PREBOARD 33B

1.) The nurse in the medical surgical unit is planning care for a client who reports difficulty sleeping. Which of the
following interventions should the nurse include in the client's plan of care? Select all that apply.
a. Turn off equipment alarms at the client's bedside.
b. Coordinate with the health care team to cluster care activities.
c. Keep the client's door closed and minimize excess night time noise.
d. Encourage the client to perform a consistent bedtime routine each night.
e. Offer the client additional pillows to promote a comfortable sleeping position.

2.) The nurse is observing a staff member care for a client who is at risk for aspiration. Which of the following
actions by the staff member would require the nurse to intervene? Select all that apply.
a. provides the client with verbal reminders to chew and swallow
b. encourages the client to sit upright for 30 minutes after meals
c. positions the client in the semi-Fowler position before meals
d. reminds the client to tilt the chin upward when swallowing
e. serves the client thickened liquids with meals

3.) The nurse has been advised that a client with dehydration has an elevated serum calcium level. Which of the
following actions should the nurse take? Select all that apply.
a. Implement fall precautions
b. Check the client for Chvostek sign
c. Initiate continuous cardiac monitoring
d. Assess the client for lethargy and confusion
e. Monitor the client for hyperactive bowel sounds

4.) The nurse is observing a staff member perform an otoscopic examination for an adult client. The nurse should
intervene if the staff member is observed
a. instructing the client to keep the head still during the examination
b. straightening the client's ear canal by pulling the pinna down and back
c. siting the client's head towards the opposite side of the ear being examined
d. inspecting the client's ear canal for foreign bodies before inserting the otoscope

5.) The nurse is talking with a client who has a visual impairment. Which of the following statements by the client
would indicate a correct understanding of home safety? Select all that apply.
a. "I can borrow my spouse's reading glasses to read my prescription medication bottles."
b. "I plan to paint the edges of my front porch steps using a bright color."
c. "I will use low-wattage light bulbs in my home to prevent shadows"
d. "I have small rugs around my home so I will not slip on the floor."
e. "I should drive to the grocery store only during the day"

6.) The nurse and unlicensed assistive personnel (UAP) are caring for a client with soft wrist restraints. Which of the
following activities would be appropriate for the nurse to assign to the UAP? Select all that apply.
a. Assist the client with performing range-of-motion exercises.
 b. Assess the client's skin and neurovascular status.
c. Remove the restraints while the client is sleeping
d. Reapply restraints after repositioning the client.
e. Offer the client food and fluids regularly.

7.) The nurse is caring for a client at 7 weeks gestation who has abdominal cramping and heavy vaginal bleeding
with the passage of large blood clots. Which of the following actions should the nurse take? Select all that
apply.
a. Administer ibuprofen to the client.
b. Auscultate fetal heart tones with a handheld Doppler device.
c. Obtain a blood specimen to check serum human chronic gonadotropin level.
d. Obtain a blood specimen for blood type and crossmatch.
e. Prepare the client for a transvaginal ultrasound.

8.) The nurse is teaching a client with stable angina who has a new prescription for sublingual nitroglycerin. Which
of the following information should the nurse include? Select all that apply.
a. "Place the tablets in a pill organizer while traveling."
b. "Take one tablet every 5 minutes for a maximum of three doses. "
c. "Move to a seated or lying position before taking the medication."
d. "Place the tablet under your tongue and allow it to fully dissolve."
e. "Continue taking your sildenafil as needed for erectile dysfunction."

9.) The nurse is assessing a newborn who was born 14 hours ago. Which of the following assessment findings would
require follow-up? Select all that apply.
a. protruding tongue
b. bilateral single palmar crease
c. asymptomatic 10-second pauses in respirations
d. heart rate that varies with inspiration and expiration
e. upward-slanting almond-shaped eyes
f. short and flattened nasal bridge

10.) The nurse is caring for an adolescent female client who reports fatigue, dyspnea, and heavy vaginal bleeding
during menstrual cycles. Which of the following actions should the nurse take? Select all that apply
a. Ask the client about episodes of dizziness
b. Inspect the client's lips, tongue, and oral mucosa
c. Assess the client's eating habits and dietary intake.
d. Instruct the client to use tampons instead of sanitary pads
e. Review the results of the client's most recent complete blood count

11.) The nurse is teaching a client with diabetes Mellitus and vulvovaginal candidiasis about the prevention of future
Infections. Which of the following information should the nurse include? Select all that apply.
a. "Avoid sitting for long periods in damp exercise clothing."
b. "Select undergarments that are cotton, rather than nylon."
c. "Avoid wearing tight-fitting clothing such as jeans or pants."
d. "Limit sugar intake and routinely monitor serum glucose levels."
 e. "Limit douching to twice weekly and use an unscented product."

12.) The nurse is talking with a client with asthma about the proper use of a peak flow meter. Which of the following
statements by the client would indicate a correct understanding of peak flow meter use?
a. "I will record every peak flow measurement even if I cough during the attempt."
b. "I will rest my tongue against the opening of the mouthpiece when using the peak flow meter."
c. "I will exhale slowly into the mouthpiece to obtain a peak flow measurement."
d. "I will use the peak flow meter every day as directed for two weeks to establish my personal best."

13.) The nurse and licensed practical nurse (LPN) are caring for assigned clients. Which of the following activities
would be appropriate for the nurse to assign to the LPN? Select all that apply.
a. Initiate a blood transfusion for a client who has iron deficiency anemia.
b. Administer a pneumococcal vaccine to a client with heart failure.
c. Perform an initial assessment for a client with multiple sclerosis.
d. Reinforce discharge teaching with a client who has pneumonia.
e. Provide colostomy care for a client with ulcerative colitis.

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19.) The nurse has taught the client about home management of Addison disease. Which of the following
statements by the client would indicate a correct understanding of the teaching? Select all that apply.
a. "I should take my prednisone in divided doses in the morning and afternoon."
b. "I will likely need an increased dose of prednisone if I become ill."
c. "I can expect to taper down my prednisone dose completely after my symptoms resolve."
d. "I will practice using coping skills in response to stressful situations."
e. "I should purchase an emergency medical identification bracelet indicating that I have Addison disease."

20.) The nurse in the pediatric unit is caring for a 10-year-old client. Which of the following actions should the nurse
take? Select all that apply.
a. Explain the routine of care directly to the client.
b. Offer praise when the client performs self-care tasks.
c. Ask the parent to bring the clients schoolwork to be completed.
d. Encourage the client to participate in art therapy with other clients.
e. Minimize discussing upcoming procedures with the client until the preoperative period.

21.) The nurse has taught a client with hyperlipidemia who has a new prescription for atorvastatin, Which of the
following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
a. "I plan to take atorvastatin before I go to sleep at night."
b. "I will avoid drinking grapefruit juice while taking atorvastatin."
c. "I should expect to experience muscle soreness while taking atorvastatin."
d. "I should stop taking atorvastatin once my cholesterol is within normal levels."
 e. "I may need to have additional liver function tests performed while taking atorvastatin."

22.) The nurse at an outpatient care facility is reviewing telephone messages from clients previously seen at the
facility. The nurse should first telephone the client who
a. had radiation therapy yesterday and reports ulcerations in the mouth
b. has bleeding between menstrual cycles and is taking a combined oral contraceptive
c. had an endoscopic colonoscopy earlier today and reports fever, abdominal pain, and bloating
d. has bacterial pneumonia and reports nausea and loose, watery stools after taking antibiotics

23.) The nurse is teaching a client with heart failure about recommended dietary modifications. Which of the
following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
a. "I should avoid eating foods that are high in fiber."
b. "I can roast chicken using fresh herbs and lemon."
c. "I can make a sandwich with lean turkey deli meat."
d. "I will eat fresh vegetables instead of canned vegetables."
e. "I will eat frozen meals for dinner with measured portions."

24.) The nurse is teaching a client who has a wound infected with methicillin-resistant Staphylococcus. Which of the
following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
a. "I will keep my wound covered with a clean, dry bandage."
b. "I will clean contaminated surfaces with a disinfectant solution."
c. "I will place my used bandages in a sealed bag before disposing of them."
d. "I will not share a bed with my spouse until the infection has resolved."
e. "I will soak in a warm bath daily to facilitate heating of my wound."

25.) The nurse is caring for a client with a suspected small bowel obstruction who is vomiting and reports abdominal
pain. The client has a blood pressure of 92:54 mm Hg and a heart rate of 122/min. It would be priority for the
nurse to
a. administer morphine
b. initiatie an IV fluid bolus
c. administer ondansetron
d. insert a nasogastric tube

26.) The nurse is preparing to administer a unit of packed RBCs to a client. Which of the following items gathered by
the nurse would be essential to follow-up?
a. blood transfusion consent form
b. Filtered Y-type administration tubing
c. lactated Ringer solution to prime the tubing
d. an 18-gauge peripheral venous access device (VAD)

27.) The nurse is caring for a client with myasthenia gravis. Which of the following findings would be essential to
follow up?
a. respiratory rate of 22/min and oxygen saturation level of 91% on room air
 b. ptosis of the upper eyelid worsens with repetitive eye movement
c. temperature of 101.8 F (38.8 C) and heart rate of 110/min
d. speech weakens after speaking for several minutes

28.) The nurse in the emergency department is caring for a client who is reporting body chills and swelling, redness,
and pain in the left lower extremity. Which of the following actions should the nurse take? Select all that apply
Click the exhibit button for additional client information.

a. Administer IV vancomycin as prescribed.

b. Initiate an IV bolus of 0.9% sodium chloride.
c. Review the client's most recent hemoglobin A1c.
d. Obtain blood specimens for blood culture and sensitivity.
e. Obtain a blood specimen to check the client's serum lactate level.

29.) The nurse is teaching a client who has a mechanical aortic valve and a new prescription for warfarin. Which of
the following statements by the client would require follow-up?
a. "I plan to use an electric razor to shave."
b. "I can take naproxen for minor pain or discomfort."
c. "I should have my INR level checked periodically."
d. "I will need anticoagulation therapy for the rest of my life."

30.) The nurse is teaching a client with diabetes mellitus about lifestyle modifications. Which of the following
information should the nurse include? Select all that apply.
a. "Inspect your feet monthly."
b. "Perform aerobic exercise regularly."
c. "Schedule routine eye examinations."
d. "Practice stress reduction techniques."
e. "Plan to get the influenza vaccine annually."

31.) The nurse has attended a staff education program about menstrual irregularities. Which of the following should
the nurse recognize as causes of secondary amenorrhea? Select all that apply.
a. BMI of 15.2 kg/m²
b. elevated prolactin level
c. copper intrauterine device
d. polycystic ovary syndrome
 e. excessive strenuous exercise

32.) The nurse in the telemetry unit is caring for assigned clients. The nurse should first check the client who
a. is receiving warfarin and has atrial fibrillation with a heart rate of 92/min
b. is receiving atenolol and has sinus bradycardia with a heart rate of 54/min
c. had a ventricular pacemaker inserted 2 days ago and has a pacemaker spike before the QRS interval noted
on continuous cardiac monitoring
d. had a myocardial infarction 1 day ago and has a premature ventricular contraction every third heartbeat
noted on continuous cardiac monitoring

33.) The nurse in a long-term care facility is observing staff members caring for clients at risk for developing pressure
Injuries. The nurse should intervene if a staff member is observed
a. limiting time sitting in a chair to one hour for a client who is obese
b. adjusting the head of the bed to 30 degrees for a client with quadriplegia
c. applying foam protectors to the heels of a client who is unable to get out of bed
d. placing a donut-shaped cushion on the seat of a chair for a client who is emaciated

34.) The nurse is reviewing new orders for a client who had shoulder surgery and reports pain, warmth, and
erythema of the left calf. Which of the following orders should the nurse clarify? Select all that apply.
a. D-dimer level now
b. CT scan without contrast of the left lower extremity
c. elastic compression stockings to bilateral lower extremities
d. venous Doppler ultrasound of the left lower extremity
e. heparin 80 units/kg IV bolus

35.) The nurse is teaching a client about thrombolytic therapy for treatment of an acute myocardial infarction.
Which of the following statements by the client would indicate a correct understanding of the teaching?
a. "The medication will regulate my heart rhythm."
b. "The medication will prevent future myocardial infarctions."
c. "The medication will decrease my blood pressure."
d. "The medication will improve the blood flow to my heart."

36.) The nurse is preparing to collect a sputum sample for a client who requires airborne precautions. Which of the
following personal protective equipment should the nurse put on before entering the room? Select all that
apply.
a. shoe covers
b. clean gloves
c. protective gown
d. N95 respirator mask
e. protective eye shield
37.) The nurse is obtaining medications from the automated medication dispensing system and notes that
acetaminophen was dispensed instead of prescribed acetazolamide. Which of the following would be an
example of correct documentation to include in the incident report?
a. "The wrong medication was dispensed but was not administered."
b. "This situation most likely occurred because the medication names are similar."
c. "This was not a medication error because the medication was not administered."
d. "The lighting made it difficult to use the automated medication dispensing system."

38.) The nurse is caring for a client who has sepsis and suspected disseminated intravascular coagulation (DIC).
Which of the following findings would support a diagnosis of DIC? Select all that apply. Click the exhibit button
for additional information.

a. petechiae on the lower extremities

b. hematocrit level increased from 32% to 34% (0.32 to 0.34)
c. platelet level decreased from 150,000/mm3 to 50,000/mm3 (150x 103/L to 50x 103/L)
d. bleeding from the peripheral venous access device site
e. crackles auscultated bilaterally

39.) The nurse is caring for a 55-year-old male client.

40.) The nurse is caring for a client who is receiving clozapine. It would require immediate follow-up if the client
 a. reports a dry mouth and has not had a bowel movement in 2 days
b. appears withdrawn and does not attend group therapy
c. has a decreased absolute neutrophil count
d. has a heart rate of 98/min

41.) The nurse in the emergency department is caring for a client who reports nausea, dizziness, and worsening left
shoulder pain. Which of the following actions would be a priority for the nurse to take?
a. Obtain a blood specimen to check cardiac enzymes.
b. Administer oxygen via nasal cannula.
c. Insert a large-bore peripheral venous access device.
d. Obtain a 12-lead ECG.

42.) The nurse is performing a cardiovascular assessment for a client. It would require follow-up if the client's
a. carotid pulse matches the apical pulse
b. jugular vein is pulsating when the head of the client's bed is at 30 degrees
c. carotid pulse strength is 3+ on palpation
d. jugular vein is visible when the head of the client's bed is at 60 degrees

43.)

44.) The nurse is planning care for a client who has increased intracranial pressure. Which of the following
interventions should the nurse include in the client's plan of care? Select all that apply.
a. Ensure the environment is calm and quiet.
b. Maintain the head of the client's bed at 30 degrees.
 c. Encourage the client to cough and deep breathe hourly.
d. Instruct the client to avoid beaning down during bowel movements.
e. Perform passive range-of-motion exercises of the lower extremities.

45.) The nurse is caring for assigned newborns. The nurse should first assess the newborn who
a. was born 3 days ago and has yellowing of the skin and sclera
b. has shallow, irregular respirations and bluish discoloration of the feet
c. experienced shoulder dystocia at birth and has a negative Moro reflex
d. was born via vacuum-assisted vaginal delivery and cannot be aroused to feed

46.)

47.) The nurse at an outpatient care facility is reviewing telephone messages from clients previously seen at the
facility. The nurse should first telephone the client who reports
a. nausea and vomiting after taking oxycodone
b. heart palpitations after using an albuterol inhaler
c. unexpected weight lies after starting methylphenidate
d. a dry cough and shortness of breath after starting amiodarone

48.) The nurse is caring for a client with schizophrenia who is experiencing delusions of reference. Which of the
following statements by the client would be consistent with delusions of reference?
a. "The cashier at the coffee shop is in love with me."
b. "The staff is trying to poison me with the tap water."
c. "The president relies on my telephone calls for safety."
d. "The newspaper is a message sent to me in secret code."

49.) The nurse is participating in a quality improvement initiative to decrease catheter-associated urinary tract
infection (CAUTI) rates. It would best indicate a reduction in CAUTI rates if
 a. medical record audits reveal a decrease in the number of CAUTIs
b. client surveys show a decrease in negative client feedback regarding catheter care
c. nursing surveys show a decrease in the number of clients with CAUTIs
d. pharmacy records show a decrease in the number of prescriptions for antibiotic therapy

50.) The nurse is talking with the spouse of a client who is receiving end-of-life care. The spouse is considering organ
donation and asks the nurse, "What would you do if this were your family member?" Which of the following
responses would be appropriate for the nurse to make?
a. "You seem unsure about this decision. Tell me what you know about organ donation."
b. "I will ask the social worker to come discuss your options and help you make a decision."
c. "You should choose organ donation for your spouse. I would if it were my family member"
d. "Organ donation often provides comfort to family members who are grieving the loss of a loved one."