, 160 Questions
PLEASE NOTE: Health care system is continuously changing, guidelines and
recommendation could differ from time to time, the answers of below questions were
made up to our best knowledge and elimination of wrong answers – and remember that
most of the time there are more than a correct answer but you have to choose the MOST
important or priority or what’s within nursing scope of practice. We tried our best to have
all answers correct but we do not guarantee that 100%. You must study and review them
as well. Good luck!
1.After receiving IV fluids in the emergency department, an elderly client is admitted to
the acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9%
normal saline at 125 ml/hour via saline lock and has a bounding pulse, tachycardia, and
pedal edema. When contacting the healthcare provider, the nurse anticipates a
prescription what intervention?
A) Remove the saline lock from the client’s arm.
B)Increase the rate of the normal saline infusion.
C) Decrease the rate of the normal saline infusion.
D) Change the IV solution to 0.45% saline solution.
2. A client who is admitted to the care unit with syndrome of inappropriate antidiuretic
hormone (SIADH) has developed osmotic demyelination. Which intervention should
the nurse implement first? A) Patch one eye.
B) Evaluate swallow.
C) Reorient often.
D) Range of motion.
, 3. The nurse is preparing a client who had a below-the-knee (BKA) amputation for
discharge to home. Which recommendations should the nurse provide this client?
(Select all that apply)
A) Wash the stump with soap and water.
B) Avoid range of motion exercise.
C) Apply alcohol to the stump after bathing.
D) Inspect skin for redness.
E) Use a residual limb shrinker.
4. After 2 days treatment for dehydration, a child continues to vomit and have diarrhea.
Normal saline is infusing and the chi ld’s urine output is 50ml/hour. During morning
assessment, the nurse determines that the child is lethargic and difficult to arouse.
Which should the nurse implement?
A) Increase the IV fluid flow rate.
B) Review 24-hour intake and output.
C) Obtain arterial blood gases.
D) Perform a finger stick glucose test.
5. A client with bleeding esophageal varices receives vasopressin IV. What should the
nurse monitor for during the IV infusion of this medication?
B) Chest pain and dysrhythmia.
C) Hypotension and tachycardia.
D) Decreasing GI cramping and nausea. A)
Vasodilatation of the extremities.
, 6. A male client with an antisocial personality disorder is admitted to an inpatient mental
health unit for multiple substance dependency. When providing a history, the client
justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this
client’s history is most likely to include which finding?
A) Multiple convictions for misdemeanors and Class B felonies.
B) Delusions of grandiosity and persecution.
C) Suicidal ideations and multiple attempts.
D) Photos and panic attacks when confronted by authority figures.
7. An older client is admitted for repair of a broken hip. To reduce the risk for infection
postoperative period., which nursing care intervention should the nurse include the
client’s plan of care? (Select all that apply)
A) Administer low molecular weight heparin as prescribed.
B) Teach client to use incentive spirometer every 2 hours while awake.
C) Remove urinary catheter as soon as possible and encourage voiding.
D) Maintain sequential compression devices while in bed.
E) Assess pain level and medicate PRN as prescribed.
8. The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client with insulin
shock. How should the nurse administer the medication?
A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
B. Push undiluted slowly though the currently infusing IV.
C. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
D. Ask the pharmacist to add the Dextrose to a TPN solution.
9. A client with arthritis has been receiving treatment with naproxen and now reports
ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should
the nurse monitor?
A) Serum Calcium.
B) Erythrocyte sedimentation rate.
C) Osmolality.
D) Hemoglobin.
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