1. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to
the emergency department (ED) with full thickness burns to all surfaces of both lower
extremities. What percentage of body surface area should the nurse document in the
electronic medical record (EMR)?
9%
18 %
36 %
45 %
• Rational: according to the rule of nines, the anterior and posterior surfaces of one
lower extremity is designated as 18 %of total body surface area (TBSA), so both
extremities equals 36% TBSA, other options are incorrect.
2. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that
the medication is having the desired effect?
Decrease in serum T4 levels
Increase in blood pressure
Decrease in pulse rate
Goiter no longer palpable
3. An older male client with type 2 diabetes mellitus reports that has experiences legs pain
when walking short distances, and that the pain is relieved by rest. Which client behavior
indicates an understanding of healthcare teaching to promote more effective arterial
circulation?
Consistently applies TED hose before getting dressed in the morning.
Frequently elevated legs thorough the day.
Inspect the leg frequently for any irritation or skin breakdown
Completely stop cigarette/ cigar smoking.
• Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and
improve arterial circulation to the extremity.
,4. A community health nurse is concerned about the spread of communicable diseases among
migrant farm workers in a rural community. What action should the nurse take to promote the
success of a healthcare program designed to address this problem?
Establish trust with community leaders and respect cultural and family
values
5. The nurse performs a prescribed neurological check at the beginning of the shift on a client
who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s
Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to
determine?
The client’s previous GCS score
When the client’s stroke symptoms started
If the client is oriented to time
The client’s blood pressure and respiration rate
Rationale: The normal GCS is 15, and it is most important for the nurse to
determine if it abnormal score a sign of improvement or a deterioration in the
client’s condition
6. The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is
stable enough to be transferred. Which client status report indicates readiness for transfer
from the critical care unit to a medical unit?
Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
7. Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
One inch- border around the edge of the sterile field set up in the operating room
A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
An open sterile Foley catheter kit set up on a table at the nurse waist level
Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
• Rationale: A sterile package at or above the waist level is considered sterile. The
edge of sterile field is contaminated which include a 1-inch border (A). A sterile
objects become contaminated by capillary action when sterile objects become in
contact with a wet contaminated surface.
8. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms
when taking the blood pressure using the same arm. After confirming the presence of spams
what action should the nurse take?
Ask the UAP to take the blood pressure in the other arm
, Tell the UAP to use a different sphygmomanometer.
Review the client’s serum calcium level
• Administer PRN antianxiety medication.
• Rationale: Trousseau’s sign is indicated by spasms in the distal portion of an
extremity that is being used to measure blood pressure and is caused by
hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
9. A 56-years-old man shares with the nurse that he is having difficulty making decision about
terminating life support for his wife. What is the best initial action by the nurse?
Provide an opportunity for him to clarify his values related to the decision
Encourage him to share memories about his life with his wife and family
Advise him to seek several opinions before making decision
Offer to contact the hospital chaplain or social worker to offer support.
• Rationale: When a client is faced with a decisional conflict, the nurse should first
provide opportunities for the client to clarify values important in the decision. The
rest may also be beneficial once the client as clarified the values that are
important to him in the decision-making process.
10. A client is being discharged home after being treated for heart failure (HF). What instruction
should the nurse include in this client’s discharge teaching plan?
Weigh every morning
Eat a high protein diet
Perform range of motion exercises
Limit fluid intake to 1,500 ml daily
11. A woman just learned that she was infected with Heliobacter pylori. Based on this finding,
which health promotion practice should the nurse suggest?
Encourage screening for a peptic ulcer
12. A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
13. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum
potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?
Cardiac rhythm and heart rate.
Daily intake of foods rich in potassium.
, Hourly urinary output
Thirst ad skin turgor.
14. The nurse note a depressed female client has been more withdrawn and non-communicative
during the past two weeks. Which intervention is most important to include in the updated
plan of care for this client?
Encourage the client’s family to visit more often
Schedule a daily conference with the social worker
Encourage the client to participate in group activities
Engage the client in a non-threatening conversation.
• Rationale: Consistent attempts to draw the client into conversations which focus
on non-threatening subjects can be an effective means of eliciting a response,
thereby decreasing isolation behaviors. There is not sufficient data to support the
effectiveness of A as an intervention for this client. Although B may be indicated,
nursing interventions can also be used to treat this client. C is too threatening to
this client.
15. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel)
subcutaneously once weekly. The nurse should emphasize the importance of reporting
problem to the healthcare provider?
Headache
Joint stiffness
Persistent fever
Increase hunger and thirst
• Rationale: Enbrel decrease immune and inflammatory responses, increasing the
client’s risk of serious infection, so the client should be instructed to report a
persistent fever, or other signs of infection to the healthcare provider.
16. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding
indicates that the client understands long- term control of diabetes?
The fating blood sugar was 120 mg/dl this morning.
Urine ketones have been negative for the past 6 months
The hemoglobin A1C was 6.5g/100 ml last week
No diabetic ketoacidosis has occurred in 6 months.
• Rationale: A hemoglobin A1C level reflects he average blood sugar the client had
over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client
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