1. A nurse at the family planning clinic triages several clients over the phone.
Which of the following clients should the nurse instruct to come to the clinic?
A-A client who uses a diaphragm for contraception and has lost 30 lb in the
past 6 months dieting
B- A client who had an intrauterine device (IUD) inserted yesterday and has
,cramping and bleeding
C- A client who has started taking oral contraceptives and is experiencing
bright red vaginal
breakthrough bleeding
D-A client who has sharp pain in her shoulder following a laparoscopic tubal
ligation yesterday
Ans- A-A client who uses a diaphragm for contraception and has lost 30 lb in the
past 6 months dieting
2. A nurse is providing teaching to a client who has osteoporosis and a new
prescription for alendronate. Which of the following statements by the client
indicates an understanding of the teaching?
- "I will take this medication within 15 minutes of eating."
- "I will take this medication at bedtime."
- "I will take this medication with 8 ounces of water."
- "I will increase my caffeine intake while taking this medication.": Ans- - "I
will take this medication with 8 ounces of water."
3. A nurse is giving discharge instructions to a client who has a new ileostomy.
,The nurse should recognize that the teaching has been effective when the
client states,
- "My stoma size will stay the same, even after it has healed."
-"My stoma will drain liquid fluid continuously."
-"I will change my pouch system every 2 weeks.
-I will ensure that my medications are enteric coated.": Ans- -"My stoma will
drain liquid fluid continuously."
4. A nurse is teaching a newly licensed nurse about informed consent. Which
of the following statements should the nurse include in the teaching? (Select
all that apply.)
- "By witnessing the signing of the informed consent form, the nurse is
indicating that the client
voluntarily gave consent."
- "A client who signs an informed consent form should understand the treat-
ment plan."
- "A client who signs an informed consent form should be competent."
,- "The nurse should disclose the purpose of the treatment before the client
signs the consent form."
- "Signing the informed consent form indicates that the family agrees to the
treatment options.": Ans- - "By witnessing the signing of the informed consent
form, the nurse is indicating that the client
voluntarily gave consent."
- "A client who signs an informed consent form should understand the treatment
plan."
- "A client who signs an informed consent form should be competent."
5. . A nurse is admitting a client who has antisocial personality disorder. Which
of the following client behaviors should the nurse identify as consistent with
this disorder?
- Compulsive attention to details -
- Socially awkward in group situations
- Uses others for personal gain
-Avoids interacting with others: Ans- -Uses others for personal gain
6. A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive
,personnel (AP). When admitting a client who is experiencing acute liver failure
and who has ascites and an NG tube, which of the following tasks is most
appropriate for the nurse to delegate to the LPN?
- Insert an indwelling catheter if the client has not voided in 3 hr.
- Obtain the abdominal girth now and every 4 hr.
- Assess and document the level of consciousness every hour.
- Measure the amount of gastric drainage every 2 hr: Ans- - Insert an
indwelling catheter if the client has not voided in 3 hr.
7. A nurse is planning care for a client who has a sealed radiation implant and
is to remain in the hospital for 1 week. Which of the following should the nurse
include in the plan of care?
- Limit each of the client's visitors to 1 hr per day.
- Remove dirty linens from the room after double bagging.
- Wear a dosimeter film badge while in the client's room.
- Ensure family members remain at least 1 m (3.2 feet) from the client
Ans- - Wear a dosimeter film badge while in the client's room.
8. A nurse is planning care for a newborn who has hyperbilirubinemia and is to
,receive phototherapy. Which of the following interventions should the nurse
include?
- Clothe the newborn in light cotton.
- Check the newborn's temperature every 8 hr.
- Administer 120 mL (4 oz) of water between feedings.
,- Place the newborn 45 cm (18 in) from the light source: - Place the newborn 45
cm (18 in) from the light source
9. 9. A nurse is assessing an adult male client who has a BMI of 20. The
nurse should identify that the client's BMI falls within which of the following
categories?
- Healthy weight
- Malnutrition
- Overweight
- Obesity: - Healthy weight
10. A nurse is performing high-frequency chest compressions using a me-
chanical chest compression device for a child who has cystic fibrosis. Which
of the following findings indicates the treatment has been effective?
- The child develops a dry, hacking cough.
- The child has increased nasal secretions.
- The child has increased sputum production.
- The child develops diminished breath sounds
Ans- - The child has increased sputum production.
,11. A nurse is planning care for a client who has a gambling disorder. Which
of the following instructions should the nurse provide to the client?
- Participate in a 12-step program.
- Plan to take clozapine for the next 6 months.
- Use systematic desensitization to decrease gambling behaviors.
- Learn to use projection to adapt to stressful experiences
Ans- - Participate in a 12-step program.
12. At the start of an evening shift on a cardiac unit, a licensed practical nurse
brings the nurse a list of client reports. Which of the following client reports
should the nurse assess first?
- Constipation
- Indigestion
- Swollen ankles
- Urinary frequency: - Indigestion
13. A nurse in a newborn nursery is performing assessments on four neonates
that are all less than 24 hr old. The nurse should plan to notify the provider of
which of the following findings?
- Head circumference 1 cm greater than chest
,- Positive Babinski reflex on bilateral feet
- Passage of meconium stool
- Pinna below the outer canthus of the eye: - Pinna below the outer canthus of
the eye
, 14. A nurse is giving change-of-shift report about a client who is 36-hr post-
operative to another nurse. Which of the following should the nurse include?
- Daily bath given at 1000
- Vomited a large amount of emesis immediately after surgery
- Flushed IV with 0.9% sodium chloride
- Pain relieved by position change: - Pain relieved by position change
15. A nurse is caring for a client who has a newly implanted sealed internal ra-
diation device to treat cervical cancer. Which of the following is an appropriate
action for the nurse to take?
- Prohibit visitors for the first 24 hr
- Require the client wear a dosimeter badge.
- Keep a 3-foot distance from the radiation implant.
- Maintain the client on bed rest for 72 hr
Ans- - Maintain the client on bed rest for 72 hr.
16. A nurse is preparing to witness a client's signature on an informed consent
for a total knee arthroplasty. Which of the following client statements indicates
the nurse should contact the surgeon?
- "I wonder if the metal in my knee will show up in airport screenings."
- "The physical therapy has not been working, so I will need to have the
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