,A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse
should identify which of the following as an indication of hopelessness?
a. The client wants to talk about the diagnosis with nursing staff
b. The client has a decreased energy level
c. The client makes funeral arrangements
d. The client requests a second opinion
A nurse is preparing to collect data on a preschooler. Which of the following behaviors by
the child indicates that he is ready to cooperate? (Select all that apply)
c. Allows the nurse to touch him on the arm
d. Plays with toys in the examining room
c. Answers questions asked by the
nurse d. Makes eye contact with the
nurse
e. Sits on his parent’s lap when the nurse enters the room
A nurse on a mental health unit is planning care for a group of clients. Which of the
following clients should the nurse see first?
e. A client who has bipolar disorder and is displaying flights of ideas
f. A client who has ADHD and has an inability to concentrate
g. A client who has schizophrenia and is having command hallucinations
h. A client who has depressive disorder and is withdrawn
A nurse is caring for a client who recently gave birth to her first child. The newborn is
crying and the client states, “ I can’t seem to do anything right. What should I do?” Which
of the following responses should the nurse make?
i. “I’ll take him back to the nursery, so you can get some rest.”
j. “Babies need to cry soon after they are born to develop their lungs.”
k. “Let me show you how to swaddle and cuddle him, then you try.”
l. “If I turn him on his side, maybe he’ll go back to sleep.”
4. A nurse is using a glucometer to measure a client’s capillary blood glucose level, Which
of the following actions should the nurse take?
a. Test the first drop of blood that forms after the puncture
b. Wear sterile gloves
c. Keep the finger in a dependent position
d. Select the central tip of the finger
5. A nurse is reviewing the home medications of a client who recently had transient
ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client
that which of the following over-the-counter medications interacts adversely with
clopidogrel?
a. Docusate sodium
b. Ranitidine
c. Vitamin D3
, d. Naproxen
6. A nurse is collecting data from a client who has a long leg cast that was applied 2 days
ago. The client’s foot is pale with a weak pedal pulse, and the client reports foot numbness.
Which of the following actions should the nurse plan to take first?
a. Administer opioid pain medication
b. Apply an ice pack to the affected extremity
c. Check for pain with passive movement of the affected extremity
d. Elevate the affected extremity with several pillows
7. A nurse in a provider’s office is reinforcing teaching about cigarette smoking with a client.
Which of the following adverse effects should the nurse include in the teaching?
a. Decreased hemoglobin
b. Somnolence
c. Bradycardia
d. Decreased blood pressure
8. A nurse is contributing to the development of an in-service program for mental
health nursing staff. The nurse should include that the st aff can medicate a client
against his will, without a court hearing, in which of the following situations?
a. A client who has a serious mental illness
b. A client who is having difficulty making decisions about his treatment
c. A client for whom the benefits of the medication outweigh the risks
d. A client who is attempting to hurt himself or others
9. A nurse is reinforcing teaching with a client who has a new prescription for digoxin.
Which of the following instructions should the nurse include in the teaching?
a. “Monitor for muscle weakness while taking the medication.”
b. “Rotate injection sites when administering the medication.”
c. “Withhold the medication if your pulse rate is above 100 beats per minute.”
d. “Increase your intake of dietary fiber to increase absorption.”
10. A charge nurse is discussing confidentiality requirements with a newly licensed nurse
when sharing a client’s medical information. Which of the following individuals should the
charge nurse identify as appropriate with whom to share client information?
a. A nurse from another unit after a client commits suicide
b. A social worker who is assigned to an involuntary committed school-age client
c. A client’s partner after the client reports intimate partner abuse
d. A client’s employer who is concerned about safety due to substance use
11. A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation.
Which of the following findings should the nurse report to the provider?
a. Hgb 13.2 g/dL
b. Urine protein 3 plus
c. Fasting blood glucose 72 mg/dL
, d. BUN 15 mg/dL
12. A nurse is collecting data from a client who is 4 hr postoperative following a
hemicolectomy. Which of the following findings is the nurse’s priority, requiring
immediate intervention?
a. Pain rating of 9 on a scale from 0 to 10
b. Blood pressure 160/90 mm Hg
c. Oxygen saturation 89%
d. Abdominal dressing with a moderate amount of bright red drainage
13. A nurse in a provider’s office is collecting data from a client who has a history of
hypertension during his annual physical examination. Which of the following findings
should the nurse report to the provider immediately?
a. A 2 kg (4.4 lb) weight gain
b. Blurred vision
c. Potassium 3.6 mEq/L
d. Resumption of cigarette smoking
14. A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of
the following actions should the nurse take first?
a. Place the client on bed rest
b. Obtain the clients ABG levels
c. Prepare the client for a ventilation-perfusion scan
d. Elevate the head of the client’s bed
15. A nurse is reinforcing teaching on a client who has diabetes mellitus. Which of the
following laboratory tests is the most accurate of blood glucose effective management?
a. Urine ketones
b. Glucose tolerance test
c. Glycosylated hemoglobin
d. Fasting blood glucose
16. A charge nurse on a mental health unit is supervising a newly licensed nurse. For
which of the following actions by the newly licensed nurse should the supervising nurse
intervene?
a. Requests a client to assist with distributing lunch trays
b. Tells a client he will lose his phone privileges if he does not take his medication
c. Encourages a client to participate in a recreational therapy group
d. Places mechanical restraints on a client who is hitting another staff member
17. A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on
seizure precautions. Which of the following materials should the AP place in the client’s
room?
a. Oral suction equipment
b. Wrist restraints
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