1.The client is having an arteriogram. During the procedure, the client tells the nurse, "I’m feeing really hot." Which response would be best?
a."You are having an allergic reaction. I will get an order for Benadryl."
b."That feeling of warmth is normal when the dye is injected."
c."That feeling of warmth indicates that the clots in the coronary vessels are dissolving."
d."I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing."
2.The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
a.The nursing assistant wears gloves while giving the client a bath.
b.The nurse wears goggles while drawing blood from the client.
c.The doctor washes his hands before examining the client.
d.The nurse wears gloves to take the client’s vital signs.
3.The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
a.The client loses consciousness.
b.The client vomits.
c.The client’s ECG indicates tachycardia.
d.The client has a grand mal seizure.
4.The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
a.Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
b.Scrape the skin with a piece of cardboard and bring it to the clinic
c.Obtain a stool specimen in the afternoon
d.Bring a hair sample to the clinic for evaluation
5.The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
a.Treatment is not recommended for children less than 10 years of age.
b.The entire family should be treated.
c.Medication therapy will continue for 1 year.
d.Intravenous antibiotic therapy will be ordered.
6.The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
a.The client receiving linear accelerator radiation therapy for lung cancer
b.The client with a radium implant for cervical cancer
c.The client who has just been administered soluble brachytherapy for thyroid cancer
d.The client who returned from placement of iridium seeds for prostate cancer
7.The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
a.The client with Cushing’s disease
b.The client with diabetes
c.The client with acromegaly
d.The client with myxedema
8.The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
9.Which assignment should not be performed by the licensed practical nurse?
a.Inserting a Foley catheter
b.Discontinuing a nasogastric tube
c.Obtaining a sputum specimen
d.Starting a blood transfusion
10.The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
a.Continuing to monitor the vital signs
b.Contacting the physician
c.Asking the client how he feels
d.Asking the LPN to continue the post-op care
11.Which nurse should be assigned to care for the postpartal client with preeclampsia?
a.The RN with 2 weeks of experience in postpartum
b.The RN with 3 years of experience in labor and delivery
c.The RN with 10 years of experience in surgery
d.The RN with 1 year of experience in the neonatal intensive care unit
12.Which information should be reported to the state Board of Nursing?
a.The facility fails to provide literature in both Spanish and English.
b.The narcotic count has been incorrect on the unit for the past 3 days.
c.The client fails to receive an itemized account of his bills and services received during his hospital stay.
d.The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.
13.The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
a.Call the Board of Nursing
b.File a formal reprimand
c.Terminate the nurse
d.Charge the nurse with a tort
14.The home health nurse is planning for the day’s visits. Which client should be seen first?
a.The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
b.The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
c.The 50-year-old with MRSA being treated with Vancomycin via a PICC line
d.The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
15.The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
a.A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
b.The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
c.A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
d.The client who arrives with a large puncture wound to the abdomen and the client with chest pain
16.The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
a.The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
b.The child should be allowed to instill his own eyedrops.
c.The mother should be allowed to instill the eyedrops.
d.If the eye is clear from any redness or edema, the eyedrops should be held.
17.The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
a."It is okay to give my child white grape juice for breakfast."
b."My child can have a grilled cheese sandwich for lunch."
c."We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."
d."For a snack, my child can have ice cream."
18.A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
a.Ask the parent/guardian to leave the room when assessments are being performed.
b.Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital.
c.Ask the parent/guardian to room-in with the child.
d.If the child is screaming, tell him this is inappropriate behavior.
19.Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
a.Remove the mold and clean every week.
b.Store the hearing aid in a warm place.
c.Clean the lint from the hearing aid with a toothpick.
d.Change the batteries weekly.
20.A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
a.Body image disturbance
b.Impaired verbal communication
c.Risk for aspiration
21.A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
d.Vomiting and diarrhea
22.The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
a.Intravenous access supplies
b.A tracheostomy set
c.Intravenous fluid administration pump
23.A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
24.The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
a.Ham sandwich on whole-wheat toast
b.Spaghetti and meatballs
c.Hamburger with ketchup
25.The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?