Safe and Effective Care Environment 3. pneumonia.

4. hyperthermia.
I. Management of Care
5. During morning assessment, a nurse assesses four
1. A nurse is caring for a client who is exhibiting signs clients. Which client is the priority for follow up?
and symptoms characteristic of a myocardial infarction 1. An 84-year-old client with heart failure who’s on
(MI). Which statement describes priorities the nurse telemetry and 2 L/minute of oxygen.
should establish while performing the physical 2. A 42-year-old client who has left lower lobe
assessment? pneumonia and an I.V. line.
1. Assess the client’s level of pain and administer 3. A 48-year-old client with chronic obstructive
prescribed analgesics. pulmonary disease with occasional atrial fibrillation.
2. Assess the client’s level of anxiety and provide 4. A 73-year-old client who has pneumonia with coarse
emotional support. crackles, is receiving 2 [/minute of oxygen, and has an
3. Prepare the client for pulmonary artery I.V. line.
catheterization.
4. Ensure that the client’s family is kept informed of his 6. A client with stage IV heart failure has a living will
status. indicating that he doesn’t want to be placed on a
RATIONALE: The cardinal symptom of MI ventilator. A nurse is caring for this client when he
is persistent, crushing substernal begins experiencing severe dyspnea. The nurse should:
pain or pressure. The nurse should 1. call for respiratory therapy to intubate the client.
first assess the client’s pain and 2. administer oxygen, morphine, and a bronchodilator
prepare to administer nitroglycerin or for client comfort.
morphine for pain control. The client 3. ask the client’s family to consent to ventilator
must be medically stabilized before placement.
pulmonary artery catheterization can 4. administer oxygen and hope the client will change his
be used as a diagnostic procedure. mind.
Anxiety and a feeling of impending RATIONALE: A living will is a
doom are characteristic of MI, but the statement of a client’s wishes in the
priority is to stabilize the client event that a life-threatening illness
medically. Although the client and his or injury occurs. The client’s comfort
family should be kept informed at should be paramount and the nurse
every step of the recovery process, should respect his wishes. Morphine,
this action isn’t the priority when oxygen, and bronchodilators can
treating a client with a suspected MI. relieve dyspnea and make the client
more comfortable, which will enable
2. Delegation is the process of transferring work to him to breathe more easily. The nurse
subordinates. A nurse-manager may appropriately shouldn’t arrange for intubation
delegate which task? without the client’s consent or ask
1. Scheduling staff assignments for the next month his family for permission to initiate
2. Terminating a nursing assistant for insubordination mechanical ventilation.
3. Deciding on salary increases for nurses after they
complete orientation 7. A charge nurse completing a deceased client’s chart
4. Telling a staff nurse to initiate disciplinary action audit notes that the chart contains a copy of the client’s
against one of her peers advance directive and the do- not-resuscitate (DNR)
RATIONALE: Scheduling may be safely order. While reviewing the nurses’ notes, the charge
and appropriately delegated. nurse finds documentation of a code blue and
Termination, disciplinary action, and cardiopulmonary resuscitation with a physician entry to
salary increases shouldn’t be “Discontinue code blue due to existing advanced
delegated to staff, who don’t have the directives and DNR from client.” What does the
power and authority to take such charge nurse conclude? Select all that apply.
actions.
1. The nurse was correct to call a code blue.
2. The physician was correct to stop resuscitation
3. A client is admitted with inflammatory bowel efforts.
syndrome (Crohn’s disease). Which therapies should the 3. By calling a code blue, the nurse disregarded the
nurse expect to be part of the care client’s advance directives and DNR order.
plan? Select all that apply. 4. She must have read the chart incorrectly.
1. Lactulose therapy 5. The code should have continued.
2. High-fiber diet
3. High-protein milkshakes
8. Two nurses are discussing a client’s condition in the
4. Corticosteroid therapy
elevator. The employer of the mentioned client
5. Antidiarrheal medications
overhears the conversation and fires the client. The
nurses may be liable for which accusation?
4. Hyperbaric oxygen therapy increases the blood’s 1.Assaut
capacity to carry and deliver oxygen to compromised 2.Battery
tissues. This therapy may be used 3.Neglect
for a client With: 4.Breath of confidentiality
1. a compromised skin graft.
2. a malignant tumor.
9. A nurse is making assignments for the infant unit. The The other statements about implantable
shift’s team members include a licensed practical nurse cardioverter-defibrillators are all
(LPN) with 10 years of experience, a registered nurse true.
(RN) with 3 months of experience, and a client care
assistant. Which assignment is most appropriate for the 12. Which situation demonstrates correct principles of
LPN? confidentiality?
1. An infant being discharged to home following 1. An emergency department nurse reports suspected
placement of a gastrostomy tube child abuse.
2. An infant just returned from the post anesthesia care 2. Two nurses in an elevator are discussing a client’s
unit who requires hourly assessment of vital signs status.
3. An infant requiring abdominal dressing changes for a 3. A nurse copies and e-mails client information to a
wound infection friend.
4. An infant with agonal respirations who ¡s receiving 4. During change-of-shift report, a nurse talks about a
palliative care client’s personal problems.
RATIONALE: The infant requiring RATIONALE: Any health care provider
dressing changes ¡s within an LPN’s must report suspected child abuse.
scope of practice. This care has a Sharing this information doesn’t
predictable outcome. Client and violate the client’s right to
family teaching — such as how to care confidentiality. A discussion of
for a gastrostomy tube — is an RN’s confidential information in a public
responsibility. A client care place may be overheard and is a breach
assistant can be assigned to obtain of confidentiality. Any client
vital signs and report the findings to information, whether written or
the supervising RN. Because the electronic, is considered
outcome of the infant with agonal confidential; e-mailing it to a friend
respirations is unpredictable, the RN would be considered a breach of
shouldn’t delegate his care to the confidentiality. Nurses must discuss
LPN. client’s problems during change-of-
shift report, but these discussions
10. A nurse is caring for a client who has returned to his should be limited to information
needed to provide safe care.
room after a carotid endarterectomy. Which action
should the nurse take first?
13. A nurse is caring for a client who has a history of
1. Ask the client if he has trouble breathing.
sleep apnea. The client understands the disease process
2. Take the client’s blood pressure.
when he says:
3. Ask the client if he has a headache.
1. “I need to keep my inhaler at the bedside.”
4. Place antiembolism stockings on the client.
2. “I should eat a high-protein diet.”
RATIONALE: The nurse should first
assess the client’s breathing. A 3. “I should become involved in a weight loss
complication of a carotid program.”
endarterectomy is an incisional 4. “I should sleep on my side all night long.”
hematoma, which could compress the RATIONALE: Obesity and decreased
trachea causing breathing difficulty pharyngeal muscle tone commonly
for the client. Although the other contribute to sleep apnea; the client
measures are important actions, they may need to become involved in a
aren’t the nurse’s top priority. weight loss program. Using an inhaler
won’t alleviate sleep apnea, and the
physician probably wouldn’t order an
11. A client signed a consent form for participation in a
inhaler unless the client had other
clinical trial for implantable cardioverter-defibrillators. respiratory complications. A high-
Which statement by the client indicates the need for protein diet and sleeping on the side
further teaching before true informed consent can be aren’t treatment factors associated
obtained? with sleep apnea.
1. “This implanted defibrillator will protect me against
some of those bad rhythms my heart goes into.” 14. A monitor technician on the telemetry unit asks a
2. “I wonder if there is any other way to prevent these charge nurse why every client whose monitor shows
bad rhythms.” atrial fibrillation is receiving warfarin(Coumadin). Which
3. “The physician will make a small incision in my chest response by the charge nurse is best?
wall and place the generator there.” 1. “It’s just a coincidence; most clients with atrial
4. “A wire from the generator will be attached to my fibrillation don’t receive warfarin.”
heart.” 2. “Warfarin controls heart rate in the client with atrial
RATIONALE: The client wondering if fibrillation.”
there is another way to prevent the 3. “Warfarin prevents atrial fibrillation from progressing
abnormal rhythms indicates that other to a lethal arrhythmia.”
treatment options weren’t discussed 4. “Warfarin prevents clot formation in the atria of
with the client. Before participating
clients with atrial fibrillation.”
in a clinical trial, the client must
be informed of all other available
treatment options. 15. A registered nurse should assign a nursing assistant
to care for a client with inflammatory bowel disease
who:
1. requires assistance with ambulation. started on the insulin infusion protocol. The nurse must
2. requires nasogastric suctioning. monitor the client’s blood glucose levels hourly and
3. requires continuous pulse oximetry monitoring. watch for which early signs and
4. is receiving patient-controlled analgesia. symptoms associated with hypoglycemia?
1. Sweating, tremors, and tachycardia
II. Safety and Infection Control 2. Dry skin, bradycardia, and somnolence
3. Bradycardia, thirst, and anxiety
16. A client in the emergency department is diagnosed 4. Polyuria, polydipsia, and polyphagia
with a communicable disease. When complications of
the disease are discovered, the client is admitted to the 21. A nurse is caring for a cardiac client who requires
hospital and placed in respiratory isolation. Which various cardiac medications. When the nurse helps the
infection warrants airborne isolation? client out of bed for breakfast, the
1. Mumps client becomes dizzy and asks to lie down. The nurse
2. Impetigo helps the client lie down, puts up the side rails, and
3. Measles obtains the client’s blood pressure,
4. Cholera which is 84/50 mm Hg. It’s time for the nurse to
administer the client’s medications: nitroglycerin,
17. A client is returned to his room after a subtotal metoprolol (Lopressor), and furosemide (Lasix). Which
thyroidectomy. Which piece of equipment is most action by the nurse is best?
important for the nurse to keep at the client’s bedside? 1. Withhold the medications and notify the physician.
1. Indwelling urinary catheter kit 2. Administer the medications immediately.
2. Tracheostomy set 3. Encourage the client to sit up and eat breakfast.
3. Cardiac monitor 4. Administer the nitroglycerin and metoprolol and
4. Humidifier withhold the furosemide.

18. Which nursing intervention is most appropriate if a 22. A physician orders digoxin (Lanoxin) elixir for a
client develops orthostatic hypotension while taking toddler with heart failure. Immediately before
amitriptyline (Elavil)? administering this drug, the nurse must check the
1. Consulting the physician about substituting a different toddler’s:
type of antidepressant 1. serum sodium level.
2. Advising the client to sit up for 1 minute before 2. urine output.
getting out of bed. 3. weight.
3. Instructing the client to halve the dosage until the 4. apical pulse.
problem resolves
4. Informing the client that this adverse reaction should 23. A client with myasthenia gravis is receiving
disappear within 1 week continuous mechanical ventilation. When the high-
pressure alarm on the ventilator sounds, what
19. A nurse preceptor is observing a new graduate should the nurse do?
during care of a client in contact isolation. Which action 1. Check for an apical pulse.
by the new graduate indicates a need 2. Suction the client’s artificial airway.
for further teaching about handling infectious 3. Increase the oxygen percentage.
materials? 4. Ventilate the client with a handheld mechanical
1. The nurse wears gloves during each client contact. ventilator.
2. The nurse washes her hands when entering and
exiting the room. 24. A client receives a sealed radiation implant to treat
3. The nurse disposes of articles contaminated with cervical cancer. When caring for this client, the nurse
blood in the room’s biohazard container. should:
4. The nurse uses alcohol gel to clean her hands after 1. consider the client’s urine, feces, and vomitus to be
changing linen soiled with urine and feces. highly radioactive.
RATIONALE: Using alcohol gel isn’t 2. consider the client to be radioactive for 10 days after
acceptable after the nurse has been in implant removal.
contact with soiled material. The 3. allow soiled linens to remain in the room until after
nurse should wash her hands with soap the client is discharged.
and water. The nurse demonstrates 4. maintain the client on complete bed rest with
appropriate handling of infectious
bathroom privileges only.
materials by wearing gloves with each
client contact, washing her hands with
soap and water when she enters and 25. Which precautions should a nurse include in the care
exits the room, and disposing plan for a client with leukemia and neutropenia?
contaminated articles in the room’s 1. Have the client use a soft toothbrush and electric
biohazard container. razor, avoid using enemas, and watch for signs of
bleeding.
20. A client with status asthmaticus requires 2. Put on a mask, gown, and gloves when entering the
endotracheal intubation and mechanical ventilation. client’s room.
Twenty-four hours after intubation, the client is
3. Provide a clear liquid, low-sodium diet. 3. Provide a clear liquid, low-sodium
4. Eliminate fresh fruits and vegetables, avoid using diet.
enemas, and practice frequent hand washing. 4. Eliminate fresh fruits and
vegetables, avoid using enemas, and
practice frequent hand washing.
26. Which infection control equipment is necessary for
the client diagnosed with Clostridium difficile diarrhea?
1. Gloves Health Promotion and Maintainance
2. Mask
3. Face shield 31. A nurse is evaluating the external
4. N-95 respirator fetal monitoring strip of a client who
is in labor. She notes decreases in
the fetal heart rate (FHR) that
27. A nurse is teaching a client how to rotate insulin coincide with the client’s
injection sites. What is the purpose of rotating injection contractions. What term does the nurse
sites? use to document this finding?
1. To prevent bruising 1. Prolonged decelerations
2. To prevent medication leakage from tissue or muscle 2. Early decelerations
3. To prevent erratic drug distribution 3. Late decelerations
4. To prevent formation of hard nodules 4. Accelerations
RATIONALE: A deceleration is a
28. A client is admitted to the facility with a productive decrease in the FHR below the
baseline. When decelerations occur at
cough, night sweats, and a fever. Which action is most
the same time as uterine contractions,
important in the initial care plan? they’re called early decelerations.
1. Assessing the client’s temperature every 8 hours Early decelerations result from head
2. Placing the client in respiratory isolation compression during normal labor and
3. Monitoring the client’s fluid intake and output don’t indicate fetal distress.
4. Wearing gloves during all client contact Prolonged decelerations, also known as
RATIONALE: Because the client’s signs reflex bradycardia, are decreases in
and symptoms suggest a respiratory fetal heart rate that last 60 to 90
infection (possibly tuberculosis), seconds. These decelerations occur in
respiratory isolation is indicated. response to sudden vagal stimulation.
Every 8 hours isn’t frequent enough to Prolonged decelerations may indicate
assess the temperature of a client fetal distress. Late decelerations
with a fever. Monitoring fluid intake start after the beginning of a
and output maybe required, but the contraction. The lowest point of a
client should first be placed in late deceleration occurs after the
isolation. The nurse should wear contraction ends. Accelerations are
gloves only for contact with mucous transient rises in the fetal heart
membranes,broken skin, blood, and rate that are normally caused by fetal
other body fluids and substances. movements and uterine contractions.

29. A client who is disoriented and restless after 32. A nurse is providing teaching to a client who’s being
sustaining a concussion during a car accident is admitted discharged after delivering a hydatidiform mole. Which
to the hospital. Which nursing diagnosis expected outcome takes highest priority for this client?
takes the highest priority in this client’s care plan? 1. “Client will state that she may attempt another
1. Disturbed sensory percept/on (visual) pregnancy after 3 months of follow-up care.”
2. Dressing or grooming self-care deficit 2. “Client will schedule her first follow-up Papanicolaou
3. Impaired verbal communication (Pap) test and gynecologic examination for 6 months
4. Risk for injury after discharge.”
RATIONALE: Because the client is 3. “Client will state that she won’t attempt another
disoriented and restless, the most pregnancy until her human chorionic gonadotropin
important nursing diagnosis is Risk (hCG) level rises.”
for injury. Although Disturbed sensory
4. “Client will use a reliable contraceptive method until
perception (visual), Dressing or
her follow-up care is complete in 1 year and her hCG
grooming self-care deficit, and
Impaired verbal communication may all level is negative.”
be appropriate, they’re secondary RATIONALE: After a molar pregnancy,
because they don’t immediately affect the client should receive follow-up
the client’s health or safety. care, including regular HCG testing,
for 1 year because of the risk of
developing chorionic carcinoma. After
30. Which precautions should a nurse removal of a hydatidiform mole, the
include in the care plan for a client hCG level gradually falls to a
with leukemia and neutropenia? negative reading unless chorionic
1. Have the client use a soft carcinoma is developing, in which case
toothbrush and electric razor, avoid the hCG level rises. A Pap test isn’t
using enemas, and watch for signs of an effective indicator of a
bleeding. hydatidiform mole. A follow up
examination wouki be scheduled within
2. Put on a mask, gown, and gloves weeks of the client’s discharge. The
when entering the client’s room.
client must not become pregnant during 4. A client who had coronary artery bypass surgery 2
follow-up care because pregnancy weeks earlier
causes the hCG level to rise, making RATIONALE: Hospices provide
it indistinguishable from this early supportive, palliative care to
sign of chorionic carcinoma. terminally ill clients, such as those
with late-stage AIDS, as well as their
33. A client comes to the clinic because she has families. Hospice services wouldn’t be
experienced a weight loss of 20 lb (9.1 kg) over the last appropriate for a client with left-
month, even though her appetite has been “ravenous” sided paralysis resulting from a
and she hasn’t changed her activity level. She’s stroke, a client who’s undergoing
diagnosed with Graves’ disease. Which other signs and treatment for heroin addiction, or one
who recently had coronary artery
symptoms support the diagnosis of Graves’ disease?
bypass surgery because these health
Select all that apply. problems aren’t necessarily terminal.
1. Rapid, bounding pulse
2. Bradycardia
39. A child is being discharged with proventil (Albuterol)
3. Heat intolerance
nebulizer treatments. The nurse should instruct the
4. Mild tremors
parents to watch for:
5. Nervousness
1. tachycardia.
6. Constipation
2. bradypnea.
3. urine retention.
34. An adolescent is receiving chemotherapy for 4. constipation.
lymphoma. Which statement by the adolescent
supports a nursing diagnosis of Deficient
40. A client asks the nurse what the difference is
knowledge related to mouth care?
between osteoarthritis (OA) and rheumatoid arthritis
1. “I use a soft toothbrush to clean my teeth.”
(RA). Which response is correct?
2. “I remove white patches from my tongue and cheeks
1. “OA is a non-inflammatory joint disease. RA is
with my toothbrush.”
characterized by inflamed, swollen joints.”
3. “I rinse my mouth every 2 to 4 hours with a solution
2. “OA and RA are very similar. OA affects the smaller
of baking soda and water.”
joints and RA affects the larger, weight-bearing joints.”
4. “I don’t use commercial mouthwashes.”
3. “OA affects joints on both sides of the body. RA is
usually unilateral.”
35. A nurse is teaching a client about rheumatoid 4. “OA is more common in women. RA is more common
arthritis. Which statement by the client indicates in men.
understanding of the disease process?
1. “It will get better and worse again.”
41. A nurse records a client’s history and discovers
2. “When it clears up, it will never come back.”
several risk factors for coronary artery disease (CAD).
4. “I’ll definitely need surgery for this.”
Which cardiac risk factors can the client control?
5. “It will never get any better than it is right now.”
1. Diabetes, hypercholesterolemia, and heredity
2. Diabetes, age, and gender
36. A child who was hospitalized for sickie cell crisis is 3. Age, gender, and heredity
being discharged. Which parent outcome demonstrates 4. Diabetes, hypercholesterolemia, and hypertension
effective teaching regarding prevention of future crises?
1. The parent verbalizes the need to stay away from
42. In the first stage of labor, a client with a full-term
persons with known infections.
pregnancy has external electronic fetal monitoring
2. The parent verbalizes appropriate dietary restrictions.
(EFM) in place. Which EFM pattern
3. The parent verbalizes the need to restrict fluid intake.
suggests adequate uteroplacental-fetal perfusion?
4. The parent participates in an aerobic exercise
1. Persistent fetal bradycardia
program.
2. Variable decelerations
3. Fetal heart rate accelerations
37. A child is receiving chemotherapy for treatment of 4. Late decelerations
acute lymphocytic leukemia. During discharge
preparation, which topic is most important for the nurse
43. A nurse should expect to administer which vaccine
to discuss with the child and parents?
to the client after a splenectomy?
1. How to help the child adjust to an altered body image
1. Recombivax HR
2. How to increase the child’s interactions with peers
2. Attenuvax
3. The need to decrease the child’s activity level
3. Pneumovax 23
4. Ways to prevent infection
4. Tetanus toxoid
RATIONALE: Pneumovax 23, a polyvalent
38. Which client would qualify for hospice care? pneumococcal vaccine, is administered
1. A client with late-stage acquired immunodeficiency prophylactically to prevent the
syndrome (AIDS) pneumococcal sepsis that sometimes
2. A client with left-skied paralysis resulting from a occurs after splenectomy. Recombivax
stroke HB is a vaccine for hepatitis B.
3. A client who’s undergoing treatment for heroin Attenuvax is a live, attenuated virus
addiction vaccine for immunization against
measles (rubeola). Tetanus toxoid is
administered to prevent tetanus
resulting from impaired skin integrity 1. Ventricular dilation
caused by traumatic injury. 2. Systemic hypertension
3. Aortic valve malfunction
44. A nurse assigns to a neonate an Apgar score of 8 at 5 4. Increased atrial contractions
minutes. The nurse understands that this score
indicates: 49. A nurse is caring for a client who is receiving
1. a neonate who’s in good condition. chemotherapy and has a platelet count of 30,000/mm3.
2. a neonate who’s mildly depressed. Which statement by the client indicates a need for
4. a neonate who’s moderately depressed. additional teaching?
4. a neonate who needs additional oxygen to improve 1. “I floss my teeth every morning.”
the Apgar score. 2. “I use an electric razor to shave.”
RATIONALE: An Apgar score of 8 3. “I take a stool softener every morning.”
indicates that the neonate has made a 4. “I removed all the throw rugs from the house.”
good transition to extrauterine life.
A score of 4 to 6 would indicate
moderate distress; a score of O to 3 50. A diet plan is developed for a client with gouty
would indicate severe distress. arthritis. The nurse should advice the client to limit his
intake of:
1. organ meats.
45. A nurse is performing discharge teaching with a
2. fresh fruits.
client who has an implantable cardioverter defibrillator
3. green vegetables.
(lCD) placed. Which client statement
4. freshfish.
indicates effective teaching?
1. “I’ll keep a log of each time my lCD discharges.”
51. A client with chronic renal failure plans to receive a kidney
C 2. “I can’t wait to get back to my football league.”
transplant. Recently, the physician told the client that he is a
0 3. “I have an appointment for magnetic resonance poor candidate for transplant because of chronic uncontrolled
imaging of my knee scheduled for next week.” hypertension and diabetes mellitus. Now, the client tells the
4. “I need to stay at least 10’ away from the nurse, “I want to go off dialysis. I’d rather not live than be on
microwave.” this treatment for the rest of my life.” Which responses are
RATIONALE: The client stating that he appropriate? Select all that apply.
should keep a log of all ICD 1. Take a seat next to the client and sit quietly.
discharges indicates effective 2. Say to the client, “We all have days when we don’t feel Ike
teaching. This log helps the client going on.”
and physician identifý activities that 3. Leave the room to allow the client to collect his thoughts.
may cause the arrhythmias that make 4. Say to the client, “You’re feeling upset about the news you
the ¡CD discharge. He should also got about the transplant.”
record the events right before 5. Say to the client, “The treatments are only 3 days a week.
the discharge. Clients with ICDs You can live with that.”
should avoid contact sports such as
football. They must also avoid 52. Which signs and symptoms might a nurse observe in a
magnetic fields, which could client having an adverse reaction to a loop diuretic? Select all
permanently damage the lCD. Household that apply.
appliances don’t interfere with the 1. Weakness
ICD. 2. Irregular pulse
3. Hyperactive bowel sounds
4. Decreased muscle tone
46. A nursing assistant is caring for a client with 5. Potassium level of 3.1 mEq/L
Clostridium difficile diarrhea and asks the charge nurse, 6. Ventricular arrhythmias
“How can I keep from catching this from the client?”
The nurse reminds the nursing assistant to wash her 53. A nurse is caring for a client with advanced cancer. Based
hands and to ensure that the client is placed: on the nursing progress notes below, what should be the
1. on protective isolation. nurse’s next intervention?
2. on neutropenic precautions.
3. in a negative-pressure room.
4. on contact isolation.

47. A nurse assesses a client in the physician’s office.

Which assessment findings support a suspicion of
systemic lupus erythematosus (SLE)?
1. Facial erythema, pericarditis, pleuritis, fever, and
weight loss
2. Photosensitivity, polyarthralgia, and painful mucous
membrane ulcers
3. Weight gain, hypervigilance, hypothermia, and edema
of the legs
4. Hypothermia, weight gain, lethargy, and edema of the 1. Reread the Patient’s Bill of Rights to the client.
arms 2. Call the client’s spouse to discuss the client’s statements.
3. Tell the client that he can receive adequate pain relief only
48. Which complication does a third heart sound (53) in the hospital.
indicate?
4. Explain that an advance directive can express the client’s 58. A nurse is caring for a client who underwent surgical repair
wishes. of a detached retina of the right eye. Which interventions
RATIONALE: The nurse should explain how an advance should the nurse perform? Select all that apply.
directive can be used to express the client’s wishes. An 1. Place the client in a prone position.
advance directive is a legal document that’s used as a 2. Approach the client from the left side.
guideline for life-sustaining medical care of the client with an 3. Encourage deep breathing and coughing.
advanced disease or disability who can no longer indicate his 4. Discourage bending down.
own wishes. This document can include a living will, which 5. Orient the client to his environment.
instructs the physician not to administer life-sustaining 6. Administer a stool softener.
treatment, and a health care power of attorney, which names
another person to act on the client’s behalf for medical 59. A client is admitted with a possible diagnosis of
decisions in the event that the client can’t act for himself. The osteomyelitis. Based on the documentation below, which
Patient’s Bill of Rights doesn’t specifically address the client’s laboratory result is the priority for the nurse to report to the
wishes regarding future care. Calling the spouse is a breach of physician?
the client’s right to confidentiality. Stating that only a hospital
can provide adequate pain relief in a terminal situation
demonstrates inadequate knowledge on the nurse’s part of
the resources available through collaboration with hospice

54. While assessing a client’s spine for abnormal curvatures,

the nurse notes lordosis. Identify the area of the spine that is
affected by lordosis.

1. Rheumatoid factor
2. Blood culture
3. Alkaline Phosphatase
4. ESR

60. A nurse is caring for dlent5 with diabetes insipidus and

must be aware of the disorder’s pathophysiology. Place the
following events in chronological sequence to show the
pathophysiologic process. Use all of the options.

55. A client is ordered heparin 6,000 units subcutaneously

every 12 hours for deep vein thrombosis prophylaxis. The
pharmacy dispenses a vial containing 10,000 units/ml. How
many milliliters of heparin should the nurse administer?
Record your answer using one decimal place.
Answer: 0.6ml 61. The nurse is admitting a client with newly diagnosed
diabetes mellitus and left-sided heart failure. Assessment
56. A nurse is caring for a client with a hiatal hernia. The client reveals low blood pressure, increased respiratory rate and
complains of abdominal pain and sternal pain after eating. The depth, drowsiness, and confusion. The client complains of
pain makes it difficult for him to sleep. Which instructions headache and nausea. Based on the serum laboratory results
should the nurse recommend when teaching this client? Select below, how would the nurse interpret the client’s acid—base
all that apply. balance?
1. Avoid constrictive clothing.
2. Lie down for 30 minutes after eating.
3. Decrease intake of caffeine and spicy foods.
4. Eat three meals per day.
5. Sleep in semi-Fowler’s position.
6. Maintain a normal body weight.

57. A nurse is performing cardiac assessment. Identify where

the nurse places the stethoscope to best auscultate the
pulmonic valve.

1. Metabolic Alkalosis
2. Metabolic Acidosis
3. Respiratory Alkalosis
4. Respiratory Acidosis
62. An elderly client has a history of aortic stenosis. Identify 66. The nurse is evaluating an electrocardiogram (ECG) tracing.
the area where the nurse should place the stethoscope to best Which graphic shows the QT interval?
hear the murmur.

63. A nurse should expect to find which defining

characteristics in a client with a nursing diagnosis of ineffective
tissue perfusion (peripheral)? Select all that apply.
1. Edema
2. Skin pink in color
3. Strong, bounding pulses
4. Normal sensation
5. Skin discoloration
6. Skin temperature changes

64. While examining the hands of a client with osteoarthritis, a 67. A client with a bicuspid aortic valve has severe stenosis and
nurse notes heberden’s node on the second (pointer) finger. is scheduled for valve replacement. While teaching the client
Identify the area on the finger where the nurse observed the about the condition and upcoming surgery, the nurse shows a
node. heart illustration. Which valve should the nurse indicate as
needing replacement?

65. 1. A client with sepsis and hypotension is being

treated with dopamine hydrochloride. A nurse asks a
colleague to double-check the dosage that the client is
receiving. The 250-ml bag contains 400 mg of dopa-
mine, the infusion pump ¡s running at 23 mI/hour,
and the clent weighs 80 kg. How many micrograms
per kilogram per minute is the client receiving? Record
your answer using one decimal point.
Answer: 7.7 mg/kg/min 68. A nurse places electrodes on a collapsed individual who
was visiting a hospitalized family member, the monitor
exhibits the following. Which interventions should the nurse
do first?

1. Place the client on oxygen

2. Confirm the rhythm with a 12-lead ECG
3. Administer amiodarone I.V. as prescribed
4. Assess the client’s airway, breathing, and circulation.
69. Following coronary artery bypass graft surgery, a client is
admitted to the surgical intensive care unit and connected to a 1. Morphine LV. 2 mg every 2 hours P.R.N. for shortness of
cardiac monitor. The nurse can’t detect a pulse or blood breath
pressure and observes the following pattern on the 2. Furosemide I.V. 40 mg every 6 hours
electrocardiogram (ECG) monitor. What does this pattern 3. 0.9% normal saline solution I.V. at 150 ml/hour
show? 4. Dobutamine 5 mcg/kg/minute I.V

73. A client who is receiving procainamide has the following

electrocardiogram (ECG) tracing. The nurse anticipates that
the physician will order which drug?

1. Artifact
2. Ventricular tachycardia
3. Ventricular fibrillation
4. Pulseless electrical activity
1. Quinidine sulfate
70. A nurse determines that a hockey player hospitalized with 2. Lidocaine (Xylocaine)
bilateral leg fractures is hemodynamically stable, She observes 3. A higher dose of procainamide (Pronestyl)
the following pattern on the electrocardiogram (ECG) monitor. 4. Magnesium sulfate
Which nursing intervention is most appropriate at this time? RATIONALE: This ECG shows torsades de pointes. In this
variant form of ventricular tachycardia, QRS complexes rotate
about the baseline, their amplitude decreasing and increasing
gradually as the rhythm progresses. To shorten the QT interval
and prevent this arrhythmia from recurring, the physician is
likely to order magnesium sulfate. Because torsades de
pointes is precipitated by a long QT interval, drugs that
1. None; this arrhythmia is benign prolong the QT interval, such as quinidine and procainamide,
2. Administering atropine sulfate, 0.5 mg, as ordered to are contraindicated. The most effective treatment is overdrive
increase heart rate. pacing with an electronic pacemaker until the offending drug
3. Continuing to monitor if lengthening PR intervals is excreted. Typically, such drugs as lidocaine — normally
4. Evaluating the client’s serum electrolyte studies effective in suppressing ventricular activity — fail to convert
torsades de pointes to a normal sinus rhythm.
71. A nurse observes the following pattern when monitoring
the electrocardiogram (ECG) of a stable client. What should 74. A client is admitted with acute coronary syndrome. The
the nurse do? nurse measures the client’s blood pressure at 97/66 mm Hg,
obtains a palpable femoral pulse, notes that the client is
awake and coherent, and observes the following pattern on
the electrocardiogram (ECG) monitor. Based on these findings,
the nurse should take which action?

1. Continue to observe for deterioration of the heart rhythm.

2. Administer 0.5 mg of atropine sulfate by I.V. push as
ordered.
3. Prepare for transvenous pacemaker insertion as ordered.
4. Administer amiodarone (Cordarone) 150 mg I.V. as ordered. 1. Defibrillate at 200 jouIes as ordered.
2. Administer a precordial thump as ordered.
72. A nurse is caring for a client with pulmonary edema. The 3. Administer amiodarone (Cordarone) 150 mg I.V.
physician writes the following orders. Which order should the 4. Continue to defibrillate at increasing joules, as ordered,
nurse clarify? until a stable heart rhythm is restored.

75. The nurse is assessing a client who has had a myocardial

infarction. The nurse notes the cardiac rhythm shown on the
electrocardiogram strip below. The nurse identifies this
rhythm as:

1. Atrial fibrillation.
2. Ventricular tachycardia.
3. Premature ventricular contractions.
4. Sinus tachycardia.
76. The nurse is assessing a client who has had a myocardial 1. Urine output.
infarction (MI). The nurse notes the cardiac rhythm on the 2. Heart rate.
monitor (see the electrocardiogram strip below). The nurse 3. Blood pressure.
should: 4. Respiratory rate.

80. An 85-year-old client is admitted to the emergency

department (ED) at 8 PM with syncope, shortness of breath,
and reported palpitations (See nurse's notes below). At 8:15
PM, the nurse places the client on the ECG monitor and
identifies the following rhythm (see below). The nurse should
do which of the following? Select all that apply.

1. Notify the physician.

2. Call the rapid response team.
3. Assess the client for changes in the rhythm.
4. Administer lidocaine as prescribed.

77. Captopril, furosemide, and metoprolol are prescribed for a

client with systolic heart failure. The client's blood pressure is
136/82 and the heart rate is 65. Prior to medication
administration at 9 AM, the nurse reviews the following lab
tests (see chart). Which of the following should the nurse do
first?

1. Administer the medications.

2. Call the physician.
3. Withhold the captopril.
4. Question the metoprolol dose.

78. The nurse observes the cardiac rhythm (see below) for a
client who is being admitted with a myocardial infarction.
What should the nurse do first?

1. Apply oxygen.
2. Prepare to defibrillate the client.
3. Monitor vital signs.
1. Prepare for immediate cardioversion. 4. Have the client sign consent for cardioversion as
2. Begin cardiopulmonary resuscitation (CPR). prescribed.
3. Check for a pulse. 5. Teach the client about warfarin (Coumadin) treatment and
4. Prepare for immediate defibrillation. the need for frequent blood testing.
6. Draw blood for a CBC count and thyroid function study.
79. The nurse is monitoring a client admitted with a
myocardial infarction (MI) who is at risk for cardiogenic shock. 81. Twenty-four hours after a client undergoes aortic valve
The nurse should report which of the following changes on the replacement surgery, the following pattern appears on the
client's chart to the physician? electrocardiogram (ECG) monitor. How should the nurse
interpret this pattern?

1. Atrial fibrillation
2. Normal Sinus tachycardia
3. Atrial Flutter
4. Multifocal atrial tachycardia
82. A client is admitted to the surgical intensive care unit 85. A nurse is evaluating an external fetal monitoring strip.
following small-bowel resection. The ECG monitor shows the Identify the are on this strip that causes her to be concerned
pattern below. What does this pattern indicate? about uteroplacental insufficiency.

1. Ventricular tachycardia
2. Atrial Flutter
3. Atrial fibrillation
4. Normal sinus rhythm

83. On the waveform below, identify the area that indicates

possible umbilical cord compression.

86. The nurse is preparing to administer digoxin 0.25 mg IVP to

a client in severe congestive heart failure who is receiving
D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance.
1. Administer the medication over 5 minutes.
2. Dilute the medication with normal saline.
3. Draw up the medication in a tuberculin syringe.
4. Check the client’s identification band.
5. Clamp the primary tubing distal to the port.
11. Correct Answer: 3, 2, 4, 5, 1
3. Because this is less than 1 mL, the nurse
should draw this medication up in a 1-mL
tuberculin syringe to ensure accuracy of
dosage.
2. The nurse should dilute the medication
84. While waiting to receive report at shift change, a nurse with normal saline to a 5- to 10-mL bolus
reads the entry below in a client’s chart. After reading this to help decrease pain during administration
note, the nurse knows her client is in which stage of labor? and maintain the IV site longer.
3. Administering 0.25 mg of digoxin in
0.5 mL is very difficult, if not impossible,
to push over 5 full minutes, which is the
manufacturer’s recommended administration
rate. If the medication is diluted
to a 5- to 10-mL bolus, it is easier for the
nurse to administer the medication over
5 minutes.
4. The nurse must check two identifiers
according to the Joint Commission safety
guidelines.
5. The nurse should clamp the tubing
1. Stage 1, latent phase between the port and the primary IV line
2. Stage 2 so that the medication will enter the vein,
3. Stage 1, active phase not ascend up the IV tubing.
4. Stage 1, transition phase 1. Cardiovascular and narcotic medications
RATIONALE: During the active phase of stage 1 labor, are administered over 5 minutes.
membranes may rupture spontaneously. Contractions last
about 40 to 60 seconds and recur every 3 to 5 minutes, and 87. The client is in the cardiac intensive care unit on
the cervix dilates from about 3 cm to 7 cm. During the latent dopamine, a vasoconstrictor, and B/P increases to 210/130.
phase of stage 1, contractions last 20 to 40 seconds and occur Which intervention should the intensive care nurse implement
every 5 to 30 minutes and the cervix dilates from O to 3 cm. first?
During stage 2 labor, the cervix is fully dilated and effaced and 1. Discontinue the client’s vasoconstrictor, dopamine.
the neonate is born. During the transition phase of stage 1, 2. Notify the client’s healthcare provider.
contractions last 60 to 90 seconds and occur every 2 to 3 3. Administer the vasopressor hydralazine.
minutes and the cervix dilates from 7 cm to 10 cm. 4. Assess the client’s neurological status.
12. 1. The nurse should first discontinue the
medication that is causing the increase in
the client’s blood pressure prior to doing
anything else.
2. The nurse should notify the HCP but not
prior to taking care of the client’s elevated
blood pressure. 2. The client receiving a beta-adrenergic blocker who has an
3. The client may need a medication to decrease apical heart rate of 62 beats/min.
the blood pressure but the nurse 3. The client receiving nonsteroidal anti-inflammatory drugs
should first discontinue the medication (NSAIDs) who has just finished eating breakfast.
causing the elevated blood pressure. 4. The client receiving an oral anticoagulant who has an
4. The nurse must first decrease the client’s International Normalized Ratio (INR) of 2.8.
blood pressure prior to assessing the client. 15. 1. The client receiving a CCB should avoid
MAKING NURSING DECISIONS: The test taker grapefruit juice because it can cause the CCB to rise to toxic
should remember that when the client is in levels. Grapefruit juice inhibits cytochrome P450-3A4
distress, do not assess. The nurse must intervene and take found in the liver and the intestinal wall. This inhibition
care of the client. If any of the options is assessment data the affects the metabolism of some drugs and can, as is the case
HCP will need or an intervention that will help the client, with CCBs, lead to toxic levels of the drug. For this reason,
then the test taker should not select the option to notify the the nurse should investigate any medications the client is
HCP. taking if the client drinks grapefruit juice.
2. The apical heart rate should be greater than 60
88. The charge nurse is making client assignments in the beats/minute before administering the medication; therefore,
cardiac critical care unit. Which client should be assigned to the nurse would not question administering this medication.
the most experienced nurse? 3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be
1. The client with acute rheumatic fever carditis who does not taken with foods to prevent gastric upset; therefore, the nurse
want to stay on bed rest. would not question administering this medication.
2. The client who has the following ABG values: pH, 7.35; 4. The INR therapeutic level for warfarin (Coumadin), an
PaO2, 88; PaCO2, 44; CO3, 22. anticoagulant, is 2 to 3; therefore, the nurse would not
3. The client who is showing multifocal premature ventricular question administering this medication.
contractions (PVCs).
4. The client diagnosed with angina who is scheduled for a 91. Which individual is at greatest risk for developing
cardiac catheterization. hypertension?
13. 1. The client with rheumatic heart fever is A) 45 year-old African American attorney
expected to have carditis and should be on B) 60 year-old Asian American shop owner
bed rest. The nurse needs to talk to the client C) 40 year-old Caucasian nurse
about the importance of being on bed rest D)55 year-old Hispanic teacher
but this client is not in a life-threatening The correct answer is A: 45 year-old African American attorney
situation and does not need the most experienced The incidence of hypertension is greater among African
nurse. Americans than other groups in the US. The incidence among
2. These ABG values are within normal limits; the Hispanic population is rising.
therefore, a less experienced nurse could care
for this client. 92. A child who ingested 15 maximum strength
3. Multifocal PVCs are an emergency acetaminophen tablets 45 minutes ago is seen in the
and are possibly life threatening. An emergency department. Which of these orders should the
experienced nurse should care for this nurse do first?
client. A) Gastric lavage PRN
4. A cardiac catheterization is a routine procedure B) Acetylcysteine (mucomyst) for age per pharmacy
and would not require the most experienced C) Start an IV Dextrose 5% with 0.33% normal saline to keep
nurse. vein open
D) Activated charcoal per pharmacy
89. The primary cardiac nurse is delegating tasks to the The correct answer is A: Gastric lavage PRN Removing as much
unlicensed assistive personnel (UAP). Which delegation task of the drug as possible is the first step in treatment for this
warrants intervention by the charge nurse of the cardiac unit? drug overdose. This is best done by gastric lavage. The next
1. The UAP is instructed to bathe the client who is on drug to give would be activated charcoal, then mucomyst and
telemetry. lastly the IV fluids.
2. The UAP is requested to obtain a bedside glucometer
reading. 93. Which complication of cardiac catheterization should the
3. The UAP is asked to assist with a portable chest x-ray. nurse monitor for in the initial 24 hours after the procedure?
4. The UAP is told to feed a client who is dysphagic. A) angina at rest
14. 1. All clients in the ICU are on telemetry, and B) thrombus formation
the UAP could bathe the client. This would C) dizziness
not warrant intervention by the charge D) falling blood pressure
nurse. The correct answer is B: thrombus formation Thrombus
2. The UAP can perform glucometer checks at formation in the coronary arteries is a potential problem in the
the bedside, and there is nothing that indicates initial 24 hours after a cardiac catheterization. A falling BP
the client is unstable. This would not occurs along with hemorrhage of the insertion site which is
warrant intervention by the charge nurse. associated with the first 12 hours after the procedure.
3. The UAP can assist with helping the client
sit up for a portable chest x-ray as long as the 94. A client is admitted to the emergency room with renal
UAP is not pregnant and wears a shield. calculi and is complaining of moderate to severe flank pain and
4. This client is at risk for choking and is nausea. The client’s temperature is 100.8 degrees Fahrenheit.
not stable; therefore, the charge nurse The priority nursing goal for this client is
should intervene and not allow the UAP A) Maintain fluid and electrolyte balance
to feed this client. B) Control nausea
C) Manage pain
90. The nurse is administering medications to clients in the D) Prevent urinary tract infection
cardiac critical care area. Which client should the nurse The correct answer is C: Manage pain The immediate goal of
question administering the medication? therapy is to alleviate the client’s pain.
1. The client receiving a calcium channel blocker (CCB) who is
drinking a glass of grapefruit juice.
95. What would the nurse expect to see while assessing the intubation or a tracheostomy in the event of further or
growth of children during their school age years? complete obstruction.
A) Decreasing amounts of body fat and muscle mass
B) Little change in body appearance from year to year 100. In children suspected to have a diagnosis of diabetes,
C) Progressive height increase of 4 inches each year which one of the following complaints would be most likely to
D) Yearly weight gain of about 5.5 pounds per year prompt parents to take their school age child for evaluation?
The correct answer is D: Yearly weight gain of about 5.5 A) Polyphagia
pounds per year School age children gain about 5.5 pounds B) Dehydration
each year and increase about 2 inches in height. C) Bed wetting
D) Weight loss
96. At a community health fair the blood pressure of a 62 year- The correct answer is C: Bed wetting In children, fatigue and
old client is 160/96. The client states “My blood pressure is bed wetting are the chief complaints that prompt parents to
usually much lower.” The nurse should tell the client to take their child for evaluation. Bed wetting in a school age
A) go get a blood pressure check within the next 48 to 72 child is readily detected by the parents
hours
B) check blood pressure again in 2 months
C) see the health care provider immediately
D) visit the health care provider within 1 week for a BP check
The correct answer is A: go get a blood pressure check within
the next 48 to 72 hours The blood pressure reading is
moderately high with the need to have it rechecked in a few
days. The client states it is ‘usually much lower.’ Thus a
concern exists for complications such as stroke. However
immediate check by the provider of care is not warranted.
Waiting 2 months or a week for follow-up is too long.

97. The hospital has sounded the call for a disaster drill on the
evening shift. Which of these clients would the nurse put first
on the list to be discharged in order to make a room available
for a new admission?
A) A middle aged client with a history of being ventilator
dependent for over 7 years and admitted with bacterial
pneumonia five days ago
B) A young adult with diabetes mellitus Type 2 for over 10
years and admitted with antibiotic induced diarrhea 24 hours
ago
C) An elderly client with a history of hypertension,
hypercholesterolemia and lupus, and was admitted with
StevensJohnson syndrome that morning
D) An adolescent with a positive HIV test and admitted for
acute cellulitus of the lower leg 48 hours ago
The correct answer is A: A middle aged client with a history of
being ventilator dependent for over 7 years and admitted with
bacterial pneumonia five days ago The best candidate for
discharge is one who has had a chronic condition and is most
familiar with their care. This client in option A is most likely
stable and could continue medication therapy at home.

98. A client has been newly diagnosed with hypothyroidism

and will take levothyroxine (Synthroid) 50 mcg/day by mouth.
As part of the teaching plan, the nurse emphasizes that this
medication:
A) Should be taken in the morning
B) May decrease the client's energy level
C) Must be stored in a dark container
D) Will decrease the client's heart rate
The correct answer is A: Should be taken in the morning
Thyroid supplement should be taken in the morning to
minimize the side effects of insomnia

99. A 3 year-old child comes to the pediatric clinic after the

sudden onset of findings that include irritability, thick muffled
voice, croaking on inspiration, hot to touch, sit leaning
forward, tongue protruding, drooling and suprasternal
retractions. What should the nurse do first?
A) Prepare the child for x-ray of upper airways
B) Examine the child's throat
C) Collect a sputum specimen
D) Notify the healthcare provider of the child's status
The correct answer is D: Notify the health care provider of the
child''s status These findings suggest a medical emergency and
may be due to epiglottises. Any child with an acute onset of an
inflammatory response in the mouth and throat should receive
immediate attention in a facility equipped to perform