1. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-
old. Which of the following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure. - B. Tell the child they will feel
discomfort during the catheter insertion.
2. A nurse is caring for a client who has arteriovenous fistula Which of the
following findings should the nurse report?
A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation. - B. Absence of a bruit.
3. A nurse is providing discharge teaching for a client who has an
implantable cardioverter defibrillator which of the following statements
demonstrates understanding of the teaching?
A. "I will soak in the tub rather and showering"
B. "I will wear loose clothing around my ICD"
C. "I will stop using my microwave oven at home because of my ICD"
D. "I can hold my cellphone on the same side of my body as the ICD" - B. "I will wear loose
clothing around my ICD"
4. A nurse is caring for a client who is at 14 weeks gestation and reports
feelings of ambivalence about being pregnant. Which of the following
responses should the nurse make?
A. "Describe your feelings to me about being pregnant"
B. "You should discuss your feelings about being pregnant with your
provider"
C. "Have you discussed these feelings with your partner?"
D. "When did you start having these feelings?" - A. "Describe your feelings to me about being
pregnant"
5. A nurse is planning care for a client who has a prescription for a bowel-
, training program following a spinal cord injury. Which of the following actions
should the nurse include in the plan of care?
A. Encourage a maximum fluid intake of 1,500 ml per day.
B. Increase the amount of refined grains in the client's diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled
defecation times. - D. Administer a rectal suppository 30 minutes prior to scheduled
defecation times.
6. A nurse is caring for a client who is in active labor and requests pain
management. Which of the following actions should the nurse take?
A. Administer ondansetron.
B. Place the client in a warm shower.
C. Apply fundal pressure during contractions.
D. Assist the client to a supine position. - B. Place the client in a warm shower.
7. a nurse in an emergency department is performing triage for multiple
clients following a disaster in the community. To which of the following types
of injuries should the nurse assign the highest priority?
A. Below-the knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10cm (4in) laceration to the forearm - A. Below-the knee amputation
8. a nurse manager is updating protocols for the use of belt restraints. Which
of the following guidelines should the nurse include?
A. Remove the client's restraint every 4hr
B. Document the client's condition every 15 min
C. Attach the restrain to the bed's side rails
D. Request a PRN restrain prescription for clients who are aggressive - B. Document the client's
condition every 15 min
9. A nurse is teaching an in-service about nursing leadership. Which of the
following information should the nurse include about an effective leader?
A. Acts as an advocate for the nursing unit.
B. (Unable to read) for the unit
C. Priorities staff request over client needs.
D. Provides routine client care and documentation. - A. Acts as an advocate for the nursing unit.
10. A nurse is reviewing the laboratory findings of a client who has diabetes
mellitus and reports that she has been following her (unable to read) care.
The nurse should identify which of the following findings indicates a need to
revise the client's plan of care.
A. Serum sodium 144 mEq/
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