1. The nurse is completing the admission assessment B. Sluggish and unequal
of a 3-year old who is admitted with bacterial menin- pupillary responses
gitis and hydrocephalus. Which assessment �nding
is evidence that the child is experiencing increased
intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging
fontanels
D. Blood pressure uctuations and syncope
2. A client with acute pancreatitis is admitted with se- A. Abdominal pain de-
vere, piercing abdominal pain and an elevated serum creases when lying supine
amylase. Which additional information is the client
most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice week-
ly.
3. A child newly diagnosed with sickle cell anemia (SCA) A. Instructions about how
is being discharged from the hospital. Which informa- much �uid the child
tion is most important for the nurse to provide the should drink daily
parents prior to discharge?
A. Instructions about how much uid 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
,4. To auscultate for a carotid bruit, the nurse places the I placed the red dot on the
stethoscope at what location. (Select the location on base of the neck on the
the image with a red dot). right side
5. After receiving report on an inpatient acute care unit, D. The client with a bowel
which client should the nurse assess �rst? obstruction due to a volvu-
A. The client with an obstruction of the large intestine lus who is experiencing
who is experiencing abdominal distention abdominal rigidity
B. The client who had surgery yesterday and is expe-
riencing a paralytic ileus with absent bowel sounds
C. The client with a small bowel obstruction who has
a nasogastric tube that is draining greenish uid
D. The client with a bowel obstruction due to a volvu-
lus who is experiencing abdominal rigidity
6. A teenager presents to the emergency department D. Respiratory alkalosis
with palpitations after vaping at a party. The client
is anxious, fearful, and hyperventilating. The nurse
anticipates the client developing which acid base im-
balance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
7. A client with dyspnea is being admitted to the medical Fowlers
unit. To best prepare for the client's arrival, the nurse
should ensure that the client's bed is in which posi-
tion?
A. Supine
B. supine; feet elevated higher than head
, C. supine; head elevated higher than feet
D. Fowlers
8. The nurse is taking the blood pressure measurement A. Frequent syncope
of a client with Parkinson's disease. Which information C. Flat a ect
in the client's admission assessment is relevant to the D. Blurred vision
nurse's plan for taking the blood pressure reading?
(Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat a ect
D. Blurred vision
E. Frequent drooling
9. While caring for a client's postoperative dressing, the B. Culture for sensitive or-
nurse observes purulent drainage at the wound. Be- ganisms
fore reporting this �nding to the healthcare provider,
the nurse should review which of the client's laborato-
ry values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
10. A preschool-aged boy is admitted to the pediatric unit B. Ask the older brother
following successful resuscitation from a near-drown- how he felt during the in-
ing incident. While providing care to the child, the cident
nurse begins talking with his preadolescent brother
who rescued the child from the swimming pool and
initiated resuscitation. The nurse notices the older
boy becomes withdrawn when asked about what hap-
pened. Which action should the nurse take?
, A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the inci-
dent
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
11. A male client with cirrhosis has jaundice and pruritus. A. Encourage the client to
He tells the nurse that he has been soaking in hot use cooler water and ap-
baths at night with no relief of his discomfort. Which ply calamine lotion after
action should the nurse take? soaking
A. Encourage the client to use cooler water and apply
calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the
client can use for symptom relief
C. Suggest that the client take brief showers and apply
oil-based lotion after showering
D. Explain that the symptoms are caused by liver dam-
age and cannot be relieved
12. An older client with a long history of coronary artery B. Reduced preload
disease (CAD), hypertension (HTN), and heart fail-
ure (HF) arrives in the Emergency Department (ED)
in respiratory distress. The healthcare provider pre-
scribes furosemide IV. Which therapeutic response to
furosemide should the nurse expected in the client
with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload
13.
of a 3-year old who is admitted with bacterial menin- pupillary responses
gitis and hydrocephalus. Which assessment �nding
is evidence that the child is experiencing increased
intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging
fontanels
D. Blood pressure uctuations and syncope
2. A client with acute pancreatitis is admitted with se- A. Abdominal pain de-
vere, piercing abdominal pain and an elevated serum creases when lying supine
amylase. Which additional information is the client
most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice week-
ly.
3. A child newly diagnosed with sickle cell anemia (SCA) A. Instructions about how
is being discharged from the hospital. Which informa- much �uid the child
tion is most important for the nurse to provide the should drink daily
parents prior to discharge?
A. Instructions about how much uid 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
,4. To auscultate for a carotid bruit, the nurse places the I placed the red dot on the
stethoscope at what location. (Select the location on base of the neck on the
the image with a red dot). right side
5. After receiving report on an inpatient acute care unit, D. The client with a bowel
which client should the nurse assess �rst? obstruction due to a volvu-
A. The client with an obstruction of the large intestine lus who is experiencing
who is experiencing abdominal distention abdominal rigidity
B. The client who had surgery yesterday and is expe-
riencing a paralytic ileus with absent bowel sounds
C. The client with a small bowel obstruction who has
a nasogastric tube that is draining greenish uid
D. The client with a bowel obstruction due to a volvu-
lus who is experiencing abdominal rigidity
6. A teenager presents to the emergency department D. Respiratory alkalosis
with palpitations after vaping at a party. The client
is anxious, fearful, and hyperventilating. The nurse
anticipates the client developing which acid base im-
balance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
7. A client with dyspnea is being admitted to the medical Fowlers
unit. To best prepare for the client's arrival, the nurse
should ensure that the client's bed is in which posi-
tion?
A. Supine
B. supine; feet elevated higher than head
, C. supine; head elevated higher than feet
D. Fowlers
8. The nurse is taking the blood pressure measurement A. Frequent syncope
of a client with Parkinson's disease. Which information C. Flat a ect
in the client's admission assessment is relevant to the D. Blurred vision
nurse's plan for taking the blood pressure reading?
(Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat a ect
D. Blurred vision
E. Frequent drooling
9. While caring for a client's postoperative dressing, the B. Culture for sensitive or-
nurse observes purulent drainage at the wound. Be- ganisms
fore reporting this �nding to the healthcare provider,
the nurse should review which of the client's laborato-
ry values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level
10. A preschool-aged boy is admitted to the pediatric unit B. Ask the older brother
following successful resuscitation from a near-drown- how he felt during the in-
ing incident. While providing care to the child, the cident
nurse begins talking with his preadolescent brother
who rescued the child from the swimming pool and
initiated resuscitation. The nurse notices the older
boy becomes withdrawn when asked about what hap-
pened. Which action should the nurse take?
, A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the inci-
dent
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions
11. A male client with cirrhosis has jaundice and pruritus. A. Encourage the client to
He tells the nurse that he has been soaking in hot use cooler water and ap-
baths at night with no relief of his discomfort. Which ply calamine lotion after
action should the nurse take? soaking
A. Encourage the client to use cooler water and apply
calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the
client can use for symptom relief
C. Suggest that the client take brief showers and apply
oil-based lotion after showering
D. Explain that the symptoms are caused by liver dam-
age and cannot be relieved
12. An older client with a long history of coronary artery B. Reduced preload
disease (CAD), hypertension (HTN), and heart fail-
ure (HF) arrives in the Emergency Department (ED)
in respiratory distress. The healthcare provider pre-
scribes furosemide IV. Which therapeutic response to
furosemide should the nurse expected in the client
with acute HF?
A. Increased cardiac contractility
B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload
13.
