Question Number 1 of 25

The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for
puerperal infection?

The correct response is "C".

A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
B) 2 days post partum, temperature of 101.2 degrees Farenheit this morning
C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days
D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
Your response was "B".

The correct answer is C: 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days

A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth,
constitutes a post partum infection.

Question Number 2 of 25
A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following
is appropriate reinforcement of information by the nurse?

The correct response is "A".

A) "Drink at least 8 glasses of water a day."
B) "Be sure to take the medication with food."
C) "It is safe to take with oral contraceptives."
D) "Stop the medication after 5 days."
Your response was "A".

The correct answer is A: "Drink at least 8 glasses of water a day."

Bactrim is a highly insoluble drug and requires a large volume of fluid intake. Taking with food is not necessary. Options 3
and 4 are incorrect instructions with use of bactrim

Question Number 3 of 25
A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees
Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which
assessment would have alerted the nurse first to the client's change in condition?

The correct response is "B".

A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature
Your response was "C".

The correct answer is B: Respiratory rate

Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for
decreased oxygenation is increased respiratory rate.

Question Number 4 of 25
A client calls the evening health clinic to state “I know I have a severely low sugar since the Lantus insulin was given 3
hours ago and it peaks in 2 hours.” What should be the nurse’s initial response to the client?

The correct response is "B".

A) What else do you know about this type of insulin?
B) What are you feeling at this moment?
C) Have you eaten anything today?
D) Are you taking any other insulin or medication?
Your response was "B".

The correct answer is B: What are you feeling at this moment? When a client has changed from stable to unstable the
initial response is to do further assessment of the client.
Question Number 5 of 25
The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been
prescribed. Today's prothrombin level is 40 (normal range 10-14). Which of the following is a priority assessment?

The correct response is "A".

A) Neurological signs
B) Lung sounds
C) Homan's sign
D) Gum bleeding
Your response was "B". The correct answer is A: Neurological signs
Question Number 6 of 25
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?

The correct response is "C".

A) Obtain emergency equipment
B) Assess heart rate, rhythm and all pulses
C) Apply pressure to the vessel insertion site
D) Use cold packs at the exit incision site
Your response was "C".

The correct answer is C: Apply pressure to the vessel insertion site If a central venous catheter is accidentally removed,
pressure should be applied to the vein entry site assessments are a priority in this post-CVA client

Question Number 8 of 25
Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?

The correct response is "D".

A) Measure the vital signs
B) Palpate the abdomen
C) Assess for breath sounds
D) Verify tube patency
Your response was "D".

The correct answer is D: Verify tube patency Tube patency should be checked prior to all feedings. The feeding should not
be attempted if the tube is not patent

Question Number 9 of 25
During a fluid exchange for the client who is 48 hours post insertion of the abdominal Tenckhoff catheter for peritoneal
dialysis, the nurse knows that the appearance of which of the following needs to be reported to the health care provider
immediately?
The correct response is "D".
A) Slight pink - tinged drainage
B) Abdominal discomfort
C) Muscle weakness
D) Cloudy drainage
Your response was "C".

The correct answer is D: Cloudy drainage Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation
of the peritoneum). Other options are expected side effects of peritoneal dialysis.

Question Number 10 of 25
A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
The correct response is "C".
A) repeat glycohemoglobin in 24 hours
B) document accuchecks, intake and output every 4 hours
C) humulin N 20 units IV push
D) IV fluids of 0.9% normal saline at 125 ml per hour
Your response was "C".

The correct answer is C: humulin N 20 units IV push Regular insulin is the only insulin that can be given by the
intravenous route. This is the initial order to question. Another order to question is option 1 although it is not a priority
since the client would not be harmed by this action. This lab test gives the average glucose on the hemoglobin molecule
for the past 2 to 3 months. There would be no need to repeat it at this time. A fasting glucose in the morning would be
more appropriate to obtain. The other orders are within expected actions in this situation.

Question Number 11 of 25
The nurse is caring for a client who is receiving total parenteral nutrition (hyperalimentation and lipids). What is the priority
nursing action on every 8 hour shift?

The correct response is "C".

A) Monitor blood pressure, temperature and weight
B) Change the tubing under sterile conditions
C) Check urine glucose, acetone and specific gravity
D) Adjust the infusion rate to provide for total volume
Your response was "B".

The correct answer is C: Check urine glucose, acetone and specific gravity

Because of the high dextrose and protein content in parenteral nutrition, the nurse should assess the urine at least every
8 hours

Question Number 12 of 25
The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the
formation of deep vein thrombosis?

The correct response is "D".

A) Elevate the foot of the bed
B) Apply knee high support stockings
C) Encourage passive exercises
D) Prevent pressure at back of knees
Your response was "C".

The correct answer is D: Prevent pressure at back of knees

Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.

Delaune, S & Lander, P. (2002). Fundamentals in Nursing: Standards and Practice. (2nd ed). Clinton Park, New York:
Delmar

Question Number 13 of 25
What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline
(Pamelor)?

The correct response is "B".

A) Symptom relief occurs in a few days
B) Alcohol use is to be avoided
C) Medication must be stored in the refrigerator
D) Episodes of diarrhea can be expected
Your response was "B".

The correct answer is B: Alcohol use is to be avoided

Alcohol potentiates the action of tricyclic antidepressants

Question Number 14 of 25
A client returns from the operating room after a right orchiectomy. For the immediate post operative period the nursing
priority would be to

The correct response is "B".

A) Maintain fluid and electrolyte balance
B) Manage post operative pain
C) Ambulate the client within 1 hour of surgery
D) Control bladder spasms
Your response was "A".
The correct answer is B: Manage post operative pain

Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery

Question Number 15 of 25
A client is waiting to have an intravenous pyelogram (IVP). The most important factor to be obtained by the nurse prior to
the procedure is

The correct response is "B".

A) time to the client's last meal
B) the client's allergy history
C) assessment of the peripheral pulses
D) results of the blood coagulation studies
Your response was "B".

The correct answer is B: the client''s allergy history

Intravenous Pyelogram is a dye study that uses an iodine-based contract. Therefore, the study is contraindicated in clients
with allergy to iodine.

Question Number 16 of 25
A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and
swelling of the fingers. The first action of the nurse should be

The correct response is "C".

A) Elevate the arm no higher than heart level
B) Remove the cast
C) Assess capillary refill of the exposed hand and fingers
D) Apply a warm soak to the hand
Your response was "C".

The correct answer is C: Assess capillary refill of the exposed hand and fingers

A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure
within a confined area) which requires immediate pressure reducing interventions

Question Number 17 of 25
When caring for a client with urinary incontinence, which content should be reinforced by the nurse?

The correct response is "D".

A) Hold the urine to increase bladder capacity
B) Avoid eating foods high in sodium
C) Restrict fluid to prevent elimination accidents
D) Avoid taking antihistamines
Your response was "D".

The correct answer is D: Avoid taking antihistamines

Antihistamines can aggravate urinary incontinence and should be avoided in clients with urinary incontinence. Holding the
urine, avoiding sodium, and restricting fluids have not been shown to reduce urinary incontinence.

Question Number 18 of 25
A client arrives in the emergency department after a radiologic accident at a local factory. The next action of the nurse
would be to

The correct response is "B".

A) begin decontamination procedures for the client
B) ensure physiologic stability of the client
C) wrap the client in blankets to minimize staff contamination
D) double bag the client’s contaminated clothing
Your response was "D".
The correct answer is B: ensure physiologic stability of the client

The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic
contamination.

Question Number 19 of 25
A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the
nurse?

The correct response is "C".

A) Foul smelling urine
B) Burning on urination
C) Elevated temperature
D) Nausea and anorexia
Your response was "A".

The correct answer is C: Elevated temperature

Elevated temperature after 72 hours on an antibiotic indicates the antibiotic is not effective in eradicating the offending
organism. The provider should be informed immediately so that a more effective medication can be prescribed, and
complications such as pyelonephritis are prevented. Options 1 and 2 are expected with cystitis. Option 4 may be related
to the antibiotics as a side effect and should also be reported to the provider

Question Number 20 of 25
The nurse is caring for a school aged child with a diagnosis of secondary hyperparathyroidism following treatment for
chronic renal disease. Which of the following lab data should receive priority attention?

The correct response is "A".

A) Calcium and phosphorus levels
B) Blood sugar
C) Urine specific gravity
D) Blood urea nitrogen
Your response was "B".

The correct answer is A: Calcium and phosphorus levels

Calcium and phosphorous levels will be elevated until the client is stabilized.

Question Number 21 of 25
The nurse is caring for a pregnant woman with pregnancy induced hypertension receiving magnesium sulfate
intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped
significantly, and 8 hour output is 200 ml. What should the nurse do first?

The correct response is "C".

A) Administer calcium gluconate
B) Call the health care provider immediately
C) Discontinue the magnesium sulfate
D) Perform additional assessments
Your response was "C".

The correct answer is C: Discontinue the magnesium sulfate

The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take
measures to ensure the safety of the client.

Question Number 22 of 25
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate
action by the nurse?

The correct response is "D".

A) Pruritic rash
B) Dry, hacking cough
 C) Chronic fatigue
D) Elevated temperature
Your response was "A".

The correct answer is D: Elevated temperature

It is a priority to report this finding since clients on hemodialysis are prone to infection and the first sign is an elevated
temperature. Other findings should be reported to the care provider as well

Question Number 23 of 25
The nurse must know that the most accurate oxygen delivery system available is

The correct response is "A".

A) The venturi mask
B) Nasal cannula
C) Partial non-rebreather mask
D) Simple face mask
Your response was "A".

The correct answer is A: The venturi mask

The most accurate way to deliver oxygen to the client is through a venturi system such as the Venti Mask. The Venti Mask
is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen.
The size of the opening to the reservoir determines the concentration of oxygen. The client’s respiratory rate and
respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be
delivered by this system is 55%.

Question Number 24 of 25
The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally
disconnects from the drainage tube. The first action the nurse should take is

The correct response is "D".

A) Reconnect the tube
B) Raise the collection chamber above the client's chest
C) Call the health care provider
D) Clamp the chest tube
Your response was "A".

The correct answer is D: Clamp the chest tube

Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the
chest cavity. Clamping the tube close to the client’s chest is the first action. Health care provider notification follows this
action

Question Number 25 of 25
The nurse is responsible for decisions regarding client room assignments. Which possible roommate would be most
appropriate for a 3 year-old child with minimal change nephrotic syndrome?

The correct response is "C".

A) 2 year-old with respiratory infection
B) 3 year-old fracture whose sibling has chickenpox
C) 4 year-old with bilateral inguinal hernia repair
D) 6 year-old with a sickle cell anemia crisis
Your response was "C".

The correct answer is C: 4 year-old with bilateral inguinal hernia repair

The nurse must know that children with nephrotic syndrome are at high risk for development of infections as a result of the
standard use of immunosuppressant therapy as well as from the accumulation of fluid (edema). Therefore, these children
must be protected from sources of possible infection. The sickle cell crisis has potential to have occurred from an
infectious process