1. A 35 year old female client with cancer refuses to allow the nurse to insert an IV for a
scheduled chemotherapy treatment, and states that she is ready to go home and die. What
intervention should the nurse initiate?
A. evaluate the client's mental status for competence to refuse treatment
B. review the client's medical record for an advance directive
C. determine if a DNR prescription has been obtained
D. document that the client is being discharged against medical advice
2. A client with chronic renal disease is admitted to the hospital for evaluation prior to a
surgical procedure. Which laboratory test indicated the client's protein status for the
longest length of time.
A. Urine urea
B. transferrin
C. prealbumin
D. serum albumin
3. What client statement indicates to the nurse that the client requires assistance with
bathing?
A. "I only bathe every other day"
B. "I left my eyeglasses at home"
C. "I don't understand why I'm so weak and tired"
D. "I wasn't able to pack a bag before I left for the hospital"
4. How should a nurse handle linens that are soiled with incontinent feces?
A. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper
B. put the soiled linens in an isolation bag, then place it in the dirty linen hamper
C. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room
D. place an isolation hamper in the client's room and discard the linens in it.
5. When caring for an immobile client, what nursing diagnosis has the highest priority?
A. altered tissue perfusion
B. impaired gas exchange
C. risk for fluid volume deficit
D. risk for impaired skin integrity
6. The nurse assess an immobile, elderly male client and determines that his blood pressure is
138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the
last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on
, these assessment findings, what nursing action is the most important for the nurse to
implement?
A. encourage additional additional fluid intake
B. provide the client with an additional blanket
C. turn the patient Q2
D. administer a PRN anti hypertensive prescription
7. The home health nurse visits an elderly female client who had a brain attack three months
ago and is now able to ambulate with the assistance of a quad cane. Which assessment
finding has the greatest implications for this client's case?
A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago
B. the client tells the nurse that she does not have much of an appetite today
C. the husband, who is the caregiver, begins to weep when you ask how he is doing
D. the nurse notes that there are numerous scatter rubs throughout the house.
8. The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch
in diameter and finds that there is straw-colored drainage seeping from the wound. What
description of this finding should the nurse include in the client's record?
A. stage 1 pressure sore draining sero-anguineous drainage
B. one-inch pressure sore draining serous fluid
C. pressure sore draining serous fluid
D. pressure sore on heel with a small amount of purulent drainage.
9. A medication is prescribed to be given QID. What schedule should the nurse use to
administer this prescription?
A. 800
B. 0800, 1200, 1600, 2000
C. every other day at 0800
D. 0800, 1200, 1600, 2000, 0000, 0400
10. The nurse working in the emergency department is assessing four client's ability to tolerate
pain. Which client is likely to tolerate a higher level of pain.
A. A 23-year-old woman who sprained her knee while biking
B. a 55-year-old woman who has had moderate low back pain for three months
C. A 10-year-old who was burned by a camp fire earlier today
D. A 70 year-old who has a postoperative infection from a surgery one week ago.
11. A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "
will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse
to provide?
a. "It won't hurt because you're such a big boy"
b. "It may hurt a little because of the incision made in your throat"
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