1) The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma.

Which would the nurse expect to note specifically in this disorder?

A. Increased calcium level
B. Increased white blood cells
C. Decreased blood urea nitrogen level
D. Decreased number of plasma cells in the bone marrow

2)The nurse is creating a plan of care for the client with multiple myeloma and includes which
priority intervention in the plan?
A. Encouraging fluids
B. Providing frequent oral care
C. Coughing and deep breathing
D. Monitoring the red blood cell count

3) A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which
assessment finding would the nurse expect to note specifically in the client? A. Fatigue
B. Weakness
C. Weight gain
D. Enlarged lymph nodes

4) During the admission assessment of a client with advanced ovarian cancer, the nurse
recognizes which manifestation as typical of the disease?
A. Diarrhea
B. Hypermenorrhea
C. Abnormal bleeding
D. Abdominal distention

5) The nurse is caring for a client with lung cancer and bone metastasis. What signs and
symptoms would the nurse recognize as indications of a possible oncological emergency?
Select all that apply.
A. Facial edema in the morning
B. Weight loss of 20 lb (9 kg) in 1 month
C. Serum calcium level of 12 mg/dL (3.0 mmol/L)
D. Serum sodium level of 136 mg/dL (136 mmol/L) E. Serum potassium level of 3.4 mg/dL (3.4
mmol/L) F. Numbness and tingling of the lower extremities
A. A,C,F
B. D,E,F
C. A,C,D
D. None of the above

6) A client who has been receiving radiation therapy for bladder cancer tells the nurse that it
feels as if she is voiding through the vagina. The nurse interprets that the client may be
experiencing which condition?
A. Rupture of the bladder
B. The development of a vesicovaginal fistula
C. Extreme stress caused by the diagnosis of cancer
D. Altered perineal sensation as a side effect of radiation therapy

7) The nurse is conducting a history and monitoring laboratory values on a client with multiple
myeloma. What assessment findings should the nurse expect to note? Select all that apply.
A. Pathological fracture
B. Urinalysis positive for Bence Jones protein
C. Hemoglobin level of 15.5 g/dL (155 mmol/L)
D. Calcium level of 8.6 mg/dL (2.15 mmol/L)
E. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)
A. C,D,
B. A, B, E
C. B,C,D
D. All of the above

8) The nurse is teaching a client about the risk factors associated with colorectal cancer. The
nurse determines that further teaching is necessary related to colorectal cancer if the client
identifies which item as an associated risk factor?
A. Age younger than 50 years
B. History of colorectal polyps
C. Family history of colorectal cancer
D. Chronic inflammatory bowel disease

9) The nurse is assessing the perineal wound in a client who has returned from the operating
room following an abdominal perineal resection and notes serosanguineous drainage from the
wound. Which nursing intervention is most appropriate?
A. Clamp the surgical drain.
B. Change the dressing as prescribed.
C. Notify the surgeon.
D. Remove and replace the perineal packing.

10) The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note
documentation of which most common sign or symptom of this type of cancer? A. Dysuria
B. Hematuria
C. Urgency on urination
D. Frequency of urination

11) The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of
developing this problem?
A. A 25-year-old woman who runs
B. A 36-year-old man who has asthma
C. A 70-year-old man who consumes excess alcohol
D. A sedentary 65-year-old woman who smokes cigarettes
12) The nurse has given instructions to a client returning home after knee arthroscopy. Which
statement by the client indicates that the instructions are understood? A. "I can resume regular
exercise tomorrow."
B. "I can't eat food for the remainder of the day."
C. "I need to stay off the leg entirely for the rest of the day." D. "I need to report a fever or
swelling to my health care provider."

13) The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg
appears fractured. Which intervention should the nurse take?
A.Try to reduce the fracture manually.
B. Assist the victim to get up and walk to the sidewalk.
C. Leave the victim for a few moments to call an ambulance. D. Stay with the victim and
encourage him or her to remain still.

14) Which cast care instructions should the nurse provide to a client who just had a plaster cast
applied to the right forearm? Select all that apply.
A. Keep the cast clean and dry.
B. Allow the cast 24 to 72 hours to dry.
C. Keep the cast and extremity elevated.
D. Expect tingling and numbness in the extremity.
E. Use a hair dryer set on a warm to hot setting to dry the cast.
F. Use a soft, padded object that will fit under the cast
to scratch the skin under the cast.
A. A,B,C
B. D,E,F
C. B,C,D
D. all of the above

15) The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse
would be most concerned with which finding?
A. Redness around the pin sites
B. Pain on palpation at the pin sites
C. Thick, yellow drainage from the pin sites D. Clear, watery drainage from the pin sites

16) The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?
A. Dependent edema
B. Diminished distal pulse
C. Presence of a "hot spot" on the cast
D. Coolness and pallor of the extremity

17) A client has sustained a closed fracture and has just had a cast applied to the affected arm.
The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and
administers an analgesic, with little relief. Which problem may be causing this pain?
A. Infection under the cast
B. The anxiety of the client
C. Impaired tissue perfusion
D. The recent occurrence of the fracture

18) The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client
has a leg fracture and had a plaster cast applied. Which position would be best for the casted
leg?
A. Elevated for 3 hours, then flat for 1 hour
B. Flat for 3 hours, then elevated for 1 hour
C. Flat for 12 hours, then elevated for 12 hours
D. Elevated on pillows continuously for 24 to 48 hours

19) A client is being discharged to home after application of a plaster leg cast. Which statement
indicates that the client understands proper care of the cast? A. "I need to avoid getting the cast
wet."
B. "I need to cover the casted leg with warm blankets." C. "I need to use my fingertips to lift and
move my leg." D. "I need to use something like a padded coat hanger end to scratch under the
cast if it itches."

20) A client being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse responds knowing that which would most likely
result from this improper crutch measurement?
A. A fall and further injury
B. Injury to the brachial plexus nerves
C. Skin breakdown in the area of the axilla
D. Impaired range of motion while the client ambulates

21) The nurse is assessing the motor and sensory function of an unconscious client who
sustained a head injury. The nurse should use which technique to test the client's peripheral
response to pain?
A. Sternal rub
B. Nailbed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle

22) The nurse is caring for the client with increased intracranial pressure as a result of a head
injury? The nurse would note which trend in vital signs if the intracranial pressure is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
B. Increasing temperature, decreasing pulse,
decreasing respirations, increasing blood pressure
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
D. Decreasing temperature, increasing pulse,
decreasing respirations, increasing blood pressure

23) A client recovering from a head injury is participating in care. The nurse determines that the
client understands measures to prevent elevations in intracranial pressure if the nurse observes
the client doing which activity?
A. Blowing the nose
B. Isometric exercises
C. Coughing vigorously
D. Exhaling during repositioning

24) A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding
would alert the nurse that cerebrospinal fluid is present?
A. Fluid is clear and tests negative for glucose.
B. Fluid is grossly bloody in appearance and has a pH of 6. C. Fluid clumps together on the
dressing and has a pH of 7.
D. Fluid separates into concentric rings and tests
positive for glucose.

25) A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse
should include which measures in the plan of care to minimize the risk of occurrence? Select all
that apply.
A. Keeping the linens wrinkle-free under the client
B. Preventing unnecessary pressure on the lower limbs
C. Limiting bladder catheterization to once every 12 hours D.Turning and repositioning the client
at least every 2 hours E. Ensuring that the client has a
bowel movement at least once a
week
A. A,B,D
B. C,D,E
C. A,C,D
D. None of the above

26) The nurse is evaluating the neurological signs of a client in spinal shock following spinal
cord injury. Which observation indicates that spinal shock persists?
A. Hyperreflexia
B. Positive reflexes
C. Flaccid paralysis
D. Reflex emptying of the bladder

27) The nurse is caring for a client who begins to experience seizure activity while in bed. Which
actions should the nurse take? Select all that apply.
A. Loosening restrictive clothing.
B. Restraining the client's limbs.
C. Removing the pillow and raising padded side rails.
D. Positioning the client to the side, if possible, with the head flexed forward.
E. Keeping the curtain around the client and the room door open so when help arrives they can
quickly enter to assist.
A. A,B,D
B. C,D,E
C. A,C,D
D. None of the above

28) The nurse is assigned to care for a client with complete right-sided hemiparesis from a
stroke (brain attack). Which characteristics are associated with this condition? Select all that
apply.
A. The client is aphasic.
B. The client has weakness on the right side of the body.
C. The client has complete bilateral paralysis of the arms and legs.
D. The client has weakness on the right side of the face andtongue.
E. The client has lost the ability to move the right arm but is able to walk independently.
F. The client has lost the ability to ambulate independently but is able to feed and bathe herself
or himself without assistance.
A. D,E,F
B. A,B,D
C. C,D,E
D. None of tha above

29) The nurse has instructed the family of a client with stroke (brain attack) who has
homonymous hemianopsia about measures to help the client overcome the deficit. Which
statement suggests that the family understands the measures to use when caring for the client?
A. "We need to discourage him from wearing eyeglasses." B. "We need to place objects in his
impaired field of vision." C. "We need to approach him from the impaired field of vision."
D."Weneedtoremindhimtoturnhisheadtoscanthe lost visual field."

30) The nurse is assessing the adaptation of a client to changes in functional status after a
stroke (brain attack). Which observation indicates to the nurse that the client is adapting most
successfully?
A. Gets angry with family if they interrupt a task
B. Experiences bouts of depression and irritability
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self

31) A 55-year-old male client confides in the nurse that he is concerned about his sexual
function. What is the nurse's best response?
A. "How often do you have sexual relations?"
B. "Please share with me more about your concerns."
C. "You are still young and have nothing to be concerned about."
D. "You should not have a decline in
testosterone until you are in your 80s."

32) The nurse is interviewing a middle-aged woman with a history of fibrocystic disorder of the
breasts. Which statements made by the client indicate a need for further teaching? Select all
that apply.
A. "I might experience pain in my underarm region."
B. "My symptoms will decrease just before menstruation."
C. "After I experience menopause, my symptoms may lessen." D. "Taking oral contraceptives
now will increase my symptoms."
E. "Upon self-breast examination, I may detect lumpiness
in the upper, outer area of my breasts."
A. A,B,D
B. D,E
C. B,D
D. None of the above

33) The nursing student is asked to discuss information related to the uterus with female high
school students. Which statements by the nursing student are accurate? Select all that apply.
A. "The uterus consists mostly of skeletal muscle."
B. "The uterus is a pelvic organ when not pregnant." C. "The uterus weighs approximately 2.2 lb
(1000 g) at term pregnancy."
D. "The uterus weighs approximately 2 oz (60 g) in the nonpregnant state."
E. "The uterus is composed of 3 layers: endometrium, myometrium, and perimetrium."
A. A,B,D
B. B,C,D,E
C. B,D,E
D. None of the above

34) A preadolescent client asks the nurse about the onset of puberty. The nurse describes
which changes as indicating puberty? Select all that apply.
A. Mood swings occur.
B. Pubic hair will develop.
C. Breast development begins.
D. Uterus matures to adult size.
E. Height will increase due to a growth spurt.
A. B,C,D,E
B. A,B,C,D
C. C,D,E
D. A,C,E

35) The nurse presents a seminar on sexually transmitted infections. Which information about
syphilis should the nurse include in this presentation? Select all that apply. A. A blood test will
confirm the diagnosis.
B. Syphilis signs and symptoms are divided into stages.
C. Syphilis can be spread through vaginal, anal, or oral sex. D. Having syphilis once provides
lifelong immunity
from repeat infection.
E. Syphilis will always be present in a chronic state, as there is no cure for this illness.
A. A, B,D
B. B,C,D,E
C. A, B, C
D. All of the above

36) The nurse is performing an assessment on a client admitted to the hospital who was
diagnosed with toxic shock syndrome (TSS). Which assessment question would assist in
eliciting the most specific data regarding the cause of this syndrome? A. "Did you start your
menses at an early age?"
B. "Have your menstrual periods been irregular?"
C. "Do you use tampons during your menstrual period?" D. "Have you been consuming a high
intake of green leafy vegetables?"

37) The clinic nurse has provided instructions regarding home care measures to a female client
diagnosed with pelvic inflammatory disease (PID). Which statement, if made by the client,
indicates an understanding of these measures?
A. "I need to avoid tight-fitting clothing."
B. "I need to douche once in the morning and once in the evening."
C. "I need to see a primary health care provider to
get an intrauterine device for birth control."
D. "I need to wear tampons instead of sanitary pads when I have my menstrual period."

38) A female client is suspected of having a vaginal infection caused by the organism Candida
albicans. Which assessment question would elicit data associated with this infection?
A. "Have you had any vaginal discharge?"
B. "Do you have any blood in your urine?"
C. "Have you had any flank pain or headaches?"
D. "Have you noticed any swelling in your feet?"

39) The nurse employed in a fertility clinic is providing information to a couple considering in
vitro fertilization. The nurse's explanation should most appropriately include which information?
Select all that apply.
A. Embryo transfer occurs through an abdominal incision.
B. A fertilized ovum is transferred into the woman's uterus.
C. Mild spotting or cramping may occur following egg removal. D. A medication protocol for
follicle development will
be prescribed.
E. Ova and sperm are collected and immediately
transferred into the woman's uterus.
A. A,B,D
B. B,C,D
C. A,B,C,E
D. All of the above

40) The nurse is performing an assessment on a client who asks how she might recognize
when she is ovulating. The nurse should explain that which occurs at ovulation? Select all that
apply.
A. Breast tenderness
B. Decreased sex drive
C. Small amount of vaginal spotting
D. Slight decrease in basal body temperature
E. Lower abdominal pain known as Mittelschmerz
F. Presence of spinnbarkeit–thin and clear mucous discharge
A. A,C,E,F
B. C,D,E,F
C. A,C,D
D. ALL OF THE ABOVE

41) The nurse provides home care instructions to a client with systemic lupus erythematosus
and tells the client about methods to manage fatigue. Which statement by the client indicates a
need for further instruction?
A. "I should take hot baths because they are relaxing."
B. "I should sit whenever possible to conserve my energy." C. "I should avoid long periods of
rest
because it causes joint stiffness."
D. "I should do some exercises, such as
walking, when I am not fatigued."
42) The nurse is conducting a teaching session with a client on their diagnosis of pemphigus.
Which statement by the client indicates that the client understands the diagnosis?
A. "My skin will have tiny red vesicles."
B. "The presence of the skin vesicles is caused by a virus."
C. "I have an autoimmune disease that causes blistering in the skin."
D. "Red, raised papules and large plaques covered by
silvery scales will be present on my skin."

43) The nurse is assisting in planning care for a

client with a diagnosis of immunodeficiency and
should incorporate which action as a priority in
the plan? A. Protecting the client from infection
B. Providing emotional support to decrease fear
C. Encouraging discussion about lifestyle changes
D. Identifying factors that decreased the immune function
44) A client calls the nurse in the emergency department and states that he was just stung by a
bumblebee while gardening. The client is afraid of a severe reaction because the client's
neighbor experienced such a reaction just 1 week ago. Which action should the nurse take?
A. Advise the client to soak the site in hydrogen peroxide. B. Ask the client if he ever sustained
a bee sting in the past. C. Tell the client to call an ambulance for transport to
the emergency department.
D. Tell the client not to worry about the sting unless difficulty with breathing occurs.

45) The community health nurse is conducting a research study and is identifying clients in the
community at risk for latex allergy. Which client population is most at risk for developing this
type of allergy?
A. Hairdressers
B. The homeless
C. Children in day care centers
D. Individuals living in a group home

46) Which interventions apply in the care of a client at high risk for an allergic response to a
latex allergy? Select all that apply.
A. Use nonlatex gloves.
B. Use medications from glass ampules.
C. Place the client in a private room only.
D. Keep a latex-safe supply cart available in the client's area. E. Avoid the use of medication
vials that have rubber stoppers. F. Use a blood pressure cuff from an electronic device only
to measure the blood pressure.
A. C,D,E,F
B. A,B,D,E
C. A,C,F
D. NONE OF THE ABOVE

47) A client presents at the primary health care provider's office with complaints of a ring like
rash on his upper leg. Which question should the nurse ask first? A. "Do you have
any cats in your home?"
B. "Have you been camping in the last month?"
C. "Have you or close contacts had any flu-like symptoms within the last few weeks?"
D. "Have you been in physical contact with anyone who has the same type of rash?"

48) A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be
prescribed? A. Maintain bed rest as much as possible.
B. Administer corticosteroids as prescribed for inflammation. C. Advise the client to remain
supine for 1 to 2 hours after meals.
D. Keep the room temperature warm
during the day and cool at night.
49) A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick
and would like to be tested for Lyme disease. The client tells the nurse that she removed the
tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply.
A. Tell the client that testing is not necessary unless arthralgia develops.
B. Tell the client to avoid any woody, grassy areas
that may contain ticks.
C. Instruct the client to immediately start to take the antibiotics that are prescribed.
D. Inform the client to plan to have a blood test 4 to
6 weeks after a bite to detect the presence of the
disease.
E. Tell the client that if this happens again, to never
remove the tick but vigorously scrub the area with an antiseptic.
A. B,C,D
B. C,D,E
C. B,D,E
D. A,B,D

50)The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's
sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which
finding?
A. Swelling in the genital area
B. Swelling in the lower extremities
C. Positive punch biopsy of the cutaneous lesions
D. Appearance of reddish-blue lesions noted on the skin

51) Packed red blood cells have been prescribed for a female client with anemia who has a
hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes
the client’s temperature before hanging the blood transfu¬sion and records 100.6° F (38.1° C)
orally. Which action should the nurse take?
A. Begin the transfusion as prescribed.
B. Administer an antihistamine and begin the transfusion.
C. Administer 2 tablets of acetaminophen and begin the transfusion.
D. Delay hanging the blood and notify the primary health care provider (PHCP).

52) The nurse has received a prescription to transfuse a client with a unit of packed red blood
cells. Before explaining the procedure to the client, the nurse should ask which initial question?
A. "Have you ever had a transfusion before?"
B. "Why do you think that you need the transfusion?"
C. "Have you ever gone into shock for any reason in the past?" D. "Do you know the
complications and risks of a transfusion?"

53) A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The
client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's
temperature is 100.8o F (38.2o C) orally from a baseline of 99.2o F (37.3o C) orally. The nurse
determines that the client may be experiencing which complication of a blood transfusion?
A. Septicemia B. Hyperkalemia
C. Circulatory overload
D. Delayed transfusion reaction

54) The nurse determines that a client is having a transfusion reaction. After the nurse stops the
transfusion, which action should be taken next? A. Remove the intravenous (IV) line.
B. Run a solution of 5% dextrose in water.
C. Run normal saline at a keep-vein-open rate.
D. Obtain a culture of the tip of the
catheter device removed from the client.

55) A client has received a transfusion of platelets. The nurse evaluates that the client is
benefiting most from this therapy if the client exhibits which finding? A. Increased hematocrit
level
B. Increased hemoglobin level
C. Decline of elevated temperature to normal
D. Decreased oozing of blood from puncture sites and gums

56) The nurse has obtained a unit of blood from the blood bank and has checked the blood bag
properly with another nurse. Just before beginning the transfusion, the nurse should assess
which priority item?
A. Vital signs
B. Skin color
C. Urine output
D. Latest hematocrit level

57) The nurse has just received a prescription to transfuse a unit of packed red blood cells for
an assigned client. What action should the nurse take next?
A. Check a set of vital signs.
B. Order the blood from the blood bank.
C. Obtain Y-site blood administration tubing.
D. Check to be sure that consent for the transfusion has been signed.

58) Following infusion of a unit of packed red blood cells, the client has developed new onset of
tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement
first?
A. Maintain bed rest with legs elevated.
B. Place the client in high-Fowler's position.
C. Increase the rate of infusion of intravenous fluids.
D. Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy.
59)Thenurse,listeningtothemorningreport,learnsthatan assigned client received a unit of
granulocytes the previous evening. The nurse makes a note to assess the results of which daily
serum laboratory studies to assess the effectiveness of the transfusion? A. Hematocrit level
B. Erythrocyte count
C. Hemoglobin level
D. White blood cell count

60) A client is brought to the emergency department having experienced blood loss related to
an arterial laceration. Which blood component should the nurse expect the primary health care
provider to prescribe?
A. Platelets
B. Granulocytes
C. Fresh-frozen plasma
D. Packed red blood cells

61) A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The
nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is
dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous
(IV) bag has 400 mL remaining. The nurse should take which action first?
A. Slow the IV infusion.
B. Sit the client up in bed.
C. Remove the IV catheter.
D. Call the primary health care provider (PHCP).

62) The nurse has a prescription to hang a 1000-mL

intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also
needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse
should plan to take which action first?
A. Start a second IV site.
B. Check compatibility of the medication and IV fluids.
C. Mix the prepackaged piperacillin/tazobactam per agency policy.
D. Prime the tubing with the IV
solution and back-prime the
medication.

63) The nurse is making initial rounds on the nursing unit to assess the condition of assigned
clients. Which assessment findings are consistent with infiltration? Select all that apply. A. Pain
and erythema
B. Pallor and coolness
C. Numbness and pain
D. Edema and blanched skin
E. Formation of a red streak and purulent drainage
A. B,C,D
B. A,D,E
C. C,D
D. ALL OF THE ABOVE

64) The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the
nurse would continue stop advancing the catheter in which situation? A. The catheter advances
easily.
B. The vein is distended under the needle.
C. The client does not complain of discomfort.
D. Blood return shows in the backflash chamber of the catheter.

65) The nurse is assessing a client's peripheral intravenous (IV) site after completion of a
vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous
proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best?
A. Check for the presence of blood return.
B. Remove the IV site and restart at another site.
C. Document the findings and continue to monitor the IV site.
D. Call the primary health care provider (PHCP) and request that the vancomycin be given
orally.

66) The nurse provides a list of instructions to a client being discharged to home with a
peripherally inserted central catheter (PICC). The nurse determines that the clientneeds
furtherinstructionsiftheclientmadewhich statement?
A. "I need to wear a MedicAlert tag or bracelet."
B. "I need to restrict my activity while this catheter is in place."
C. "I need to keep the insertion site protected when
in the shower or bath."
D. "I need to check the markings on the catheter each time the dressing is changed."

67) A client has just undergone insertion of a central venous catheter at the bedside under
ultrasound. The nurse should be sure to check which results before initiating the flow rate of the
client's intravenous (IV) solution at 100 mL/hour?
A. Serum osmolality
B. Serum electrolyte levels C. Intake and output record D. Chest radiology results

68) Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the
right internal jugular for approximately 24 hours to increase urine output and maintain the
client's blood pressure. Upon entering the client's room, the nurse notes that the client is
breathing rapidly and coughing. For which additional signs of a complication should the nurse
assess based on the previously known data?
A. Excessive bleeding
B. Crackles in the lungs
C. Incompatibility of the infusion
D. Chest pain radiating to the left arm
69) Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The
nurse should prepare to administer this medication by which route? A. Orally
B. By inhalation
C. By intravenous infusion
D. Through a Sengstaken-Blakemore tube

70) Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal
varices. The nurse is preparing to administer the medication to the client. Which essential item
is needed during the administration of this medication? A. An airway
B. A suction setup
C. A cardiac monitor
D. A tracheotomy set

71) A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid
food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which
prescription regarding the PN solution will accompany the diet prescription?
A. Discontinue the PN.
B. Decrease PN rate to 50 mL/hour.
C. Start 0.9% normal saline at 25 mL/hour.
D. Continue current infusion rate prescriptions for PN.

72) The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The
client's central venous line is located in the right subclavian vein. The nurse asks the client to
take which essential action during the tubing change?
A. Breathe normally.
B. Turn the head to the right.
C. Exhale slowly and evenly.
D.Take a deep breath, hold it, and bear down.

73) The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN)
and notes that the catheter insertion site appears reddened. The nurse should next assess
which item?
A. Client's temperature
B. Expiration date on the bag
C. Time of last dressing change
D. Tightness of tubing connections

74) The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at
the top of the solution. The nurse should take which action? A. Roll the bottle of solution gently.
B. Obtain a different bottle of solution.
C. Shake the bottle of solution vigorously.
D. Run the bottle of solution under warm water.
75) A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the
primary health care provider (PHCP), and the PHCP initially prescribes that the solution and
tubing be changed. What should the nurse do with the discontinued materials? A. Discard them
in the unit trash.
B. Return them to the hospital pharmacy.
C. Save them for return to the manufacturer.
D. Prepare to send them to the laboratory for culture.

76) The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit,
determines that which clients would be the most likely candidates for parenteral nutrition (PN)?
Select all that apply.
A. A client with extensive burns
B. A client with cancer who is septic
C. A client who has had an open cholecystectomy
D. A client with severe exacerbation of Crohn's disease E. A client with persistent nausea and
vomiting from chemotherapy
A. A,B,D,E
B. C,D,E
C. A,C,E
D. B,C,D

77) The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the
central line of an assigned client. The nurse should obtain which most essential piece of
equipment before hanging the solution?
A. Urine test strips
B. Blood glucose meter
C. Electronic infusion pump
D. Noninvasive blood pressure monitor

78) The nurse is making initial rounds at the beginning of the shift and notes that the parenteral
nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until
another PN solution is mixed and delivered to the nursing unit?
A. 5% dextrose in water
B. 10% dextrose in water
C. 5% dextrose in Ringer's lactate
D. 5% dextrose in 0.9% sodium chloride

79) The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the
infusion is 1 hour behind. Which action should the nurse take? A. Adjust the infusion rate to
catch up over the next hour.
B. Increase the infusion rate to catch up over the next 2 hours.
C. Ensure that the fat emulsion infusion rate
is infusing at the prescribed rate.
D. Adjust the infusion rate to run wide open
until the solution is back on time.

80) A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1
week. The nurse should next assess the client for the presence of which condition? A. Thirst
B. Polyuria
C. Decreased blood pressure
D. Crackles on auscultation of the lungs

81) The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads
on the client's chest and before discharging the device, which intervention is a priority?
A. Ensure that the client has been intubated.
B. Set the defibrillator to the "synchronize" mode. C. Administer an amiodarone bolus
intravenously. D. Confirm that the rhythm is ventricular fibrillation.

82) A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm

effectively, the monophasic defibrillator machine should be set at which energy level (in joules,
J) for the first delivery?
A. 50 J
B. 120 J
C. 200 J
D. 360 J

83) The nurse should evaluate that defibrillation of a client was most successful if which
observation was made?
A. Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg
B. Nonarousable, sinus rhythm, BP 88/60 mm Hg
C. Arousable, marked bradycardia, BP 86/54 mm Hg
D. Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

84) The nurse is documenting information in a client's chart when the electrocardiogram
telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT).
The nurse rushes to the client's bedside and should perform which assessment first? A. Heart
rate
B. Blood pressure
C. Respiratory rate
D. Check responsiveness

85) A client is brought into the emergency department in ventricular fibrillation (VF). The nurse
prepares to defibrillate by placing defibrillation pads on which part of the chest? A. The upper
and lower halves of the sternum
B. Parallel between the umbilicus and the right nipple
C. The right shoulder and the back of the left shoulder D. To the right of the sternum and to the
left of the precordium
86) An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and
cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being
administered effectively by noting which action?
A. The ratio of compressions to ventilations is 30:2.
B. The carotid pulse is palpable with each compression.
C. Respirations are given at a rate of 10 breaths per minute.
D. The chest compressions are given at a
depth of 1.5 to 2 inches (2.5 to 5 cm).

87) The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a
cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which
activity will allow the nurse to assess the client's cardiac rhythm? A. Hold the defibrillator
paddles firmly against the chest.
B. Apply adhesive patch electrodes to the chest and move away from the client.
C. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device.
D. Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm.

88) The nurse is teaching adult cardiopulmonary resuscitation (CPR) guidelines to a group of
laypeople. The nurse observes the group correctly demonstrate 2-rescuer CPR when which
ratio of compressions to ventilations is performed on the mannequin?
A.10:1
B. 15:2
C. 20:1
D. 30:2

89) The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community

members. The nurse tells the group that when chest compressions are performed on infants,
the sternum should be depressed how far?
A. At least 2 inches (5 cm)
B. About 11⁄2 inches (4 cm)
C. At least one half the depth of the chest
D. Deep enough to make a finger impression

90) The nursing instructor teaches a group of students about cardiopulmonary resuscitation.
The instructor asks a student to identify the most appropriate location at which to assess the
pulse of an infant younger than 1 year of age. Which response would indicate that the student
understands the appropriate assessment procedure?
A. Radial artery
B. Carotid artery
C. Brachial artery
D. Popliteal artery

91) An ultrasound is performed on a client at term gestation who is experiencing moderate

vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On
the basis of these findings, the nurse should prepare the client for which anticipated
prescription?
A. Delivery of the fetus
B. Strict monitoring of intake and output
C. Complete bed rest for the remainder of the pregnancy
D. The need for weekly monitoring of coagulation
studies until the time of delivery

92) Fetal distress is occurring with a laboring client. As the nurse prepares the client for a
cesarean birth, what is the most important nursing action?
A. Slow the intravenous flow rate.
B. Continue the oxytocin drip if infusing.
C. Place the client in a high Fowler's position.
D. Administer oxygen, 8 to 10 L/minute, via face mask.

93) The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor.
The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first
nursing action with this finding?
A. Gently push the cord into the vagina.
B. Place the client in Trendelenburg's position.
C. Find the closest telephone and page the primary health care provider stat.
D. Call the delivery room to notify the staff that the client will be transported immediately.

94) The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum
and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse
respond to this finding initially?
A. Document the finding.
B. Encourage the client to ambulate.
C. Encourage the client to increase fluid intake.
D. Contact the obstetrician (OB) and inform him or her of this finding.

95) A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse
notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a
pulmonary embolism. Which should be the initial nursing action?
A. Initiate an intravenous line.
B. Assess the client's blood pressure.
C. Prepare to administer morphine sulfate.
D. Administer oxygen, 8 to 10 L/minute, by face mask.

96) The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm,
but that bleeding is excessive. Which should be the initial nursing action?
A. Record the findings.
B. Massage the fundus.
C. Notify the obstetrician (OB).
D. Place the client in Trendelenburg's position.

97) The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for
the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for
admission of this newborn, what is the nurse's highest priority?
A. Turn on the apnea and cardiorespiratory monitors.
B. Connect the resuscitation bag to the oxygen outlet.
C. Set up the intravenous line with 5% dextrose in water.
D. Set the radiant warmer control temperature at 36.5° C (97.6° F).

98) A child undergoes surgical removal of a brain tumor. During the postoperative period, the
nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has
decreased significantly from the baseline value. The nurse suspects that the child is in shock.
Which is the most appropriate nursing action?
A. Place the child in a supine position.
B. Place the child in Trendelenburg's position.
C. Increase the flow rate of the intravenous fluids.
D. Notify the primary health care provider (PHCP).

99) A child has a right femur fracture caused by a motor vehicle crash and is placed in skin
traction temporarily until surgery can be performed. During assessment, the nurse notes that the
dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?
A. Administer an analgesic.
B. Release the skin traction.
C. Apply ice to the extremity.
D. Notify the primary health care provider (PHCP).

100) The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication.
During the infusion, the client complains of pain at the insertion site. On inspection of the site,
the nurse notes redness and swelling and that the infusion of the medication has slowed in rate.
The nurse suspects extravasation and should take which actions? Select all that apply.
A. Stop the infusion.
B. Prepare to apply ice or heat to the site.
C. Restart the IV at a distal part of the same vein.
D. Notify the primary health care provider (PHCP).
E. Prepare to administer a prescribed antidote into the site.
F. Increase the flow rate of the solution to flush the skin and subcutaneous tissue.
A. A,B,D,E
B. B,C,D
C. A,C,D,E
D. NONE OF THE ABOVE