A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for
injuries sustained from a fall. His parents are very concerned that the child has
regressed in his toileting behaviors. Which information should the nurse provide to the
parents?
A. A retraining program will need to be initiated when the child returns home.
B. Diapering will be provided since hospitalization is stressful to preschoolers
C. A potty chair should be brought from home so he can maintain his toileting skills
D. Children usually resume their toileting behaviors when they leave the hospital – ans
D. Children usually resume their toileting behaviors when they leave the hospital
A 7-year old is admitted to the hospital with persistent vomiting, and a nasogastric tube
attached to low intermittent suction is applied. Which finding is most important for the
nurse to report to the healthcare provider?
A. Shift intake of 640mL IV fluids plus 30mL PO ice chips
B. Serum pH of 7.45
C. Gastric output of 100 mL in the last 8 hours
D. Serum potassium of 3.0 mg/dL – ans D. Serum potassium of 3.0 mg/dL
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the
hospital. Which information is most important for the nurse to provide the parents prior
to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family – ans A. Instructions about how
much fluid the child should drink daily
A client asks the nurse for information about how to reduce risk factors for benign
prostatic hyperplasia (BPH). Which information should the nurse provide?
A. Consume a high protein diet
B. Increase physical activity
C. Take vitamin supplements
D. Obtain a prostate-specific antigen blood level test – ans B. Increase physical activity
A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of
hyperemesis gravidarum. Which action is most important for the nurse to implement?
A. Obtain the client's 24-hour dietary recall
B. Document mucosal membrane status
C. Schedule a consult with a nutritionist
D. Initiate prescribed intravenous fluids – ans D. Initiate prescribed intravenous fluids
A client diagnosed with calcium kidney stones has a history of gout. A new prescription
for aluminum hydroxide is scheduled to begin at 0730. Which client medication should
the nurse bring to the healthcare provider's attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose – ans B. Allopurinol
A client fell in the bathroom when left unattended by the unlicensed assistive personnel
(UAP). Which information should the nurse include in the client's health record?
A. The UAP left the client to assist another client
B. The last time client was assisted to the bathroom
C. The unit was understaffed when the client fell
D. The client fell sustaining a fracture to the left hip – ans D. The client fell sustaining a
fracture to the left hip
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports
sleeping only three hours during the past 48 hours. Based on these findings, it is most
important for the nurse to review the laboratory value for which medication?
A. Lorazepam
B. Fluoxetine
C. Divalproex
D. Olanzapine – ans C. Divalproex
A client in the third trimester of pregnancy reports that she fells some "lumpy places" in
her breasts and that her nipples sometimes leak a yellowish fluid. She has an
appointment with her healthcare provider in two weeks. What action should the nurse
take?
A. Tell the client to begin nipple stimulation to prepare for breast feeding.
B. Reschedule the client's prenatal appointment for the following day
C. Explain that this normal secretion can be assessed at the next visit
D. Recommend that the client start wearing a supportive brassiere – ans C. Explain that
this normal secretion can be assessed at the next visit
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for
the nurse to report to the healthcare provider?
A. Volume of each voiding is more than 300mL
B. Serum potassium that is elevated
C. Relief of flank pain that radiated into the groin
D. Hematuria that is beginning to turn pink – ans D. Hematuria that is beginning to turn
pink
A client is diagnosed with Meniere's disease. Which problem should the nurse identify
as most important in the plan of care?
A. Risk for ineffective self-health management related to deficient knowledge
B. Ineffective coping related to personal vulnerability
C. Risk for injury related to vertigo
D. Anxiety related to disruption of lifestyle – ans C. Risk for injury related to vertigo.
A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for
adverse effects of the medication, which serum laboratory value is most important for
the nurse to monitor?
A. Glucose
B. Calcium
C. Platelet count
D. White blood cell count - ansC. Platelet count
A client is recovering in the critical care unit following a cardiac catheterization. IV
nitroglycerin and heparin are infusing. The client is sedated but responds to verbal
instructions. After changing positions, the client complains of pain at the right groin
insertion site. What action should the nurse implement?
A. Check femoral site for hematoma formation
B. Stimulate the client to take deep breaths
C. Evaluate the integrity of the IV insertion site
D. Assess distal lower extremity capillary refill - ansB. Stimulate the client to take deep
breaths
A client is scheduled for a spiral computed tomography (CT) scan with contrast to
evaluate for pulmonary embolism. Which information in the client's history requires
follow-up by the nurse?
A. CT scan that was performed 6 months earlier
B. Metal hip prosthesis was placed 20 years ago
C. Report of client's sobriety for the last 5 years
D. Takes metformin for type 2 diabetes mellitus - ansD. Takes metformin for type 2
diabetes mellitus
A client presents to the emergency department with muscle aches, headache, fever,
and describes a recent loss of taste and smell. The nurse obtains a nasal swab for
COVID-19 testing. Which action is most important for the nurse to take?
A. Place the nasal swab specimen for COVID-19 directly into a biohazard bag
B. Move the client to a private room, keep the door closed, and initiate droplet
precautions.
C. Teach the client to wear a mask, hand wash, and social distance to prevent
spreading the virus
D. Explain to the client to inform others that they may have been potentially exposed in
the last 14 days. - ansA. Place the nasal swab specimen for COVID-19 directly into a
biohazard bag
A client presents to the labor and delivery unit with a report of leaking fluid that is
greenish-brown vaginal discharge. Which action should the nurse take first?
A. Start an intravenous infusion
B. Administer oxygen via facemask
C. Perform a vaginal exam
D. Begin continuous fetal monitoring - ansD. Begin continuous fetal monitoring
A client presses the call bell and requests pain medication for a severe headache. To
assess the quality of the client's pain, which approach should the nurse use?
A. Ask the client to describe the pain
B. Observe body language and movement
C. Identify effective pain relief measures
D. Provide a numeric pain scale - ansA. Ask the client to describe the pain
A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the
nurse implement first?
A. Observe the appearance of the stool
B. Assess the elasticity of the client's skin
C. Review the client's laboratory values
D. Auscultate the client's bowel sounds - ansA. Observe the appearance of the stool
A client tells the nurse about working out with a personal trainer and swimming three
times a week in an effort to lose weight and sleep better. The client states that it still is
taking hours to fall asleep at night. Which action should the nurse implement?
A. Advise the client that lifestyle changes often take several weeks to be effective
B. Encourage the client to exercise everyday to eliminate bedtime wakefulness
C. Ask the client for a description of the exercise schedule that is being followed
D. Determine the amount of weight the client has lost since increasing activity - ansC.
Ask the client for a description of the exercise schedule that is being followed
A client who experienced a cerebrovascular accident (CVA) is aphasic and has left
sided paralysis. Which nurse should be responsible for coordinating the progression of
this client's care?
A. Nurse case manager
B. Adult nurse practitioner
C. Neurology unit supervisor
D. Risk management nurse - ansB. Adult nurse practitioner
A client who gave birth 48 hours ago has decided to bottle feed the infant. During the
assessment, the nurse observes that both breasts are swollen, warm, and tender on
palpation. Which instruction should the nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve pressure - ansA. Apply ice
to the breasts for comfort
A client who is admitted for primary hypothyroidism has early signs of myxedema coma.
In assessing the client, in which sequence should the nurse complete these actions?
(descending order) - ans1. Observe breathing patterns
2. Assess blood pressure
3. Measure body temperature
4. Palpate for pedal edema
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