1. Aregistered nurse (RN) on the 7 a.m.–3 p.m.

shift is planning
client assignments for the day. Which clients would be
appropriate for the RN to assign to the licensed practical nurse
(LPN)? Select all that apply.

• A client who had a mastectomy 2 days ago

• A client with type 1 diabetes mellitus who has a foot ulcer

• A client with left-side weakness who will need assistance with personal care

• A newly admitted client with chronic obstructive pulmonary disease

(COPD)
• A client being transferred in from the intensive care unit with a deep vein
thrombosis and a heparin drip
2. A home care nurse is assigned to visit a prenatal client with a
diagnosis of hyperemesis gravidarum (HEG). During physical
assessment of the client, the nurse should first:

• Weigh the client

• Assess the client’s intake and output

• Encourage the client to verbalize her feelings about the diagnosis • Review the

3. A registered nurse (RN)

results of the hemoglobin and hematocrit determinations
on the night shift has a licensed practical nurse (LPN) and an
unlicensed assistive personnel (UAP)on the team and is planning
the client assignments for the night. Which client does the RN
assign to the LPN? Select all that apply.

• A client who undergoing a 24-hour urine collection

• A client with a nasogastric tube who underwent bowel resection 2 days ago • A
client with urinary frequency who needs assistance in getting to the bathroom
• A client scheduled for renal dialysis in the morning who needs assistance with
hygiene
• A client who has been fitted with skeletal traction of the right leg after an open
reduction measures
4. A nurse is monitoring a client with preeclampsia who is receiving
intravenous magnesium sulfate to prevent seizures. The nurse
notes that the client’s respiratory rate is 10 breaths/min. On the
basis of this finding, the nurse first:

• Takes the client’s vital signs health care provider

• Contacts the health care provider

 • Discontinues the magnesium sulfate

• Checks the most recent serum magnesium sulfate level

5. A client who has just undergone abdominal surgery calls the

nurse and states, “I feel as if I just split open.” The nurse
checks the abdominal incision and finds wound evisceration. The
nurse immediately:

• Documents the findings

• Notifies the operating room

• Takes the client’s vital signs

• Contacts the health care provider

6. A client is receiving an intravenous (IV) infusion of 1000 mL of

normal saline solution at a rate of 125 mL/hr. The client suddenly
complains of shortness of breath, and the nurse notes the
presence of dependent edema and puffiness around the client’s
eyes. The nurse suspects circulatory overload and immediately:

• Slows the IV rate

• Administers a diuretic

• Contacts the health care provider

• Places the client in a supine position

7. A nurse is performing closed suctioning through a tracheostomy

for a ventilator-dependent client. During the procedure, the alarm
on the cardiac monitor sounds and the nurse notes severe
bradycardia. The nurse stops suctioning the client and
immediately:

• Contacts the respiratory therapist

• Rechecks all ventilator connections

• Oxygenates the client manually with 100% oxygen

• Increases the degree of PEEP the client is receiving

8. Inner maxillary fixation (IMF) is performed on a client who

sustained a mandibular fracture in a motor vehicle crash. During
an assessment, the client begins to vomit. The nurse suctions
the client but is unsuccessful, and the client
exhibits signs of hypoxia. The nurse immediately:

• Cuts the mouth wires

 • Administers an antiemetic

• Contacts the anesthesiologist

• Places the client is a supine position

9. A child arrives at the emergency department experiencing

anaphylaxis after being stung by a bee on the right arm. The
nurse should first:

• Call a code

• Start an intravenous (IV) line

• Initiate cardiopulmonary resuscitation (CPR)

• Place a tourniquet proximal to the site of the insect sting

10. A nurse is preparing to care for a child being admitted to the
hospital with infectious gastroenteritis. The priority nursing
intervention is:

• Obtaining a stool sample for culture

• Administering prescribed antimicrobials

• Starting an intravenous (IV) line as prescribed

• Instructing the parents in home care measures to prevent infection 11. A nurse
is caring for a client after tonsillectomy and adenoidectomy. The
nurse notes that the client has become restless and is swallowing
frequently. List in order of priority the actions that the nurse should
take in this situation, with number 1 as the first action.

⚫ Maintaining NPO status

⚫ Inspecting the client’s throat

⚫ Notifying the surgeon
⚫ Checking the client’s vital signs

12. A nurse is caring for a client with a diagnosis of endocarditis

when the client suddenly begins to experience chest pain,
dyspnea, and tachypnea. The nurse suspects that the client has
a pulmonary embolism. List in order of priority the actions that the
nurse would take in this situation, with number 1 as the first
action.

Correct
 ⚫ Ensuring that the intravenous (IV) line is patent ⚫

Placing a nasal oxygen cannula on the client

⚫ Preparing the client for a computerized tomography (CT)

scan

⚫ Notifying the health care provider

⚫ Preparing an IV heparin sodium infusion

13. A client is brought to the emergency department after a motor

vehicle crash in which the client sustained a blunt chest injury
when his chest struck the steering wheel. The client is
complaining of sharp pain on inspiration and dyspnea. The
nurse notes the absence of breath sounds on the affected side.
The nurse would immediately:

• Obtain a chest x-ray

• Notify the health care provider

• Place the client in a semi-Fowler position

• Prepare a thoracentesis tray and chest drainage equipment

14. A registered nurse (RN) is planning assignments for six clients

on a nursing unit. The RN has an RN, a licensed practical nurse
(LPN), and an unlicensed assistive personnel (UAP) on the
nursing team. Which clients should the nurse assign to the RN?
Select all that apply

• A client who requires tap water enemas until clear

• A client with newly diagnosed type 1 diabetes mellitus

• A client requiring complete assistance with personal care

• A client with gastrointestinal bleeding and a hemoglobin of 7.3 mg/dL (73 g/L)

• A client who was admitted during the night after an acute asthma attack • A
client who has undergone amputation of the right leg amputation and a dressing
change
15. A registered nurse (RN) is planning the client assignments for
the day. To which nurse does the RN appropriately assign care
of a woman undergoing brachytherapy with a sealed radiation
source for cervical cancer?
 • A pregnant nurse who has special expertise in oncology

• A nurse who has worked with clients undergoing brachytherapy in the past • A
male nurse who has never worked with a client undergoing
brachytherapy
• A nurse who is also assigned to provide care to another client undergoing
brachytherapy
16. A client is complaining of chest pain, and the nurse notes that
the client’s skin is cool and clammy. The client is receiving
oxygen at a rate of 2 L/min, and the pulse oximetry reading is
84%. Which action should the nurse take first?

• Administering nitroglycerin

• Taking the client’s vital signs

• Increasing the oxygen to 3 L/min

• Obtaining an arterial blood gas (ABG) specimen

17. A nurse is assigned to care for a client with a closed chest

drainage system that was inserted 1 day ago after the client
sustained a stab wound to the chest. List in order of priority
the actions that the nurse would take in caring for the client, with
number 1 the first action.

The correct order is:

⚫ Assessing the client’s level of discomfort ⚫ Assessing

patency and function of the chest tube ⚫ Asking the client

to cough and deep-breathe ⚫ Checking the client’s vital

signs

18. An emergency department (ED) nurse receives a telephone call

and is informed that several victims from a train accident will be
brought to the ED. The nurse who received the telephone call
must first:

• Activate the agency disaster plan

• Empty all available rooms in the ED

• Ensure that the triage rooms are stocked with additional dressing supplies • Call
the intensive care unit (ICU) and asks for nurses to assist with the victims
19. A home health nurse is assigned to three client visits today. One
client requires twice-daily irrigation of an abdominal wound. Another
client was discharged from the hospital yesterday after cardiac
catheterization and will require an admission assessment and
assistance with the scheduling of medications. The last client has
diabetes mellitus and requires a blood specimen for serum glucose
testing to be drawn. The nurse will schedule the assignment by
visiting:

• The client with diabetes mellitus first, the client with the wound irrigation
second, and the client requiring admission last
• The client needing wound irrigation first, the client with diabetes mellitus
second, and the client requiring admission last
• The client requiring admission first, the client with diabetes mellitus second, and
the client needing wound irrigation last
• The client with diabetes mellitus first, the client requiring admission second, and
the client needing wound irrigation last
20. A registered nurse is planning client assignments for the day.
Which clients should the nurse assign to the unlicensed assistive
personnel (UAP)? Select all that apply.

• A client scheduled for colonoscopy

• A client who underwent mastectomy 2 days ago

• A client scheduled for discharge after cardiac catheterization

• A client with diarrhea who requires assistance with hygiene care • A client on
strict bed rest who requires range-of-motion exercises every 2 hours
21. A registered nurse (RN) must determine how best to assign an
RN and a licensed practical nurse (LPN) to provide care to a
group of clients. Which is the appropriate assignment?

• Assigning the RN to care for a woman with newly diagnosed metastatic

carcinoma who has two school-aged children
• Assigning the RN to care for a woman, hospitalized for chest pain, who is being
discharged home today with no medications
• Assigning the LPN to care for a client who has undergone craniotomy and was
transferred from the intensive care unit (ICU) this morning
• Assigning the LPN to provide initial discharge teaching about cardiac medications to

22. A nurse is monitoring

a client who has undergone a coronary artery bypass graft
a postoperative client on an hourly basis. The nurse notes that the
client’s urine output for the past hour is 20 mL. On the basis of this
finding, the nurse should first:
 • Call the health care provider

• Increase the rate of the IV infusion

• Check the client’s overall intake and output record

• Administer a 250-mL bolus of normal saline solution (0.9%)

23. A nurse is delegating tasks to the nursing staff. Which tasks are
appropriate for the unlicensed assistive personnel (UAP? Select
all that apply.

• Feeding a newly admitted client with dysphagia after a stroke

• Obtaining frequent oral temperatures from a client who is receiving a blood

transfusion
• Accompanying a man being discharged home to his transportation at the
hospital entrance
• Obtaining a 24-hour dietary recall from a client admitted to the hospital with
anorexia nervosa
• Obtaining a clean-catch urine specimen from a client who is complaining of
urgency and frequency
24. A nurse on the day shift (7 a.m.–3 p.m.) is assigned to care for
four clients. In planning care, which client does the nurse assess
first?

• A client scheduled for a barium enema at 9 a.m.

• A client requiring a daily dressing change on an amputation stump • A client

with emphysema who is receiving oxygen at a rate of 2 L/min • A client who has
undergone angioplasty and is preparing to be discharged at 10 a.m.
25. A nurse is planning client assignments for the shift. Which clients
would the nurse assign to the unlicensed assistive personnel
(UAP)? Select all that apply.

• A client receiving blood transfusions

• A client who needs to be ambulated with a walker twice a day

• A client with incontinence who requires a bladder scan after each void • A client
with diabetes mellitus who requires blood glucose testing every 2 hours
• A client on a bowel management program who requires a daily rectal
suppository
26. A registered nurse is in charge of the emergency department on
the night shift when a client is brought for treatment after being
sexually assaulted. The nurse has never cared for anyone after a
sexual assault. To determine the interventions that the client
 requires, the nurse would first:

• Call the police department

• Call the nursing supervisor

• Call the nurse in charge of the day shift

• Check unit policy regarding the protocol for care to clients who have been
sexually assaulted
27. A client with a spinal cord injury suddenly experiences a severe
headache and nasal stuffiness. The client is also diaphoretic,
hypertensive, and bradycardic. The nurse determines that the
client is experiencing autonomic dysreflexia and immediately:

• Notifies the health care provider

• Checks the bladder and catheterizes the client

• Raises the head of the bed to a high Fowler position

• Performs a rectal examination to check for a fecal impaction

28. A client calls the nurse at the emergency department (ED), says
that he thinks that he came in contact with poison ivy while
working in his yard, and asks the nurse for advice. The nurse
tells the client immediately to:

• Take a shower

• Come to the ED

• Soak in a warm oatmeal bath

• Apply hydrocortisone cream to the areas that may have been in contact with
the poison ivy
29. A nurse notes that the site of a client’s peripheral intravenous
(IV) catheter is red and inflamed and feels hard on palpation. On
the basis of this assessment, the nurse should first:
• Remove the IV catheter

• Slow the rate of infusion

• Notify the health care provider

• Place warm compresses on the IV site

30. A nurse assesses a client at the beginning of the shift and notes
an intravenous (IV) infusion is running at 100 mL/hr and that 800
mL of fluid remains in the IV bag. Thirty minutes later, the client
calls the nurse and complains of shortness of breath. The nurse
sees that 400 mL of IV solution remains in the IV bag. The nurse
 immediately:

• Administers oxygen

• Elevates the head of the bed

• Notifies the health care provider

• Stops the rate of the IV infusion

31. A client complains of pain at the site of an intravenous (IV)

catheter. On assessment, the nurse notes that the site appears
bruised and concludes that the client has a hematoma. The
nurse first:

• Applies ice to the IV site

• Removes the IV catheter

• Applies pressure to the site

• Notifies the health care provider

32. A nurse suspects that a client receiving a unit of packed red

blood cells (RBCs) is experiencing a transfusion reaction. List in
order of priority the actions that the nurse should take in this
situation, with 1 as the first action.

⚫ Notifying the blood bank

⚫ Discontinuing the infusion

⚫ Sending the blood bag and tubing to the blood bank

⚫ Notifying the health care provider

⚫ Keeping the IV line open with 0.9% normal saline

solution
33. A nurse is caring for a client with a central venous catheter. The
client suddenly complains of chest pain and dyspnea. During
assessment of the client, the nurse notes hypotension,
tachycardia, and a loud churning sound over the pericardium on
auscultation. The nurse suspects an air embolism and
immediately:
 • Obtains an electrocardiogram

• Clamps the central line catheter

• Places the client in a high Fowler position

• Connects a syringe to the line and aspirates as much fluid as possible 34. A
nurse responds to a disaster call in which a building collapsed and
several victims were seriously injured. Which victim will the nurse
attend to first?

• A victim with an amputated arm

• A victim with a closed fracture of the leg

• A victim with a sprained ankle and a minor laceration on the head • A victim with

35. A mother rushes into the

massive head trauma who is in cardiopulmonary arrest
emergency department with her child and tells the nurse that the
child has drunk bleach from a bottle that the mother was using to
clean bathrooms. The nurse notes that child is alert but sees areas
of irritation around his mouth. Which intervention does the nurse
immediately begin preparing for?

• Insertion of a nasogastric tube

• Administration of syrup of ipecac to induce vomiting

• Dilution of the corrosive substance with water or milk

• Administration of an agent to neutralize the corrosive substance 36. A nurse in a

postanesthesia care unit (PACU) receives a client who is being
transferred from the operating room after abdominal surgery. The
PACU nurse ensures that the client has a patent airway and that the
respiratory pattern is adequate. Which interventions should the
PACU nurse perform next?

• Orienting the client to the surroundings

• Checking the Foley catheter for urine output

• Assessing he abdominal dressing for drainage

• Checking the client’s pulse oximetry readings

37. A nurse notes that a client who is attached to a cardiac monitor

has suddenly began exhibiting the following rhythm.
 After contacting the health care provider, which
intervention does the nurse prepare the client for?

• Administration of adenosine

• Administration of heparin sodium

• Insertion of a permanent pacemaker

• Transesophageal echocardiography (TEE)

38. A client who experienced ventricular fibrillation has undergone

defibrillation three times, without success. The nurse would next:

• Increase the IV flow rate

• Perform defibrillation one last time

• Assess the client’s level of consciousness

• Continue cardiopulmonary resuscitation (CPR)

39. A nurse in the ambulatory care unit is caring for a client after
cataract extraction. The client suddenly complains of severe pain
in the affected eye. The nurse must immediately:

• Notify the surgeon

• Place the client in a supine position

• Administer the prescribed pain medication

• Tell the client that this is to be expected after surgery

40. A client arrives at the emergency department after experiencing

a traumatic blow to the eye, and a hyphema is diagnosed. The
nurse should first:

• Place a patch and shield on the eye

• Administer prescribed cycloplegic eye drops

• Ensure that the client is placed in a semi-Fowler position

• Tell the client that reading and watching television are restricted 41. A client
comes to the emergency department after being hit in the eye with a
hockey puck. Which action does the nurse, seeing that the client
has periorbital ecchymosis, implement immediately?
 • Applying ice to the affected eye

• Irrigating the affected eye with cool water

• Placing a pressure dressing on the affected eye

• Applying a warm saline compress to the affected eye

42. A client arrives in the emergency department complaining of
feeling “something in my eye” and reports that some dust blew
into the eye. The nurse would first:

• Apply a patch to the eye

• Assess the client’s vision

• Examine the eye, using fluorescein

• Irrigate the eye with sterile normal saline solution

43. A client who has been bitten on the right arm by a snake arrives
at the emergency department. The nurse immediately:

• Applies ice to the site of the bite

• Prepares to administer tetanus prophylaxis

• Immobilizes the affected arm at heart level

• Places a tourniquet above the site of the bite

44. A client arrives in the emergency department and reports that an

acid solution was splashed into his eye. The nurse immediately:

• Performs visual acuity tests

• Applies litmus paper to the conjunctiva

• Swabs the eye with a corticosteroid ointment

• Irrigates the eye with copious amounts of sterile normal saline solution 45. A nurse
assessing a client with a closed chest tube drainage system notes
constant bubbling in the water seal chamber. The nurse assesses
the system for air leaks but is unable to locate a visible leak. Based
on this finding, the nurse next:

• Milks the chest tube

• Clamps the chest tube

• Replaces the drainage system

• Reduces the degree of suction being delivered

46. A nurse is caring for a client who has just experienced a

 pulmonary embolism. List, in order of priority, the actions that the
nurse would take in this situation, with 1 as the first action.

⚫ Preparing an intravenous (IV) heparin solution ⚫

Elevating the head of the bed

⚫ Notifying the health care provider

⚫ Applyinglow-flow oxygen by way of nasal cannula

47. A client who has sustained a severe burn injury is brought to the
emergency department (ED). Which action does the ED nurse
implement immediately?

• Cleansing the burn wounds

• Administering tetanus prophylaxis

• Covering the client with a warm blanket

• Administering 100% oxygen by way of face mask

48. A registered nurse (RN) on the day shift has been assigned to
care for four clients. Once the nurse has made initial rounds and
checked all of the assigned clients, which client will the RN care
for first?

• A client who is scheduled for surgery at 1 p.m.

• A client who is scheduled for occupational therapy at 10 a.m.

• A client with metastatic carcinoma who has just received pain medication • A
client scheduled for an ultrasound at 11 a.m. who is on
nothing-by-mouth (NPO) status
49. A nurse is assigned to care for four clients. Which client would
the nurse would assess first during initial rounds?

• A client with pneumonia

• A client who is in Buck’s traction

• A client with chronic renal failure

• A client with a diagnosis of cirrhosis

50. A nurse is changing a client’s central intravenous (IV) catheter

dressing. During the procedure, the unit secretary calls the nurse
over the handheld radio and says that a health care provider has
telephoned and is asking to speak to the nurse. The nurse
should:
 • Have the unit secretary transfer the call to the nurse’s handheld radio • Place

a sterile towel over the client’s catheter site and answer the call • Ask the unit
secretary to place the health care provider on a telephone hold until the
dressing change is complete
• Ask the unit secretary to inform the health care provider that the call will be
returned after the dressing change has been completed
51. A man calls a nurse in the emergency department (ED) and tells
the nurse that his wife “just got a bloody nose.” The man then
asks the nurse what to do to stop the bleeding. The nurse tells
the man immediately to:

• Bring his wife to the ED

• Place a cool compress on the back of the woman’s neck

• Place a cotton ball or tampon in the nostril that is bleeding

• Place the spouse in a sitting position, leaning forward with the head tipped
downward
52. A client arrives in the nursing unit after internal maxillary fixation
(IMF) surgery. The nurse immediately:

• Administers an antiemetic to prevent vomiting

• Places suction equipment and wire cutters at the bedside

• Positions the client on one side with the head slightly elevated

• Connects the nasogastric (NG) tube to low intermittent suction 53. A

postanesthesia care unit (PACU) nurse is assessing a newly
admitted client. The client’s blood pressure is 78/52 mm Hg and the
pulse rate is 120 beats/min. List in order of priority the actions that
the nurse should take in this situation, with 1 indicating the first
action.

⚫ Notifying the anesthesia care provider and the

surgeon

⚫ Making certain that the airway is patent and

administering oxygen

⚫ Elevating the client’s feet and legs

⚫ Increasing the intravenous (IV) fluid infusion rate in

accordance with unit protocol
 ⚫ Checking the client’s Foley catheter for urine output

54. A nurse assessing a peripheral intravenous (IV) site notes

blanching, coolness, and edema at the site. What should the
nurse do first?

• Remove the IV catheter

• Measure the area of infiltration

• Apply a warm compress to the site

• Check for blood return from the IV site

55. A nurse monitoring a client who has just undergone cardiac

catheterization notes the presence of a hematoma at the
catheter insertion site. The nurse immediately:

• Places ice on the insertion site

• Applies a pressure dressing to the insertion site

• Assesses the client’s blood pressure and radial pulse

• Checks the peripheral pulse in the affected extremity

56. A nurse is preparing to care for a client who is undergoing
cardioversion. Once the procedure is complete, the nurse
ensures that the client has a patent airway and administers
oxygen to the client, then:

• Checks the client’s vital signs

• Provides emotional support to the client

• Administers antidysrhythmic medication

• Checks the client’s chest for paddle burns

57. A mother brings her child to the emergency department because

an insect has flown into the child’s ear and the child is
complaining of a buzzing sound. The nurse uses a flashlight in
an attempt to coax the insect out of the ear, but this intervention
is unsuccessful. Which action should the nurse take next?

• Placing diluted alcohol in the ear

• Irrigating the ear with sterile water

 • Placing cotton in the ear to stop the buzzing sensation

• Using an otoscope and ear forceps to remove the insect

58. An emergency department nurse is conducting an assessment of

a client who has sustained a circumferential burn to the right
arm. What should the nurse assess first?

• Heart rate

• Radial pulse

• Temperature

• Blood pressure (BP)

59. A nurse is caring for a client who is receiving intermittent

feedings by way of a nasogastric tube. Before feeding the client,
the nurse checks tube placement and determines correct
placement, then:

• Checks the residual volume

• Warms the feeding to 100° F (37.8°C)

• Irrigates the nasogastric tube with tap water

• Raises the head of the client’s bed 15 degrees

60. A health care provider places an intestinal tube in a client. After

insertion, the nurse immediately:

• Initiates a tube feeding

• Positions the client on the right side

• Secures the tube to the client’s face with tape

• Documents the insertion and the client’s tolerance of the procedure 61. A client is
admitted to the emergency department with a complaint of severe
crushing chest pain that radiate down
both arms. The client is dyspneic, and the nurse immediately
places a cannula on the client to deliver oxygen at 4 L/min and
inserts an intravenous (IV) catheter. The health care provider
orders an immediate troponin determination, a chest x-ray, a 12-
lead electrocardiogram (ECG), and morphine
sulfate 2 mg IV. What will the nurse do first?

• Obtain a 12-lead ECG

• Administer the IV morphine sulfate

 • Call radiology to set up the chest x-ray

• Draw blood for the troponin determination

62. A nurse is monitoring a client in the active stage of labor who is

receiving oxytocin . The nurse checks the fetal monitor and sees
this:

The nurse immediately places an oxygen cannula on the mother

and then:

• Documents the findings

• Stops the oxytocin infusion

• Places the mother in a supine position

• Transports the client to the delivery room

63. A client is brought to the labor unit, and, as the nurse is attaching
the fetal heart monitor, the client’s membranes rupture
spontaneously. The nurse immediately assesses the fetal heart
rate, then:

• Checks the client’s temperature

• Checks the character of the amniotic fluid

• Prepares the client for immediate delivery

• Documents the spontaneous rupture of the client’s membranes

64. A client who has sustained an open pneumothorax as a result of
a gunshot wound is brought to the emergency department (ED)
with an occlusive dressing, placed by a paramedic, over the
wound. The ED nurse assesses the client and notes extreme
respiratory distress and distended jugular neck veins. On the
 basis of these assessment findings, the nurse should first:

• Contact the health care provider

• Remove the occlusive dressing

• Assess the client’s blood pressure

• Check the client’s pulse oximetry readings

65. A client who sustained serious rib fractures in a motor vehicle

accident is exhibiting signs of flail chest. With which immediate
treatment measure does the nurse prepare to assist?

• Inserting a chest tube

• Splinting the ribs with a rib strap

• Administering an opioid analgesic for pain

• Endotracheal intubation with mechanical ventilation

66. A client with pneumonia is admitted to the hospital, and the

health care provider writes prescriptions for the client. Place the
health care provider’s prescriptions in order of priority for the
nurse, with 1 as the first action.

The correct order is:

⚫ Obtaining a chest x-ray

⚫ Administering oxygen at 3 L/min by way of nasal cannula

⚫ Administering a prescribed antibiotic by way of the

intravenous (IV) route

⚫ Obtaining sputum specimens for a Gram stain and culture

and sensitivity

67. A nurse conducting a postpartum assessment notes that the

client’s uterus is not firmly contracted. The nurse would first:

• Massage the uterine fundus

• Check the client’s vital signs

• Contact the health care provider

• Prepare to administer a rapid infusion of dilute oxytocin

68. A client who has just undergone surgery is receiving continuous
 intravenous (IV) morphine sulfate for pain control. On
assessment of the client, what does the nurse check first?

• Temperature

• Respiration

• Urine output

• Surgical incision

69. A nurse monitoring a client undergoing peritoneal dialysis notes

that the client is experiencing problems with inflow of the
dialysate. The nurse first:

• Repositions the client

• Milks the peritoneal dialysis tube

• Places the client in a supine low Fowler position

• Asks the client about recent problems with constipation

70. A nurse is caring for a client undergoing peritoneal dialysis. The

nurse checks the client and notes that the drainage from the
outflow catheter is cloudy. The nurse first:

• Increases the flow of peritoneal dialysis

• Adds heparin sodium to the dialysate solution

• Adds antibiotics to the next several dialysis bags

• Checks the client’s white blood cell (WBC) count

71. A nurse in charge of an emergency department (ED) arrives at

work at 11 p.m. and is told that four registered nurses scheduled
to work will not be reporting to work because they are ill. Every
trauma room is busy, and emergency medical services has just
called to report that several victims of a fire will be brought to the
ED. The nurse in charge immediately:

• Closes the ED temporarily to incoming clients

• Calls the nursing supervisor to discuss activation of the disaster plan • Tells

emergency medical services to take the victims to another hospital • Demands that
the nurses from the evening shift stay until all of the victims have been treated
72. A woman is brought to the emergency department (ED) in a
severe state of anxiety after witnessing a child’s drowning. The
nurse assigned to care for the client would first:
 • Teach the client relaxation techniques

• Take the client to a quiet room with minimal stimulation

• Encourage the client to describe the events of the accident

• Provide the client with a gross motor activity to drain some tension
73. A nurse reviews the laboratory values of a client with bipolar
disorder who is taking lithium carbonate (Lithobod) and notes
that the serum lithium level is 2.0 mEq/L (2.0 mmol/L). On the
basis of this laboratory value, the nurse first:

• Calls the health care provider

• Places the client in the seclusion room

• Administers the prescribed dose of lithium carbonate

• Documents the laboratory report in the client’s record

74. A nurse on the surgical nursing unit is assessing a postoperative

client who is experiencing tachycardia and tachypnea. The
client’s blood pressure is 88/60 mm Hg and the pulse rate is 100
beats/min. The client is receiving oxygen at 2 L/min by way of
nasal cannula, and the pulse oximetry reading is 92%. Once it
has been determined that the airway is patent, what should the
nurse do next?

• Notify the surgeon

• Check the client’s dressing for bleeding

• Prepare a blood transfusion administration set

• Elevate the client’s feet and legs above heart level

75. A nurse is assigned to care for a client in the fourth stage of

labor. What does the nurse plan to do first?

• Provide oral fluids

• Assess the uterine fundus

• Place an ice pack on the perineal area

• Allow the father and grandparents to visit and hold the newborn 76. A labor nurse is
caring for a client with a known history of sickle cell anemia. Which
action does the nurse implement as a priority to help prevent sickle
cell crisis?

• Providing continuous fetal monitoring

 • Administering intravenous (IV) fluids as prescribed

• Maintaining strict asepsis when performing procedures

• Administering oxygen only if the client complains of shortness of breath 77. A

nurse is caring for a client who sustained a serious burn injury 24
hours ago. On assessment, the nurse finds that the client’s urine
output is 0.3 mL/kg/hr, blood pressure is 88/60 mm Hg, and heart
rate is 110 beats/min. The nurse would immediately:

• Notify the health care provider

• Cover the client with a warm blanket

• Increase the intravenous (IV) flow rate

• Make a note to reassess the client in 30 minutes

78. A nurse is getting a postoperative client out of bed for the first
time since surgery. The nurse raises the head of the bed, and
the client complains of dizziness. Which action should the nurse
take first?

• Contacting the health care provider

• Checking the client’s apical heart rate

• Calling for assistance in getting the client out of bed

• Lowering the head of bed slowly until the dizziness passes

79. A hospitalized client with a history of angina pectoris is

ambulating in the corridor. The client suddenly complains of
severe substernal chest pain that radiates to the jaw. List in
order of priority the actions that the nurse should take in this
situation, with 1 as the first action.

The correct order is:

⚫ Obtaining a 12-lead electrocardiogram

⚫ Administering a nitroglycerin tablet sublingually ⚫

Contacting the health care provider

⚫ Assisting the client to back to bed

80. A client arrives at the emergency department with an episode of

status asthmaticus. The nurse first:
 • Obtains a set of vital signs

• Starts an intravenous (IV) line

• Places the client in a high Fowler position

• Administers oxygen at 21% by way of a Venti mask

81. A nurse teaches a client with urolithiasis about the signs of

urinary obstruction and the interventions to be taken if
obstruction is suspected. The nurse tells the client that if signs of
urinary obstruction occur, the client should
immediately:

• Drink 1500 mL of water

• Check the pH of the urine

• Perform a self-catheterization

• Call the health care provider

82. A nurse enters the room of a client with type 1 diabetes mellitus
and finds the client difficult to arouse. The client’s skin is warm and
flushed and the pulse and
respiratory rate are increased from the client’s baseline. The
nurse would first:

• Give the client 4 oz (120 ml) of orange juice

• Administer a bolus dose of 50% dextrose

• Check the client’s capillary blood glucose

• Prepare an intravenous (IV) insulin infusion

83. A client undergoing mechanical ventilation pulls out the

endotracheal tube. The nurse would immediately:

• Call a code

• Suction the client

• Prepare for re-intubation

• Call x-ray to obtain a chest x-ray

84. A nurse is monitoring a client with an oral endotracheal tube

inserted that is attached to mechanical ventilation. The nurse
assesses the client and notes that the client has unequal breath
sounds. On the basis of this assessment finding, the nurse would
first:
 • Suction the endotracheal tube

• Contact the health care provider

• Apply humidified oxygen to the client

• Check the depth marking at the client’s lips

85. A cardiac monitor alarm sounds, and the nurse notes an erratic
rhythm on the screen. The immediate nursing action is to:

• Call a code

• Assess the client

• Obtain a rhythm strip for evaluation

• Check the cardiac electrodes attached to the client

86. A nurse assesses the closed chest tube drainage system of a

client who underwent pulmonary wedge resection 12 hours ago.
The nurse notes that there has been no chest tube drainage for
the past hour. The nurse first:

• Strips the chest tube

• Assesses the client’s heart rate

• Checks for an air leak in the system

• Checks for obstructions or kinks in the chest drainage system

87. A nurse is suctioning an adult client undergoing mechanical

ventilation through a tracheostomy tube. During the procedure,
the nurse notes that the client’s oxygen saturation on pulse
oximetry has dropped to 89%. The nurse would:
• Stop and oxygenate the client with 100% oxygen

• Call respiratory therapy to check the pulse oximeter

• Increase the suction pressure and continue suctioning

• Obtain a pediatric suction catheter and suction the client

88. A nurse is caring for a client with a closed chest tube drainage
system. When the client is repositioned, the chest tube is
disconnected. The nurse immediately:

• Notifies the health care provider

• Instructs the client to perform a Valsalva maneuver

• Submerges the end of the tube in a bottle of sterile water

• Clamps the chest tube as close to the insertion site as possible

89. A ventilator’s high-pressure alarm sounds. The nurse rushes to
the client’s room and assesses the client but is unable to
determine the cause of the alarm. The nurse immediately:

• Calls the respiratory therapist

• Inserts an oral airway into the client

• Ventilates the client manually with the use of a resuscitation bag • Silences
the alarm and continues trying to determine the cause of the alarm
90. A nurse performing nasopharyngeal suctioning and suddenly
notes the presence of bloody secretions in the catheter. The
nurse should immediately:

• Contact the health care provider

• Suction more vigorously to remove the blood

• Check the degree of suction pressure being applied

• Encourage the client to cough out the bloody secretions

91. A client with a fracture of the left arm that has been set in a cast
complains of severe, diffuse pain that is unrelieved by pain
medication. On further assessment, the nurse notes that the
pulse distal to the site of injury has weakened and that the tissue
is pale. On the basis of these assessment findings, the nurse
first:

• Elevates the extremity

• Contacts the health care provider

• Continue to assess the client’s pain level

• Checks to see whether it is time for more pain medication

92. A nurse who is caring for a client with a tracheostomy tube notes
heavy bleeding from the stoma and sees that the tracheostomy
tube pulsates with the client’s heartbeat. Suspecting that a
trachea–innominate artery fistula has developed, the nurse
immediately removes the tracheotomy tube. The next nursing
action is:
• Transporting the client to surgery

• Initiating an intravenous (IV) line

• Inserting a smaller tracheostomy tube

• Applying direct pressure to the innominate artery at the stoma site 93. A nurse
is caring for a client who had a tracheostomy tube inserted 24 hours
ago. The client begins to cough vigorously, accidentally
decannulating (dislodging) the tube. The nurse immediately:

• Calls respiratory therapy

• Calls the health care provider

• Replaces the tracheostomy tube

• Ventilates the client with the use of a manual resuscitation bag and face mask

94. A nurse determines that a client with type 1 diabetes mellitus is

having a mild hypoglycemic reaction. The nurse immediately
gives the client:

• 6 oz (180 ml) of diet soda

• A graham cracker

• A full-size candy bar

• 1 tablespoon of honey

95. The mother of a 6-year-old calls a nurse who lives in the

neighborhood and reports that her child has accidentally
splashed alcohol into her eyes. The nurse tells the mother
immediately to:

• Darken the room

• Have the child rest with the eyes closed

• Have the child wipe the eyes with a wet towel

• Hold the child’s head with the eyes under running lukewarm tap water for 20
minutes
96. A nurse notes that a client who has just been given a diagnosis
of AIDS appears anxious and is reluctant to ask questions.
Which initial action by the nurse is the best way to deal with the
observation?

• Allowing the client time to be alone

• Asking a family member to be present when caring for the client • Asking
the client direct questions regarding feelings about having the disease
• Identifying common fears and questions expressed by other clients with the
same diagnosis
97. A client who is receiving a blood transfusion suddenly
experiences chills, a high fever, vomiting, and diarrhea and
complains of abdominal cramping. The nurse, noting that the
 client’s blood pressure has dropped significantly, suspects that
the client is experiencing a bacterial sepsis reaction to the
transfusion. The nurse immediately stops the blood transfusion,
hangs an intravenous (IV) bag of normal saline solution to be
infused at a keep-vein-open rate, and contacts the health care
provider, who prescribes several
interventions. Which prescription will the nurse implement first?

• Contacting the blood bank

• Obtaining blood for cultures

• Administering the prescribed IV corticosteroid

• Administering the prescribed IV broad-spectrum antibiotic

98. A client returns from the operating room after the application of
skeletal traction to treat a fractured femur. Which action would
the nurse implement first in the care of the client?

• Checking the client’s temperature

• Asking the client about the presence of pain

• Instructing the client in the use of the trapeze

• Assessing the neurovascular status of the affected extremity

99. A child with a diagnosis of pertussis (whooping cough) is being

admitted to the pediatric unit. Which health care provider’s
prescriptions does the nurse implement first?

• Obtaining a pulse oximetry reading

• Encouraging the intake of oral fluids

• Administering the prescribed antibiotic

• Administering pertussis immune globulin

100. A home care nurse is assigned to visit a client who lives alone.
The client was recently discharged from the hospital after cardiac
catheterization and placement of two stents in the right main
coronary artery. The client tells the nurse that she has been
experiencing chest pain and has taken 3 sublingual nitroglycerin
tablets, with no relief. What
immediate action should the nurse take?

• Call an ambulance to take the client to the ED

• Drive the client to the emergency department (ED)

• Inform the home healthcare agency of the situation

• Call a family member to come and stay with the client