiography or ultrasonography
54. The nurse in a maternity unit is reviewing the clients’ records. Which clients should the nurse identify as
being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

1. A primigravida with abruptio placenta

2. A primigravida who delivered a 10-lb infant 3 hours ago
3. A gravida 2 who has just been diagnosed with dead fetus syndrome
4. A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood
5. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

55. The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment
findings should the nurse expect to note? Select all that apply.

1. Uterine rigidity
2. Uterine tenderness
3. Severe abdominal pain
4. Bright red vaginal bleeding
5. Soft, relaxed, nontender uterus
6. Fundal height may be greater than expected for gestational age

56. The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the
presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

1. Notify the primary health care provider of the findings.

2. Reposition the mother and check the monitor for changes in the fetal tracing.
3. Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen.
4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

57. The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is
experiencing labor dystocia. The nurse determines that which risk factors in the client’s history placed her at
risk for this complication? Select all that apply.

1. Age 54 years
2. Body mass index of 28
3. Previous difficulty with fertility
4. Administration of oxytocin for induction
5. Potassium level of 3.6 mEq/L (3.6 mmol/L)

58. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what
is the most important nursing action?

1. Slow the intravenous flow rate.

2. Continue the oxytocin drip if infusing.
3. Place the client in a high Fowler’s position.
4. Administer oxygen, 8 to 10 L/minute, via face mask.

59. The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse
determines that the client has understood the instructions if she makes which statements? Select all that apply.

1. “I should wear a bra that provides support.”

2. “Drinking alcohol can affect my milk supply.”
3. “The use of caffeine can decrease my milk supply.”
4. “I will start my estrogen birth control pills again as soon as I get home.”
5. “I know if my breasts get engorged, I will limit my breastfeeding and supplement the baby.”
6. “I plan on having bottled water available in the refrigerator so I can get additional fluids easily.”
60. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis.
Which instructions should be included on the list? Select all that apply.

1. Wear a supportive bra.

2. Rest during the acute phase.
3. Maintain a fluid intake of at least 3000 mL/day.
4. Continue to breast-feed if the breasts are not too sore.
5. Take the prescribed antibiotics until the soreness subsides.
6. Avoid decompression of the breasts by breast-feeding or breast pump