1. A nurse is caring for a client who is taking alprazolam. Which of the following prescriptions
should the nurse clarify with the provider?
A. Digoxin
B. Lorazepam
C. Atomoxetine
D. Ceftriaxone
2. A nurse is assessing a client who is postoperative following abdominal surgery. The client
states “I feel like my incision ripped open” the nurse notes dehiscence of the incision. which
of the following actions should the nurse take?
A. Extend the client’s legs above heart level
B. Place the client in low fowlers position.
C. Instruct the client to perform the Valsalva maneuver
D. Apply a dry gauze dressing to the incision.
3. A nurse is caring for a client who is receiving radiation therapy through a sealed implant.
Which of the following actions should the nurse take?
Wear a lead apron when providing care for the client.
4. A nurse is inserting an IV catheter for a client who requires fluid replacement. Which of the
following actions should the nurse take?
A. Apply the tourniquet 15cm (6 in) above the insertion site
B. Check for pulsation at sited proximal to the tourniquet
C. Anchor the vein by stretching the skin 2.5 cm (1 in) proximal to the insertion site
D. Wipe the skin dry before inserting the catheter
5. A nurse is administering medications to a client who has dysphagia and a new prescription
for divalproex sodium extended-release tablets. Which of the following actions should the
nurse take?
Administer the medication with applesauce
6. A nurse is completing a dietary assessment for a client who is Jewish and observes kosher
dietary practices. Which of the following behaviors would the nurse expect to fine?
A. Leavened bread maybe eaten during Passover.
B. Shellfish is commonly consumed in the diet.
C. Meat and dairy products are eaten separately.
D. Fasting from meat occurs during Hanukkah.
7. A nurse is assessing a client who has minor injuries following a motor-vehicle crash and
appears agitated and apprehensive. The nurse identifies that the client is in the arm stage of
general adaptation syndrome and should expect which of the following findings.
Tachycardia
8. A nurse is caring for a client who has a femur fracture and is on bedrest with Buck’s extension
traction. which of the following actions should the nurse take?
A. Inspect the client’s skin under the device every 8 hours
9. A charge nurse is creating assignments for the next shift for several nurses and one of them is
pregnant. Which of the following clients should the charge nurse assign to a nurse who is not
pregnant?
A. A 60-year-old client who is recovering from shingles
B. A 20-year-old client who is HIV positive
C. A 40-year-old client who is suspected of having tuberculosis
D. An 80-year-old client who has alcoholic pancreatitis and is being treated for impetigo
10. A nurse is caring for a client who has a partial laryngectomy and is receiving continuous
internal feeding at 65 ml/hr through a gastrostomy tube. which of the following findings
requires immediate intervention by the nurse?
A. The gastric residual volume is 250 mL following two hours of infusion.
B. The client is lying in a supine position.
C. The infusion pump for administering continuous feeding is turned off.
D. Interior feeding bag and tubing are not dated.
11. A nurse is teaching a client about smoking cessation. Which of the following client
statements should the nurse identify as an understanding of the teaching?
A. If I stop abruptly I cannot use a nicotine replacement.
B. After 6 months, my risk of heart disease is the same as that of a nonsmoker
C. I will set a specific date to stop smoking
D. I will use high carbohydrate snacks as a substitute for cigarette.
12. A nurse has been caring for a female client who has bruises on her arms that are a result
of physical abuse by her partner. The client states, “I don’t know how much longer I can take 
this, but I’m afraid he’ll really hurt me if I leave” Which of the following is an appropriate
nursing intervention?
A. Assist the client to identity personal behaviors that trigger abusive behavior
B. Insist that the client report the abusive behavior to the proper authority
C. Offer to speak to the client’s partner regarding his abusive behavior
D. Help the client to recognize the signs of escalation of abusive behavior
13. A client who is 8 hr postpartum asks the nurse if she will need to receive Rh immune
globulin. The client is gravid 2, para 2, and her blood type is AB negative. The newborn’s blood
type is B Positive. Which of the following statements is appropriate?
A. “You only need to receive Rh immune globulin if you have a positive blood type. “
B. “You should receive Rh immune globulin within 72 hours of delivery.”
C. “Both you and your baby should receive Rh immune globulin at your week appointment.”
D. “immune globulin is not necessary since this is your second pregnancy.”
14. A client hospitalized for a bone marrow transplant is in protective isolation while undergoing
total body radiation and intense chemotherapy. The client’s sibling comes to visit but has
obvious manifestations of an upper respiratory infection. which of the following nursing actions
is appropriate at this time?
A. Allow the sibling to wave at the client through the window or door.
B. Allow the sibling to visit after donning a sterile gown, mask and gloves, but prohibit physical
contact.
C.
D.
15. A nurse is planning care for a client who takes haloperidol for the treatment of
schizophrenia. which of the following should the nurse include in the plan of care?
A. Monitor the client for hypothermia
B. Screen the client for tardive dyskinesia
C. Check the client’s weekly potassium level
D. Schedule the client for a 24hr urine collection
16. A nurse is performing a vision screening for a client. which of the following findings should
the nurse identify as an indication that the client has cataracts?
A. Report of a chronic dull ache in the eyes
B. Bilateral redness of the sclerae
C. Increased opacity of the lens of the eye
D. Report of seeing halos around lights
17. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the
following actions should the nurse take?
A. Encourage the client to ambulate in the hallway 1 hr before bedtime
B. Tell the client to avoid drinking fluids 1 hr before bedtime
C. Schedule routine care tasks during hours when the client is awake
D. Advise the client to leave the television in the room on when trying to fall asleep
18. A nurse is providing discharge teaching to a client who is postpartum and plans to
breastfeed. which of the following should the nurse recommend the client increases in their diet
during lactation?
A. Vitamin D
B. Iron
C. Vitamin A
D. Calcium
19. A nurse is providing nutritional counseling to the parents of a toddler. Which of the
following instructions should the nurse include in the teaching?
A. Offer snacks throughout the day
20. A nurse is assessing a client’s cardiovascular system. Identify where the nurse should place
the diaphragm of the stethoscope to best hear the closing of the aortic heart valve.
(Selectable areas or Hot Spots” can be found by moving your cursor over the artwork until the
cursor changes appearance, usually into a hand. Click only on the Hot Spot that corresponds
to your answer.)
A. option A
21. A nurse is planning to perform wound irrigation for a client who has an open secondary
wound. When creating a sterile field. which of the following actions should the nurse take?
A. Set up the sterile field 7.6 cm below waist level
B. Hold the bottle of sterile solution with the palm over the label while pouring
C. Place the sterile items within 1 cm of the edge of the sterile border
D. Place the lid of a bottle of sterile solution within the sterile field
22. A nurse is planning an education session for a client who has type 1 diabetes mellitus.
which of the following should the nurse plan to include when teaching the client to monitor
for hypoglycemia?
A. diaphoresis
B. polyuria
C. abdominal pain
D. thirst
21. A nurse is instructing a group of newly hired nurses about medication to promote fetal lung
maturation. which of the following medications should the nurse include in the instructions?
A. Betamethasone
22. A nurse is caring for a client who has atypical depression and is taking phenelzine. Which of
the following is appropriate for the nurses to offer as an evening snack?
A. Low fat yogurt
23. A nurse is planning care for a newborn who is receiving phototherapy. Which of the
following actions should the nurse include the plan of care?
A. Assess the infant’s eyes for corneal irritation every 4 hrs
24. A nurse is caring for a client who is receiving a blood transfusion at 125 ml/hr and develops
a hemolytic reaction. Which of the following actions should the nurse perform?
A. infuse 0.9% sodium chloride IV.
B. Administer an antipyretic.
C. Decrease the infusion rate to 75 mL/hr.
D. Place the client in a left lateral position.
25. A nurse is planning care for a client who has schizophrenia and is having difficulty
expressing their feelings. which of the following referrals should the nurse make?
A. art therapist
B. speech -language pathologist
C. social worker
D. recreational therapist
26. A nurse from the state health department is instructing a group of nurses regarding
reportable infections. Which of the following infections should the nurse report to the centers
for disease control and prevention?
A. Lyme disease
B. Herpes simplex virus 2
C. Staphylococcus aureus
D. Candida albicans
27. A nurse is preparing to provide education about electroconvulsive for a client who has major
depressive disorder. Which of the following should the nurse include in the teaching?
A. A general anesthetic is administered prior to ECT treatment
B. ECT treatment are administered once every 6 months
C. Oral antidepressants are discontinued after ECT treatment
D. Implied consent is required prior to ECT treatment
28. A nurse is teaching a client and their family about home hospice care. Which of the
following information should the nurse include in the teaching?
A. Hospice care improves quality of life thorough palliative care.
B. Hospice care provides 24 hours, in home care.
C. Hospice care is intended to postpone death.
D. Hospice care encourages the family to coordinate health care services.
29. A nurse is preparing to administer an enteral feeding via NG tube for a client the day after
verifying placement of the tube using a chest x-ray. Which of the following methods should the
nurse use to confirm placement prior to initiating the feeding?
A. Test the pH level of the clients gastric aspirate
30. A nurse is assessing a client who has non-Hodgkin’s lymphoma. Which of the following
findings should indicate to the nurse that the clients might be experiencing syndrome of
inappropriate antidiuretic hormone?
A. Diminished deep tendon reflexes
31. A nurse received change of shift report on four clients. Based on the shift report information
which of the following clients would the nurse plan to assess first?
A client who had a hip arthroplasty reports pain and erythema in their calf
32. A nurse is caring for a client who is postpartum and has a new prescription for
methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When
reviewing the client’s medical history, the nurse should recognize which of the following
diagnosis as a contraindication to the administration of methylergonovine?
A. Hypertension
B. Diabetes mellitus
C. Migraine headaches
D. Hepatitis B
33. A nurse is caring for a client who is undergoing peritoneal dialysis and notes that the
dialysate outflow has become cloudy. Which of the following complications of this procedure
should the nurse suspect?
Peritonitis
34. A home health nurse is teaching a guardian about administering tube feedings to their 3-
month-old infant. Which of the following information should the nurse include in the teaching?
Allow the infant to suck on the pacifier during feedings?
35. A nurse in an inpatient psychiatric unit is setting short-term goals for an adolescent client
who was admitted for treatment of anorexia nervosa. which of the following is an appropriate
short-term goal the nurse should set?
A. The client will reach an appropriate body weight
B. The client will gain 2 to 3 lb weekly
C. The client will verbalize a realistic body image
D. The client will develop a personalize meal plan
36. A nurse is preparing to witness a client’s signature on an informed consent for a total knee
arthroplasty. Which of the following client statements indicates the nurse should contact the
surgeon?
A. “I am thankful there are no serious complications from this type of surgery”
B. “I wonder if the metal in my knee will show up in airport screenings”
C. “The physical therapy has not been working, so I will need to have the surgery”
D. “I look forward to being able to bend my knee again when I sit in a chair”
37. A nurse is caring for a client who reports chest pain. Which of the following laboratory
findings indicates myocardial damage?
A. aPTT 80 secs
B. Troponin I 1.8ng/ml
C. ESR 17MM/HR
D. Human B type
38. A nurse is caring for a school-age child who has a blood pressure of 88/50 mmhm and
develops septic shock. Which for the following medications should the nurse expect the
provider to prescribe?
Dopamine
39. A nurse is caring for a client who is receiving a controlled epidural analgesia infusion.
Which of the following nursing actions is appropriate?
Covering the insertion site with a transparent dressing
40. A nurse discovers that the wrong dosage was given to a client. When determining what
action to take, the nurse should recognize that which of the following ethical principles should
be applied?
A. Veracity
B. Paternalism
C. Fidelity
D. Utility
41. A nurse notices smoke coming from a client’s room and discovers a fire in the wastebasket.
after moving the client to safety. which of the following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher.
42. A home health nurse is teaching the parents of a school-age child who has Legg-Calvé-
Perthes disease. Which of the following information should the nurse include?
A. “Your child will be contagious until the first round of antibiotics is complete.”
B. “Your child should perform weight-bearing exercises daily”
C. “Your child should continue to attend school”
D. “Your child will need to increase their daily caloric intake until they gain 5 pounds.”
43. A nurse in the post anesthesia care unit is caring for four postoperative clients. The nurse
realizes that coughing poses a risk to which of the following clients.
A client who had a thyroidectomy
44. A nurse in a mental health facility is interviewing a newly admitted client. which of the
following actions should the nurse take when conducting the interview?
Insist the client use direct eye contact during the interview
45. A nurse on a medical unit has just received change-of-shift report. Which of the following
clients should the nurse assess first?
A. A 68-year-old client who had a myocardial infarction 2 days ago and reports chest pain on a
scale of 0 to 10
B. INA 48-year-old client who has AIDS, pneumocystis pneumonia, and a temperature of 38.3 C
(101F)
C. A 60-year-old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an
oxygen saturation of 89%
D. A 26-year-old female client who has pelvic inflammatory disease and is unable to void
46. A nurse is caring for a client who has just returned to the unit following a bronchoscopy.
Which of the following actions by the assistive personal requires the nurse to intervene?
A. Encourages the client to use the incentive spirometer.
B. Elevates the head of the client’s bed.
C. Offers oral fluids to the client.
D. Checks the client’s pulse oximetry
47. A nurse is interviewing a client who presents with multiple injuries that are consistent with
intimate partner abuse. After establishing trust and rapport which of the following should the
nurse say?
“Let’s talk about what happened to you”
48. A client at 38 weeks of gestations enters the emergency department. the nurse should
recognize that which of the following indications that the client is in the latent phase of labor?
The cervix is dilated 2cm
49. A nurse is caring for a client who is 2hr postoperative following an Ileal conduit
procedures for bladder cancer. For which of the following findings should the nurse notify the
provider?
A. a dusky-colored stoma
B. absence of bowel sounds
C. serosanguineous drainage
D. urinary output 40ml/hr
50. A nurse is teaching a client who has a low-literacy level about home management of
diabetes mellitus. which of the following actions is appropriate?
Show the client an educational video
51. A nurse is caring for a group of clients. the nurse should request a referral for a speech
language pathologist for which of the following clients?
A client who has difficulty swallowing
52. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate by
continuous IV infusion. Which of the following client findings medication toxicity?
A. Blood glucose of 150 mg/dL
B. Urine output of 20 mL per hour
C. Systolic blood pressure at 140 mm Hg
D. BUN 20 mg/dL
53. A nurse is assessing a client who has pneumonia. Which of the following findings is
priority for the nurse to report to the provider?
A. Change in vocal tone after drinking liquids
B. Nocturia with episodes of incontinence
C. Oral temp of 100.4 F degree
D. Weight loss 1.8 kg in a month
54. A nurse is providing teaching about preventing mastitis to a client who is postpartum and
breastfeeding her newborn. Which of the following instructions should the nurse include?
A. “Wear an underwire bra between feedings.”
B. “Cover your breasts immediately after feedings.”
C. “Apply cold compresses to your breasts before feedings.”
D. “Try to have your baby empty your breasts with each feeding.”
55. A nurse is caring for a client who will be receiving a transfusion of platelets. The nurse
recognizes that the expected outcome of this treatment will be which of the following?
Decreases in bleeding from puncture sites
56. A nurse is caring for a client who has just given birth to a stillborn newborn. Which of the
following is the priority task for the nurse to facilitate in the client’s grief process?
A. Overcoming feeling of guilt about the NB death
B. Dealing with feelings of anger resulting from NB death
C. Acknowledging the reality of NB death
D. Understanding the reason for NB death
57. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive
phototherapy. Which of the following interventions should the nurse include?
Place the newborn 45cm (18in) from the light source
58. A nurse is precepting a nursing student who brings the following client observations to the
nurse’s attention. Which of the following clients should the nurse assess first?
A. A client who is 3hr post Foley catheter removal and has not voided
B. A client who is 3days postoperative colectomy with a large, loose melena stool
C. A client who is 1-day postoperative total hip replacement with a pain level of 7 on a scale of
0 to 10
D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1
hr ago
59. A nurse in a pediatric unit is caring for a group of clients. For which of the following disease
should the nurse implement droplet precautions?
Pertussis
60. A nurse is planning to delegate a client assignments to an assist personnel. which of the
following tasks is appropriate for the nurses to delegate?
A. Just the flow rate of the client’s oxygen tank
B. Collecting urine sample
C. Measuring the clients pain level
D. Monitoring blood glucose levels
61. A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following
actions should the nurse plan to take?
Use a designated stethoscope when Caring for the toddler
62. A nurse is assessing a client who has 2, para 1. the client is at 41 weeks of gestations and is
receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate
for which of the following findings?
Contractions occur every 90 seconds
63. A nurse is caring for a client who has fractures ribs, has developed thrombophlebitis, and is
being treated with a heparin drip. The client develops hematuria and has an activated partial
thromboplastin time of 100 seconds. which of the following actions should the nurse take first?
Turn off the heparin drip
64. A nurse is providing teaching to the parent of a 6-month-old infant who is teething and
having difficulty sleeping. Which of the following instructions should the nurse include?
A. “Rub your child’s gums with an aspirin tablet before bedtime.”
B. “Place an amber teething necklace on your child before bedtime.”
C. “Administer acetaminophen drops to your child before bedtime.”
D. “Apply a teething product containing benzocaine to your child’s gums before bedtime.”
65. A nurse is admitting a client who has antisocial personality disorder. Which of the following
client’s behaviors should the nurse identify as consistent with this disorder?
A. Compulsive attention to details
B. Avoids interacting with others
C. Uses others for personal gain
D. Socially awkward in group situations
66. A nurse is teaching a prenatal class about evidence of effective breastfeeding to a group of
parents. Which of the following information should be included? Select all that apply.
A. Newborn swallowing sounds are audible while breastfeeding
B. Newborns stools are yellow and seedy after 7 days of breastfeeding
C. Maternal breasts become soft following feedings
67. A nurse is providing discharge teaching to a client who has schizophrenia and is starting
therapy with clozapine. Which of the following is the highest priority for the client to report to
the provider?
A. Constipation
B. Blurred vision
C. Fever
D. Dry Mouth
68. A nurse is providing postoperative teaching to a client who has a newly inserted pacemaker.
Which of the following statements by the client indicates that the teaching has been effective?
“I will use my cell phone on the ear opposite of my pacemaker”
69. The nurse is caring for a client who is receiving lactated ringers to treat fluid volume
deficit. The nurse should identify that which of the following findings indicates a therapeutic
response to the treatment?
Increased hemoglobin and hematocrit levels
70. A nurse is caring for a client who is receiving systematic desensitization therapy to treat
agoraphobia. Which of the following client statements should indicate to the nurse that the
treatment has been effective?
A. “I have been able to watch a church service on television without anxiety.”
B. “I was able to sit on a park bench for 30 minutes.”
C. “I enjoyed a visit from four of my work friends at my house.”
D. “I had a panic attack when driving by the grocery store.”
71. A nurse is assessing a client who has pericarditis. Which of the following findings is the
priority?
A. paradoxical pulse
B. Dependent edema
C. Pericardial friction rub
D. Substernal chest pain
72. A nurse is caring for a preschool-age child who has a short-leg, plaster cast applied 1hr ago.
Which of the following is an appropriate intervention?
Support the affected leg on a pillow
73. A nurse is caring for a client who is taking allopurinol. The nurse should monitor which of
the following laboratory findings to determine the effectiveness of the medication?
A. Uric acid level
B. Serum chloride
C. Serum albumin
D. Magnesium level
74. A nurse is assessing a client prior to performing a blood draw. The nurse should identify that
an allergy to which of the following foods can indicate that the client has an allergy to latex?
A. Avocados
B. Eggs
C. Peanuts
D. Shellfish 
75. A nurse is delegating tasks to an assistive personnel. For which of the following clients
should the nurse have the AP measure vital signs?
A client who is requesting pain medication 2 days after surgery
76. A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
77. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions
should the nurse take?
A. Monitor fort abdominal ascites
B. Implement a low-carbohydrate diet.
C. Review serum amylase levels
D. Place warm compresses on area of pruritus.
A nurse is preparing to discharge a client who is to be transferred to a long-term care facility.
The nurse should recognize that which of the following actions is a breach of client
confidentiality?
discussing the client’s reaction to the transfer with another staff nurse
78. A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a
continuous IV infusion. After confirming compatibility, which of the following actions should
the nurse take?
A. Occlude the IV tubing above the injection port.
B. Use the injection port farther from the IV catheter insertion site.
C. Check for blood return after medication administration.
D. Flush the IV tubing with a heparinized solution.
79. A nurse is caring for a client who has a new prescription for lithium carbonate. prior to
administering the first dose, which of the following laboratory values should the nurse
evaluate?
A. ABG
B. Total cholesterol
C. Thyroid hormones
D. Hemoglobin
80. A nurse is caring for four clients. which of the following tasks can the nurse delegate to an
assistive personnel?
A. Perform chest compressions during cardiac resuscitation.
B. Perform a dressing change for a new amputee.
C. Assess effectiveness of antiemetic medication.
D. Provide discharge instructions
81. A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should
assess for which of the following potential contraindications?
Shellfish allergy
82. A nurse is caring for a client who has a chest tube and notes continuous bubbling in the
water-seal chamber. Which of the following actions should the nurse take?
A. Turn down the wall suction
B. Observe the system for an air leak
C. Obtain a prescription to discontinue the chest tube
D. Empty the drainage from the collection chamber
83. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis.
Which of the following instructions is appropriate for the nurse to include in the plan of care?
A. Assist the client to a supine position.
B. Recommend prophylactic acyclovir (Zovirax) for the client’s family.
C. Initiate droplet precautions for the client.
D. Perform a Glasgow Coma Scale every 24 hr
84. A nurse is caring for a client who has a new prescription for chlorpromazine by IM injection.
Which of the following is an appropriate nursing action?
A. Administer chlorpromazine with a loop diuretic
B. Check orthostatic blood pressure 1 hr after administration
C. Administer once daily 30 min before breakfast
D. Check weekly calcium levels
85. A nurse is planning care for a child who is unresponsive and has increased intracranial
pressure. Which of the following actions should the nurse take?
A. schedule routine oral suctioning
B. pad the side rails of the bed
C. obtain isolation supplies
D. place the child in the Trendelenburg position
86. A nurse is providing dietary teaching to a client who has an increased cholesterol level.
Which of the following foods should the nurse recommend?
A. Beef liver
B. Egg whites
C. Steamed claims
D. Broiled lobster
87. A nurse is caring for a client who has meningitis. Which of the following assessments should
the nurse perform?
A. Homans’ sign
B. Trousseau’s sign
C. Brudzinski’s sign
D. Chvostek’s sign
88. A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via
continuous IV infusion. Which of the following findings should the nurse report to the provider?
A. Respiratory rate 14/min
B. Blood pressure 150/98 mm Hg
C. Magnesium 9 mEq/L
D. 2+ deep tendon reflexes
89. A nurse is teaching a client who has a new prescription for digoxin. Which of the following
statements should the nurse include in the teaching?
A. “Notify your provider if you experience muscle weakness.”
B. “Reports a weight gain of one-half pound per day.”
C. “Expect this medication to increase your blood pressure.”
D. “You will need to take a diuretic while taking this medication.”
90. An infection control nurse is reviewing the medical records of several clients. Which of the
following infections should the nurse report to the centers for disease control and prevention?
A. Candidiasis
B. Pelvic inflammatory disease
C. MRSA
D. Syphilis
91. A nurse is preparing to administer eye drops to a preschooler who has conjunctivitis. Which
of the following actions should the nurse take?
A. Maintain the child in a sitting position for 3 min following administration
B. Administer the drops directly to the center of the eyeball
C. Apply pressure to the lacrimal punctum for 1 min following administration
D. Wipe excess medication from the outer canthus toward the nose
92. A nurse is caring for a client who has schizophrenia. the client’s states “run cats soon the
rain throwing procedure mechanical paper lake.” The nurse should document that the client is
demonstrating which of the following speech alterations?
A. Echolalia
B. Word salad
C. Neolgisms
D. Clang association
93. A nurse is discussing a living will with a client. Which of the following statements by the
client indicates an understanding of this document?
A. It expresses my wishes about distribution of my belongings after death
B. It designates a family member to make my health care decisions
C. It is required for anyone undergoing surgery
D. It communicates my wishes for end-of-life care
94. A nurse is planning care for a client who has anew diagnosis of dysphagia. Which of the
following foods should the nurse recommend?
A. Apple juice
B. Oatmeal
C. Beef broth
D. Toast
95. A nurse is assessing a client who is 8 hr postoperative following a right modified radical
mastectomy. Which of the following should the nurse recognize as the priority finding?
A. Urinary output of 100ml in 4 hr
B. Coughing frothy, pink secretions
C. Emesis of 110ml of thick yellow fluid
D. Red drainage on the dressing
E.
96. A nurse is caring for a client who has s diagnosis of antisocial personality disorder. The nurse
should expect the client to demonstrate which of the following?
A. Magical thinking
B. Mood swings
C. Ritualistic behaviors
D. Poor impulse control
E.
97. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following
findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
98. A nurse is providing care for a newly admitted client. Which of the following interventions
should the nurse plan to take?
Initiate iv access for the client
99. A home health nurse is admitting a client who has prescribed peritoneal dialysis. Which of
the following actions should the nurse take first?
A. Confirm schedule for delivery of supplies
B. Coordinate interdisciplinary health care services
C. Demonstrate how to perform the procedure
D. Clarify the clients actual and perceived health needs
E.
100. A nurse is assessing a client for pitting edema. when pressing into the dorsal side of the
client’s foot, the nurse’s fingers leaves a depression in the skin that is 8mm (0.3 in) deep. With
which of the following clarifications should the nurse document this finding?
A. 1+ edema
B. 2+ edema
C. 3+ edema
D. 4+ edema
101. A nurse is caring for a client following a possible exposure to anthrax. Which of the
following actions should the nurse take?
A. Administer antitoxin
B. Quarantine the client
C. Monitor the client for a productive cough
D. Begin prophylactic treatment with ciprofloxacin
102. A nurse is creating a plan of care for a client who has anorexia n nervosa. Which of the
following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
103. A nurse is caring for a client who is receiving gentamicin. Which of the following findings
indicates the client is developing toxicity?
A. Lethargy
B. Weight gain
C. Tinnitus
D. Blurred vision
104. A nurse is preparing to discharge a newborn who has an atrial septal defect. The nurse
should expect the provider to refer the client to which of the following Interprofessional team
members?
A. Case manager
B. Physical therapist
C. Occupational therapist
D. Nurse manager
105. A nurse is assessing an adolescent who has anorexia nervosa. Which of the following
findings should the nurse expect?
A. Hypertension
B. Menorrhagia
C. Hypokalemia
D. Diarrhea
E.
106. A nurse is admitting a client to the medical surgical unit. Which of the following actions
should the nurse take first?
A. Place the client’s valuables in the facility’s safe.
B. Observe the client’s level of mobility
C. Administer prescribed medications
D. Electronically enter the prescriptions from the provider
107. A nurse is teaching a group of farmworkers who works with pesticides about minimizing
exposure. Which of the following information should the nurse include in the teaching?
a. Change clothes after working in the field
b. Apply petroleum jelly to the nostrils prior to working in the field
c. Wipe fruits and vegetables from the field with a dry cloth before consuming
d. Take a hot shower 1 hr after finishing work
108. A nurse is caring for a client who is manic. Which of the following activities is appropriate
for the nurse to suggest?
A. Participating in a basketball game with other clients
B. Playing a computer game with another client
C. Taking a daily walk on the hospital grounds
D. Reading quietly in the room
109. A nurse is performing disaster triage following a natural disaster. Which of the following
should the nurse identify as the highest priority to receive care?
A. A client who has agonal respirations
B. A client who has an open skull fracture and is unresponsive
C. A client who has a traumatic arm amputation
D. A client who has a fracture of the femur
110. A nurse in the clinic is providing information to a client who has mastitis of the left breast.
The client asks the nurse, “does this mean that I must stop nursing my baby?” which of the
following is an appropriate statement by the nurse?
A. “No, you can continue to nurse from both your breasts”
B. ” Yes, you will have to discontinue breastfeeding “
C. ” No but you should alternate between the right breast and the bottle”
D. ” Yes, but you can resume nursing when you are done with your antibiotics”
111. A community health nurse us caring for a client who requests a referral for family therapy.
The nurse should initiate a referral to which of the following members of the interdisciplinary
team?
A. Occupational therapist
B. Social worker
C. Recreational therapist
D. Paramedical technologist
E.
112. A nurse on an orthopedic floor is completing the morning assessments on several clients.
Which of the following clients has the greatest risk for fat embolism syndrome (FES)?
A. A 24 yr old male who has a casted femur fracture
B. A 10 yr old female who has an ulnar fracture in an external fixator
C. A 49 yr old male who has multiple rib fractures
D. A 62 yr old female who has vertebral fractures due to osteoporosis
113. A nurse is assessing a full-term newborn who is 24 hr old. Which of the following findings
should the nurse report to the provider?
A. The newborns neck is short and surrounded by skin folds
B. The newborns glucose level is 50 mg/dl
C. The newborns sclera have a yellowish tiny
D. The newborn has experienced a weight loss of 3% since birth
114. A nurse on mental health unit receives report on four clients. Which of the following clients
should the nurse attend to first?
A. A client who had compulsive behavior and is frequently drinking from the water fountain
B. A client who has begun to demonstrate catatonic behavior
C. A client who is making sexual comments to clients of the opposite sex
D. A client who is having auditory hallucinations and is becoming agitated
E.
115. A nurse is setting up a sterile field for a dressing change on a postoperative client. Which
of the following actions should the nurse plan to take to maintain the sterile field?
A. Select a work surface at the nurse’s hip level
B. Drop the items onto the sterile field from a height of 20.3 cm
C. Open the first flap of the sterile package away from the nurse body
D. Apply sterile gloves to the non-dominant hand first
E.
116. A nurse is teaching the parent of an infant about the manifestations of food allergies. The
nurse identifies which of the following findings as a common manifestations of a food allergy?
A. Vomiting
B. Dry mouth
C. Decreased respiratory rate
D. Hypertension
E.
117. A nurse is assessing a client who has systemic lupus erythematous (SLE). Which of the
following is an expected finding?
A. Dry, raised facial rash
B. Subcutaneous nodules
C. Hyperuricemia
D. Polycythemia
118. A nurse is preparing to administer enoxaparin to a client. which of the following actions
should the nurse plan to take?
A. Inject the medication in the lateral abdominal wall
B. Expel the air bubbles at the top of the prefilled syringe
C. Massage the injection site to evenly distribute the medication
D. Administer an NSAID for injection site discomfort
119. At the beginning of the day shift, a team leader delegates the following tasks to the assist
personal (AP): bathe four clients, distribute fresh water, and obtain morning vital signs. at noon,
the nurse asks the AP to transport one client to physical therapy. The AP reports too clients still
need bed baths. Which of the following is an appropriate strategy for the nurse to delegate
more effectively in the future?
A. Set a clear time frame for the completion of each tasks
B. Plan a more reasonable job assignment
C. Coassign a more qualified individual to assist the AP
D. Volunteer to give the baths for the AP
120. A nurse manager at a public health clinic is concerned about the rising n umber of sexually
transmitted infections in the community. The purpose of which of the following is to generate
new ideas to address the public health concern?
A. A brainstorming session with nurses
B. A community wide program
C. Role playing with nurses
D. Personal discussions with clients
121. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus.
The nurse should evaluate which of the following laboratory test to determine effective long-
term management of blood glucose levels?
A. 3hr oral glucose tolerance test
B. HBA1c
C. Fasting blood glucose test
D. Urinalysis for ketones
122. A nurse is teaching a client who is to start taking phenelzine for major depressive disorder.
Which of the following foods should the nurse teach the client to avoid consuming while taking
this medication?
A. Cheddar cheese
B. Bananas
C. Chicken
D. Peanut butter
123. A nurse is about to administer an injection to a client when the client states, “I don’t want
that injection. the last time I got that I was sore for a week.” The nurse goes ahead and 
administers the injection against the clients wishes. The nurse committed which of the
following?
A. Battery
B. Assault
C. Coercion
D. A break of duty
124. A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal.
Which of the following findings should the nurse expect?
A. Hyperflexia
B. Meiosis
C. Euphoria
D. Hypothermia
125. A community health nurse is performing a vision screening on a 4-month-old infant. When
shining a light source into the infant’s visual field. which of the following is an expected finding?
A. The infant’s eyes turn toward the light
B. The infant’s head turns away from the light
C. The infant’s eyes remain focused toward the floor
D. The infant closes their eyes
E.
126. A nurse is assessing a client who has pneumococcal pneumonia. Which of the following
findings should the nurse expect?
Tachypnea
127. A nurse is teaching the parent of a school-age child who has scabies about the
application of permethrin 5% cream. the Nurse should include which of the following as a
potential adverse effect of the medication?
A. Burning
B. Discoloration
C. Photosensitivity
D. Alopecia
128. A nurse is collecting a specimen for an aerobic culture from a client who has a draining
pressure injury. Identify the sequence of actions the nurse should take? AEBCD.
a. Assess the appearance of the wound
b. Place the swab in the culture tube
c. Cleanse the wound with 0.9% sodium chloride irrigation
d. Cover the wound with a sterile dressing
e. Obtain the specimen from granulation tissue of the wound
129. A nurse is caring for a group of clients in an inpatient mental health facility. Which of the
following tasks should the nurse delegate to an assistive personnel?
A. Obtain the vital signs of a client who has experienced a seizure
B. Witness a client’s signature on an informed consent document
C. Sit with a client who has anorexia nervosa during meals
D. Complete an incident report following a client fall
130. A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. generalized edema
B. elevated urine specific gravity
C. thready pulse
D. increase hematocrit
131. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse
a list of client reports. which of the following client reports should the nurse assess first?
A. Constipation
B. Indigestion
C. Swollen ankles
D. Urinary frequency
132. A nurse is caring for a group of clients. Which of the following clients should the nurse
identify as being at risk for metabolic alkalosis?
A. a client who has kidney failure
B. a client who has severe hyperemesis
C. a client who has type 2 diabetes mellitus
D. a client who has chronic constipation
133. A nurse is assessing a client who has COPD and experienced recent weight loss. which of
the following findings should the nurse report to the provider immediately?
A. A barrel chest
B. Coughing and wheezing after eating
C. Abdominal bloating
D. A drop in oxygen saturation to 91% while eating
134. A nurse is providing teaching about car seat safety to the parent of a term newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
A. “I should place a rolled blanket along each side of my babies head in the car seat.”
B. “I should put the car seat retainer clip at the level of my baby’s belly button.”
C. “I should place my baby’s car seat rear facing until 6 months of age.”
D. “I should position my baby’s car seat at a 90-degree angle in the car.”
135. A nurse is caring for a postoperative client. Which of the following interventions will
reduce the risk of deep-vein thrombosis?
A. Massage the lower extremities while resting in bed
B. Place a pillow under the client’s knees
C. Apply venous plexus foot pumps
D. Encourage client to dangle legs when sitting on the edge of the bed
E.
136. A community health nurse is preparing to collect data to study the health of a local
community. The nurse should plan to obtain information about which of the following factors
during a windshield survey?
A. The availability of religious facilities
B. Influenza incidence rates the current year
C. The leading cause of death for the prior year
D. Individual perceptions about how residents interact
E.
137. A nurse is assessing the vitals of a newborn who was born 8hrs ago. Which of the following
findings requires interventions by the nurse?
A. Blood pressure 72/45 mm Hg
B. Respiratory rate 44/min
C. Heart rate 156/min
D. Temperature 36.2 C
138. A nurse administers a dose of metoclopramide to a client prior to a chemotherapy
treatment. the client develops uncontrolled contractions of the head and neck muscles. Which
of the following medications should the nurse administer?
A. Hydromorphone
B. Diphenhydramine
C. Albuterol sulfate
D. Amitriptyline
139. A nurse in the emergency department is caring for a client following a motor-vehicle crash.
Which of the following actions should the nurse take first?
stabilize the cervical spine
140. A nurse is admitting an unidentified female infant who was brought into the emergency
department. Based on the assessment findings, the nurse should estimate the infants age to be
which of the following?
3-month-old
141. A nurse in a clinic is teaching a client who is postmenopausal about estrogen therapy.
Which of the following information should the nurse include in the teaching?
A. Estrogen therapy decreases the risk for breast cancer
B. Estrogen therapy increase the risk for thrombus formation
C. Estrogen therapy can cause weight loss
D. Estrogen therapy increases the risk for seizures.
142. A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased
blood pressure. The nurse should identify that these findings are potential manifestations of
which of the following?
Opioid intoxication
143. A nurse is providing teaching to the guardian of a 5-month-old infant about introducing
new foods. Which of the following instructions should the nurse include in the teaching?
“introduce a new food every 5 to 7 days”
144. A nurse is teaching a group of newly hired nurses about placenta previa. Which of the
following client findings should the nurse include?
bright red vaginal bleeding
145. Four clients present to the emergency department. The nurse should plan to see which
of the following clients first?
A. A 6-year-old client whose left shoulder is dislocated
B. A 26-year-old client for sickle cell disease and a severe joint pain
C. A 76-year-old client was confused, febrile and has foul smelling urine 
D. A 50-year-old client who has slurred speech, is disoriented, and reports a headache
146. A nurse is performing an admission assessment for a client who is to undergo a
colonoscopy. The client informs the nurse that he took prescribed medications before coming
to the clinic. which of the following medications is the priority to report to the provider?
A. Metoprolol
B. Clopidogrel
C. Metformin
D. Digoxin
147. A charge nurse is evaluating the time management skills of a newly licensed nurse.
Which of the following actions should the charge n nurse identify as an effective time
management skill?
A. Delegates creation of a client’s teaching plan to a licensed practical nurse
B. Completes activities for one client before moving to the next client
C. Focuses on activities rather than objectives
D. Skips break times to catch up on charting
148. A nurse is caring for a client who has a newly implanted sealed internal radiation device
to treat cervical cancer. Which of the following is an appropriate action for the nurse to take?
A. Prohibit visitors for the first 24 hrs
B. Keep a 3-foot distance from the radiation implant
C. Maintain the client on bed rest for 72 hr
D. Require the client wear a dosimeter badge
149. A nurse in a provider’s office is teaching to a client who is at 16 weeks of gestations and has
a new prescription for ferrous sulfate. Which of the following instructions should the nurse
include?
“take your iron medication with fluids other than coffee or tea”
150. A nurse is caring for a client who has heart failure and has started taking loop diuretic.
Which of the following findings indicates the client is experiencing an adverse effect of the
medication?
A. Decreased reflexes
B. Weight gain of 1.4 kg.
C. Increased urinary output
D. Jugular vein distention.
151. A nurse is performing a skin assessment for a client who is on bedrest. Which of the
following actions should the nurse take to prevent a pressure injury?
A. Encourage client fluid intake of 2,500 ml daily.
B. Moisturize dry skin areas on the client every other day.
C. Place a dehumidifier in the client’s room.
D. Apply a donut ring pillow under the client’s sacral area.
152. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed
nurse. Which of the following statements indicates the newly licensed nurse understands the
purpose of the teaching?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
E.
153. A nurse is performing high-frequency chest compressions using a mechanical chest
compression device for a child who has cystic fibrosis. Which of the following findings indicates
the treatment has been effective?
The child has increased sputum production
154. A nurse is planning care for a client who is at 10 weeks of gestations and has a history of
urinary tract infections (UTI’s). Which of the following information should the nurse plan to
include in the teaching about UTI prevention?
A. Decrease intake of citrus foods and beverages.
B. Wear nylon underwear.
C. Empty the bladder before and after intercourse.
D. Increase the time between voiding.
155. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. the
client is scheduled to have the morning dose at 0700. The should schedule the trough level at
which of the following times?
A. 2100
B. 0900
C. 1300
D. 1800
156. A nurse is caring for a client who has breast cancer and has been receiving
chemotherapy. Which of the following laboratory values should the nurse report to the
provider?
A. WBC 3,000/mm3
B. Hemoglobin 14 g/dl
C. Platelet 250,000/mm3
D. aPTT 30 seconds
157. A nurse is reviewing the laboratory report of a client who has a magnesium level of 1.0
men/ml. Which of the following assessment findings should the nurse expect?
A. Confusion
158. A charge nurse is teaching a group of unit nurses about the policy for clients who have a
history of MRSA. which of the following information should the nurse include?
A. A client who has a history of MRSA will need antibiotics
B. A client who has a history of MRSA can develop immunity to the infection
C. A client who has a history of MRSA requires a protective environment
D. A client who has a history of MRSA can still transmit the infection
160. A nurse is setting up a sterile field before preforming a dressing change on a client who is
postoperative. Which of the following actions should the nurse plan to take to maintain the
sterile field? (Select all that apply)
A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap
B. Open the first flap of the sterile package toward the nurse’s body
C. Place a surgical pack with a sterile drape on the work surface
D. Select a work surface at the nurse’s waist level
E. Apply sterile gloves before opening the pack
161. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following
clients would benefit from a three-way indwelling catheter?
A. A female client who is prone to development of blood clots in the urine
B. A female client who has a history of chronic urinary tract infections
C. A male client who has spontaneous bladder emptying
D. A male client who has postoperative acute urinary retention
162. A nurse is providing teaching about nutrition to the parents of a preschooler who has
chronic renal failure. Which of the following indicates understanding teaching?
A. I should encourage my child to eat foods that are high in phosphorous
B. I should limit my child’s intake of unsaturated fats
C. I should encourage my child to eat more foods that contain sodium
D. I should limit my child’s intake of proteins
163. A nurse is preparing to administer enoxaparin to a client. Which of the following actions
should the nurse take?
A. Apply firm pressure to the injection site following administration.
B. Expel the air bubble from the syringe prior to injection.
C. Insert the syringe needle halfway into the client’s skin.
D. Administer the medication into the client’s muscle.
164. A nurse is caring for a child who has infectious mononucleosis. Which of the following
findings are associated with this diagnosis? Select all that apply
A. splenomegaly
B. Koplik spots (this is associated with measles)
C. Malaise
D. Vertigo
E. Sore throat
165. A nurse is analyzing the cardiac rhythms of for telemetry clients in the coronary care
unit. Identify the rhythm strip that the nurse would recognize as indicative of a client who
should be receiving warfarin?
a. Rhythm C
166. A nurse is teaching a client about nutritional intake. The nurse should include which of
the following in the teaching?
A. ” Carbohydrates should be at least 45% of your caloric intake.
B. “Protein should be at least % of your calorie intake.”
C. ” Carbohydrates should be at least 30% of your caloric intake.”
D. “Protein should be at least 60\% of your caloric intake.”
167. A nurse is caring for a client who has schizophrenia. The nurse should expect to exhibit
which of the following manifestations? (Select all the apply.)
A. Repeats the word of others when speaking
B. Speaks in word salad
C. Expresses interest in ADLs
D. Has a blunt affect
E. Experiences delusions
168. A nurse manager in a community health clinic is reviewing the medical records of clients
who have diagnoses of communicable diseases. Which of the following infectious diseases
should the nurse report to the Centers for Disease Control and Prevention?
A. Impetigo
B. Pneumocystis pneumonia
C. HPV
D. Hep a
169. A nurse is teaching a client who is at 35 weeks of gestation about amniocentesis. Which of
the following statements should the nurse include in the teaching?
A. You should receive terbutaline subcutaneously at the start of the test
B. You will need to have a fully bladder at the start of the test
C. You will have to stay in the hospital overnight for fetal monitoring after the test
D. You should monitor and report the onset of contractions after the test
170. A nurse is caring for a client who has heart failure and a potassium of 3 mEq/L. The nurse
should obtain verification of which of the following prescriptions from the provider?
A. Digoxin 0.125 mg PO daily
B. Strict intake and output
C. Cardiac monitoring
D. Spironolactone 25 mg PO daily
171. A nurse is assessing a client who was brought to the ED by hid adult child. The client has
visible contusions on all four extremities. Which of the following actions should the nurse take?
A. Report the incident to Adult Protective Services
B. Interview the client with his adult child present
C. Tell the client he must answer every assessment question
D. Advise the client to consult a social worker
172. A nurse is reviewing the medical records of four clients. Which of the following
prescriptions represent correct documentation?
A. Atropine 4 mg IV stat
B. Lorazepam 1.0 IV PRN every 6 hr
C. Sucralfate 1g PO 1 hr ac
D. Enoxaparin 30 mg SC every 12 hr
173. A nurse manage is reviewing documentation standards with a group of newly licensed
nurses. Which of the following statements should the nurse manager include in the teaching?
A. Include the complete name of the medication morphine sulfate
B. Do not use a leading zero to a decimal point
C. Write the letter U when noting the dosage of insulin
D. Use the abbreviation QOD when indicating every other day.
174. A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of
the following medications should the nurse expect the provider to prescribe?
A. Varenicline
B. Disulfiram
C. Sertraline
D. Clonidine
175. A nurse is planning care for a client who has a gambling disorder. Which of the following
instructions should the nurse provide to the client?
A. Participate in a 12-step program
B. Plan to take clozapine for the next 6 months
C. Use systematic desensitization to decrease gambling behaviors
D. Learn to use projection to adapt to stressful experiences
176. A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints
for a client who threw a chair in the day room. The nurse should identify which of the following
findings as an indication to remove the restrains?
A. The client follows the nurse’s simple instructions.
B. The client apologizes for their aggressive behavior.
C. The client requests that the restraints be removed.
D. The client maintains eye contact while talking with the nurse.
177. A circulating nurse is implementing a “time out” before moving a client who is having a
total hip arthroplasty to the surgical suite. Which of the following actions should the nurse take?
Check if an antibiotic was administered within the last 90 min
Check if there is an advance directive document on the chart
Confirm the client’s identity with one identifier
Confirm the provider has marked the surgical site
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