PREBOARD APRIL 2021

1. The parent of a 21-day old male infant reports that the infant is “throwing up a lot”. Which
assessment should the nurse make to help determine if pyloric stenosis is an issue? SELECT ALL
THAT APPLY.

1. Assess the parent’s feeding technique.

2. Check for family history of gluten enteropathy
3. Check for history of physiological hyperbilirubinemia
4. Check if the vomit is projectile
5. Compare the current weight to birth weight

2. Which client condition is concerning and requires further nursing assessment and intervention?
SELECT ALL THAT APPLY.

1. Before liver biopsy, pulse is 80/min and blood pressure is 120/80 mm Hg; 1 hours afterward,
pulse is 112/min and BP is 90/60 mm Hg
2. Before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is
80/min and BP is 126/82 mm Hg
3. Client with coronary artery disease on metoprolol; pulse is 62/min
4. Elderly client with black stools; pulse is 112/min
5. Neonate crying inconsolably at feeding time; pulse is 160/min

3. The nurse assists with a staff education conference about appropriate non pharmacological pain
management interventions for newborns and infants. Which of the following strategies should be
included in the presentation? SELECT ALL THAT APPLY.

1. Administer an oral sucrose solution to a newborn during circumcision procedure

2. Apply a cold pack to a newborn’s heel 30 minutes before performing a heel stick
3. Assist the parent to hold a newborn skin – to- skin during an immunization injection.
4. Offer pacifier to an infant while performing venipuncture
5. Swaddle an infant while leaving one arm unwrapped during an IV dressing change.

4. The nurse is admitting a client at 41 weeks gestation for induction of labor due to oligohydramnios.
Considering the client’s indication for induction, what should the nurse anticipate?

1. Additional neonatal personnel present for birth

2. Intermittent fetal monitoring during labor
3. Need for forceps-assisted vaginal birth
4. Need for uterotonic drugs for postpartum hemorrhage

5. The most recent laboratory results for a 12 – month old who is HIV – positive show a CD4
lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates
administering which immunizations? SELECT ALL THAT APPLY.

1. Haemophilus influenza type B (Hib)

2. Hepatits A (Hep A)
3. Measles, mumps, rubella (MMR)
4. Pneumococcal conjugate vaccine (PCV)
5. Varicella

6. The clinic nurse supervises a graduate nurse who is teaching the parents of a 2-year old with acute
diarrhea about home management. The nurse would need to intervene when the graduate nurse
provides which instruction
 1. “Do not administer antidiarrheal medications to your child.”
2. “Follow the bananas, rice, applesauce and toast diet for the next few days.”
3. “Record the number of wet diapers and return to the clinic if you notice a decrease”
4. “Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides”

7. The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot.
Which of the following sign of heart failure should the nurse teach the parents to report to the health
care provider? SELECT ALL THAT APPLY.

1. Cool extremities
2. Increase in appetite
3. Puffiness around the eyes
4. Reduction in number of wet diapers
5. Weight gain

8. Which of the following drug administrations should be reported as a practice error? SELECT ALL
THAT APPLY.

1. Cephalexin administered; client has history of anaphylaxis from penicillin

2. Hydromorphone 2 mg administered; client reports pruritus
3. Immunizations for a 3 month old administered in ventrogluteal site
4. Oral niacin (nicotinic acid) administered; client has facial flushin
5. Warfarin administered; client at 12 weeks gestation

9. The parent of an 11 month old client child calls the pediatric outpatient clinic and tells the nurse that
the child is exposed to measles 2 days ago during a family trip to a theme park. What is the best
response by the nurse?

1. Bring the baby into the clinic for the measles, mumps, rubella (MMR) vaccine
2. Check the baby’s temperature twice a day
3. Do not allow the child to have contact with other children
4. Does your child have a fever or rash?

10. The nurse is planning education for clients in group prenatal care who are entering the second
trimester of pregnancy. Which of the following are appropriate for the nurse to include in second
trimester teaching? SELECT ALL THAT APPLY.

1. Anticipate light movements around 16-20 weeks gestation

2. Expects to have an abdominal ultrasound for fetal anatomy evaluation
3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal
4. Increase consumption of iron – rich foods like meat and dried fruit
5. Plan for gestational diabetes screening near the end of the second trimester

11. A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be
administered safely at this prenatal visit? SELECT ALL THAT APPLY.

1. Influenza injection
2. Influenza nasal spray
3. Measles, mumps and rubella
4. Tetanus, diphtheria and pertussis
5. Varicella
12. The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus
and end – stage renal disease who is scheduled for dialysis today. Which medication should the
nurse hold for clarification prior to administration?

1. Atenolol
2. Calcium acetate
3. Insulin lispro
4. Vitamin E

13. The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct
techniques? SELECT ALL THAT APPLY.

1. Apply the suction for no longer than 5-10 seconds

2. Insert catheter with low, intermittent suction applied
3. Set suction higher than 130 mm Hg for thick copious secretions
4. Wait at least 1 minute between suction passes
5. Withdraw the catheter immediately if the client begins coughing

14. A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action
would be appropriate to reduce the client’s risk aspiration pneumonia?

1. Fully inflate the cuff before feeding

2. Have the client sit in an upright position with the neck hyperextended
3. Partially or fully deflate the cuff
4. Provide a modified diet of pureed foods

15. The initial prenatal laboratory screening results of a client 12 weeks gestation indicated a rubella
titer status of non immune. What will the nurse anticipate as the plan of care for this client?

1. Administer measles, mumps, rubella (MMR) vaccine now

2. Administer MMR vaccine immediately postpartum
3. Administer MMR vaccine in the 3rd trimester
4. An MMR vaccine is not indicated for this client

16. The family practice nurse is conducting client intake histories. Which client findings or histories
indicate a need for heightened concern that the client may have cancer. SELECT ALL THAT APPLY.

1. The 60 yr old client was just diagnosed with benign prostatic hyperplasia (BPH)
2. The client reports a mobile, golf ball – sized lesion under the skin over the right thigh that feels
doughy
3. The client reports a nagging cough with hoarseness for the past 3 months
4. The female client who weighed 150 lb (68 kg) has lost 15 lb (6.8 kg) in 3 months without dieting
5. The male client reports a skin change on the breast that looks like an orange peel

17. The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy.
Which assessment data indicate that the nurse needs to contact the health care provider
immediately?

1. Absence of gag reflex

2. Bright red blood mixed with sputum
3. Headache
4. Respirations 10/min and saturation of 92%
18. An elderly client with end – stage renal disease who has refused dialysis is admitted to a long – term
care facility for rehabilitation following hospitalization. The next days, the client becomes agitated
and says to the nurse, “I’ve got to get back home to my things. Have so much to do.”Which is the
most likely interpretation of this client’s behavior?

1. The client has been admitted to the facility without the client’s consent
2. The client is becoming delirious and should be assessed for infection
3. The clients is concerned that someone might steal possessions
4. The client wants to take care of business before imminent death

19. The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which
of the following should the nurse monitor before giving these medications? SELECT ALL THAT
APPLY.

1. Digoxin level
2. Glucose
3. INR
4. Platelet count
5. Serum potassium

20. The home health nurse visits a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally
on even – numbered days. Which of the following client statement show that teaching has been
effective? SELECT ALL THAT APPLY.

1. “I need to call my health care provider if I have trouble reading”

2. “I need to check my blood pressure before taking my medicine”
3. “I should call the HCP if I develop nausea and vomiting”
4. “I should check my heart rate prior to taking this medication”
5. “I will call the HCP if I feel dizzy and lightheaded”

21. The nurse is caring for a client with a chest tube that was placed 2 hours ago for pneumothorax.
Where would the nurse expect gentle, continuous, bubbling?

1. Air leak monitor

2. Collection chamber
3. Suction control chamber
4. Water seal chamber

22. The nurse takes the admission history of a 70 year old client diagnosed with chronic obstructive
pulmonary disease (COPD). Which of the following statements by the client does the nurse
recognize as contributing to the development of COPD? SELECT ALL THAT APPLY.

1. “I have been drinking alcohol almost daily since age 20”

2. “I have been overweight for as long as I can remember”
3. “I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year”
4. “I know I eat too much food”
5. “I was a car mechanic for about 40 years and had my own garage”

23. The nurse teaches safety precautions of home oxygen use to a client with emphysema being
discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the
need for further teaching? SELECT ALL THAT APPLY.

1. “I can apply Vaseline to my nose when my nostrils feel dry from the oxygen”
2. “I can cook on my gas stove as long as I have a fire extinguisher in the kitchen”
 3. “I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath”
4. “I should not polish my nails when using my oxygen”
5. “I should not use a wool blanket on my bed”

24. The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse
monitors for complications. The initial postprocedure monitoring plan should include what? SELECT
ALL THAT APPLY.

1. Level of alertness
2. Lung sounds
3. Oxygen saturation
4. Respiratory pattern
5. Temperature
6. Urine output

25. The school nurse creates a cafeteria menu for a newly enrolled child with a celiac disease. Which
lunches would be appropriate for this child? SELECT ALL THAT APPLY.

1. Beef barley soup with mixed vegetables and French bread

2. Grilled chicken, baked potato, and strawberry yogurt
3. Mexican corn tacos with ground beef and cheese
4. Peanut butter and jelly on rice cakes with an oatmeal cookie
5. Rice noodles with chicken and broccoli

26. The nurse observes an ambulating client begin to experience a tonic – clonic seizure. Which nursing
actions should be implemented immediately? SELECT ALL THAT APPLY.

1. Guide the client to the floor and gently cradle the head
2. Insert a tongue blade to prevent client from swallowing the tongue
3. Move objects that may cause injury away from the client
4. Physically restrain the client to prevent injury
5. Place the client in left lateral position
6. Remain with the client, observed and record the seizure activity

27. A nurse is caring for 3 month old infant who has bacterial meningitis. Which clinical findings
support this diagnosis? SELECT ALL THAT APPLY.

1. Depressed anterior fontanelle

2. Frequent seizures
3. High – pitched cry
4. Poor feeding
5. Presence of Babinski sign
6. Vomiting

28. The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitides who
has stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse ti
wear when performing a dressing change? SELECT ALL THAT APPLY.

1. Disposable gown
2. Face shield
3. Gloves
4. N95 respirator
5. Surgical mask
29. The parent of a 3 year old calls and tells the nurse of finding the child in the bathroom with an empty
bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the
nurse’s priority response?

1. “Call the poison control center. I will give you the number”
2. “Give your child about a cup of water to dilute the mouthwash”
3. “How did your child get hold of mouthwash?”
4. “What is your child doing right now?”

30. A client of the Orthodox Jewish faith with a history of type 2 diabetes mellitus is hospitalized,
recovering from a total right hip arthoplasty. At noon, the client consumed a lean roast beed
sandwich with lettuce and mustard, carrot and celery sticks and fresh fruit. What would be the most
appropriate 2:00 PM snack for this client?

1. Angel food cake and fresh strawberries

2. Crackers and low fat cheese
3. Hard – boiled egg and blueberries
4. Nonfat plain yogurt

31. A client with chronic obstructive pulmonary disease reports recent weight loss and poor appetite.
The client states that bloating, exhaustion and shortness of breath make eating “not worth the
effort”. Which statement by the nurse are appropriate to help improve the client’s nutritional status?
SELECT ALL THAT APPLY.

1. “Avoid drinking fluids while you are eating meals”

2. “Eat small frequent meals that are high in calories and protein”
3. “Exercise before you eat to improve your appetite”
4. “Increase your intake of high – fiber foods, such as broccoli and cabbage”
5. “Perform oral hygiene before eating meals”

32. After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment
finding is most concerning?

1. Client rates leg pain as 7

2. Negative Homan sign
3. Prominent varicose veins bilaterally
4. Right calf is 4 cm larger than left calf

33. Which client finding is most important for the nurse to follow up?

1. Client with distinct liver edge even with right costal margin
2. Client with pyelonephritis who has costoverbal angle tenderness
3. Client with rash that has purplish blotches that do not blanch
4. Client with spinal injury whose toes joint downward with the Babinski test

34. The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which
assessment findings require immediate follow up by the nurse? SELECT ALL THAT APPLY.

1. Cannot flex the chin toward the chest

2. Eyes move in opposite direction of head when head is turned to side
3. New onset of right arm drift
4. Pupils 8 mm in diameter bilaterally
5. Toes point downward when sole of foot is stimulated
35. The nurse is planning of care for a client immediately following a thyroidectomy. Which of the
following nursing actions are appropriate to include in the plan of care? SELECT ALL THAT APPLY.

1. Assessing frequently for facial or extremity numbness or tingling

2. Encouraging the client to perform neck flexion and extension frequently
3. Ensuring that a tracheostomy insertion kit is at the bedside at all times
4. Maintaining the head of the bed at 30-45 degrees
5. Monitoring the client’s voice strength and quality

36. A client is admitted with sever acute pancreatitis. While obtaining the client’s blood pressure, the
nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this
symptom?

1. Decreased albumin
2. Elevated troponin
3. Hyperkalemia
4. Hypocalcemia

37. The nurse in an ambulatory clinic is speaking with the parents of a 2 year old child diagnosed with
acute otitis media. Which information is most important for the nurse to include in the instructions
to the parents?

1. “The child may be given acetaminophen ibuprofen drops for pain”

2. “The child must complete the entire course of the prescribed antibiotic”
3. “The child should return to the clinic to evaluate effective of the treatment”
4. “The child may be given a decongestant to relieve pressure on the tympanic membrane”

38. A 48 year old female client with metastatic breast cancer is scheduled to receive her first dose of
trastuzumab (Herceptin). Which of the following results would prompt the nurse to hold the
prescribed treatment and discuss the assessment with the ordering health care provider?

1. Positive human epidermal growth factor receptor 2 (HER2)

2. Positive lymph node involvement
3. Blood glucose 130mg/dl (7.22 mmol/L)
4. Irregular apical pulse

39. The nurse is working with a couple who are experiencing intense anxiety after their home was
completely destroyed by a fire. The nurse understands that the initial intervention should be to…

1. … determine what community housing resources are available.

2. …suggest finding an apartment with a sprinkler system.
3. …explore the couple’s feeling of grief or loss.
4. …provide a brochure on relaxation and stress relief.

40. The nurse is caring for a 20 year old male client who has not been previously vaccinated for human
papilloma virus (HPV). The client states “I thought the HPV vaccine is only given to women.” What
would be the best response by the nurse

1. “Only sexually active people need to receive the HPV vaccine.”

2. “Vaccination for HPV is recommended for both males and females and helps prevent cancer.”
3. “The HPV vaccine is given in multiple separate injections.”
4. “There are different HPV vaccines that protect against different types of virus.”
41. The nurse is teaching the client with chronic pancreatitis about prevention of an acute attack. Which
statement by the client requires additional teaching?

1. “I will stop smoking”

2. “I will limit my alcohol intake to 1-2 glasses a day”
3. “I will avoid caffeinated beverages”
4. “I will take the pancrealipase as ordered”

42. During the 1 month old baby check up, the parents respond to questions about their newborn.
Which of the parent’s comments is of greatest concern to the nurse?

1. “The baby does not sleep for longer than 2 hours at a time”
2. “We notice the baby is fussy and cries a lot”
3. “The baby seems to want to eat every couple of hours.”
4. “When the baby spits up, it shoots across the room”

43. A Native American chief visits his newborn son and performs a traditional ceremony that involves
feathers and chanting or singing. Which of the following actions by the nurse is an example of
cultural awareness?

1. The nurse silently reflects about how her biases regarding Native Americans can influence how she
approaches the client’s parent.
2. The nurse begins a discussion with the client’s parent by asking “Tell me about other traditions you
tribe uses.”
3. The nurse contacts the social services to perform a home evaluation before the newborn is
discharged
4. The nurse notifies the nursing supervisor to request the parent to stop chanting or singing because
of noise concerns

44. The client is admitted to the emergency department with hypertensive crisis. Which finding requires
immediate action by the nurse?

1. Weakness in left arm

2. Jugular vein distention
3. Crackles at the lung bases
4. Lower extremity pitting edema

45. A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed
in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client’s
dinner. What action should the nurse take next?

1. Serve the dinner in the seclusion room, maintaining observation

2. Accompany the client to the dining area and maintain observation
3. Hold the meal until after the seclusion order has been discontinued
4. Obtain a contract for safe behavior before accompanying the client to the dining area

46. A 48 year old male client who is being admitted to the emergency department with an acute
myocardial infarction (MI) gives the following list of medications to the nurse. Which medication
would the nurse recognize as having the most immediate implications for the clients care?

1. Losartan
2. Captopril
3. Furosemide
4. Sildenafil
47. The nurse is caring for a client with orders of oxygen (O2) per nasal cannula at 5L/min.
Approximately what fraction of inspired oxygen (FIO2) is the client receiving?

1. 40%
2. 36%
3. 28%
4. 21%

48. A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which
action included in the TEE shall the nurse implement first?

1. Start a peripheral IV line

2. Place the client on NPO status
3. Administer O2 per nasal cannula
4. Give Midazolam (Versed) 1 mg IV push

49. The nurse is planning care for a client with a cerebral vascular accident (CVA). Which approach
would be most effective in the prevention of skin breakdown?

1. Place client in the wheelchair for four hours daily

2. Pad the bony prominences
3. Massage reddened bony prominences
4. Reposition every 2 hours when in bed

50. A client has received prescription for nitrofurantoin to treat a urinary tract infection. Which of the
following statements made by the client indicates that the need for additional teaching about the
medication?

1. “I will be sure to finish taking the antibiotics, even if I start feeling better.”
2. “I will spend extra time in the sun to get plenty of vitamin D”
3. “I’ll call my primary health care provider immediately if I develop a rash after taking the medication”
4. “I will take the medication with food”

51. The nurse is teaching a client with migraine headache about Almotriptan. Which statement by the
client indicates that the teaching was effective?

1. “I will wait to take the medication until the pain has become unbearable”
2. “I will take the medication as soon as I notice migraine symptoms”
3. “If the first dose does not help, I can take 2 more doses 15 minutes apart”
4. “I will take a dose every morning to make sure to prevent an acute attack”

52. A nurse is working to establish a therapeutic relationship with a client. Which action would support
the nurse’s goal?

1. Advise the client on problem solving techniques

2. Praise the client for appropriate behavior
3. Establish trust and rapport with client
4. Identify with that the client is feeling

53. The nurse is planning care for a client with a T6 level spinal injury. In conjunction with physical
therapy, what types of assistive device would be included in the plan of care to help with mobility?

1. Motorized wheelchair with breath control

2. Crutches and bilateral knee-ankle-foot orthoses
 3. Bilateral leg braces and quad cane
4. Torso brace and steerable knee walker

54. The nurse is neurology office is reviewing information about Levetiracetam with a 30 year old female
client with a history of seizures. Which instruction about the medication should the nurse make sure
to include?

1. “Call the office immediately if you feel like hurting or killing yourself”
2. “You should stay avoid becoming pregnant while taking this medication”
3. “You should stay away from large crowds and sick children”
4. “You might experience irregular menses and intermittent bleeding”

55. The nurse is caring for a postoperative client who develops evisceration of the abdominal incision.
Which intervention should the nurse implement first?

1. Place the client on NPO status

2. Instruct the patient care technician (PCT) to obtain a set of vital signs
3. Cover the wound with a sterile, saline – soaked dressing
4. Call the appropriate health care provider immediately

56. The nurse perform a heel stick for a blood glucose check on a 1 hour old, full term newborn who
weighed 9 pounds (4.1 kg) at birth. The serum glucose reading is 45 mg/dl (2.5 mmol/L). What action
is needed by the nurse?

1. Give oral glucose water

2. Check the pulse oximetry reading
3. Notify the pediatrician
4. Repeat the test in 2 hours

57. A client with Parkinson’s disease is prescribed Benztropine (Cogentin). For which of the following
shall the nurse call the health care provider immediately?

1. The client is complaining of dizziness when standing up

2. The client is exhibiting bradykinesia and slurred speech
3. The client’s heart rate increased for 80 to 95 beats per minute
4. The client has a history of primary angle – closure glaucoma

58. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. The
client has a nursing diagnosis of risk for impaired skin integrity. Which of the following interventions
should the nurse include in the client’s plan of care?

1. Wear a supportive, tight-fitting bra during therapy

2. Wear swimsuit cover – up when going to the pool
3. Use a mild soap and tepid water to clean the affected are
4. Apply ice packs to the affected area to reduce itching

59. The client has been hospitalized 48 hours for multiple injuries sustained in a motor vehicle accident.
An elevated blood alcohol level was present at the time of accident. Which finding (s) should be a
priority in the plan of care?

1. Hallucinations
2. Loss of appetite and nausea
3. Diaphoresis
4. Fine tremors
60. A client admitted to a voluntary hospital mental unit with a diagnosis of suicidal ideation. The client
has been on the unit for 2 days and now states “I demand to be released now!”. The appropriate
response from the nurse should be which of these statements?

1. “You have a right to sign out as soon as we get the health care provider’s discharge order”
2. “You cannot be released because you are still at risk being suicidal”
3. “Let’s discuss your decision to leave and then we can prepare you for discharge”
4. “You can be released only if you sign a no suicide contract before you leave”