1.

Which clients lab values requires immediate intervention

a. Client with cancer
2. A client is admitted with diabetic ketoacidosis…
a. Urine ketones
3. Client is admitted to the hospital with community acquired pneumonia…
a. Obtain an ABG sample
4. The nurse is preparing a client for surgery who was admitted to the emergency center
following…
a. Notify the provider
5. A nurse receives a report on a client who is four hours post-total abd hysterectomy
a. Evaluate the skin turgor
6. Nurse is teaching a husband how to care for his wife….
a. Tennis shoes with Velcro
7. An elderly female client grimaces and demonstrates guarding behavior
a. Ask client to describe how she is feeling
8. On the third postoperative day, client had a hip replacement……(SATA)
a. Administer a PRN…
b. Present a calm…
9. When implementing a therapeutic milieu on a psychiatric unit,,,,,
a. Encourage client participation in planning
10. The nurse is conducting an initial admission assessment for a woman who is muslim….
a. Ascertain if client request the nurse be the same gender

11. The nurse enters the room of a client who is six hours postop…
a. Advise the client to perform deep breathing without coughing
12. The nurse observes that while ambulating a client in the hall…..
a. Respiratory rate
13. Client with medical diagnosis of a ruptured cerebral aneurysm….
a. 5.
14. The nurse is assessing a 3-yr old child with head injury….
a. An increased BP
15. What is the best nursing action when providing morning care for an ambulatory client with an
indwelling cath….
a. Keeping cath intact, assist client w/shower
16. Peak and trough level was obtained….
a. Increased peak, increased trough
17. Prior to receiving a 120ml hypertonic fleet enema
a. Obtain a bedside commode
18. The healthcare provider prescribes a loading dose of digoxin 0.5 mg…….
a. 2.4
19. Following A total thyroidectomy, the nurse plans to observe a client for complications…
a. Complains of muscle twitching
20. (PHOTO OF PERSON HEAD) head injury assess for rhinorrhea so sample can be tested for
presence of CSF
 a. Click nose
21. Nurse observes a client with amyotrophic lateral sclerosis….
a. Apply a water soluble lubricant
22. A client with a long history of unstable angina….
a. Provide a bedside commode for toileting
23. Which instruction should the nurse provide client recently dx w/ Raynard’s disease
a. Use heating pad
OR
b. Wear gloves
24. The nurse is teaching a client with kidney disease who is being discharged…
a. Read labels
25. Pt with chronic kidney disease(CKD) arrives at ED…..
a. Analyze cardiac waveform for peaked T waves
26. A hospitalized, adult client who had a gastric bypass…..
a. Reassure the client
27. A male infant is admitted to pediatric unit w/ pertussis…..
a. Explain the need to maintain droplet precautious
28. When performing postural drainage on a client/ COPD….
a. Explain that the client may be placed in 5 positions
29. A student nurse reports to the charge nurse that a UAP……
a. Review the situation with the UAP
30. A client diagnosed with stable angina secondary to ischemic…..
a. Call 911
31. To control asthma, a client is a residential treatment facility…..
a. Explain that the client should not use disk more than 2x day
32. A male client is asked about his reason for coming to the mental health clinic….
a. Why do you think….
33. The nurse is caring for a preschool-aged child with CHD…….
a. CT scan
34. A nurse who works on a med surg unit…..
a. 36- year old post cardiac cath
35. Client with a new tracheostomy is producing blood tinged secretions
a. Hyperoxygenate to the client w/ 100%
36. At change of shift, a female client nurse informs…..
a. Start prophylactic trmnt
37. A woman is brought to the labor and delivery unit….
a. Massage the fundus and give an oxytocic agent (?)
38. A woman who is 36 weeks pregnant spills hot grease…..
a. Monitor the client distal pulses
39. Which is expected outcome statement…..
a. Client will receive well-balanced diet from meals on wheels
40. A client with draining skin lesions….(SATA)
a. Institute contact, use standard, send wound drainage
41. The nurse is preparing a client with an exacerbation of systemic lupus…
 a. Take prescribed corticosteroid
i. OR
b. Use a walker
42. The nursing is documenting a client fluid intake @ breakfast….
a. 780
43. Child who is preparing to enter the 1 st grade….
a. Ensure that the child’s lunch is hypoallergenic diet
44. While completing the triage assessment….
a. Red
45. An older male client arrives at the healthcare center w/ complaints…..
a. Eval the client for bladder
46. When preparing a client for a paracentesis…..
a. Obtain the client current weight
47. A client who takes NSAIDs….
a. Observe for GI bleeding
48. When entering the room of a sedated postop client….
a. Low intermittent suction prescribed for the naso tube is turned off
49. The nurse is teaching a client with cancer….
a. Washes the radiation site with antibacterial soap
50. A client with metabolic syndrome…..
a. Reduce intake of high cholesterol
51. A client who is 32 weeks gestation arrives at clinic….
a. Listen to fetal heart rate
52. The nurse is assessing a male client who is receiving furosemide 40mg….
a. These muscle cramps in my legs
53. The nurse is caring for a client with long hx of alcohol dependence….
a. Give prescribed analgesic
54. In reviewing dietary instructions for a client w/ osteoporosis…
a. Berry yogurt
55. The healthcare provider prescribes interferon beta-1b 0.125 mg….
a. 0.5
56. Two clients are admitted to the unit at once…..
An RN to care for both because RN has to do 1st assessment on PTs
57. A mother of a 14 yr old who had below the knee amp…
a. A reaction of anger is your child attempts to cope with his loss
58. A full term, 24 hour old infant in nursery regurgitates….
a. Suction the oral and nasal
59. Which short-term outcome should the nurse include..client with dementia….
a. Performs activities of daily living for 3 seq days
60. An older client with hx of type 2 diabeties…(SATA)
a. Palapate pedal, test lower extremities, obtain urine
61. During the immediate post op period, client w. vacuum drained….
a. Decrease blood pressure
62. A young adult is brought to ED after taking handful of drugs…(SATA)
 a. Auscultate, obtain x-ray, assess for symmetrical
63. Two days after a abscess of the chin drained…
a. Assess airway
64. The nurse is collection a urine specimen…..
a. A clean catch
65. A client with heart failure develops pulmonary edema….
a. Implement cardiac telemetry
66. A 30-year-old primigravida delivers 9 pound…
a. Observe signs of uterine hemorrhage
67. The nurse assesses a client being treated for herpes zoster(shingles)…(SATA)
a. Functional ability, pain scale, skin integrity
68. An adult male with toxic alcohol levels……
a. Document the client refusal
69. A client with chronic kidney disease on peritoneal dialysis….
a. Exit site infection
70. A young adult visits the clinic reporting sx assoc w/ gastritis…
a. Consumes 10 or more drinks
71. The nurse is caring for clients on a surgical unit.. delegate to UAP…
a. Document client fluid output
72. The nurse is obtaining a systolic BP by palpation….
a. Inflate BP cuff to 120
73. While the nurse is reviewing physician orders….computer locks up….
a. Notify information services.
74. The nurse is caring for a client following a correction of aortic stenosis…
a. Administer furosemide 40 mg
75. A client with acute respiratory distress watches everything…..
a. Explain details before client
76. During an annual physical exam, older client fasting blood sugar….
a. Random blood glucose
77. An older male client who is living with his adult son…..
a. reality reinforcement****
78. The nurse is evaluation teaching about drug therapy to treat gout…..
a. The pain and swelling can be controlled by taking this drug every day
79. The Practical Nurse is caring for a client with acute heart failure…..
a. Clarify the prescription with provider
80. When advising a new mother….
a. Difficulty swallowing secretions
81. At 0100 on a client second postop night..unable to sleep
a. Bring client prescribed PRN
82. A child weighing 66 pounds….
a. 15
83. A client receives a prescription for 100 mL 0.9 % sodium….
a. 25
84. An older adult is admitted to intensive care with dx of hyperosmolar….(SATA)
 a. Assess for tachycardia, adjust infusion rate, auscultate the lungs
85. The nurse documents that an adult male client who is depressed sleeps until lunch…..
a. Social isolation